When Maryland issued an emergency order to immediately suspend the license of a physician accused of endangering autistic children, regulators in 11 other states took similar action, yanking his credentials based on what happened in Maryland.

Hawaii was the last to do so.

Although taking timely action is considered critical to protecting the public, Hawaii regulators typically have been slow to respond in cases involving Hawaii-licensed doctors first sanctioned in other states, according to a Honolulu Star-Advertiser investigation.

The reciprocal discipline case involving Dr. Mark R. Geier was a prime example.

Maryland regulators accused Geier of treating autistic children with methods that carried substantial risk of serious harm and that were not consistent with evidence-based medicine. One therapy included injecting children with a compound normally used to chemically castrate sex offenders, according to Maryland regulatory documents. Based on the Maryland findings, the medical board there took emergency action in April 2011 to summarily suspend Geier’s license.

Within a few months several other states where Geier also was licensed followed suit, and by the end of 2012, Geier’s credentials had been suspended or revoked in all the states but Hawaii.

It wasn’t until April 2013 — two years after Maryland issued its emergency order — that the Hawaii Medical Board revoked his license. That legal process began in July 2012.

Long wait for action

Even though Geier wasn’t practicing in the islands at the time, the delayed action for an emergency case reflects a system that can unnecessarily put patients at risk, consumer advocates say. That’s especially so given the growing popularity of telemedicine, the high percentage of Hawaii-licensed physicians with out-of-state addresses and a national effort to make practicing in multiple states easier.

The Geier case highlights what has long been a problem in Hawaii. For cases warranting action, the state often is slow to sanction a Hawaii-licensed physician who has been disciplined in one or more other states, according to the newspaper’s findings.

Mainland regulators told the Star-Advertiser that reciprocal discipline cases — those triggered by actions elsewhere — are decided much more quickly than other discipline cases because another board already has investigated the underlying facts and determined sanctions were warranted.

But getting data to compare such cases is problematic.

Neither the Federation of State Medical Boards, the national organization that represents all boards, nor the Department of Commerce and Consumer Affairs, which oversees Hawaii physicians, compiles data on how long reciprocal discipline cases take to resolve. Differences in licensing laws across the country add to the difficulty of making state-by-state comparisons.

Several indicators, however, underscore the notion of Hawaii as a laggard.

The Hawaii board took nearly 28 months on average to sanction a doctor who had been disciplined in at least one other state, according to a Star-Advertiser analysis of the roughly 60 reciprocal discipline decisions posted on the panel’s website.

Subtracting two to three months to account for when Hawaii learns of the initial discipline, the average still topped two years — an inordinately long period, analysts say. Some cases took three years or longer to wrap up. One lasted more than a decade.

"I just can’t imagine why it would take so long," said Robert Oshel, retired associate director for research and disputes for the National Practitioner Data Bank, which compiles information on adverse actions against physicians nationwide. "It just doesn’t make any sense."

Stark state differences

While comparison data is hard to come by, Washington state’s experience provides some perspective.

Reciprocal discipline cases there generally take about six months to resolve, compared with 18 months for all physician cases resulting in discipline, according to Michael Farrell, policy development manager for the Washington State Medical Quality Assurance Commission.

Cases triggered by discipline elsewhere are much easier to process, Farrell wrote in an email to the Star-Advertiser. "The evidence supporting the action is simply the (discipline) order from the other state," he said. "We don’t have to prove the underlying facts."

Representatives from several other states agreed with Washington’s assessment or told the Star-Advertiser essentially the same thing.

Hawaii’s sluggish response time also is reflected in another indicator.

When the Star-Advertiser analyzed 11 cases since 2005 in which at least four other states took action against a physician for the same underlying set of circumstances, Hawaii was a laggard.

In six of the 11 cases, Hawaii was the last or next-to-last state to impose sanctions. In three other cases it still hasn’t taken action, and in one other Hawaii imposed no discipline, even though five other states did so, according to the Star-Advertiser analysis.

The remaining case showed Hawaii responding in a more timely fashion — but not by much. Instead of being the last or second to last, Hawaii was the 16th of 22 states to act.

Investigations take time

Asked about the long response periods, DCCA officials said that over the past decade the Regulated Industries Complaints Office, which handles enforcement, has substantially cut the time for resolving medical complaints to an average of 219 days. But they could not provide data for reciprocal discipline cases, citing the limitations of the department’s case management system.

DCCA officials wouldn’t even acknowledge, as other states did, that cases triggered by discipline elsewhere generally proceed more quickly.

"Since each case is different, it is difficult to say that reciprocal discipline cases take less time to resolve," Daria Loy-Goto, complaints and enforcement officer for DCCA, said in a written statement.

DCCA officials said the department must conduct its own investigation to determine whether the underlying conduct constitutes a violation under Hawaii law. That could entail getting additional information from the other state, they added, and a violation in that state might not be one in Hawaii, given differences in state law. Also, the other state’s order might not include an admission of wrongdoing from the physician, or it might specify that the discipline agreement cannot be used as evidence in other proceedings, the officials said.

But other states told the Star-Advertiser that if another board imposes discipline more serious than a reprimand, that generally is sufficient grounds for reciprocal action.

Asked why the Geier case took so long to resolve, DCCA noted that it filed legal action against him in July 2012 and that the matter went through a contested case hearing, leading to the April 2013 license revocation.

Geier did not respond to email and phone messages left at his mainland residence seeking comment.

DCCA officials acknowledged that some cases take longer than desired. But the staff has worked hard to ensure that those are limited to a few outliers representing the exception, not the rule, they said.

"While we strive to process cases as timely and efficiently as possible, good prosecutions are built on thorough investigations and solid evidence," Loy-Goto said.