Florida md march 2016

MARCH 2016 • COVERING THE I-4 CORRIDOR

Osceola Regional Medical Center Heart & Vascular Institute TAVR: New Era of Percutaneous Delivery

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FLORIDA MD - MARCH 2016 1

contents 4

MARCH 2016 COVERING THE I-4 CORRIDOR

 COVER STORY

A growing number of frail, elderly patients who suffered from aortic valve stenosis are leading longer, more productive lives after percutaneous transcatheter aortic valve replacement at Osceola Regional Medical Center Heart & Vascular Institute.

PHOTO: DONALD RAUHOFER / FLORIDA MD

The Edwards Sapien transcatheter heart valve replacement was approved by the United States Food and Drug Administration (FDA) in November 2011 as an alternative for patients with inoperable, severe, symptomatic aortic valve stenosis. Prior to FDA approval, there was no viable treatment for these high-risk patients.

This past summer, the Osceola Regional Heart & Vascular Institute transcatheter aortic valve replacement (TAVR) team began using the latest Edwards Sapien 3 with excellent results. So far, a total of 16 patients have had the procedure, and all have experienced relief from the debilitating symptoms of angina, syncope and/or heart failure that in severe cases can lead to an inability to mobilize and a decreased quality of life.

MOROF H.E.L.P.S. PREPARE FUTURE HEALTHCARE LEADERS TODAY 22 DON’T CALL ME A PROVIDER-- FED UP WITH EXCESSIVE OVERSIGHT, DOCTORS GET ORGANIZED 23 ADVANCES IN TREATING BACK PAIN PROVIDE HOPE FOR MILLIONS OF PATIENTS

PHOTO: PROVIDED BY OSCEOLA REGIONAL MEDICAL CENTER

ON THE COVER: DR. ANTHONY NUNEZ, DR. JOOBY JOHN, DR. SAYED T. HUSSAIN, AND DR. KHURRAM MOIN

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DEPARTMENTS 3

FROM THE PUBLISHER

9

PULMONARY & SLEEP DISORDERS

10 BEHAVIORAL HEALTH

12 HEALTHCARE LAW 13 MARKETING YOUR PRACTICE 14 CANCER 16 ORTHOPAEDIC UPDATE 18 HEALTHCARE BANKING, FINANCE AND WEALTH 19 INSURANCE 20 INPATIENT REHABILITATION 2 FLORIDA MD - MARCH 2016

FROM THE PUBLISHER

I

am pleased to bring you another issue of FloridaMD. It’s hard to imagine anyone who is not familiar with the March of Dimes and the work they do to address the problems of premature births and babies born with birth defects. They are always searching for results and services that will help families have healthier babies. April 30, 2016 is the annual Central Florida March for Babies. It’s a wonderful team-building opportunity for your staff and their families and a great time for a great cause. Listed below are instructions on how you and your family can join the march or how to form a team for your whole practice. I hope to see all of you there.

Best regards,

Donald B. Rauhofer Publisher

COMING UP NEXT MONTH: The cover story focuses on the Multidisciplinary Head and Neck Care at UF Health Cancer Center – Orlando Health. Editorial focus is on Surgery and Scoliosis.

Join more than a million people walking in March of Dimes, March for Babies and raising money to help give every baby a healthy start! Invite your family and friends to join you in March for Babies, or even form a Family Team. You can also join with your practice and become a team captain. Together you’ll raise more money and share a meaningful experience.

When: Saturday, April 30th • 7:00am Registration • 8am Opening Ceremonies • Where: Lake Eola, Downtown Orlando Steps for New Users: 1. Go to marchforbabies.org 2. Click JOIN or START A TEAM 3. If you choose JOIN A TEAM, search for the team name in the search bar or browse through the least of teams in alphabetical order 4. If you choose START A TEAM, fill out the information for your new team and click save 5. Save your username and password for future reference.

Some keys to success: Ask your friends, family and colleagues to support you by donating to the March of Dimes. This can help you raise more money.

The main reason why people do not donate is that no one asked them to give (don’t be shy)! Emailing them is an easy way to ask.

You’re done! Your personal page has been created for you and you are ready to begin fundraising!

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Heidi Ketler, Sajid Hafeez, MD, Daniel T. Layish, MD, William Boyles, Julie Tyk, Jeff Holt, Marni Jameson, Tom Murphy, Colleen Lane, Anita White, Dorothy Mowbray, Corey Gehrold Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information.

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COVER STORY

Osceola Regional Medical Center Heart & Vascular Institute – New Era of

Percutaneous Delivery: TAVR Relieves Severe, Symptomatic Aortic Stenosis in Inoperable Patients

By Heidi Ketler A growing number of frail, elderly patients who suffered from aortic valve stenosis are leading longer, more productive lives after percutaneous transcatheter aortic valve replacement at Osceola Regional Medical Center Heart & Vascular Institute.

The Edwards Sapien transcatheter heart valve replacement was approved by the United States Food and Drug Administration (FDA) in November 2011 as an alternative for patients with inoperable, severe, symptomatic aortic valve stenosis. Prior to FDA approval, there was no viable treatment for these high-risk patients.

This past summer, the Osceola Regional Heart & Vascular Institute transcatheter aortic valve replacement (TAVR) team began using the latest Edwards Sapien 3 with excellent results. So far, a total of 16 patients have had the procedure, and all have experienced relief from the debilitating symptoms of angina, syncope and/or heart failure that in severe cases can lead to an inability to mobilize and a decreased quality of life.

“Our TAVR team’s outcomes are comparable to any large, met-

ropolitan institution,” says interventional cardiologist Sayed T. Hussain, M.D., F.A.C.C., medical director of Osceola Regional’s structural heart program. “We have had excellent outcomes during the procedures and the 30-day post-op period, with no deaths and no major complications in all of our patients.”

Dr. Hussain of Florida Cardiology is joined on the Osceola Regional Heart & Vascular Institute TAVR team by fellow interventional cardiologists Khurram Moin, M.D., F.A.C.C., of Cardiac Clinic; and Jooby John, M.D., M.P.H., F.A.C.C., F.S.C.A.I., of Cardiovascular Associates; and cardiothoracic surgeon Anthony Nunez, M.D. Heather Daniels, M.S.N., A.R.N.P.-C., G.N.P., is the valve clinic coordinator, overseeing logistics for each TAVR patient, from start to finish.

“Our oldest TAVR patient is 94 and doing great. All of our patients feel better the next day or two, once they recover from the anesthesia,” says Dr. Hussain. The outcomes are so impressive and technology increasingly refined that he and his colleagues believe TAVR will mirror standard cardiac catheterization – offered

PHOTO: DONALD RAUHOFER / FLORIDA MD

Heart & Vascular Institute Team - Back row from the left: Tony Thompson, RN, CCRN, Drew O’Gara, ARNP, Walter Cintron, CVT, Brent Waldon.

Front Row: from the left: Cecelia Zorro, RN, Wendy Penny, RN, VP of CV Services, Anthony Nunez, MD, Heather Daniels, ARNP, Valve Coordinator, Sayed T. Hussain, MD, Medical Director TAVR program, Khurram Moin, MD, Georgia Brown, RN, Kristine Hammer, RN, Director of Procedural Services, Jan Sauerstein, RCIS and Annie Morales, CST. Not pictured: Jooby John, MD.

4 FLORIDA MD - MARCH 2016

COVER STORY as an outpatient procedure, using conscious sedation, a safer alternative to general anesthesia even for those with advanced emphysema.

PHOTO: PROVIDED BY OSCEOLA REGIONAL MEDICAL CENTER

TREATMENT OPTIONS FOR REPAIRING AORTIC STENOSIS Aortic stenosis is the most commonly diagnosed heart valve condition in the United States, affecting approximately five of every 10,000 adults. Its prevalence is expected to increase as the population ages.

Aortic stenosis (AS) risk factors include age, gender, hypertension smoking, diabetes and serum LDL and lipoprotein levels. The condition is characterized by the gradual calcification of the heart valve. It begins with no obstruction to ventricular blood outflow and a long latent period with low morbidity and mortality.

Dr. Jooby John, interventional cardiologist and echo technologist Deborah Ramsey review echo results on a potential TAVR patient. Potential TAVR cases are presented and discussed regularly at hospital multidisciplinary TAVR conferences.

Progression of AS from the base of the valve cusp to the leaflets eventually causes serious outflow obstruction. While there is no way to predict progression rate, it occurs more rapidly in elderly patients with coronary artery disease and chronic renal insufficiency.

On average, survival is two to three years after symptoms develop, with a high risk of sudden death. “Aortic stenosis is a fatal condition to have, more so than cancer,” says Dr. Hussain.

There is no medication to reverse AS. The only definitive treatment is aortic valve replacement (AVR), and surgical valve replacement has been the treatment of choice for operable patients with symptomatic, severe AS and some with asymptomatic, severe AS.

FDA approved for only severe, symptomatic AS in patients at high risk for SAVR and predicted post-TAVR survival of greater than 12 months.

The procedure involves minimally invasive percutaneous access that can take one or an innovative combination of the following approaches: • • •

Transfemoral via a femoral artery.

Transaortic via a limited sternotomy.

Transapical via a limited lower thoracotomy.

The femoral route is the most common method of catheter insertion, followed by transapical access.

Surgical aortic valve replacement (SAVR) involves a sternotomy and cardiopulmonary bypass. The surgeon then removes the diseased valve and replaces it with an artificial valve made either of animal or synthetic materials. The surgery typically lasts six to eight hours, and patient recovery time can take from four to 12 weeks.

During the procedure the diseased valve is replaced with a bioprosthetic valve using a balloon catheter under flouroscopic guidance. The procedure takes an hour or two, and patient recovery is typically a matter of days. Endovascular skills and smaller sheaths enable the Osceola Regional TAVR team to perform the transfemoral procedures using percutaneous pre-closure rather than surgical cutdown, further reducing recovery time.

The overall five-year survival rate in all adults after AVR is 8094 percent, and the 10-year survival rate is 68-89 percent. Perioperative mortality increases with age, from 1.3 percent in patients younger than 70 years to 5 percent at age 85 and 10 percent in patients 90 years or older.

Several of Osceola Regional’s earlier cases underscored the value of TAVR and the expertise of the TAVR team. “These patients presented a unique set of challenges,” says Dr. Hussain. “Most of them had heart failure and shortness of breath and were unable to mobilize.”

Studies have found, however, that the short- and long-term prognoses of elderly patients selected for SAVR are favorable and that patient age has limited incremental impact on long-term survival in moderate- and high-risk patients. Severe lung disease and renal failure indicate a poor long-term prognosis after SAVR.

Among the early patients were three Jehovah’s Witnesses, whose religious beliefs prohibit blood transfusions. Blood-product transfusions are often used during cardiac surgery to offset the morbidity and mortality associated with anemia. Transfusion refusal is a contraindication for traditional surgery.

Transcatheter aortic valve replacement (TAVR) is currently

“We also were impressed by a patient who we thought would FLORIDA MD - MARCH 2016

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PHOTO: PROVIDED BY OSCEOLA REGIONAL MEDICAL CENTER

COVER STORY

Hybrid Operating Room at Osceola Regional utilized for TAVR procedures. This state-of-the-art OR combines an operating suite with a cardiac catheterization laboratory and peripheral angiographic imaging capabilities. This unique technology allows interventional cardiologists, cardiovascular surgeons and anesthesiologists perform procedures simultaneously.

be a straightforward surgical candidate,” says Dr. Khurram Moin.

“Once we dug deeper into his chart other things factored into it and he was found to be a high-risk SAVR candidate. We went ahead and did TAVR, and the next day the patient was sitting up in the chair, ready to go home. You simply don’t have that after open-heart surgery.”

The last two Osceola Regional TAVR patients had the shortest lengths of hospital stay to date: 2.5 days. The prior average was three to five days.

TAVR VALVE CLINIC: MULTIDISCIPLINARY, PATIENT-FOCUSED, COMPASSIONATE “Outside of clinical trials, TAVR is only available to patients deemed too high a risk for surgery,” says Dr. Anthony Nunez.

“It takes two cardiac surgeons to independently examine patients and to certify a patient as high risk, before we take the treatment decision to the next step.”

Severe AS cases are then carefully assessed at Osceola Regional by the multidisciplinary heart valve team that includes the interventional cardiologists and cardiovascular surgeons, as well as anesthesiologists and echocardiographers, among other operating room and medical staff. The TAVR team meets in conference once a week to review all of the studies on each patient and collaborate to optimize patient-centered treatment of complex valve disorders.

“The choice to use surgical AVR or TAVR is based on welldefined clinical guidelines. Consideration also is given to the estimated risk and benefit of the procedures, as well as existing comorbidities, including coronary artery disease,” Dr. John says.

“Comprehensive pre-planning determines success.”

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“One of the key things is, we want to assess the patient as soon as possible for timely intervention,” says Ms. Heather Daniels.

“Part of my role is to help the flow through the process for timely evaluation and intervention. Sometimes the patient needs tests or procedures, such as (percutaneous coronary intervention) on one of their coronary arteries. I make sure the patient is scheduled for that first and TAVR within a week or two after.”

“Heather brings everything together for the patient and the medical staff,” says Dr. John. “That she is a nurse practitioner is an additional benefit. She can place orders for such things as medical scans, lab tests (echocardiograms), and perform a much more involved clinical role. She evaluates patient symptoms and comorbidities, such as kidney failure and severe emphysema, which requires a pulmonary consult.”

“As part of her job, Heather has to know everything about the patient,” says Dr. John, noting the time and organization required on her part.

Ms. Daniels also writes a note about the patient’s objectives after TAVR implant on the corner of each medical chart. Dr. John summarizes one: “Patient wants TAVR, so he can help his wife with Parkinson’s disease around the home.”

It’s a unique touch that resonates with the physicians on the TAVR team, says Dr. John. “It puts a very human face on each case, underscoring that this patient is not just a 26 millimeter aortic valve or a 10 millimeter iliac artery.

“It emphasizes that what we do is important. It’s not just because the data shows it’s important. It’s because the patient may go back home with a better ability to help another elderly family member who is sick. It’s about quality of life, not just for the patient but also for the patients’ families.

COVER STORY “The vast majority of our TAVR patients are older than 80.

Many have spouses who depend on them.”

The personal note on the corner of the patient chart “reminds (the TAVR team) why we do our very best to get this patent home safely. His wife depends on it. He can’t stay in the hospital for seven days; he needs to be home in two to three days.”

The challenge, say the Osceola Regional TAVR specialists, is changing the belief that it is too late to refer for AVR older patients with AS and significant and serious co-morbidities. But this is generally the condition of the TAVR candidate.

INCREASING AWARENESS OF TAVR IN THE MEDICAL COMMUNITY

“We want to educate the public and the medical community about technological advances in aortic valve replacement and the improved outcomes, so we can help folks with aortic stenosis have a better quality of life, breathe better and feel better,” says Ms. Daniels.

The Placement of Aortic Transcatheter Valves (PARTNER) trial found that inoperable patients with severe AS had improved survival with TAVR compared with medical management. In high-risk patients, survival was similar with TAVR and surgical AVR.

“It takes decades to get aortic stenosis and most don’t realize it’s creeping up. And then they get the procedure, and they notice ‘This is how I should be feeling.’ I think the benefits of TAVR often come as a revelation for the patients, their family members and sometimes even for us doctors,” Dr. John says.

“In properly selected patients surgical AVR and TAVR consistently produce excellent results in prolonging life and improving quality of life,” says Dr. Moin.

“It’s important for the medical community to realize that TAVR is an option, and there are patients out there who could benefit from it,” he says. “If a murmur is detected on echocardiography or a previously active 95 year old who is now unable to get the mail, they may have aortic stenosis, and TAVR may be an option. There are 95-year-old patients getting TAVRs in this country who do very well and live many more productive years.”

Despite clear treatment guidelines, excellent surgical outcomes and high mortality of symptomatic valve disease, about one-third of patients with severe, symptomatic AS do not receive necessary valve replacement.

“It is not that we get referred patients for TAVR who can get SAVR. The problem is the other way around. Patients who qualify for TAVR and are high risk for SAVR don’t get referred,” says Dr. John.

FUTURE OF PERCUTANEOUS DELIVERY

He points to studies that have shown from 30-50 percent of patients with severe aortic stenosis who need aortic valve repalcement surgery never get it.

“We now have a treatment that is safe and possible in patients who could not withstand open-heart surgery. This is a gigantic leap,” says Dr. John.

The ability to treat a condition that was once thought to be untreatable has many within the cardiovascular community hoping that a new era of percutaneous delivery has arrived.

PHOTO: PROVIDED BY OSCEOLA REGIONAL MEDICAL CENTER

Osceola Regional Medical Center

FLORIDA MD - MARCH 2016

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COVER STORY “I wouldn’t be surprised if in the future TAVR becomes routine, even for those at low-risk for open-heart surgery,” says Dr. Hussain.

As examples, he says, the Heart & Vascular Institute structural heart team has sights set on newer percutaneous technologies for treating mitral valve regurgitation in medically frail and elderly patients who are deemed inoperable due to comorbid disease.

Catheter-based therapies for valvular heart disease also may be offered to patients with early-stage regurgitant lesions to prevent progressive ventricular enlargement.

Another percutaneous, transcatheter device under consideration is the Watchman device for closure of the left atrial appendage (LAA) in patients with non-valvular atrial fibrillation who are high risk for anticoagulants or whose therapy failed, and they seek a non-pharmacologic alternative. By closing off the LAA, the risk of stroke may be reduced, allowing discontinuation of warfarin.

Since FDA approval TAVR has become even more effective.

“Only five years ago, the vascular complications produced significant mortality. Smaller sheath sizes today have greatly minimized those risks,” Dr. John says.

TAVR sheaths now range in size from 14 French to 22 French, compared with earlier technology that ranged from 22 French to 26 French. (Three French equals 1 millimeter.) Osceola Regional’s TAVR team currently uses size 14 and 16 French - some of the smallest sheaths available for this procedure.

“The reality is that as the technology gets smaller, complications decline dramatically, so in the future the vast majority of patients with AS may be candidates,” says Dr. John, adding that now with better preoperative (computed tomography) imaging, fewer TAVR patients experience paravalvular aortic regurgitation.

Cardiovascular specialists across the country are anticipating the results of the PARTNER II cohort A trial, a randomized, controlled, multicenter trial comparing TAVR using the Sapien XT system (a previous-generation valve) to surgical AVR in patients at intermediate risk for surgical mortality. The report is scheduled to be presented at the American College of Cardiology 2016 meeting this month.

The findings may help confirm what seems intuitive: expanding the indications for TAVR to lower-risk patients. The primary TAVR concerns relate to stroke, paravalvular regurgitation, access-site vascular complications and advanced atrioventricular block requiring permanent pacemaker implantation, in addition to the lack of data on long-term durability of the percutaneous valves.

According to Dr. John, results that find the expanded use of TAVR to this intermediate-risk cohort to be safe and beneficial will likely be considered by the FDA; and FDA approval might potentially follow. The devices are already approved for intermediate-risk aortic stenosis patients in Europe.

DEDICATED CARDIOVASCULAR AND EMERGENCY CARE Osceola Regional Medical Center is the only full-service car8 FLORIDA MD - MARCH 2016

diovascular hospital in the region, focused on positively impacting the health and welfare of a growing region through two flagships: cardiovascular and emergency care.

It also is a teaching hospital, offering residencies, such as its obstetrics and gynecology residency. Approved by the American Osteopathic Association, the residency is one of the first of its kind in the southeast. The hospital also has an internal medicine residency sponsored by the University of Central Florida College of Medicine. Currently, a total of 41 residents are under the supervision of 35 physicians, who provide comprehensive, didactic, bedside teaching.

The advanced level of care at this 318-bed hospital is validated by a number of achievements, such as the national rating recognition in heart surgery excellence by the Society of Thoracic Surgeons. The ranking is reserved for the top 13 percent nationally.

Osceola Regional is the only accredited chest pain center with percutaneous coronary intervention in Osceola County. Its blue seal status signifies that the emergency coronary care team can open a heart vessel in 90 minutes or less. The hospital also is accredited as a primary advanced stroke center by The Joint Commission - the only one in Osceola County.

A provisional-status Level II trauma center, the Osceola Regional Emergency Department has been accepting Level II trauma patients since May 1, 2015. Currently its average STEMI (ST-elevation myocardial infarction) times beat the national 90-minute benchmark. At Osceola Regional it takes emergency staff an average of 59 minutes from patient arrival to reestablish blood flow.

The Osceola Regional pediatric emergency room has boardcertified pediatric emergency physicians and emergency staff members who are specially trained in pediatric emergency care and pediatric advanced life support. A pediatric intensive care unit is scheduled to open at Osceola Regional this year to complement their new pediatric inpatient unit and affiliation with Nemours.

In November, Osceola Regional Medical Center earned its fifth “A” for hospital safety by The Leapfrog Group. It also was named for the first time to Leapfrog’s annual top hospitals list in the Urban Hospitals category (one of three in the state). The recognition cites Osceola Regional’s commitment to providing safe, high-quality health care.

The Heart & Vascular Institute touts itself as a pioneering facility, staffed by a talented and accomplished medical staff. As a result, it has brought many firsts to the region. In addition to TAVR, it was the first in the region to implant the world’s smallest implantable cardiac monitor (ICM) available in 2014.

To learn more about Osceola Regional Medical Center, visit osceolaregional.com. The physician referral number is (800) 447-8206. 

PULMONARY AND SLEEP DISORDERS

Pulmonary Rehabilitation

By Daniel T. Layish, MD, FACP, FCCP, FAASM Pulmonary rehabilitation can benefit patients with a wide variety of lung diseases including COPD, pulmonary fibrosis, cystic fibrosis, and sarcoidosis (among other chronic respiratory illnesses). Pulmonary rehabilitation does not replace standard medical and/or surgical treatments for these lung diseases. Rather, it supplements and complements standard therapy.

Patients with COPD (and other chronic lung diseases) develop shortness of breath with activity. This leads to the tendency to avoid activity, which in turn leads to deconditioning. It is felt that one of the main benefits of pulmonary rehabilitation is to break the cycle of deconditioning. Pulmonary rehabilitation programs typically include two or three outpatient sessions per week for 10 to 12 weeks. Typically, a pulmonary rehab program will include aerobic exercise, strength training, patient education in management of lung disease - including nutrition, energy conservation, medication compliance, bronchial hygiene, and breathing strategies. The component of group support is also felt to be a significant contributor to the success of these programs. The group support motivates the patient to attend the pulmonary rehab sessions. It also allows the patient to realize that there are other people suffering from chronic respiratory illness and to see how they are able to overcome these obstacles. Pulmonary rehabilitation is considered to be critical both before and after lung transplantation. Occasionally, a patient will have such a significant functional and symptomatic improvement after pulmonary rehab that transplant can be delayed.

Pulmonary rehabilitation programs are typically multidisciplinary in nature and may include a respiratory therapist, registered nurse, exercise physiologist, nutritionist, physical and/ or occupational therapists. The staff is trained to encourage the patient’s self management and coach them to adopt healthier habits through lifestyle modification. To enroll in a pulmonary rehabilitation program requires a medical referral. Pulmonary rehabilitation is covered by most third party payors. Pulmonary rehabilitation is appropriate for any stable patient with a chronic lung disease who is disabled by respiratory symptoms.

The pulmonary rehab program should involve assessment of the patient’s individual needs and creation of a treatment plan that incorporates realistic goals tailored to each patient. Evidence based analysis consistently reveals improvement in health related quality of life after pulmonary rehabilitation as well as improved exercise tolerance. Pulmonary rehabilitation has been shown to improve the symptom of dyspnea and increase the ability to perform activities of daily living. Pulmonary rehabilitation has also been shown to reduce health care utilization (including frequency of hospitalization) and decreases length of stay (when hospitalization is required). Pulmonary rehabilitation has not been demonstrated to improve survival.

ditioning. Some pulmonary rehabilitation programs will therefore include a “graduate” or maintenance program after the patient finishes the initial program.

Patients who develop shortness of breath often become anxious which in turn exacerbates the sensation of dyspnea and this can become a vicious cycle. Pulmonary rehabilitation can be very helpful in addressing this problem. Sometimes pulmonary rehabilitation will require supplemental oxygen with exercise.

Although the strongest evidence regarding pulmonary rehabilitation programs is in the setting of COPD, it has been shown to be beneficial in a variety of disease states. Pulmonary rehabilitation has been shown to be a cost effective tool in the fight against chronic lung disease. It is currently felt to be underutilized.

Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. He may be contacted at 407841-1100 or by visiting www.cfpulmonary.com.

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The benefit from a pulmonary rehabilitation program may decline over time if the individual does not maintain their conFLORIDA MD - MARCH 2016

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BEHAVIORAL HEALTH

Expanded Services Now at COVER STORY University Behavioral Center

By Sajid Hafeez, MD University Behavioral Center is growing in the new year the addition of outpatient services including mental health intensive outpatient and partial hospitalization programs. UBC is currently undergoing renovations to expand our outpatient area to accommodate the new programs.

The new programs meet Monday- Friday from 8:30-2:30PM

for PHP, Monday, Tuesday and Thursday from 5:30-8:30PM for psychiatric IOP and Monday, Wednesday and Friday from 5:30-8:30PM for Substance Use Disorder IOP. The benefits of these outpatient programs are significant to our patients.

Central Florida Pulmonary Group, P.A. Serving Central Florida Since 1982 Our physicians are Board Certified in Internal Medicine, Pulmonary Disease, Critical Care Medicine, and Sleep Medicine

Specializing in: • • • • • • • • • •

Asthma/COPD Sleep Disorders Pulmonary Hypertension Pulmonary Fibrosis Shortness of Breath Cough Lung Cancer Lung Nodules Low Dose CT - On Site Clinical Research

Daniel Haim, M.D., F.C.C.P. Daniel T. Layish, M.D., F.A.C.P., F.C.C.P. Francisco J. Calimano, M.D., F.C.C.P. Francisco J. Remy, M.D., F.C.C.P. Ahmed Masood, M.D., F.C.C.P. Syed Mobin, M.D., F.C.C.P. Eugene Go, M.D., F.C.C.P. Mahmood Ali, M.D., F.C.C.P. Steven Vu, M.D., F.C.C.P. Ruel B. Garcia, M.D., F.C.C.P. Tabarak Qureshi, M.D., F.C.C.P. Kevin De Boer, D.O., F.C.C.P. Jorge E. Guerrero, M.D., F.C.C.P. Roberto Santos, M.D., F.C.C.P. Hadi Chohan, M.D. Jean Go, M.D. Guillermo Arias, M.D. Erick Lu, D.O. Downtown Orlando East Orlando Altamonte Springs 1115 East Ridgewood Street 10916 Dylan Loren Circle 610 Jasmine Road 407.841.1100 | www.cfpulmonary.com | Most Insurance Plans Accepted

10 FLORIDA MD - MARCH 2016

The PHP and IOP programs offer individuals the intensity of therapy and intervention with the convenience of remaining at home during the evenings and weekends.

PHP allows a patient to stay with their MD after hospitalization and attend 6 hours of treatment a day. IOP provides 3 Hours a day of intensive treatment.

UBC is very excited to announce that we will be using certified Dialectical Behavioral Therapy (DBT) within our programs.

DBT has been a therapy used with various groups and in many settings from individual therapy to inpatient hospitals. UBC will be using a method of this treatment to work with the diverse population that we treat. DBT has been proven to enhance motivation for treatment, build vital skills for handling crisis and relationships that can be transferred into a patient’s life, and structures treatment in a way that speeds up our ability to be effective. UBC is one of only two mental health facilities in the nation that is providing these services. DBT in our facility will ensure that we are making progress to create a change that will last.

Vidhya Jaishankar, MD will be providing outpatient medication management for children, adolescents and women here at University Behavioral Center. Dr. Jaishankar is board certified in child and adolescent psychiatry and general psychiatry.

She has been in practice for over 10 years and specializes in ADHD treatment, mood disorders and anxiety disorders. Appointment times are currently available. We had the privilege to sit down with Dr. J (as we call affectionately call her here at UBC) and here is what she had to say...

What is your personal philosophy on mental health?

“Having a diagnosis of a mental health

BEHAVIORAL HEALTH disorder is no different than being given a diagnosis of any other medical condition. There should not be a stigma regarding individuals with mental health diagnoses. Everyone deserves to be respected.” She also believes in the biopsychosocial model of treatment which includes medical, psychological and social aspects of wellness. A combination in each area will be most beneficial to the individual.

What do you like most about your profession?

“I can make a difference and I also take joy in seeing my patients grow from young children to thriving adults” What do you find most challenging about psychiatry?

“I feel that psychiatry is an art. There is no one size fits all treatment regimes. I also feel it is important to listen to my patients and not be judgmental. Lastly, we are seeing mental health issues occurring at much younger ages these days. Research is showing that the earlier we intervene the better the prognosis is.”

Tell us about a situation in which you felt you helped a patient?

“I was working with a young man who was exhibiting extreme defiance, out of control behaviors and mood swings. Over years of treating this young man I was able to watch him graduate high school, get a job and mature into a productive adult.”

What do you like to do in your spare time?

In her spare time Dr. J enjoys involvement in the Indian community, cooking and traveling.

We are very excited to offer these new services with, not only a highly intelligent and talented physician, but a passionate and caring physician. Welcome Dr. Jaishankar!

To schedule an appointment call 407-281-7000 today!

Sajid Hafeez, M.D., is a child and adolescent psychiatrist who is serving as a Medical Director of the Acute Care Baker Act Unit at the University Behavioral Center. He also served as the Center’s Medical Director of the long term Residential Units: ASAPP Unit (for adolescent boys with inappropriate sexual behaviors), Solutions Unit (for adolescent boys with behavior problems), Promises and Stars Unit (for adolescent females with behavioral problems as well as victims of sexual abuse), and Discovery Unit (for children ages 5-13 with behavioral as well as inappropriate sexual problems). In addition, Dr. Hafeez also Served as an Assistant Professor of Psychiatry at the University of Central Florida (Voluntary Position). He was also the Chief of the Adolescent Psychiatry Unit, an Attending Psychiatrist of the Comprehensive Psychiatry Emergency Program and of the Mobile Crisis Team at the Westchester Medical College. At Vassar Brother’s Medical Center in New York. Dr. Hafeez was the Director of Outpatient Child & Adolescent and Adult Psychiatric Clinic as well as Director of Consultation and Liaison Psychiatry. Dr. Hafeez received his adult Psychiatry and Residency Training at the University of Kansas Medical Center in Kansas City. He received his Child and Adolescent Psychiatry fellowship training at the New York Medical College New York and at Children’s National Medical Center of George Washington University in Washington, DC. Dr. Hafeez can be reached at 407-281-7000 or by visiting www. universitybehavioral.com.  FLORIDA MD - MARCH 2016 11

HEALTHCARE LAW

Key Takeaways for Health Care Providers: CMS Final 60 Day Overpayment Rule

By William Boyles, Esq. and Julie A. Tyk, Esq. On February 12, 2016, the Center for Medicare and Medicaid Services (“CMS”) published the much-anticipated Final Rule (the “Final Rule”) regarding Section 6402(a) of the Affordable Care Act, concerning the reporting and returning of Medicare Part A and B overpayments. The Final Rule is of critical importance to healthcare providers seeking to avoid liability for reverse false claims under the False Claims Act (FCA).

Section 6402(a) requires a person who has received an overpayment to report and William Boyles, Esq. Julie A. Tyk, Esq. return the overpayment within 60 days (“60-Day Rule”) of identification or the date any corresponding cost report is due. Previously, the term “Identify” was not defined. Under the Final Rule, “identified” is defined as “when the person has, or should have through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment. A person should have determined that the person received an overpayment and quantified the amount of the overpayment if the person fails to exercise reasonable diligence and the person in fact received an overpayment.”

The Final Rule clarifies that the 60-day clock does not start to tick while the provider is conducting its “reasonable diligence” into whether the provider has received an overpayment and is quantifying the amount of the overpayment. However, CMS does not view the reasonable diligence period as never-ending. The preamble discusses a six month time frame as a “benchmark” for how long the reasonable diligence should take absent “extraordinary circumstances”. The Final Rule acknowledges that complex investigations, like a Stark Law violation, that are referred to the CMS Voluntary Self-Referral Disclosure Protocol, fall within this “extraordinary circumstances” category.

The Final Rule also states that the 60-day clock begins on the day the provider received the information about the potential overpayment and failed to exercise reasonable diligence.

Failing to make reasonable diligence efforts may result in the provider or supplier knowingly retaining an overpayment because it acted in reckless disregard or deliberate ignorance of whether it received such an overpayment. That overpayment liability can, in turn, result in FCA liability under 31 U.S.C. § 3729(a)(1)(G) as “reverse” false claims. Under the FCA, a person can be liable for “knowingly concealing, or knowingly or improperly avoiding or decreasing” an obligation to the government.

An overpayment that is not reported and returned within 60 days of identification, as defined, becomes an “obligation.” Thus, providers should expect that the government will be interested in examining whether a provider did or did not exercise reasonable diligence in evaluating the propriety of any particular claim.

The Final Rule applies to overpayments from traditional Medicare – Parts A & B. Medicare Parts C & D Plans and Prescription Drug Plan sponsors are subject to a separate rule that was issued in May 2014. The Final Rule will be effective March 14, 2016.

It is not retroactive, though CMS advises providers and suppliers that the Affordable Care Act statutory requirements have been in effect since 2010. The Final Rule also settled on a 6-year look-back period. The 6-year look-back is not retroactive, and will be effective March 14, 2016.

For more insight on the Final 60-Day Overpayment Rule, please contact William Boyles, Esq. or Julie A. Tyk, Esq. with Gray Robinson’s Health Care Practice Group. 

12 FLORIDA MD - MARCH 2016

MARKETING YOUR PRACTICE

How to Become a More Efficient Practice Administrator Right Now

By Jennifer Thompson Do you wear a lot of hats at your office? Have you ever gone through an entire day and feel like you’ve got nothing done but aren’t sure why?

We’ve been there too, and we’ve seen it hundreds of times with clients at offices just like yours. You’ve got a challenging schedule.

There’s a daunting to-do list buried under a few files. And don’t even mention the little questions from doctors and staff that can suddenly throw your entire day into a tailspin. Next thing you know, something is getting rushed, forgotten about or postponed.

So, how can you get more work done quickly and effectively?

You can start by reading this post and choosing one thing to implement today. Then, gradually work your way up to include all of the tips, take a breath and tackle your day.

Establish Your Daily and Weekly Priorities First Thing: Take some time either before or right when you get into the office to get out a sticky pad and literally rank and write down your priorities for the day and the week ahead. Writing down a list of goals and tasks will help you instantly see what you have to do in a more clear and concise way. Want to take it a step further? Categorize the activities into 3 subsets: • What has to get done • What you want to do • What you should do (but can probably wait) This will help you decide what your staff and your physicians need most from you as well as give you something to look forward to and reaffirm what can wait until later.

Clear Away Low Priorities: Once you write down your goals and schedule time to complete your tasks, you’ll probably find a few small tasks that need to get done, but really aren’t super important for today (or this week for that matter). Before you know it, these lower priority tasks can pile up and suddenly take a full day to complete.

Instead of waiting, see how many of your low priority tasks you can shuffle around so you don’t have to do them at all. Here’s a few ways to shuffle the deck: • Delegate to a team member • Consider having a conversation rather than a meeting • Organize emails into priorities and answer the most important first Using these quick techniques you’ll find you can typically open up 1-3 hours of your day to take on higher priority or planning tasks - assuming you’ve got a good, competent staff and have set clear expectations for them.

Turn Off the Outside World: Have a task you need to do but can’t get motivated for? Unplug your computer from the internet, turn off your wifi connection, put your phone in a drawer and close your office door to disappear from the outside world for a little bit.

Hear that? Peace. Silence. By removing the chime of instant messages, the notification of a new email and the passerby stopping to chat, you’ll have no choice but to buckle down and mow through a few items on your to-do list.

Of course, this tip isn’t recommended for an extended amount of time, but it can help you eliminate distractions and put your mind 100% into what you should be doing. Try doing this for 15 minutes a day to start and working your way up to several 15 minute intervals throughout the day.

Use Evernote to Keep Things Organized: When you plug back into the World Wide Web, download a free version of Evernote to help you keep track of your ideas. Evernote is great because you can create notebooks and then write notes inside each of those notebooks and it syncs across all of your devices.

Your notes are searchable, so even if you don’t remember where you put them, you can use their powerful search function and pull exactly what you’re looking for when you need it. You can also set reminders and share notebooks with fellow staffers so you can all collaborate together. Your notes are saved on Evernote servers so you won’t have to tote around legal pads and worry about misplacing any important reminders.

Turn that frown upside down with these simple, effective tips to help you get more What Did We done today.

Miss? Have a productivity tip you swear by at your practice? Let us know what we missed using @DrMarketingTips on Twitter.

Jennifer Thompson is co-founder and chief strategist for DrMarketingTips.com, a website designed to help medical marketing professionals market their practice easier, faster and better. 

FLORIDA MD - MARCH 2016 13

CANCER

Driving Awareness about Male Cancers and Men’s Health, One Patient at a Time

By Jamin Brahmbhatt, MD and Sijo Parekattil, MD Every year, 300,000 men die from cancer in the U.S., according to the Centers for Disease Control and Prevention. It is the second leading cause of death for men after heart disease — yet often there is a lack of awareness within this group and there needs to be more emphasis on cancer prevention and screenings.

Prostate, lung, melanoma, bladder and colorectal cancer are the most common forms of cancer in men and will account for an estimated 475,000 cases of male cancers this year. Many of these types of cancers are preventable with lifestyle changes, and curable if caught early, but the main problem we see is getting men into our office in the first place. Part of the reason men don’t like to go to the doctor has to do with uncertainty and fear, but quite simply lack of awareness is also a common reason. We need to help men take a proactive role in their health.

ENCOURAGE MEN TO GET SCREENED Men need to understand the importance of screening, but they also need to be encouraged, especially for prostate cancer screenings. There’s been a lot of debate about the benefits of prostate cancer screening. While the blood test isn’t perfect, men should be screened. In the right setting and if done properly, especially in a primary care doctor’s office, this test is beneficial and can save their life if the cancer is caught early. Annually more than 180,000 men will be diagnosed with prostate cancer. We suggest men get a PSA test and rectal exam beginning at age 50 or at age 40-45 if they have high risk factors.

With more than 70,000 men diagnosed with colorectal cancer each year, it’s important for them to begin screening at age 50 or earlier if they have a family history. Colonoscopy remains the best screening tool for colorectal cancer. We also need to encourage men to make lifestyle changes to avoid increased risk of colon cancer which includes an improved diet, exercise, and avoid using tobacco.

Bladder cancer is the fourth most common cancer in men, yet often men aren’t screened for this type of cancer. The best way to screen is a urinalysis. The analysis must have greater than three red blood cells on microscopic evaluation. It’s common for primary care doctors to do a dipstick test to check for urine in the blood, but a microscopic urinalysis is more effective. If a male patient has a positive microscopic evaluation and/or gross hematuria — and not just a positive dipstick test — that’s when he should see a urologist. The workup then includes imaging of the upper tracts using a CT Urogram and a cystoscopy to look inside the bladder.

We see a range of patients at the PUR Clinic in Clermont.

We may see someone with blood in their urine or elevated PSA. Others may have major symptoms like significant weight loss and/or severe urinary retention from cancer. In cases where the cancer has advanced, the only option is palliative care. However, 14 FLORIDA MD - MARCH 2016

if we get men to a urologist when they only have minor symptoms, the odds of treating the disease and curing the Jamin Brahmbhatt, MD disease are much higher.

In addition to screenings, we can’t overlook the importance of men just getting their annual exams in their primary care doctor’s office. These exams can also lead to early detection of other cancers such as melanoma. If caught early, many types of melanoma are curable, but unfortunately the symptoms, Sijo Parekattil, MD spots on the skin, often are ignored.

Patients need to get regular skin checks. Regularly following up and encouraging patients to come in for an annual exam can help doctors diagnose symptoms before they become larger health issues.

START THE CONVERSATION Patient education is critical to cancer prevention and awareness. As doctors we all do this, but there’s always room to do more.

With lung cancer, this is especially important. Lung cancer is the second most common cancer in men, and 80 percent of these cases are due to smoking. Smoking also increases the risk for bladder cancer, prostate cancer and heart disease — all of which are among the leading causes of male death. Patients need to be reminded of the harmful effects of smoking and provided resources to quit the habit such as medical therapies, hypnosis and smoking cessation programs.

ENLIST HELP As medical professionals we can only can do so much to empower male patients to take control of their health. We have found that it’s beneficial to also enlist the help of women.

We need to encourage women to get the men in their lives to see a doctor. If a female patient comes in for her annual exam, talk to her about getting her husband, brother, father or son to come in for a checkup as well.

A 2015 survey commissioned by Orlando Health, found that more than 80 percent of men could remember the make and model of their first car, but only about half could remember the last time they went to the doctor for a check-up. These numbers are eye-opening and reveal a lot about men and their health. In general, women are better health advocates and we should encourage them to get involved.

BE THE EXAMPLE As physicians, it’s important to live by our own advice. If we are preaching better health and wellness then we as their doctors

CANCER also need to be taking care of our own bodies. Take some time yourself to exercise and eat better. The same screening tests we recommend to our patients we also should be undergoing on an annual basis.

In 2014, we started the Drive for Men’s Health to raise awareness about men’s health issues, driving from Clermont to New York City to California to interact with and educate millions of men about their health. Unfortunately, we were talking the talk but not walking the walk. Since then, we’ve made lifestyle changes to get healthier. Between the two of us we have lost over 60 pounds. We know that for people to take the Drive for Men’s Health seriously, we must embody the mission.

Going back to that survey about men and their car, we think that’s a pretty good analogy. We need to encourage men to think of their bodies like a car. If a check engine light goes off or we get a flat tire, we check it right away. The same should be said for our body. If we don’t pay attention to our bodies’ signals in the same way, we will break down.

Men’s health needs to be a priority. Thousands of men are diagnosed each year with cancer and thousands more will lose their battle with this disease. If cancer is caught early, it has a better chance of survival and a cure. As physicians, we need to break down barriers with our male patients and encourage them to see a doctor once a year and do their screenings. These screenings may not be fun, but they’re necessary and they save lives. Men’s health shouldn’t be ignored. Let’s start the conversation, one patient at a time.

Jamin Brahmbhatt, MD and Sijo Parekattil, MD are Co-Directors of The PUR Clinic – Personalized Urology & Robotics – at South Lake Hospital, in partnership with Orlando Health in Clermont, FL. They specialize in chronic groin and testicular pain, male infertility, urologic oncology, sexual dysfunction, and men’s health. Dr. Brahmbhatt completed his medical training at Boston University School of Medicine and his urology residency at the University of Tennessee Health Science Center in Memphis, TN. His residency was followed by a one-year clinical fellowship in robotic microsurgery and male infertility at the University of Florida. Dr. Brahmbhatt is an active member of many local and national healthcare organizations, including the American Urological Association, Florida Urological Society, Society of Laproendoscopic Surgeons, Society of Male Reproduction & Urology, and Robotic Assisted Microsurgery and Endoscopic Society. He frequently speaks at community and academic events and has published book chapters and journal articles on his clinical and research interests.

Dr. Parekattil completed his urology residency training at Albany medical Center and then went on to complete ORTHOPAEDIC dual fellowship training from the SUBSPECIALTIES Cleveland Clinic Foundation, Cleve• SPINE land in Laparoscopy/Robotic Surgery • ELBOW and Microsurgery/Male Infertility.

• FOOT & ANKLE Dr. Parekattil has received numerous • HAND & WRIST • HIP awards including two Annual Innova• KNEE tor Awards from the Cleveland Clinic • ONCOLOGY Foundation and the Golden Garland • PEDIATRICS Award in Medicine. He has published • SHOULDER • SPORTS MEDICINE several articles in the field of robotic • PAIN MANAGEMENT microsurgery and has three textbooks • PHYSICAL THERAPY on Male Infertility and a surgical textbook on Robotic Microsurgery. He has performed some pioneering work in SAME DAY, NEXT DAY APPOINTMENTS AVAILABLE the arena of robotic microsurgery and OVIEDO SATURDAY WALK-IN CLINIC has now performed over 1,000 such NO APPOINTMENT NECESSARY | 9AM - 1PM procedures.  Downtown Orlando | Winter Park | Sand Lake | Lake Mary | Oviedo | Lake Nona

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3

SPECIAL FEATURE ORTHOPAEDIC UPDATE

What is Tommy John Surgery?

By Corey Gehrold Tommy John is changing the face of baseball now more than he ever did as a professional pitcher; and it’s all because of a surgery named after him.

The surgery, officially known as an ulnar collateral ligament (UCL) reconstruction, has changed and extended the careers of dozens of professional baseball pitchers in the last few years alone.

In fact, a combined 59 Major League Baseball (MLB) pitchers underwent Tommy John surgery in 2014 and 2015.

Tommy John surgery is performed when baseball pitchers tear an important stabilizing ligament in their throwing elbow and all nonsurgical treatment options to return to play have failed.

“When the UCL sustains a tear, the throwing athlete (most often a pitcher) usually complains of pain on the inside, or medial part, of the elbow as well as a loss of velocity and control,” says Randy S. Schwartzberg, M.D., a board certified sports medicine specialist at Orlando Orthopaedic Center. “If non-surgical treatment fails, the surgical treatment involves replacing the ligament with a tendon graft. This is the procedure termed Tommy John surgery or UCL reconstruction.”

tears can also be experienced by other athletes, such as wrestlers and gymnasts as well, though these types of injuries are seen far less outside of baseball players.”

WHAT ARE THE SYMPTOMS OF UCL TEARS?

Randy S. Schwartzberg, MD

Symptoms associated with a UCL injury include pain on the inner side of the elbow, looseness or instability in the elbow, decreased ability to throw, and a “pop” or “tearing” sensation at the site of the injury.

“Athletes will also notice newfound elbow stiffness and they may feel a slight numbness or tingling in the small

Dr. Schwartzberg says, in most cases, the UCL needs to be completely replaced in order to fully stabilize the strucTearing of the ulnar collateral ligament (UCL) is occurring with greater frequency in youth pitchers due to overuse. When the ligament tears, the ture of the elbow. Although small partial tears can ofUCL needs to be completely replaced in order to fully stabilize the structure ten be managed nonoperatively, more significant tears of the elbow. This procedure is commonly known as Tommy John surgery. usually need ligament reconstruction to allow the player to return to throwing and pitching commensurate with their prior level.

WHAT CAUSES UCL TEARS? “Damage to the UCL can occur suddenly or gradually after continued stress on the throwing athlete’s elbow,” says Dr. Schwartzberg.

Baseball pitchers are most susceptible to this injury because of the extremely high stresses seen by the medial part of the elbow during the throwing motion. With repetitive use, the ligament becomes compromised and tears. Then, it is unable to stabilize the medial part of the elbow against the high stresses seen during throwing.

In youth baseball, the tearing of the UCL is occurring with greater frequency in young pitchers due to overuse. “These young athletes are at particular risk because of their developing bones, muscles, tendons, ligaments and their open growth plates,” says Dr. Schwartzberg.

“Coupled with the fact that many young pitchers now play year round and may demonstrate poor throwing mechanics, the rise in throwing injuries is no surprise.”

“Other causes include contact sports where one may fall on an outstretched hand, ultimately dislocating the elbow,” says Bradd G. Burkhart, M.D., a board certified sports medicine specialist and colleague of Dr. Schwartzberg’s at Orlando Orthopaedic Center. “UCL ligament 16 FLORIDA MD - MARCH 2016

ORTHOPAEDIC UPDATE and ring fingers of the injured arm,” says Dr. Schwartzberg. “Swelling and bruising may also be noticeable after roughly 24 hours post injury.”

WHAT HAPPENS DURING TOMMY JOHN SURGERY? Tommy John surgery is performed under general anesthesia by a trained orthopaedic surgeon who typically specializes in sports medicine. Ligament reconstruction begins with an incision on the inner part of the elbow where the damaged ligament is removed. From there, holes are drilled to accommodate the new tendon grafts, often taken from the palmaris longus tendon found in the forearm or the gracilis tendon in the leg. These holes are drilled in the ulna and humerus bones of the elbow precisely where the ulnar collateral ligament attaches.

“Then we place the new tendon into the sockets created in the ulna and humerus. The graft is then secured with fixation devices to allow an accelerated rehabilitation approach,” says Dr. Schwartzberg.

WHAT HAPPENS AFTER TOMMY JOHN SURGERY? For most patients, recovery from Tommy John surgery will take six to nine months.

It may take some pitchers up to one year to return to their previous level of activity.

“After one week in a splint, the throwing athlete is placed into a hinged elbow brace with no range of motion restrictions.

Rehabilitation commences with progressive functional activities leading up to an interval throwing program at the four month postoperative mark,” says Dr. Burkhart.

“Although range of motion and strength about the elbow returns within a couple of months of the surgery, the throwing athlete still has a large amount of work to ready the elbow for throwing,” said Dr. Schwartzberg.

“Rehabilitation of the entire body is paramount for the pitcher. A quality program will address the legs, core strengthening and shoulder work in addition to the elbow. A properly supervised interval throwing program and professional pitching mechanics evaluation are also important. With this approach, most pitchers can ultimately return to their prior performance levels.”

For more resources on overuse injuries in youth baseball players, including video and prevention tips, visit OrlandoOrtho. com. 

HealthSouth Rehabilitation Hospital of Altamonte Springs Offers a Higher Level of Care.

HERE’S HOW.

Our patients and families hear a lot about a higher level of care. What does this mean to you? Our rehabilitation teams work with patients and their families, providing superior care with quality outcomes to return patients to maximum independence at home and in the community.

To a patient recovering from an illness, injury or surgery, a higher level of care means: • Personalized goals for a faster return home • Comprehensive team approach to rehabilitative care • Advanced technologies for the latest treatments • Frequent physician* visits • Three hours of therapy over a day, five days a week • 24-hour certified rehabilitation nursing care Choose a rehabilitation leader that makes a difference for patients and families with a higher level of care. HealthSouth Rehabilitation Hospital of Altamonte Springs. *The hospital provides access to independent physicians

Be sure and check out our website at www.floridamd.com!

A Higher Level of Care®

831 South State Road 434 • Altamonte Springs, FL 32714 407 587-8600 healthsouthaltamontesprings.com ©2016:HealthSouth Corporation:452913

FLORIDA MD - MARCH 2016 17

HEALTHCARE BANKING, FINANCE AND WEALTH

Office Space – Leasing versus Buying

By Jeff Holt, CMPE, VP, Senior Healthcare Business Banker with PNC Bank Although most financial experts agree that it makes more sense to buy a home than rent an apartment, the pros and cons of office ownership aren’t quite so clear-cut.

Physicians need to weigh a variety of factors when making this important decision, including: - The availability of rental office space in the area.

If office rent is reasonable in the area in which you practice, then it may be best to rent. But if rents are high and you are planning to practice in that area for a long time, then it may make sense to buy, especially if you buy a building that can be expanded or remodeled as needed.

- How long you plan to practice in the area.

Selling a commercial office building—especially office space designed for special purposes—can be an involved process. In a medical group, that leads to the thorny issue of what to do when you or someone else wants to retire or move.

- Whether the capital earmarked for a building will be needed for other practice expenses.

No doubt, real estate ties up assets. You have to decide whether it makes more sense to use your capital to invest in facilities or for growth and other aspects of practice operations.

- How fast you are growing.

Once you buy the property, you’ve obviously lost some flexibility if you need to move later. For this reason, purchasing may not be the best option for fast-growth practices or practices that have a hard time forecasting their space needs.

THE CASE FOR A CONCRETE INVESTMENT Even with so many factors to consider, owning real estate outright instead of leasing may make good sense for a number of reasons.

1) You lock in your cost of occupancy.

Rents typically will always go up, but your mortgage payment won’t.

2) You build equity in your building.

Over the long term, the property can possibly represent more worth than the practice itself.

3) You could potentially save on taxes.

You may enjoy tax savings if you lease space to additional tenants, and also have an opportunity in other ways to save on payroll taxes. *(Consult with your financial advisor for verification) 4) You provide yourself with options.

When it comes time to retiring, you could include the property 18 FLORIDA MD - MARCH 2016

as part of practice assets or keep the property and lease it to the new owner. These rent payments can then provide a steady retirement income.

In the end, it may make sense to turn to a trusted financial advisor to “run the numbers” and help you decide whether purchasing or leasing makes the most sense for your practice.

THE ISSUE OF LIABILITY When you assume ownership of a building, you also assume all of the liabilities that come along with it— everything from slip-and-falls in the lobby to non-compliance with the Americans with Disabilities Act (ADA).

Most physician-owners develop a limited-liability corporation to manage the property, which charges rent to the physician group, making for cleaner bookkeeping. From an asset protection standpoint, this strategy is dead on. A risk-producing asset, such as an office building, should be contained in a separate entity from your other assets. *(Consult with your legal advisor for verification) As I discuss with all of my physician clients that for each person the circumstances are different. It is important to communicate your plans with your trusted advisors (CPA, Healthcare Banker, Attorney, and Insurance Agent), and in the end the right plan of action will be clear.

Jeff Holt is a Senior Healthcare Business Banker and V.P. with PNC Bank’s Healthcare Business Banking and is a Certified Medical Practice Executive. He can be reached at (352) 385-3800 or Jeffrey.Holt@pnc.com.



Sea Notes Photography Donald Rauhofer – Photographer Head Shots • Brochures • Meetings Events • Portraits • Arcitectural

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INSURANCE

Top Five HIPAA Compliance Issues

By Tom Murphy The Office of Civil Rights (OCR), a division of Health and Human Services (HHS), is the entity within the federal governments responsible for enforcing HIPAA. This is the storing, accessing and sharing of personal health information (PHI). The OCR has provided a list of the top five HIPAA compliance issues they have seen since 2003.

formation visible to all employees of a medical practice when only certain employees should have this access.

1. Impermissible Uses and Disclosures of Protected Health Information

Effective 1/1/2016, the Office for Civil Rights is stepping up its enforcement of violation of the HIPAA Privacy Rule and even if your practice does not receive a formal complaint, the OCR is tasked with performing random audits of medical practices and the business associates of these practices.

This comes in many forms and can include disclosing patient information without the proper permission or providing patient treatment details to an unauthorized party.

2. Lack of safeguards for Protected Health Information A disgruntled employee of a medical practice in Florida discarded boxes of patient records in a dumpster near the practice Every medical practice regardless of size is required to implement safeguards to protect health information.

3. Lack of Patients Access to Their Health Information Patients have the right to access their personal health information within 30 days of a request. The practice can charge the usual and customary fees associated with copying these records but the practice must provide them upon the patient or authorized party request.

4. Lack of Administrative Safeguards of Electronic Protected Health Records This is the fastest growing area of compliance issues due to the exploding use of technology in every area of healthcare. You only to need read the headlines every day to recognize that healthcare organizations of all sizes are experiencing serious issues with cybercrime as well as problems within their own organization.

5. Use or Disclosure of More than the Minimum Necessary Health Information This is using or providing more than the necessary protected health information necessary to perform ones job. This can be in the form of having protected healthin-

HIPAA TRAINING FOR STAFF

We always recommend that any medical practice or business that falls under the HIPAA guidelines as a “covered entity” should be providing annual HIPAA compliance training for all employees. This can be accomplished in a few different ways. The physician or group medical professional liability insurance company typically has risk management specialists and a wealth of information on their websites. This is going to be your best option and it is free of charge.

You can also go to (www.hhh.gov/hipaa to get information about the HIPAA guidelines and compliance training.

Tom Murphy is a medical malpractice insurance and workers’ compensation specialist with Danna-Gracey. He can be reached at or (800) 966-2120 or Murphy@dannagracey.com. 

Patient Assistance Resources The CF Foundation is committed to improving the lives of all people and families with CF. We can help you with: •Insurance coverage and benefits •Resources to pay for therapies and medications •Legal information •Other concerns Tell us your issue.

We will help you find a solution.

888-315-4154 • parc@cff.org • www.cff.org

FLORIDA MD - MARCH 2016 19

INPATIENT REHABILITATION

A High Level of Care Through Inpatient Rehabilitation

By Colleen Lane HealthSouth Rehabilitation Hospital of Altamonte Springs is a 50 bed inpatient rehabilitation hospital that offers comprehensive inpatient rehabilitation services designed to return patients to leading active and independent lives.

Our hospital provides a wide range of physical rehabilitation services, a vast network of highly skilled, independent private practice physicians and HealthSouth therapists and nurses, and the most innovative equipment and rehabilitation technology, ensuring that all patients have access to the highest quality care. Designed with our patient’s care in mind, HealthSouth Rehabilitation Hospital of Altamonte Springs offers 50 private rooms with beautiful views, multi-channel televisions, and wireless internet capabilities.

In addition to caring for general rehabilitation diagnoses such as orthopedics, cardiac, pulmonary and neurological conditions, HealthSouth Rehabilitation Hospital of Altamonte Springs has specialized inpatient programs for stroke, brain injuries, trauma and many other conditions.

This state of the art, 55,000 square-foot hospital serves patients throughout Seminole, Orange, and Osceola Counties and is located at 831 South State Road 434, Altamonte Springs, Florida 32714.

Rehabilitation is covered in full or part by most health insurance plans, including Medicare and Medicaid.

The hospital has contracts with most major insurance companies and is willing to negotiate with other companies as needed.

To make a referral or for more information, contact our admissions department at 407 587-8600. You will be put in contact with one of our rehabilitation liaisons to perform a pre-admission screening and coordinate transfer to our hospital. See more at: www. healthsouthaltamontesprings.com. 

COMING UP NEXT MONTH: The cover story focuses on the Multidisciplinary Head and Neck Care at UF Health Cancer Center – Orlando Health.

Editorial focus is on Surgery and Scoliosis.

20 FLORIDA MD - MARCH 2016

MOROF H.E.L.P.S. Prepare Future Healthcare Leaders Today

By Dorothy Mowbray, M.O.R.O.F. Media Committee Chair and Board Member For all the doctors who wished they had learned “about that” in school, Medical Office Resources Of Florida (MOROF) has partnered with FSU and UF medical and dental schools to provide an educational series to fill in the gaps with topics to aid doctors and dentists about life after school. Dubbed as Healthcare Education Leadership Program for Students (H.E.L.P.S) was born out of the need to better prepare students for the rigors of running their own business.

H.E.L.P.S. launched with an inaugural lunch and learn style format at UF College Dentistry in Gainesville on Feb. 16, 2016.

About 50 dental students gobbled up pizza, sponsored by MOROF Member Longwood CPA, and learned about leadership from Kevin McCarthy, a local author of The On-Purpose Person and The On-Purpose Business Person. He stressed how following your passion can drive you into a fulfilling life and not just a job in your specific field of study. “Always remember” he said, “the biggest and brightest smile needs to be yours!” The message was received, as attendee Mina Ghorbanifarajzadeh said, “I personally enjoyed knowing that having a purpose, finding and owning it, can be easier than one thinks. Then, making sure that it’s never forgotten and pushes you forward is the harder part. It brought more focus to my purpose in dental school and life.” Maybe this event will even make the history books, as Mina is the 2019 Class Historian at the UF College of Dentistry!

On March 10, the FSU College of Medicine, Orlando Regional Campus hosted the kick-off H.E.L.P.S. dinner, sponsored by MOROF Member, Merrill Mal Insurance, for third and fourth year medical students. This financial health educational topic included information on filing personal tax forms and best practices with student loans. According to the Association of American Medical Colleges, medical school students face an average debt of $176,000 and spend at least a decade of their post-residency years repaying it. It’s a top concern for medical students, so it’s not a surprising first topic in their H.E.L.P.S. series.

As thrilling as filling out tax forms can be, speaker MOROF Member Thomas P. Abrassart, CPA, CFP, CGMA and President of Longwood CPA, encouraged these future doctors to financially think long term. “When you’re 70 years old, you’re not going to wish you spent more time working, therefore, beginning with the end in mind is critical to achieving work/life balance throughout your career. Practitioners should not limit their financial planning to tax time. Having an overall strategy for life and finances will win out over day to day tactics every time. If it seems overwhelming, just begin at the beginning and adjust as necessary.”

For these educational series, MOROF provides a list of topics to each school so that they can select the best topic at that time for their students. Tailoring it to the needs of each school is key in making this impactful for the students. Topics include discussions about leadership, personal finances, business finances, employed vs. self-employed, how to market a medical practice, needs and types of insurance, the business of healthcare, etc. These educational series will continue at FSU College of Medicine’s Orlando Regional Campus and UF College of Dentistry in Gainesville with another program on April 15, 2016 at each location. Additional topics and dates are being added to their calendars. Plus, these presentations are being taped so that student groups could potentially host a video viewing vs. a live presentation down the road. Jeff Holt, MOROF Education Committee Chair and VP at PNC Bank, says “There’s lots of potential to this whole project, so we want to be prepared for many ways that this could grow and help students be better prepared.”

MOROF is also reaching out to other area medical schools to explore ways to conduct these educational series for their students.

MOROF hopes that more medical schools, their alumni and other healthcare professionals will get involved in helping better prepare our future doctors for a more successful life after school. Insights from alumni who have learned from the school of hard knocks are always appreciated. Plus, students are encouraged to find mentors willing to pass down their knowledge and expertise. Contact MOROF for more information about speaking, sponsoring, or being a thought leader in the MOROF H.E.L.P.S. project.

Medical Office Resources of Florida provides educational resources for existing practices online through www.mor-of.net , on LinkedIn MOROF (open group), and their YouTube Channel MOROForlando. MOROF. also meets the fourth Thursday of each month from 7:30 a.m. to 9 a.m. at the Venue On The Lake at the Maitland Civic Center. The address is 641 South Maitland Ave., Maitland, FL 32751. Healthcare professionals are always welcome as guests.

RSVP at www.mor-of.net. 

COMING UP NEXT MONTH: The cover story focuses on the Multidisciplinary Head and Neck Care at UF Health Cancer Center – Orlando Health.

Editorial focus is on Surgery and Scoliosis.

www.floridamd.com FLORIDA MD - MARCH 2016 21

DON’T CALL ME A PROVIDER — Fed Up

With Excessive Oversight, Doctors Get Organized – Part One By Marni Jameson “I am not a provider, whatever that is,” a cardiologist from Pennsylvania said angrily over the phone the other day. “I’m a physician.”

He wasn’t angry with me. I hadn’t demoted him with that euphemism. He was mad at the system. And he was venting.

A lot of doctors are venting. As the executive director of a national association dedicated to giving doctors a voice and championing their causes (which, really, are all of our causes), I get a lot of calls like this.

Doctor are fed up. But what’s different now than from even five years ago is that doctors are actively banding together. All over the country groups of frustrated physicians are organizing and speaking out against a system that is demeaning their profession, undermining their authority, and intruding on their patient relationships.

Calling doctors “providers” is just the beginning. But it’s emblematic. Physicians, in general the most educated members of our society, don’t take kindly to bureaucrats, insurance executives or health-care administrators blurring the line that once separated those with eight years or more of medical training from those with half that.

Putting doctors on the same plane as nurses or nurse practitioners or physician assistants is a demotion. But when bureaucrats, insurance companies and health-care administrators call all medical professionals providers, it not only knocks doctors down a peg, it makes it appear less obvious when they slip in someone less qualified to deliver care.

As one doctor asked me lately: “How did we go from being at the top to the food chain to being the food?”

But more worrisome than being dumped into the provider pool, doctors tell me, are the regulations plaguing them. They bristle at meaningful use regulations. They resent spending hours of their day filling in computer data when they could be delivering patient care.

They didn’t go to medical school to spend 20 minutes of every hour jumping through payers’ hoops to get prior authorizations for patients. They find it insulting when they have to get permission from an insurance company representative to do what they know is best for their patient, they tell me.

And they balk at government’s coopting their office hours in a patient-data gathering exercise that is of no value to the patient or the doctor.

“Before I can talk to my patient about a sinus infection, I first 22 FLORIDA MD - MARCH 2016

have to ask whether he has any firearms in his house, or whether he has ever thought about hurting himself, to please the government,” said Dr. Elaina George, an Atlanta otolaryngologist, AID member, and a leader in the Association of American Physicians and Surgeons. Like many physicians, she finds the questions time-consuming and intrusive.

Doctors also are realizing that they are partly to blame for letting this happen. They’ve been asleep at the switch, and busy getting more training, removing gallbladders and mending bones, while government, payers and hospitals have been advancing their agendas.

But they are paying attention now. Proof lies in the number of organizations like the Association of Independent Doctors that have been forming and growing and melding. AID, which turns three this month, is a doctor advocacy group that enlightens consumers, businesses and lawmakers about the importance of supporting independent doctors. It now has more than 1,000 members coast to coast in 14 states and has a frequent voice on the national stage.

In next month’s column, I will introduce other organizations that have joined in the fight to save the practice of medicine.

Together, we are making progress.

Marni Jameson is the executive director of the Association of Independent Doctors, a national nonprofit dedicated to helping reduce health-care costs by helping consumers, businesses and lawmakers understand the value of keeping America’s doctors independent www.aid-us.org. 

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Advances in Treating Back Pain Provide Hope for Millions of Patients

by Robert A. Hirschl, MD We’ve all experienced it before.

Back pain is one of the most common ailments in the country — 80 percent of adults will experience it at some point.

While most back pain can improve or go away with conservative treatment, medication and time, surgical approaches — especially minimally invasive methods — have evolved over the years to treat back pain caused by more serious underlying health conditions.

damage — and potential, long-term muscle weakness and paralysis — are major risks when you undergo back or spinal surgery. However, each patient is different, and the risks won’t be the same for everyone. I also can tell you that the risks of these complications are minimal,

ETIOLOGIES OF BACK PAIN There are many different causes of back pain. While some people may have a soft tissue injury, like a muscle strain or ligament tear, others may have arthritis that affects the joints in their back or neck.

Disc degeneration, in which the spinal discs change as we age, also is a culprit. It can lead to more serious health conditions like a herniated disc and spinal stenosis, which causes the spinal canal to narrow and leads to pain and numbness in the neck, arms, lower back, and legs.

In my practice I see a range of patients, from people with vertebral fractures after major trauma to those with neoplastic conditions involving spinal cord tumors. In neurosurgery, many patients also may have nerve root or spinal cord compression or other degenerative changes that affect the spine, like hypertrophied ligaments or facet joint degeneration.

It’s important to understand the cause of back pain in order to treat it. With certain conditions, like arthritis or a muscle strain, anti-inflammatory medication and some rest may help ease a person’s discomfort.

However, when the underlying cause is a spinal cord or neurological issue, surgical intervention often is the best option for treating patients.

ADVANCES IN BACK PAIN TREATMENT Many people often are leery about back or spinal surgery because of the perceived risks. There’s a misconception that nerve FLORIDA MD - MARCH 2016 23

especially if a highly qualified and trained surgeon performs the procedure.

Back and spinal surgery is usually the last and best option for people who have tried other remedies to cure their back pain.

Patients who do not improve with conservative treatment or have neurological deficits due to nerve root or spinal cord impingement may benefit from surgical intervention.

Spinal surgery has improved dramatically in recent years. New minimally invasive techniques and instrumentation have made spinal surgery much safer, with less blood loss, less normal tissue disruption and faster healing times.

The advantages of minimally invasive spinal surgery aren’t just a smaller incision. These new techniques provide options to patients who once would have been considered “poor surgical candidates” because of medical comorbidities or age. Because these procedures aren’t open, there’s less blood loss. Take degenerative scoliosis surgery, for example. The traditional procedure required a long midline incision, dissecting all muscle and soft tissue from the bones of the spine, removing several areas of bone, placing hardware and manually reducing the deformity. This technique usually causes about a liter or more of blood loss, and more times than not requires blood transfusions. For a high-risk patient, a surgery of this nature was out of the question. However, with new minimally invasive techniques, we can now make a small one-inch incision on the side, not disrupt any back muscles or soft tissue and correct the deformity — typically with less than 5cc of blood loss.

Introducing Michelle Bilsky Danna-Gracey Danna-Gracey Lead Lead Agent, Agent, Orlando Orlando Office Office

Danna-Gracey is pleased to introduce Michelle Bilsky our newest team member. Heading up our Orlando office, Michelle brings over 26 years in the insurance industry to Danna-Gracey.

Michelle holds a Bachelor of Science degree from the University of Central Florida and an Executive Leadership Certificate from The Wharton School in Philadelphia, PA., as well as certifications in behavior analysis, risk management, HIPAA and OSHA. Michelle is also a frequent and highly rated speaker on industry related topics and has been recognized and approved to provide CME credits for her lectures.

For a no-obligation assessment of your current malpractice coverage, or for more information on additional coverages designed to protect your practice, such as workers’ compensation, cyber liability, medical directorship, employment practices liability (EPLI), and investigatory coverage, contact Michelle today at 888.496.0059 or michelle@ dannagracey.com to see what she can do for you.

888.496.0059

michelle@dannagracey.com • dannagracey.com 24 FLORIDA MD - MARCH 2016

Minimally invasive spinal surgery has other benefits, as well. These techniques don’t cause as much disruption to normal soft tissue, which reduces healing time for patients. The hospital stay also is much shorter compared to the traditional procedure. Patients are up and walking the same day and often go home that day or the following day after surgery.

Aside from degenerative scoliosis surgery, there are several other minimally invasive surgical techniques that are successful in treating back pain. These include decompressive procedures such as microdiscectomy, a procedure that reduces nerve pressure to relieve back pain and leg pain; minimally invasive laminectomy, a surgery that removes a section of the bone in the back of the spine and overgrown ligaments to provide relief for spinal stenosis; and foraminotomy, which decompresses nerve roots to relieve inflammation and pain.

There’s also minimally invasive decompressive and stabilization procedures such as transforaminal lumbar interbody fusion (TLIF) and Direct lateral interbody fusion (DLIF), both of which are spinal fusion surgeries that correct anatomical issues and health conditions (like degenerative disc disease) that cause back pain.

New biologic agents and biomaterials also are available to help with recovery after spinal surgery. These agents and materials help the patient heal more effectively. I’ve been fortunate to be personally involved in the development of new technology and

biomaterials for minimally invasive spinal surgery. I’ve worked with many companies to help them develop spinal instrumentation and am currently involved in the development of biological agents and new biomaterials to promote bone growth and healing. These things also have informed my own work. I’ve created multiple patents on spinal instrumentation that have been developed or that are currently in development, and I’ve produced new biomaterials to improve the efficacy of spinal fusions. One of my current passions is working on new implants that have bone-stimulating properties. These implants are currently being tested and show great promise.

Millions of Americans will experience back pain at some point in their lives. While underlying causes may range from something as treatable as a soft tissue injury to more serious conditions like degenerative scoliosis, advances in minimally invasive surgery have expanded the possibility that more patients can get relief and have a better quality of life. We’ve come a long way in the last decade, and I’m incredibly hopeful about where we’ll be in the next.

Robert A. Hirschl, MD earned his medical degree from The Ohio State University College of Medicine, where he also served his residency in neurological surgery and completed a fellowship in endovascular neurosurgery/interventional neuroradiology. He served on the faculty at Ohio State as a clinical instructor and director of endovascular neurosurgery. In 2010, he was awarded the clinical excellence award.

Prior to joining Orlando Health, Dr. Hirschl was medical director and chairman at Mercy Neurosurgery in Des Moines, Iowa.

In this role, he earned the 2013 Angel of Mercy award for exceptional patient care.

Additionally, he was named “One of the 62 Spine Surgeon Inventors to Know”

by Becker’s Spine Review in 2012 for inventing several surgical instrumentation devices.

Dr. Hirschl has been published in multiple journals, including the Journal of Pediatric Neurology, the Journal of Neurosurgery, and the Journal of Robotic Surgery.

He has also authored several book chapters, including Endovascular Surgical Neuroradiology published in 2015 and Endovascular Technique for Tumor Embolization in Youmans Neurological Surgery.

To schedule an appointment with Dr. Hirschl please call 321.841.7550. 

2016

EDITORIAL CALENDAR

Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market.

Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD. It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

JANUARY –

Digestive Disorders Diabetes

FEBRUARY –

Cardiology Heart Disease & Stroke

MARCH –

Orthopaedics Men’s Health

APRIL –

Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

JUNE –

Allergies Pulmonary & Sleep Disorders

JULY –

Imaging Technologies Interventional Radiology

AUGUST –

Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICU’s Autism OCTOBER –

Cancer Dermatology

NOVEMBER – Urology Geriatric Medicine / Glaucoma DECEMBER – Pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information.

FLORIDA MD - MARCH 2016 25

PrOvisiOnal trauma center

when minutes matter...

OsceOla regiOnal medical center designated as PrOvisiOnal level ii trauma center.

Osceola regional has been designated by the Florida department of health, Office of trauma, as a Provisional level ii trauma center. this means that Osceola regional will now be able to provide residents of Kissimmee, Osceola, Polk county and south Orlando with trauma care in their own community and ensure that critically injured patients have access to treatment faster, which could mean the difference between life and death.

Osceola regional is proud to be able to meet a true community need for easier access to comprehensive trauma care when minutes matter.

For more information, please visit OsceolaRegional.com or call toll free, 1-800-447-8206.

Osceola Regional Medical Center | 700 W. Oak Street, Kissimmee, FL 34741 | 407-846-2266