Audit of the Board of Registration in Medicine Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Board of Registration in Medicine

Overview

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 certain activities of the Board of Registration in Medicine (BORIM) for the period July 1, 2016 through June 30, 2018.

We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Below is our audit objective, indicating the question we intended our audit to answer, the conclusion we reached regarding the objective, and where the objective is discussed in the audit findings.

Objective	Conclusion
Do BORIM’s oversight and monitoring of controls over Physician Health Services’ (PHS’s) operation ensure due process and quality treatment of substance use disorders for physicians who have been reported as practicing medicine while impaired?	No; see Findings 1 and 2

 

To achieve our objective, we gained an understanding of BORIM’s internal control environment related to our audit objective by reviewing applicable laws, regulations, and agency policies and procedures, as well as conducting inquiries with BORIM’s staff and management. Our audit involved examining some of the physician health program (PHP) services PHS provided to physicians who had been reported as practicing medicine while impaired that were relevant to BORIM’s fulfillment of its mission. However, we also determined that there was no contract between BORIM and PHS for PHP services and that PHS did not receive any direct payments from BORIM; physicians are responsible for paying for any services. Therefore, our ability to perform any audit testing at PHS was limited at best, so we focused our audit work on assessing how effectively BORIM oversaw and administered PHS’s provision of PHP services.

We performed the following procedures to obtain sufficient, appropriate audit evidence to address the audit objective.

We reviewed BORIM’s oversight and monitoring of PHS’s operation of the Commonwealth’s PHP, including oversight and monitoring of 27 physicians with BORIM probation agreements (PAs) for substance use requiring PHS monitoring,⁶ and whether BORIM used oversight controls over PHS, by performing the following tests:

• We conducted interviews with BORIM management and board members to understand BORIM’s oversight of PHS’s operations.
• We performed an inquiry with BORIM’s management and board of directors regarding whether BORIM had a formal contractual relationship with PHS according to the best practices of the Federation of State Medical Boards (FSMB).
• We performed an inquiry with BORIM management regarding whether the BORIM board of directors had established adequate program standards for PHS, including a confidential impaired physician program approved by BORIM, establishment of rules and regulations for the review and approval of a medically directed PHP, a review of its approved program/s on a regular basis, and selection of treatment providers and facilities in accordance with FSMB best practices.
• We performed an inquiry with BORIM’s management and board of directors regarding whether BORIM monitored or required a program performance review to ensure that PHS met FSMB best practices.
• We performed an inquiry with BORIM’s management and board of directors regarding whether the 27 physicians who had PAs that involved PHS during the audit period were provided with a fair disposition process (i.e., due process).

We tested all 27 physicians identified as having BORIM PAs with a requirement of substance use monitoring provided by PHS during the audit period. We performed the following procedures:

• We reviewed the physicians’ Claris⁷ case records to verify the accuracy of the impairment complaint type, BORIM board of directors’ actions, and probation status.
• We determined whether PAs were signed by the physicians and the BORIM board of directors’ chair or vice chair and were on file. We reviewed the PAs to verify requirements for substance use monitoring, a PHS substance use monitoring contract, and any additional monitoring requirements.
• BORIM receives from PHS an initial physician evaluation report, quarterly compliance monitoring reports on physician compliance that include a summary of substance testing dates and results, and a final report stating that the physician has completed treatment. We examined the Physician Health and Compliance (PHC) Unit PA monitoring case files to verify the timely receipt of signed PHS quarterly compliance monitoring reports. We also reviewed additional monitoring reports required by PAs, including reports submitted by the physicians’ personal physicians, worksite monitors, and chaperones, for receipt and timeliness (see Other Matters). We also reviewed the reports for completeness, duplications, and any missing reports. We reviewed and discussed these cases with the PHC Unit compliance manager.
• We reviewed each BORIM physician online profile to verify the accuracy of the physician status listed and discussed any discrepancies with BORIM management.
• For each physician who completed a PA during the audit period, we reviewed the petition for the termination date of the PA, if applicable; the petition submittal date to the BORIM board of directors; and meeting minutes. We compared the submittal dates to the BORIM board of directors’ review dates to assess timeliness.

Data Reliability

To gain an understanding of BORIM data systems and controls, we interviewed the information technology staff member responsible for their oversight.

To assess the reliability of the data on the list of physicians with active PAs involving PHS, we interviewed BORIM management employees who were responsible for oversight of this data entry. We also searched the list for hidden rows and columns and duplicate records. We then traced a sample of 11 physicians from the list to Claris and OnBase⁸ records to verify case information, such as physician name, sanction date, impairment type, PA start and end dates, BORIM board of directors’ meeting minutes, and Claris records.

With regard to the accuracy of the list of physicians with active PAs provided by the PHC Unit manager, we compared these data to BORIM monthly and quarterly monitoring report spreadsheets, meeting minutes for the BORIM board of directors and complaint committee, the BORIM board of directors’ actions per the BORIM website, the PHC Unit internal audit report, and Claris case files.

BORIM’s Enforcement Unit provided us with a data extract from Claris that listed 41 cases regarding complaints of physicians practicing while impaired that were received during the audit period. To assess the reliability of this data extract, we traced a sample of five records from the extract to OnBase records to verify case information, including physician name, complaint type, complaint date issued, complaint date closed, and license number. We also reviewed security, access, segregation of duties, and contingency planning controls over the systems and tested user access controls.

We deemed the list of physicians with active PAs and the data extract list of impairment cases to be sufficiently reliable for our audit purposes.

6.     Although there were other physicians with PAs during the audit period, our findings focus on the 27 who had PAs with PHS for substance use.

7.     Claris is the database BORIM uses to maintain physician records, including information regarding licensing type and status, complaints received, enforcement investigations, legal proceedings, and the BORIM board of directors’ actions.

8.     OnBase is the electronic record of scanned hardcopy documents related to physicians, including licensing information, complaints, investigations, and legal proceedings.

Date published:	April 7, 2020