0117 1 BEFORE THE NEVADA STATE BOARD OF MEDICAL EXAMINERS 2 -oOo- 3 4 5 BOARD MEETING 6 7 8 Friday, March 1, 2002 9 10 11 12 13 14 1105 Terminal Way Suite 30 15 Reno, Nevada 16 17 18 19 20 Reported by: DENISE PHIPPS, CCR #234, RDR, CRR 21 22 23 24 SIERRA NEVADA REPORTERS (775) 329-6560 25 0118 1 A P P E A R A N C E S 2 MEMBERS PRESENT 3 4 CHERYL A. HUG-ENGLISH, PRESIDENT 5 JOEL LUBRITZ PAUL A. STEWART 6 SOHAIL U. ANJUM STEPHEN MONTOYA 7 DONALD H. BAEPLER ROBIN L. TITUS 8 RICHARD LEGARZA - General Counsel 9 LARRY D. LESSLY - Executive Director MAUREEN E. LYONS - Deputy Executive Director 10 ROBERT A. FRANTZ - Financial Manager 11 CHARLOTTE M. BIBLE - Assistant Chief Deputy Attorney General 12 13 14 15 16 17 18 19 20 21 22 23 24 SIERRA NEVADA REPORTERS (775) 329-6560 25 0119 1 . Call to Order and Announcements............ 1 2 . Approval of Minutes........................ 1 4 . Consideration of Petition by Forensic Pathology Services for Advisory Opinion on Whether Unsupervised Autopsy Technicians Independently Conducting External Autopsy Inspections and Complete Eviscerations Constitutes the Practice of Medicine Without a License................. 3 5 . Consideration of Petition by Edwin P. Homansky, M.D., for Advisory Opinion on His Directorship of the Mobile Healthcare Program Proposed by American Medical Response - Las Vegas................................. 12 6 . Legal Reports............................. 39 7 . Reports................................... 43 8 . Executive Staff Report.................... 68 9 . Discussion of Request by Washoe Medical Center Board of Trustees for the Nevada State Board of Medical Examiners to Conduct Criminal Background Checks when a Medical Doctor Applies for and Renews Registration of Nevada Licensure....................... 97 13 . Ratification of Licenses Issued, and Reinstatements of Licensure and Changes of Licensure Status Approved Since the November 30 & December 1, 2001 Board Meeting............................ 119 19 . Matters for Future Agenda................ 120 20 . Public Comment........................... 126 0001 1 RENO, NEVADA, FRIDAY, MARCH 1, 2002, 3:25 P.M. 2 -o0o- 3 4 1. CALL TO ORDER AND ANNOUNCEMENTS 5 6 PRESIDENT HUG-ENGLISH: I'll call this March 7 1st meeting of the Nevada State Board of Medical 8 Examiners to order. 9 Welcome to everybody. I just have one 10 announcement before we get started. I think someone in 11 our midst snuck in a birthday that should be 12 recognized. Larry Lessly had an important birthday 13 this last week. 14 MS. LYONS: Actually, only two days ago. 15 MR. LESSLY: Don't look bad for 40. 16 PRESIDENT HUG-ENGLISH: We won't sing, but 17 happy birthday. 18 19 2. APPROVAL OF MINUTES 20 21 PRESIDENT HUG-ENGLISH: Okay. Has everyone 22 had an opportunity to read the minutes and are there 23 any changes that we need to make from our last meeting, 24 actually two meetings? 25 MEMBER LUBRITZ: On page 19, item 10, and 0002 1 on page 20, item 9, Lubritz was not present. 2 PRESIDENT HUG-ENGLISH: But we felt you 3 here. 4 Okay. 5 MEMBER LUBRITZ: I don't know if there were 6 other times, but those are at least two that I picked 7 up. You might want to make sure. 8 MS. LYONS: On the adjudications? 9 MEMBER LUBRITZ: That's correct, page 19, 10 page 20. Item 10 on page 19, item 9 on page 20. 11 PRESIDENT HUG-ENGLISH: Thank you. Any 12 other corrections that people have noticed? 13 If not, could I have a motion to approve the 14 minutes? 15 MEMBER BAEPLER: So moved. 16 MEMBER LUBRITZ: Second. 17 PRESIDENT HUG-ENGLISH: There's been a 18 motion and a second. 19 All in favor. Opposed? 20 (Whereupon a motion was made, seconded, 21 and passed unanimously.) 22 PRESIDENT HUG-ENGLISH: The minutes have 23 been approved. 24 All right. Agenda Item 3 has been 25 withdrawn. So we won't deal with Dr. Handsfield's 0003 1 request to change restrictions on his license. 2 3 4. Consideration of Petition by Forensic Pathology Services for Advisory Opinion on Whether 4 Unsupervised Autopsy Technicians Independently Conducting External Autopsy Inspections and 5 Complete Eviscerations Constitutes the Practice of Medicine Without a License. 6 7 PRESIDENT HUG-ENGLISH: So that will bring 8 us to Agenda Item 4, which is consideration of petition 9 by the Forensic Pathology Service for an advisory 10 opinion on whether unsupervised autopsy technicians 11 independently conducting external autopsy inspections 12 and complete eviscerations constitutes the practice of 13 medicine without a license. 14 I think everybody has had an opportunity to 15 read the advisory opinion. And I'd like to open it for 16 discussion if anybody has any comments. 17 MEMBER MONTOYA: They're essentially using 18 these people as technicians to do whatever to get 19 prepared to do the autopsy, is what I'm understanding. 20 They're not making any diagnosis; they're simply 21 getting things prepared for the autopsy. 22 MEMBER LUBRITZ: What I understand is that 23 they actually are going in, they actually eviscerate 24 and then send the eviscerated parts to someone else who 25 then does it. But it's important to see what's there 0004 1 prior to doing the evisceration as well to look over 2 and whatever. And then someone else looks at it and 3 then writes up the report. 4 MEMBER ANJUM: You have to look at the whole 5 body before doing the autopsy. That's an important 6 part of the examination, of the autopsy. And before 7 you take the part out, you look, what does it look 8 like, what relations are missing there and arrangement 9 or disarrangements and everything. So the whole 10 practice sounds totally absurd to me. And then the 11 legal part of it, moving the parts across the street, I 12 don't know who came across this idea and what in mind 13 these guys have been doing. 14 MEMBER MONTOYA: Are these people trained to 15 say the liver is in its right position, the gall 16 bladder is in normal position? 17 MR. LEGARZA: She doesn't say it in her 18 request. She said so-called technicians come in there. 19 There was no way for me to arrive at what their 20 training was or wasn't. 21 MEMBER ANJUM: There's no training course 22 anywhere I know of to be an autopsy technician. 23 MEMBER MONTOYA: It's all OJT. 24 MEMBER BAEPLER: Is this a statewide 25 problem? 0005 1 MR. LEGARZA: This is a letter from a 2 pathologist in Reno who says it's happening in Las 3 Vegas. 4 MEMBER BAEPLER: In Las Vegas? 5 MR. LEGARZA: That's what her letter says. 6 MEMBER TITUS: It's not a competition issue? 7 MEMBER BAEPLER: No. 8 PRESIDENT HUG-ENGLISH: And she quotes this 9 autopsy service as 1-800-AUTOPSY that does it. 10 MR. LEGARZA: Someone flies into the state 11 of Nevada, autopsies, conducts full evisceration; they 12 send the stuff to California. Somebody does a written 13 autopsy report and sends it back to Nevada. I say it's 14 practicing medicine in the state of Nevada. 15 MEMBER LUBRITZ: I agree. 16 MEMBER TITUS: We would certainly not treat 17 this any different than we would treat our 18 telemedicine, teleradiology or anything else, except 19 they're shipping body parts. 20 MEMBER MONTOYA: And they don't have an 21 immediate supervisor. 22 MR. LEGARZA: That's the impression I get 23 from the letter. There is no licensed M.D. There's no 24 Nevada licensed M.D. present at the time that these 25 eviscerations are made. She doesn't even know if a 0006 1 licensed M.D. does the stuff -- 2 MEMBER TITUS: Do we know how widespread it 3 is, how often it happens? 4 MEMBER ANJUM: We can question people coming 5 from donor company, the doctors don't take the parts. 6 MR. LEGARZA: We've taken a position on that 7 in the past. The donor thing is okay because you're 8 coming to get that part and it's going somewhere and 9 there's no medical determination made with respect to 10 any cause of death or anything like that. This is just 11 a donor/donee situation, and we have in the past 12 informally, at least since I've been here, said that's 13 okay. This is different. At least I think it is. 14 MEMBER LUBRITZ: Do we allow a technician 15 to come in and take a part, as opposed to a physician? 16 MR. LEGARZA: Yes. 17 MEMBER ANJUM: They can take the good part 18 of the body. 19 MR. LEGARZA: Somebody has already conducted 20 an autopsy on that body. They've already made a 21 determination as to cause of death, as to the viability 22 of the organs that someone is harvesting. Organ 23 harvesting is a completely different story. 24 MEMBER MONTOYA: That's why I was working up 25 the angle, can trained technicians do this, do they 0007 1 have an immediate supervisor? That's what my take is 2 on what these autopsy technicians were doing. Though 3 it bothers me that they're shipping. I was thinking 4 that they must have some supervisor here that they do 5 these autopsies under. 6 MR. LEGARZA: That's not what the letter 7 says. 8 PRESIDENT HUG-ENGLISH: It says: "To my 9 knowledge a representative from 1-800-AUTOPSY 10 flies in or drives in from California. To my 11 knowledge this is a nonphysician, nonlicensed 12 autopsy assistant. This assistant conducts a 13 full evisceration at the funeral home and then 14 either carries or ships the specimens to 15 California, and that a party in California, 16 presumably a licensed physician, but I'm unsure 17 of this, then performs some sort of study and 18 furnishes a written autopsy report." 19 So it sounds like from this that -- and, 20 granted, we don't really have full knowledge from this 21 letter, but what I think we can do is definitely give 22 an opinion that if this is what's going on, it's not 23 okay. 24 MEMBER MONTOYA: Are they running like a 25 K-Mart autopsy service? I mean, there's a real formal 0008 1 one done in the hospital, then there's the I don't want 2 to get a real good one, let's see if we can get a cheap 3 one. 4 MEMBER ANJUM: We don't know even if the 5 allegations are correct. 6 MEMBER TITUS: Just because they advertise, 7 have they ever called 1-800-AUTOPSY? Who would call 8 1-800-AUTOPSY? 9 MEMBER MONTOYA: It's not high on my list. 10 MEMBER TITUS: Is the Clark County, Washoe 11 County Sheriff's Department using these people to do 12 their coroner's cases? 13 PRESIDENT HUG-ENGLISH: Sounds like a local 14 funeral home in Las Vegas that's using them. Probably, 15 from the sounds of it, there must be more than one. 16 MEMBER TITUS: There must be some connection 17 to the coroner. 18 MR. LEGARZA: It's not a complaint. It's a 19 request for an advisory opinion. 20 MEMBER STEWART: The coroner's office 21 performs its own autopsies. They have licensed 22 physicians and forensic pathologists, and they perform 23 their own work. They do not -- 24 MEMBER BAEPLER: Under what circumstances 25 would a funeral home undertake one? 0009 1 MEMBER STEWART: I guess if you wish as a 2 family member to have your loved one have an 3 independent autopsy. 4 MEMBER BAEPLER: Has a doctor even suggested 5 it, to find out? 6 MEMBER STEWART: If the doctor suggested it, 7 then the pathologist at Sunrise Hospital or the 8 pathologist at AML perform autopsies. 9 MEMBER BAEPLER: Okay. 10 MEMBER TITUS: Who would even use this? Can 11 you investigate it and look into it, call 1-800-AUTOPSY 12 and see? 13 MEMBER ANJUM: Is it our jurisdiction to 14 investigate this? 15 MEMBER BAEPLER: If they're practicing 16 medicine, yes. 17 MEMBER ANJUM: If they're doing it, right. 18 MEMBER TITUS: I think physicians also -- 19 here is one of the issues that have come up again with 20 this telemedicine/teleradiology, the physicians are 21 being out of our state then doing treatments within our 22 state, to me it seems like it's the same issue of a 23 physician to pathologist in California practicing 24 medicine on a Nevada dead resident, but it's 25 nonetheless practicing on a Nevada resident without a 0010 1 license in our state. We would ask no less of them 2 like we do our radiologists to be licensed or to 3 qualify for a license of some sort. So to me that's 4 the issue. 5 PRESIDENT HUG-ENGLISH: I think if you read 6 the paragraph of the advisory opinion, that autopsies 7 being conducted in the state of Nevada are the practice 8 of medicine and may only be conducted in the state of 9 Nevada by licensed physicians. And I think that's what 10 we're saying. And what tasks a Nevada licensed 11 physician may delegate to a medical autopsy assistant 12 or whomever is present to assist must be tasks that are 13 performed in the presence of the autopsy physician 14 under his or her direct supervision, and the physician 15 must know or have reason to know that the person to 16 whom the tasks are delegated is capable of performing 17 those tasks. 18 MEMBER BAEPLER: That's pretty clear. 19 PRESIDENT HUG-ENGLISH: I think that's very 20 well stated and very clear of what needs to happen. 21 And I think clearly, if something is going on that 22 doesn't meet this, we need to get the word out. 23 MEMBER TITUS: You'll send that letter to 24 1-800-AUTOPSY? What do we do from here? 25 MR. LEGARZA: The advisory opinion goes back 0011 1 to the licensed physician who requested it. 2 MEMBER ANJUM: Do we take any action? 3 MR. LEGARZA: Well, I suppose if someone 4 wants to refer this to the investigative committee. 5 MEMBER BAEPLER: I think it needs to be 6 looked at. 7 MR. LEGARZA: Okay. I'll instruct the 8 investigative staff to open a case file. 9 MEMBER ANJUM: You can ask someone for 10 information or look into somewhere, whether they need a 11 license or not. 12 PRESIDENT HUG-ENGLISH: I have a feeling 13 that they didn't consider that, that this has just sort 14 of been going on and nobody has really stopped to look 15 at it until now. And I think that this letter has sort 16 of generated some interest. 17 MEMBER TITUS: So one of our investigators 18 will call 1-800-AUTOPSY and see what they get? 19 MR. LEGARZA: We'll open an investigative 20 file and take it from there. How does that sound? 21 MEMBER TITUS: Sounds good to me. 22 PRESIDENT HUG-ENGLISH: Okay. 23 MEMBER STEWART: Do we need a motion to 24 approve the advisory opinion? 25 PRESIDENT HUG-ENGLISH: Yes. 0012 1 MEMBER STEWART: So moved. 2 MEMBER TITUS: Second. 3 PRESIDENT HUG-ENGLISH: There's been a 4 motion and a second. Any further discussion on the 5 advisory opinion? 6 All in favor? Opposed? 7 (Whereupon a motion was made, seconded, and 8 passed unanimously.) 9 PRESIDENT HUG-ENGLISH: The motion 10 carries. 11 12 5. Consideration of Petition by Edwin P. Homansky, M.D., for Advisory Opinion on His Directorship of 13 the Mobile Healthcare Program Proposed by American Medical Response - Las Vegas 14 15 PRESIDENT HUG-ENGLISH: The next item on the 16 agenda is consideration of petition by Edwin Homansky 17 for an advisory opinion on his directorship of the 18 Mobile Healthcare Program proposed by American Medical 19 Response. 20 And, again, the advisory opinion is in your 21 agenda book. I think everyone has had an opportunity 22 to look at that. And I'll open it for discussion. 23 The issue here is basically whether or not 24 EMTs or paramedics can indeed work in other arenas 25 other than under emergency situations. And the 0013 1 advisory opinion has stated that, basically reviews 2 what the definition of what a medical assistant means, 3 which is very clear. And that medical assistants under 4 this law of Nevada participate in the treatment of a 5 patient under the direct supervision of a physician and 6 assist in the care of the patient. They don't operate 7 independently under a physician's license following 8 written protocols. 9 So I think clearly this is a jump from what 10 has been out there; that the advisory opinion that has 11 been written states that it would constitute the 12 practice of medicine and would violate the standards 13 set forth in our current statutes. 14 MEMBER BAEPLER: That seems pretty clear, 15 too. 16 MEMBER MONTOYA: Absolutely. Getting these 17 guys out there with some kind of training, standing out 18 there waiting for an accident to happen, they're not 19 quite EMTs, just medical assistants. 20 MEMBER BAEPLER: Then they have to read a 21 protocol to see what they have to do. 22 MEMBER MONTOYA: There is no protocol. 23 MEMBER TITUS: For physicians assistants 24 there is a level of competency that's required, and 25 they're trying to circumvent that. 0014 1 MEMBER MONTOYA: Trying to dumb it down. 2 MEMBER TITUS: Do you need a motion to 3 accept the letter? 4 PRESIDENT HUG-ENGLISH: I do believe there's 5 someone in the audience who has requested to speak to 6 us briefly, please. 7 MR. WADHAMS: I will be brief. I appreciate 8 the courtesy of the Board to allow me to speak. 9 I'm Jim Wadhams. I'm an attorney. I 10 represent Dr. Homansky and American Medical Response. 11 I think the two considerations, issues for 12 your consideration, there are two really: What is the 13 level of activity? And as our petition describes, it's 14 really first aid and injury assessment. Not treatment. 15 Secondly, there is direct supervision of a 16 physician at all times. So I think putting those two 17 together, the question presented for you is an 18 extension of a practice that is fairly common, 19 particularly in multi-clinic settings for a 20 practitioner to have medical assistants at multiple 21 locations. 22 MEMBER BAEPLER: But under the direct 23 supervision is by a cell phone. 24 MR. WADHAMS: That is correct. It would be 25 by a cell phone. Immediately available. But that same 0015 1 circumstance would occur where there's a multiple 2 clinic setting and one physician, it would be by either 3 a land line or a cell phone as well. The suggestion or 4 the comment was made about protocol. That's to further 5 corroborate that those individuals are, at most, 6 executing first aid/injury assessment and calling for 7 emergency personnel if that's necessary. 8 So the level of activity, I think that's an 9 important question: Does that rise to the practice of 10 medicine? And two, is the level of supervision 11 sufficient? And I guess the question that goes further 12 is, if the Board chooses to restrict that or redefine 13 that or narrow that, it may be necessary to do that 14 through the adoption of a regulation as you have in the 15 physician assistant area. 16 But in all respect, I think that the 17 question is what is the level of the activity and does 18 that rise to the independent practice, or is the 19 supervision and the activity combined sufficiently 20 restricted to be within the scope of control of an 21 individual physician. 22 I'd be happy to answer any questions. 23 MEMBER ANJUM: Also the level of training 24 that person has. 25 MR. WADHAMS: Yes, sir. 0016 1 MEMBER ANJUM: Because he's an EMT or nurse 2 practitioner or what it is. And how much we should 3 allow them to care for and what are the limits here. 4 MR. WADHAMS: I think that's precisely the 5 question as we presented in the petition. These people 6 will be EMT intermediate or higher. Could be any level 7 above that but no less than that. But again the 8 question I think that that begs is what level of 9 activity will they engage in. They will not even be 10 allowed under this proposal to engage in that which an 11 EMT could engage in through an ambulance company. It 12 is not emergency service delivery, it is injury 13 assessment, potentially first aid, and then basically 14 calling whatever service is necessary. A triage 15 function. 16 MEMBER STEWART: May I ask a couple of 17 questions? 18 PRESIDENT HUG-ENGLISH: Go ahead. 19 MEMBER STEWART: Mr. Wadhams, do you 20 understand how EMTs function in the real world by way 21 of AMR or fire department? 22 MR. WADHAMS: In general. 23 MEMBER STEWART: They operate under a 24 supervising physician, a county health officer, and 25 they operate under a direct physician, an emergency 0017 1 room physician, and they perform certain assessment 2 tasks and diagnostic tasks confirmed by the emergency 3 room physician. Is that a fair statement? 4 MR. WADHAMS: That's about my level of 5 understanding, Dr. Stewart. 6 MEMBER STEWART: How is this different than 7 that? 8 MR. WADHAMS: Significantly different in 9 that as you see in the petition we have indicated 10 should emergency service be necessary, that level of 11 service, it would be called in separately from this 12 activity. This is really a first aid activity to go do 13 an injury assessment. If emergency service is 14 necessary, it would not be performed by that medical 15 assistant. They would call the dispatcher and deal 16 with the ambulance service. 17 MEMBER MONTOYA: But it's still a practice 18 of medicine, although not much medicine, but it's still 19 the practice of medicine. 20 MR. WADHAMS: I think that's precisely the 21 question that the Board is asked to consider. Is that 22 practice of medicine by a medical assistant in the 23 direct physical presence of the physician okay? I'm 24 comfortable that this Board has no difficulty with that 25 notion. Is it okay if we are in adjacent suites? That 0018 1 probably is okay. And apparently, by practice, it's 2 okay if we are in a location in Green Valley, in 3 Summerlin and in Central Las Vegas. 4 MR. LEGARZA: I don't know that to be the 5 case, counsel. 6 MEMBER LUBRITZ: That's not how medical 7 assistants work. 8 MR. LEGARZA: I don't know that to be the 9 case, counsel. 10 MEMBER LUBRITZ: Medical assistants work 11 with the doctor there. I'm not sure they work in 12 another office and call in something to a doctor by a 13 cell phone or any other means. So that is not the 14 way -- 15 MEMBER ANJUM: The doctor would have to be 16 in the office with the medical assistant, physician 17 assistant. 18 MEMBER TITUS: There's a big difference in 19 issue here. Physician's assistant versus - 20 MEMBER ANJUM: But medical assistant or EMT 21 does not prescribe or institute any treatment without 22 doctor's permission and advice. If they have to start 23 a normal saline drip, they ask the ER doctor; he okays 24 it. 25 MEMBER TITUS: EMT can start a normal saline 0019 1 solution. 2 MEMBER ANJUM: But keeping in touch with the 3 doctor, describing those things. 4 MR. WADHAMS: I think your comment to me 5 raises the question that's at hand here, and that is 6 that first and foremost what is the level of activity 7 in which these individuals would be engaged. 8 MEMBER TITUS: I'm concerned about the delay 9 in diagnosis. If they're responding as a first 10 responder to an injury or whatever and make a 11 determination if they need to call somebody else in, 12 they're either going to call the next level in, then 13 there's the delay, or they're going to treat. There's 14 two options there. Is there always going to be a need 15 to call somebody else in? 16 MEMBER BAEPLER: Perhaps you can clarify 17 that by saying how does this operate. You reference 18 once called to a business site or location. Would you 19 have like a standing agreement or contract with a 20 construction company as a client, or could anybody in 21 the community, in case it's a car wreck or a home 22 accident or anything, accessible to everybody. And if 23 so, how does that compete with our regular ambulance 24 service and paramedics and so forth? 25 MR. WADHAMS: Just to remind the Board, this 0020 1 is being presented by Dr. Homansky and American Medical 2 Response, which is the old Mercy Ambulance in Las 3 Vegas. 4 MR. LEGARZA: But there's a specific 5 difference between what those people can do and the 6 provisions and the authority of Chapter 450B of the 7 Nevada Revised Statutes and what a medical assistant 8 can do under the Medical Practice Act of the State of 9 Nevada. Big difference. 10 MR. LESSLY: It's not being presented by 11 anyone other than Dr. Homansky. This Board has no 12 authority to render an advisory opinion to anyone other 13 than a licensee of the Board. 14 MR. WADHAMS: I apologize. Dr. Homansky has 15 requested the opinion. But I think the two questions 16 that were just raised really require a bit of an 17 answer. What is the plan under which this is being 18 performed? And I think the direct answer to you is 19 businesses could contract with Dr. Homansky to provide 20 this service. And I think that raises the question 21 that was raised at this end of the Board. Is that a 22 delay? I guess the question is: What's the 23 alternative? 24 MEMBER BAEPLER: I was thinking the 25 confusion that could result if I have an accident or 0021 1 some crisis at the university, who do I call? This 2 group? The ambulance company? 3 MEMBER TITUS: The whole 911 access seems to 4 be -- 5 MEMBER BAEPLER: Would this be part of the 6 911 system? 7 MR. WADHAMS: No. This is separate and 8 apart. This is contracted for by an employer to have 9 somebody other than the human resource or the 10 supervisor of a particular department making a medical 11 decision. 12 PRESIDENT HUG-ENGLISH: And then I have an 13 issue with, I mean the way this is described, it's 14 designated as mobile medical technicians to various job 15 sites to provide nonemergency medical services to 16 workers at job sites. That doesn't sound to me like 17 evaluating and triaging out. That sounds to me like 18 treatment of injuries or things that occur on site. 19 And I also have an issue with - I mean a lot 20 of these job sites would be considered SIIS injuries, 21 and how does that interact then with our SIIS providers 22 and the necessity for work-related injuries to go 23 through that system in order to get coverage? I think 24 it really complicates all of that. 25 MR. WADHAMS: I think you're raising an 0022 1 excellent question; the larger the employer, the 2 complex employment sites, you'll see a gravitation 3 towards somebody to help make these decisions before 4 911 is automatically dialed. And that's I think where 5 this is headed. 6 Dr. Homansky sees a need for somebody to 7 assist in either rendering the first aid or, as 8 mentioned in the petition, they may come out to do a 9 drug test. They may be out doing drug testing on 10 employees. But rendering of care is not contemplated 11 in this process. You've got to put a bandage on 12 somebody when you call 911 or send them down to the 13 worker's comp doctor, that could be done. But I think 14 it's clear that they do not intend to do the level that 15 the EMTs on an ambulance company would do. They would 16 be someone separately, if that's the circumstance. 17 MR. LEGARZA: They're going to go out there, 18 look at someone that's injured, they're going to make a 19 determination as to what care this person needs? 20 MR. WADHAMS: If it's an emergency, as Dr. 21 Baepler identified, 911 would have been already called. 22 This is in a routine circumstance. And I think the 23 alternative, the alternative is these major employers 24 will hire such programs to be done by themselves. Is 25 it not better to have that done under the supervision 0023 1 of a physician who has some judgment that can be 2 exercised? 3 MR. LEGARZA: Only if the state of Nevada 4 allows that physician to engage in that activity. In 5 my opinion it doesn't. 6 MEMBER STEWART: Could we divide this into 7 two parts for a second? Injury assessment, can we 8 explain how injury assessment is the practice of 9 medicine, and then first aid; and could we explain how 10 first aid is the practice of medicine? 11 MR. LEGARZA: The opinion says that what 12 they're going to do is once called to a work site or 13 business location under the supervision of a physician, 14 who is Dr. Homansky back at his office, will provide 15 injury assessment and first aid. If necessary, the EMT 16 may coordinate transportation to occupational medical 17 clinics or emergency care facilities. Under no 18 circumstances will the EMT render emergency medical 19 care. 20 It's my opinion that that part of what 21 they've asked the opinion on as to whether or not that 22 can be done by a medical technician, that's -- the only 23 people that I know that can operate under protocols in 24 the state of Nevada under the Medical Practice Act are 25 APNs and PAs, not medical technicians. Medical 0024 1 technicians aren't out there -- 2 MEMBER BAEPLER: In my operation we have 3 laboratories, and accidents can happen. We routinely 4 train people in first aid, CPR, et cetera. You have 5 to. Now, if it's serious, we'll be calling 911. But 6 we're not going to just let the person lie there until 7 somebody shows up. If there's an appropriate first 8 step that our people are trained to do, it might be 9 CPR, might be treating a burn, just the basic common 10 sense things you do and don't do. 11 MS. BIBLE: That would be emergencies. And 12 emergencies, gratuitous service, that's not the 13 practice of medicine. 14 MEMBER BAEPLER: This might come under the 15 same category. 16 MEMBER TITUS: But they're charging for the 17 supervision. This isn't a first responder on accident 18 scene which we are covered for by statute, anybody can 19 practice medicine, go up to the patient and take care 20 of them initially. These people would be called out 21 and then that patient or the company or corporation 22 would be billed for the services of these folks. 23 MEMBER STEWART: My problem is that anybody 24 in the world can perform first aid. 25 MEMBER TITUS: Right. 0025 1 MEMBER STEWART: So I believe the advisory 2 opinion is that first aid is first aid. 3 MEMBER ANJUM: It does not require a 4 license. 5 MEMBER STEWART: That does not require a 6 license. It just doesn't require a supervisory 7 physician. I think this hinges upon what injury 8 assessment is and is defined to be and if that is or is 9 not the practice of medicine. I don't think the Board 10 can say that somebody walking down the street cannot 11 perform first aid. And whether there's a consideration 12 for performing first aid or not, I don't think makes 13 any difference. I don't think we want to go there. 14 If the opinion is that injury assessment 15 requires an EMT acting under protocol, or requires a 16 diagnosis by a physician, then I have no problems. 17 MR. LEGARZA: All this opinion says is that 18 Dr. Homansky is a licensed physician in the state of 19 Nevada, cannot do what you're proposing with your 20 medical technicians. The Medical Practices Act doesn't 21 allow it. 22 PRESIDENT HUG-ENGLISH: In my view, injury 23 assessment would come under the practice of medicine 24 because you are making an assessment and a judgment as 25 to what needs to happen next. And in order to make 0026 1 that judgment -- 2 MEMBER STEWART: I have no problem with 3 that. 4 MEMBER ANJUM: Injury assessment is being 5 taken too lightly. It's not that you have a broken 6 finger or toenail, you can have a head injury, you can 7 have an eye injury, an internal injury. That takes a 8 long time for an experienced physician to assess, 9 whether this is an emergency or not. 10 For somebody that's not trained to make the 11 assessment on the scene and say you can go to the 12 doctor tomorrow, there's nothing wrong with you, I've 13 talked to my doctor, I would be afraid of what he would 14 not send to a clinic or to an emergency room, rather 15 than he would send to a clinic. If he sends 100 16 people, they go home later on, that's fine. But if he 17 misses one internal injury or a head injury or cornea 18 injury, that would be a mistake. And unless that 19 person on the scene who is making that assessment is 20 properly trained for that and they have training for -- 21 do we have a certificate for that? Do we have a 22 license for that? I don't know. 23 MR. WADHAMS: That is precisely the point. 24 And you two gentlemen have framed the problem that's 25 being sought to be addressed here. The university 0027 1 trains somebody, a lab assistant or a graduate student, 2 to do CPR. They might decide that their liability is 3 better covered by having a physician supervise that 4 activity on contract. So you have medical -- somebody 5 who is medically trained that can say to those people 6 here is what you do rather than hoping that the 7 university has somebody there that day, that the 8 graduate assistant knows what he's doing. It's 9 precisely, I think, the problem you identified. 10 It's a legitimate question for this Board. 11 Is it better to allow that service under the right 12 circumstances and the right supervision to be made 13 available to employers who have such exposure, or is it 14 better to leave that to volunteers who might be trained 15 at the CPR class over at the corner, as I was? I would 16 rather have one of you supervise someone doing that to 17 me rather than have me do it to somebody else. I think 18 that's precisely the question. 19 MR. LESSLY: It's not really a question of 20 whether or not it's better. It's a question of whether 21 it's legal or appropriate. 22 MEMBER MONTOYA: If he wants to be legal he 23 can send out a physician's assistant or nurse 24 practitioner, and then everybody is covered. Nobody 25 will have a problem. 0028 1 MR. LEGARZA: Or the Board of Medical 2 Examiners can adopt a regulation to allow it to happen. 3 The law as it is now, I don't think the doctor can 4 engage in the conduct, period. 5 MEMBER BAEPLER: Is it a statute we're 6 dealing with or a policy? 7 MR. LEGARZA: It's a regulation. 8 MEMBER BAEPLER: It's a regulation. 9 MR. LEGARZA: Medical technician is someone 10 who doesn't have to be otherwise licensed. Medical 11 technicians always work under the direct supervision of 12 a physician. This isn't what is being proposed by this 13 physician. He's proposing something that a PA or an 14 APN can do under our law, as I understand it. 15 PRESIDENT HUG-ENGLISH: The other issue is 16 that it does give the appearance of more credibility or 17 more confidence by the way it's stated. But the 18 reality is these people do not have much training, and 19 because it would be presented to that business as this 20 is done under the supervision of a physician, it would 21 appear on the surface to that business that, gee, we're 22 getting a physician's care here when in reality they're 23 not. They're getting a medical technician who has very 24 minimal training, who is not trained in diagnosis or 25 assessment skills at a setting where serious injury or 0029 1 events can occur and being in a position to make 2 judgment calls, and being in a position to talk to a 3 physician on the phone to present that situation in 4 terms that a decision in treatment is made. 5 And in my mind that constitutes the practice 6 of medicine. 7 MR. WADHAMS: At the risk of taking one 8 opportunity too many, I do appreciate your indulgence. 9 I think the Board understands the issue. I think the 10 question was asked: Is there a regulation that 11 prohibits this? There is clearly not a regulation that 12 prohibits this. The statute and regulations say 13 medical assistants may only operate under the 14 supervision of a physician. And that the physician has 15 an obligation to see that they're adequately trained 16 for what he's going to ask them to do. That does not 17 specify that there can be no hallway between that 18 supervision, no adjacent building, nor two miles. It 19 doesn't say that. So the regulation is not clear. 20 The Board is asking to formulate a policy in 21 that regard. I respect your deliberations. And again 22 I think the debate has focused on what the issue is. 23 What is the level of the activity, who is responsible? 24 But I do think that the public policy question is, is 25 it better to make that service that is being performed 0030 1 by volunteers available by contract to those employers 2 who are sufficiently aware of the risk to do so, not to 3 practice medicine, but to make those immediate 4 assessments before medicine is called to answer? That, 5 I think, is the question. 6 I do appreciate you letting me talk as much 7 as you have. Thank you very much. 8 PRESIDENT HUG-ENGLISH: I think the question 9 before us is, we have presented to us an advisory 10 opinion that basically states that it would violate the 11 standards set forth in our current NRS and NAC Chapter 12 630. And I think the Board at this point needs to make 13 a determination whether we're going to accept this 14 advisory opinion so that we can give some feedback to 15 Mr. Homansky. 16 MEMBER MONTOYA: I believe the advisory 17 opinion is right on with what we need to adopt. So it 18 goes along with what our philosophy is and what we're 19 comfortable with. Because I'm not comfortable with 20 cutting medical assistants loose, and God knows as long 21 as they have the phone and say that's the direct 22 supervision -- 23 MEMBER BAEPLER: On the other hand, we 24 always have to be open to new concepts. When the Board 25 adopts a policy, you tend to adopt it in terms of 0031 1 current availability and practice and so on. I don't 2 want to discourage new and good ideas, simply by 3 saying, well, our policy doesn't permit it, you know. 4 So I'm not sure that applies in this instance. And I 5 feel a little bit more comfortable that least people 6 aren't going to be looking for automobile accidents to 7 stop and service. It would be the contractual 8 relationship. It hinges on definitions. And I think 9 the definitions have been clearly defined. 10 MEMBER ANJUM: I think if there's an EMT 11 working under a nonemergency condition, he's already 12 licensed to practice as an EMT and he's making those 13 assessment as a nonemergency and he has the same 14 connection with a physician as he would do in an 15 emergency situation. In only that situation would I 16 think it would look okay. 17 If it's somebody who has some training that 18 we don't know what kind of training it is, it's kind of 19 difficult. But EMT is posted in an area, available for 20 an area, not lights flashing, make some assessment, at 21 least we have the EMT license and we know his degree 22 and level of knowledge and his assessment and he's been 23 certified. A physician supervising in that situation, 24 it would be a little more appropriate. 25 PRESIDENT HUG-ENGLISH: The difference I 0032 1 think, though, is that EMTs are licensed for emergency 2 settings only. And this is a totally different setting 3 that we're now talking about that are nonemergency 4 settings that could grow into -- are we then going to 5 allow EMTs to be in sort of a semi-urgent care on the 6 corner that then can evaluate nonemergent situations 7 under the supervision of a physician by phone? I think 8 this really expands the scope of what an EMT is 9 licensed and trained to do. 10 MEMBER BAEPLER: If the level of training is 11 a concern, I don't even know if this would be a 12 possibility with them, but if a PA was performing this 13 function, would that meet your criteria? 14 PRESIDENT HUG-ENGLISH: Absolutely. 15 MEMBER ANJUM: No problem. Or nurse 16 practitioner. 17 MEMBER BAEPLER: But if a PA was physically 18 there supervising the EMTs, could the EMTs exercise -- 19 MEMBER ANJUM: But if an EMT can work on an 20 emergency situation, it's not that he cannot make an 21 assessment that this is not an emergency. And he's 22 trained to deal with the emergency because he makes an 23 assessment, is this an emergency or it's not an 24 emergency. He's not totally unaware. 25 MR. LEGARZA: He operates under the 0033 1 authority of the Chapter 450 of the statutes. EMTs 2 don't operate under our authority. We have nothing to 3 do with EMTs and how they function and how they 4 operate. The question from this physician is: Can I 5 as a physician send out medical technicians to do this 6 procedure, or these procedures, whatever they may be? 7 The question is: Is it the practice of medicine? 8 Opinion: Yes; can't do it. 9 An EMT, they say in their letter that they 10 probably will use EMTs to do this kind of stuff who are 11 highly qualified people. Chapter 450B allows EMTs to 12 do certain things under their licensing, their 13 supervision and their disciplinary proceedings. We're 14 talking about what you can do under Chapter 630, not 15 450B. All you can do under Chapter 630, as I 16 understand it at least, is practice medicine as a 17 physician. Or if you want to practice under a 18 protocol, you practice as a PA or APN under a protocol 19 of a physician. Period. You don't go out as an EMT or 20 a medical technician or anybody else and do at least 21 what part of this is proposing. 22 I didn't address the other stuff they say 23 they're going to do because I don't think it's within 24 our jurisdiction. Is it the practice of medicine? 25 Yes. Is it being done by medical technicians? Yes. 0034 1 No doctor: You can't get into that business. 2 MEMBER MONTOYA: Almost like health 3 maintenance, trying to maintain on the job site. 4 MR. LEGARZA: The practicalities are 5 probably that they're going to offer this service at 6 less cost than the ambulance. Probably going to offer 7 this service at less cost than it would cost them to 8 send out a PA or APN. 9 MEMBER LUBRITZ: Are you looking for a 10 motion? 11 PRESIDENT HUG-ENGLISH: Yes. 12 MEMBER LUBRITZ: I propose that we accept 13 the advisory opinion as stated. 14 MEMBER MONTOYA: I second. 15 PRESIDENT HUG-ENGLISH: There's a motion and 16 a second. 17 MEMBER STEWART: Can I amend your motion to 18 eliminate the words "first aid" and let the opinion 19 stand upon itself that the assessment is practice of 20 medicine on the basis that I don't believe that we 21 should be legislating first aid? I believe we should 22 be talking about assessment. 23 MEMBER LUBRITZ: Sure. 24 MEMBER BAEPLER: However, you're saying in 25 effect that functioning to perform first aid is all 0035 1 right. 2 MR. LEGARZA: Under the auspices of a 3 physician? As a medical technician? 4 MEMBER STEWART: No, sir. Where I'm coming 5 from is you've said that Dr. Homansky can't do this 6 because, underlined, injury assessment and first aid. 7 MR. LEGARZA: Where is that underlined? 8 MEMBER STEWART: Paragraph two, last 9 sentence. 10 MEMBER TITUS: Just a statement what they 11 say. 12 MR. LEGARZA: That's what they say. 13 MEMBER TITUS: He's just quoting theirs. 14 MEMBER STEWART: I'm very sensitive to the 15 issue that first aid is given by anybody who is there. 16 And that is not the practice of medicine, counselor. 17 MR. LEGARZA: These people are going to be 18 sent out there by this organization to do injury 19 assessment, and after they make that injury assessment 20 these people are going to conduct that first aid, as I 21 understand what they're saying they're going to do. 22 MEMBER STEWART: It is my opinion that 23 anybody can conduct first aid. It is my opinion that 24 only doctors or PAs or nurse practitioners can conduct 25 injury assessment. And I would like to draw the 0036 1 distinction so that we're not on record saying that 2 M.D.s, PAs and nurse practitioners are the only ones -- 3 MEMBER BAEPLER: How do you define injury 4 assessment? If I see a guy that has a cut and I say 5 that's going to take a larger Band-Aid, that's an 6 injury assessment, you know, in one context. 7 MEMBER STEWART: But if you've gone to a 8 first aid course given by the Red Cross or the Boy or 9 Girl Scouts, they do different things, Don. 10 MEMBER LUBRITZ: I'm going to retract what 11 I said, will I accept it. And the reason that I won't 12 accept it is just because what they're saying, then 13 we'll be getting someone is a coming up saying, gee, 14 can I send someone out to do first aid? So I think we 15 should leave it as it stands. 16 MEMBER ANJUM: Plus, it does not require 17 any -- anybody can do first aid and CPR on the site. 18 You do it right or wrong, you're not legally liable. 19 But if you make an assessment this is an injury or a 20 Band-Aid and you have a license for that and you are 21 under the supervision, then you become liable, too. 22 If you're just walking on the side road and 23 say this is not bad -- 24 MEMBER STEWART: I'm concerned with the 25 words "first aid". 0037 1 MR. LEGARZA: Look over in the second page 2 of what I say, at least what I understand. 3 "What Dr. Homansky proposes," the third 4 paragraph from the bottom, "is that as medical 5 director of Mobilehealth Care Program of 6 American Medical Response, he," being Dr. 7 Homansky, "will send medical assistants 8 designated as mobile medical technicians to 9 various job sites to provide nonemergency 10 medical services in the field to workers at 11 various job sites performing under written 12 protocols adopted by Dr. Homansky without his 13 personal presence in each and every instance, if 14 at all. 15 Therefore, you are advised it would be our 16 advice that what Dr. Homansky proposes 17 constitutes the practice of medicine by 18 unlicensed individuals and," in answer to your 19 question, "would violate the standards set forth 20 in the Medical Practices Act." 21 MEMBER BAEPLER: Nonemergency procedures is 22 not first aid. 23 MR. LEGARZA: They ask a lot of questions. 24 They ask them a lot of different ways, a lot of 25 different things they want to do. But what they want 0038 1 to do is send out guys in a mobile health care vehicle 2 or van or something. 3 MEMBER ANJUM: Nonemergency medical service 4 is the right word and that's the practice of medicine. 5 MEMBER TITUS: I think we have a motion and 6 we have a second. 7 MS. BIBLE: If I can clarify. When we were 8 talking about emergency and first aid, and there's a 9 specific statutory provision that addresses that, under 10 NRS 630.047(3)(a), this chapter, 630 of the Medical 11 Practices Act, does not prohibit gratuitous service 12 outside of a medical school or medical facility by a 13 person who is not a physician, a physician assistant or 14 practitioner of respiratory care in cases of emergency. 15 So you even have a section in here that 16 takes out those kinds of cases of first aid by people 17 at the university. And it relates to the fact that 18 it's gratuitous services in an emergency. You're not 19 going to say that those people need a license to do 20 that kind of thing. 21 PRESIDENT HUG-ENGLISH: Okay. There is a 22 motion and a second. 23 Is there any further discussion? 24 All in favor? Opposed? 25 Chair votes in favor of the motion and the 0039 1 motion carries. 2 (Whereupon a motion was made, seconded, and 3 passed unanimously.) 4 5 6. LEGAL REPORTS 6 7 PRESIDENT HUG-ENGLISH: That brings us to 8 our legal reports. Dick, you can start us off. 9 MR. LEGARZA: I don't have anything much. 10 Everybody seems to be in compliance. What I do want to 11 do is I do want to hand out to everyone a copy of the 12 financial disclosure statement to remind all of you 13 it's due April 1st. 14 MEMBER BAEPLER: April Fool's Day. 15 PRESIDENT HUG-ENGLISH: May I emphasize that 16 they really do stick to those deadlines? 17 MR. LEGARZA: And they try to get nasty with 18 people that don't file them on time. 19 MEMBER JONES: I might also remind you, you 20 have to do both annual 3-31 and appointment, or they'll 21 send it back to you saying you have to do that. So be 22 sure you -- on that first line, public office, term of 23 date appointed. Do both Annual 3-31 and it says new 24 appointment. You have to do -- maybe they changed it. 25 Because we had to do -- because I got mine sent back 0040 1 and so did Cheryl. 2 MEMBER BAEPLER: Office is just a member on 3 this Board. And then the item or date appointed, 4 that's your original appointment date? 5 MEMBER JONES: Annual 3-31, I think they 6 took it off. They put new above it. So it's okay. 7 You just have to do the -- 8 MEMBER BAEPLER: Which box do we check? 9 MEMBER JONES: The annual 3-31. Right? 10 MR. LEGARZA: I don't know what you check. 11 I just know that they get real mad when you don't get 12 it in. 13 MEMBER JONES: See where they put new above 14 appointment? Before it was just appointment and you 15 had to do both of those. 16 MEMBER BAEPLER: I see what you're saying. 17 MEMBER JONES: But now they've put new 18 appointment. 19 MEMBER BAEPLER: If it's not your first 20 year, then it would be new. But then it would be 21 annual. It's an annual report, not an annual 22 appointment. 23 PRESIDENT HUG-ENGLISH: Right. And they 24 used to send these to us in the mail so we would get 25 them as a reminder, but now they don't. And I found 0041 1 out the hard way last year, the fact that they went to 2 this web site instead of sending it in the mail, we 3 really do need to be -- and I appreciate, Dick, you 4 copying this for us as a reminder, because it is 5 difficult to remember unless you get something in the 6 mail or a reminder to do it. 7 MEMBER BAEPLER: Who do we send it to? 8 PRESIDENT HUG-ENGLISH: You can either do it 9 on the web site. But if not, it goes to the Nevada 10 Commission on Ethics. 11 MEMBER JONES: You can't do it on the web 12 site because you have to sign it. 13 PRESIDENT HUG-ENGLISH: That's right. 14 MEMBER TITUS: Fill out the form on the web 15 site and then print it and sign it. 16 MEMBER BAEPLER: Nevada Commission on 17 Ethics. 18 PRESIDENT HUG-ENGLISH: It gives the 19 address. 20 MEMBER TITUS: There's a little funky 21 building in Carson City, because I dropped mine off 22 personally last year. It's not that easy to find. 23 MS. LYONS: April 1st, 4:49 p.m. 24 MEMBER TITUS: The door was open. People 25 were filing in. 0042 1 MR. LEGARZA: You see all the publicity they 2 got on it this year, all the assessments they made and 3 they compromised a lot of the assessments. Of course 4 in the paper they were talking about Polaha, as his 5 being compromised from 14,000 to 5,000. Some citizens 6 are griping about that. I think there's a legitimate 7 legal argument that you guys may not have to do this, 8 but the best legal advice is do it and get it in on 9 time. 10 They used to send them out all the time. 11 They're not doing it anymore, even though the law 12 requires them to do it. That was part of an argument 13 that we made to them in a case. But get it in before 14 April the 1st. They're not going to be as charitable 15 next year. 16 PRESIDENT HUG-ENGLISH: Okay. Thank you. 17 Charlotte. 18 MS. BIBLE: I think the last time I was 19 here we had a motion to dismiss pending in the Dr. 20 Millgram petition for administrative review. It was 21 granted. That petition was dismissed. 22 I have no outstanding petitions for judicial 23 review. 24 PRESIDENT HUG-ENGLISH: Great. That's it? 25 MS. BIBLE: That's all I have. 0043 1 PRESIDENT HUG-ENGLISH: Is Carol Bowers 2 here? 3 MR. LESSLY: Vic is here. 4 5 6 7. REPORTS 7 8 PRESIDENT HUG-ENGLISH: Okay. Agenda Item 9 7, we'll go to some of our reports and we'll hear Chris 10 from our diversion program. 11 MEMBER BAEPLER: We got a handout on that. 12 UNIDENTIFIED SPEAKER: Carol is not here. 13 She's been quite ill since right after Christmas. She 14 had some surgery related to her large weight loss, 15 which was 125 pounds. She had a lot of tissue taken 16 out. She had a pulmonary embolus afterwards. So she 17 was quite sick for about a month. And then she had 18 some existence of a scar and infection and last week 19 they opened her up and cleaned that all out, and she's 20 not flying up here today. She wanted to, but I thought 21 that was just ridiculous. 22 I do have her report. And I can go over 23 that. I think everybody has it. The initial part of 24 it just talks a little bit about some of the general 25 things. I will tell you that I've given about a talk a 0044 1 week nowadays in Las Vegas, at one hospital or 2 organization or another. There's several on here that 3 haven't been listed. 4 But Larry and I also spoke at the medical 5 school. Was it early this month? Or February. We did 6 our good guy/bad guy routine. I was the good guy. I'm 7 a good guy at the medical school. Sure. He's a 8 lawyer. 9 But actually that went really well. I think 10 that's our tenth year, maybe. 11 MR. LESSLY: At least. 12 UNIDENTIFIED SPEAKER: That's for the second 13 year medical students. I also met with the, I'd like 14 to say the Board of Sociopathy, but it's not that. 15 It's the Social Workers Board. And they're interested 16 in forming a diversion program, I think. I don't know 17 if that will ever get off the ground. They don't have 18 a lot of funding. 19 Going to the numbers here. I was somewhat 20 taken aback by the number 85, because we never had that 21 many people before. Although we've had, as everyone 22 knows, an awful lot of respiratory therapists join our 23 program. Specifically we have 13 under long-term 24 contract who go to groups. And we have six who are 25 under a short-term contract. So these six will be done 0045 1 in six months, assuming that they pass all their urine 2 tests. Otherwise they might join us for more time, or 3 go to treatment. 4 The numbers also are a little bit misleading 5 because there are three new applicants who are included 6 who are not licensed yet but they have signed up with 7 us. There are four M.D.s who are unlicensed who are 8 included in those numbers. And there's one PA who is 9 unlicensed in that number. 10 There are also about eight or nine 11 physicians who are going to finish five-year contracts 12 with us in the next six months. So we're going to have 13 some numbers change pretty dramatically here. 14 Other than that, I think we're doing pretty 15 well with -- we're pretty much keeping up with things. 16 We have more people, more physicians in Las Vegas under 17 contract at this time than we do in Reno, which I think 18 it's the first time we've ever had that. We had 25 in 19 Las Vegas and we have 24 in Reno. 20 MEMBER BAEPLER: I'm concerned about the 21 scale of the -- now you start off and you don't have 22 enough people to reach an economy of scale. You keep 23 adding and adding. This is great news. I think the 24 need is there. But you also reach a plateau where you 25 have enough now where you've reached an economy of 0046 1 scale. When you get much bigger, you suddenly have to 2 add staff and then you dig yourself a hole again. Are 3 we close to maxing out without adding staff? 4 Could you take another 20 or 30 without 5 adding staff? 6 UNIDENTIFIED SPEAKER: I think we could. 7 Yeah. I do. Simply because we're going to lose a few 8 here. But I think if we got another giant, I don't 9 know if we could handle another influx like we just had 10 with the respiratory therapists or not. That might do 11 it. We still have an awful lot of volunteer work, 12 basically, is what happens. We really only have one 13 employee. We do have someone who handles our 14 accounting for us. So we pay for that as an outside 15 service. 16 But we're stretched pretty thin, and I 17 really think that overall we're not doing very well in 18 terms of the service that we provide in the north right 19 now. I really don't. I think we're just not here. 20 And we've had some discussions about that. And I've 21 asked that some changes be made in that regard. 22 But I really think that it's always been 23 okay. Everything is fine in the north. If you're not 24 paying attention to it, you're not here, it's not going 25 to remain that way. So I think we're pushing it a 0047 1 little bit. 2 And I've asked Carol to spend more time up 3 here, basically. The other thing we'll have to do is 4 get an office. She still does a lot of this stuff in 5 her house. I'm not really comfortable with having 6 records in her house anymore. She has a boyfriend 7 there. They may end up married pretty quick, but I 8 just don't think we can do that anymore. We have to 9 have an office. 10 PRESIDENT HUG-ENGLISH: Vic, when you say 11 she's doing a lot of this at her house, is she meeting 12 with people at her house and having them do urines at 13 her house and that kind of thing? 14 UNIDENTIFIED SPEAKER: No. It's done at my 15 office, anything like that. The meetings are all at my 16 office. Any time we meet with physicians or physician 17 assistants, it's at my office. We had a situation 18 where they came up here and had the people meet at the 19 Airport Plaza, which was out of the question. And 20 we've had those discussions. And that's not going to 21 happen anymore. 22 MEMBER ANJUM: Why would she take medical 23 records home then? 24 UNIDENTIFIED SPEAKER: We never had an 25 office before. So the records on these people were 0048 1 always kept at the executive director's house. And we 2 never had a separate office. We really couldn't afford 3 a separate office. And Carol was a single person and 4 that seemed to be reasonable at that time. I just 5 don't know that it is anymore. I think these records 6 are -- people are very, very concerned about the 7 confidential nature of these records. And we just have 8 to take it out of there. I just can't see it 9 continuing. But she doesn't meet with people in her 10 house, not at all. 11 What happened over at the Airport Plaza is 12 not going to happen again. 13 PRESIDENT HUG-ENGLISH: How often does she 14 meet with people that are under contract, or you or 15 Carol or somebody, how often are these people 16 evaluated? 17 UNIDENTIFIED SPEAKER: We have different 18 ways of doing that. And Carol does not meet with all 19 these people every month. I've asked her to, at a 20 minimum, and certainly in the north, to talk to every 21 person at least every two weeks. But it hasn't 22 happened. We rely on other physicians up here in terms 23 of observing other people. We rely on Dr. Caughlin and 24 Dr. Belcourt, Dr. Herz. And we meet monthly up here to 25 talk about how people are doing up here. So we have to 0049 1 rely on other volunteers to do that. 2 PRESIDENT HUG-ENGLISH: How about in Vegas, 3 how often? 4 UNIDENTIFIED SPEAKER: In Vegas we see them 5 pretty much all the time. I'll see them or Carol will 6 see them every month. We also have somebody that goes 7 and gets urines on them who sees them, of course. We 8 require certain things, especially newcomers, they have 9 to come to a meeting at my office that's every Tuesday. 10 So there's 12 or 13 of those people under contract that 11 we're seeing every week in a smaller group. Then we 12 have a meeting on Thursdays. And under contract, 13 they're required to be there. 14 I'm almost -- if I'm in town, I'm there. If 15 Carol is in town, she's there. The exception being if 16 one of us is up here. But we don't see everybody up 17 here on a regular basis. And I think we should. 18 Personally, I just think we should. The people pay 19 $200 a month. I think they deserve more service than 20 that. 21 MEMBER ANJUM: That was his question: Do 22 you need more help? 23 UNIDENTIFIED SPEAKER: I really think it can 24 be done. That's what I've asked to happen. I think -- 25 Larry and I talked about maybe even using an office 0050 1 down the hall here, because that's been a little bit 2 touchy: Do you want them to come to the Board? Because 3 we have a separation from the Board. But we're talking 4 about that. I just really think she needs to see the 5 people on a monthly basis face to face. 6 MEMBER BAEPLER: Since you keep their 7 identity confidential to the members of this Board, you 8 almost can't have them walking in and out of an office 9 on this floor. 10 MR. LESSLY: Sure you could. You guys are 11 never here. 12 MEMBER BAEPLER: That's true. I'd have to 13 think through the impact of that. 14 MEMBER MONTOYA: You generally hold the 15 meetings after office hours, so there really isn't 16 anyone here. 17 UNIDENTIFIED SPEAKER: If she came up here, 18 spent a week up here in Reno and used an office here, 19 then she would be seeing people in the daytime, too. 20 So I don't know that that's -- 21 PRESIDENT HUG-ENGLISH: Another thought 22 would be if you have connections with Dr. Caughlin and 23 Belcourt, so forth, there may be availability through 24 them through one of their offices where -- 25 UNIDENTIFIED SPEAKER: It's a possibility. 0051 1 That's what we do in Las Vegas, certainly. 2 PRESIDENT HUG-ENGLISH: So it feels like it 3 would be awkward to be here. There may be some other 4 options. But I certainly think that's better than the 5 Airport Plaza. 6 UNIDENTIFIED SPEAKER: Oh, yeah. That's a 7 good suggestion. I'm not sure who to approach. But we 8 have enough people on our diversion committee, we'll 9 find someone who would be willing to do that. But 10 because of the nature of it, you can't fly up every 11 day. You have to come up here for a week and do it 12 that way. So we'll see. I have to work on that. I 13 think we need to have much more of a presence here. 14 I've also asked that all the hospitals that 15 donate money to us, like Ely and Elko, we need to be in 16 those places. Maybe not every year, but we need to 17 give a talk at least every other year. 18 We are solvent moneywise. And we're 19 basically hanging in there with that. When we start 20 doing some of these things like offices and having her 21 up here a little bit more, obviously that will take 22 some more money. But we have managed to stay afloat 23 that way. 24 MEMBER STEWART: Do you think your relapse 25 rate is standard? As you read through and look at each 0052 1 one, you have a percentage of relapses that you have 2 sent back for more and more. 3 UNIDENTIFIED SPEAKER: Sure. I don't know 4 if we're standard for, say, the average across the 5 country in terms of that number. We probably are about 6 the same. We might be -- we may be a little higher 7 simply because we tend to get -- and I think a lot of 8 times we've had some people who have contacted us from 9 other states that we've advised them not to bother 10 coming here because they have no monetary recovery. 11 And they really don't. They're coming from other 12 places that they have recovery. It's hard to believe 13 that someone hasn't had a urine in a year. I don't 14 think that's going to fly here. So we may catch them a 15 little bit more. We might report them a little higher. 16 I do know our overall success rate is 90 17 percent. That's pretty good. And our overall death 18 rate is 10. We don't have anybody in between. Well, 19 we have one doctor from Fallon who doesn't practice 20 medicine anymore. The rest of them are dead. 21 PRESIDENT HUG-ENGLISH: I was clarifying, if 22 that's what you said. The death rate is 10 percent? 23 UNIDENTIFIED SPEAKER: We have one guy who 24 doesn't practice medicine anymore who has failed our 25 program. All the rest of them are dead. Anybody else 0053 1 that we've had who did not, was not successful in 2 recovery, they're all dead. 3 PRESIDENT HUG-ENGLISH: That's a pretty 4 frightening statistic. 5 UNIDENTIFIED SPEAKER: It is. But we have a 6 doctor from Fallon who is reapplying here. He's still 7 alive. 8 I think overall we're doing pretty well. We 9 haven't had a meeting of our foundation since the 10 summer. Part of that is because of Carol's health 11 recently. We're scheduled to have one in April. 12 Arnie is going to be a member of our board, 13 but he's not been there yet. And some of that is he's 14 been traveling an awful lot. We're trying to arrange a 15 time when he can be there. But we expect him to be a 16 very good member on the health foundation board. 17 MEMBER BAEPLER: Fred Kirschner still with 18 you? 19 UNIDENTIFIED SPEAKER: Yes. We looked at 20 some things to try to raise some money with Fred. We 21 were looking at sort of an approach of evaluating 22 doctors somewhat like we might function as the employee 23 aide group or what do you call that? 24 PRESIDENT HUG-ENGLISH: The assistance 25 program? 0054 1 UNIDENTIFIED SPEAKER: Something like that. 2 He started to look in that direction with ideas we 3 didn't have certain things, but we do have a lot of 4 those things already done. Mission statements. We had 5 to do that to have nonprofit status. So that kind of 6 dwindled. We didn't go anywhere with it. But that was 7 in terms of grants. 8 MEMBER BAEPLER: It's all on my desk. 9 UNIDENTIFIED SPEAKER: That was one of the 10 reasons why Fred was really there, was to look at ways 11 of raising money. 12 MEMBER BAEPLER: It's all on my desk waiting 13 for Fred to get back, to sort through it to see where 14 we can find the money. 15 UNIDENTIFIED SPEAKER: We'll have the 16 meeting in April. We'll go over that. 17 MEMBER BAEPLER: I'm sure Fred will go over 18 it with me. 19 PRESIDENT HUG-ENGLISH: Thanks, Vic. Any 20 other questions? 21 Thanks for coming up. 22 From our physician advisory committee. 23 MS. LYONS: They've requested that agenda 24 item be postponed until at least 5:45 because he's 25 flying in from San Jose. 0055 1 PRESIDENT HUG-ENGLISH: All right. Just 2 remind me to come back to it. 3 From our practitioner of respiratory care. 4 UNIDENTIFIED SPEAKER: I had hoped to have a 5 letter from the Nevada Society for Respiratory Care 6 which was submitted to myself and my two associates on 7 the advisory committee. 8 Unfortunately, it's in the mail and it 9 didn't make it, apparently, this morning. But as 10 you'll find, you'll each be receiving a letter from our 11 professional society thanking the Board and, in 12 particular, the licensing administrative staff in the 13 gargantuan task of getting 630 some odd respiratory 14 therapists licensed in 1998. 15 MR. LESSLY: 662. 16 MR. WADHAMS: That's interesting, because I 17 remember when the counselor and I first talked about 18 this project, we predicted around 700 practitioners. 19 Even though there was no way of knowing in this state. 20 We do know of about 50 that for one reason or another 21 elected not to go for licensure here and left the 22 state. And that puts us at just about the 700 that we 23 appreciated. 24 I hear the statistics on the diversion 25 committee, and, frankly, that is not as bad as I 0056 1 anticipated. Maybe it's the pessimistic side of my 2 nature. There's the other 50, very possibly. At the 3 same board meeting of the Nevada Society that I 4 attended, we heard some very complimentary reports on 5 how our practitioners were handled in the diversion 6 committee down south. At the same time we did have 7 some very disgruntled individuals in our northern 8 community. And apparently you all are aware. So I 9 will not belabor the point. 10 MEMBER BAEPLER: Used to be the reverse. 11 UNIDENTIFIED SPEAKER: This is a good thing, 12 because it tells me something about this Board. 13 Because, frankly, I thought I was going to have the job 14 of coming and saying the good news is we have 650 15 practitioners out there that were amazed at this 16 Board's ability to get them licensed. The bad news is 17 we have a few up north that felt they were treated less 18 than professionally when they entered the diversion 19 program. 20 As long as you're aware of that, I will end 21 my report. And please look for the letter. It's 22 addressed to the good doctor. But there are copies 23 going to everybody on the Board, and I believe the 24 majority of the practitioners in this state meant the 25 words you'll see in that letter. 0057 1 PRESIDENT HUG-ENGLISH: Thank you very much. 2 Just for clarification, I think that what's 3 been referred to, Vic commented a little bit about the 4 last time when Carol was up, and I think probably 5 because of the time pressure to get everybody done in a 6 short period of time and evaluated in a short period of 7 time, it was done at the Airport Plaza. None of us 8 were aware that was happening until I received a letter 9 from one of those disgruntled respiratory therapists. 10 And we had talked about that, and it really isn't an 11 appropriate place to carry out those evaluations. So 12 that won't happen again. That's why we're looking for 13 another office or place to do it. 14 But I think that's at least the only thing 15 that I know about that people were upset about. 16 UNIDENTIFIED SPEAKER: That was it. 17 Frankly, there were a bunch of people at the meeting 18 that were very impressed with the way they were 19 handled. They felt it was sensitive, professional and 20 appropriate, where you apparently have a physician's 21 office or somewhere where they do the testing. That's 22 what they expected. That's how they were handled. 23 PRESIDENT HUG-ENGLISH: You can give that 24 feedback, that we have taken that into account and we 25 will make sure that the situation is -- 0058 1 MEMBER BAEPLER: What's the Airport Plaza? 2 PRESIDENT HUG-ENGLISH: The hotel where you 3 guys stay. In the lobby. 4 MEMBER BAEPLER: Right. 5 PRESIDENT HUG-ENGLISH: Where you used to 6 stay. 7 Anybody have any further questions on 8 respiratory care issues? 9 If not, we'll go on to the investigative 10 committee report. 11 MR. LEGARZA: It's not ready. 12 PRESIDENT HUG-ENGLISH: Want to do the 13 secretary/treasurer report tomorrow, too? 14 MR. LESSLY: We can do that tonight. 15 MR. FRANTZ: I have everything here to pass 16 out. 17 MEMBER LUBRITZ: Just to let you know, we 18 did a lot. 19 PRESIDENT HUG-ENGLISH: You've been very 20 busy. 21 MR. FRANTZ: To be honest, there hasn't been 22 much to report on. Hasn't been much change. The only 23 thing we've done in the last month or two is that we 24 haven't done any investing. The interest rate in CDs 25 has been so low, we've held back and let the money roll 0059 1 back into the money market account. However, I talked 2 to Joel and I talked to Larry about it. We did go out 3 and bought a Fannie Mae note for $500,000, which will 4 mature here in a year from now. The purchase will be 5 done on March the 20th. It pays 2.41 percent, which is 6 terrible, but it's better than what we're getting in 7 the money market account. Of course now we see the 8 stock market starting to improve as of yesterday. So 9 the interest rates may be driven up a little bit more 10 here as the shortage in funds become available for 11 investing by banks. We'll wait and see here. 12 But we don't have much going on. And out 13 there in the future it's not locked up for a long 14 period of time. And there isn't anything spectacular 15 on the financial report. 16 I'll just point out a couple things to you 17 here. If you go to the last page, just to let you 18 know, that we have in our budget right now $125,000 for 19 computer and equipment here. And we've used $23,000 of 20 that. At the same time, under equipment, we've got 21 $20,000 budgeted. We've used 17,000 of that for buying 22 some new equipment, furniture for the office as we've 23 added staff. So that's used up those funds. And 24 that's basically it. It's pretty basic. Not anything 25 spectacular. 0060 1 We're about two-thirds of the way through 2 the fiscal year. We're doing about 130, $140,000 a 3 month. 4 PRESIDENT HUG-ENGLISH: Thank you. 5 MEMBER LUBRITZ: Is that what it has run, 6 reasonably, in the past? 7 MR. FRANTZ: Somewhere around that figure. 8 I projected about 150,000 a month in expenses. We had 9 an expense come through for our maintenance contract on 10 our computer software for our licensing files. I 11 forget about it. And it comes through and it's $20,000 12 for a one-year maintenance contract on it. It's 13 something we can't go without because Maureen is on the 14 phone with them all the time. I think it's money well 15 spent. 16 PRESIDENT HUG-ENGLISH: Any further 17 questions? 18 MEMBER STEWART: Of the $135,000 shortfall 19 in interest, how much does that really translate on 20 June 30th? Are you going to be $100,000 down? 21 MR. FRANTZ: No, it won't be 100,000. We've 22 got a $500,000, I think it's either a Federal Home Loan 23 Bank certificate out there. It gets paid on a 24 quarterly basis or semiannual basis. It will be about 25 14, $15,000. If anything, we're probably going to 0061 1 be -- I'm afraid to say because rates are so terrible. 2 I would say we'll probably be -- we'll be about 80, 3 90,000 short. 4 MEMBER STEWART: In regard to the 5 registration fees and the application fees, is that 6 just because it's gotten -- are there less than you 7 expected? 8 MR. FRANTZ: You do a projection, it's hard 9 to come up with. 10 MEMBER STEWART: I'm not complaining. 11 MR. FRANTZ: You throw it out there. I was 12 talking to Larry this morning. In the last two months 13 or probably the last three or four weeks I've seen an 14 increase in M.D. license requests coming through. I 15 don't know if there's a reason why, that we were going 16 through licensing the respiratory care individuals and 17 we just didn't have the time to focus on that or what 18 it was. I don't know. But I certainly see an increase 19 in that. We're starting to do maybe ten a week M.D. 20 wise. 21 MEMBER TITUS: There was a lot of debate on 22 the cost or initial licensure fee for respiratory 23 therapists on what we were charging these folks. Have 24 we now had time or will it take a while to pencil in 25 how much it really cost to get these guys licensed 0062 1 and -- 2 MR. LESSLY: It's not a question of how much 3 it cost to get them licensed, it's a question of what 4 the cost is to regulate them. We won't know that for a 5 while. We've not had a disciplinary action against a 6 respiratory therapist. That's a major factor in the 7 expense in regulating a profession, what's the 8 disciplinary rate. We assume it's going to be low. If 9 it is -- 10 UNIDENTIFIED SPEAKER: We pray it's going to 11 be low. 12 MR. LESSLY: If Mr. Legarza ends up 13 prosecuting 25 respiratory therapists this biennium, 14 we'll have to adjust based on that. I don't think that 15 will happen. The answer is we don't have track records 16 sufficient for that yet. 17 PRESIDENT HUG-ENGLISH: Thanks again. 18 Legislative issues. That's me. Although 19 it's not a legislative year, and we thought that we 20 finished with that last summer, we haven't. And Larry 21 and I have made several trips down to Carson to the 22 Legislature over a couple of different issues. The 23 first one that came up was medical errors, and there's 24 a committee in the Legislature that is looking at the 25 issue of medical errors, trying to decide what 0063 1 constitutes a medical error, trying to sort out who is 2 responsible for determining what actions are taken for 3 identifying and reporting medical errors and so forth. 4 I wrote something on the Board's behalf that 5 basically summarized what this Board does and the 6 jurisdiction that we have. And then we went down and 7 listened to quite a lengthy discussion about medical 8 errors that really focus more on the nursing issue in 9 hospital settings and became sort of a focus of the 10 nursing shortage and some of the errors that were 11 occurring as a result of too little staff in difficult 12 situations. 13 The bottom line is that I don't think that 14 there are going to be any recommendations from this 15 committee that will impact this Board or suggest that 16 we do things differently than the way we do. I think 17 they were very happy with the way that this Board 18 follows up on complaints and the way we handle 19 investigations and so forth. 20 But it's an interesting process. There are 21 a lot of unknowns. It's certainly an issue that's a 22 hot topic nationally as well as now on our state level. 23 And they have indicated, I think in April, that they're 24 going to have an opinion rendered from this committee. 25 So we'll have some follow-up on that in June. 0064 1 The second issue we were called down for is 2 there's also a task force on suicide prevention. And 3 they asked us to appear. And I again went down and 4 spoke on the Board's behalf on this issue. There has 5 been a proposal or at least a consideration by this 6 committee from the standpoint that they may be looking 7 at increasing or adding a CME requirement for 8 additional hours on suicide prevention. And so I spoke 9 about that as it relates to the fact, as you all know, 10 that we've had numerous requests on specific topics 11 like domestic violence and child abuse issues and 12 various other topics, that it becomes very difficult to 13 mandate CMEs in each of these categories. 14 And basically that was my message, that this 15 is an important topic, that we need to pay attention to 16 it and, yes, we probably need to get more educational 17 information out to physicians, but this isn't the way, 18 this is not the way to do it, to mandate additional CME 19 hours. And there are a couple of studies going on, 20 actually through Dr. Files (phonetic) in surgery with 21 the School of Medicine and someone with the Department 22 of Psychiatry that are actually doing studies on ways 23 to prevent suicide. 24 What really isn't clear up to this point is 25 whether contact with the physician actually prevents 0065 1 suicide. 2 So, again, I don't look to the results of 3 this committee as changing anything. I think they 4 listened and they certainly received our input, which 5 was also, I think, pretty much said from the other, the 6 DO board was also there making similar comments. 7 So those are kind of the issues that are 8 ongoing. There really is no resolution. They're in 9 committee stages right now, but it's managed to take up 10 a few trips down to Carson. 11 Does anybody have any questions about any of 12 those? 13 MEMBER STEWART: What would happen if we 14 used the newsletter for somebody to write, an 15 appropriate person to write, not one of us, but an 16 appropriate person, a psychiatrist, a domestic abuse 17 counselor, et cetera, et cetera, an ethicist, who might 18 write a two, three-page discussion about the topic 19 that we could show that we are trying to educate the 20 physicians in this state about these important issues? 21 PRESIDENT HUG-ENGLISH: I think it's a good 22 suggestion, and it's one I made in my presentation. 23 MEMBER STEWART: Then I'll be quiet. 24 PRESIDENT HUG-ENGLISH: No. I think it's a 25 very good forum to present information in a way that 0066 1 makes it accessible but is not mandatory and that 2 provides good information. 3 In addition, I think another format that 4 could be used is to create a monograph, have someone 5 like that hired to create a monograph that's 6 distributed to the physicians statewide that maybe even 7 would encompass CME credit hours voluntarily, if it's 8 completed and sent back in or something like that. So 9 that there are a lot of ways to get to the same end 10 without, again, requiring more CME credits. 11 MR. LESSLY: You folks don't hear about all 12 the comments, but we get numerous requests from special 13 interest groups -- I'll use that descriptive term, for 14 lack of a better term -- wanting us to require 15 continuing medical education in their field. Elder, 16 abuse of the elderly, spousal abuse. And everyone has 17 got an agenda item they want continuing medical 18 education to be required in. 19 Years ago we convinced the Legislature: Let 20 us handle that. That's changed in a lot of states. A 21 lot of states do have mandatory CME. I just trust that 22 we don't get to that point. 23 MEMBER BAEPLER: One has to be very careful, 24 too, of statistics in this case. When we talk about 25 murders per hundred thousand or whatever. 0067 1 MR. LESSLY: Tobacco use. 2 MEMBER BAEPLER: Total alcohol consumption 3 per individual in the state. Most of the time these 4 figures reflect the total population of the state of 5 Nevada, which is, what, a little over two million now, 6 and the more than 40 million tourists slumped together. 7 And it's hard sometimes to break out the statistics as 8 to Nevada residents, excluding tourists or including 9 tourists. And unfortunately it can make the residents 10 look pretty bad on occasion when you divide the total 11 number of such episodes into the resident population 12 only. 13 And the suicide rate in Nevada is very, very 14 high. But I don't really know if anyone has ever 15 broken out how many of the suicides are from the 40 16 million plus people vis-a-vis the two million or so 17 that live here. I've never seen those figures. 18 PRESIDENT HUG-ENGLISH: That's a good point. 19 Actually, that's some of the things that Dr. Files' 20 study is actually looking at as well. 21 And I think that it's certainly an important 22 issue and one that's, I think, good to generate 23 discussion on. But I don't think that's the 24 appropriate way to resolve it. I want to thank Larry 25 for coming with me to Carson on several visits. 0068 1 MR. LESSLY: We turned around once. 2 PRESIDENT HUG-ENGLISH: Once in the middle 3 of a snowstorm, we didn't make it through Washoe 4 Valley. 5 MR. LEGARZA: I want to thank Larry for 6 going with you, too. 7 MEMBER STEWART: But if there's some way we 8 could in the future have articles discussing what we 9 think good medical practice is and, for want of a 10 better word, the special interest discussions, we 11 believe this is important, we believe these are the 12 things that you might look for, thought you'd like to 13 know, thank you kindly articles, they might be very 14 helpful for the physicians. 15 PRESIDENT HUG-ENGLISH: I think we certainly 16 can institute that. 17 Okay. Moving on to number eight, our 18 executive staff report. Larry. 19 20 8. EXECUTIVE STAFF REPORT 21 22 MR. LESSLY: You know, this got changed from 23 the executive director report to the executive staff 24 report because I've wisely delegated a lot of the 25 reports today to the other two executive staff members 0069 1 you see here. I'll jump around and cover the few 2 things I have. 3 All the controversial ones have all been 4 assigned to them. 5 Consideration of request for members and 6 staff attendance at educational meetings. We have the 7 Federation meeting coming up. I believe we have 8 heretofore learned that Cheryl, Robin, Jackie, Marlene, 9 Don, those are the five board members who have 10 expressed an interest in going. 11 MEMBER BAEPLER: What are the dates? 12 MS. LYONS: Wednesday, April 24th, you fly 13 over there. And then it's Thursday, Friday and 14 Saturday. So you'd fly back on Sunday the 28th. 15 MR. LESSLY: From the staff -- we've had all 16 of those approved. From the staff, we've had me, 17 Maureen, Dick and Bob approved to go to that. Cheryl 18 is the delegate. Her delegate form has gone in. My 19 form as executive director has gone in. Our way and 20 our expenses are paid by the Federation. 21 In addition, the Federation has a policy or 22 a bylaw that says any member of a medical board who 23 leaves the board remains a Fellow of the Federation for 24 a period of three years after leaving the board. 25 Mr. Rosencrantz is in that capacity and may very well 0070 1 wish to go to that meeting, and I would ask you propose 2 a motion to approve his expenditures to attend as a 3 fellow. 4 MEMBER LUBRITZ: So moved. 5 MEMBER MONTOYA: Second. 6 PRESIDENT HUG-ENGLISH: There's a motion and 7 a second. 8 All in favor? Chair votes in favor as well. 9 Motion carries. 10 (Whereupon a motion was made, seconded, and 11 passed unanimously.) 12 MR. LESSLY: In conjunction with this, 13 something else has happened, which is good and bad. I 14 received a call several weeks ago from the Federation 15 saying that the Puerto Rico Board of Medical Examiners 16 has not been particularly active in the past. They 17 have a number of new board members and some new 18 funding, would like to come up to speed as an operating 19 board. And they went to the Federation and asked the 20 Federation to pick the most progressive and best 21 administered board in the country for them to go visit 22 to get that help. The Federation has suggested they 23 come to us. 24 So on the day after the close of the meeting 25 in San Diego, four members of the Board in Puerto Rico 0071 1 and the executive director wish to fly to Reno and 2 spend a couple of days with us learning how we function 3 and receiving some instruction from both board members 4 and staff. 5 I've not received the official request from 6 the board in Puerto Rico. But I'm told it's coming. I 7 took it upon myself to say yes we would, because how do 8 you say no? 9 So the bottom line is we're prepared to do 10 that from a staff standpoint. You'll remember, those 11 of you who have gone through or participated in the new 12 member orientation session, we do a session here in the 13 room with all of our senior people. We would do the 14 same thing with the Puerto Rico board. We would have 15 the staff presentation on licensing, discipline, legal 16 work, administration, financial, whatever, and give 17 them a tour of our facilities. We think that will take 18 about two days. 19 It would be scheduled for the 29th and 30th 20 of April, which is a Monday and a Tuesday. 21 I would certainly like to see some Board 22 members participate in that orientation also, if at all 23 possible. 24 It might not be necessary to be here two 25 days. We'll have to see when we get the request and 0072 1 confirm the dates as to exactly how much time would be 2 involved. But I would like to see Board members come 3 and talk about a perspective from both the public and 4 the M.D. side. 5 So I assume we will hear more about that in 6 the next few weeks, but it's tentatively scheduled for 7 that period of time. 8 On the annual report: We discussed that a 9 moment ago. And the newsletter will be going out 10 sometime this month or next month. We now have the 11 statistics from the Federation of State Medical Boards 12 on our disciplinary actions. I will tell you that 13 statistics are up this year. We had 20 actions filed. 14 That's a little bit better than we've had in the past 15 few years. Maureen will put that report together, and 16 that's simply a statistical report and little 17 biographical report about Board members. And that goes 18 out to the members of the Legislature, a number of 19 other groups and individuals in the state. That will 20 be going out, I would assume, next month -- 21 MS. LYONS: This month. 22 MR. LESSLY: Maybe the end of this month. 23 And the only other information item I have - 24 MEMBER BAEPLER: To tie the calendar down, 25 our next regular meeting is at the beginning of June? 0073 1 MS. LYONS: June 1st. 2 MR. LESSLY: 1st or 2nd. 3 The Nevada Broadcaster Association contract 4 is due to be considered again for the months of April 5 through June of 2002. Dr. Montoya, I understand, has 6 made an announcement, film and radio. And I assume 7 they're going to be using it, if they haven't already 8 used it. 9 We have statistics. Cheryl has had a chance 10 to look at those statistics. I will tell you the 11 statistics are not particularly overwhelming, but 12 they're not any worse than they have been. It's still 13 a bargain to us. And I would tell you that we're still 14 getting calls based on those public service 15 announcements. 16 I would recommend a motion to consider that 17 contract, and what we would do is pay $5,000 a month 18 and we look at it quarterly. So I would ask for a 19 motion to continue the contract of April the 1st 20 through June the 30th of 2002. 21 MEMBER STEWART: So moved. 22 MEMBER MONTOYA: Second. 23 PRESIDENT HUG-ENGLISH: There's a motion and 24 a second. 25 Any further discussion on that? 0074 1 You can circulate the book around so you can 2 look at some of the spots and how often they've aired. 3 But I think it's worth the money. It seemed to be well 4 received. 5 MR. LEGARZA: Are we getting much play in 6 the north? 7 MR. LESSLY: Yeah. 8 MR. LEGARZA: It seems like the numbers of 9 complaints have increased I think fairly good in the 10 south but I don't see -- a lot of people even refer to 11 the spots that that's where they learn about it. But 12 the north doesn't seem to be along the same line. 13 MR. LESSLY: I notice the TV thing has been 14 running during the day on the weekend. We're getting 15 better coverage than we did in the past timewise in the 16 north. We don't keep any statistics whether it's a 17 north or south call. But we're still getting calls. 18 PRESIDENT HUG-ENGLISH: All in favor? 19 Opposed? Chair votes in favor of the motion. 20 (Whereupon a motion was made, seconded, and 21 passed unanimously.) 22 MR. LESSLY: Last thing is I put a request 23 in under this agenda item. The Federation of State 24 Medical Boards is looking for test development item 25 writers for the exam. If any are interested in that, 0075 1 let me know. I'll pass that on to Carol, who is the 2 vice president in charge of that project, and you can 3 write test questions. 4 Those are the only items that I have under 5 the staff report. I guess we ought to start with 6 something that might take a few moments and that's 7 consideration of video conferencing meetings of the 8 board. That's Bob Frantz. 9 Let me tell you how this got on here. 10 You'll recall that the Clark County Medical Association 11 doesn't like the fact that you're having meetings here 12 and not having them in Las Vegas, Nevada. My opinion, 13 meetings in Las Vegas, Nevada cut out the rest of the 14 state. Meetings in Reno, Nevada cut out the rest of 15 the state. Meetings in Elko, Nevada cut out the rest 16 of the state. If you really want to cover the state, 17 you need to go to video conferencing. I'm not here to 18 advocate for or against it, but I've asked Bob to put 19 together a proposal through the auspices of the medical 20 school statewide, and he can tell you what the cost for 21 that sort of thing would be. You can take it or leave 22 it or you can do what you want to do with it. So Bob. 23 MR. FRANTZ: As one of these jobs that Larry 24 delegated here very effectively, I had, thanks to Dr. 25 Hug-English, gave Larry a phone number for Tracy Beach 0076 1 of the university. And I tried to contact him, and his 2 girl immediately sent me over to one of the people who 3 could handle it by the name of Mike Wahley at the 4 school there, who, when I originally talked to him, I 5 thought he was born in a foreign country and didn't 6 speak English. But he turned out to be a very nice guy 7 and kind of steered me in the right direction to make 8 the contacts that I needed to make. And he got me over 9 to a place called SCM at the university. And they set 10 it all up, all the video conferencing network through 11 the university and does that for the school of medicine 12 exchange. Greg Abner contacted me on my inquiry, and 13 he's been working with me. 14 What he did is come up with a packet of 15 information there which I've given you. He's broken 16 down the costs in two categories. One, preparing for 17 the digital feature, and the other one is just doing it 18 as of now, the cost involved. And it's just 19 postponing, having to make the changes later. It's not 20 an inexpensive process. 21 As you turn to the first page, it's $28,200, 22 which does not take into consideration the annual costs 23 on it. And the annual cost runs around, approximately, 24 if you go to about the third page here, it just gives 25 you some of the cost right there. It's about $10,000 a 0077 1 year to have this capability. And we'd be hopefully 2 going through the University School of Medicine, 3 setting the conference points down in Las Vegas and one 4 in Elko. 5 I don't have any idea what those points are 6 going to cost yet. I've made a call and have not 7 received a response back yet. I'm assuming that since 8 Tracy Beach has been supportive of this Board, chances 9 are we would probably be able to use their sites both 10 in Elko and Las Vegas. 11 MEMBER BAEPLER: Beyond the annual cost, 12 what's that predicated on? Four meetings a year, four 13 uses of this a year? 14 MR. FRANTZ: It's just a flat cost per year. 15 It's not based on meetings. It's just allowing us to 16 have access to it. 17 MEMBER ANJUM: Then we pay for the time we 18 use? 19 MR. FRANTZ: No. That would take care of 20 that. That's included. What happens is we meet, the 21 Board meets on Friday afternoon, goes into Friday 22 evening and then Saturday. We may have to have what 23 they call a facilitator in Las Vegas and in Elko to 24 operate the equipment, and the time for the meeting to 25 be over with, get everybody out of there or let them 0078 1 all in, whatever it is, and move on. So chances are we 2 may have to pay that person's costs and any other kind 3 of related costs that may be involved in the use of 4 those conference rooms. 5 So I don't know what those costs are going 6 to be. Just based on what we do on a yearly basis 7 before for board meetings, four times a year, I've 8 given them a copy of our schedule for the year so they 9 see what we do. Doesn't appear to be any conflicts 10 involved with using those conference rooms as of this 11 time. But if we decide to go with this or the board 12 decides to go with this, then there's some time 13 involved in getting it all set up as far as notifying 14 them, let them do the technical work, get it all 15 networked together. 16 MEMBER BAEPLER: Would this mean a typical 17 board meeting might ultimately consist of the Reno 18 members of the Board and all the staff meeting here and 19 the Las Vegas, southern members, meeting there, that we 20 would not -- 21 MR. LESSLY: Absolutely not. 22 MEMBER TITUS: This is mostly for the intent 23 of any physicians or for any members of the public who 24 want to make comment, have access at that time. 25 MEMBER BAEPLER: They would have access to 0079 1 the meeting. 2 MEMBER TITUS: It wouldn't offset flying Las 3 Vegas up here or any of the costs from bringing board 4 members to -- 5 MR. LESSLY: It's an additional cost. 6 MEMBER BAEPLER: People would have the 7 option of giving testimony rather than coming up, that 8 sort of thing. 9 PRESIDENT HUG-ENGLISH: Right. 10 MEMBER ANJUM: When we ask people to appear 11 in front of the Board, they can appear on the -- 12 MR. LESSLY: I think from a legal standpoint 13 you never want to have anyone appear who has an issue 14 as a licensee other than in front of you. 15 MEMBER LUBRITZ: This would be merely for 16 people who want input and the ability to listen to, 17 see, hear what's going on. 18 MR. LESSLY: Statewide there's people that 19 want that. 20 MEMBER BAEPLER: That concerns me. It would 21 be quite an expenditure. Our experience has been, when 22 we meet in Las Vegas, the attendance is really no 23 different than in Reno. If someone has something to 24 present, they're there. But we don't get an audience 25 of interested people, it seems, at any meeting. 0080 1 MEMBER LUBRITZ: It would seem that with 2 the cost outlay it might be reasonable for us to see 3 how many people would want to come and just buy them a 4 ticket. 5 (Laughter) 6 MR. LESSLY: For the next ten years? 7 PRESIDENT HUG-ENGLISH: I think this came 8 up, and the reason we asked Bob to look into this was 9 -- I think, Don, you may have been the one who 10 initially brought it up, that we have had questions in 11 the past as to public availability to the Board 12 meetings. And even though it is limited to a few 13 selected individuals, do we have a responsibility as a 14 Board to provide that? And I think that's the question 15 and that's what -- I mean obviously it is an expense. 16 We didn't know quite how much it was when we looked 17 into this. I think that's the issue as we go forward 18 as a Board. Do we want to have the ability that people 19 statewide can, if they want to access these meetings? 20 MEMBER BAEPLER: It's hard to put it on a 21 trial basis. Because you make these up, the 22 expenditures, and you decide after a few episodes to 23 drop it. 24 MR. LESSLY: The only request outside of the 25 medical society that we've had about access to meetings 0081 1 has come from the press. The press has asked a couple 2 times if they could call in and listen to our meeting. 3 Well, you can't do that with one telephone line over 4 here, with a speaker phone. What if you have two 5 requests, how do you decide? So my feeling is that if 6 the press is really interested, they will send someone 7 to this meeting, as you will note by the presence of 8 Mr. Ryan here today. But those are the only two groups 9 who have made this type of request. 10 MEMBER TITUS: Has there been any kind of 11 reconsideration about not having a meeting down in Las 12 Vegas? I know it was an issue because of the events 13 that happened and travel and all. 14 MR. LESSLY: How would the people in Reno 15 get to participate? 16 MEMBER TITUS: I think in my mind it's a 17 fair point for Las Vegas, it was a standard thing we 18 did, was travel to Las Vegas once a year. I felt that 19 was actually a good thing to have happen. I certainly 20 understand after September 11 why we didn't go there in 21 December. That was very clear. But I think for one I 22 would like to reconsider why we're not resuming going 23 to Las Vegas once a year. 24 MEMBER ANJUM: It's a good chance to see how 25 many people show up. And not too many people show up, 0082 1 then we really say we don't have -- 2 MEMBER TITUS: We conduct and have two 3 meetings. 4 MEMBER ANJUM: We see how many people show 5 up here. We give them two, three chances here and one 6 chance, see what kind of response do we get. If we 7 have meetings there two or three times, we have three 8 people sitting in the back, we can say we'll buy you a 9 ticket, you know. 10 (Laughter) 11 MR. LESSLY: Next time we'll set the 12 schedule up, I think that's a perfect consideration. 13 We said we're doing it for this period. Next time it's 14 certainly open for consideration. 15 MEMBER BAEPLER: For a slight compromise, 16 Joel, that the IC meetings could still be here because 17 there's so much staff involvement, we're forever 18 sending them to the files to get information that you 19 can't predict. That's one of the most awkward things 20 is trying to figure out what do you need to transport 21 to Vegas to have a meeting. 22 PRESIDENT HUG-ENGLISH: That is a difficult 23 issue. And it is a little cumbersome for the staff. 24 But this was not a forever decision that we made this 25 year. It was, as you said, Robin, it was based on the 0083 1 fact that things were unstable and travel was difficult 2 at the time when our meetings were scheduled. 3 It's something to evaluate, if people feel 4 they want to go back to the one meeting down in Vegas, 5 we can certainly put that back in the schedule for next 6 year. It does -- I think the investigative committee, 7 I need other people's feedback on that, because it does 8 mean you don't have access to going out and getting 9 something you need easily. 10 MEMBER BAEPLER: It's hard to compare us to 11 someone like the Board of Regents because the Board of 12 Regents have a huge office complex in Las Vegas as they 13 do in Reno and Elko and they have a board meeting. 14 Everything you see sitting here would be permanent in 15 both ends of the state. They don't transport any of 16 that type of thing back and forth. But that's a very 17 unusual proposition or unusual situation for any state 18 entity to have that kind of regional offices, which the 19 education system demands, of course. 20 Even then, it's less convenient to meet in 21 Las Vegas or Elko than it is in Reno, because of the 22 central office being in Reno. But it works. 23 MEMBER ANJUM: I think we should give that a 24 try first. If that doesn't work out very well, then we 25 can think about some alternatives. 0084 1 PRESIDENT HUG-ENGLISH: I don't think there 2 was a time frame on this. This was really for 3 information so that we can make a decision. Is that 4 everybody's consensus? 5 MEMBER ANJUM: Where do you do the meeting 6 in Las Vegas? 7 MR. LESSLY: We rent a place. 8 PRESIDENT HUG-ENGLISH: That's been an issue 9 in the past, that it hasn't always been the most ideal 10 setting with the noise and the garbage trucks. The 11 last ones were nice accommodations. 12 MEMBER ANJUM: I think if we find a 13 conference room in the convention place where we have 14 access to the phones and the fax that we need to send 15 things back and forth, that may be a better idea. 16 MR. LESSLY: Do I gather what we're saying 17 here is no action on video conferencing at this time? 18 PRESIDENT HUG-ENGLISH: Yes. 19 MEMBER BAEPLER: I think this is good 20 information that we can think about. 21 MEMBER MONTOYA: This is to set up one room, 22 is it 20,000 per room? 23 MR. FRANTZ: It's just setting up this room 24 only. It's got four monitors. 25 MR. LESSLY: You can go anywhere -- if you 0085 1 look at the map, you can go anywhere in the university 2 medical school system with this. But we would have to 3 do the equipment in this room only. It would be 4 depending upon the use of their equipment and their 5 locations and other governmental entities who are 6 locked into their network in these locations. We can 7 go to Pahrump. 8 MEMBER BAEPLER: Is there a single outlet in 9 Las Vegas for this system? 10 MR. LESSLY: There's more than one. 11 MEMBER STEWART: You could go to Bradley; 12 you could go to Sawyer? 13 MR. LESSLY: Just the university system. 14 Certain hospitals. 15 UNIDENTIFIED SPEAKER: Community College of 16 Southern Nevada. 17 MR. FRANTZ: I tried to make contact with 18 the Legislative Council Bureau and get them to kind of 19 get me some information. Nothing came out of them. 20 The only one that came through was the university. So 21 that's the one I went with. 22 MR. LESSLY: We will file this away, if 23 that's the consensus of the Board. 24 Bob, why don't you talk about the printing 25 of 630. 0086 1 MR. FRANTZ: Basically it will look like 2 this, new book, blue cover. It's going to have the 3 information here. The only thing wrong on this sheet, 4 2002 will be the date on the bottom for the Nevada 5 Revised Statutes and regulations covering physicians, 6 physicians assistants, nurse practitioners, respiratory 7 care. 8 I got a call from the printing office over 9 at the state. They gave me a time frame, try the last 10 week of the month, because we're in March right now, to 11 get this out. I guess it's going to be a little 12 thicker. I don't know if it's going to be as thick as 13 a Reader's Digest, but be bound very similar to that. 14 So just for your information. 15 As soon as we get them, we'll mail them out. 16 MR. LESSLY: To every licensee. 17 MR. FRANTZ: We've ordered 10,000 copies and 18 Larry has agreed to sign off on the front of -- Dick 19 and Larry will have a signing. 20 MR. LEGARZA: There's a place for the 21 president and secretary/treasurer to sign, right, 22 Larry? 23 PRESIDENT HUG-ENGLISH: Autographed copy. 24 (Laughter) 25 MR. LESSLY: In this regard, in one of your 0087 1 handouts today is a set of new regulations. Our 2 regulations are up-to-date as of right now. What you 3 have there are all the regulations as opposed to the 4 mismatch we've had in the past, what's been temporary, 5 what's been permanent. We've got nothing out there 6 pending for approval or at the Legislative Council 7 Bureau. So what we have waited on, what we would go to 8 print with are statutes out of the last session and 9 these regulations that you have been given. 10 MEMBER LUBRITZ: How many copies will you 11 be mailing out? 12 MR. LESSLY: We have as of the 27th of 13 February 4,380 active M.D.s, 1,036 inactive M.D.s, 196 14 PAs and 662 respiratory care practitioners. 15 MEMBER LUBRITZ: How many -- 16 MR. LESSLY: 6,274. 17 MEMBER LUBRITZ: That's going to cost you 18 how much? 19 MR. LESSLY: A lot. 20 MEMBER LUBRITZ: How many members do you 21 have in Reno and in Las Vegas? 22 MR. LESSLY: In the state of Nevada you have 23 active 3,520. Of those, 65 percent, or 2,313, are in 24 Clark County. 25 MEMBER LUBRITZ: That will cost you how 0088 1 much? 2 MR. LESSLY: We don't know yet until we 3 weigh the document. 4 MEMBER LUBRITZ: An idea? 5 MR. LESSLY: Over a buck. 6 MEMBER LUBRITZ: You'll mail those for 7 $2,000? 8 MR. FRANTZ: No, 5,000. 9 MR. LESSLY: 5,000, ballpark figure. 10 MEMBER BAEPLER: I think it's necessary. 11 MEMBER LUBRITZ: I'm not saying it's not 12 necessary. 13 MEMBER STEWART: It's mandatory. 14 MEMBER LUBRITZ: What I'm saying is if it's 15 going to cost you $5,000, you can hire people a lot 16 cheaper to go around individually to just deliver them. 17 MR. LESSLY: The difficulty with that, Joel, 18 is when we mail these out, my guess would be of the 19 6,274 we're going to mail out, we're probably going to 20 get 1,074 returned because the licensee hadn't bothered 21 to tell us where his office is or where it's been 22 changed. 23 MEMBER STEWART: He should be sanctioned. 24 MR. LESSLY: Dr. Stewart, I would love to 25 see that. 0089 1 Thank you, Bob. 2 The rest of the agenda items here are things 3 that Maureen can discuss. We'll start with the status 4 of the enhancements to the Board's web site, which is 5 the on-line profiling project. 6 MS. LYONS: We're still moving along the 7 same track that we were that I told you at the last 8 Board meeting. 9 Casey Miller is working on cleaning up our 10 disciplinary actions in the computer. She's halfway 11 through the alphabet. She does it on a part-time basis 12 from home. But she's making everything absolutely 13 consistent and accurate and she's going through all the 14 hard copy files and cleaning them up at the same time. 15 So it really is a very worthwhile project. 16 Once she completes that, we will actually be 17 ready to put it on line, because we'll feel comfortable 18 that our information is accurate. We don't want to put 19 anything on line unless we're really comfortable with 20 that. 21 MEMBER STEWART: What is your time frame? 22 MR. LESSLY: This fiscal year? 23 MEMBER STEWART: Before June 30? 24 MR. LESSLY: I want to see the money spent 25 out of the account before June 30. 0090 1 MEMBER STEWART: That would be wonderful. 2 That's within a year of -- 3 MR. LESSLY: That's entirely up to what we 4 have, we can't vouch right now because of all the 5 various systems. It depends really on how quick Casey 6 is at that. 7 MEMBER STEWART: But your goal is to do it, 8 you said you were going to do it at the last June 9 meeting, you'll try have it done within the year. 10 MR. LESSLY: That's a goal. 11 MEMBER LUBRITZ: What's going in there as 12 far as the complaints go? Is it actions taken, cases 13 closed, in other words, the same thing that we get in 14 investigative committee? 15 MR. LESSLY: No. 16 MS. LYONS: Only actions that were formally 17 taken by the Board that became formal actions. 18 MR. LESSLY: The other thing Maureen can 19 talk about, let me make one comment before we start, if 20 any of you called, you know we have a new telephone 21 system here. And we know that it is working 22 appropriately because you cannot get me or Mr. Legarza. 23 There's a reason that Mr. Legarza and Mr. Lessley do 24 not have voice mail and that is, if we had voice mail, 25 we would spend our entire day, he would be returning 0091 1 telephone calls from physicians who don't like what 2 happened on their requirement that they appear in front 3 of the investigative committee or people who are 4 griping because the investigative committee didn't 5 immediately summarily execute against a physician, they 6 filed a complaint. I would be getting some of those, 7 plus every disgruntled applicant for licensure who 8 doesn't think he should have to take the SPEX 9 examination. 10 We will privately give you a number that you 11 can dial directly to us, but we're the only two in the 12 office who do not have voice mail. 13 I'll let Maureen explain to you what's going 14 on, but I will tell you that it has already been of 15 great assistance as far as the workload on the front 16 desk. 17 MEMBER BAEPLER: What would help, I don't 18 mind dialing zero to get the two of you, if you could 19 mail out a one-page sheet with the number. I always 20 have to spell somebody's last name to get connected. 21 MR. LESSLY: We don't want you calling 22 anybody but Dick, me or Maureen. 23 MEMBER BAEPLER: But I have to dial her name 24 to get her. She doesn't respond on zero. 25 MS. LYONS: That's right. I don't have much 0092 1 to say to that. 2 MEMBER ANJUM: What about a number we can 3 get for the officers? 4 MS. LYONS: Tomorrow morning I'll hand out a 5 sheet with everyone's extension to all the members. 6 PRESIDENT HUG-ENGLISH: Larry and Dick tried 7 to hide from me, but I found them. The first time I 8 called it, it said there is no one by this name. 9 MR. LESSLY: It's because you didn't listen 10 to the entire message. 11 MS. LYONS: Then we changed it. Initially 12 we set it up and it went along pretty smoothly, 13 although I wasn't here that day. 14 MR. FRANTZ: I think Maureen was gone. 15 MS. LYONS: I was ill or something. Since 16 then we've had to come back and changed, made the 17 message a little bit more simplified, because you 18 initiate something like that and then problems come up, 19 you address those problems. So now I think we have it 20 down pretty pat. 21 The receptionist, or actually now her title 22 is credentialing specialist, because she's not really a 23 receptionist anymore. She does get the overflow of 24 people that don't know who they want, they hit zero and 25 they get Carolyn. But she definitely has had a drop in 0093 1 the phone calls she's getting. That's really helped 2 with answering phones more quickly and efficiently, not 3 keeping people on hold as much. So overall it's a 4 success. And the staff, I haven't heard any complaints 5 really about it. They seem to be dealing with their 6 voice mail and everything pretty well. 7 MR. LESSLY: We really didn't want to do it, 8 but I'm amazed how few gripes there have been about it. 9 So what that assumes is the American public is used to 10 it now and it's okay. 11 MEMBER STEWART: Have you done a traffic 12 study or any of these things that tell you how many 13 busy signals you're getting? I only say that because 14 when I talked to you on whatever day I called to talk 15 to you, I had to call five times to get somebody. 16 MR. LESSLY: We've added lines as a result. 17 MS. LYONS: How long ago was that? 18 MEMBER STEWART: Tuesday, Wednesday. 19 MS. LYONS: We've added additional lines. 20 Perhaps we need to think about adding more. 21 MEMBER BAEPLER: I've never gotten a busy. 22 MEMBER STEWART: When I tried to call you, I 23 got a ring on the sixth try. 24 MEMBER BAEPLER: On the 888 number? 25 MEMBER TITUS: The problem is they have 0094 1 caller ID; they're screening out their calls. 2 MEMBER LUBRITZ: Do you have dedicated 3 outgoing lines for staff? 4 MS. LYONS: Two of those. And then we have 5 four both-way calls, phone lines. 6 MEMBER STEWART: You have six for how many 7 employees? 8 MS. LYONS: 14. 9 MEMBER MONTOYA: I have six in my office. 10 MEMBER LUBRITZ: That's woefully -- 11 MS. LYONS: We stay on the phone a long 12 time. 13 MEMBER MONTOYA: That's what I mean, you 14 need more lines. 15 MEMBER LUBRITZ: You need specific lines in 16 which your employees have lines to call out. 17 MS. LYONS: If we need to add more lines 18 than that, we'll have to upgrade our system. So I 19 guess we can look into doing that and getting an 20 estimate from Nevada Bell for doing that. 21 MR. LESSLY: We've had no real gripes. 22 MEMBER STEWART: I'm not griping, Larry. 23 MEMBER TITUS: Are your six lines tied up 24 when you're on the Internet? 25 MS. LYONS: That's with a T-1 line. 0095 1 MEMBER STEWART: You spend $15,000 a quarter 2 telling the public we're here. You spend $25,000 3 upgrading the system so that we can present ourselves 4 on the Internet. Have you done a traffic study to 5 figure out how many call rejections you get? The phone 6 company will do that for free. If I just had a bad 7 day, then six lines for 14 employees from the public 8 was wonderful. If not, then you need to decide if you 9 need more outgoing lines for the staff to do their 10 business and leave the incoming lines for the public. 11 It is not a problem for me to redial Mr. Lessley's 12 phone until I get him. 13 MS. LYONS: I think additional outgoing 14 lines might be something that we should consider 15 myself. But we'd have to look into getting a new 16 system. 17 PRESIDENT HUG-ENGLISH: It seems to me that 18 if the public were getting that kind of response, we 19 would be hearing about it. I don't think many people 20 are going to be as patient as you were, Paul, and not 21 say something if they called five times and didn't get 22 through. I think most people are going to say how 23 come. 24 MR. LESSLY: We can certainly look at it. 25 PRESIDENT HUG-ENGLISH: If there's a way to 0096 1 check it. 2 MEMBER STEWART: I even looked at my phone 3 card in my wallet to make sure I wasn't having a senior 4 moment. 5 MEMBER TITUS: That's a lot of times to try 6 to call somebody. 7 MEMBER STEWART: I tried to call three times 8 from the airport to tell Mr. Frantz to come pick us up. 9 Maybe you are more busy than you think you are. 10 MEMBER LUBRITZ: Rather than having a new 11 system, you can run individual lines, have a separate 12 phone for outgoing calls for your people so you don't 13 have to really upgrade. If there are people like we 14 have, we know our accounts receivable, they stay a long 15 time. They have to call on their individual lines. 16 They have their regular lines, but if they're going to 17 be on the phone with anyone, I'm the person that gets 18 prior approvals. They have their separate lines, so we 19 didn't have to go through putting in the new system but 20 ran individual lines. 21 MS. LYONS: That would mess up our system. 22 Because Carolyn can see who is on their phone or not. 23 If you had a separate line, she wouldn't know. 24 MEMBER TITUS: She wouldn't need to know 25 that. 0097 1 MR. LESSLY: We'll look at it. 2 MEMBER BAEPLER: When you make out that 3 directory can you give us your emails too and I can 4 stay off the phone? 5 PRESIDENT HUG-ENGLISH: Let's move on. Did 6 you have anything else, Maureen? 7 MR. LESSLY: I think that's all we need to 8 talk about there, but I missed one informational item. 9 That is on the educational meetings. I have a package 10 on the Fifth International Conference on Medical 11 Regulation to be held in Toronto that some of you have 12 expressed some interest in attending. I don't know if 13 you've got it on your own or not. If you'd like, I can 14 make copies of what I have here if anyone is 15 interested. 16 And that's all we have under that report. 17 PRESIDENT HUG-ENGLISH: Okay. Thank you. 18 19 9. Discussion of Request by Washoe Medical Center Board of Trustees for the Nevada State Board of 20 Medical Examiners to Conduct Criminal Background Checks when a Medical Doctor Applies for and Renews 21 Registration of Nevada Licensure. 22 PRESIDENT HUG-ENGLISH: Then we'll move on 23 to Agenda Item 9, and this is a discussion of Request 24 by Washoe Medical Center Board of Trustees for the 25 Nevada State Board to conduct criminal background 0098 1 checks when a medical doctor applies for and renews 2 registration of Nevada licensure. 3 I think we have some visitors with us that 4 want to make a presentation. 5 Dr. Carlson, would you join us. 6 DR. CARLSON: I'd like to introduce Betsy 7 Vandeman. She's the manager of medical staff services 8 at Washoe, and new since -- beginning about last year. 9 And I appreciate -- 10 PRESIDENT HUG-ENGLISH: You're welcome to 11 have a seat. 12 DR. CARLSON: I can stand. I thank you very 13 much for having us here. You probably wonder why 14 Washoe is appearing here. And this all started back in 15 2000. 16 The Washoe Medical Center Board of Governors 17 reviewed their board role, and we wrote it. And one 18 area we wanted to revisit was the credentialing 19 process. And obviously the board is responsible for 20 the privileges and credentialing of the medical staff, 21 executive committee. 22 And at this time we asked Dr. Les Smith, who 23 was the chief of staff, and also Karen Massey, who was 24 the manager at that time, to give the board a review of 25 the process. 0099 1 I should point out that all the members of 2 the board individually rotate through the medical 3 executive committee meetings and also the credentialing 4 meetings, so they have an idea of what takes place. 5 Anyway, this was done in July of 2000. And 6 we requested some more information. And Dr. Phil 7 Landis, who is the quality manager at Washoe, gave us 8 some more information, and he noted -- he gave us the 9 application to look at. I gather the application is 10 the same throughout Northern Nevada for all the 11 hospitals. And one of the points that he brought up 12 was that there was no provision in the application to 13 do criminal background checks. 14 And we have an attorney on our board, Mike 15 Alonzo, and he felt that we should consider doing 16 criminal background checks or fingerprinting for 17 applicants to Washoe Medical Center. And this was sent 18 back to the medical exec. And about that time we had a 19 switch in managers, and Betsy came in to take over. 20 And she had a lot of work to do. 21 In May of 2001, there was a presentation to 22 the medical exec, and they felt that they wanted some 23 more information and also some legal advice. And so 24 Betsy did a lot of research, and this was brought back 25 to the board in October. And at that time it was felt 0100 1 that they wanted to see the State Board of Medical 2 Examiners to do the checks rather than an individual 3 hospital. This went to the board, and we agreed. And 4 I was asked to write a letter. So that's why you got a 5 letter. 6 And I hope all of you have a copy of a 7 letter we sent. And also there should have been an 8 American Medical Association newsletter that, November 9 2001, that Betsy found. And I would like to point out 10 there was some additional information that the AMA came 11 out with after the report that you got. And basically 12 the corrections that they wanted to add was that there 13 are now seven states that require physicians to submit 14 fingerprints as far as criminal background checks. And 15 just to repeat, those states are California, Florida, 16 Idaho, Virginia, South Carolina, Texas and Louisiana. 17 In addition, New Jersey, North Carolina, 18 Rhode Island, conduct criminal background checks but do 19 not require fingerprinting. Kansas also conducts 20 criminal background checks if they feel it necessary. 21 I would also like to point out, it was in 22 the newsletter, that Florida, last year, began 23 requiring fingerprinting on all license renewals. 24 Interesting to note, of the 48,000 renewals 25 they had, the state officials discovered 15 physicians 0101 1 who failed to state their criminal convictions on their 2 renewal applications. 3 MEMBER LUBRITZ: Out of how many? 4 DR. CARLSON: 48,000. 5 MEMBER LUBRITZ: They had 15? 6 DR. CARLSON: Approximately four percent, or 7 2,000, had committed crimes of that 48,000. 8 MEMBER LUBRITZ: How many did they not know 9 had crimes? 10 MEMBER BAEPLER: 15. 11 Of the 2,000 that had crimes, how many were 12 unidentified prior to -- 13 DR. CARLSON: 2,000 of the 48,000 they 14 didn't know about until after the fingerprinting. 15 MEMBER LUBRITZ: The board did not? 16 DR. CARLSON: Of Florida, yes. 17 PRESIDENT HUG-ENGLISH: The 15 then were -- 18 I'm sorry. I'm confused. 19 DR. CARLSON: Let me restate it. They found 20 15 physicians who didn't declare a criminal event on 21 their renewal application. 22 On most applications, in most states, you're 23 aware that -- have you ever had a -- anyway, does 24 that -- 25 PRESIDENT HUG-ENGLISH: Okay. 0102 1 DR. CARLSON: Then the other point was that 2 four percent of the applicants in renewals, or 2,000, 3 had committed crimes. 4 MEMBER BAEPLER: But they declared that on 5 their application, presumably? 6 DR. CARLSON: They may have. 7 MS. VANDEMAN: Those are original 8 applicants. The 15 were renewals. 9 DR. CARLSON: Thank you. That's why Betsy's 10 here. 11 The other interesting thing that I thought 12 was interesting was at this time -- well, the AMA news 13 report mentioned this, that fingerprints should be 14 further verified with the Federal Bureau of 15 Investigations National Crime Information Center. It 16 was further noted that the local law enforcement 17 agencies were apt to work with state medical boards if 18 there was appropriate language in the state statutes 19 that required background checks and fingerprinting. 20 Flaws and weaknesses in this system have created 21 problems. And I'd like to just cite a few instances of 22 those flaws and weaknesses. And some of you may 23 remember the Nork case. He was an orthopedic surgeon 24 in Sacramento. And he performed about 36 unnecessary 25 laminectomies. 0103 1 And one of his patients, Gonzales, sued him. 2 And, finally, the Superior Court ruled in 1973, in the 3 case of Gonzales versus Nork, that the hospital should 4 have known that Dr. Nork's substandard practice existed 5 and should have taken steps to protect other patients. 6 This case showed that the hospital board is ultimately 7 responsible for overseeing physician credentialing, 8 privileging. 9 There's some other examples. There was a 10 dentist, Roarke, who was a counterfeit M.D., and he 11 performed surgeries in a number of states, including 12 Canada, before he was caught. 13 The last one I want to mention, and you 14 probably are aware or have heard of it, and that's 15 Michael Swango. And he was a doctor that was convicted 16 of murdering patients with toxic injections who managed 17 to find continuous employment by giving false 18 information from 1983 to 1997. 19 James Stewart wrote a book about Dr. Swango 20 entitled Blind Eye. You may or may not have read it. 21 And Blind Eye: How the Medical Establishment Let a 22 Doctor Get Away With Murder. And I'll just go over a 23 little bit about his history. 24 MEMBER BAEPLER: Sir, we're very familiar 25 with that case, have heard the author. Fingerprinting 0104 1 him would not have discovered this. 2 DR. CARLSON: It would have. 3 MR. LESSLY: He was never charged with 4 anything until he was convicted of murder. 5 DR. CARLSON: Let me back up. I will go 6 over his history. 7 MS. VANDEMAN: What would have caught him 8 was when physicians take on the identity of a physician 9 who has a clean record, and that's where the 10 fingerprinting picks them up, they aren't who they say 11 they were. 12 DR. CARLSON: Let me go over a little bit 13 about the history. He went to medical school in 14 Southern Illinois University after getting discharged 15 from the Marines honorably. 16 MEMBER STEWART: We've all read the book. 17 PRESIDENT HUG-ENGLISH: We all got the book 18 distributed. We're pretty familiar with his history. 19 DR. CARLSON: I don't want to bore you with 20 it. But since it was raised, he did serve some time in 21 prison. And after he got out of prison he falsified 22 documents and underwent a name change to David Adams 23 and then applied for residencies, and he was employed 24 in a number of states: South Dakota, New York. Then 25 he finally went to Africa. He would have been picked 0105 1 up. Actually the FBI, the article I read, believes 2 Swango ranks among the most prolific serial killers in 3 American history. 4 MEMBER LUBRITZ: May we interrupt? 5 Who do you think would take on the duty once 6 they are fingerprinted? Let's assume you put that 7 there. Who would then take on the duty and with what 8 time frame would they have to run all these through to 9 check all the criminals in the United States to see if 10 this person was a criminal? 11 DR. CARLSON: I think the main thing is to 12 go through the FBI. 13 MEMBER LUBRITZ: How long would it take 14 them to do that? 15 DR. CARLSON: I think in California, and 16 correct me, they asked for at least six months -- 17 MS. VANDEMAN: It's increased since 18 September 11th, no question, because they're requiring 19 fingerprinting for a much broader range of our 20 population. However, prior to that they said, a 21 mandatory, it took up to three months in the state of 22 Nevada for the national check. But you can get access 23 to the National Data Bank. We couldn't, Washoe Medical 24 Center couldn't. But if it's in the state statute, 25 you'd have that ability. 0106 1 MEMBER LUBRITZ: What did you estimate 2 would be, given Florida's statistic, how many 3 physicians would you think we would pick up here? 4 MS. VANDEMAN: I'm going on kind of watching 5 the OIG reports and things, which I don't know if 6 that's a legitimate estimation. Certainly you see a 7 lot more of that coming out from southern Nevada, 8 certainly because there's a higher population of 9 physicians down there. I don't anticipate a great 10 number. However, I do know that especially in our 11 rural areas it's much easier to go into those rural 12 areas. They just don't go through the credentialing. 13 We shake physicians until their teeth fall out going 14 through the credentialing process. The rural hospitals 15 don't have that ability. And so I think that's 16 probably where you're going to see them more than in 17 Reno, Nevada. But purely a guesstimate on my part. 18 My concern is this is very much a national 19 movement; that if one hospital starts it, it then 20 becomes standard and another hospital starts it. And 21 it's rare that a physician is on staff at one hospital 22 in urban areas. So then they have to go through it for 23 every single hospital. And it becomes difficult to 24 create a system that is uniform. You've gotta come up 25 with what's going to exclude somebody. Are child care 0107 1 payments going to exclude a physician from practicing? 2 There are all kinds of things that come through on 3 criminal background checks, and it needs to be uniform 4 and it needs to be fair. And I mean there's no 5 question it's a huge national movement. It's going to 6 be mandated at some point. Not today. Not tomorrow. 7 But I think we're going to see it. 8 MEMBER TITUS: Just a clarification. I just 9 can't let that go. As a rule, as a doctor practicing 10 20 years in Yerington, who has done credentialing, I 11 would beg to argue with you about us allowing doctors 12 with less than thorough checks in their application 13 processes. 14 I would argue if you did this, you 15 necessarily wouldn't find more criminals in rural 16 Nevada than you would in Clark County. 17 MS. VANDEMAN: Especially if you're 18 practicing in hospitals, I would agree with you 100 19 percent. We do some credentialing for rural physicians 20 that are just in clinics. They don't have privileges 21 at hospitals or in accredited hospitals. And I don't 22 know, like I said, it's purely my guess. I don't know. 23 MEMBER STEWART: Mr. Lessley, do we need a 24 statute change to say we could fingerprint physicians? 25 MR. LESSLY: Sure. 0108 1 MEMBER STEWART: We'd have to do this by 2 statute. 3 MEMBER BAEPLER: We don't have the authority 4 at the present time, do we? 5 PRESIDENT HUG-ENGLISH: This is an 6 informational item only. It's not an action item. 7 It's being raised to the Board because it's come up. 8 And it really is to provide information and for the 9 Board to have some discussion as to whether it's 10 something that we're interested in doing. 11 I think a couple of the things that are 12 problematic is that obviously it would require a 13 statutory change for us. We don't have the authority 14 to do that right now. 15 And the other question that I have, and Mr. 16 Legarza, maybe you can help me with this, but I don't 17 think if we did background checks that we would be able 18 to give that information to hospitals for 19 credentialing. 20 MS. VANDEMAN: You wouldn't. What it would 21 do is preclude a license. See, we require a license. 22 MR. LESSLY: No, it wouldn't preclude a 23 license. We have convicted felons practicing medicine 24 in the state of Nevada. It is grounds for denial of a 25 licensure, but it's not mandatory. 0109 1 DR. CARLSON: But that would be your 2 decision. 3 MS. VANDEMAN: Right. If you decided that 4 whatever came through on those criminal background 5 checks did not preclude a license, then it shouldn't 6 preclude them practicing medicine in our hospital. 7 MR. LESSLY: You would like to move the 8 liability for your credentialing from Washoe Medical 9 Center to the Nevada State Board of Medical Examiners 10 on the advice of your attorney? 11 MS. VANDEMAN: No, not at all. I think if 12 you have a physician that applies for credentialing at 13 Washoe Medical Center, Saint Mary's Hospital, Northern 14 Nevada -- 15 MEMBER BAEPLER: It would be quite a burden 16 to do it for every applicant, but for every two years 17 to redo every licensee in the state of Nevada. 18 MR. LESSLY: We wouldn't be renewing 19 licenses. 20 MEMBER BAEPLER: You would be waiting 21 forever for every fingerprint check to come back, 22 because if it takes three, four, five, six months to 23 get back, we license every two years, goodness, that 24 would be a horrendous ordeal. I also suspect that the 25 vast majority of honorable physicians who have no 0110 1 criminal record whatever would object to being treated 2 like a culinary worker and going to the work card 3 procedure, in essence, is what you're equating it to, 4 you know. 5 MEMBER LUBRITZ: Honestly, if you sat 6 through this Board and came here all the time, I think 7 you'd find that we do not a good job, we do an 8 outstanding job. And there are people that are going 9 to get by, but there's still people that get by. If 10 you did fingerprinting, you say there's one more step 11 that we could do here. One more. I think we stay 12 pretty busy and we do a pretty good job. And to me, 13 just anecdotally, this would be just another burden. I 14 think we do a good job, and I think that if you need 15 more help with your people, then you need to hire more 16 people and get them to do it. 17 MEMBER TITUS: The actual act of getting 18 fingerprinted is pretty standard for lots of different 19 positions people hold. I voluntary drive for the 4-H 20 kids. Before I could do that I had to get 21 fingerprinted. It's just mandatory. I don't really 22 think that -- 23 MEMBER BAEPLER: You don't think there would 24 be that problem? 25 MEMBER TITUS: There may be people that 0111 1 would object to it. I think I'm equal to a culinary 2 worker. Why should I be held to a higher level? I 3 think a lot of us have been fingerprinted for a lot of 4 things. The issue itself isn't getting fingerprinted, 5 the question is the burden of time and obligation for 6 our Board. 7 MEMBER BAEPLER: Tremendous. 8 MEMBER ANJUM: It's a very lengthy process, 9 every six months you have to go through 4,000 10 physicians and take six months to get the answer back 11 on the fingerprints. 12 MR. LESSLY: The question really is not the 13 time or what's involved in doing it or the convenience 14 of fingerprints, what is the necessity to do that for 15 this Board to issue a license. 16 (Tape change and court reporter took a 17 break.) 18 MR. LEGARZA: And as they're telling me 19 now from the nursing board here in the state of Nevada 20 that does require it, it's going to be about a four- to 21 six-month process because of 9-11. 22 Now, we license physicians on the average 23 within about a 60- to 90-day period. It can be even 24 done quicker if the physician will get out there and 25 work at it. So you're going to have a delay there. 0112 1 And it gets back to the question: Who is it that we're 2 missing? 3 I mean, consider the group of people that 4 you're working with. I don't know many convicted 5 felons that are really running around that we don't 6 already know about or we wouldn't be able to find in 7 other ways besides fingerprinting. I'm not saying it's 8 bad. But biennial, I think it would be an absolutely 9 horrible burden. 10 MEMBER STEWART: The thing with California, 11 they only fingerprint you at initial application. 12 DR. CARLSON: Florida is the only one I'm 13 aware of that -- 14 MR. LEGARZA: That's not going to help you 15 people. We're not going to certify a bunch of 16 information that seems it's going to make it less of a 17 burden for you. 18 MR. LESSLY: You cannot assume that we 19 denied a license because of a criminal background 20 check. 21 MR. LEGARZA: In your own credentialing 22 processes -- I don't see how anything that we would do 23 is going to have a direct, be direct assistance to you. 24 MS. VANDEMAN: I think from what I know from 25 how other states do it, they choose certain things. 0113 1 Certainly all felonies, certainly things that are 2 directly related to patient care issues, to preclude 3 someone from getting a license. There's a lot of 4 things. No, it's not going to -- 5 MEMBER ANJUM: That's all circumstantial, 6 too. 7 MR. LESSLY: There's no state that has an 8 automatic preclusion for a license for a felony. No 9 state in the United States. 10 MEMBER STEWART: The doctor issue in 11 Sacramento revolved around the issue that the hospital 12 knew what he was doing. He was not doing criminal 13 deeds, he was doing malpractice deeds. 14 DR. CARLSON: For privileges. 15 MEMBER STEWART: And was he capable of doing 16 the privileges that the hospitals had given him. It 17 had no relationship to whether or not he was a 18 criminal. 19 PRESIDENT HUG-ENGLISH: Let me ask a 20 question: In your research with this, are there any 21 states or areas that you know of where the hospitals 22 have taken on this responsibility? Because it would 23 seem to me that the length of time it would take for 24 someone to get a license would really be dramatically 25 lengthened if we were to do this on just new licensees. 0114 1 But once a license is granted and somebody is going for 2 credentialing or privileges, I mean to have a three- to 3 four-month period is different than not having your 4 license at all. So has that been looked at? 5 MS. VANDEMAN: That's what started the whole 6 thing, Washoe Medical doing it as part of our 7 credentialing process. If you do do it, do you do it 8 just initially? All the same questions you're asking. 9 Is it value added? Are the percentages, the potential 10 percentages different? We feel the same way you do. 11 We don't think we have a whole lot of criminal 12 officials on staff. 13 MEMBER LUBRITZ: Why are you asking us to 14 do it? 15 MS. VANDEMAN: Because it's a really huge 16 national movement. 17 MEMBER LUBRITZ: We haven't heard about it 18 through the Federation of State Medical Boards. 19 PRESIDENT HUG-ENGLISH: Actually, there has 20 been. The Federation, in their last bulletin, does 21 mention the fact that they are in favor of boards 22 considering this. 23 MEMBER ANJUM: This is going to be a trend. 24 It's going to get in eventually. 25 PRESIDENT HUG-ENGLISH: Probably. 0115 1 MR. LESSLY: It may or may not. The states 2 doing it are doing it for reasons we don't have. 3 Florida has a very unique situation which we don't 4 really need to go into. California, their medical 5 board has criminal jurisdiction as well as 6 administrative jurisdiction. Their investigators can 7 come out and arrest you for a violation of the 8 California Medical Practice Act. They are a law 9 enforcement agency and they have that access. They 10 have the criminal investigative staff to do that and 11 are charged statutorily with that responsibility. So 12 the boards doing it have a different situation than we 13 do. 14 PRESIDENT HUG-ENGLISH: I think one of the 15 things that gives me confidence in the process that we 16 have is that we do get the Federation report of any 17 action that has been taken not only in this state but 18 nationally, and so we do have those that get picked up 19 that way that maybe haven't put it on their application 20 either for renewal or initial licensure. And then 21 those people are coming before this Board for us to 22 make a determination what happens. And so I think the 23 sense from this Board is we don't think we're missing 24 that many by the process we have. I think we have one 25 of the most stringent -- well, we have the most 0116 1 stringent guidelines in the nation for initial 2 licensure. We have three years postgraduate training 3 mandated. In addition, after the last legislative 4 session, now it has to be three years progressive 5 postgraduate training to get a license. 6 And so I think we have taken steps in other 7 ways to ensure that the licensees that come to this 8 state are qualified and have been thoroughly evaluated. 9 And so I think that's where this Board is having a 10 little bit of an issue as to whether or not we need to 11 put one more hurdle in place that maybe in the data 12 you're giving us we're going to pick up 15 out of 13 48,000. And is that really worth the time and the 14 effort and the expense to do it? I don't know. 15 DR. CARLSON: It is to that one person who 16 may be injured. 17 PRESIDENT HUG-ENGLISH: I think it's an 18 important issue. I think it's one that's timely to be 19 raised. And certainly we can't take any action on it 20 today because it's for information. 21 MEMBER BAEPLER: The Florida statistics 22 which suggest that one out of 3,000 licensees, which 23 means that in the state of Nevada we would pick up 1.5 24 doctors, if we had the same problem as Florida. We 25 have less than 5,000 doctors. Okay. It equates to 0117 1 like, if the Florida situation was identical to ours, 2 if my math is correct, I believe approximately 1.5 3 doctors would be caught. 4 PRESIDENT HUG-ENGLISH: Anybody have any 5 further discussion? 6 Dr. Carlson, did you have anything else you 7 wanted to add? 8 DR. CARLSON: Well, no. I think it's going 9 to come eventually especially after 9-11. 10 PRESIDENT HUG-ENGLISH: I think you're 11 probably right. I think the issue of how and when, 12 certainly if we were to even look at it, we would need 13 to go to the Legislature to do it. 14 DR. CARLSON: At Washoe we don't feel as a 15 hospital we should do it individually. That's why 16 we've presented it to you, and it should be by your 17 Board. 18 MS. VANDEMAN: And I think the national 19 statistics for people that are running these test quite 20 well to -- it's like your point about the physician in 21 Yerington, your credentialing process. We're really 22 doing a good job. We really are. The processes are in 23 place to really filter out. If places that are doing 24 these checks have that small of a number, my fear is, 25 as I go to conventions that are geared towards my 0118 1 profession, which is a very different audience than the 2 people in here, the movement is just it's almost -- 3 it's almost a frenzy. It's just amazing. 4 When I was in Chicago just recently, I was 5 amazed. I specifically signed up for a three-hour 6 thing. This guy, it was an attorney that got up and 7 was talking about the credentialing process, doing such 8 a wonderful job of filtering out physicians. And he 9 was actually booed off of the stage because of his 10 stance on criminal background checks. So I fear that I 11 would like to see -- I fear it's going to come on us 12 whether or not the statistics show that it's value 13 added. But if it does, I would very much like to 14 protect physicians from having to go through it for 15 every single hospital that they're on staff for. So if 16 down the road it starts coming to that, I would 17 appreciate looking at that. Because when a physician 18 applies for seven hospitals in Las Vegas, that would be 19 hugely expensive and very onerous for them to do that 20 individually. 21 MEMBER STEWART: Don't they have a central 22 verification office? 23 MS. VANDEMAN: If it comes to the point 24 where individual hospitals start, because it's a 25 national movement, start having to do this, it could be 0119 1 really -- 2 MEMBER LUBRITZ: I think if the national 3 movement does that, they should spend more time and 4 more money doing more productive things, like giving 5 away some free care to patients rather than trying to 6 nail one or three out of 48,000. I think you all have 7 better things to do. Personally. 8 PRESIDENT HUG-ENGLISH: Well, I thank you 9 both for coming and bringing it to our attention, and I 10 think it certainly warrants a lot of discussion. 11 DR. CARLSON: One point, Washoe spent about 12 $80 million on indigent care. We are doing our part. 13 MEMBER LUBRITZ: We are too, doctor. Thank 14 you very much for coming. 15 DR. CARLSON: Thank you for having us. 16 MR. LESSLY: We can do matters for future 17 agenda that I can talk about. We can do ratification, 18 No. 13. We can have dinner and come back tomorrow and 19 finish. 20 21 13. Ratification of Licenses Issued, and Reinstatements of Licensure and Changes of 22 Licensure Status Approved Since the November 30 & December 1, 2001 Board Meeting. 23 24 PRESIDENT HUG-ENGLISH: 13 is ratification 25 of licenses issued and reinstatements of licensure and 0120 1 changes of licensure status. I think you all have 2 looked at that. 3 MEMBER STEWART: Move to approve the action. 4 MEMBER LUBRITZ: Second. 5 PRESIDENT HUG-ENGLISH: There's a motion to 6 approve and a second. 7 Any discussion? 8 All in favor. Opposed? 9 Chair votes in favor of the motion. The 10 motion carries. 11 (Whereupon a motion was made, seconded and 12 passed unanimously.) 13 14 19. MATTERS FOR FUTURE AGENDA 15 16 MR. LESSLY: The only two things we have 17 left, we have Agenda Item 18 has been withdrawn by the 18 Clark County Medical Society, and matters for future 19 agenda, at the June meeting we traditionally do the 20 review of staff and the salary evaluations. I need a 21 meeting of the internal affairs committee which is 22 chaired by Dr. Jones. Dr. Stewart and Dr. Lubritz 23 would need to be looking at a meeting sometime in the 24 month of May for that purpose. And we have some other 25 things that need to be discussed at that time, in 0121 1 addition to the salary and the staff evaluations. 2 On the June agenda we would like to discuss 3 the legislation or regulation changes, if any Board 4 members feel appropriate, for the next legislative 5 session or that simply need to be done in conjunction 6 with legislation in the form of regulation. 7 And we need to schedule elections and 8 appointments of committees on the agenda meeting. I 9 would ask these three things go on the agenda as 10 matters for future agenda. 11 PRESIDENT HUG-ENGLISH: We need a motion. 12 MEMBER LUBRITZ: Did not Dr. Chanderraj ask 13 to move -- 14 MR. LESSLY: He asked if we would take him 15 off of this agenda and put him on that agenda. You 16 might just include that. 17 MEMBER BAEPLER: Really? So he won't be 18 here? 19 MR. LESSLY: He will not be here. 20 MEMBER BAEPLER: That's an agenda item which 21 -- 22 PRESIDENT HUG-ENGLISH: 18. 23 Is there a motion? 24 So ordered. 25 MR. LESSLY: With that, that's as far as we 0122 1 can go tonight. 2 3 7. REPORTS 4 5 PRESIDENT HUG-ENGLISH: Actually, John just 6 arrived. So we'll put you to work. 7 UNIDENTIFIED SPEAKER: I apologize for my 8 lateness here. 9 MEMBER BAEPLER: I told you your timing was 10 perfect. I met him at the door. 11 UNIDENTIFIED SPEAKER: The report I have to 12 make tonight would be is that one of the physician 13 assistant advisory committee members resigned. Sue 14 Vanslaw actually left the state. And I would like to 15 present to the Board Brian Laub as a representative 16 candidate for the position. 17 Brian has been a Nevada resident since 1980. 18 He works in Fernley in a rural health clinic, in family 19 practice there, is the current president of the Academy 20 of Physician Assistants and the first northern 21 president. And it's been a nice bridge in the last few 22 years with the north and the south getting our 23 membership together. 24 Brian also serves on the National House of 25 Delegates and the American Academy of Physician 0123 1 Assistants. 2 And he's highly recommended by myself, Nancy 3 Munoz and the departing Susan Vanslaw. 4 MEMBER BAEPLER: How many members are on 5 your board? 6 UNIDENTIFIED SPEAKER: We've had three so 7 far. 8 MEMBER BAEPLER: Okay. 9 The question I have is that Brian has been 10 practicing in Nevada from 1997, and I'm not quite sure 11 as far as the regulation how that would apply for an 12 advisory member. I know that other members have to 13 currently reside in Nevada for five years. The medical 14 board members that serve, the six-member medical board 15 have to have practiced in Nevada for five years or 16 licensed in Nevada for five years. 17 MR. LESSLY: I think the PAs -- 18 MEMBER TITUS: Since 1997. 19 UNIDENTIFIED SPEAKER: It was actually 20 toward the end of 1997. 21 UNIDENTIFIED SPEAKER: I thought they were 22 the same as a therapist. It was three years. 23 MEMBER BAEPLER: He's seven or eight months 24 away from meeting that requirement, if it's five. End 25 of 2002 would do it. 0124 1 UNIDENTIFIED SPEAKER: Right. 2 MEMBER BAEPLER: Check and see if it's five 3 or three. 4 UNIDENTIFIED SPEAKER: It's 630.060 and 075 5 in the revised statutes. 6 MEMBER TITUS: I would move we accept your 7 recommendation pending his legitimate length of time in 8 Nevada. 9 UNIDENTIFIED SPEAKER: 630.060, 10 qualification of members. And then below that, in 11 630.075, appointment of physician or member of public 12 to serve. 13 MR. LESSLY: None of those apply. 14 DR. CARLSON: You have a separate section 15 under advisory committee, same thing for RCPs. 16 MR. LESSLY: It's three years. 17 PRESIDENT HUG-ENGLISH: Well, that's great. 18 MEMBER BAEPLER: I think he'd be a good 19 member. 20 UNIDENTIFIED SPEAKER: Yes. I mean we 21 really feel strongly. Nancy and Susan and I discussed 22 it. 23 PRESIDENT HUG-ENGLISH: Great. Was there a 24 motion? 25 MEMBER TITUS: Motion. 0125 1 PRESIDENT HUG-ENGLISH: And a second? 2 MEMBER JONES: Yes. 3 PRESIDENT HUG-ENGLISH: All in favor? 4 Opposed? 5 The Chair votes for the motion. The motion 6 carries. He's appointed. 7 (Whereupon a motion was made, seconded and 8 passed unanimously.) 9 PRESIDENT HUG-ENGLISH: Oh, that's you 10 sitting there. Well, welcome. 11 Anything else, John? 12 UNIDENTIFIED SPEAKER: Actually, there's no 13 report beyond that. 14 PRESIDENT HUG-ENGLISH: I think that's good 15 news, then. 16 MEMBER STEWART: Literally the problems that 17 exist in the southern part of the state in regard to 18 medical malpractice case and the insurance that exist 19 with Saint Paul leaving the state, I think I know the 20 answer to this, but I'd like to hear it from you. Does 21 the Board have anything that it should say? 22 MR. LESSLY: It has absolutely no 23 jurisdiction over the issue whatsoever. 24 MEMBER STEWART: Thank you. 25 PRESIDENT HUG-ENGLISH: Okay. Any further 0126 1 discussion? 2 3 20. PUBLIC COMMENT 4 5 PRESIDENT HUG-ENGLISH: Before we recess, I 6 need to ask if there's any public comment. 7 Members of the general public may bring 8 matters not appearing on the agenda to the attention of 9 the Board. We may discuss the matters but may not act 10 on the matter. If the Board desires, the matter may be 11 placed on a future agenda. Comment would be limited to 12 accommodate the Board's schedule and other speakers. 13 Anybody who has public comment? Hearing 14 none, we'll recess for the evening. 15 (Recess taken at 6:05 p.m.) 16 17 18 19 20 21 22 23 24 25 0127 1 STATE OF NEVADA, ) ) ss. 2 COUNTY OF WASHOE. ) 3 4 I, DENISE PHIPPS, Certified Court Reporter in 5 and for the County of Washoe, State of Nevada, do 6 hereby 7 certify; 8 That on March 1, 2002, at the Nevada State 9 Board of Medical Examiners, I was present and took 10 verbatim stenotype notes of the Hearing entitled 11 herein, and thereafter transcribed the same into 12 typewriting as herein appears; 13 That said hearing was taken in stenotype 14 notes by me, a Certified Court Reporter, and thereafter 15 reduced to typewriting under my direction as herein 16 appears; 17 That the foregoing transcript is a full, true 18 and correct transcription of my stenotype notes of said 19 hearing. 20 Dated at Reno, Nevada, this 2nd day of April, 21 2002. 22 23 24 DENISE PHIPPS, CCR #234, RDR, CRR 25