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Comprehend How to Fulfill the Michigan Lara Form

thank you for joining us for Lara live I.am here with dr. Peter Graham from.Sparrow and Lansing and my name is Kim.Gattaca I'm the deputy director for.licensing and regulatory affairs and we.are here today to discuss maps and some.of the new opiate legislation that's.been enacted and and some of those are.going to be in effect July 1 of this.year and several of them have already.gone into effect this year and so if you.have specific questions please put them.in the comments below for those of you.who are joining us here with us today.and we will try to address them as soon.as we can so let's just start this whole.conversation about maybe some of your.experiences with maps as you know we.replace the entire system and maps being.the Michigan RNA prescription system and.you're a physician and maybe you could.share with us some of your experiences.and then we can start going into maybe.any questions that you might have with.some of the new laws that are taking.effect sure and I'll try to reflect some.of the questions they've heard from my.colleagues you can make er important.I've been in practice 20 odd years so.that creeps up in a hurry I'm old enough.to remember the previous maps I think.most of us are so the new iteration has.been a welcome change.hey I said you're probably glad to hear.that and not to associate it whoever.developed the previous maps I'm sure.back in the mid 90s oh it's created at.the state of the art cutting edge and.all the rest and personally it's very.clunky that sign on is not easy trying.to get your login credentials is not an.easy process the avarice backed map.system has a really easy touch feel to.it feels like most of the other.web-based interfaces that most of us are.used to impede your credit card bill.online you can handle maps it's easy.the only issue with it it's not really.pretend actually this is a both good and.bad thing Matt's it the newer maps.much quicker so searches the pretty much.instantaneous table the batch searches.were able to look at different.parameters listen they say have out of.state filled data which is really.helpful to us I'm particularly of our.colleagues who are in border areas like.Benton Harbor or iron mouth there's a.place whereby a state border.the only drawback at this point I think.the good news with a Peres's they're big.enough outfit have enough footprint that.very will work with the EMR vendors to.integrate it in tomorrow flow which is.already starting to happen it may not be.as easy if you're in solo practice or.single practice but for those of us who.have the right kind of support in the.right type of EMR there the process of.integrating those into you Marshall is.that's when it really becomes a most.usable you don't have to essentially go.from page to page or out of that.creation of your string else and also I.would love to see the day when there's a.wet an app-based like smartphone or.Android based app so I'm hoping.somewhere in person an app versus.working on ice thing that yes we are we.are working with efforts and and that is.I think one of the technology solutions.that that you'll see coming down the.road here and on the roadmap and and so.this is great feedback to hear that the.new system is working well and just as.you know Sparrow has also submitted.their information and wolf is in line to.integrate their system with map so we're.hopeful to get that done before the end.of the year personnel so I'm looking.forward to the other things I would say.there's the instrument itself which is I.think very usable and fairly usable user.friendly especially in comparison I was.there previously there's still some I.would categorize it as ambiguity and my.prescriber colleagues have know what the.new laws been particularly around how.often how frequently do you run Maps how.what is the requirement to change the.first of the month and so any clarity in.that would be helpful you know something.you have to do every single time you're.an opiate or change a dose or sure until.it happens or what Polly sure so the.church of maps Public Act 248 of 2017.requires that a prescriber before.prescribing or dispensing a schedule two.to five.substance that exceeds a three-day.supply that they would need to run a.Maps reports and review that information.prior to prescribing and and so in terms.of the frequency it would be in essence.before you prescribe that particular.drug and when it comes to refills for.example and a lot of times what what a.practitioner will do is they might say.I'm going to give you a 30-day supply or.not or a 90-day supply so basically 30.days and then two 30-day refills and so.what we have stated in our frequently.asked questions with these new laws is.that you could prescribe an opiate or.controlled substance when they do not.fill bait but what gets trapped in in.our system is is not the filthy but.actually the when the prescription was.written original original prescription.correct so so in that regard the.prescriber would not have to check it.over 30 days for example would be that.one time on the front end okay.this that's very helpful has been what a.lot of concern about that same with the.informed consent process and or by about.maps but at the same type of ambiguity.that I need to do this every single time.patient comes in for say just a recheck.a refill and something they've been.taking for years do I need to do that in.that context so in that context no.unless you were to so say you were.seeing a kind of pain patient for years.and you kept them on the same opioid.throughout the years the only time that.you would need to fill out that start.talking form or consent form under PA.246 of 2017 would be to but if you also.decide to change the opiate so you've.been on the same opiate for the last.several years and you decided as their.physician.you know let's try something else.because I'm seeing that your quality of.life and your functionality isn't well.let me clear facts are up and they.change over via opiate do we mean change.dose or change particularly agent.there's a question it would be the.change in agent okay so it.the change in the drug so and and not.the dosage so dosage changes it's the.same drug but you're you know either.maybe increasing it decreasing it based.on the medical need of that patient so.in that type of example you would not.need to have a new form completed I.think the other piece that that is.important to clarify is that the law.took effect on June 1 of this year and.there was we've gotten a lot of.questions from to the department from.practitioners that do I need to have all.my chronic pain patients come in doing.one yeah no you would not need to do.that it's not retroactive so it's just.moving forward June 1 and then moving.forward and only if you to change their.opiate and again the agent versus dosage.ok that's really helpful and that brings.me to reminds me of another source of a.think angst for a lot of my fellow.prescribers and folks who are trying to.make sure they're in compliance with us.you know what on the one hand what are.the what are the consequences and I know.it's Kevin unanswerable having been a.said offense or playing time and what is.really the intent what are they trying.to what is the department trying to.accomplish and what was the legislature.trying to accomplish so you know I'd.started the premise that most Doc's.99.999% absolutely want to stay within.compliance law that's not even question.they want also do the right thing for.their patients so they're trying to.figure out how do we do this safely.sanely.so put you on the spot a little bit I.mean how what does that look like from.your plain view is and I can maybe talk.about that a tiny bit that's like you.know and I actually appreciate that.question and and you know obviously with.your experience having been the former.chair of our Board of Medicine and so.you understand sort of the regulatory.side and and the department's mission to.and in the board's mission to protect.the health welfare of the public and our.patients and citizens across the state.so so I'm not surprised by that question.that that's to be expected but really.the intent and and I think I'll go back.to more of the legislative intent of.that start talking form was to provide.at a provider and prescriber level.opiate education to their patients you.know I think one of the things that I.heard quite a bit in a committee during.public testimony and and in talking with.our legislative partners as we were.working through all of these blood bills.in the package that get signed was the.concern that so many parents and.families and and and children and adults.that were being prescribed and opiate.particularly you know I think a good.example would be a football athlete that.gets injured and they go see their.doctor and or they go to the hospital.either place in and they get treated and.they there's some home when 30 pills of.vicodin but with no understanding of the.risks involved in taking an opiate and.of risks of addiction of you know what.does what signs to look for of a.possible addiction like withdrawal.symptoms you know and and you know and.just how quickly that they can be.impacted by that and and so a lot of it.was just a lot of families just felt.like they weren't even aware of the.risks and so that was really the intent.was for the prescribers to provide that.education that was somewhat missing and.and so that that since from from laws.perspective you know the way the way.we're looking at it is is no was the.education provided when prior to.prescribing that that opiate and one of.the requirements with that start talking.form is to put it in the medical record.and now there are some exemptions for.minors for example if it's an emergency.situation if it's associated with.surgery or.the inpatient outpatient you know and so.so there are some exemptions from that.and and then for the adults if they're.receiving treatment and the opiate for.inpatient administration or example.where it's being administered by a.health professional within the facility.there won't be that need so for that.more right I think those are all really.really helpful like hey the the informed.consent part of it has really been.interesting to me in that conversation.my colleagues are the last six twelve.months really coming up for this and.then part would I try to remind folks of.you know like we we've done in font.consent as part of you know appropriate.practice of prescribing everything I.mean you really should think about that.our patients are really looking to us.not just to write a prescription and.shove it in and walk out the door these.days hit the send button on the arm and.walk out the door but to have a.conversation with them that was this.intended to do what are the positive.effects potentially were to eat side.effects with what to look forward to or.Eva and I would assume that most and.again having seen this in the regulatory.and most practitioners really do and if.we look at standard Carey typically do.have a conversation with their patients.all this is doing is documenting correct.and even prior to this is this kind of.editorializing a little bit my apartment.even prior to the most recent public egg.really was an expectation of the.standard practice the water and the.board it promulgated that you would be.doing informed consent and vacuuming.that in some way shape or form anyways.so really all that certain talking does.is give you a standardized form to use.and in some ways makes a little simpler.I mean I know this kind of glass.half-full kind of looking at it but I.think it really does make things a.little easier for practitioners so I.hope that context comes across as people.get used to using it's really just more.about the how often I think that was.really more than right do I need to do.this and I'm glad you brought the.inpatient side of it I know that create.an inch from end this amount of.heartburn they're particularly.colleagues and minority emergency.department actually I can have to check.this every time no you know so he goes.through the windshield of their car take.care of it and don't stop and check naps.do it.yeah so yeah that's true for so for the.start talking form for the adult.patients within the both the law and and.and we I think have had to put some.further clarity or may have to do so.because in a start talking form under.the adult patients it does say for.inpatient administration and so it.doesn't clearly state that for the minor.which is a look at odd so what we've.we've tried to take the approach that.you know there are specific exemptions.for the minor and and that typically.when you're talking about administration.of a drug for inpatient use a lot of.times it's not prescribing it's actually.ordering there you know so so we did a.discussion a meaningful one I didn't.provide that clarity reference that if.they're ordering or administering and.whether it's you know dealing with the.start talking form and then as well as.for maps the same thing so we we did.clear by because the mass provision or.the Maps check provision I should send.it to PA 248 it does reference the.exemption if you're in a hospital or.freestanding surgical outpatient.facilities so a surgical center for.example so a facility licensed under.article 17 and so it provides exemption.from having to check maps so again we.just added the clarity about if you're.ordering a drug or inpatient use and.administration that you wouldn't have to.do that because because in those.instances if you were to check maps for.inpatient ministration none of that is.reported to the system anyway so you're.not going to see anything correct and so.so we tried to put that clarity in the.fa Q's and and so just wanted to note.that that you know a lot of time a lot.of this really comes down to the.prescriber understanding the difference.between ordering an inpatient.administrative in this administration of.the drug versus prescribing to the.patient where the patient's taking the.drugs home and I think you know.again from kind of my point of view I.think it is also a helpful bridge to.look at what was the intent of the.legislation and it can spend a lot of.time trying to so so oh it's the intent.of a legislature and then there are.people who get doctorates doing nothing.but studying that but you know as I.understand it it kind of like that a.process that over the last 12 so months.you know I don't think the intent of the.legislature was to prevent people who.needed opiates particularly an emergency.setting from having access to it's.really to make sure we're monitoring or.being diligent about safety and risk and.you know in an inpatient setting I think.we all as practitioners intrinsically.know that you know in some ways more.hazardous settings but in some ways you.know much closer monitoring is much.closer all the rest so go back to intent.and it wasn't to curtail availability of.opiates in that setting this nature.being mindful about risk and sharing.that with patient surrenders to the rest.yeah okay that that's true and you know.I think if you look at the start talking.forum about I mentioned the intent was.was at the prescriber level to provide.that education that families just were.unaware of that the patients were.unaware of the risks and then when you.talk about the registering and checking.of maps prior to prescribing a control.substance that exceeds a three-day.supply the intent there was to have the.prescriber or the practitioner assess.the patient's risk for possible.substance use disorder for doctor.shopping for you know a patient who's.gone to multiple practitioners or.multiple pharmacies 15 or same drugs.that you as a perspective might be.prescribing to that patient and why no.way I want to know and then you know PA.251 of 2017 with the seven-day supply.for acute pain that limitation the.intent there was really to get.prescribers to you know look closely at.the pain and and and what they're.treating that patient and and you know.for acute pain.a patient need a 30-day supply.oh you know and and that could be argued.guys you're a physician so I might have.just walked into something I should.issue you know I think the intent was.was to try to reduce the volume of an.opiate being prescribed possibly a.post-op surgery for example because the.rationale for that was what happens is.is when you when you prescribe a patient.such a high number of days supply that.you know maybe they only needed seven.day or ten day or ordering day or even.five day or three day whatever it might.be you know I think the practice has.been that you just give a 30 day supply.and then now you've got a patient that.has these opiates that are how they've.used and the burden what do they do.exactly it is one of my favorite friends.and colleagues and one of Smurfs.orthopaedic surgeons they know and he'll.appreciate that as a comment that he.said they basically just sit over.somebody's toaster for you know happier.and that's about what right right anyway.well if we can rubber that for a second.because they that's about the quantity.limits yet and that's crazy the world.isn't good in and of itself I I think.it's fascinating at the par the reason I.smile is new and you start talking to.and I would give elbow throw a tiny bit.of shade if my surgical colleagues I for.those of you out in the internet world.I'm a family physician by application.background and not a surgeon that work.with lots of them and call them friends.and all that good stuff as I've talked.to them and as they've watched and.learned and accommodate it to this it's.been a really interesting process for.them because we I mean yes I question.why do you prescribe you and yet to.traditionally it was seeing against I.mean thirty Beca it was like it and now.it's Marco was gonna be when I went to.the door why do you do that need to see.kind of a label pots and feelings as.waves Trent training scar and it really.is it's not a test in particular science.it's not and when and the science that.has been done is really pre clear some.of it.at university Michigan Health System and.it does some really good groundbreaking.research and I'm showing that the median.number of doses not days the doses that.are taken out of those prescriptions.usually somewhere in two two and a half.Wow so if you give so many 30 tablets 28.of them are like you said they're just.sitting around medicine cabinet and.fighting diversion or overdose or all.sorts other stuff we don't want to see.it happen so the other didn't know as.ice or shade you go back to I think.surgeons have really kind of embraced.this and really want to understand how.to do this the right way.so I give them a lot of credit for it.they come back to one of the other.sources of heartburn you probably.helpful to have some clarity from the.department and kind of understanding.from practitioner point of view you know.the the three-day sort of they think.intrinsically makes sense to folks that.sort of matches up with what we see is.an acute scenario something kind of an.acute injury that's really minor or.strain ambulatory and can be treated.that basis the seven-day is sure that's.usually in a postdoc context are those.kinds of things how do we see the.difference from a kind of monitoring and.you know how do you know what's chronic.how do you know what's cute because I.assume the intent wasn't to prevent.people from using opiates for chronic.pain you know we've got a lot of work to.do and do that more appropriately that.it wasn't to say no absolutely can't do.that correct so so I think that's been.that's a question that's come up quite.often that we've received from even just.citizens as well as practitioners is you.know I'm treating chronic pain patients.or I'm a chronic pain patient myself.kind of scenario and this law is now.limiting the current pain to you know.seven-day supply okay.no it does not it's just dealing with.the acute pain and really what.pa2 2:51 says is it basically says when.treating acute pain you're limited to a.seven-day supply and then it just.defines what a cute pain is that's it so.there's no reference to chronic pain I.think there might have been some.confusion because in some of the.previous draft versions of the pending.legislation before.in law did talk about a limitation on.chronic pain of prescribing an opiate.but it it was taken out and so so the.final version was just the seven-day.supply for acute pain with that.definition of what is acute pain and and.so so obviously and you know we've.talked about this and I've talked about.this with with physicians when I've gone.and traveled on the states to do.presentations on not only maps but also.these new laws and have been joined by.DHHS and they partnered up with us on.helping to provide clarity with all.these laws as well and they've been a.great partner to work with and so but.you know again you know with with regard.to really all these laws not just even.the acute pain and and but in particular.for this one when you said you know.transitioning from acute pain to chronic.pain so you might have a patient that.you know had surgery on their back and.it was acute pain you know we treated.for acute pain but it progresses into.into chronic pain just use that as an.example and so our hope would be in.attending from a regulatory and that a.prescriber or the primary care physician.or practitioner will note appropriately.in the patient's medical charts that you.know in the you can see that history.that was chronic pain but a transition.and or was acute pain the transitioned.into chronic pain and that in doing so.they're able to medically justify you.know that this is why we're treating or.we've we've increased the opiate or.we've changed the opiate because it's.now turned into chronic pain and so just.you know for the physicians that are.listening in the prescribers that are.listening on this Laurel live segment.document and and just show the medical.necessity and and just note it properly.I mean when we look at our cases that.that we take on remember that regulatory.standpoint a lot of it comes down to the.documentation it's a familiar.you know from the org perspective and.what you all have to review and so it's.it's difficult to refute something.that's been medically documented yeah no.I think that's an excellent point and to.any of my past from present residents.out there you see why I harp on you.about document document document is if.you didn't write it down it didn't.happen I think again it's helpfully.connecting to purpose and then it's.really difficult to derive intent and.then you would put with this with the.actually it expects of physicians as.diligence confidence and good moral.character and if you can demonstrate.those things that you're trying to.follow a lot you know no one is gonna.it's not gonna result in a bad outcome.most likely if you have a good rationale.or documented need the kind of thing I.think that's a really important point so.I appreciate that.I just I also I get into a lot of.conversations with colleagues are really.very worried about this I want it what.it means and I think they're concerned.about oversight and I hasten to point.out to it look you know the the state of.Michigan and Toto doesn't employ enough.people to monitor every single.prescription it's just not possible.so really unless a particular incident.occurs or a particular way is brought to.the attention of Department very.unlikely you know for any particular.incidence but you never know which.particular one is you should still.practice as if people are hoping yes and.and you know again our our goal is is to.when we build a case against a a.licensed health professional whether.they're a prescriber or whether they're.you know just you know issues with with.good moral character or you know some.other possible violation of the public.health code our goal is to really.identify the worst of the worst and and.you know I think in the last two years.we've successfully suspended roughly.about 50 prescribers but I think a.couple of dispensers and they're over.prescribers over dispensers.but in those.cases and I think all about meeting one.of the summer suspensions stock he.appealed and and the licensee is.actually agreed to to no longer.prescribe the controls and surrendered.their license to the board for example.and so so in those instances we built a.case where they were over prescribing.such high volumes that any any good.practitioner would say that is just.completely unethical doing patient harm.and and you know physicians take pride.in and the oath that they've taken when.they become a licensed professional.licensed doctor for example in doing no.harm to their patients and and it makes.the whole profession with that when.you've got practitioners that are.illegally prescribing with no medical.sound medical reason to do so and where.they're actually causing death in some.cases so but even just the impact to the.the individual patient where they are.feeding into their addiction not helping.them to the impact that has with family.their family members or loved ones.around that person that's trying to help.them and then the community impact so so.those are the things that that we are.really focused on and not to go after.the nearly 60,000 prescribers in the.state of Michigan nineteen eighty nine.ninety nine percent of whom are doing it.just buying her and or want to do it.correct absolutely I mean there is.definitely I mean and I would say kudos.due to all you know really all the.health systems I mean we've worked with.pretty much all the health systems who.have contacted us and Michigan Health.and Hospital Association have been great.partners and ms/ms and all the health.care associations MOA they've been great.in in terms of trying to understand the.laws and wanting to understand you know.how does Lara view these and what's.Lara's focus but departments focused and.and really trying to help licensees be.in compliance and that helps us from a.regulatory body because.we are limited on our resources and the.more we can get everybody to understand.what does it mean to be in compliance I.think will be better for everybody so so.we've gotten a couple of questions here.through this Lara live segment so one of.the questions that's come up is does.this apply to hospice with regard to the.Maps check and registering to map so.that that's a great question we have.gotten that question often whether it.applies to hospice skilled nursing.facility homes for the aged at adult.foster care and so what we've done is.again going back to the frequently asked.questions is that we have provided some.clarity and made the statement that if.you are ordering a controlled substance.for inpatient administration so you're.administering it to the patient within.those facilities then the law does not.apply in that kind of instance one of.the things that we have said though that.you know the best time in those facility.types to check Maps though in would be.and really a best practice would be to.check it when the patient or resident of.the skilled nursing facility is being.admitted because it'd be no different.than checking the medical record.whatever you get opinions coming in to a.facility to just review that maps just.to make sure that whatever drugs that.that are ordered for that patient or.resident in the facility there's not a.contradiction or they you know of what.they've been already receiving and so.forth like that.however hospice also is done and within.people always say a large portion of.this is too high any military bases.right enemies and and so the challenge.becomes is that it is actually being.prescribed to the patient and dispensed.to the patient in the patient's home.which is different than inpatient.administration and ordering and so in.that essence the Maps check does apply.however we are working with the Michigan.Hospice Association and.we're working on some draft language to.hopefully get that piece fix just.because of the of the recognition of its.end-of-life care and of the recognition.that you could have a patient that the.prescriber may have to change the the.prescription so quickly.absolutely it just you know it just may.not be accessible on wheels check that.it's correct.I mean is it can I I've heard from.hospice providers that have said that.you know it could change within two.hours I mean it was true and you know.and I'm there with with I've had.experience with hospice because my my.grandmother went in and out of Hospice.god bless her she she was she kept.hanging on but she kept going in and out.but particularly right before she did.die and in their final days you know I'd.see you know the nurse changing the drug.there frequently and and and so you know.it that's a that's probably one of the.more unique kind of scenarios situations.and so we're working through that issue.okay.the other one was our physicians allowed.to delegate the start talking consent.activities to a hospice agency I think.again I'm going to go back to not be so.focused on the facility type but again.the requirement of the prescriber and.and so prescriber based on one six two.one five can delegate activities to a.licensed or unlicensed individual so.long as that licensed or unlicensed.individual is properly trained educated.and can carry out the duties of the task.assigned and so so that would be.regardless of the facility environment.of clinical setting that was that is.that how you would take that yeah well.if they take a question one in two ways.if you're the context of the physician.or practitioner or prescriber working.within a hospital based her orientation.I think you answered the question can my.my delegated staff as long as they're.appropriately trained I have oversight I.think the other would be if I am.referring some of these to Hospice.I'm managing medications while they're.in the intere of a hospice agency for.other things I would take it in that.context based on would I understand the.public cake you'd still be responsible.for that conversation with the patient.correct.and let unless you had some specific.clear delegation to the folks working.within that hospice and were clear line.of sight into their training their.qualifications I think it'd be a take.down an awful lot of risk to delegate.that to them without a really very clear.document written relationship it would.certainly standing firm miscible under.the Act if you want to do that well I.can see particularly again in some rural.areas this may be more common you have.it would not be uncommon thing to have a.primary care physician who is really the.only prescriber for little-league.counties around our miles around who.would be responsible for maintaining.those medications any home based hospice.staff that's primarily nurse driven or.home carrier those kinds of folks so you.can see it in that context that's a.really good question yes it is.and then if multiple prescriptions are.written do you need a separate consent.for each drug or one per patient that's.because this is a very good question and.so we've actually responded individually.we've gotten that by email and the way.we responded it is if you're using the.Department of Health and Human Services.form which can be found on their website.at michigan.gov/uia.the way that form is set up in the.format of it it does basically allow you.to put in the opiate name the dosage of.that opioid but what it doesn't include.is multiple lines to put in for eligible.so so so what we've said is if you use.that form that we would recommend that.you would have to do one for each each.drug or you we've also in its online -.it's the description everything we do.know that a prescriber can use this form.as a template they don't have to use the.exact form that was.by DHHS but they can use it as a.template and turn it into an electronic.form or modify it where they could add.in those additional lines if they wanted.to to give the prescriber options in.case they need to prescribe more than.one and set it up that way we do note.that they might want to have an attorney.review whatever form they create just to.make sure it meets the requirements of.the law but you know there's some.limitations with the current form well.and I guess my answer and that one would.be don't get too caught up in the form.the form is an instrument designed to.document conversation so I would say to.anybody prescribing out there if you're.prescribing multiple scheduled two to.five substances you know this.intrinsically the risk goes up it's not.that it's good or bad and it's sometimes.it's very medically appropriate to do.that but you should still be having a.clear conversation the patient here's.what I'm doing here's why here's what.can go wrong here's when you need to.kind of take me here's additionally.looking out for so irrespective of.whether it's one line or two lines or.performs it's really more about the.conversation and clearly document that.many years they have it and I think the.other piece that we've responded to is.we've noted that each Ovid and I think.the one thing is for that form it's just.opiate based so it's not all scourge it.may not be all scheduled so it's just.anything within opiate and so is that.each opiate agent might be might have.different levels of risks and so a.conversation might actually be a little.bit different that's a really good so.that's just something we have also.mentioned that's really good point I.think we all notice intrinsically and.there's some combinations in particular.they're really hazardous looking.landlords are doing yeah and just to.know tell if you out there in Facebook.land please please please don't mix.opioids and benzos it district yes.better still see that so the review this.is a common question we get reviewing.maps online or do we need to print and.keep a copy in the patient chart and.this is covered in our ethic hues.there's actually a whole section on this.and so the answer.is is its it once you've reviewed it you.pulled the report you reviewed it you.don't need to scan you just I can make.that you reduce it correct and and but.even if you didn't even note that that's.a good practice a note that you've.reviewed it but our response has been.that our system it has auto trailers.metadata built in right away correct so.we know we know that when when somebody.is accessed that report and a lot of.health systems and hospital systems in.particular are actually putting in the.patient's record just a checkbox yeah.that they reviewed it and and so which.is great I mean that's an ABS ideal but.but one of the things that we have said.is if any practitioner decides to put.that report into the patient's medical.care we have said that it cannot be.accessible to any unauthorized users.it cannot be accessible to the patient.because there is a provision in the law.that has to maintain confidentiality of.it and it also the reason why because I.know we've gotten some pushback from.from even patients and medical.practitioners about why can't they give.a copy of that Maps report to the.patient we've actually received.complaints from patients that said that.contacted the department said I have.this maps before this is my name at the.top but this isn't my data and then and.then unfortunately them you know the.practitioner is actually in violation of.the voices so yeah but it's not even.well actually both so so the thing is is.that and and so we've we don't want that.to happen number one for the prescriber.or who's innocently trying to be helpful.certainly they can they can talk about.it to the patient and even you know.review it but just not give them a hard.copy or put it in where others could.access that access that last word that's.an that one metadata is both your friend.that the weary of it so I know that.please don't document that you would.advance if you didn't correct right yes.so as well no because it's absolutely so.another really good question that's come.in is what is the role of pharmacist but.keeping track of information collected.from mass so really you know with with.regard to these laws there's only so the.the mandated use and registration is.actually part of the prescribers and.then the there's a requirement in the.law that requires dispensers which would.be your pharmacist or veterinarians and.your prescribers who dispense in a.doctor's office are required to report.the dispensation of these drugs to maps.and and there is only one law that.actually talks about a pharmacist role.which is seven a public act two.fifty-two of 2017 which talks about if.the federal regulations go into effect.that allow for a pharmacist to do a.partial fill of a schedule to drop but.the federal rates have not gone into.effect yet about the partial fill up but.it just if it does then then they would.be allowed to do so under the federal.reg but that's the only thing that is.really referencing pharmacists and in.the role with all of these these laws.and so when it comes to you know keeping.track of the information and I'm not.sure if this question is based on on.their reporting requirements or based on.their obligation to review maps before.they dispense and and so best practice.would be for the dispenser to review and.run a Maps report before they dispense.but currently they're not mandated to do.so not mandated but what he's going to.point out and say from the payer side.most pharmacies when they're in the.process of processing affiliates all I.trying.usually the the warehouse is the data.warehouses they're getting data back.from including national data banks so.basically it snaps on steroids so they.have a claim history that they're.looking at simultaneous signs they look.at said you pharmacists are actually a.really important part of this they are.cannot possibly give them enough kudos.for what they are willing to do and some.of the things that they've been able to.attack you know they see it from two.different lenses they see you and visual.patient I think but they also see.community and occasionally practitioners.and really help identify or we've got.some problem spots that's a root that's.an excellent question.yeah and they've you know and they you.know we have gotten some questions from.from the mission pharmacists Association.and they've been great to work with in.terms of their role with a lot of these.laws and implementing them and you know.I think one of the questions that we've.gotten from pharmacies and pharmacists.is what if they see a script that's 10.days supply first of an opioid seven-day.stop lever you know the challenge for.the pharmacists is that they they.they're limited on the amount of.information that they're receiving.direct from the prescriber or the.physician and so our response to that.kind of question is the Board of.Pharmacy rule does allow for a.pharmacist to not fill a script if they.feel that it's questionable or if maybe.they can't get a hold of the prescriber.to clarify for example they do have that.ability just because again as you said.the pharmacists do play a very.significant important role and and you.know they are the ones that really know.these drugs really are trained to know.all of those drugs and the the possible.interactions with these drugs and you.know the the risks and dangers involved.when you combine those are as appeals.with you know other drugs and you know.so so they're gonna be that that sort of.last check before that drug goes home.with that patient and so so while they.may not know you know cuz that 10-day.supply could actually be for chronic.pain it may not be sure your cue payment.you know but pull it up is so again they.have to make their best decision just.like as physicians do you know based on.the information that they may have.available to them but they do always.have an option to not fill oshi FM is.the key.oh there is that clinic so veterinarians.they are defined as a prescriber and.answers there they've got dual roles but.one of the things if you go under the.veterinary and provisions throughout.their section of the code it refers to.animals as being a patient so if you.look at the code where any where it says.patient that means it's humans so okay.so but for veterinary medicine it's it.refers to animal and so that's not human.patients that would be a widow so so no.because all of these laws refer to.patients they do not the only exception.so in the start talking form to this get.back at the specific question.veterinarians are not required because.it's strictly being applied to human.patients not animals but the one law.that does apply to the veterinary.clinics would be under PA 248 the Maps.check and registration if they are.dispensing within their clinic so and.it's not as again they're functioning.essentially as a pharmacy correct.correct so but if they are prescribing.where the dispensing of that drug for.that animal is happening in a pharmacy.they're exempt from checking maps if.they are in administering the the drug.to the animal for surgery in patient.scenario we sort of it then then they.would be exempt the only time that they.would not be exempt from having to check.maps would be as if they prescribed more.than a three-day supply of the.controlled substance and and they.dispense it to the patient's owner right.there at the clinic versus sending it to.the pharmacy for the pickup.can we another question is can we.document start talking form on the day.of examination even though we would not.be prescribing the mitigation until the.day of the surgery yes so yeah so again.it's not about the form all right the.start talking form has to be completed.before prescribing so even if if the the.doctor is prescribing here's the opiate.that you're going to have post-surgery.then they would have to have that.conversation then because they're there.it has to happen before prescribing.right in and I mean ideally in the way.I've seen this usually applied and in.front consent for surgery is usually a.multi-stage process and usually those.two cameras even emergent surgeries or.things and impatient passive databases.usually there's a fairly lengthy.discussion between surgeon and patient.beforehand they weren't why are we.wanting to do this what are that.discussion in fact so assume post-op.pain management would be part of that.discussion real nitty-gritty of it.usually does come either immediately.postoperatory it drops through severe.tests again it gets back to intent it's.but the conversation is not about you.know how many minutes before it to be.fair to the surgeons I'm guessing.somebody who might be involved in the.surgical practice asses they do live in.a world that comes down to minutes and.seconds correct and sometimes what they.are judged against is you know when did.things happen literally based on time.stamps so it's it's a good question I.think it's it's one that it's good.different a little quick that's great.and then another question that we often.get and we try to address this in epic.use is what is the department consider.being appropriate timing of checking of.maps before you describing anyone at all.so our answer is that you know we didn't.want to specify you know within 72 hours.or within 40 hours or you know a certain.time frame because really the best.practice is is you know before you.prescribe that controlled substance and.how do you how you define the for could.it you know could it be a year in.advance or.you know but ideally you know whenever.you're treating a patient you you know.want to have an understanding of what's.going on with that patient as close to.when you're probably treating that.patient and so so that's where you know.we didn't want to get into the whole you.know you've almost do it every.correct so we just we didn't want to.create that that sort of limitation or I.think that's I'm sorry you know I think.that's a really helpful message to.prescribers because there's been a.meeting on both ways do I need is there.frequency that I absolutely have to.check this and I to me an understanding.as much as they do from the regulatory.environment prior to the acts and and.now post there really isn't a lot of.difference in the standard of care right.it was an expectation beforehand the you.know one of the things you should be.monitoring to responsibly prescribing.controlled substances what is the rest.of the fill history was the risk it.didn't really change it's just how you.documented the requirement is there so.you should be checking in on a.reasonably frequent basis and it depends.on how long somebody's been on that.particular agent how stable they are how.effective it is other risks other things.that might bring it to your attention so.mmm and I think the probably just you.know to put it into context the timing.of checking a Maps you know we would.recommend is close to when you're seeing.that patient just because it reduces.that patient from thinking that oh my.doctor's not gonna check the system you.know for the next thirty days or the.next ninety days or whatever so in.between I'm gonna start going to all.these other practitioners to see because.they're not gonna catch up and so so.that's why we might want to be very.careful because you know so I think.again reasonableness here is in common.sense and you know you you want to get.you always want to have the most current.and accurate information as close to.when you're going to treat that patient.and so that that's how we we tried to.address that and we'll go from there.got two really good questions looks like.we're kind of ringing the warning track.on time so are we received we are we.requiring players to check maps for.non-opioid scheduled for draw that's a.good question.yes you are yes so it's for all.schedules two to five Controlled.Substances it's not just the.opiate-based and you know one of the.things that I should just point out and.note to our listening audience is that.we did have a physician contact our.office and thanking the Department for.implementing the Maps mandate I guess.would be the way to put it the maps.registration in use requirement because.this particular physician treats.children for a TD and adderall is a.common drug used to treat a DD and they.commonly referred it one and it's also.commonly diverted and this position.prior to the new law taking effect had.not checked maps and but then of course.did because to be in compliance with the.new law and thank us because he had no.idea that the the young patient had been.receiving multiple prescriptions and.adderall and and so and would never have.known that you know and so so and it.wasn't a situation where the minor.patient was taking that all of the.alcohol but it was just unfortunate and.that happiness unfortunately that.happens and and so but a lot of the.schedule for drugs are the ones that are.actually more in abuse I don't I think.it's worth reminding particularly the.prescribers in the audience yeah you.know patient is smiling happy seems nice.engaged and they may be the person who's.misusing or converting don't really know.you can't tell by looking at exactly you.shouldn't assume and I think we'd also.be surprised by the economic value of.some of the things that you prescribe.they get outside of legal channels and.you're right gabapentin for example.which a lot of us kind of regarded or.tramadol observes of quote tape and.books are not okay I don't know they.have a pretty high street value they do.okay is this really good question.there's a reason we want to look at does.the start talking form applied to all.schedule two to five drugs are only.opiates only opiate opioids so that is.some of the laws are just opiates and.some are and the really the only one of.CrossFit does is the math check in.alignment but nothing would stop you.from using that form or that and again.it's about the conversation right Aki's.assume that anything with risk you want.to be doing appropriate than pumpkin.salad yeah so so I think our time is up.so I just wanted to say thank you for me.and joining me for this.Lara live segment and really appreciate.it and thank for those of you who.participated.you know this life great questions yes.thank you for all the questions and if.any of you who are listening and.watching have further questions feel.free to email those questions to our.Maps team which the email address is.Michigan gov at EPL - maps or x-rays by.the way around its EPL - mr. og MACO.- max at michigan.gov if you have.further questions.

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Do military members have to pay any fee for leave or fiancee forms?

First off there are no fees for leaves or requests for leave in any branch of the United States military. Second there is no such thing as a fiancée form in the U.S. military. There is however a form for applying for a fiancée visa (K-1 Visa)that is available from the Immigration and Customs Service (Fiancé(e) Visas ) which would be processed by the U.S. State Department at a U.S. Consulate or Embassy overseas. However these fiancée visas are for foreigners wishing to enter the United States for the purpose of marriage and are valid for 90 days. They have nothing to do with the military and are Continue Reading

How do you know if you need to fill out a 1099 form?

It can also be that he used the wrong form and will still be deducting taxes as he should be. Using the wrong form and doing the right thing isnt exactly a federal offense

How can I fill out Google's intern host matching form to optimize my chances of receiving a match?

I was selected for a summer internship 2016. I tried to be very open while filling the preference form: I choose many products as my favorite products and I said I'm open about the team I want to join. I even was very open in the location and start date to get host matching interviews (I negotiated the start date in the interview until both me and my host were happy.) You could ask your recruiter to review your form (there are very cool and could help you a lot since they have a bigger experience). Do a search on the potential team. Before the interviews, try to find smart question that you are Continue Reading

How do I fill out the form of DU CIC? I couldn't find the link to fill out the form.

Just register on the admission portal and during registration you will get an option for the entrance based course. Just register there. There is no separate form for DU CIC.

Can you become a barber through apprenticeship?

You're most likely seeing apprentices barbering and not an actual licensed barber or self employed people who need more training. If you go to a real salon they all have their licenses and are professionally adequate. Anyways: owning a building to collect rent from a barbershop business doesn't require a license. This depends on your location but usually three licenses are required to run a barbershop: your barber's license, a business license, and a department of health license. You can also accept "friend and family members" to "schedule" an "appointment" at your "garage" and get away with low revenues. The fastest way to become a barber is through apprenticeship, and then taking your local area's test. Opening a barbershop is easy, after you have your clients set, so worry about that first.

What does a salon apprentice do?

It depends on the state laws. Some allow for apprenticeship some require actual school. Then there are some that will hire you towards the end of your school and help transition to licensed cosmetologist. Call around different shoos. Ask if they are hiring. Some are busy enough where they need a receptionist. Start there.

How long does it take to do a hairdressing apprenticeship?

Here are some amazing and completely free resources online that you can use to teach yourself data science. Besides this page, I would highly recommend following the Quora Data Science topic if you haven't already to get updates on new questions and answers! Step 1. Fulfill your prerequisites Before you begin, you need Multivariable Calculus, Linear Algebra, and Python. If your math background is up to multivariable calculus and linear algebra, you'll have enough background to understand almost all of the probability / statistics / machine learning for the job. Multivariate Calculus: What are the Continue Reading

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