Winter 2018 (January-March)

MISSOURI Official Publication of the Missouri Academy of Family Physicians

Family Physician

January-March 2018 Volume 37, Issue 1

2018 Advocacy Day Be the Voice of Your Academy Page 2 2018 Family Physician of the Year Nominate a Deserving Physician Today Page 7 ISSUE FOCUS: Technology Enhancing the Care of Your Patients Pages 8-28 Annual Fall Conference Recap Page 30

TECHNOLOGY: ENHANCING THE

CARE OF PATIENTS IN FAMILY MEDICINE

2018 missouri academy of family physicians'

ADVOCACY DAY

Be the Voice of Your Academy

February 19-20 Monday, February 19 6:00 a.m. – 8:30 p.m.

Detailed Legislative Briefing

Tuesday, February 20

7:30 am – 9:00 am Buffet Breakfast & Briefing, Capitol Plaza Hotel, Lincoln Room

VIS MO-AF IT P.ORG TO REGIS TER!

9:00 am – 9:30 am Walk to State Capitol 9:30 am – 1:30 pm Legislative Visits (appointments made by MAFP staff) 9:30 am – Noon MAFP Display, State Capitol, Third Floor Rotunda 10:30 am Group Photo – Meet at MAFP Display, Third Floor Rotunda 11:30 a.m. – 1:30 pm Lunch at Capitol Plaza Hotel, Lincoln Room (Available until 2:00 p.m.)

1:30 pm – 5:00 pm Board Meeting – Capitol Plaza Hotel, Lincoln Room

Capitol Plaza Hotel, Jefferson City

Group Lodging Rate: $99.00 (single/double) Telephone: (573) 635-1234 | Online | Group Block Code: MOAFP A limited number of complimentary sleeping rooms are available at Capitol Plaza Hotel on a first come, first served basis. Contact Kathy Pabst at (573) 635-0830 or at kpabst@mo-afp.org.

executive commission Board Chair - Kathleen Eubanks-Meng, DO (Blue Springs) President - Mark Schabbing, MD (Perryville) President-Elect - Sarah Cole, DO, FAAFP (St. Louis) Vice President - Jamie Ulbrich, MD, FAAFP (Marshall) Secretary/Treasurer - James Stevermer, MD, FAAFP (Fulton)

MARK YOUR CALENDAR

board of directors

MAFP Advocacy Day February 19-20, 2018 Capitol Plaza Hotel, Jefferson City, MO

District 1 Director: John Burroughs, MD (Kansas City)

Alternate: Jared Dirks, MD (Kansas City) District 2 Director: Lisa Mayes, DO (Macon)

Alternate: Vacant District 3 Director: Emily Doucette, MD (St. Louis)

Director: Kara Mayes, MD (St. Louis)

Alternate: Dawn Davis, MD (St. Louis) District 4 Director: Jennifer Scheer, MD, FAAFP (Gerald)

Alternate: Kristin Weidle, MD (Washington) District 5 Director: Vacant

Alternate: Vacant District 6 Director: David Pulliam, DO, FAAFP (Higginsville)

Alternate: Carrie Peecher, DO (Marshall) District 7 Director: Wael Mourad, MD, FAAFP (Kansas City)

Director: Afsheen Patel, MD (Kansas City)

Alternate: Beth Rosemergy, DO (Kansas City) District 8 Director: John Paulson, DO (Joplin)

Alternate: Charlie Rasmussen, DO, FAAFP (Branson) District 9 Director: Patricia Benoist, MD, FAAFP (Houston)

Alternate: Vacant District 10 Director: Deanne Siemer, MD (Jackson)

Alternate: Vicki Roberts, MD, FAAFP (Cape Girardeau) Director at Large: Kurt Bravata, MD (Buffalo) resident directors Alicia Brooks, MD, SLU Ann Lottes, MD, SLU (Alternate) student directors John Heafner, MSPH, SLU MiMi Liu, SLU (Alternate)

AAFP Board Review Express February 7-10, 2018 Hyatt Regency at the Arch St. Louis, MO

MAFP Board of Directors Meeting February 20, 2018 Capitol Plaza Hotel, Jefferson City, MO AAFP Annual Chapter Leadership Forum/National Conference of Constituency Leaders April 26-28, 2018 Sheraton at Crown Center, Kansas City, MO

Show Me Family Medicine Conference (formerly ASA) June 8-9, 2018 The Lodge at Old Kinderhook, Camdenton, MO MAFP Board of Directors Meeting June 10, 2018 The Lodge at Old Kinderhook, Camdenton, MO AAFP National Conference of Family Medicine Residents & Students (NCFMRS) August 2-3, 2018 Kansas City Convention Center, Kansas City, MO

INSIDE THIS ISSUE Pg. 4 6 7 8 29 30 32 34 35

President's Report Executive Director's Report Nominate the 2018 Familt Physician of the Year The Impact of Technology on Healthcare 2018 Alaskan CME Cruise Annual Fall Conference Recap Members in the News Help Desk Answers Register for the 2018 Opioid Summit

Advertisements Pg. 5 MHPPS 11 Midwest Dairy 18 MO Beef Industry Council 21 MPM-PPIA 31 Stanley's Pharmacy Circassia 32 SSM Health 35 Direct Primary Care Clinics, LLC. St. Louis University

aafp delegates Todd Shaffer, MD, MBA, FAAFP, Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate mafp staff Executive Director - Kathy Pabst, MBA, CAE Communications and Education Manager - Sarah Mengwasser Membership and Programs Coordinator - Becki Hughes Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101 p. 573.635.0830 f. 573.635.0148 www.mo-afp.org office@mo-afp.org The information contained in Missouri Family Physician is for information purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinion expressed in each article(s) is the opinion of its author(s) and does not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no responsibility for the opinion expressed thereon.

AAFP Board Review Express

February 7-10, 2018 Hyatt Regency at the Arch St. Louis, MO

Designed by and for family physicians, this course reflects the blueprint of the American Board of Family Medicine (ABFM) exam.

The in-depth review covers the evidence-based principles and medical guidelines of family medicine focuses on 14 body system categories, population-based care, and patient-based systems.

Visit: aafp.org/cme for more information.

MO-AFP.ORG 3

Take A Stand; We Cannot Lose Our Values

I Mark Schabbing, MD President

4

would like to thank all of you who were able to attend our Annual Fall Conference at Big Cedar Lodge in Ridgedale, MO. It was another successful event that was skillfully organized by our staff. If you have not been able to join us in the past, I would like to invite you to come next year to enjoy the wonderful scenery that Big Cedar Lodge has to offer.

At this time I would like to focus on what the MAFP does for you in relation to advocacy on the state level. We have had Pat Strader, who has been our lobbyist for more than 15 years, making sure that our values have been heard and understood in Jefferson City. She has artfully worked both sides of the aisle so we are not seen as a partisan organization.

Advocacy is a unique benefit that the MAFP provides for our members. We make sure that the needs of our patients are not forgotten and at the same time we are not lost in some of the specialty or hospital-driven agendas.

Unfortunately, our lobbyist sometimes can only be as effective as our PAC. PAC funds cannot be funded from our membership dues; therefore, it takes a little more effort on our part to expand the PAC. Today there are over 2,000 members in our Academy. Our PAC contributions typically range between $3,000-6,000 a year. Simple math tells us that is $1.50 to $3.00 per member. You cannot even buy a value meal from McDonald’s with this amount. Think of what a $50 to $100 donation from each one of our members would do to bolster our PAC today. Medicine is changing on a daily basis. We are being driven by more regulations from the government, insurance demands, and by hospital policy. If we do not take

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2018

the initiative to make a seat at the bargaining table, our values and needs will be lost in an afterthought as the lawmakers and lawyers craft the new health care system.

I urge you to take two minutes to visit the MAFP website mo-afp.org. Here, with a couple clicks

"

Today there are over 2,000 members in our Academy.

Our PAC contributions typically range between $3,000-6,000 a year. Simple math tells us that is $1.50 to $3.00 per member."

of a mouse, a donation can be made easily.

Encourage your partners and colleagues to do the same. If you would like to take it one step further, I invite you join us February 19-20th for our annual Advocacy Day in Jefferson City. On the evening of the 19th we will be given an update of issues that are being discussed by the lawmakers and how these issues may be affecting us in the near future. On the 20th, we will then make our way to the Capitol to discuss those issues with our individual legislators. If you are interested in attending, we make it easy. You can register by going to our website under Advocacy and view the agenda.

Thank you on behalf of the board of your MAFP, and I wish you and your families a Merry Christmas and a happy healthy New Year.

We are dedicated to rural and underserved areas of our great state! Recognized as Missouri’s leading non‐ prot health care focused job placement program, MHPPS helps health care professionals nd a community that best ts their personal and professional needs.

Opportuni�es throughout our Rural & Urban Areas: Find Out More: Contact Us Today!

Joni Adamson  Loan Repayment Op�ons Manager of Recruitment  Compe��ve Salary & Comprehensive Benets jadamson@mo‐pca.org / 573.636.4222  Team Based Models of Care / Care Coordina�on www.mhpps.org  Li�le or no Call / Moving Allowance / Signing Bonus

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Today more than

3,500 children will try their first cigarette.

Stop kids from starting.

Volunteer to be a Tar Wars presenter. www.tarwars.org

Supported in part by a grant from the American Academy of Family Physicians Foundation. 5 MO-AFP.ORG TW hlf horiz.10_v2.indd 1

9/3/10 11:58 AM

A New Year Brings New Ventures

2 Kathy Pabst, MBA, CAE Executive Director

6

018 will be a year of transition for the Missouri Academy of Family Physicians.

After 15 years of commitment and support to the Academy, Pat Strader, our lobbyist, is transitioning to retirement... but not so quickly. Although she will continue to work with her smaller clients, and consult the MAFP during the next legislative session, Pat will have more time to enjoy family and friends, and step away from the daily grind of the Capitol. Her role in elevating family medicine in this divided building, both politically and physically, has been significant as she was instrumental in the recent passage of the direct primary care legislation (2015). Her continual review of the over 2,000+ introduced bills has kept the Academy apprised of health care legislation that may impact you, your patients, and your practice. Our presence at the capitol would not be the same without her active role on a variety of legislative issues including scope of practice, Medicaid expansion, PDMP and opioid abuse, and other practice legislation.

Pat’s leadership will certainly be missed. Be sure to express your appreciation to her at this year’s Advocacy Day, February 19-20, 2018.

Speaking of advocacy, your voice does have an impact...and we need you now more than ever to share your experiences with your legislators.

Whether you contact them by telephone, email, face to face, or even present testimony at a hearing, your message does make a difference.

We are always identifying and recruiting members to present testimony on important legislation.

Even though it may not impact you, your practice, or you patients today...it may tomorrow.

Unfortunately, we may not be notified of a hearing until a few days before the actual meeting.

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2018

Letting me know your availability is as simple as a quick email to kpabst@mo-afp.org with your availability and areas of expertise. You are our best resource and we are here to represent you!

Another change in 2018 will be the enhancement of the Transition to Practice conference. Last year was the inaugural meeting that drew over 20 residents to Jefferson City for a two-day conference of new physicians sharing their “I wish I knew” opportunities. This year’s conference will be held August 17 and 18 at the Doubletree Hotel, Jefferson City. A team of residents and students attended the Annual Fall Conference and identified what they needed to be better family medicine students, residents, and new physicians. Look for more information in the next issue of the Missouri Family Physician to learn more about this exciting new program.

The annual Multi-State Forum is being held in February this year, and Missouri is the host state, but that doesn’t mean we will have the meeting in Missouri. As the host state, we are responsible for all the meeting logistics at the hotel (DFW airport), identifying regional topics important to the future of family medicine, and selecting experts on these topics to share their successes that can be incorporated into our work environment and challenges that we learn to do better.

With these new ventures, there is one thing that will remain constant. Your MAFP staff, Kathy, Sarah, and Becki, are here to work with you to improve family medicine for Missouri physicians, residents and students. We are all on the same team, working together with you and for you. We want to thank you for the opportunity to do what we love for better healthcare for all Missourians.

2018

Family Physician of the Year

An outstanding, caring, family physician in your community deserves the title “Missouri Family Physician of the Year.” The Missouri Academy supports over 2,300 active members in the workforce – doing extraordinary things every day. You know them, and we would like to acknowledge them.

Nominations may be made by the public, as well as by physicians.

Nominees must meet the eligibility requirements to be considered for this award.

The Missouri Academy is accepting submissions up to the deadline of Monday, February 5, 2018.

Visit the MO-AFP website to nominate someone today!

www.mo-afp.org

MO-AFP.ORG 7

The Impact of

TECHNOLOGY on healthcare

From improved operational efficiency to standards in patient care, communication, electronic medical records, telehealth/ telemedicine, and mobil apps, the healthcare transformation has enhanced the entire experience for both patients and medical professionals.

In the following pages you will read articles published by family physicians who know firsthand just how technology is affecting healthcare.

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MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2018

Telemedicine: The Future (and Past) of Medicine A brief look back at the history and current perspectives of an important resource in today’s medical community.

T

elemedicine. What is it?

Defined as the utilization of communication resources through electronic means to provide healthcare from a distance.

It is often used interchangeably with telehealth which encompasses a broader scope. The Health Resources and Services Administration defines telehealth as “the use of electronic information and telecommunication technologies to support and promote long-distance clinical health care, patient and professional healthrelated education, public health and health administration. Technologies include video conferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.”

Telemedicine has endless potential and becomes increasingly important in today’s healthcare environment with perpetually advancing healthcare technology. It can help patients overcome barriers to receiving healthcare including lack of transportation, poor mobility, understaffed/underfunded local clinics, and residence in remote areas. It can connect patients to specialists or primary care providers. Chronic and acute health problems can be addressed. It can potentially reduce hospital admissions and healthcare costs as a whole with the use of remote monitoring of chronic conditions. It is not only convenient but also increases access to healthcare, attributes that can benefit all of the general public.

In 2015, the US market for telemedicine was estimated to be worth nearly $5 billion and is predicted to be worth over $6.5 billion by 2020, growing at a predicted 6.3% compound annual growth rate. To put this in perspective, national health expenditures in 2015 came out to $3.2 trillion which equates to 17.8% of the GDP or just under $10,000 per person. In 2016, more than $16 million was awarded by the Health Resources and Services Administration to improve healthcare access to rural areas, specifically benefitting telehealth technology and $92 million

was allocated to support activities of meaningful use of health IT. Globally, the telemedicine market is expected to exceed $34 billion by 2020, of which, North America makes up the largest portion of the global market. Telemedicine is still a small piece of the healthcare puzzle, but expect it to continue to take on a larger role in the evolving digital age.

To fully appreciate and understand where the future of telemedicine is going, it can be helpful to reflect on where it has been. The earliest reports of using electronic means to promote medical evaluation and treatment dates back to the 1870s with the invention of the telephone

by Alexander Graham Bell on March 10, 1876.

The telephone may have been perhaps the most important advancement in promoting a cultural of providing medical care over a distance.

“Mr. Watson, come here. I want to see you,” is often quoted as the first instance of the telephone’s use by its inventor, Alexander Graham Bell. Thomas Watson was listening on the receiving device across the hall and arrived promptly to celebrate the achievement. A lesser known story is that this event has also been considered by many, the first use of telehealth services as Bell was calling upon his assistant for first aid as he had spilled battery acid on his clothes. Although the intent for the use of healthcare was not the primary driving force behind the invention of the telephone, it has stood the test of time and proved to be essential in medicine over 140 years later.

The influence on the invention of the telephone on the medical community was profound.

The medical journal, The Lancet, published multiple letters to the editor in February 9, 1878 with the discussion of the use of the telephone to possibly assist medical diagnostics and improve auscultation methods. It was suggested that this technology may allow for better auscultation of heart and lung sounds by William Brown in the Popular Science Review in 1878. It took technology several years to meet these conceptual ideas. In 1910 an electronic stethoscope was designed with capacity to

Geoff Dankle, MD PGY-2, Family and Community Medicine University of Missouri Columbia

continued on page 10

MO-AFP.ORG 9

continued from page 9

amplify heart sounds three times louder than the traditional stethoscope with an attachment of a “telephone relay” invented by an electrical engineer, G.S. Brown, which could amplify heart sounds more than 20 times. This allowed for the transmission via phone lines miles away. The sounds were described as heard as loud and clear as when heard locally.

Early use of the telephone was also described in literature to assist in medical diagnostics.

An anonymous letter published in The Lancet on November 29, 1879 described a case of an anxious mother calling her family doctor at a late hour concerned that her child had the croup. The doctor asked for the child to be placed near the telephone to hear the child cough. The doctor listened to the cough and stated his assessment that the child did not have the croup based on his perception over the telephone and abated the mother’s worries. This is thought to be one of the first medical consultations over the telephone and it was suggested in The Lancet that this may ease office-based clinical practice by reducing unnecessary visits. However, later articles brought up concerns that patients may be inclined to abuse the service if they believe that a conversation over the phone would displace an in-person consultation especially if the cost of a call is only a penny.

The first transmission of radiologic images by telephone and radio wires occurred between West Chester and Philadelphia, Pennsylvania in 1948. Discussed in an article written by Cooley Gerson-Cohen titled “Telegnosis” in 1950, images were passed a total distance of 24 miles. This benefitted the rural hospital that did not have to have a radiologist on site to interpret imaging.

Many rural hospitals could only arrange part-time radiology services at that time.

The first use of video communication in the United States is attributed to the University of Nebraska in 1959 where two-way television was utilized to transmit neurological examinations among other information to medical students across campus. Technology was expanded for use in 1964 with a link to the Norfolk State Hospital located 112 miles away to provide speech therapy, neurologic examination, psychiatric diagnostic services for difficult cases, research seminars, and education/training. These services grew out of concern for limited access to health care resources by remote populations.

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MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2018

In 1967, physicians based at the University of Miami partnered with the City of Miami Fire Department to develop use of voice radio channels to transmit telemetric electrocardiographic information from fire rescue units to Jackson Memorial Hospital. This is now a mainstream application for first responders and paramedics in that cardiac rhythms are transmitted to emergency departments.

Throughout the 1960s and 1970s, NASA invested significant time and research dedicated to telemedicine applications during the manned space-flight program. It was largely unknown the effects that the zero gravity environment of outer space would have on the astronauts. There was a need to constantly monitor vital signs including heart rate, respiratory rate, blood pressure, and

"

It [telemedicine] does however, provide, an essential adjunct for those that have difficulty with access to care and those that need vigilant monitoring of chronic conditions. It provides a convenient service and can assist in taking a weight off of a very full system."

temperature. Medical support systems were implemented for evaluating and treating in flight emergencies.

This created further projects domestically including collaboration with the U.S. Indian Health Service and Lockheed Missile and Space Company. The STARPAHC project (Space Technology Applied to Rural Papago Advanced Healthcare) was developed from 1973-1975 on the Papago reservation in southern Arizona. Goals of the project included exploration of providing improved healthcare to remote populations.

The Papago people lacked access to acute medical care and this project provided the most advanced technology at the time to deliver a telemedicine based service. This was considered a breakthrough in progress for the development of telemedicine.

The progress with the internet in the 1990s further advanced rapid dissemination of information, especially with regard to medical applications. It allowed for support of practically all information and traffic needed for telemedicine services through internet protocols including: patient education modalities, medical imaging, real-time audio/video, and vital signs/ measurements. With this, modern telemedicine services became a reality.

Recent legislation and government resources have also driven progress in the telemedicine industry. In 2009, President Obama signed the ARRA/HITECH Act. This was a $789 billion dollar stimulus package of which $19 billion was allocated as an incentive to hospitals and physicians demonstrating “meaningful use” of electronic medical records. The Patient Protection and Affordable Care Act in 2010 led to creation of Accountable Care Organizations to enhance care coordination. Telemedicine also seeks to promote the goals of improving care coordination, fitting within the care models generated.

Telemedicine will continue to grow into the future, however, it cannot fully replace all of the services of practical healthcare delivery.

William Osler, the founder of modern medicine, would most likely agree. An in-person evaluation allows the physician a full sensory experience in observation and evaluation of a patient to make the most accurate diagnoses. It does however, provide an essential adjunct for those that have difficulty with access to care and those that

need vigilant monitoring of chronic conditions. It provides a convenient service and can assist in taking a weight off of a very full system.

References: • United States Telemedicine Market Analysis, Size, Share, Growth Trends and Forecasts (2016 – 2021). https://www.medgadget.com/. April 14, 2017 • HHS FY2016 Budget in Brief. www.HHS.gov.

February 4, 2015 •NHE Fact Sheet. Centers for Medicare and Medicaid Services. www.CMS.gov. June 14, 2017 • Aronson, Sydney. The Lancet on the Telephone. Medical History, 1977, 21:69-87 • Gershon-Cohen J, Cooley AG. Telediagnosis.

Radiology. 1950;55:582–587 • Perednia DA, Allen A. Telemedicine Technology and Clinical Applications. Journal of the American Medical Association.

1995;273(6):483–487 • Nagel EL, Hirschman JC, Mayer PW, et al.

Telemetry of Physiologic Data: An Aid to FireRescue Personnel in a Metropolitan Area.

Southern Medical Journal. 1968; 61:598–601 • Zundel KM. Telemedicine: History, Applications, and Impact on Librarianship.

Bulletin of the Medical Library Association. 1996; 84(1):71–79 • History of Telemedicine. MD Portal. Last Updated 9/23/2015. http://mdportal.com/ education/history-of-telemedicine/ • Gruessner, Vera. The History of Remote Monitoring, Telemedicine Technology. mHealth Intelligence. November 9, 2015

MidwestDairy.com MO-AFP.ORG 11

A Real-Life Success Story: Embedding Registries in Residency Training Programs

Beth Rosemergey, DO, FAAFP is a board-certified family physician.

Dr. Rosemergey is an associate professor and serves as vicechair for outpatient clinics in the Department of Community and Family Medicine at University of Missouri Kansas City School of Medicine. She currently practices family medicine and is the program director for the UMKC Family Medicine Residency. She graduated with a bachelor’s degree in Biology from Wilkes University in 1984 and received her doctorate of Osteopathic Medicine from the Kansas City University of Medicine and Biosciences in 1988. Dr. Rosemergey completed her family medicine residency and served as chief resident at Truman Medical Center Lakewood in 1992. She has special interests in ambulatory care, the Patient-Centered Medical Home, chronic disease management, population health and preventative care.

A

Jacob Shepherd, MD is a resident physician in the UMKC Family Medicine Residency Program.

Dr. Shepherd is in his final year of residency at Truman Medical Center Lakewood, and he is pursuing an area of concentration in Health Informatics. Dr. Shepherd received his medical degree from Saba University School of Medicine and received a bachelor’s degree in Biology with a minor in Chemistry at The University of North Texas. Dr. Shepherd is currently a captain in the United States Air Force and will go on active duty upon completion of residency in July 2018.

t the recent Cerner Health Conference in Kansas City, Missouri in October, Truman Medical Centers (TMC) executives, physicians, nurses and other leaders shared how they are using Cerner solutions and services to improve quality and efficiency of care.

In total, TMC speakers presented at 16 sessions, which attracted more than 14,000 attendees from 26 countries.

Two TMC clinicians, Beth Rosemergey, DO; Jacob Shepherd, MD; and a patient, Stacy Rawlings, shared a real-life patient story regarding using technology to improve patient outcomes in a residency clinic setting.

Ms. Rawlings was admitted to the TMC’s Emergency Department with high blood pressure. Upon admission, she presented symptoms of urinary retention and 12

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2018

Stacy Rawlings a mother of five, wife, daughter and patient. Ms. Rawlings lives in Raytown with her family. She has home schooled her children for 22 years and is the founder and administrator of THRIVE Family Co-op (Pre-K - 12) with 90 kids.

She teaches personal finance at the high school level. She is active in church, supper club and loves spending time with her family.

peripheral neuropathy and was diagnosed with new onset diabetes with elevated blood sugars in the 400s, an Hb A1C of 14.2 and BMI of 31.9.

Over the next year, Ms. Rawlings would come in for monthly visits, and Dr. Shepherd used the Cerner HealtheRegistries and Scorecards solution in his previsit planning to get a more holistic view of her care.

Within a single view, Dr. Shepherd could easily see if Ms. Rawlings was overdue for a foot or eye exam, for example, or if her A1Cs were trending in a positive direction.

This technology continues to help Dr. Shepherd identify what clinical best practices have been completed or not completed, which, in turn, helps him provide his patients like Ms. Rawlings with the quality care they deserve. Dr. Shepherd said the reason he

Stacy Rawlings, featured in a Cerner video, tells Dr. Shepherd, "I couldn't have done it without you."

Hear more on Ms. Rawlings’ journey here: https://www.youtube.com/watch?v=vLrlI8mYLwM&feature=youtu.be

gets to work early and spends the first part of his day on pre-visit planning is so he can be more efficient and spend more time with his patients. "The goal of technology should be to make health care providers proficient so that they can spend more face time with patients and build the rapport necessary to create better patient outcomes," stressed Dr. Shepherd.

"

The goal of technology should be to make health care providers proficient so that they can spend more face time with patients and build the rapport necessary to create better patient outcomes."

Jacob Shepherd, MD

Dr. Shepherd’s patients feel more cared for and valued. Ms. Rawlings said she is now healthier and happier. She continues to stay motivated to work on her diet and exercise. Over the past year, her BMI has dropped from 31.9 to 28. She is now on one blood pressure medication and almost off of short-acting insulin. Her insulin requirement has been cut in half, and her A1C has decreased to 6.4 from 14.2.

During the presentation, several Cerner associates

and clients were moved to tears when they heard how Ms. Rawlings has gotten her life back. She said she used to not be able to walk up a flight of stairs because of her health, and now she regularly walks 10,000 steps a day.

The University of Missouri Kansas City (UMKC) Family Medicine Residency Program is based out of TMC’s Lakewood Campus. The residency focuses the Patient-Centered Medical Home (PCMH) model and strives to provide the tools residents need to be successful family physicians.

The Bess Truman Family Medicine Residency Clinic has been recognized since 2013 as a Level 3 (highest distinction) Patient-Centered Medical Home by The National Committee for Quality Assurance (NCQA). The Family Medicine Residency has a robust ambulatory curriculum that teaches resident physicians how to use the registries, scorecards and pre-visit planning to improve patient outcomes. The Ambulatory Care longitudinal curriculum at UMKC Family Medicine includes four block rotations (PCMH in PGY 1 and 2, Outpatient Leadership and Preceptorship in PGY3).

Some examples of the skills residents obtain include: population health management, value-based reimbursement, coding/billing expertise, teambased care practice, experience conducting quality improvement projects, managing patient safety and patient satisfaction.

After interviewing at 12 different residency programs across the country, Dr. Shepherd ranked UMKC No. 1 because of its innovative approach to technology. The UMKC Family Medicine faculty engage their residents in the use of technology for the betterment of patient care.

MO-AFP.ORG 13

Re-visiting Wellness

I Kurt Bravata, MD Citizens Memorial Healthcare, Buffalo, MO

14

n this data-driven age of healthcare, medical practice is constantly evolving to meet the demands of our information storage and reporting framework. Although individual primary care providers and patients benefit from these informational repositories and data tracking systems, much of the preventative health maintenance we do in the United States is in essence guided by the data collection requirements of Centers for Medicare and Medicaid Cervices (CMS) as set by the United States Preventative Services Task Force (USPSTF).

At the risk of reviving a dead issue here, I want to re-visit the concept of wellness encounters and how we implement them into real life practice.

I realize that this is a topic that had its time in the healthcare debate and that now most of us simply follow along and do a pretty good job (so we think) performing wellness visits on a handful of compliant patients who are willing to schedule these every year. There are also others among us who feel that since wellness is something we do all the time during our routine health-maintenance visits, there is no need to schedule separate additional encounters to accomplish this task.

Whatever our personal opinions may be about the healthcare system’s standardized data-tracking requirements, electronic health records (EHRs) are here to stay and if you accept federal or state funding, CMS sets the rules.

For sure, the EHR has greatly increased our ability to track health maintenance, epidemiological data, and disease processes.

We are now able to measure our performance through The Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS consists of 81 measures across five domains of care, and is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service.

Through Meaningful Use, we are encouraged (one could say pressured) to use certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, reduce health disparities, engage patients and family, improve care coordination, population and public health, and to maintain privacy and security of patient health information. In primary care settings, a large percentage of healthcare decisions made by healthcare providers are driven by the demands set by HEDIS and Meaningful Use measures.

One of the questions we have to ask ourselves

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2018

is, “Are EHRs and other electronic medical databases driving our medical decisions for the better while facilitating good healthcare delivery, or are they perversely driving us to treat the medical record first, rather than tailoring care to the needs of the individual patient in front of us?” I imagine that in most cases, the answer is a complex mixture of both considerations. Enter the Medicare Wellness Visit (MWV) as a case in point.

"

Are EHRs and other electronic medical databases driving our medical decisions for the better while facilitating good healthcare delivery, or are they perversely driving us to treat the medical record first, rather than tailoring care to the needs of the individual patient in front of us?”

I first learned about Medicare Wellness Visits back in 2011 when they were introduced by the Affordable Care Act while I was in residency. I remember thinking it odd that a separate medical visit was being recommended during which patient “wellness” was being addressed. At the time, I thought, “Isn’t ‘wellness’ what physicians address during every medical visit?” I wondered if such visits were necessary, or if they were just another hoop medical providers needed to jump through to satisfy the bureaucratic demands of our increasingly complex healthcare system. I heard from patients who shared concerns that this was primarily a visit to talk about “end-oflife planning” and to discontinue unnecessary health maintenance initiatives on their way to the morgue, so-to-speak. In short, many patients told me that they thought this was a self-serving effort by Medicare to save money. These concerns were of course being exacerbated by the partisan debate splitting the country socio-politically at the

time. As always, the truth lies somewhere in the middle.

Although I do think that cost savings and revenue generation are among the benefits provided by Medicare Wellness Visits, I have come to see these encounters as an extremely beneficial opportunity to dedicate focused attention on the implementation and tracking of health maintenance. I find that these visits are relatively straight forward and that they can be completed in short order without much stress if done correctly.

The key is to educate your patients on the purpose and nature of Medicare Wellness Visits. One must advise them that these are primarily free-to-patient counseling visits during which pertinent info is gathered and updated, meds are reconciled, appropriate screenings are ordered, and needed vaccines are administered. They also need to be informed that a comprehensive head-to-toe physical exam is not usually performed during these visits. It is important that patients come to the visit with this expectation, so they are not disappointed when other issues that they may want to address are deferred to a secondary encounter or subsequent visit.

Recently, wellness visits became a central topic of discussion at my clinic in rural southwest Missouri. It became evident through our qualitycare tracking (Data Reporting & Visualization System - DRVS) that our clinic was not consistently meeting the benchmark set for number of wellness visits. This was shocking to us. We could not understand how this could be possible when we do so much “wellness” and preventative “health maintenance” in our practice. To give you a perspective, we have two physicians (of which I am one) and three NPs in my clinic who all routinely provide primary care, in addition to three PAs who cover most of the urgent-care issues in our walk-in clinic. As the junior physician, I knew that it had taken me some time to develop a good system for scheduling separate wellness visits amidst the already frequent routine visit schedule that my often complex chronic-care patients keep. However, this past year, I was certain that I had done a pretty good job of scheduling yearly wellness visits for the bulk of my patients. Since a large percentage of my patients are geriatric, it has become fairly reflexive to schedule their yearly wellness visits and I would say the same for my female patients

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Dr. Kurt Bravata and his 107 year old nursing home patient smile for the camera.

as it is the intuitively ideal opportunity to perform pap smears and order mammograms. Well-child visits and school physicals are equally intuitive to schedule annually. However, it became clear that I was not doing as good a job at scheduling wellness visits for my healthy young adult and middle-aged males.

Further investigation revealed that our documentation and coding habits were not always sufficient to allow the medical coders to capture all the other types of wellness visits we were actually doing. For instance, in addition to my MWV’s and Well-woman exams, I had been making an effort to code many of my routine health-maintenance and chronic-care visits using the primary problem of Routine Medical Exam Z00.00 which I had discovered was the same ICD-10 Z-code as Medicare Wellness (initial and subsequent) and General Adult Medical Examination Without Abnormal Findings. I thought that as long as I was coding correctly for the health maintenance that I did during the visit would count towards my overall wellness numbers. Although this was partially true, I was missing an essential understanding about how medical coders read visit notes. In my mind, I thought of the visit reason as being a starting point initiated by the rooming nurse and the rest

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of the note from HPI to Assessment and Plan as a progression that flowed from there. Rarely did I consider the need to go back and revise the visit reason to match where the encounter had landed when it came to inserting my problem list.

As my coders later explained, you can’t simply code for Wellness or Routine Medical Exam without making sure that these visit reasons are documented in the nursing intake and the HPI, even if you did all of the wellness and health maintenance that such a visit should entail. Their explanation was that insurance companies and CMS could potentially consider it fraud if this level of documentation was not included to match the problem list and associated codes attached to the note. In hindsight, I guess I knew this conceptually, but had never fully applied it in this context.

This prompted me to want to do some more research about Wellness Visits to make sure we were meeting the standards and maximizing the potential of these encounters. Unfortunately, the more I investigated these encounters, the more I found there to be great uncertainty about what can and can’t be documented during a Wellness Visit without generating additional charges to the patient.

In general, the consensus seems to be that anything that is deemed “preventative” is considered appropriate during a wellness visit.

This means that performing medication refills, and coding for vaccines and screenings should not result in the patient receiving unexpected bills. This is especially true for straight Medicaid, however managed care or commercial plans may allow other chronic care problems (i.e. hypertension and diabetes) to be addressed and coded during the visit. When the required preventive health maintenance and associated codes are documented correctly in Medicare Wellness Visit, you can also address and code for chronic diagnoses with no additional co-pay. That being said, the general rule of thumb should be to try to stick to preventive codes only and to avoid procedure codes during wellness visits. To play it safe, an additional visit note may be generated to address separate acute/chronic issues and procedures.

I find this to be one of the trickiest parts of the MWV, as I rarely have time to schedule patients for a secondary encounter during the same day and acute issues often cannot wait until a later time. Hence, I have sometimes addressed such issues (i.e. URI, allergic rhinitis, etc.) off of a separate non-billable chart note, or documented

them in the MWV and let the patient know that this would likely result in added charges that they would be liable to pay. Split billing can be done when you provide a significant, separately identifiable, medically necessary evaluation and management (E/M) service in addition to the Annual Wellness Visit (AWV). If documented and coded appropriately, reporting the Current Procedural Terminology (CPT) code with modifier -25, Medicare may pay for the additional service.

However, this portion of the visit must be medically necessary to treat the beneficiary’s illness, injury, or disability.

It is important to note that Medicare and Medicare Replacement plans, don’t pay for yearly physical exams. They only pay for the Initial Preventative Physical Exam (IPPE), otherwise known as the Welcome to Medicare Wellness Exam, and subsequent Annual Wellness Exams (Encounter for Medicare Wellness Exam). You would use your templates specific for them.

Annual Medicare Wellness Visit is not considered

"

I can attest that with an open mind and willingness to learn, the EMR can be effectively used to maximize one’s ability to track and deliver excellent preventative care."

a physical. In essence, it is a preventative health maintenance counseling visit which entails specific wellness components, however, there is nothing prohibiting a physical being done at the same time. We also can do breast, pelvic, and prostate exams as well as diabetic foot exams during Medicare Wellness Visits as long as we complete the main required components of the AWV. Since Medicare will only cover the IPPE or AWV, routine chronic care visits for Medicare patients should not have the ICD-10 code Z00.00 code (CPT code G0101), as in Routine Medical or Physical Exam. This is the same for other insurance plans as well, which will only pay for one routine physical a year.

When billing is done correctly, Medicare covers 100% of the AWV if all components are met and if performed by a Physician, Nurse Practitioner, or other approved Medical Professional. Initial MWVs

are coded as G0438, earning relative value units 4.98, billed at $456, and reimbursed at around $175. Subsequent MWVs are coded as G0439, earning relative value units 3.26, billed at around $274, and reimbursed at around $130.

One thing I have found particularly confounding is the increasing number of patients who have responded to my request to schedule a Medicare Wellness Visit, by stating that they already had one done by a nurse from their insurance company who either called them or came to their house. I am then faced with the problem of educating and persuading the patient that a nurse-counseling visit is not the same thing as a medical office visit with a physician during which necessary healthcare updates and screenings can be ordered. It’s not uncommon in such instances to have patient’s appear reluctant to schedule what they think is an unnecessary duplication of services. However, I have found that with a little education and coaxing, patients do usually see the benefits of the Medicare Wellness Visit. Most patients appreciate the opportunity for free face-to-face encounter with their provider, paid for by Medicare Part B and Medicare Managed Care plans (i.e. Medicare Advantage).

As a physician, I especially appreciate the opportunity to promote preventive care in the most vulnerable patient population, the aging and aged. One would hope that carrying out these visits yearly actually results in their stated goal: to prevent the onset of disease and disability, by slowing the progression and exacerbation of existing illnesses, through health promotion and disease detection. MWVs are also proposed to help foster the coordination of screening and preventive services that may already be covered and paid for under Medicare. For sure, Medicare Wellness generates highly reimbursed visits which enhance revenue by increasing RVUs, annual wellness volume, and ancillary services covered

by Medicare. In addition, Centers for Medicare and Medicaid Services (CMS) has even offered incentives to patients, such as a $25.00 reward in certain instances where patients schedule MWVs, through the benefits enhancement program of the next generation Accountable Care Organization (ACO) model (https://innovation.cms.gov/Files/ slides/nextgenaco-benefitsenhancements-slides. pdf).

In an article published June 7th 2017, in STAT, titled Does Medicare’s free annual wellness visit do any good?, Harvard Medical School instructor and Brigham and Women’s Hospital physician Ishani discussed the following research findings

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published in the June 6th edition of JAMA: This study found that only eight percent of Americans eligible for the annual wellness visit had one in its first year of the Affordable Care Act; which rose to 16 percent by 2014. They discovered that these rates were driven more by doctors or medical practices offering the visits than by patients asking for them. In addition, the chance of getting a wellness visit varied significantly based on geography. Patients who belonged to an accountable care organization (ACO - a group of clinicians who work together to provide coordinated care for Medicare patients) were more likely to get the visits. Nearly half of all annual wellness visits were performed by just 10 percent of the doctors who provided them.

Women were slightly more likely to get their Medicare Wellness visit (17 percent of eligible women in 2014 compared to 15 percent of men).

Also more likely were white urban-dwellers who lived in more educated and affluent areas. The single biggest predictor of getting an annual wellness visit in 2014 was having had one the year before (53 percent of patients who had gotten the visit in 2013 followed suit the next year, compared to 10 percent of those who hadn’t.).

Now that I am in my fourth year of postresidency practice, I feel I am finally in a good rhythm scheduling IPPE’s, AWV’s, Well-woman’s, and Well-child’s. I have determined to start doing a better job scheduling annual physicals for young healthy males (18-49 y/o). Still, I think it is emblematic of our growing dependence on EMR prompts and health-maintenance trackers that young men with no major wellness goals to monitor may be overlooked and subsequently fall through the cracks when it comes to annual preventative care. Although I know I have a ways to go, I am definitely becoming more proficient at coding my visits with the appropriate problem codes to describe what was actually discussed and addressed during my visits.

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However, I am sure that one of my downfalls is that I am stubborn when it comes to practice style. I still want to use Routine Medical Exam (Z00.00) as the primary encounter code at the top of my routine chronic care follow-up visits.

Maybe I am getting caught up in semantics, but in my mind, this does not necessarily indicate that an annual physical was done. My argument is that I don’t think it should be treated the same as Routine Physical Exam or Wellness Exam which also carry the same code as Z00.00, since the wording could easily mean something more generic, such as routine medical visit to followup on diabetes, HTN, HLD, hypothyroid, etc. as one might often do every three to six months.

However, I also understand that Routine Medical Exam could easily be used to indicate that a physical was done, but to get credit for this one would have to document this as the visit reason and HPI and physical exam would have to support this. Ideally, if a physical exam was intended, one would start off by using the appropriate wellness documentation template for this visit.

In summary, wellness visits are a great opportunity to enhance the quality and consistency of preventive health maintenance for our patients. Effective patient recruitment, education, and scheduling, along with appropriate visit documentation and coding, are key to achieving good success with billable annual preventative health maintenance. One must become adept at utilizing and updating the electronic health maintenance record in a way that is efficient and meaningful. Inputted data must be retrievable and easily accessed when needed for future reference. I can attest that with an open mind and willingness to learn, the EMR can be effectively used to maximize one’s ability to track and deliver excellent preventative care.

Additional Sources: The ABCs of The Annual Wellness Visit https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNProducts/ downloads/AWV_chart_ICN905706.pdf Medicare Annual Wellness Visit: Rules & Benefits https://www.bc.edu/content/dam/bc1/ schools/cson/Academics/continuing_ed/2017/ NP%20Conference/W1.%20Medicare%20 Annual%20Wellness%20Visit%20-%20Part%20 1%20-%20Johnson.pdf

Breaking Down the Telemedicine Barriers; Are Family Physicians Ready?

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n established patient calls the office for a same day appointment and is told that there are no openings in any provider’s schedule for the next week. He has not been in the office for over a year.

This 57-year-old male presents with intense pain in his right big toe that is 9/10. He has had similar pain previously in the same location approximately twice for which he has never been seen. He was out drinking with friends last night.

He denies fever. ROS is otherwise negative.

Past Medical History: HTN Medications: Lisinopril/Hctz 20/12.5mg 1 po qd Allergies: No Known Drug Allergies PE: Vitals: Temp 97.1 Gen: Appears in distress due to pain Skin: 1st MTP joint – red, swollen, warm and tender to palpation

What is different about this patient presenting with gout? The difference is this patient was seen via telemedicine instead of in an office or clinic.

Telemedicine provides cost-effective, convenient, and portable healthcare. A rising number of providers are considering adding telemedicine to their practice; however, for many physicians, adapting to this delivery system can seem daunting due to concerns which include: quality assurance, time allocation, training requirements and an online limited physical exam. Furthermore, some providers feel telemedicine will fragment patient rapport and continuity of care, which could further fragment healthcare. Despite multiple published surveys showing patients are ready for telemedicine, these concerns raise the question, “Is Medicine ready for Telemedicine?”

These concerns, while valid, should not deter physicians from embracing innovation as

Minote Parab, MD Medical Director Mid-Atlantic Region, Humana

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healthcare advances into this new technologydriven frontier. Addressing these concerns can generate a more inviting view of telemedicine.

Regarding quality assurance, telemedicine physicians are held to the standards for both brick and mortar and telemedicine practice.

On top of this, many telemedicine providers practice in multiple states and are, thus, vetted by multiple state medical boards and payor contracted credentialing organizations. They must demonstrate knowledge of federal and multiple states’ regulations about practice and prescribing.

Although medicine is essentially the same no matter how it is practiced, via office or telemedicine, specialized telemedicine training is essential. Organizations should make this protected training time to assuage providers’ fears of being overloaded with more work. Training should include basic technology, trouble-shooting issues, appropriate online care, and regulations pertinent to telemedicine. Formal training as opposed to trial and error, ensures a smoother transition for patient and physician alike.

Another concern is the physical examination, or lack thereof, via telemedicine. This should be thought of not so much a limitation, but a factor to help determine what is appropriately seen in a telemedicine setting. Some diagnoses are easily supported in telemedicine using evidence-based medicine from the office environment combined with office experience. A standard of care has already begun to take shape as more physicians and organizations have honed their telemedicine practices. Despite the progress, it takes a conscientious team to work through diagnoses and symptoms commonly seen to develop telemedicine standardization that can be disseminated to new providers and organizations.

Instead of thinking of telemedicine as fragmenting care, we should embrace telemedicine’s ability to strengthen continuity of care and build patient rapport by making health care more accessible and affordable all the while maintaining quality of care. Often patients cannot be seen by their primary care provider for a variety of reasons, including provider unavailability, self-pay status, high deductibles and copays.

Sometimes the patient is in a location that is inaccessible to in-person care, such as those patients traveling or residing in rural locations.

Finally, a follow-up plan is essential.

Documentation and communication with the primary care physician should be no different than would be expected in the brick and mortar practice. Also, due to unchartered waters for many patients utilizing this delivery system, it is 20

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important to take the time to educate and set patient expectations from the beginning.

As mentioned before, telemedicine can address the gaps in healthcare. It can improve patient care through compliance, access, continuity and outcomes, and help capture revenue that would otherwise be lost. In 2014 the telemedicine global market was valued at $14 billion and the projected market for 2020 is $35 billion. North America dominated the market in 2014, but the Asia Pacific is expected to dominate by 2020.1 According to the Tractica report, telehealth video consultations sessions will increase from 19.7 million in 2014 to 158.4 million by 2020.2 In fact, the telemedicine provider REACH Health survey done in 2015 said 44% of organizations indicated telemedicine as high priority, and 22% as top priority.3 Looking back at this case, what does telemedicine offer our patient?

In 2013, less than half of US adults reported being able to secure same- or next-day appointments with their physicians, and less than 40% reported being able to obtain care after hours without going to the emergency department.4 Gout is one of the most poorly treated medical conditions. Gout is unlike other rheumatologic diseases in that a gold standard assessment is available, i.e., MSU crystal positivity. While this gold standard has high specificity, its feasibility and sensitivity may be inadequate.5 While it is ideal to send each patient for joint aspiration, it is not common practice. Gout is typically diagnosed using clinical criteria.6 The 2015 ACR/EULAR criteria for the classification of gout, a clinical-only version can be considered for use in settings in which synovial aspiration or tophus aspiration is not feasible.6 Many patients experience a delay in gout diagnosis due to office availability, but telemedicine offers easy access to healthcare so patients can be seen and diagnosed quickly.

Treating gout flares as quickly as possible (<24hrs) is ideal. For most patients, a typical history, classic exam observed by webcam, and use of clinical criteria, can support the diagnosis. Once these patients are seen via video conferencing, counseled and treated, a follow-up plan can help the patient enter the heath system, or simply follow-up and continue appropriate longterm management. With time, we will be able to determine if adding this new type of visit will improve patient compliance and outcomes.

Once followed up in the office, future acute gout exacerbations managed via telemedicine helps decrease overall patient cost while offices are free to see those medical conditions truly appropriate

for an in-person visit. For initial diagnosis, when in doubt, it is important to explain to the patient, why, when and where the patient should be seen in an office setting.

It is obvious that technology has changed people’s lives, and its use within medicine should be no different. By allowing access to care to anyone who has even the simplest technology (PCs, notebooks and mobile devices), telemedicine can improve the quality of life of both physicians and patients. It is important to learn more about this topic, keep an open mind to its value, speak of its concerns, expect high standard of care, and develop standardized guidelines. Ongoing discussion and collaboration will help ensure best care practices in telemedicine and help to alleviate the concerns mentioned above while improving the current health care system.

References: 1. Pallardy, Carrie. “Telemedicine market value to rocket to $35B value by 2020.”Becker’s Health IT & CIO Review. Scott Becker.2016. http://www. beckershospitalreview.com/healthcare-informationtechnology/telemedicine-market-value-to-rocket-to-

35b-value-by-2020.html Assessed April 13,2016 2. Jayanthi, Akanksha. “Telemedicine consult sessions to increase 700% by 2020.”Becker’s Health IT & CIO Review. Scott Becker.2015.http:// www.beckershospitalreview.com/healthcareinformation-technology/telemedicine-consultsessions-to-increase-700-by-2020.html Accessed April 13,2016 3. Jayanthis, Akanksha. “Comparing telemedicine objectives with success: 7 key findings.” Becker’s Health IT & CIO Review. Scott Becker.2016 http:// www.beckershospitalreview.com/healthcareinformation-technology/comparing-telemedicineobjectives-with-success-7-key-findings.html Assessed April 13,2016 4. Schoen C, Osborn R, Squires D, Doty MM. Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries. Health Aff (Millwood).

2013;32(12):2205-2215 5. Tuhina N, et al. (2015) 2015 Gout Classification Criteria. ARTHRITIS & RHUEMATOLOGY, 67(10),2557-2568 6. Am Fam Physician. 2014 Dec 15;90(12):831836

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Telemedicine Update: A Family Physician Approach to Allergy and Care Coordination with the Allergist

C Tania Elliott, MD FAAAAI, FACAAI Associate Attending, NYU Health Chief Medical Officer, EHE

Minote Parab, MD Medical Director Mid-Atlantic Region, Humana

22

harles Babbage is considered the "father of the computer” as he conceptualized and invented the first mechanical computer in the early 19th century.

Intel launched the first microprocessor chip in 1971, and a computer took up an entire room. In 1972, Murphy and Bird conducted 500 patient consultations via interactive television and Bird offered the first formal definition of telemedicine.

He refined his definition of telehealth to include, "the practice of medicine via interactive audiovideo communication system” in 1975. Fastforward to 2017 where three billion people carry smartphones in their pockets, each more powerful than that room-sized computer.

Telemedicine and telehealth are also more clearly defined. According to AAFP, telemedicine is the practice of medicine using technology to deliver care at a distance, over a telecommunications infrastructure, between a patient at an originating (spoke) site and a physician, or other practitioner licensed to practice medicine, at a distant (hub) site. Telehealth refers to a broad collection of electronic and telecommunications technologies and services that support at-a-distance healthcare delivery and services. Telehealth technologies and tactics support virtual medical, health and education services.1 mHealth, on the other hand, is known as mobile health and is form of telemedicine using wireless devices and cell phone technologies.2 Why is there such a need to change how we practice medicine?

According to projections by the Association of American Medical Colleges, the nation will be short more than 90,000 total physicians by 2020, and 130,000 physicians by 2025.3 Annals of Family Medicine projects that the United States will need 52,000 more primary care physicians by 2025.4 Access to specialist care can also prove challenging, as it is often limited to academic centers. Telemedicine can be leveraged to improve access to not only family physicians, but specialties, in particular, allergists.

With approximately only 3,000 active Allergists nationwide5, telemedicine offers the advantage to

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facilitate care coordination between specialties.

This is already an integral component of family physician visits, and soon to become more valuable as we see a change in payment model.

Today, 75 percent of health plans offer telemedicine service reimbursement, and according to the American Telemedicine Association, more than 15 million Americans

"

The top five urgent care conditions currently treated through telemedicine services include allergies, cough, upper respiratory infections, sinusitis, and rashes."

received some form of medical care remotely in the last year. However, telemedicine is not as simple as “skyping” with a patient. Web-side manner, physical examination, clinical decision making, documentation and care coordination need to be adapted for a video platform, in addition to supporting a HIPAA-compliant technology platform.

The top five urgent care conditions currently treated through telemedicine services include allergies, cough, upper respiratory infections, sinusitis, and rashes. The prevention, diagnosis, and treatment of allergic and immunologic conditions are everyday occurrences for the practicing family physician, whether it be the management of more benign conditions (e.g., allergic rhinitis) or severe and potentially lifethreatening conditions (e.g., anaphylaxis, status asthmaticus).6 Let’s discuss how telemedicine can be used to diagnose allergic rhinitis and improve care coordination with allergists.

Allergic rhinitis is the fifth most common chronic disease in the United States, and affects about one in six Americans.7 Allergic rhinitis also

accounts for as much as $2 to $4 billion in lost productivity annually, and an estimated 800,000 to two million lost school days.8 Although few studies exist on how to differentiate among types of rhinitis, a thorough and comprehensive history usually suggests the correct diagnosis.9 A focused physical examination should follow the history. Acute illness with a viral infection will cause more generalized symptoms and occasional fevers pointing towards the most common type of nonallergic rhinitis. Whereas, patients with chronic allergic symptoms may have allergic shiners (i.e., blue-gray or purple discoloration under the lower eyelids), or they may breathe through their mouths, both of which signs can be seen with high quality webcams.

Conjunctivitis, also seen via webcam, can be a component of allergic rhinitis or acute viral upper respiratory infection (URI). A careful examination of the nose is important to identify structural abnormalities, obvious polyps, mucosal swelling, and discharge. Examining the pharynx for enlarged tonsils or pharyngeal postnasal drip also can help identify viral causes or chronic drainage from chronic rhinitis.9 This can be addressed with the use of peripheral devices, that employ store and forward technology, typically from an originating site. Lymphadenopathy, which can be addressed by a physician directed physical exam, may suggest a viral or bacterial cause of rhinitis9, whereas, wheezing or eczema suggesting an

allergic cause, may be detected through webcam and peripheral devices. Aside from adapting for a telemedicine physical exam, the diagnosis of allergic rhinitis through history, as well as initiation of treatment using over the counter/ prescription medications, and counseling are similar to office based practice. Using real-time video consultations with a patient from their home can be tremendously valuable for allergy patients. Video enables the trained physician to see directly into the patientâ&#x20AC;&#x2122;s home to provide guidance on trigger avoidance, thereby helping to make a more accurate recommendation based on environmental context. It also enables a physician to interface directly with a patient during a time of need.

Family physicians should send patients for an in-person office visit, or refer patients to an Allergist when Immunoglobulin Eâ&#x20AC;&#x201C;specific skin or blood testing is recommended, first line treatment (e.g., environmental controls, allergen avoidance, medication) has been ineffective, a diagnosis of allergic rhinitis is uncertain, identification of a certain allergen could affect therapy, or to aid in titration of therapy.7 Other reasons to refer to an allergist include evaluation of primary immunodeficiency, interpretation of Immunocap (formally RAST testing) results, as well as difficult to treat asthmatics, initial workup for food allergy, management of urticaria and angioedema, and evaluation and management of atopic and

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The time for virtual visits is no longer the future of medicine; it is now."

contact dermatitis. Allergist referrals typically and historically take place in an office setting; however, average wait time to see an Allergist in the office is approximately three weeks. Allergists as well can utilize telemedicine for some appropriate visits. Not only does telemedicine promote longitudinal care coordination, but new technology such as three-way video conferencing, improves collaborative care allowing the patient visit to occur with the family physician and the specialist at the same time.

Aside from allergic rhinitis, telemedicine for chronic disease management of other allergic diseases is promising. Allergic asthma or extrinsic asthma is the most common form of asthma and it is defined as asthma caused by an allergic reaction. A recent Cochrane review concluded that current randomized evidence does not demonstrate important differences between face-to-face and remote asthma check-ups in terms of exacerbations, asthma control, or quality of life.10 A follow-up randomized controlled trial demonstrated that telemedicine was as effective as in person care for children with asthma.11 Additional telemedicine applications for patients with asthma include real time advice in a setting of perceived asthma exacerbation, proper inhaler technique, home environmental trigger assessment, medication management, and real-time video guidance with school nurses and teachers. Remote video visits will continue to expand in scope of practice as more store and forward technologies come on the horizon, from stethoscopes to interactive asthma pump device counters. Improved molecular diagnostics and interactive patient engagement apps will give physicians the additional tools they need to catch disease early and keep patients motivated and engaged in their healthcare.

Telemedicine can improve patient outcomes, not only through initiating timely medical visits 24

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for minor urgent care complaints, but also by monitoring chronic conditions more closely, and allowing greater time for counseling. Telemedicine does not only improve patient access to care with family physicians, but it also improves access to specialists and help with care coordination. The time for virtual visits is no longer the future of medicine; it is now.

References: 1. “Telehealth and Telemedicine.” AAFP. (1994) (July 2016 BOD). Retrieved from http://www. aafp.org/about/policies/all/telemedicine.html on 4/6/17 2. Americantelemed.org [Internet]. What is mHealth? Is it a type of telemedicine or something different? from americantelemed.org.

[Updated 2015: 04-15]. Available from: http:// www.americantelemed.org/about-telemedicine/ faqs#.VaT5d53D9mM 3. Gordon, Dani. “15 things to know about the physician shortage.” Becker’s Hospital Review.

Scott Becker. July 24,2014 http://www.beckershospitalreview.com/hospitalphysician-relationships/15-things-to-know-aboutthe-physician-shortage.html Assessed April 4, 2017 4. Ann Fam Med November/December 2012 vol.

10 no. 6 503-509 5. Adapted from 2012 A/I Workforce-Report.pdf 6. American Academy of Family Physicians Recommended Curriculum Guidelines for Family Medicine Residents Allergy and Immunology.

AAFP Reprint No. 274. Revised 6/2015 by Allegiance Health Family Medicine Residency Program, Jackson, MI 7. Am Fam Physician.2015 Nov 15;92(10):942944 8. Diedtra Henderson. (2015, February 3) New Guidelines for Allergic Rhinitis Released.

Medscape. Retrieved 4/4/17 from http://www. medscape.com/viewarticle/839130 9. Am Fam Physician.2006 May 1;73(9):15831590 10. Cochrane Database Syst Rev. 2016 Apr 18 11. Portnoy et Al Ann Allergy Asthma Immunol 117 (2016) 241e245

Technology Tools and Trends for Better Patient Care: Beyond the EHR

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rom remote monitoring of chronic diseases to virtual assistants in the exam room, technology will improve practice.

For many physicians, health information technology (IT) begins and ends with their electronic health record (EHR) system, a product that may not generate much satisfaction for them. The rocky road to EHR implementation may have colored some physicians' perceptions of health IT, but electronic tools are getting more intuitive and useful by the day. Encouraging developments in many sectors of health IT have the potential to expand the reach and capabilities of family physicians immediately and in the near future. This article highlights some health IT trends that promise to improve patient care now and in the near future.

Patient portals and patient-generated health data Medicare's meaningful use program and the new Quality Payment Program have helped drive the adoption of patient portals, but most practices are still learning how to optimize them.

When fully implemented as part of everyday workflows, patient portals can help practices serve and communicate with patients at any time, even outside regular office hours. Making information readily available through a portal or

secure messaging for patients and their families can promote adherence to treatment regimens and care planning.1 These capabilities can also help you keep revenue within your practice by avoiding penalties and earning incentives under Medicare and other value-based or direct primary care payment models. Portals also help motivated patients be more engaged in their care, which can give them more control over their medical conditions and reduce their longterm out-of-pocket costs.2,3 Most data currently flows from the practice to the patient portal, but as patients generate more of their own health data through such things as wearable devices or remote patient monitoring (more on these trends later), we expect to see them submitting that data to portals more often.

Telemedicine and telehealth Although telemedicine in its traditional form still exists, the acceptance and prevalence of virtual visits and e-consults are redefining the term and changing the face of the technology, which typically includes webcams (for synchronous visits), telehealth software, and sufficient Internet speeds. Outside of rural and undeveloped areas, virtual visits once were conducted solely between direct-to-consumer national telehealth service organizations dealing with conditions typically seen in an urgent care setting. That phase could

Steven E. Waldren, MD, MS Thomas Agresta, MD, MBI Theresa Wilkes, MS, CPHI, CHTS-PW Dr. Waldren is the director of the Alliance for eHealth Innovation at the American Academy of Family Physicians (AAFP).

Dr. Agresta is the section leader for informatics at the Connecticut Institute for Primary Care Innovation (CIPCI) in Hartford, Conn., and is a professor, the director of medical informatics in family medicine, and the director for clinical informatics at the Center for Quantitative Medicine at the University of Connecticut in Farmington.

Theresa Wilkes is the medical informatics strategist for the Alliance for eHealth Innovation at AAFP. continued on page 26 MO-AFP.ORG 25

continued from page 25

be labeled “telehealth 1.0.”4 Today, “telehealth 2.0” is well underway, with the volume of reported virtual visits increasing exponentially as greater numbers of payers and employers agree to cover telehealth services, diagnostic peripheral devices allow virtual physical exams for a wider number of presenting conditions, and more medical practices adopt telemedicine.5,6,7 Traditional practices are embracing telemedicine for a number of reasons, including the growth of value-based payment models that incentivize physicians to provide greater access to care and increasingly hold them accountable for cost and resource use. Practices that use the direct primary care model also see telemedicine as a way to improve patient outcomes while containing costs for both patients and themselves. Plus, giving patients the option of a virtual visit with their trusted family physician helps prevent them from turning to direct-toconsumer telehealth services, which can result in fractured care and lost revenue. Finally, telemedicine lets physicians make care more convenient for themselves and their patients.

Remote monitoring and patient-contributed data Technology is making it easier for physicians and other clinicians to monitor patients in their homes for a number of chronic diseases in a more routine and automated way. For example, practices can use remote monitoring to track patient weight for congestive heart failure, fasting glucose for diabetes, blood pressure for hypertension, and oxygen saturation for chronic obstructive pulmonary disease (COPD). Data can be incorporated directly into the patient portal and EHR so that it is available for use during 26

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2018

patient self-management, care management planning, or at the point of care. Converging and overlapping technologies are assisting this automation, such as the increased use of smartphones by patients. A recent Pew Research Center report indicated that nearly 75 percent of Americans own a smartphone, including more than 40 percent of those over the age of 64.8 Many smartphones can use software applications and Bluetooth or other wireless connections to automatically upload and securely store data from commercial grade medical devices including scales, glucometers, blood pressure cuffs, heart rate monitors, pulse oximeters, and others. For example, the Propeller is a sensor that attaches to an inhaler to electronically record and, through a mobile app, sends the physician data that can help treatment for asthma and COPD. AliveCor makes a fingertip sensor strip that patients can use to record an EKG and deliver results to their smartphone and their physician via a mobile app.

In the clinical setting, many commonly used EHRs and their connected patient portals can securely import these data from a smartphone or tablet, making them available to clinicians at any point in the process of care, such as for tracking the weights of a recently discharged patient with congestive heart failure or the fasting glucose levels of a patient with diabetes who is taking a new medication.9 It has long been an obstacle for this type of technology, but the user interfaces for these devices are getting better and more patientfriendly. Some commercial products can now display normal, abnormal, and critical results along with recommended actions, such as glucometers that advise patients when to

contact a physician in response to consistently low glucose readings. EHR vendors continue to upgrade their products to facilitate better data integration and display for physicians. EHRs are increasingly able to display large quantities of patient-generated data as graphics that highlight trends and out-of-range data in ways that are easy to understand and interpret. These systems also enable clinical decision support by filtering these data and alerting clinicians only when there are worrisome abnormal variations, which can reduce the clinical workload and let providers focus on the most important issues.

Secure messaging Direct exchange is a way of sending secure email using HIPAA-compliant standards that are now part of certified EHR technology (CEHRT).

In fact, you likely already have this capability in your EHR. It functions like regular email but is more secure and is recognizable by “@Direct” in the email address. It has become very popular in recent years with more than 1.4 million Direct exchange email addresses and users sending millions of messages each month.10 Direct exchange makes it easy for physicians to send messages securely to colleagues, health care organizations, and to patients. It also supports the sharing of patient data between EHR systems as well as health information exchanges, which ultimately improves the delivery of coordinated, collaborative care.

Opening up the EHR A key weakness of EHRs is that most are closed systems without the ability to readily exchange data or integrate with other external software.

But this is changing. Pressured by requirements of the Centers for Medicare & Medicaid Services' CEHRT program and newly authorized financial penalties against information blocking under the 21st Century Cures Act, vendors are being forced to make their products more open. Additionally, market forces are pushing vendors toward interoperability to compete against larger EHR competitors. As a result, physicians will no longer be completely dependent on their EHR vendors to provide them with the functionality they want. One CEHRT requirement is that vendors must provide within the EHR an open application-programming interface (API), a piece of technology that is a cornerstone of the modern internet. An API enables authorized third-party vendors to securely access the data within an EHR, which gives physicians the ability to connect external devices to their EHR, send data to applications that can apply evidence-based medicine, integrate

population management software, and export data to another EHR. API's also make it easier for physicians to receive patient-generated health data through apps like those discussed previously.

Machine learning The health care industry has not kept up with the cutting edge of information technology, but exploring advancements outside our industry does allow us to see the potential of these innovations for family medicine and primary care. If you have ever used Google or Facebook, then you have taken advantage of machine learning. In essence, machine learning is programming that lets the computer learn how to do something rather than simply follow a series of programmed commands to do something. This innovation has profound promise for healthcare given its complexity and scale. It is not feasible for programmers to code all of the requisite complexity of healthcare into the computer. Even if it were, they would have to revise the code every time we learned something new. With machine learning, a single computer, working with thousands of other computers in the online “cloud,” can continually review new data and adjust its understanding. We are seeing machine learning provide significant advancements in how computers recognize and understand human speech. This could potentially reduce the amount of data entry physicians must perform and help sift through voluminous amounts of patient data and evidence to quickly find information.

There are some specific subdomains of machine learning: Computer vision. Scientists and software engineers are working to train computers how to “see.”11,12 For example, they have created machine learning models that can “look” at a picture of a skin lesion and with a high degree of accuracy determine if the lesion is potentially malignant. There are also models that can interpret a retinal scan and identify diabetic retinopathy changes as accurately as an average ophthalmologist. The goal is for computers to be able to distinguish between normal and abnormal results in many arenas, which could potentially allow primary care physicians to perform a wider array of screening tests and do so at a lower cost.

Affective computing. One of the newest areas of machine learning, this involves developing models that allow a computer to recognize, interpret, and mimic human affect. The potential of affective computing for medicine is fascinating. Imagine if a computer playing an educational video to a patient could recognize when the patient became

continued on page 28 MO-AFP.ORG 27

continued from page 27

confused. It could then notify practice staff that the patient needed additional information around a specific topic or even offer its own alternative or additional education around that topic.

Virtual assistant. Technically this is not a subdomain of machine learning but rather an application of a number of machine learning models. You may have already interacted with a virtual assistant, such as Amazon's Alexa and Echo devices or the Google Assistant feature of Google Home. Imagine if you had such a device in the exam room linked to the EHR and a display screen on the wall. As you were conducting your office visit, you could ask the virtual assistant to display and trend the patient's latest hemoglobin A1C values. You would not have to redirect your attention from the patient to search for data in the chart. Just as Amazon's Alexa can order dog food from the grocery store, you could direct the virtual assistant to order a lab test or prescribe a new medication. The artificially intelligent virtual assistant could ease many administrative burdens faced today by physicians.

The “Internet of Things” Computers are becoming ubiquitous. Even refrigerators have computers that can connect to the internet. You can look into the refrigerator from your smartphone while at the grocery store to see if you need to buy milk. In healthcare, wearable devices like activity trackers have become mainstream. There are also instances of pill bottles that can track and report when the bottle was opened. All of these things are connected and communicating enormous amounts of data from their sensors. Computer applications can aggregate these data streams to extend the physician's reach beyond the walls of the clinic and provide a new set of capabilities to health IT. For example, physicians and nursing staff could use wearable devices that let the EHR know exactly where they are located.

The EHR can then recognize when the nurse or physician enters an exam room and log them in.

If the patient's smartphone is linked to the EHR, it could also know when the patient is in the room and open the chart. The EHR would also know how much time the physician or nurse spends with specific patients. These data can be used to personalize appointment lengths or support timebased billing.

The next big thing This article only begins to consider the innovations in health IT, and the rate of innovation is continuing to accelerate. Although it is easy to see how current technologies can improve the lives 28

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2018

of patients, physicians, and staff, the most exciting innovations have yet to see the light of day.

Source: Fam Pract Manag. 2017 Sep-Oct;24(5):28-32 References:

1. Robert Wood Johnson Foundation. Lessons Learned: The Value of Personal Health Records and Web Portals to Engage Consumers and Improve Quality. 2012. http://www.rwjf.org/content/dam/ farm/reports/issue_briefs/2012/rwjf400251.

Accessed August 2, 2017 2. Nagykaldi Z, Aspy CB, Chou A, Mold JW. Impact of wellness portal on the delivery of patientcentered preventive care. J Am Board Fam Med. 2012;25(2):158–167 3. James J. Health policy brief: patient engagement. Health Aff (Millwood). 2013;32(2):1– 6 4. Kosowsky J, Prewitt E. Q&A: How telehealth is just getting started. NEJM Catalyst website. http:// catalyst.nejm.org/qa-telehealth-technology-justgetting-started. October 24, 2016. Accessed July 18, 2017 5. Teladoc sets record with 100,000 visits during November. Teladoc website. http://bit.ly/2uFTPJl. December 6, 2016. Accessed July 18, 2017 6. Herman B. Virtual reality: more insurers are embracing telehealth. Mod Healthc.

2016;46(8):16–19 7. Japsen B. Most employers paying for doctor telemedicine visits. Forbes website. http://bit. ly/2wNzxv0. October 28, 2016. Accessed Aug. 15, 2017 8. Smith A. Record shares of Americans now own smartphones, have home broadband Pew Research Center website. http://www.pewresearch. org/fact-tank/2017/01/12/evolution-oftechnology. Published January 12, 2017. Accessed July 18, 2017 9. Kumar RB, Goren ND, Stark DE, Wall DP, Longhurst CA. Automated integration of continuous glucose monitor data in the electronic health record using consumer technology. J Am Med Inform Assoc. 2016;23(3):532–537 10. DirectTrust website. DirectTrust metrics 1st quarter 2017. http://bit.ly/2tnzIPP. Accessed July 18, 2017 11. Peng L, Gulshan V. Deep learning for detection of diabetic eye disease. Google Research Blog https://research.googleblog.com/2016/11/ deep-learning-for-detection-of-diabetic.html.

Published Nov. 29, 2016. Accessed July 18, 2017 12. Esteva A, Kuprel B, Novoa RA, et al.

Dermatologist-level classification of skin cancer with deep neural networks [published correction appears in Nature. 2017.] Nature.

2017;542(7639):115–118

Family medicine Summer cme Getaway: alaSka cruiSe

SponSored by iowa academy oF Family phySicianS in partnerShip with the miSSouri, nebraSka, and arizona chapterS

aboard the celebrity SolStice

July 13-20, 2018

Ship departS From Seattle, waShinGton

2018

THE ALASKAN CME CRUISE We are pleased to announce

that the Iowa, Missouri & Nebraska AAFP Chapters have joined together to offer you a breathtaking, unique, and memorable vacation cruise to Alaska! Join us as we depart from Seattle and explore various ports in Alaska and Canada aboard the beautiful Celebrity Solstice for a week full of relaxation, fun, and CME. Ship Departs from Seattle, Washington with stops at ports in: KetchiKan tracy arm FjorD juneau

1 2 3 4 inSiDe paSSage/ SKagWay 5 Victoria, BritiSh columBia

each cabin oceanview category and above will have the choice of 1 complimentary perk for 1st and 2nd guest only: o $150 per person onboard credit o Prepaid gratuities o Classic beverage package (includes alcoholic beverages up to $9, and soda package) o Unlimited internet Please note: 3rd & 4th guests will automatically receive the classic soda package and 40 internet minutes

ADDITIoNAL INFoRMATIoN:

delivered by your colleagues. CME will be scheduled for the mornings we are at sea. Details and programming will be updated on the website as we finalize topics/speakers

• Gratuities are $94.50 per person for all categories except suites which are $98 per person.

• Travel Protection is available through Celebrity for $159 per person payable with final payment.

CRUISE REgISTRATIoN: (all fees are per person)

CRUISE DEpoSIT/ pAyMENT SCHEDULE:

CME: You will have the opportunity to participate in 12 to 15 credits of CME

There are limited cabins available in the categories below.

rates are cruiSe only 1st & 2nd guest. 3rd & 4th guest current rate at time of booking per celebrity tBD. airfare is not incluDeD.

o A1-Aqua Class $2711.30 o C2-Concierge Class $2561.30 o 1C- Deluxe Oceanview w/Verandah $2361.30 o 2A- Deluxe Oceanview w/Verandah $2341.30 o 2B- Deluxe Oceanview w/Verandah $2301.30 o S2- Sky Suite $3811.30 o 9- Inside Stateroom $1581.30

• Deposit is $500 per cabin and $1000 per suite due upon registration.

• Final Payment is due by April 13, 2018

CRUISE CANCELLATIoN/ATTRITIoN:

• From 89-57 days prior to sailing the cancellation penalty is $250.00 per person.

• From 56-29 days prior to sailing the cancellation penalty is 50% per person.

• From 28-15 days prior to sailing the cancellation penalty is 75% per person.

• From 14-0 days prior to sailing there is no refund.

To RESERVE A CABIN:

please visit our website at

www.iaafp.org/alaska

You must register for the CME portion of the cruise separately this can be done by going to www.iaafp.org/alaska under the education tab.

Another Successful AFC in the Books

T

he 25th Annual Fall Conference was a hit this year with over 200 attendees and 32 exhibit tables.

Friday held sessions on opioids, autism, hypertension, hepatitis c, and bipolar disease. Students and residents met that afternoon for a special session focusing on the newly implemented Transition to Practice conference which debuted last year. Students and residents gave input and ideas on how to make the conference more engaging and identified ways to increase attendance. They ended the meeting with a little fun by bowling at Fun Mountain, a new adventure complex geared toward families at Big Cedar Lodge. Friday evening, MAFP held a wine, beef, and cheese pairing event, hosted by Missouri Wine and Grape Board, and sponsored by Midwest Dairy Council and Missouri Beef Industry Council. Saturday kicked off with sessions on sports concussions, rheumatoid arthritis, angioedema, an informative session on MACRA/MIPs, PDMP discussions, vitamin d levels and skin biopsies. Sunday held the KSA: Childhood Diseases, hosted by Jim Stevermer, MD and Sarah Swofford, MD. Mitchell Edwards, PGY2, St. Louis University, took the time to write an article on his reflections of the conference.

Student Input

Mitchell Edwards, PGY2, St. Louis University

30

This November, 14 medical students from Saint Louis University (SLU) School of Medicine, ranging from their first to their final year of studies, were granted the opportunity to attend the MAFP’s 25th Annual Fall Conference in the Branson area.

MAFP President, Dr. Mark Schabbing, remarked how encouraged he was that this year’s meeting had the greatest number of medical students he’d ever seen at the Annual Fall Conference. Earlier in the year, the MAFP issued an open invitation to sponsor medical students and family medicine residents from Missouri to attend the conference and stay at Big Cedar Lodge. A group of SLU students thought that this would be a wonderful opportunity to further explore an interest in family medicine while taking in the natural beauty of the Ozarks. Following the conference, the SLU crew reflected on their experience and had many positive comments to share.

Many students felt that we gained the most from networking at the conference. Fourth year student and MAFP Student Director, John Heafner, stated, “The conference provided wonderful opportunities

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2018

for networking with physicians across the state of Missouri as well as exhibitors from hospitals, pharmaceutical companies, and loan forgiveness programs.” On networking at a working group meeting featuring SLU students and FM residents, mainly from the Cox Family Medicine Residency, M3, Julie Friend, commented, “I very much enjoyed getting to talk with current residents at programs throughout Missouri to hear what they had to say about family medicine and their residency program.” At the working group meeting, organized

by MAFP Executive Director, Kathy Pabst, residents and students also discussed the role that they will have in future MAFP meetings, and the possibility of a joint meeting focusing solely on Missouri FM residents and medical students dedicated to pursuing FM. Students and residents got to know each other better after the meeting as they bowled at the aquatic-themed lanes at Big Cedar Lodge’s Fun Mountain.

Other students most enjoyed the plenary sessions. As pre-clinical students generally spend more time learning from books than from patients, M2, Erin Lindsey, mused, “It was refreshing

to get a chance to learn from a clinicallyoriented perspective; sometimes we spend so much time studying physiology and mechanisms that it’s easy to forget about the human side of medicine.”

A crowd favorite was Dr. Kirk Moberg’s “Opioid Prescribing: Safe Practice, Changing Lives”, where delegates learned of practical guidelines for prescribing opioids and monitoring these patients in the outpatient setting to better address the opioid epidemic.

The opportunity to participate in the MAFP’s legislative effort during the MAFP board meeting was a valuable experience for SLU third year student and MAFP Alternate Student Director, Mimi Liu. Her comments were as follows: “Being able to see how MAFP advocates for primary care and family physicians was definitely a new and unique experience. We discussed the legislative agenda for this year’s session, and talked about positions that the MAFP would stand on for certain issues, from APRN scope of practice to medical marijuana. Being interested in advocacy, but having had no prior experience with it, I found the legislative process fascinating and more complex than I previously imagined. I would encourage any student who is interested in healthcare policy to try and get elected to the board.”

For many in our group, the conference ignited or further fuelled a passion for family medicine. Some students arrived without a clue of what they will specialize in while others were already dedicated to a career in family practice. Third year student, Betsy Schuele, noted, “It was very interesting to learn about how many different paths a family medicine doctor can take in residency and afterwards.”

Expanding on the breadth of family medicine as a specialty, M2, Andrew Ngo, wrote, “The conference reminded me of why I was so interested in family medicine in the first place.” He went on to say, “Family medicine [appears to be] a very challenging, but rewarding field, as family physicians must possess a large body of knowledge and be prepared to utilize that knowledge appropriately to help patients with whatever health concerns they have.”

Beyond all that we gained from the conference itself, being immersed in the breathtaking sights of the Branson area was such a pleasure. Students went to the nearby attraction, ‘Top of the Rock’, an Ozark peak equipped with three restaurants, a wine and whiskey cellar, a wedding chapel, and a golf course, all overlooking panoramic views of Table Rock Lake. On the Friday evening of the conference, the sunset, awash with pink, violet, gold, and red hues, was a humbling sight as we watched in awe as the sun passed slowly below the horizon.

Overall, we all had an amazing time at the MAFP Annual Conference. On behalf of the group coming from SLU, we would like to thank the MAFP for sponsoring us to attend and we look forward to sending more SLU students, hopefully together alongside students and residents from many other sites in Missouri, to pursue a passion for family medicine at future meetings.

THANK YOU TO OUR SPONSORS Annenberg Center for Health Sciences California Academy of Family Physicians Circassia Pharmaceuticals Direct Primary Care Clinics, LLC. Integrity Continuing Education Midwest Dairy Council Missouri Beef Industry Council Missouri Wine and Grape Board PeerView Network SSM Health Stanley's Pharmacy St. Louis University

circassia.com MO-AFP.ORG 31

MEMBERS the

IN NEWS NEWS TO SHARE?

Family Medicine Physicians Receive Endowments

The Missouri Family Physician magazine welcomes your input.

Please submit newsworthy items for review to: office@mo-afp.org

"

L-R: Richelle Koopman, MD, MS; Erika Ringdahl, MD; Debra Parker Oliver, PhD, MSW; and Steven Zweig, MD, MSPH.

The MU Department of Family and Community Medicine celebrated the naming of three endowed professors with a ceremony on Nov. 8. The newly endowed professors include: • Richelle Koopman, MD, MS, Jack M. and Winifred S. Colwill Professor • Debra Parker Oliver, PhD, MSW, Paul Revare, MD, Family Professor of Family Medicine • Erika Ringdahl, MD, William C. Allen, MD, Professor

“Being named an endowed professor truly is an achievement. Naming three professors at the same time is a first for our department and speaks to the talent we have in family medicine.”

- Steven Zweig, MD, MSPH Koopman received a medical degree from the University of Pittsburgh School of Medicine and completed residency training at the University of Pittsburgh Medical Center-St. Margaret Memorial Hospital. She joined the MU Family and Community Medicine faculty in 2007.

Parker Oliver received a master's degree in social work and a doctorate in medical sociology at MU. She joined the MU Family and Community Medicine faculty in 2007.

Ringdahl received a medical degree from the University of Iowa College of Medicine, Iowa City, and completed residency training at MU. She joined the MU Family and Community Medicine faculty in 1994.

Mourad in Leadership at Swope Health Services

ssmhealthcareers.com

32

Dr. Wael Mourad was named Associate Chief Medical Officer at Swope Health Services. Mourad ensures that SHS clinics are in compliance with all Missouri, Kansas and federal clinical policies, regulations and performance standards. In addition to his administrative duties, he also provides direct patient care.

Previously, Dr. Mourad was Medical Director of the Continuing Medical Education (CME) Division of the American Academy of Family Physicians.

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2018

Mourad

NOTE: The below composite has been reprinted as the result of an error in the previous issue.

2017-2020 2017-2018 RESEARCH FAMILY MEDICINE RESIDENCY RESEARCH FAMILY MEDICINE RESIDENCY PROGRAM PROGRAM KANSASMISSOURI CITY, MISSOURI KANSAS CITY, 2017-2018 R3 CHIEF RESIDENTS

CLASS OF 2018

R Dianne Elledge, DO

Anna Hanson, MD

Robert Kreikemeier, DO

Faisal Ali, MD

Nathan Boehr, DO

Christopher Chappell, DO

Ed Christiansen, MD

Christopher Fotopoulos, DO

Georgina Green, MD

Joanita Idicula, MD

Kendall Johnson, DO

Tommel Samani, MD

2017-2018 R

Dianne Elledge, DO

Ha

CLASS OF 2019

Priscilla Borden, MD

Gaurav Chaturvedi, MD, PhD

Sourab Chopra, MD

Gewel de los Santos, MD

Manveer Flora, MD

Brittney Frisby, MD

Joseph Meier, MD

Will Patton, DO

Varsha Pawate, MD

Hazen Short, MD

Maureen Weber, MD

Max Zollicker, MD

Ed Christiansen, MD

Ch Foto

Priscilla Borden, MD

Chat

Joseph Meier, MD

Pa

CLASS 2020

Rachel Allen, MD

Daniel Haire, DO

Emily Hansen, DO

Christine Khong, MD

Rachel McDonald, MD

Sean Rutschke, DO

Sabrina Sahadevan, MD

Joseph Sayegh, MD

Ben Saylor, DO

Kayt Schlepphorst, MD

Rhiannon Talbot, DO

Chelsea Willis, DO

Rachel Allen, MD MO-AFP.ORG 33

H

HDAs HelpDesk Answers

Low-Carbohydrate Diet or Low-Fat Diet; Which is Better for Weight Loss?

EVIDENCE-BASED ANSWER

Patients on very-low-carbohydrate ketogenic diets (<60 g/d carbohydrates or <10% of calories) achieve about 1 to 2 kg more weight loss over 6 to 12 months compared with patients on low-fat diets. Less carbohydrate restriction (<225 g/d or <45% of calories) is not consistently better than a low-fat diet (SOR: A, meta-analyses of RCTs).

Kristen Killen, MD Amanda Allmon, MD University of MissouriColumbia, School of Medicine Columbia, MO

34

A

EVIDENCE SUMMARY

2013 systematic review and meta-analysis of 13 RCTs (N=1,415) compared weight loss in patients assigned to very low-carbohydrate ketogenic diets (<50 g/d carbohydrates or 10% of daily energy from carbohydrates) or low-fat diets (low calorie with <30% calories each day from fats) over at least a 12-month period.¹ Included RCTs enrolled patients older than age 18 with mean body mass index of more than 27.5 kg/m². Studies were excluded if they involved pharmacological interventions or were duplicate publications of other included trials.

In 13 trials (12–24 months’ duration), weight loss in the ketogenic diet group (n=712) ranged from 0 to 13 kg and in the low-fat diet group (n=703) ranged from 0.2 to 12 kg. The ketogenic diet group had more mean weight loss than the low-fat diet group (weighted mean difference [WMD] –0.91 kg; 95% CI, –1.7 to –0.17). Limitations included high dropout rate (4 of 13 trials with >50% dropout rates) and poor adherence to prescribed carbohydrate restriction.¹ A 2012 systematic review and meta-analysis of 23 RCTs (N=2,788) compared the effects of lowcarbohydrate diets (<45% calories from carbohydrates or <225 g/d carbohydrates) versus low-fat diets (<30% calories from fat) on weight loss in overweight and obese adults.² This meta-analysis included 11 RCTs from the meta-analysis above, but also included trials with less carbohydrate restriction and trials of shorter duration (≥6 months). Exclusion criteria included nonrandom treatment allocation, no difference in carbohydrate or fat intake between the groups, or differences in other macronutrient and energy intake between the groups. After diet intervention for an average of 12.6 months, weight loss in the low-carbohydrate group (n=1,392) was 6.1 kg compared with a weight loss of 5.0 kg in the low-fat group (n=1,396), a nonsignificant difference (23 trials, n=2,788; WMD 1.0 kg; 95% CI, –0.2 to 2.2). After adjustment for possible publication bias, the difference became significant, favoring the low-carbohydrate diet group (WMD 3.2 kg; 95% CI, 2.0–4.5).²

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2018

In a subgroup analysis of 21 trials (n=not reported), patients in a highly restricted low-carbohydrate group (<60 g/d carbohydrates) had greater weight loss than patients on a low-fat diet (WMD 2.0 kg; 95% CI, 0.6−3.4). In 15 trials (n=not reported), patients with low-carbohydrate diet adherence for more than 1 year had more weight loss than patients on a low-fat diet (WMD 0.9 kg; 95% CI, 0.3−1.6). Limitations included unclear trial quality, heterogeneity of included trials, and publication bias.² 1. Bueno NB, de Melo IS, de Oliveira SL, da Rocha AT. Verylow-carbohydrate ketogenic diet v. lowfat diet for long-term weight loss: a meta-analysis of randomised controlled trials.

Br J Nutr. 2013; 110(7):1178–1187. [STEP 1] 2. Hu T, Mills KT, Yao L, Demanelis K, Eloustaz M, Yancy WS Jr, et al. Effects of low-carbohydrate diets versus low-fat diets on metabolic risk factors: a meta-analysis of randomized controlled clinical trials. Am J Epidemiol. 2012; 176 (suppl7):S44–S54. [STEP 1]

Interested in more HelpDesk Answers?

Get the answers to your clinical questions with a complementary 3 month electronic subscription to

Evidence-Based Practice!

To sign up for your free 3 month subscription, visit www.fpin.org/comp-ebp.

Friday, March 2, 2018 2018 Opioid Summit

Aim for Excellence Conference Register Now:

https://www.mhanet.com/seminars/registration.aspx?ID=D04439 This Opioid Summit is for providers that need evidence-based guidance for treatment of pain, opioid use disorder, community-based services and policy solutions.

MAFP is a co-sponsor of this summit.

Keynote Speakers: Developing a Statewide, Hospital-based Program

Traci C. Green, Ph.D., MSC Deputy Director, Boston Medical Center Injury Prevention Center Associate Professor, Boston University School of Medicine and The Warren Alpert School of Medicine of Brown University Providence, R.I.

America’s Fentanyl Crisis: A National Perspective with Notes for the Field Jon E. Zibbell, Ph.D. Senior Health Scientist RTI International Atlanta, GA

A “Medication First” Model of OUD Treatment and the Opioid STR Grant Ned Presnall, MSW, LCSW Executive Director of Clayton Behavioral Adjunct Professor and research collaborator at Washington University in St. Louis Consultant for Missouri's State Targeted Response to the Opioid Epidemic St. Louis, MO

The Face of Recovery

Tessalean Woods Engagement Specialist/CSS Queen of Peace Center St. Louis, MO

Break sponsored by:

dpcareclinics.com

slu.edu/medicine MO-AFP.ORG 35

YOUR specialty.

YOUR community.

YOUR interest group.

Get involved with an AAFP member interest group (MIG) to: • Develop leadership skills • Join forces with peers who share common interests • Share ideas and influence AAFP policy • Encourage others to advocate for family medicine Each specialized group offers an online community to connect and exchange ideas, and you can choose from nearly 20 MIG topics.

Find your family within family medicine.

Join an AAFP member interest group.

aafp.org/mig