Audit  Audit of the Board of Registration in Medicine

Audit calls on the Board of Registration in Medicine (BORIM) to formalize its relationship with Physician Health Services (PHS), the commonwealth’s physician health program (PHP) provider. The audit examined the period of July 1, 2016 through June 30, 2018.

Organization: Office of the State Auditor
Date published: April 7, 2020

Executive Summary

In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of the Board of Registration in Medicine (BORIM) for the period July 1, 2016 through June 30, 2018. Under its enabling statute (Section 10 of Chapter 13 of the General Laws), BORIM is responsible for licensing physicians and acupuncturists and supporting a high quality of healthcare by ensuring that only qualified and competent physicians are licensed to practice in the Commonwealth. To meet its responsibilities, BORIM arranges for confidential treatment through Physician Health Services (PHS) for physicians who have conditions that may impair their ability to practice medicine.

BORIM uses PHS, a nonprofit corporation founded by the Massachusetts Medical Society, as the primary provider of the Commonwealth’s physician health program (PHP).1 The PHP is designed to provide consultation, assessment, support, and referrals for treatment to physicians, residents, and medical students who have potentially impairing health conditions (e.g., substance use disorders, mental health issues, and physical illness) that may compromise their ability to practice medicine. Physicians may seek treatment voluntarily or be required to seek treatment as part of BORIM’s disciplinary action.

The objective of our audit was to assess how effectively BORIM administered the provision of PHP services to physicians through PHS. In particular, we determined whether BORIM had proper controls in place that would allow it to monitor and evaluate PHP services and, as necessary, effect the proper delivery of these services to ensure that physicians who participated in the program received quality care and completed all of their required treatment before being allowed to practice medicine.

Below is a summary of our findings and recommendations, with links to each page listed.

Finding 1

BORIM had inadequate oversight controls, including monitoring, over PHS.


  1. BORIM should establish oversight and monitoring controls over PHS, including the following:
    a. BORIM should establish a formal contract with PHS documenting PHS’s responsibilities as the PHP provider.
    b. BORIM’s board of directors should formally approve PHS as the Commonwealth’s PHP provider.
    c. BORIM should establish policies and procedures that PHS, its vendors, and other providers must follow to ensure that impairment cases are properly and consistently handled.
    d. BORIM should implement a requirement of PHS program reviews to determine whether PHS meets BORIM’s expectations.
    BORIM should ensure that a fair disposition process for dispute resolution is provided to physicians under PHS care.
    f. BORIM should document monthly meetings between its Physician Health and Compliance Unit and PHS.

Finding 2

BORIM did not effectively monitor and control PHS’s compliance reporting related to physicians with BORIM probation agreements.


  1. BORIM should implement controls over monitoring activities to ensure policy compliance, timely submission of complete required reports, and prompt notification to PHS of physicians who require monitoring reports.
  2. BORIM should maintain records of all data for all years on the monthly and quarterly monitoring spreadsheet.


A PDF copy of the audit of the Board of Registration in Medicine is available here.

1.     The Massachusetts Medical Society identifies PHS as the Commonwealth’s PHP provider, and BORIM uses PHS for most impairment cases. However, BORIM does use other providers for competency issues and for instances where a physician requests a provider other than PHS.





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