April 2011



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April 2011

April 2011
The American Congress
of obstetricians
and gynecologists TODAY
Essential assessments
for women at every
stage of life
Preventive
care
We continue our broad
effort to support our
Fellows and advance
our specialty through a variety
of programs and initiatives. During
our successful Congressional
Leadership Conference (CLC) in
early March, attendees made a
record number of congressional
visits, disseminating information
about why we must repeal
the Independent Payment Advisory
Board, and promoting a
bill to encourage states to establish Maternal
Mortality Review Committees. We held a
joint panel session with the president of the
American College of Nurse Midwives, Holly
Powell Kennedy, CNM, PhD. Our discussion
focused on successful collaborative practice.
Read more on page five.
This year marks the 25th anniversary of our
Voluntary Review of Quality of Care Program
(VRQC). This program is ACOG’s hidden
gem, and an example of how we are working
to improve patient safety across the country.
Years ago, I became involved in this important
program and served as team leader. Read
ACOG Today’s interview with Program Director
John S. Wachtel, MD, on page eight to
learn how the VRQC is a valuable resource for
your hospital’s ob-gyn department.
Among recent practice updates
is our April Committee Opinion
on primary and preventive care, a
reminder to all of us that often the
only doctor a woman sees is her
ob-gyn, so we must take care of all
aspects of her health. Read a summary
on page six.
Another Committee Opinion
from our Committee on Patient
Safety and Quality explains how
to prepare for emergencies and be
effective in emergency response.
This document is described on page 10.
I look forward to seeing Fellows from across
the nation at the ACM in Washington, DC,
April 30–May 4. Don’t miss the President’s
Program on Monday morning featuring Francis
S. Collins, MD, PhD, director of the National
Institutes of Health, covering the future directions
of genomics, Roberto J. Romero, MD,
discussing causes of preterm labor and cerebral
palsy, and David A. Grimes, MD, exposing the
horrific magnitude of misogyny as a major public
health issue around the world.
Plan to attend the welcome reception on
Sunday to reconnect with colleagues and
friends, and join us on Tuesday for the president’s
dinner party, a festive event where we
will honor retiring Executive Vice President
Ralph W. Hale, MD, and his wife, Jane.
Message From the President
Ensuring the best patient care Find this issue online at
www.acog.org/goto/acogToday
Executive Vice President
Ralph W. Hale, MD
Director of Communications
Penelope Murphy, MS
Editor
Laura Humphrey
Design and Production
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Permission to Photocopy/Reprint
Laura Humphrey, editor
email: lhumphrey@acog.org
Address Changes
800-673-8444, ext 2427,
or 202-863-2427
Fax: 202-479-0054
email: membership@acog.org
Copyright 2011 by
The American Congress of
Obstetricians and Gynecologists
PO Box 70620
Washington, DC 20024-9998
(ISSN 0400-048X)
Main phone: 800-673-8444 or
202-638-5577
The American Congress of Obstetricians and
Gynecologists (ACOG) does not endorse or
make any representation or warranty, express or
implied, with respect to any of the products or
services described herein.
ACOG Today’s mission is to keep members
apprised of activities of both The American
Congress of Obstetricians and Gynecologists
and The American College of Obstetricians and
Gynecologists.
cover: illustration source
APRIL 2011 V olume 55, Issue 3
TODAY
Richard N. Waldman, MD,
President
Free poster
Lifetime of care. Order this oversized poster developed by
ACOG’s Office of Communications for your office. Email
communications@acog.org or call 800-673-8444, x2560.
Complimentary, but supply is limited.
2 ACOG TODAY APRIL 201 1 www.ACOG.ORG
The executive desk
The AMA and you
Ralph W. Hale, MD,
Executive Vice President
inside
Makena™ price reduction is inadequate
PRIC E REMAINS PRO HIBITIV E
On April 1, K-V Pharmaceutical Company announced that
it is reducing the cost of its drug Makena™ from $1,500 per
dose to $690 per dose, clearly acknowledging the negative
impact of their original pricing strategy. Although this may seem like
a relatively significant price reduction, unfortunately it remains a
woefully inadequate response. This “lower” price still remains prohibitively
high for a safe and effective treatment that is currently
available at a much lower price in the form of compounded 17
hydroxyprogesterone caproate (17P).
The College applauds the FDA’s statement that it will not prevent
compounding pharmacies from continuing to produce valid prescriptions
for 17P, a medication that has been safely used for years
to help prevent preterm labor in certain high-risk pregnant women.
Although there are clear benefits to having an FDA-approved
version of 17P, there is no evidence that Makena™
is more effective or safer than the currently used compounded
version. In fact, the evidence used to obtain FDA
approval for Makena™ relied primarily on data obtained using
the compounded product.
The College, along with the Society for Maternal-Fetal
Medicine, American Academy of Pediatrics, American
College of Osteopathic Obstetricians & Gynecologists, National
Medical Association, American Academy of Family
Physicians, American College of Nurse-Midwives, and the
Association of Women’s Health and Obstetric and Neonatal
Nurses, will continue to collaborate to ensure that this medication
is accessible and affordable to every pregnant woman who
needs it. The US health care system simply cannot be expected to
absorb the cost of Makena™ at its current prohibitive price without
significant negative repercussions.
“What does the
American
Medical Association
(AMA) do for me?”
This is a question we often
hear from our members whenever
we urge them to join
or continue their membership
in the AMA. There are
a number of answers to this
question, but I want to emphasize
one important component:
Scope of Practice Partnership
(SOPP). The SOPP is a cooperative effort
of the AMA and other leading national and
state medical and national medical specialty
societies.
The SOPP was formed to protect patient
safety and address legislative or regulatory
expansions of scope of practice by nonphysician
health care professionals that may
threaten the health and safety of patients.
This goal is accomplished through a combination
of legislative, regulatory, and judicial
advocacy, as well as programs providing information,
research, and education.
The SOPP has as its goal the
protection of the health and safety
of patients whose well-being
may be threatened by health care
practitioners who lack the education,
training, or experience to
perform procedures or services
for which they seek licensure.
Involvement by the AMA in
public policy
is important
in strengthening
the
voice of ob-gyns in policymaking.
To protect
our patients, we need
the help of the AMA and
the SOPP. Please join or
remain a member of the
AMA and of your state and
local society. Your involvement
makes a difference to
our partners, our specialty,
and most of all, to the women we care for.
Updates for well-woman care 6
Conversation with John S. Wachtel, MD 8
All women should be offered CF screening 9
April is STD awareness month . 9
Preparing for clinical emergencies 10
EHR incentives program . 11
Ne w release
The Gynecologist Workforce
in the United States: Facts, Figures,
and Implications
Author William F. Rayburn, MD, MBA,
explores evolving ob-gyn workforce issues
projected to have a broad impact
on physician satisfaction and patient
access to care. Purchase hard copies
from the ACOG online Bookstore at
www.acog.org/bookstore (search for item
#AA551), and at the ACOG Booth and Bookstore
at the ACM, April 30–May 4, in Washington, DC.
The book will be available beginning April 29 in
an online format to members at no cost at
www.acog.org/publications/obgynWorkforce.
www.ACOG.ORG april 201 1 ACOG TODAY 3
The Accreditation Council for Graduate
Medical Education (ACGME)
has selected ACOG Fellow John R.
Musich, MD, as a recipient of its Parker J.
Palmer “Courage to Lead” Award. The award
honors designated institutional officials who
have demonstrated excellence in overseeing
residency programs and fostering a superior
environment for resident education.
Dr. Musich has dedicated his ob-gyn career
to teaching. He recently retired from his
post as vice president and director of medical
education for William Beaumont Hospitals in
Michigan, a position he held since 2002. From
1983–2004, he served as chair and residency
director for Beaumont Hospital’s department
of ob-gyn in Royal Oak, MI.
“There really is no better way to give back
to the ob-gyn profession than by educating
the physicians who will lead us into the future,”
Dr. Musich said. “Few things are more
gratifying than seeing young, eager students
at the start of their careers and having the
opportunity to take part in their training.”
The William Beaumont Hospitals house 37
accredited residency and fellowship programs
with more than 400 residents and fellows.
“I think our hospital system has one of the
best educational records in the country for
its size,” he said. “This award from ACGME
is due in large part to what Beaumont became
educationally while I was there and how
Beaumont enabled me to use my positions as
a platform to contribute to medical education
on a national level.”
He was awarded The College’s Distinguished
Service Award in 2010. He served
as chair and vice chair of District V and as a
member of the Executive Board and Council
of District Chairs. He was the Junior Fellow
College Advisory Council advisor and
a member of the Presidential Task Force
on Resident Education. He was chair and
program chair for the Council on Resident
Education in Obstetrics and Gynecology.
Dr. Musich received his medical degree
from the University of Minnesota in Minneapolis
and completed his residency at the
University of Michigan in Ann Arbor, followed
by a fellowship in reproductive endocrinology
at Beaumont Hospital. He was an examiner for
the American Board of Obstetrics and Gynecology
for 15 years and recently completed a
six-year term on ACGME’s Institutional
Review Committee.
John R. Musich, MD (left), receives congratulations from ACGME’s
Chief Executive Officer Thomas J. Nasca, MD, MACP.
Two ACOG Fellows on ballot for AMA June election
ACOG has endorsed and encourages our members to support two ACOG Fellows who are running for key
positions in the AMA elections to be held in June at AMA’s annual meeting.
Mark S. Seigel, MD, a candidate for the AMA Council on Medical Services, is chair and
legislative chair of ACOG’s Maryland Section and chair of the Committee on Ambulatory
Practice Operations. He is secretary of the Physicians’ Electronic Health Record
Coalition, chair of the Delegation of the Montgomery County Medical Society to the
Maryland State Medical Society (Med Chi), member of the Small Practice Advisory
Committee of the Chesapeake Regional Information System for our Patients
(CRISP), and member of Med Chi’s Information Technology and Bylaws Committees.
He was president of the Montgomery County Medical Society twice
and president of the Maryland State Medical Society and Maryland Obstetrical
and Gynecologic Society.
John W. Spurlock, MD is running for the AMA Council on Constitution
and Bylaws. He has served as chair of ACOG’s Armed Forces
District Junior Fellows. His qualifications include serving as vice
speaker of the Pennsylvania Medical Society, member of the
Board of Trustees for the Pennsylvania Medical Society, and
chair of the AMA’s Reference Committee on Amendments
to Constitution and Bylaws in 2009.
John W. Spurlock, MD
Mark S. Seigel, MD
The labor force
ACOG Fe llow receives ACGM E Courage to Le ad award
4 ACOG TODAY APRIL 201 1 www.ACOG.ORG
ACOG President Richard N. Waldman, MD, led more than 260 ACOG members
from 49 states at ACOG’s 29th Annual Congressional Leadership Conference
(CLC), The President’s Conference, in Washington, DC, February 27–March 2.
The attendees, including more than 100 Junior Fellows, participated in 302 face-to-face
meetings on Capitol Hill. After two days of policy discussions and advocacy training,
ACOG Fellows and Junior Fellows carried two messages to their legislators:
Cosponsor the Maternal Health Accountability Act: CLC participants urged members
of Congress to cosponsor legislation, introduced by Rep. John Conyers, Jr (D-MI),
to encourage states to establish and run maternal mortality review committees (MMRs).
MMRs examine pregnancy-related deaths to identify ways to improve maternal mortality
rates. The bill would improve data collection and help eliminate disparities in maternal
health outcomes.
Repeal the Independent Payment Advisory Board (IPAB): ACOG members
urged cosponsorship of HR 452, legislation introduced by ACOG Fellow Congressman
Phil Roe, MD (R-TN) to repeal (IPAB). IPAB hurts ob-gyns and patients because it can
only recommend Medicare cuts—not any
increases in premiums or copays, or changes
in benefits—leaving physicians to shoulder
most of the cuts.
Fellows and Junior Fellows at the CLC
contributed almost $70,000 to the Ob-Gyn-
PAC at the annual PAC Party and Junior
Fellow Section Officer Leadership Development
reception, with 100% participation
by the Junior Fellows attending the reception.
“We are the future of our specialty
and it is important that we help shape
that future,” said Cynthia A. Brincat, MD,
PhD, chair of Junior Fellow Congress
Advisory Council, recognizing the value
of the achievement.
Visit booth #1821 in the exhibit hall at the ACM to
learn more about ACOG’s peer review programs
for both inpatient and outpatient women’s health
care. The Women’s Health Care Safety Certification
for Outpatient Practice Excellence is seeking innovators
to participate in upcoming pilot site visits. The Voluntary
Review of Quality of Care Program staff will be available
to discuss how peer reviewers can help improve quality and
safety in your hospital’s ob-gyn department.
Learn more about the ACM at
www.acog.org/acm.
ACO G Fellows meet with
members of Congress
ACOG President Richard N. Waldman, MD (right), and then Vice President
of Practice Activities and current Executive Vice President-designate Hal C.
Lawrence III, MD, shared the stage with the president of the American College
of Nurse-Midwives, Holly Powell Kennedy, CNM, PhD, to discuss the importance
of collaborative practice in maternity care.
Rep. Nan Hayworth, MD (R-NY ) (center), opthalmologist and spouse of District II
Chair Scott Hayworth, MD, pauses with the New York delegation after her
presentation on Legislative RX at the President’s Luncheon.
ACOG Fellows from Colorado take a br ief break in be tween Hill visits.
ACM highlight:
ACOG ’s peer
review programs
District and section fellow
officer elections
June 1 nomination deadline
Get involved! ACOG is seeking candidates
for District and Section officers to serve the
2012—2015 term. Candidates must declare
by June 1. To learn how to apply and whether
your District or Section is holding an election in
this election cycle, visit www.acog.org, click on
ACOG Departments, and then on District and
Section Activities. For more information contact
Megan Willis, Fellow election coordinator at
fellowelect@acog.org or 202-863-2531.
www.ACOG.ORG april 201 1 ACOG TODAY 5
The College has released an updated schedule of
recommended routine screenings, lab tests, and immunizations
for non-pregnant adolescents and women.
The revised schedule groups the periodic health assessments
by age range beginning at age 13 and takes into
account individual risk factors that may warrant additional screenings
or counseling.
“The purpose of the annual ob-gyn visit is to detect and treat any
new or ongoing health problems, as well as to help prevent future ones
from developing,” said Hal C. Lawrence III, MD, vice president of practice
activities and current ACOG executive vice president-designate.
“The College urges the US Department of Health and Human Services
to include these screenings, tests, and immunizations included in our
well-woman exam recommendations under the preventive services
that it is considering for inclusion under the new health care law.”
The revised schedule addresses long-standing staples of the
well-woman exam. No matter a woman’s age, there are certain components
of the annual ob-gyn exam that are standard, including
assessment of current health status, nutrition, physical activity, sexual
practices, and tobacco, alcohol and drug use. Across age groups,
the standard physical exam also includes height, weight, body mass
index (BMI), and blood pressure. Annual breast and abdominal exams
begin at age 19, and routine annual pelvic exams begin at age 21.
“Since the age a woman receives her first Pap test changed two years
ago to age 21, and most women can have them less frequently than previously
recommended, there’s this misconception that if you don’t need
a Pap then you can skip the ob-gyn visit altogether,” said Dr. Lawrence.
“Nearly every woman age 21 and older needs an annual well-woman
visit with her ob-gyn, regardless of whether cervical cancer screening is
done. The Pap test is just one part of staying healthy.”
preventive care
College updates
screening
recommendations
for
6 ACOG TODAY APRIL 201 1 www.ACOG.ORG
The new Committee Opinion, Primary and Preventive Care:
Periodic Assessments, includes information regarding which vaccinations
are recommended, by age and risk group, including the flu shot,
Hepatitis A and B, human papillomavirus
(HPV), and measles. Annual testing for
chlamydia and gonorrhea is recommended
for all sexually active adolescents and
young women up to age 25. HIV testing
recommendations include annual testing
for all sexually active adolescents, routine
screening of women ages 19–64, and
targeted screening for women with risk
factors outside of that age range. Women
from ages 21–30 should be screened every
two years for cervical cancer. Most women
age 30 and older who have had three
consecutive negative cervical cytology test
results may be screened once every three
years, with certain exceptions.
“Periodic assessments offer an excellent
opportunity for ob-gyns to provide preventive screening,
evaluation, and counseling. Personal behavioral characteristics are
important aspects of a woman’s health. Positive behaviors, such as
exercise, should be reinforced, and negative ones, such as smoking,
should be discouraged,” said Cheryl Iglesia, MD, chair of The College’s
Committee on Gynecologic Practice. “Because an ob-gyn is often the
only physician a woman will see on an
annual basis, ob-gyns need to screen
patients for psychosocial issues, including
family relationships and domestic
partner violence, as well as stress, sleep
disorders, injury prevention, and substance
abuse.”
The College’s recommendations
serve as guidelines for ob-gyns, and
they should be modified as necessary
to meet individual patient needs. “For
instance, we recommend that women
have their first mammogram at age
40, and yearly beginning at 50, but a
woman and her doctor may decide she
needs a baseline mammogram before
age 40,” said Dr. Lawrence.
Committee Opinion #483, Primary and Preventive Care: Periodic
Assessments, is published in the April 2011 issue of the Green Journal,
and is online under Publications at www.acog.org.
The Affordable Care Act guarantees
women access to preventive health
benefits with no-cost sharing in private
health plans and guarantees that all health
insurance policies sold within newly forming
state health exchanges cover maternity care.
ACOG recently provided expert guidance to
the Institute of Medicine, which is working with
the US Department of Health and Human
Services, to determine what women’s preventive
services should be covered and how policies
should be written to ensure access to the
full range of maternity care.
Hal C. Lawrence III, MD, then vice president
of practice activities and current ACOG
executive vice president-designate, testified
before the Institute of Medicine (IOM)
Panel on Preventive Services
for Women. He urged
the IOM to include
contraceptive counseling
and services in the guaranteed
preventive benefit package.
“The US has the highest rate of
unintended pregnancy in the developed world.
Approximately half of all pregnancies are unintended.
In addition to the health impact,
unintended pregnancies result in tremendous
individual and societal consequences including
family upheaval, nonattainment of educational
goals, and financial burdens,” he told the
panel. “It is essential that women have access
to counseling that supports them in choosing
a contraceptive method that is best for them
and in using that method effectively.”
Dr. Lawrence urged that an array of other
important care be provided without cost sharing,
including well-woman visits, preconception
care, counseling about and provision of family
planning, routine HIV screening of women
ages 19–64, and targeted screening for women
with risk factors outside of that
age range, and testing for
HPV as part of cervical
cancer screening.
Dr. Lawrence
said ACOG believes
screening
to identify intimate partner abuse is critically
important. “Screening for domestic and partner
violence is essential to the overall health
of women, and we urge the IOM committee
to include it in its final recommendations.
Women living with abuse need to know they
have options,” he said.
Arnold Cohen, MD, chair of the department
of ob-gyn at Albert Einstein Medical
Center, also testified on behalf of ACOG in
front of the Committee on Determination of
Essential Health Benefits, urging the IOM to
reject definitions of “medical necessity” that allow
health insurers to emphasize cost and resource
utilization over quality and clinical care.
He explained that essential benefits in women’s
health have already been defined by ACOG’s
body of work. “Our clinical and practice guidelines
are relied upon by more than 54,000
practicing ob-gyns and women’s health care
providers,” he said. “We urge you not to reinvent
the wheel but to rely instead on ACOG’s
widely available documents to define health
care benefits and medical necessity.”
ACOG helps define essential benefits under health care reform
The College’s
recommendations
serve as guidelines
for ob-gyns and they
should be modified
as necessary to
meet individual
patient needs.
www.ACOG.ORG april 201 1 ACOG TODAY 7
Please explain the purpose of the
VRQC Program.
The purpose of the VRQC Program is to provide
confidential peer review consultations
to departments of ob-gyn, assess the quality
of care provided, and offer recommendations
on patient safety and improving the quality of
care for women.
Why do you consider it “ACOG’s
hidden gem?”
The program is underutilized. Although we
have done more than 275 reviews in the past
25 years, this represents only about 10% of
hospitals that practice obstetrics in the US.
Every ob-gyn department, no matter how
outstanding its care, can benefit from a comprehensive
review by the VRQC Program.
How did you get involved with the
VRQC Program?
I have had a career-long interest in peer
review, quality assurance, and quality improvement
efforts. I began at the local level
at Stanford Hospital, then became a consultant
for the Medical Board of California, and
eventually served on The College’s national
PSQI Committee. I was accepted as a VRQC
reviewer in 1995 and became program director
in 2009. Helping improve care at hospitals
around the country perhaps has been my
most rewarding professional activity.
What are the
most common
reasons that
hospitals request
a review?
The requests are as varied as the hospitals
we review. Many hospitals want comprehensive
department evaluations to ensure they
are practicing within The College’s guidelines.
Some hospital systems want assurance
that their member hospitals are providing
safe and high quality care, even when no
problems have been identified. Other times,
a request can be related to a particular procedure,
cesarean delivery rates, or a high
incidence of non-medically indicated inductions.
Before going on site, we always discuss
the issues involved to ensure we have the
right expertise as part of the team.
What is the composition of a
review team, and does VRQC
provide training?
We have a pool of approximately 26 physician
reviewers, five nurse reviewers, and three
medical writers from which we assemble a
unique team for every site visit based on geographical
diversity, availability, and the needs
of the hospitals. Teams are usually composed
of five members: three actively practicing obgyns,
a nurse reviewer, and a medical writer.
We can add a family physician, an anesthesiologist,
and/or a certified nurse-midwife
(CNM) reviewer, if such expertise is needed.
Our ob-gyn reviewers must be board-certified
Fellows of ACOG for a minimum of five
years and experienced in peer review/quality
assurance techniques. We have a rigorous
evaluation for all new reviewers, and we
conduct training sessions every three years.
Our next training session will take place this
month in Washington, DC, just before the
start of the ACM, on April 29–30.
How are the teams received
when they arrive at the hospitals?
We begin every site visit with a meeting where
the team is introduced and the entire process
is explained. We want this to be a collegial experience
during which the invited guests help
the providers to achieve clinical excellence.
Can you describe the process
for the report production?
Once the team leaves the site, the medical
writer drafts a report based on the findings
at the hospital and recommendations
made by the team at the exit conference. The
team carefully reviews and edits this draft
to ensure consistency with current College
guidelines. The complete report of all findings
and recommendations is delivered to the
hospital about eight weeks after the site visit.
What are the most commonly
evaluated clinical problems?
Many of the reviews have a strong emphasis
on obstetric procedures such as inductions of
labor, cesarean delivery rate, VBACs, and operative
vaginal deliveries. In gynecology, we
often address inappropriate hysterectomies,
inadequate pre-op workups, or new technology.
Whether we are looking at obstetric or
gynecologic concerns, the number-one patient
safety issue is poor communication,
which is evident in many ways.
John S. Wachtel, MD
conversation
ACO G’s hidden gem:
The VR QC program
John S. Wachtel, MD, is the program director
of ACOG’s Voluntary Review of Quality of Care
(VRQC) Program. He is an adjunct clinical professor
in the Department of Ob-Gyn at Stanford
University School of Medicine, immediate past
chair of The College’s National Patient Safety and
Quality Improvement (PSQI) Committee, and
chair of the District IX PSQI Committee. In honor
of the 25th anniversary of the VRQC Program,
ACOG Today spoke recently with Dr. Wachtel.
8 ACOG TODAY APRIL 201 1 www.ACOG.ORG
More than 19 million cases of sexually transmitted diseases (STDs) occur in the US each year,
with a disproportionate share among young people and racial and ethnic minority populations.
Left untreated, STDs can cause serious health problems ranging from infertility to increased
risk of HIV infection. To help stop these silent epidemics, the 2010 Centers for Disease
Control and Prevention’s Sexually Transmitted Diseases Treatment Guidelines advise healthcare
providers on treatment, screening, and prevention. CDC revises the guidelines approximately
every three to four years. The guidelines, and information
on webinars, hard copy ordering, wall charts, pocket
guides, and iPhone and eBook versions are online at
www.cdc.gov/std/treatment/2010. Read about the 2010
changes as they pertain to adolescent females at
www.acog.org. Click on ACOG Departments and
then Adolescent Health Care.
What are the greatest strengths
of the VRQC Program?
First and foremost, this is a purely voluntary
process. Hospitals appreciate recommendations
made by the team that are based on
The College’s guidelines. The fact that we
have a nurse reviewer evaluating the quality
of the nursing staff, as well as policies
and procedures in the department, allows
all members of the hospital staff to accept
suggestions. Our attention to confidentiality
and anonymity throughout the process
is reassuring to those undergoing review.
How does the VRQC Program
evaluate its impact on the hospital?
After every review, the hospital is asked to
complete a comprehensive evaluation assessing
the program, the process, and the
individual reviewers. Again, after the final
written report is provided, a second
evaluation is requested to determine what
recommendations were implemented, which
were not, what barriers to implementation
were encountered, and other issues. While
it is very difficult to confirm improved patient
outcomes and safety parameters in
such a short time, especially with limited
data collection available at many hospitals,
the subjective feedback is overwhelmingly
positive. On occasion, the team uncovers a
critical problem requiring immediate attention,
which the hospital corrects even before
receiving the final report.
What are the future goals
for the VRQC Program?
We hope more hospitals will benefit
throughout the country by undergoing a review.
The VRQC Program is also exploring
possible ways to move into the physician
office setting to help improve quality of
care there.
An article by Abe Lichtmacher, MD,
published in Obstetrics and Gynecology
Clinics of North America (volume 35,
March 2008, 147–162) includes further
information.
Visit www.acog.org/goto/vrqc or email
vrqc@acog.org to learn more about the
VRQC Program.
April is STD awareness month
All women should be offered cystic
fibrosis screening, regardless of ethnicity
Preconception and prenatal cystic fibrosis (CF) carrier screening should be made available
to all women of reproductive age as a routine part of obstetric care, according to a revised
Committee Opinion issued by The College. In addition to an update of current guidance
for CF screening practices, the document discusses counseling strategies, special reproductive
health considerations for women with CF, and clinical management recommendations.
Cystic fibrosis is a progressive, multisystem disease that primarily affects the lungs, pancreas,
and digestive tract. CF significantly shortens the lifespan of people affected by it—median survival
is approximately 37 years. Because CF is caused by an inherited genetic mutation, carrier screening
is recommended to identify couples at risk for having a child with the disease.
The incidence of CF is highest among non-Hispanic white individuals (roughly 1 in 2,500) and
people of Ashkenazi Jewish ancestry. CF is considerably less common (but still occurs) in other
ethnic groups. The College recommends that CF carrier screening be offered to all women of
childbearing age, preferably before conception. Women who are CF carriers and their reproductive
partners may need additional screening tests and referrals for genetic and reproductive counseling.
The College also recommends contraception and preconception
consultation for women with CF who are considering pregnancy.
They should be told that their children will be CF carriers and
that their partners should also be screened to determine
carrier risk. Women with CF who want
to become pregnant can work with a multidisciplinary
team to manage issues such as
pulmonary function, weight gain, infections,
and the increased risk of diabetes and preterm
delivery.
Committee Opinion #486, Update on
Carrier Screening for Cystic Fibrosis, is
published in the April 2011 issue of
the Green Journal and online under
Publications at www.acog.org.
www.ACOG.ORG april 201 1 ACOG TODAY 9
Prevention of GBS
infection
The College has issued revised guidelines
for the prevention and treatment
of perinatal group B streptococcal
(GBS) disease. The document summarizes
the 2010 US Centers for Disease Control GBS
guidelines, which The College has endorsed,
and highlights important changes in clinical
practice for ob-gyns.
GBS is fatal in about 5% of babies who carry
it. An estimated 10%–30% of pregnant women
are infected with GBS and up to 2% will transmit
it to their newborns during delivery. Many
GBS infections occur between six hours and
seven days of birth, though late-onset infections
can develop. Infants born to black and
Hispanic women and women younger than age
20 are at increased risk.
The College recommends that all pregnant
women be screened for GBS at 35–37 weeks’
gestation and that preventive antibiotics be
given to women who test positive during labor.
“National guidelines to prevent mother-toinfant
GBS transmission have led to an 80%
reduction in early onset sepsis in neonates,”
said Ronald S. Gibbs, MD, a member of The
College’s Committee on Obstetric Practice.
“Unfortunately, despite these strides, GBS remains
the leading cause of infectious mortality
and morbidity among newborns.
“While the core recommendations are the
same, the new document provides further
direction for clinicians in implementing and improving
prevention strategies,” Dr. Gibbs added.
Included are updated case scenarios for GBS
screening and antibiotic treatment for women
with preterm labor or preterm premature rupture
of membranes; management plans for
newborns at risk of early-onset GBS disease; and
updated antibiotic regimens for women with
penicillin allergy.
Committee Opinion #485, Prevention of
Early Onset Group B Streptoccocal Disease in
Newborns, is published in the April 2011 issue of
the Green Journal and is online under Publications
at www.acog.org.
Preparing for clinical emergencies
The ob-gyn practices in an environment where true emergencies periodically occur,
particularly in the inpatient setting. A new Committee Opinion released by The
College explains how to prepare for emergencies, and how to use communication
and teamwork to increase the effectiveness of emergency response.
Whether severe shoulder dystocia, catastrophic surgical or obstetric
hemorrhage, or an anaphylactic reaction to an injection in the
office, all emergencies require prompt response. It is important for
ob-gyns to prepare for these events by assessing potential emergencies
that might occur, establishing early warning systems, designating
specialized first responders, conducting emergency drills, and debriefing
staff after actual events to identify strengths and opportunities for
improvement. Having such systems in place may reduce or prevent
the severity of medical emergencies.
Some emergencies are sudden and catastrophic, such as a ruptured
aneurysm, massive pulmonary embolus, or complete abruptio placentae. These
are best handled by rapid response teams (RRT s). “The criteria used to activate the RRT
must be clearly defined among potential ‘activators’ well in advance of any emergency,”
said Gregory W. Lau, MD, a member of The College’s Committee on Patient Safety
and Quality Improvement. Preparation for in-hospital situations requires that emergency
supplies be placed in locations well known to members of the RRT . “It is also important
to ensure that all members of the RRT receive ongoing education and training, including
experience with drills,” said Dr. Lau.
While some emergencies are abrupt and unforeseen, many are preceded by a period of
instability during which timely intervention may help avoid disaster. “All caregivers should
realize that certain changes in a patient’s condition, such as new onset difficulty with movement,
can indicate an emergency that requires immediate intervention,” noted Dr. Lau.
“These changes include some events not usually understood as emergencies. It is imperative
that bedside personnel be able to request immediate help without recrimination when
such changes occur.”
Committee Opinion #487, Preparing for Clinical Emergencies in Obstetrics and
Gynecology, is published in the April 2011 issue of the Green Journal, and online at
www.acog.org under Publications.
Gregory W. Lau, MD
Correction:
The March 2011 print edition inaccurately stated
that colorectoral cancer is the “third leading
cause of death among US women.” It is the third
leading cause of cancer death in US women.
10 ACOG TODAY APRIL 201 1 www.ACOG.ORG
Electronic health record
incentives program open
First deadline is October 1
Ob-gyns and hospitals that wish to participate in the federal
Electronic Health Record (EHR) Incentive Program, whether
Medicare or Medicaid, must register online through
the Centers for Medicare and Medicaid Services (CMS) website at:
www.cms.gov/ehrincentiveprograms. Physicians who are eligible
will receive Medicare or Medicaid incentives from CMS if they are
“meaningful users” of a certified EHR.
Providers who choose to take part in 2011 must
begin their 90-day reporting period by October 1. Eligible
professionals can receive up to $44,000 over five
years under the Medicare Program. Although participation
is voluntary, physicians who do not adopt
certified EHR technology and do not use an EHR
system in a meaningful way can face penalties in the
form of Medicare reimbursement reductions beginning
in 2015. The Medicaid EHR Incentive Program
is voluntarily offered by states beginning as early as this year, depending on
the state. Eligible professionals can receive up to $63,750 over six years.
“Now may be the time for your practice to purchase and implement an
EHR system,” said Nefertiti C. DuPont, MD, MPH, member of ACOG’s
Committee on Professional Liability. “Technology has changed and it is
evolving rapidly. Gone are the days when we can rely on paper charts to
find and record patient information.”
“One of the biggest hurdles is the financial investment of
purchasing an EHR system,” said Patrice M. Weiss, MD, chair of The
College’s Committee on Patient Safety and Quality Improvement, “but
federal funds are intended to help practices and medical centers install
and incorporate this new technology.”
The so-called “meaningful use” objectives
provide basic standards that must be met to
qualify for EHR incentive funds. “While
these may seem confusing, most of the
objectives are easily met with a good EHR
system,” said Dr. DuPont. The core objectives
of an EHR system include computerized
provider order entry for medication orders,
drug-drug and drug-allergy checks, electronic
prescribing, patient demographics, patient
problem lists, current and
past vital signs, smoking
status, clinic notes for office
visits, clinical quality measures,
electronic exchange
of information to multiple
providers, and security of
patient data.
“There are pros and cons
to EHR implementation, but it is my opinion
that the benefits outweigh the burdens,” said Dr.
DuPont. “Admittedly, it is not easy to transition
to a new system, especially for those of us who are comfortable with our
current office practices, but we may face more reductions in Medicare
reimbursement if we don’t adopt EHRs.” EHRs efficiently handle a large
amount of patient data, prescriptions, lab results, follow-up reminders,
and evidence-based guideline recommendations for physicians.
“EHRs can reduce medication errors, increase adherence to practice
guidelines, and improve immunization rates. On the business side,
EHRs can decrease transcription costs, improve billing and coding,
increase staff productivity, and improve laboratory test and imaging
utilization,” said Dr. DuPont.
Learning to use EHR systems can be difficult. “The learning curve
with this new technology is steep, so providers must be patient,” Dr.
Weiss noted. Corrupted data and software incompatibility are a few of
the known technology-related downsides to computerized record systems.
“And, of course, when computer systems crash, as they sometimes
do, access to the patient records will be affected,” she said. For these
reasons, establishing an information technology (IT) department with
round-the-clock staff support is important. Solo ob-gyn physicians who
have smaller practices can purchase EHR systems with online support.
“Technology will continue to advance quickly. The transition to
EHRs may be uncomfortable, but the time has come for many of us to
embrace a paperless office which can improve the quality of care we
provide,” said Dr. DuPont.
For information, visit www.acog.org and click on Health Information
Technology under Practice Management.
Committee Opinion #472, Patient Safety and the Electronic Health
Record, was published in the November 2010 issue of the Green Journal
and is online under Publications at www.acog.org.
ACM sessions on
elec tro nic record s
To register, visit
www.acog.org/acm
Sat urday , April 30
The Ob-Gyn in the
Electronic Age (SA304)
8:15 am–Noon
Robert Fagnant, MD
Fah Che Leong, MD
Tuesday , May 3
EMRs for OBs and
Health Reform (LT13)
12:15–1 pm
Mark S. Seigel, MD
Nefertiti C. DuPont, MD
Patrice M. Weiss, MD
www.ACOG.ORG april 201 1 ACOG TODAY 11
The American Congress of
Obstetricians and Gynecologists
PO Box 70620
Washington, DC 20024-9998
Presort
STANDARD
U.S. POSTAGE
PAID
Permit No. 251
TODAY
Making the Rounds
The following documents appear in the Green
Journal and are online under Publications at
www.acog.org.
Practice Bulletin
• 119 Female Sexual Dysfunction (April 2011)
Committee Opinions
• 487 Preparing for Clinical Emergencies in
Obstetrics and Gynecology replaces #353
(April 2011)
• 486 Update on Carrier Screening for
Cystic Fibrosis replaces #325 (April 2011)
• 485 Prevention of Early-Onset Group B
Streptococcal Disease in Newborns replaces
#279 (April 2011)
• 484 Performance Enhancing Anabolic Steroid
Abuse in Women (April 2011)
• 483 Primary and Preventive Care: Periodic
Assessments replaces #452 (April 2011)
Plan to attend the 59th ACM in Washington, DC, April 30–May 4. View the program
at www.acog.org/acm. National and international faculty will lead courses and
seminars on the latest scientific developments, standards of practice, testing procedures,
and pharmacological therapies. Outstanding symposium sessions will include a distinguished
panel on Tuesday, May 3 at 1:30 pm on lowering maternal mortality around the
world, featuring FIGO President-Elect Professor Sir Sabaratnam Arulkumaran; UK National
Clinical Director for Maternal Health Gwyneth Lewis; University of Texas Galveston
Professor Kyriakos S. Markides; and University of Louisville Professor and Maternal and
Fetal Health Director Jeffrey King, MD. Don’t miss late-breaking news from our sub-specialty
societies and the newest research from the Society of Gynecologic Investigation.
Raul Artal, MD
Chair, Committee on Scientific Program
To learn more, visit www.acog.org/acm.
Raul Artal, MD
ACM highlight:
global maternal
mortality
ACOG Courses and Coding Workshops
Ap ril 12 ACOG Webcast: Coding for Consultation Services
May 5–7 Coding Workshop, Washington, DC
May 10 ACOG Webcast: ACOG VRQC Program: Using Standardized
Worksheets for Peer Review
June 9–11 Quality and Safety for Leaders in Women’s Health Care, Chicago, IL
June 10–12 Coding Workshop, Indianapolis, IN
June 14 ACOG Webcast: Coding for Wound Repair: Post-Operative and Postpartum
July 8–10 Coding Workshop, Los Angeles, CA
July 12 ACOG Webcast: Robotic Surgery in Gynecology
August 5–7 ACOG Coding Workshop, Dallas TX
August 9 ACOG Webcast: ICD-9 to ICD-10: What to Expect
August 26–28 ACOG Coding Workshop, Richmond, VA
Sep tembe r 9–11 ACOG Coding Workshop, Las Vegas, NV
Sep tembe r 13 ACOG Webcast: Communication and Cultural Sensitivity
Octobe r 11 ACOG Webcast: Global Surgical Package Coding
Octobe r 21–23 ACOG Coding Workshop, Seattle, WA
Novembe r 8 ACOG Webcast: Thrombophilias in Pregnancy
Get updates and register at www.acog.org/postgrad/index.cfm.
To learn about freestanding postgraduate courses, email
PGC ourses@acog.org. To learn about coding courses and webcasts,
call 202–863–2498 or email coding@acog.org.