Maryland Physician Magazine January/February 2013 Issue

M A RY L A N D

Physician YOUR PRACTICE. YOUR LIFE.

VOLUME 3: ISSUE 1 JAN/FEB 2013

MORE TAILORED CARDIOVASCULAR TREATMENTS HIT: PROTECTING PATIENT DATA PROGRESS & PROMISE: MARYLAND STEM CELL RESEARCH

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Contents 10

VOLUME 3: ISSUE 1 JAN/FEB 2013

20

24

F E AT U R E S

10 Cardiovascular Update: More Tailored Treatments 16 Progress and Promise:The State of Stem Cell Research in Maryland 20 Protecting Patient Data in a Digital Age D E PA R T M E N T S

Cases

| 7 | Rough Weather Cardiac Care

Compliance Living

| 9 | Dealing with Difficult Patients

| 24 | Live a Little...Visit Delray Beach, Florida

Solutions

| 29 | Create a “WOW” Experience for Your Patients

Good Deeds

| 30 | Restoring Rhythm in Bangladesh

On the Cover: Paul A. Gurbel, M.D., director of the Sinai Center for Thrombosis Research at Sinai Hospital of Baltimore

JANUARY/FEBRUARY 2013

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JACQUIE ROTH, PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com CONTRIBUTING WRITERS Tracy Fitzgerald Jackie Kinsella

Happy New Year!

Welcoming the New Year is a time for inspiration and this issue is spot on. Our content ranges from the research and development of an oral antiplatelet medication by one of the state’s foremost cardiologists, to leading-edge stem cell research here in Maryland, to treating heart arrhythmias in Bangladesh.

February is recognized as American Heart Month, honoring heart health professionals, researchers, and ambassadors – some of whom are showcased in this issue – whose dedication enables countless Americans to live full and active lives. This year’s National Wear Red Day® is the 10th annual, taking place on Friday, February 1st. The day encourages everyone to unite in The Heart Truth’s life-saving awarenessto-action movement by putting on a favorite red dress, red shirt, or red tie to remind us that women need to protect their hearts against their #1 killer.

By mid-February, we’re often ready for a break from the bleak winter skies and look to get away or plan ahead for a family spring break trip. The Living section of Maryland Physician has featured an easy-to-get-to destination, offering a sneak peek of a city or town we recommend for a quick getaway. Until now, we’ve featured local hot spots within a three-hour drive from Baltimore and DC. This issue, we’re taking a slightly different approach; I’ve recapped highlights from my recent trip to Delray Beach, Florida – a less than three-hour flight destination (see Living page 24).

Key features of the Affordable Care Act include more access to care and improvements in the coordination and quality of patient care. As patients become more educated about their rights as healthcare consumers, as in any customer-centric business, providers may very well find their patients more demanding in their expectations for care. Social media and online ratings are impacting where healthcare consumers go for care. We deliver two articles that help you create a positive patient experience within your practice – lowering your exposure risk for malpractice and bringing in more patients (see Compliance page 9 and Solutions page 29).

This issue’s HIT feature, Protecting Patient Data in a Digital Age (page 20), underscores the critical need for providers to have patient data protected far beyond the limits of the physical office – including smartphones and cloud services. Via the use of smartphones and their apps, patients are becoming engaged and more empowered to take control of their health. Better care management lowers readmission rates, improves quality of care and directly impacts the revenue stream of any provider. The Maryland Physician March/April 2013 HIT feature will spotlight mHealth (mobile health), with a look at some of the apps in place today. We’d love to hear from you about what you personally use or what your practice has put into place.

Shoot me an email or tweet @mdphysicianmag.

Wishing you good luck with your New Year resolutions and good health!

CONTRIBUTING PHOTOGRAPHY Tracey Brown, Papercamera Photography www.papercamera.com EXECUTIVE ASSISTANT/WEBMASTER Jackie Kinsella Maryland Physician Magazine – Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC. a certified Minority Business Enterprise (MBE).

Mojo Media, LLC PO Box 1663 Millersville, MD 21108 443-837-6948 www.mojomedia.biz Subscription information: Maryland Physician Magazine is mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52.00. To be added to the circulation list, call 443-837-6948.

Reprints: Reproduction of any contact is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443-837-6948 or email jroth@ mdphysicianmag.com.

Maryland Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Maryland Physician. Advisory board members include: KAREN COUSINS-BROWN, D.O. Maryland General Hospital PATRICIA CZAPP, M.D. Anne Arundel Medical Center HOLLY DAHLMAN, M.D. Greenspring Valley Internal Medicine, LLC PAUL W. DAVIES, M.D., FACS KURE Pain Management MICHAEL EPSTEIN, M.D. Digestive Disorders Associates STACY D. FISHER, M.D. University of Maryland Medical Center REGINA HAMPTON, M.D. FACS Signature Breast Care DANILO ESPINOLA, M.D. Advanced Radiology GENE RANSOM, J.D., CEO MedChi CHRISTOPHER L. RUNZ, D.O. Shore Health Comprehensive Urology Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources.

Jacquie Roth Publisher/Executive Editor jroth@mdphysicianmag.com @mdphysicianmag 4 | WWW.MDPHYSICIANMAG.COM

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Cases

Rough Weather Cardiac Care Daniel Woronow, M.D., FACC

CASE: It was called the “perfect storm, Hurricane Sandy.” At 2 a.m. on Oct 30, 2012, a 66-yearold college professor collapsed with chest pain while bailing out his basement during the storm.

Within minutes of the 911 call, he arrived in the ER with crushing, substernal chest discomfort and “tombstone” ST segment elevation on his electrocardiogram.

Anticipating such an occurrence, the on-call cardiac catheterization lab team remained camped-out in the hospital during the storm, knowing that a frantic drive to the hospital would be impossible given the multiple road closures that night.

Within minutes after ER arrival, the patient had given informed consent and the cardiac catheterization/primary angioplasty procedure was underway. The team had reperfused his completely occluded right coronary artery (RCA) and implanted an intracoronary stent. Despite harsh weather conditions, the overall “door to balloon” time was 31 minutes. When the professor was discharged from the hospital two days later, he said, “When you are tenured in academia, you either retire vertically or horizontally. Thanks to this hospital’s heart attack team, I am not in the latter category.”

DISCUSSION Primary angioplasty as treatment for acute ST Elevation Myocardial Infarction (STEMI) has been shown to dramatically improve clinical endpoints, yet it requires prompt implementation to obtain maximum clinical benefit.1 Urgent patient transport and availability of specialized healthcare teams can be problematic during disaster conditions.2 In this instance, hospital preparedness, and the on-site availability of all crucial cath lab team members, resulted in a successful patient outcome during the pre-dawn hours of Hurricane Sandy.

Primary angioplasty for the treatment of acute myocardial infarction has been in clinical practice for almost 30 years.3 However, in 1993, the Primary Angioplasty in Myocardial Infarction (PAMI) Investigators published the landmark multihospital, prospective, randomized trial establishing the superiority of primary angioplasty over other treatment strategies for STEMI patients at tertiary care hospitals with on-site open heart surgery (OHS).4 This strategy suffered from relative inaccessibility to the majority of STEMI patients, who presented to hospitals which lacked on-site OHS. Helicopter transfer remains an effective strategy for transport from NON-OHS to OHS hospitals.

Unfortunately, inter-hospital transfer adds an average of 40 minutes to door to balloon time.5 Also, weather is frequently unacceptable for helicopter transport and helicopters are subject to mechanical failure, or worse.6 Seeking to expand the availability of primary angioplasty, in 1996 the Maryland Health Care Commission approved initiation of the Cardiovascular Patient Outcomes Research Team (CPORT) primary angioplasty study. This multihospital, prospective, randomized trial, which was led by Dr. Thomas Aversano of the Johns Hopkins Medical Institutions, determined the feasibility, efficacy, and

safety of primary angioplasty at NONOHS hospitals.7 The trial found no angioplasty-related complications that required emergency coronary artery bypass grafting (CABG). While patients were appropriately transferred to OHS hospitals if coronary angiography demonstrated significant left main coronary stenosis or coronary anatomy better suited for CABG, almost none of these were emergency inter-hospital transfers. Furthermore, CPORT side-benefits included improved equipment, resources, and staff training at all critical care areas of participating hospitals, benefiting non-cardiac as well as cardiac patients.

As of 2011, most patients in the entire state of Maryland and the District of Columbia are within minutes of the 13 NON-OHS Maryland hospitals with on-site primary angioplasty, or the 13 Maryland/DC OHS hospitals that also accept transport from hospitals lacking primary angioplasty capability.

Controversies regarding OHS compared with NON-OHS strategies for primary angioplasty will continue as new technologies emerge. Nonetheless, when STEMI strikes and transportation is problematic, sometimes the nautical adage, “any port in a storm” works best.

Daniel Woronow, M.D., FACC is a member of the Cardiovascular Patient Outcomes Research Team (CPORT) and has served as Principal Investigator at Holy Cross Hospital, Silver Spring, Md. 1

Brodie, Stuckey & Wall, et al in Journal of the American

College of Cardiology 32 (1998): 1312-1319.

2

www.nejm.org/doi/full/10.1056/NEJMp1213486.html

3

Woronow, Zinsmeister & Lindsay in American Journal

of Cardiology 56 (1985) 1007-8.

4

Grines, Browne & Marco, et al in New England Journal

of Medicine 328 (1993) 673-79.

5

Anderson, Nielsen & Rasmussen et al in New England

Journal of Medicine 349 (2003) 733-42.

6

www.cnn.com/2011/12/26/us/florida-medical-helicopter-

crash/index.html 7

Aversano, Aversano & Passamani, et al in Journal of the

American Medical Association 287 (2002): 1943-51.

JANUARY/FEBRUARY 2013

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NEW ICD-10 DEADLINE:

OCT 1, 2014

2014 COMPLIANCE DEADLINE FOR ICD-10 The ICD-10 transition is coming October 1, 2014. The ICD-10 transition will change every part of how you provide care, from software upgrades, to patient registration and referrals, to clinical documentation, and billing. Work with your software vendor, clearinghouse, and billing service now to ensure you are ready when the time comes. ICD-10 is closer than it seems.

CMS can help. Visit the CMS website at www.cms.gov/ICD10 for resources to get your practice ready.

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10

Compliance

Dealing with Difficult Patients

By Tara R. Gibson

T

HIS ARTICLE WILL PROVIDE risk management strategies to help physicians and practice staff: Better work with those patients who seem difficult Minimize the risk of liability represented by patients who persist in the behavior that earns them the label “difficult”

“Difficult” patients exist in every clinical setting. These patients may range from those who are noncompliant with their healthcare provider’s orders or advice to those who exhibit abusive behaviors. Approximately two-thirds of difficult patients are noncompliant.

Communication issues may be responsible for the behaviors of some noncompliant patients, while other patients are noncompliant by choice.

necessitates treatment. > The provider needs to determine the level of the patient’s understanding of his/her problem or disease and the patient’s goals. > The provider should consider resources to provide ongoing support and shared community for patients with chronic diseases.

The common thread in dealing with patients who are not noncompliant by choice is the need to communicate clearly and frequently regarding the purpose, goals and alternatives for treatment and medications. Some patients may not understand their behavior as noncompliant.

Specifically naming their behavior may bring understanding – to both sides.

Noncompliance by Choice

Noncompliance Due to Communication Issues

The first step in addressing noncompliance is to identify its potential causes and develop strategies to improve patient understanding and adherence. A partial list of causes and strategies for improvement follows: The patient forgot the verbal instructions. > The provider should provide written instructions, presented in easy-tofollow steps and written with minimal words in simple lay terms with oral instructions.

The patient finds a drug or treatment regimen too complex. > Include the patient in the treatment regimen, reviewing all medications prescribed by all providers. > Consider a pharmacy consultation to work out a realistic schedule for patients with multiple medications.

The patient is angry or depressed about the chronic condition that

Patients who are noncompliant by choice may fall into one of the categories described below. Potential strategies for dealing with each situation are included.

The patient threatens to sue, “go to the papers” or go online with complaints when his/her wishes are denied. > The provider should not allow the patient to intimidate or manipulate him or her, nor should he or she succumb to threats or respond in anger. > Doing and documenting what is medically justified can be argued far more successfully in a malpractice case than giving into a patient whose demands are unrealistic and may be based on questionable website information.

The patient does not pay his/her bill, even with reminders when appointments are scheduled. > Billing practices should be posted in a visible place and patients should be informed of the billing and payment policies at their first visit.

> A payment schedule workable for the patient should be developed. > Consideration needs to be given to terminating the professional relationship with the patient who is a chronic or persistent non-payer. > Until that step is taken, the practitioner needs to continue to see the patient. Medicine takes precedence until the patient has been formally terminated from the practice.

The patient becomes verbally or physically abusive when informed that the provider is running late due to an emergency or will not give him/her what he/she wants. > The practice needs to develop and maintain a policy addressing management of the patient who exhibits violent behavior in the office.

The policy should include steps up to and including isolating the individual to prevent injury to self and others. > The staff should try to calm the patient. > Police should be summoned if a patient becomes physically violent or demonstrates threatening behavior.

Difficult patients often are both a frustration and a challenge. Termination of the professional relationship should not be the first response to these individuals.

Rather the “difficult” behavior needs to be identified and addressed with the patient. However, if efforts are unsuccessful, physicians have the right to practice in a safe environment, to have their professional ability valued and to have themselves, their schedules and their staff respected. When those rights are violated or irretrievably compromised by the patient’s actions or inactions, termination of the professional relationship may be a viable option.

Tara R. Gibson, CPCU, RPLU is vice president of Risk Management, Coverys www.coverys.com JANUARY/FEBRUARY 2013

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W

Cardiovascular Update

More Tailored Treatments

BY L INDA HARDER PHOTOG RAPHY BY TRACE Y BROWN

Maryland Physician interviewed three cardiovascular specialists for the latest updates in antiplatelet medications, deep vein thrombosis and heart disease in women. In each case, patients benefit from medicine’s better understanding of individual responses to therapies.

10 | WWW.MDPHYSICIANMAG.COM

Clopidogrel is Ineffective for 30% of Patients In the process of helping to develop ticagrelor (Brilinta, Astra Zeneca), an oral antiplatelet medication that rivals clopidogrel bisulfate (Plavix, Sanofi, Bristol Myers Squibb), Paul A. Gurbel, M.D., director of the Sinai Center for Thrombosis Research at Sinai Hospital of Baltimore has learned just how long it can take to go from bench research to FDA approval of a new antiplatelet drug.

He began studying mechanisms of thrombosis while a cardiology fellow at Duke University in 1987. In the late 1990’s, his lab at Sinai Hospital discovered the pharmacodynamic limitations of clopidogrel when studying its effects on patients undergoing stenting. This groundbreaking research provided a major rationale for the development of antiplatelet agents with a more rapid, predictable and potent pharmacodynamic effect. The seminal observations of response variability and resistance to clopidogrel, the most widely used antiplatelet agent of its type worldwide, initiated the field of personalized antiplatelet therapy.

Although approved one year earlier in 28 countries, it took until July 2011 for the FDA to finally approve ticagrelor. Dr. Gurbel and his research team led the design and conduction of international pharmacodynamic and pharmacogenetic studies of ticagrelor that started in 2006.

The data gathered from these studies demonstrated the superiority of ticagrelor’s antiplatelet effect as compared to clopidogrel. This key laboratory information was submitted to the FDA and other regulatory agencies around the world and was influential in the decision to approve ticagrelor for the treatment of patients with acute coronary syndromes.

These data are now in the labeling of Brilinta.

Paul A. Gurbel, M.D., director of the Sinai Center for Thrombosis Research at Sinai Hospital of Baltimore

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Justin K. Nelms, M.D., vascular surgeon at Baltimore Washington Medical Center

“This procedure significantly decreases the morbidity of post thrombolitic syndrome.”

– Justin Nelms, M.D.

12 | WWW.MDPHYSICIANMAG.COM

Clopidogrel’s Limitations Clopidogrel is an inactive pro-drug that requires hepatic bioactivation via various enzymes, including cytochrome P450 (CYP)2C19. Therapy with clopidogrel reduces the likelihood of coronary artery thrombosis by specifically inhibiting the platelet ADP receptor, P2Y12.

However, a large proportion of the population (~25% of those of European ancestry, ~30% of African ancestry and ~50% of East Asian ancestry) has a variant of the CYP2C19 gene, termed a “lossof-function allele” that results in nonfunctional gene product. These patients may therefore less effectively metabolize clopidogrel. Dr. Gurbel and his team first reported the relation of genotype to clopidogrel’s pharmacodynamic effect in a PCI (percutaneous coronary intervention) population. The FDA has now written a boxed warning regarding the influence of genotype on clopidogrel metabolism.

Dr. Gurbel recommends that, in highrisk patients undergoing stenting who are treated with clopidogrel, strong consideration be given to assuring that an adequate antiplatelet effect is present by testing platelet function. He says, “We call this,

‘personalizing therapy.’ If the effect is not desirable, then the patient can be switched to a new, more expensive and more pharmacodynamically potent and predictable agent such as ticagrelor or prasugrel.”

These recommendations for personalizing antiplatelet therapy are now addressed in American and European cardiology treatment guidelines. “Given that clopidogrel is one of the most commonly prescribed medications for patients with vascular disease, and that it became a generic drug in 2012, it is important for clinicians to identify those who should receive the more costly alternative treatments,” Dr. Gurbel remarks.

Finally, Dr. Gurbel emphasizes that, “Clopidogrel is pharmacodynamically effective in about two thirds of patients undergoing PCI; these patients do not have high platelet reactivity (HPR).

Ischemic risk is much greater in patients with HPR. Therefore, selectively treating two thirds of patients with generic clopidogrel may provide significant cost savings. Unselected therapy with the new P2Y12 receptor blockers is associated with increased bleeding. We believe that clinicians should strive to find the

antiplatelet therapy that achieves the optimal level of platelet inhibition for the patient, regardless of cost. If generic clopidogrel is indeed pharmacodynamically effective in the patient, offering them this less expensive option appears to be a win/win scenario.”

The Future Dr. Gurbel and his team are involved in many more studies. They are planning a large multicenter international investigation of personalized antiplatelet therapy in high-risk patients undergoing coronary artery stenting. They are currently investigating the antiplatelet effects of HDL by intravenously administering purified HDL to patients with coronary artery disease. Another investigation involves the first administration in humans of a novel intravenous antiplatelet agent that blocks the ability of thrombin to activate platelets.

Studying the effectiveness of ticagrelor in other patient populations is also underway. In July 2012, AstraZeneca announced that it plans to conduct EUCLID, a new global clinical trial of ticagrelor that will compare its efficacy to that of clopidogrel in reducing cardiovascular deaths, myocardial infarction or ischemic strokes in patients with peripheral arterial disease.

New Treatment for Acute Iliofemoral DVT Deep vein thrombosis (DVT) affects 350,000 to 600,000 Americans (half of them women) each year, and these conditions may contribute to 100,000 deaths every year. Even when physicians can restore blood flow around the lower extremity clot, about half of patients show residual evidence of thrombus or stenosis one year later and the underlying valves are typically compromised.

Patients with significant DVT are likely to experience post-thrombotic syndrome, a disorder characterized by lower extremity swelling, discomfort, eczema, pruritis, ulceration and cellulitis, venous stasis, venous reflux, and chronic edema.

Justin K. Nelms, M.D., a vascular surgeon at Baltimore Washington Medical Center (BWMC), has introduced percutaneous mechanical thrombectomy and thrombolysis, the newest treatment for acute iliofemoral DVT, to the hospital.

“This procedure significantly decreases the morbidity of post

thrombolitic syndrome,” states Dr. Nelms. “However, it’s not indicated for femoral or popliteal DVT, only cases involving the iliofemoral veins.” Its greatest benefit is in situations where extensive thrombus burden is present.

These tend to be DVTs that involve the iliac and femoral veins.

A committee of vascular experts, under the direction of the Society for Vascular Surgery and the American Venous Forum, developed evidencebased practice guidelines for early thrombus removal strategies. They recommend pharmaco-mechanical strategies over catheter-directed pharmacologic thrombolysis alone in a first episode of iliofemoral DVT of less than 14 days in duration, especially in patients with limb-threatening ischemia due to iliofemoral venous outflow obstruction.

Percutaneous Mechanical Thrombectomy Description Dr. Nelms describes the procedure, “We introduce a catheter through the groin to the thrombus. A thrombolytic agent (diluted tissue plasminogen activator) is infused directly into the thrombus, softening it to facilitate its removal. We then use high-speed water jets in the catheter to create a vacuum that sucks in the thrombus, breaking it into minute fragments that are evacuated back through the catheter.”

He continues, “The procedure is performed in the endovascular suite and most patients have an overnight hospital stay. Intravenous ultrasound can be used to display the venous interior and cross sections in real time. With this technology, we can assess the adequacy of our intervention as well as identify any areas of narrowing. If the patient is found to have an underlying stenosis, angioplasty and possibly a stent may also be used.”

Percutaneous mechanical thrombectomy has a number of benefits, including: Rapid removal of the thrombus with restoration of blood flow Faster symptom resolution Shorter procedure time, shorter hospital stays and subsequent cost savings In a small fraction of patients, the procedure may cause bleeding or result in hemolysis that damages the kidneys.

Dr. Nelms notes, “Patients also

receive thrombolytic therapy to facilitate removal of the thrombus and preserve venous valve function. The main utility of percutaneous mechanical thrombectomy and thrombolysis lies in its ability to decrease the incidence and severity of post-thrombotic syndrome.”

Refer Patients with Iliofemoral DVT Early “All patients with acute, symptomatic iliofemoral DVT who present to the ER should be referred to a vascular surgeon for evaluation,” Dr. Nelms advises.

“The fresher the clot, the more likely the thrombolysis is to be effective. Within one week of symptom onset is ideal, though I advocate the procedure up to four weeks post event. A venous duplex study remains the gold standard for diagnosis.

“Many practitioners may not realize that you can or should do thrombolysis for this type of DVT,” concludes Dr. Nelms. “Percutaneous mechanical thrombectomy and thrombolysis has gained wide acceptance in academic centers and increasingly is available in community hospitals.”

Women’s Heart Disease: Shifting to Prevention It’s still apparently a challenge for women and even some physicians to grasp that cardiovascular (CV) disease, not cancer, is the number one killer of women.

“Women should start thinking about CV disease in their 30s or 40s, when they can still prevent it,” says Shannon J. Winakur, M.D., cardiologist and medical director of the Women’s Heart Center at Saint Agnes Hospital.

“Age and family history are the only risk factors you can’t change,” she claims.

“Yet, many women are not taking time to care for themselves or go to the doctor until they’re sick. Further, many practitioners still don’t take a family history of heart disease as seriously for women as for men.”

Dr. Winakur’s advice is underscored by data pooled from five studies that were presented at the American Heart Association Scientific Sessions in November 2012, indicating that healthy habits in middle age can extend longevity by as much as a decade.

Her comments are also supported by the preliminary results of a new European study presented as an abstract at the 2012 Acute Cardiac Care Congress meeting in

JANUARY/FEBRUARY 2013

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Shannon J. Winakur, M.D., medical director of the Women’s Heart Center at Saint Agnes Hospital.

“Women need to make sure they know their numbers.”

– Shannon J. Winakur, M.D.

14 |

WWW.MDPHYSICIANMAG.COM

Turkey. The study found that, compared with men, women with ST-elevation myocardial infarction (MI) had a longer delay in calling for medical assistance and receiving reperfusion once at the hospital; perhaps as a result, they were more than twice as likely to die of MI (9% vs. 4.4% of men).

Women: Know Your Numbers Dr. Winakur stresses that, “Women need to make sure they know their numbers.

At our center, we offer a 60-minute screening with our certified cardiovascular nurse for $60. Women receive a blood pressure screening, BMI, an EKG and blood work that includes a lipid profile and hemoglobin A1c. These results, combined with responses to a questionnaire, create a personalized risk factor profile. Depending on the results, we then educate each woman about her cardiac risk factors and make personalized diet, exercise and smoking cessation recommendations as appropriate. We also make referrals for a full cardiology consultation if needed.

“This service supplements what a primary care physician can do,” she continues. “Being a primary care physician these days is so difficult – you have to do everything in 10 minutes.

We’re here to help them.”

It’s especially critical that women stop smoking as early as possible. A recent prospective study of more than one million women in the UK, published

online in The Lancet, showed that women who smoke triple their risk of early death and that smoking cessation in middle age can largely reverse that risk.

Dr. Winakur states, “Other CV risk factors include autoimmune diseases, radiation therapy and other cancer treatments. Survivors of childhood cancers need to be monitored throughout their lives because they’re at higher cardiovascular risk. Physical and sexual abuse survivors are also at greater risk of heart disease.

“I would love to see more women for cardiac prevention, before treatment of an event,” she adds. “I want to empower women to take control. Patients are sometimes sheepish – they worry that it might be a false alarm, but it’s never a waste of time to get checked out.”

The issue of different symptom presentation continues to stymie prompt attention to possible cardiac disease in women. According to Dr. Winakur, “Fatigue and shortness of breath are common symptoms. Of course, the woman’s physician needs to rule out thyroid disease, anemia and other causes of fatigue.”

Staying abreast of current research requires vigilance. Dr. Winakur notes that, “A new look at the EPIC trial suggests that dietary calcium is better than taking calcium supplements, which correlated with a doubling of MI risk in a study of 24,000 German women.

Newer hormone replacement data also suggests that taking lower doses of HRT when women are in their 50s, closer to the onset of menopause, does not increase the risk of death and MI, and in some cases may lower the risk. This reinforces the importance of considering individual patient history when prescribing treatment.”

“My hope is that we can be as successful at increasing awareness of heart disease in women as Komen has been in getting attention to breast cancer,” she concludes.

Paul A. Gurbel, M.D., director of the Sinai Center for Thrombosis Research at Sinai Hospital of Baltimore Justin K. Nelms, M.D., vascular surgeon at Baltimore Washington Medical Center Shannon J. Winakur, M.D., cardiologist and medical director of the Women’s Heart Center at Saint Agnes Hospital

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PROGRESS AND PROMISE:

THE STATE OF

STEM CELL RESEARCH IN MARYLAND 16 | WWW.MDPHYSICIANMAG.COM

Colleen Christmas, M.D., geriatrician and associate professor of medicine at Johns Hopkins Bayview Medical Center,

D

BY LINDA HARDER PHOTOG RAPHY BY TRACEY BROWN

espite initial setbacks in embryonic stem cell research under the Bush Administration, stem cell research is forging ahead with an emphasis on stem cells derived from adults. Maryland is fortunate to have the Maryland Stem Cell Research Fund (MSCRF), created in 2006 by the state legislature to oversee the funding of stem cell research projects in the state. The Fund has provided over $91 million for 258 research grants in its first six years. Much, though by no means all, of the stem cell research in Maryland centers around researchers at Johns Hopkins University School of Medicine and University of Maryland Medical Center (UMMC).

Dan Gincel, Ph.D., executive director of the Maryland Stem Cell Research Foundation, says, “We use a competitive process – the best science wins. Proposals are submitted and evaluated once each year and we can typically fund 10 to 20% of the applications we receive. We’re unique; very few states have dedicated stem cell funding mechanisms. We’re also working in collaboration with researchers from California and elsewhere to leverage our funding and prevent duplication of

efforts. That lets us get research results to the market faster.”

Stem Cell Categorization

Many different types of stem cells are under investigation for clinical use, including: Embryonic – a small portion of what is funded Adult mesenchymal stem cells (MSCs) – adult stem cells isolated from bone marrow, adipose tissue, or blood that can generate bone, cartilage, fat, cells that support the formation of blood, and fibrous connective tissue Hematopoietic stem cells – adult stem cells that can give rise to blood cell types Induced pluripotent stem cells (iPS) – adult skin cells or, more recently, blood cells, that are reprogrammed to a state similar to that of embryonic stem cells Drug Development

One of the areas of great promise for stem cells is to permit testing of drugs on human cells in a laboratory setting. This is especially helpful for diseases where animal testing yields poorer results.

Curt I. Civin, M.D., director, Center for Stem Cell Biology and Regenerative Medicine, University of Maryland Medical Center

THE NATION’S FACTORY OF ALS STEM CELLS Jeffrey Rothstein, M.D., director for the Brain Science Institute at Johns Hopkins, is a patient man. A researcher at Hopkins for the past 27 years, he’s worked on understanding glial cell functions and how they affect disorders such as Amyotrophic Lateral Sclerosis (ALS) for decades. He comments, “Some of the latest research involves stem cells. In the 1980s, gene therapy was heralded as the future. But it takes a long time to develop biologics. What we know today is very rudimentary. We started in 2000 and thought it would take a few years to develop treatments. But it takes 13 to 15 years to get to FDA approval even when the steps for a new drug are known, and costs more than $1 billion. And for every 13 drugs that make it to the FDA, only one exits successfully.”

Dr. Rothstein continues, “In most neurological diseases, when brain cells die they are lost for life. It’s challenging to get cells back into the neurologic system and have them function. Pluripotent cells can be differentiated to become brain cells, creating an ideal tool to study potential drugs for ALS. It’s hard to replicate the ALS defect in mice, so having stem cells is exciting. Using them may or may not be faster but it’s a potentially more accurate approach.

“Our ALS clinic sees about 350 patients per year,” he comments. “We make the nation’s factory of ALS stem cells from skin biopsies of our ALS patients. We now have 40 different stem cell lines; we can preview the effect of drugs in the dish, and then cull them down to the ones that work best in humans. Using iPS cells not only bypasses ethical problems but is better than using embryonic stem cells.”

JANUARY/FEBRUARY 2013

| 17

cells and instead shut them down. We have new leukemia drugs moving to clinical trial that inhibit growth. That’s quicker than transplanting the cells themselves.”

Burns and Wound Healing

Stem cells are also currently used to promote tissue repair and regeneration for patients with burns or non-healing wounds. Using an extracellular matrix patch containing mesenchymal stem cells that secrete various factors to promote healing has been shown to increase cell survival and proliferation and reduce scarring. “Mesenchymal cells are like a small factory that slowly and continuously release these factors,” Dr. Gincel states.

Dan Gincel, Ph.D., executive director of the Maryland Stem Cell Research Foundation

Dr. Gincel notes, “We’re using stem cells for drug discovery, to provide a greater effect with fewer side effects. It’s a great tool for treating diseases such as ALS, Parkinson’s and Gaucher’s disease.

Dr. Ricardo Feldman at UMMC is using disease-specific human embryonic stem cells to model and treat Gaucher's disease. The controlled differentiation of iPS cells can provide an unlimited supply of patient-specific cells for disease modeling and drug discovery. The end goal is to repair the genetic defect of the Gaucher-specific iPS cells and engraft repaired autologous hemangioblasts to cure the disease.

“Drug companies are now using stem cells to screen drugs – looking for the one

effect on the cell that doesn’t exist in our body,” he continues. “With iPS, you can reproduce a cell into the millions so that you have an unlimited supply.”

At UMMC, for example, Aaron P. Rapoport, M.D., is addressing the higher incidence of cancer following a bone marrow transplant by working on immunization strategies. His work examines how T cells can be re-engineered to recognize and reject the cancer cells that cause diseases such as leukemia.

Curt I. Civin, M.D., director, Center for Stem Cell Biology and Regenerative Medicine at UMMC, says, “Some stem cells are beginning to reach the clinical trial stage. We’ve used our stem cell research to reverse the usual proliferation of cancer

Cell-based Therapies

Researchers hope to use stem cells as a renewable resource to replace damaged cells in diseases ranging from heart disease to diabetes, rheumatoid arthritis, dementia and spinal cord injury.

“Cardiac stem cell transplants are FDA-approved but not quite in clinical use yet,” says Dr. Civin. “Sunjay Kaushal, M.D., Ph.D., a pediatric cardiac surgeon

We’ve used our stem cell research to reverse the usual proliferation of cancer cells and instead shut them down.

– Curt Civin, M.D.

TISSUE REPAIR: REGENERATING HEART MUSCLE Gary Gerstenblith, M.D., cardiologist and Professor of Medicine, and Peter Johnston, M.D., interventional cardiologist and Assistant Professor of Medicine, both in the Division of Cardiology at Johns Hopkins University School of Medicine, have extensively researched the regeneration of heart muscle tissue in patients with left ventricular dysfunction (LVD) following a myocardial infarct (MI). After working on this issue for nearly a decade, they recently published two studies with promising results.

Dr. Gerstenblith notes, “Our goal is to regenerate heart muscle and restore function. Current therapies are helpful in addressing symptoms but don’t address the underlying cause.”

The CADUCEUS trial, published in the March 10, 2012 issue of The Lancet, (in collaboration with the Cedars Sinai Medical Center in Los Angeles, CA) extracted heart tissue from patients with this disease and re-implanted the autologous stem cells 6 to 12 weeks later.

The POSEIDON trial, published in the Journal of the American Medical Association on November 6, 2012 (in collaboration with the Miller School of Medicine in Miami, FL), compared the safety and efficacy of using mesenchymal stem cells (MSCs) from patients with LVD with MSCs from healthy donors. “This small pilot study showed that both healthy allogeneic cells and autologous cells are safe and beneficial in patients with chronic LVD,” says Dr. Gerstenblith. “The cells were effective even though most of these patients had had heart failure for 10 years or longer.” In fact, injection of MSC generally improved patients’ functional capacity, quality of life, and ventricular remodeling.

Future research will explore the mechanisms to the beneficial effects of stem cell therapy for patients with heart disease, what type of cell is best and how to optimize cardiac regeneration.

Dr. Johnston adds, “The ability to use allogeneic stem cells will make it possible to have nearly on-demand/off the shelf availability of cell therapy for the heart, which will be considerably more efficient from a cost and time standpoint compared to autologous cells. The optimal time for cell delivery after a heart attack has yet to be determined – that’s a topic being actively researched.”

18 | WWW.MDPHYSICIANMAG.COM

at UMMC, is addressing hypoplastic left heart syndrome in infants by extracting pieces of the right atrial appendage that is removed in the first surgical procedure.

They are loaded with cardiac stem cells; we grow them in the lab and inject them back into the infant’s heart in a subsequent procedure. That avoids multiple surgeries.”

In the lab setting, Hopkins researchers have used a patient’s stem cells to correct the genetic defect that causes sickle-cell disease. However, more time is needed to translate this work to patient care. Dr. Gincel notes, “In the near future, we’ll be able to use stem cells to treat this and other blood disorders. We also hope researchers will create a genetic mutation that will prevent the HIV receptor CCR5 against HIV-1 acquisition.

Treating neurodegenerative and other degenerative diseases is farther away, because it will take years to grow cells after severe damage is already done.”

Dr. Gincel views stem cells as the fourth ‘pillar’ of healthcare, behind pharmaceuticals, medical devices and biotech development. He predicts, “In the future, we’ll have stem cell therapies that provide a permanent fix, not just management of a disease.”

Dr. Civin concludes, “The combination of genomics and stem cell therapies will be very powerful. When a child is born, he or she will get information about their entire DNA sequence to predict genetically based diseases. Stem cell therapies will be able to do something about it.”

Curt I. Civin, M.D., director, Center for Stem Cell Biology and Regenerative Medicine, University of Maryland Medical Center Dan Gincel, Ph.D., executive director, Maryland Stem Cell Research Fund and VP, University Partnerships, TEDCO Jeffrey D. Rothstein, M.D., Ph.D., John W. Griffin Director for the Brain Science Institute; professor of Neurology and Neuroscience, and the founding director of the Robert Packard Center for ALS Research at Johns Hopkins University School of Medicine.

Gary Gerstenblith, M.D, Professor of Medicine, Division of Cardiology, cardiologist, and Peter Johnston, M.D., Assistant Professor of Medicine, Division of Cardiology, interventional cardiologist, Johns Hopkins University School of Medicine.

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Healthcare IT

Pr o t e ct i ng Pati ent D ata IN A DIGITAL AGE

BY LINDA HARDER PHOTOG RAPHY BY T RACEY BROWN

Mike Fierro, principal of Dynamed Solutions

20 | WWW.MDPHYSICIANMAG.COM

With Meaningful Use incentives as a carrot, many physicians are successfully converting their patient records from paper to digital format. However, even the most ambitious and forwardthinking practices may not be paying sufficient attention to a critical area: the privacy and security of that patient data in a digitized age. Maryland Physician spoke with some local IT vendors who have helped physician practices protect their data onsite and off. Here’s their advice.

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Expanded Fees and Threats In addition to the cost of lost business, the potential cost of a data breach has grown significantly under the HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009, part of the American Recovery and Reinvestment Act (ARRA). This act modified existing HIPAA requirements, with most changes taking effect in early 2010.

Under HITECH, the penalties for patient data violations have increased significantly, from a prior cap of $25,000 per year to a cap of $1.5 million for the worst privacy breaches. State attorneys general can now enforce the law. And business associates are now also liable for securing patient data. Should a breach occur where data is not encrypted, practices and affected business associates must notify affected patients within 60 days of the date of discovery.

With the ready transmission of digital data, practices must be prepared to protect their data far beyond the limits of their offices. And threats can come from multiple fronts – everything from a disgruntled employee to inaccurate data entry to an anonymous hacker.

Undertake a Security Audit and Implement a Plan “Physicians need to be proactive about protecting their data. They often get into

security without knowing what the total budget will be over time,” Steve Rutkovitz, CEO, Choice Technologies, states. ‘We help them to see down the road so they’re not faced with surprise after surprise.”

Security solutions vary significantly in cost and scope, but mid-size practices might expect to spend $2,500 to $10,000 for auditing, documentation and implementation.

As a starting point, practices can consider hiring a professional IT firm to conduct a security audit. This audit should include an assessment of your training policies for staff and the security of your hardware and software. The audit may take one or more days to complete.

Mr. Rutkovitz describes the typical process, “The first thing we do is an audit of everything, asking everything from ‘how is the data stored and backed up, is there remote access, to where is the fire extinguisher kept?’ We look at it holistically. Then, we provide an analysis report that identifies the risks and security gaps so that we can work with the practice to address them with different options.”

Role-Based User Access Mike Fierro, principal of Dynamed Solutions, contributes, “When we work with a physician’s office, we first have the practice determine which staff should have access to what information. For example, JANUARY/FEBRUARY 2013

| 21

Healthcare IT

PATIENT HEALTH INFORMATION SECURITY CHECKLIST > Determine role-based privileges and log-on/password requirements > Establish physical and logical access controls > Develop sanctions for intentional unauthorized access to PHI > Establish automatic timeouts for all applications > Secure network and application servers > Secure and log backup medium and medium re-use > Develop an incident response plan > Create rules for securing PHI in portable devices or sending secure messages, including data encryption, archiving, and deletion > Annual review of all business associates’ agreements and compliance > Perform a security risk analysis > Establish rules to prevent download of malicious software

the front desk staff may only need access to scheduling information, while a nurse or other clinician may need clinical information access. Many practices initially think that all staff needs access to everything, but that’s often not the case. Front desk staff may need to know that lab results came in, but they probably shouldn’t be able to access the actual results. That’s called role-based user access.”

Mr. Fierro also encourages practices to consider who needs ‘read only’ access versus who can edit/enter new information in the patient record. “Once the roles are established, we incorporate that into the EMR training. It’s not uncommon for roles to change over time, as we always try to maintain a balance between security and efficient workflow,” he notes.

Compliance policies should also describe formal sanctions against employees who fail to comply with security policies and procedures.

Wisely Select an IT Provider/Advisor While you can rely on your IT provider for assistance, ask some basic questions to ensure that they are providing sufficient oversight and are adequately certified.

“Ask your firm what certification they have,” Mr. Rutkovitz recommends.

“The highest certification level is the CompTIA [Computing Technology Industry Association] Security Trustmark™, which identifies businesses that follow security best practices. They are the gold standard; it takes more than a year to qualify.”

firewall and in the cloud when they contain sensitive patient data. When using a mobile device for general reference data, such as to look up a drug, these guidelines don’t apply.

Pat Cooley, president and CEO, RelianceNet, observes, “Securing your connections between offices, desktops and notebooks is no longer enough.

Mobile and cloud services open up new areas that require a comprehensive and proactively managed security approach.

Even practices that have internal IT support seem to be slow in responding to protect this critical area appropriately.

Practices with no internal IT should consider engaging a managed services provider who can provide the expertise that is needed on a flat-rate, predictable monthly cost.

Mr. Cooley continues, “Mobile device use is one of the fastest growing trends and it’s expected to continue to grow stronger.” He recommends: Security for patient data has to consider all devices used to access and store patient data, including mobile devices (smartphones, tablets, etc.).

Patient information on a mobile phone can put the practice at risk of HIPAA violations. Mobile devices must be secure and password-protected if they have access to any patient data.

Have a plan based on the devices you choose to support and a policy that clearly defines whether the practice will protect and support only practice-owned devices or if it will also allow and protect BYOD (Bring Your Own Device).

Broader Patient Authorization Data Encryption While HITECH surprisingly did not mandate data encryption, it’s critical that medical practices encrypt any data that is being electronically transmitted.

Encryption keys cannot be stored on the same device as the protected data. Data encryption must be validated and should meet Federal Information Processing Standards 140-2 issued by the National Institute of Standards and Technology (NIST).

Managing Mobile Devices: BYOD? The challenge has expanded to include enabling, securing, and managing devices, apps, and data outside the 22 | WWW.MDPHYSICIANMAG.COM

Mr. Fierro recommends that patient authorization forms be written generally enough to cover devices that your practice may use in the future to connect with patients. For example, if your current approach uses phone calls to remind patients about appointments or medications, but future approaches might involve text messaging or email followup, make sure your patient authorization form is sufficiently broad to cover these future approaches.

Care Coordination/Interfacing with Other Providers Another newer risk facing medical providers is that interfacing with other

Pat Cooley, president and CEO, RelianceNet

providers through a Health Information Exchange (HIE) or Patient Centered Medical Home (PCMH) requires logging into a separate system that is not truly integrated with your own. To avoid privacy issues, many systems use alerts that merely inform physicians that new information is available without divulging any PHI. In Maryland, for example, Chesapeake Regional Information System for our Patients (CRISP) has initiated a service that allows physicians to "subscribe" to patient information alerts for patients under their coordinated care. Whenever a patient has a healthcare encounter that CRISP knows about, an alert is sent to the physician that there is new information about that patient available in the secure portal. No actual personal health information is sent with the alert; physicians receive only a reminder to login and check the updated record. As of November 2012, CRISP had eight organizations that were live, with 210,000 patients subscribed, covering 471 doctors and sending about 175 alerts a day.

5 KEYS TO A MOBILE DEVICE MANAGEMENT STRATEGY User and App Access: identify and validate the people, apps, and devices that are connecting and accessing business assets App and Data Protection: Both apps and data must have controls and protection appropriate to the company and industry.

Device Management: establish policies to manage and secure appropriate mobile devices as well as PCs and other office-based devices Threat Protection: Good threat protection should protect mobile devices from external attacks, rogue apps, unsafe browsing, theft, and even poor battery use.

Secure File Sharing: Businesses should have full administrative control over distribution of, and access to, business documents on any network, especially in the cloud.

Adapted from Symantec information

While new legislation has made it incumbent on practices to be more guarded when obtaining, storing and transmitting patient data, the key is to find a balance between protecting data and allowing appropriate access. “Be cautious but don’t restrict access so much that you diminish patient care,” cautions Mr. Fierro.

Steve Rutkovitz, CEO, Choice Technologies Mike Fierro, principal, Dynamed Solutions Pat Cooley, president and CEO, RelianceNet

JANUARY/FEBRUARY 2013

| 23

Living

Live a Little...

Visit Delray Beach, Florida

By Jacquie Roth

windows that treat diners to amazing views of the Atlantic Ocean. My personal favorite was Brule Bistro, which started as a local market and has evolved over the years to offer classic, French influenced, modern, American cuisine. It was fresh and unique. A mojito inspired tequilabased cocktail served up with a flaming sprig of rosemary was memorable.

Stay and Sleep.

The Pineapple Grove Arts District of Delray Beach offers an eclectic mix of boutiques, galleries, cafes and spas. Public artwork and working artists are open for visitors throughout the district.

D

elray Beach, Florida is known for its eclectic variety of activities. I’d heard great things about it so while looking for an easy-to-get-to sunny destination, I decided it was time to go. Despite waiting out Hurricane Sandy, it was a perfect choice! The waves were incredible to witness and brought in some crazy sailboarders I had the opportunity to watch.

(Lots of) Stuff to Do.

Beachgoers and golfers will stumble into more than enough local spots to stay happy. Funky boutiques line the streets and practically guarantee a treasure finds its way into your carry-on. Music and arts devotees will want to make it a priority to spend some time at Delray’s famous “Arts Garage,”presenting live performances, foreign and documentary films. If relaxation is of utmost importance on your trip, a visit to the DU20 Holistic Oasis is a must-do. Treat yourself to a medicinal tea, 24 | WWW.MDPHYSICIANMAG.COM

followed by an acupuncture treatment to relive stress, or spend some time in a float-meditation tank, designed to allow the body to achieve pure relaxation by resetting hormonal and metabolic balance, through floating.

Good Eats.

There is no shortage of options when it comes to finding good eats in Delray.

From tiki style bars to fine dining hot spots that share the posh trends from Miami and nearby Palm Beach, the restaurants alone are reason enough to travel here. Put The Green Owl on your travel itinerary as a great “locals” spot and must-do for an out of this world breakfast.

As your day rolls on and it’s time for a spot to kick back and relax with happy hour cocktails in the sand, stop into Sandbar at Boston’s on the Beach. For an upscale dining experience, check out Salt 7, Delray’s newest hot spot, serving steak, sushi and a wide variety of raw bar options, or 50 Ocean, with floor-to-ceiling

There are an abundance of choices for where to stay during your time in Delray Beach. While the Colony Hotel & Cabana Club on Atlantic Avenue is a historic hotel with a Caribbean vibe, travelers with more of a traditional taste may want to make reservations at the Seagate Hotel and Spa or the Marriott.

I opted for new and hip with the Hyatt Place Delray Beach. Located in the Pineapple Grove Arts District and within walking distance to the shops, dining and entertainment of Atlantic Avenue, the Hyatt Place Delray Beach is as convenient as it is beautiful.

Complimentary breakfast was an added bonus, as well as the rooftop pool and hot tub, which I made good use of between afternoons of local boutique shopping and evenings out on the town. Staying at the Hyatt made it easy to take in the Pineapple Grove nightlife. Win, win!

Pick Up and Go.

I was told that Delray is the kind of place for hard chargers looking for a town where flip flops and cutoffs are the uniform for just about everywhere. My kind of place! A straight-shot, 20-minute drive from the West Palm Beach airport, it is easy to get to and can make for a perfect getaway to refocus, recharge or simply relax. For further information, a listing of upcoming events that are happening in town, and tips for planning your trip to the Delray Beach area, visit www.downtowndelraybeach.com.

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In every issue, Maryland Physician explores a different facet of the race to implement EHRs to meet Meaningful Use and other e-health government incentives. Donâ&#x20AC;&#x2122;t be

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Solutions

Create a “WOW” Experience for Your Patients

By Nancy R. Smit

M

EDICAL PRACTICES historically have been slow to embrace the “customer first” mentality that defines corporate America. Despite the fact that patients who are treated with kindness and respect are more loyal and much more likely to refer their friends, far too many patients experience a “cranky receptionist” or “poor bedside manner” when they visit their doctor’s office.

Now, more than ever, customer service and patient satisfaction need to be top priorities for your practice. Under the Affordable Care Act (ACA), one of five key measures that will be directly tied to Medicare reimbursement is the “patient/caregiver experience of care.”

With greater transparency and use of social media, online customer service ratings and comments can either drive patients to the practice or drive them away. But perhaps one of the most significant benefits of a positive patient experience is the legal buffer it provides.

Statistics show that the single biggest source of malpractice suits is the lack of a positive relationship between patient and provider.

Exceptional customer service means exceeding your patients’ expectations any time they make contact with your practice. According to Dr. Neil Baum, a urologist and leading expert on medical marketing, “if you create and maintain a ‘WOW’ experience for your patients, you will build an army of loyal supporters who will continually tell others about your practice.” Every person that comes into contact with your practice forms an impression that they will share with others, not just

your patients. High-level customer service must extend to your referral sources, hospital staff and representatives and the community.

How can you create a “WOW” experience for your patients?

STEP 1 - Create a positive and dynamic work environment.

Your staff’s attitude is the single most important factor influencing your patients’ experience. Employees who are happy and feel valued will convey that positive feeling to your patients.

Create an environment that encourages employees to share their suggestions, make sure they are well trained, and focus on their positive contributions rather than their mistakes.

STEP 2 - Treat each patient as you would like to be treated.

Ask yourself and your staff, “Would you like to be a patient is this practice?” Show each patient that you are thankful they chose your practice, that you are compassionate and that you and your staff are eager to please them. Remind everyone to smile, make good eye contact, and say “thank you” to every patient – so simple yet so often forgotten.

STEP 3 - Continually strive to see your patients on time.

Carefully monitor your schedule and make efficient scheduling a high priority.

If you are running late, have your staff explain to patients truthfully why you are not on time and give them the option to wait or reschedule. If you habitually run late, it is time to re-evaluate your scheduling process and parameters.

STEP 4 - Under promise and over deliver.

Too often, practices tell patients that their test results will be back in a week when it actually will take 10 days, creating patient calls and frustration. If, however, you tell your patients that their results will be back in two weeks, and they have them in 10 days, they are thrilled! Solicit staff suggestions about ways to reduce patient frustration simply by changing expectations.

STEP 5 - Differentiate your practice.

Brainstorm with your staff about ways to make your patients feel special, such as making follow-up calls to new patients to welcome them to your practice, sending a small gift to patients following hospitalization or surgery, recording information about family members or vacations that you can ask about during the visit, and writing thank you notes when patients refer others.

Creating a culture of service excellence and high customer service in any organization takes a team effort. It needs to begin at the top with leadership, and be continually monitored and reenforced throughout the organization. As you begin this New Year, make time to meet with your staff and discuss the importance and value of customer service to your practice. Rally your team to make “Kindness, Respect and Gratitude” the hallmarks of your practice. It is truly the best insurance you can “buy” for your practice and the only cost is the time spent with your staff.

Nancy Smit, MBA, RPT, RRT, is president and CEO, SHR Associates, Inc. www.shrassociatesinc.com

JANUARY/FEBRUARY 2013

| 29

Good Deeds

Restoring Rhythm in Bangladesh

By Linda Harder

C

ARDIOLOGIST RAFIQUE Ahmed, M.D., PhD, FACC, has quietly created the groundwork for thousands of Bangladesh residents with heart arrhythmias to live normally again, without fear of heart failure or death.

A native of Bangladesh, Dr. Ahmed has worked for more than a decade to develop the first electrophysiology (EP) services in this country of over 150 million people. In the capital of Dhaka, four heart hospitals provide many heart services and even heart surgery, but the country had no EP services until Dr. Ahmed intervened. Yet a common and treatable EP problem, supraventricular tachycardia (SVT), affects more than 400,000 people in the country.

In 2001, Dr. Ahmed began bringing donated EP equipment and other physicians to help establish two labs in Dhaka. But the critical component of training Dhaka cardiologists to perform these services themselves wasn’t begun until February, 2005, when he returned to Bangladesh with a fellow Maryland cardiologist to train local cardiologists in

2000 cardiac ablations have been performed to date in Dhaka. “The advantage of cardiac ablation is that, when successful, it’s a cure,” he notes.

“It makes a tremendous impact in the patient’s life. We had one teen that couldn’t participate in any sports until he had the procedure. After the ablation, his life was changed. Another patient was a housewife who used to pass out from her tachycardia. The ablation changed her life so much that she came a long distance just to thank me the next time I returned.”

“We’ve had over a 90% success rate with our ablations,” he adds. “That’s comparable to rates in the U.S.” Dr. Ahmed has also helped Bangladesh nurses, cardiologists and cardiac anesthesiologists come to the U.S. for training. He has contributed his home and his own funds to support many of these efforts, as well as soliciting donated equipment and catheters from Maryland hospitals. “When Western Maryland Health System was upgrading their EP lab, they donated their old equipment,

“We’ve had over a 90% success rate with our ablations. That’s comparable to rates in the U.S.” – Rafique Ahmed, M.D.

ablation, a procedure that uses electrode catheters and radio waves to return the heart to its normal rhythm.

“This is a highly cost effective form of treatment,” observes Dr. Ahmed.

“Once an electrophysiology laboratory is established, the subsequent maintenance cost is low. Most of the materials can be used many times.”

Thanks to Dr. Ahmed, more than

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which was in excellent condition, to the National Institute of Cardiovascular Disease, the main teaching hospital in Dhaka,” he recalls.

In addition to patients with supraventricular tachycardia, a growing number of Bangladesh residents suffer from coronary disease and cardiomyopathy. EP services are necessary to evaluate these patients

Thanks to the efforts of Dr. Ahmed and his colleagues, more than 2000 residents of Bangladesh have received cardiac ablations.

and reduce their risk of sudden death using defibrillators and/ or biventricular pacemaker defibrillators.

Dr. Ahmed continues. “As the team is now fully trained in ablation for tachycardia and pacemakers, for the last two years, I’ve begun focusing my training on the management of hypertrophic cardiomyopathy. And, I can expand to other areas of the country. I’m also working on developing the education curriculum so that it’s as close to what we get in the U.S. as possible.”

Rafique Ahmed, M.D., PhD, FACC, is an attending cardiac electrophysiologist with Chesapeake Cardiovascular Associates.

Maryland Physician would like to hear about your “Good Deeds.”

Please share your ideas with us at news@mdphysicianmag.com.

Good intentions or bad judgment?

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Climbing with Confidence After Catheter Ablation at

For priority transfer of your cardiac admissions, call Cardiac One-Call 866-684-8460.

To refer a patient for a cardiac surgery consult, call 301-891-6101.

Guillaume Marรงais, 37, Montgomery County, Treated with Heart Ablation for Atrial-Fibrillation