Chesapeake Physician May/June 2015 Issue

CHESAPEAKE

Physician YOUR PRACTICE. YOUR LIFE.

FORGING A NEW TRAIL: FOUR WOMEN WHO CREATED NEW PATHS IN HEALTHCARE WOMEN'S HEALTH ROUNDUP MOVING TOWARDS INTEROPERABILITY PEDIATRIC UPDATE ON SPLINTING AND CONCUSSIONS

chesphysician.com VOLUME 5: ISSUE 3 MAY/JUNE 2015

Maryland/DC/Virginia

Contents 12

VOLUME 5: ISSUE 3 MAY/JUNE 2015

F E AT U R E S

12 Forging a New Trail: Four Women Who Created

New Paths in Healthcare 18 Rethinking Proper Splinting and Concussion Treatment 22 Women’s Health Roundup D E PA R T M E N T S

Cases

| 7 | Genetic Testing for Ovarian Cancer

Solutions

| 8 | Temporary Agencies Can Solve the Challenges of Staffing Medical Offices

Compliance HIT

| 21 | Physician Practices Should Brace for HIPAA Compliance Audits

| 24 | Moving Toward Interoperability

Policy

| 28 | The Third and Final Stage of Meaningful Use

Our Bay

| 30 | Celebration of the Chesapeake Bay

On the Cover: Thu Tran, MD, an OB/GYN at Capital Women’s Care in Fulton, Md.

CHESAPEAKE

Physician YOUR PRACTICE. YOUR LIFE.

“Every great dream begins with a dreamer. Always remember, you have within you the strength, the patience, and the passion to reach for the stars to change the world.” –HARRIET TUBMAN The May/June issue is my personal favorite of each respective year. Not only because it celebrates the anniversary of the launch of what has grown to become Chesapeake Physician – Your practice. Your life. (launched May 2011 as Maryland Physician Magazine – Your practice. Your life.), but also because each May/June issue celebrates women in healthcare who are driven by passion for their individual experience in healthcare. Some of them impact thousands (if not more) of lives, some hundreds, and each has blazed her own trail of success (see page 12). Many of you have been loyal readers and advocates for this publication, print and digital, since our launch in 2011. Some of you are new to us. Welcome! We’re celebrating exciting and explosive growth via data we review and track. As this issue goes to bed, our online readership has exploded to 20,000, increasing daily, along with print copies mailed to over 13,000 physicians and healthcare providers throughout our market. What’s driving our readership growth is the collective passion of the members of my team, contributing writers and our subject matter experts. All have supported the mission I created in February 2011 when I conceptualized this platform: to build a network of physicians and healthcare stakeholders committed to delivering the highest level of quality and efficient patient care. That mission statement has grown outside of the initial Maryland geographic boundaries to include DC and NOVA. Our data supports that we are indeed getting that done and now beyond those boundaries including online readers as far as California, Britain, Israel and Korea. My team and I are constantly planning, iterating and delivering content with both form and substance, collaborating with regional healthcare providers and subject matter experts so that our content can stay relevant and of value for our readers. Collaboration is also the foundation of interoperability. In care delivery, as in business, physicians are constantly challenged by having to rely upon others to get the information they need to deliver the results they intend. In healthcare, that goal is efficient, quality patient care. Creating IT systems that can share the right data at the right time, in a way that doesn’t overwhelm providers with irrelevant information, will help to achieve that goal. We spoke with several experts to learn how disparate systems can better communicate, and what the hurdles still are. A new Alliance formed by some of the biggest EHR vendors is among the attempts to make interoperability more of a reality. Both our Healthcare IT (see page 24) and Policy (page 28) articles underscore the potential for sharing patient data in the care continuum to drive better and lower cost care. As with all change, it’s not always easy but there’s often a positive outcome. To life!

Jacquie Cohen Roth Founder/Publisher/Executive Editor jroth@chesphysician.com @chesphysician 4 | CHESPHYSICIAN.COM

If you would prefer to read Chesapeake Physician online instead of print, please email jroth@chesphysician.com or tweet @chesphysician

Maryland/DC/Virginia www.chesphysician.com

JACQUIE COHEN ROTH FOUNDER/PUBLISHER/EXECUTIVE EDITOR jroth@chesphysician.com LINDA HARDER, MANAGING EDITOR lharder@chesphysician.com PRODUCTION MANAGER Stefanie L. Jenkins sjenkins@mojomedia.biz MANAGER SOCIAL & DIGITAL MEDIA Jackie Kinsella jkinsella@mojomedia.biz CONTRIBUTING WRITER Anne K. Sessions COPY EDITOR Ellen Kinsella BUSINESS DEVELOPMENT Pat Klug pklug@mojomedia.biz PHOTOGRAPHY Tracey Brown, Papercamera Photography

Chesapeake Physician – Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC, a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 949 Annapolis, MD 21404 443.837.6948 mojomedia.biz Subscription information: Chesapeake Physician is mailed free to licensed and practicing physicians and a select group of healthcare executives and stakeholders in throughout Maryland, Northern Virginia and Washington, DC. Subscriptions are available for the annual cost of $52. To be added to the circulation list, call 443.837.6948. Reprints: Reproduction of any content is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443.837.6948 or email jkinsella@ mojomedia.biz. Chesapeake Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Chesapeake Physician. Advisory Board members include: PATRICIA CZAPP, MD Anne Arundel Medical Center HOLLY DAHLMAN, MD Green Spring Internal Medicine, LLC MICHAEL EPSTEIN, MD Digestive Disorders Associates STACY D. FISHER, MD University of Maryland Medical Center DANILO ESPINOLA, MD Advanced Radiology GENE RANSOM, JD, CEO Maryland Medical Society (MedChi) CHRISTOPHER L. RUNZ, DO Shore Health Comprehensive Urology VINAY SATWAH, DO, FACOI Center for Vascular Medicine THU TRAN, MD, FACOG Capital Women’s Care Although every precaution is taken to ensure accuracy of published materials, Chesapeake Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources. Printed on FSC certified, 100% PCW, chlorine-free paper

CASES

Genetic Testing for Ovarian Cancer By Albert Steren, MD

CASE: Julia is a 49-year-old woman with a significant family history of gynecologic and breast cancer. Julia’s mother was diagnosed with epithelial ovarian cancer at age 52 and died of complications of treatment only six months after her cancer diagnosis. Julia’s maternal aunt (her mother’s younger sister) was diagnosed with breast cancer at age 35. She did very well with treatment only to have a new breast cancer diagnosis in the contralateral breast 10 years later at age 45. Because of this family history, Julia was placed on an intensive screening protocol by her physician, with ultrasound every six months and CA-125 blood tests. Her test results were always normal. In spite of this screening, Julia presented to her primary care physician with abdominal distention and bloating. A CT scan of the abdomen and pelvis demonstrated ascites and peritoneal implants. Subsequent exploration and staging demonstrated a Stage-3C serous cancer of the ovary. Genetic testing demonstrated a mutation in the BRCA 1 gene.

DISCUSSION: In spite of advances in blood biomarker technology, no test or combination of tests has demonstrated efficacy in screening for ovarian cancer. However, our ability to screen for patients at risk for an inherited gynecologic cancer continues to improve. The hallmarks of hereditary cancer syndromes include multiple affected family members, early age of onset, and the presence of multiple and/or bilateral primary cancers. It is now possible to identify some of the genetic alterations that predispose individuals to inherited breast and gynecologic cancers. Women with mutations in the BRCA 1 cancersusceptibility gene associated with Hereditary Breast and Ovarian Cancer (HBOC) have a 65-85% risk for breast cancer and a 39-46% risk for ovarian, fallopian tube or peritoneal cancer by age 70. The present recommendation is that all women with these gynecologic cancers should receive genetic counseling and be offered genetic testing, even in the absence of a family history. This enables physicians to provide individualized assessment of cancer risk, as well as options for tailored screening and prevention strategies that may reduce morbidity. Strategies that have demonstrated improved outcomes in patients at inherited risk include breast screening with MRI, risk-reducing prophylactic surgery and chemoprevention (oral contraceptives for ovarian cancer risk). It is estimated that only 24% of newly diagnosed women with ovarian carcinoma in the United States received genetic testing for BRCA 1 and BRCA 2 mutations, despite current National Comprehensive Cancer Network (NCCN) guidelines recommending genetic counseling and testing be offered to all women with this disease. Only a small minority of women with an

inherited predisposition has been identified. Research has shown that women with an inherited mutation who have fallopian tubes and ovaries removed reduce their risk of ovarian cancer by over 90%, and also reduce their cancer-related and overall mortality. In addition, BRCA 1- and BRCA 2-related ovarian cancer are associated with improved survival, improved responses to platinum-based chemotherapy and novel therapeutics such as PARP inhibitors (a group of pharmacological inhibitors of the enzyme poly ADP ribose polymerase). Because of the direct impact on the care of the patient, as well as the value of preventing cancer in family members, all women with epithelial ovarian cancer should receive genetic counseling and be offered genetic testing regardless of age or family history. In light of the increasing complexity of available genetic tests, and because the significance of positive results is not always clear and negative results may be falsely reassuring, it is recommended that patients begin with genetic counseling to determine appropriate testing options. Experts should interpret results and recommend treatment planning, ideally as part of a multidisciplinary team of providers. Genetic testing for cancer predisposition requires informed consent that should include pre-test education and counseling concerning the risks, benefits and limitations of testing, including the implications of both positive and negative genetic test results. Referral at diagnosis allows using genetic information in treatment planning, e.g., bilateral mastectomy or clinical trials with PARP inhibitors. Albert Steren, MD, is a gynecologic oncologist at Women’s Health Specialists of Montgomery County, Md. He can be reached at asteren@aol.com.

MAY/JUNE 2015

SOLUTIONS

Temporary Agencies Can Solve the Challenges of Staffing Medical Offices By Wanda Smith

T’S 7:30 A.M. AND YOU HAVE received a call from your front desk employee, who has strep throat. Your medical assistant is 81⁄2 months pregnant, and may deliver her baby at any time. You are holding your breath until she walks in the door. Your practice manager has several appointments today and is facing a deadline to send out the credentialing information. What do you do? Who is going to answer your phones and assist the physician? This scenario is a problem faced by small and large practices each day in every city across the United States. There simply are too many patients and not enough staff to assist the provider with the more than 30 patients he or she must see on a typical day. With all of the cuts in reimbursement, budgets are tight. Providers today are staffing their offices trim and lean; so lean in fact that most offices do not have back-up employees to fill in when a position is vacant due to any type of absenteeism. Temporary Staffing Offers a Solution

What’s the solution? Savvy physicians and their practice managers have learned that they can call a temporary staffing agency specializing in flexible staffing for medical practices. Whether you need a front desk employee, a certified/ registered medical assistant, or a credentialing specialist, such staffing agencies often can send an experienced person to your office within a few hours. Physician practices ideally should not wait until the day they are in panic mode to identify a temporary staffing firm, learn about their services and put their number on speed dial. Having an advance relationship with a qualified company allows you to get the fastest 8|

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response to your urgent need for the right person to fill any given position. Temporary Staffing Facts

Flexible staffing companies have over 3 million individuals supporting healthcare practices throughout the US every day. Virtually every occupation has a place in today’s staffing workforce, including physicians, dentists, nurses, hygienists, medical technicians, therapists, home health aides and custodial care workers. Individuals choose to become temporary staffers to give them flexibility to manage their home life and schedules. Individuals use temporary assignments as a way of looking for a permanent position. Many employers have begun to realize how cost effective it is to staff their facilities with temporary staff. A staffing company will charge you a flat rate per hour, and the client only pays for the hours worked, not for sick days, holidays or lunch times. With temporary staff, employers also do not have to worry about paying for other benefits, such as workers’ compensation, insurance, federal and state unemployment, Medicare, Social Security, or medical insurance. For example, if a permanent employee makes $14 an hour, employers typically incur an hourly cost of $17.95 or more, depending on the benefits they offer. Some physicians in solo practice have chosen not to hire any permanent employees; instead, they use a temporary staffing company to staff their offices on an ongoing basis. Over the last few years, the Centers for Disease Control and Prevention

(CDC) has increased the requirements for medical assistants, adding to the difficulty in finding qualified certified or registered medical assistants.

Today more than ever, temporary-to-directhire is an excellent vehicle for employers to find the perfect fit for a new team member. Credentialing personnel, surgical posters and medical billers that are specialized and experienced in billing Medicare and Medicaid, to name just a few, also are increasingly difficult to source. Today more than ever, temporaryto-direct-hire is an excellent vehicle for employers to find the perfect fit for a new team member. Hiring a temporary worker allows you to try out that person before hiring them permanently. This trial period enables the client to gauge skills, attitude, punctuality, attendance and whether they are a good fit for the culture of the office. The next time you need to replace staff, consider reaching out to a qualified staffing company. Allow them to send you a capable, experienced candidate who has had a background check, has been drug tested and has had a skills evaluation. Wanda Smith is President/CEO/Founder of Symphony Placements, a flexible staffing and human resource solutions company specializing in staffing the front and back of a provider’s office. She can be reached at wsmith@symphonyplacements.com.

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MAY/JUNE 2015

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SPONSORED CONTENT

Setting the Course for the Future of GYN Robotic Surgery By Lisa Schwartz

ITH HEALTHCARE technology continuing to rapidly evolve, what is advanced today can easily become obsolete in several years. Take robotic surgery, for example. Emerging in the marketplace a decade ago, robotic surgery appears to be on the fast track to becoming the gold standard in a variety of medical disciplines, including gynecologic oncology. Dwight D. Im, MD, director of The Gynecologic Oncology Center at Mercy Medical Center in Baltimore, is one of the nationâ&#x20AC;&#x2122;s foremost gynecologic robotic surgeons, and is on the cutting edge of this burgeoning technology. Dr. Im, who began using the daVinci robot for surgery in 2009, has since performed more GYN robotic surgeries than any other surgeon in the nation. Dr. Imâ&#x20AC;&#x2122;s experience in robotic, as well as laparoscopic and traditional open surgery, gives him a unique perspective into the advantages of robotic surgery for both doctors and patients.

Dwight D. Im, MD, director of The Gynecologic Oncology Center at Mercy Medical Center in Baltimore

Dr. Im, who considers himself a gynecologic oncologist who utilizes a variety of surgical approaches to treat his patients, created Mercy Medical Center’s National Institute of Robotic Surgery, where he trains physicians in GYN and general robotic surgery. He says, “We are essentially training the future generations of GYN surgeons who will almost exclusively be utilizing robotic surgery versus conventional laparoscopic procedures in the next 10 years or so.” “IMSWAY” – A Surgical Roadmap for Robotic GYN Surgery As a result of his vision to bring the best robotic surgical techniques to his GYN patients at Mercy, Dr. Im has developed a roadmap of sorts – a step-by-step approach to performing robotic GYN surgery that can be utilized as a standard method by all surgeons. He calls his approach “IMSWAY” (an acronym for the procedure, which involves entering the retroperitoneal space using the infundibulopelvic ligament; the medial leaf of the peritoneum; skeletonization of the ureter, water under the bridge, arriving at the origin of the uterine artery.) Dr. Im instructs surgeons from around the globe utilizing this approach, which teaches surgeons how to perform robotic surgery, specifically robotic hysterectomy, with proficiency. “It comes down to learning the pelvic anatomy,” he says. He has trained more than 1,000 physicians in GYN robotic surgery. IMSWAY uses the robot as a tool to enter the retroperitoneal space and to guide the surgeon to identify vital

The result is a shorter surgery, better visualization utilizing the robotic tool and less bleeding for patients. Ultimately, Dr. Im hopes that IMSWAY will become the standard surgical approach for performing hysterectomies. A Decade of Growth in Robotic Surgery Over the past decade, the surgical arena has seen vast improvement in robotic surgical technology. Dr. Im recalls that when the robotic surgical system was introduced in 2005, it could be cumbersome for surgeons to use. With new models of the daVinci Surgical System introduced over the past five years, however, Dr. Im notes that the technology is quickly evolving. And, with newer robotic technology comes more innovation in surgical techniques. In fact, Dr. Im has paved the way for a number of GYN surgical innovations including Single Site Hysterectomy, which only requires a small, single port of entry through the patient’s navel, resulting in less bleeding, little or no scarring, and quicker recovery. He says that the ability to perform complex surgery through a small, single incision is what differentiates robotic GYN surgery from traditional laparoscopic surgery. Advantages of GYN Robotic Surgery for Patients and Surgeons Today, any intra-abdominal GYN surgery, except when very advanced, widely metastatic ovarian cancer is involved, can be performed using the robotic approach. Robotic GYN surgery is commonly used to treat such conditions as fibroids and abnormal uterine bleeding, as well as uterine,

“We are essentially training the future generations of GYN oncology surgeons who will almost exclusively be utilizing robotic surgery versus conventional laparoscopic procedures in the next 10 years or so.”—Dwight Im, MD organs, blood vessels and small, delicate structures, which surgeons often have trouble viewing with the naked eye. IMSWAY helps surgeons reach the surgical site and remove the affected area without injuring the vital organs or surrounding structures within the pelvic cavity.

endometrial, cervical and certain ovarian cancers, in a minimally invasive manner. Robotic surgery offers advantages for both surgeons and patients in complex GYN surgical cases. In patients who have multiple adhesions and buildup of scar tissue from previous abdominal surgeries, for example, or in morbidly

obese patients, being able to visualize the pelvic area can be extremely difficult with conventional laparoscopic surgery. “In these complex cases, the single-site robotic surgery technique offers the surgeon a 3D magnified view of the pelvic region and freedom of movement with the specialized instrumentation. It’s like performing open surgery without the big incision,” explains Dr. Im, who adds that the visualization using the robot provides a 10-fold magnification that allows him to view small vessels and nerves that he could never see before in conventional open surgery. For patients who undergo robotic GYN surgery, the benefits are clear: z Quicker recovery z Small incision, and often one small incision in the navel z Fewer complications, such as bleeding and infection that often accompany a large incision z Less pain z Faster return to work According to Dr. Im, patients who are obese or who have had prior abdominal surgery are often good candidates for robotic GYN surgery. “Obese patients who have open surgery and who remain in the hospital for several days have a higher risk of complications such as infection, bowel blockage and bleeding. For these patients, robotic GYN surgery offers many benefits.” Offering the Entire Package Dr. Im says that he has no doubt that robotic surgery, and specifically robotic GYN surgery, will be the standard in 10 to 20 years. Prepared to meet the growth in demand, Mercy already has multiple robotic surgery teams with at least half the OR staff fully trained in robotics. “Our team at Mercy has the robotic experience that makes us more efficient and one of the best,” adds Dr. Im. “Patients want to go to a medical center that has the most experience and skill in robotic surgery. At Mercy, we have the best robotic surgeons, expert OR teams and very good patient outcomes,” says Dr. Im. “For our patients, it’s truly the entire package.” Physicians can learn more about GYN robotic surgery and contact and/or refer patients to Dr. Im at Mercy Medical Center by calling 410.332.9200. MAY/JUNE 2015

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FORGING A NEW TRAIL Four Women Who Created New Paths in Healthcare BY LI NDA H A RDER • PH OTO GRA PHS BY TRAC EY B ROW N

From the first female to win the Charles F. Kettering Prize (2005) for uncovering the role of aromatase inhibitors in treating breast cancer, to a rare African American female hospital CEO, this year’s four honorees have blazed new trails in healthcare.

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“I ALWAYS BELIEVED IT WOULD WORK” Thanks to the persistence and intellect of Angela Brodie, PhD, professor of pharmacology and experimental therapeutics at the University of Maryland Greenebaum Cancer Center, most postmenopausal women with breast cancer today have a highly efficacious treatment in the form of aromatase inhibitors. Her decades of research paved the way to developing these drugs, which block the enzyme aromatase from converting androgen into small amounts of estrogen. Reducing this estrogen production decreases the growth of hormonereceptor-positive breast cancer cells in an approach that has proven far more effective than tamoxifen for women after menopause. Dr. Brodie recalls that her father was a key influence on her career choice. “He was an organic chemist who was interested in making things that would help people. My first job after graduation from college was to help set up a research lab to understand how

hormones affect breast cancer. The main treatment at the time was removing the ovaries and adrenal glands, and many women unfortunately died.” After getting her PhD, she undertook a fellowship sponsored by the National Institutes of Health (NIH) in Massachusetts. “It was an exciting place to be, and gave me the idea that one could take research from the lab to the bedside. There, I met my husband, who was working on the enzyme aromatase, which had first been discovered in that lab. He thought aromatase inhibitors might be useful for contraceptives, while I thought they could be useful for treating breast cancer. Our work created some good compounds to treat tumors.”

An Uphill Battle Dr. Brodie then moved to the University of Maryland. “They had a cancer center and I hoped they would help me to get aromatase inhibitors to patients. But the center was being reorganized, and they were not prepared to take on a risky project at that time.” Next, she approached several drug

Angela Brodie, PhD, professor of pharmacology and experimental therapeutics at the University of Maryland Greenebaum Cancer Center

work, they liked it; if they didn’t, they didn’t, regardless of my sex. It’s getting better for women today; over half of graduate and medical students are female, and more women are in leadership positions (including in our department), but most chairmen are still men.” Dr. Brodie concludes, “I’ve been working on this for 20 years and I always thought it was going to work. Our rationale was very logical, and each step supported our theories. Nothing beats hard work and a good idea. The research sometimes didn’t go right, but it is gratifying when it does. I was very focused on the research.” Deborah Addo, CEO of Inova Mt. Vernon Hospital in Alexandria, Va.

companies about developing aromatase inhibitors, but they also weren’t interested in funding clinical trials. Then, in the early ’80s, she was invited to a conference in Rome, where a London oncologist invited her to collaborate with him. She remembers, “They had lots of experience in drug development. My lab made the compound and sent it to them to use in a clinical trial. We saw significant improvement in postmenopausal women with the first trial.” She adds, “ Clinical trials subsequently found that aromatase inhibitors were more effective than tamoxifen in every aspect for postmenopausal women, including those who had failed tamoxifen. Tamoxifen can actually

Clinical trials subsequently found that aromatase inhibitors were more effective than tamoxifen in every aspect for postmenopausal women… —Angela Brodie, PhD

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increase the risk of endometrial cancer and strokes – when it binds to its receptors, it can act like estrogen in some tissues.” Following success with this first aromatase inhibitor, Ciba-Geigy (now Novartis) saw the value of this inhibitory estrogen approach and championed its commercial development. Now, there are three aromatase inhibitors approved by the FDA. A new study published in 2015 found that premenopausal women also can benefit from an aromatase inhibitor, Aromasin, if their ovaries are suppressed [SOFT (Suppression of Ovarian Function Trial)]. Dr. Brodie states, “There are still 20% of postmenopausal women who don’t benefit, and some women become resistant to aromatase inhibitors over time. We’re working on learning what causes the resistance and how to overcome it. We found a number of different mediators that are activated, and are learning how to turn them off. The big question is how to identify patients who have resistant tumors. The role of individual genomes is fascinating and may account for the women that don’t respond to aromatase inhibitors, though it will be a huge task to identify them.”

A Woman in a Man’s Field Dr. Brodie is very sanguine about being a woman in a field dominated by men. “I didn’t pay too much attention to being a woman in a man’s field. Most men were helpful, and if they liked my

FAIL FAST AND LEARN FASTER Deborah Addo, CEO of Inova Mt. Vernon Hospital in Alexandria, Va., since June 2014, might have been a physician if she hadn’t been influenced by a love relationship at a critical juncture in her life. “I always loved medicine and at first planned to be a vet or dentist, then later thought I’d become a psychiatrist. I was the valedictorian of my junior high and the salutatorian of my high school class. I got into Georgetown University as a pre-med, and worked at a hospital while going to school, so I knew all of the ins and outs of hospitals.” Healthcare administration has benefited from her change of heart. One of her early jobs was as a unit manager at Greater Southeast Community Hospital in Washington, DC, where she was the only female in that role. “I remember moving equipment in my pumps,” she recollects. “I gained lots of experience solving problems on that job – if something needed to be fixed, I fixed it.”

Opening Doors for Others Addo then was offered a position as the director for support services at Children’s National Medical Center, also in Washington. “That was the era of Total Quality Improvement (TQI),” she recalls. “They selected several of us to be educators for the organization and then asked me to lead the reengineering process.” For nearly two years, her job was to create cutting-edge models for the future. “It was an opportunity to work out of my old job and into a new one,” she observes. Then as the result of another

Thu Tran, MD, an OB/GYN at Capital Women’s Care in Fulton, Md.

personal relationship, she decided to move to Hagerstown, Md. “When I saw an ad for an administrative position in that town, it seemed like fate,” she recollects. “After being interviewed by 21 people, I was offered the position of director for case management at Washington County Hospital [now Meritus Health] in Hagerstown at a time when the case-management concept was just coming into being.” Though she didn’t have a nursing degree, Addo was so respected that she was asked to serve as interim VP for Patient Care Services while the hospital recruited a permanent VP. When the new hire was asked to leave only 18 months later, Addo again was tapped to be interim VP. After helping to thwart a union threat and creating models to increase credibility and transparency, hospital leadership asked her to take on the position permanently. She later was promoted to COO, where she remained until she took the CEO position at Inova Mt.Vernon last summer. “With each role I took on, I was the

only African American executive, and one of very few women,” she reflects. “I realized I was opening doors to pave the way for others after me.”

provide perspective.” She concludes, “I try to live by the motto of ‘Be willing to fail fast and learn faster.’”

The Class Clown

ALWAYS A SURVIVOR

While a good student, Addo could be disruptive when bored. “I learned not to take everything too seriously. I was the class clown growing up, and after I disrupted my high school calculus class a few times, my professor made a deal with me that I could do stand-up comedy for the first few minutes of class. I also learned at an early age to work hard, and that nothing will be handed to you.” She continued, “I always believed I would get into Georgetown, and that I would get each of my jobs, and I did. I was never afraid and I wasn’t willing to compromise my values. As CEO, I think I have the coolest job in the world. But it’s different than being a VP, because most of the people you work with report to you and may hesitate to challenge you. It’s important to have colleagues outside the organization to

If you met Thu Tran, MD, an OB/GYN at Capital Women’s Care in Fulton, Md., you would think she had never experienced hardship. However, she’s suffered through a number of extreme challenges. In 1975 she survived a harrowing last-minute escape from Saigon at age 14, when the communist North Vietnamese and Viet Cong forces captured the city and ended the Vietnam War. Dr. Tran recalls, “My father was a high-ranking official in Saigon. When he got news that the communists were coming, he told us we had to leave immediately. It was extremely chaotic and we were evacuated from the US Embassy roof on one of the last helicopters.” She adds, “A church in Columbus, Ohio, sponsored us from the refugee camp. We were the first Vietnamese MAY/JUNE 2015

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Nancy Gaba, MD, FACOG, chair of the Department of Obstetrics and Gynecology at George Washington (GW) University School of Medicine and Health Sciences

refugees in Columbus. Our first year was extremely challenging, as we didn’t speak English. My five siblings and I shared a dictionary to translate our schoolwork, word by word. I remember one student pulling my hair and calling me names, but overall, the Americans opened their hearts to us.” Today, Dr. Tran has great compassion for the poor because of these experiences. “My sisters and I were approved to receive free lunch vouchers, but we were so proud that we chose to go hungry rather than accept them. I worked part-time at Burger King and gave my earnings to my father to put in the family pot.” After double-majoring in French

I will spend the rest of my life supporting others’ careers. —Nancy Gaba, MD

Literature and Microbiology, and completing the first year of her MBA, Dr. Tran realized she truly loved working with people and switched to medicine. “I really love my job, in part because I see women from all generations. I’ve seen people through miscarriages, divorce, infidelity, and other tragedies.

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After their children leave home, some patients tell me they have lost their identity. I realize that, thanks to my work, I have my own identity. With my work schedule, I may not have seen every tennis game my son played, but I have a strong sense of my own identity.”

who always wanted to be a doctor, and a ninth-grade biology teacher helped launch the career path of Nancy D. Gaba, MD, FACOG, chair of the Department of Obstetrics and Gynecology at George Washington (GW) University School of Medicine and Health Sciences. “That biology teacher made me feel exceptional, and I got very excited about anatomy and biology in her class,” she remembers. Growing up, it never occurred to her that girls could face discrimination. “I went to a progressive school in New York City and was in the movie Free To Be You and Me. Before I went to Vassar, my mother explained that I might experience discrimination in college. She was right – it was the first time I saw male students being given more opportunities than female students.” Initially, Dr. Gaba was set on being a pediatrician. “I was 100% sure I would be a pediatrician and 100% sure I wouldn’t be an OB. I thought I would hate being up all night and that it would be ‘yucky,’ but it turns out I loved both the subject matter and the people in obstetrics.”

A Devastating Diagnosis In another traumatic challenge, Dr. Tran’s son was diagnosed with Stage-4 neuroblastoma when he was only three years old. She recalls, “When a resident at Johns Hopkins told us the likelihood our son would survive was at most 10%, we decided to seek all available therapies at Hopkins, and an experimental treatment with murine monoclonal antibodies at Memorial Sloan-Kettering in New York City in 2001.” Dr. Tran has used that sense of perseverance and enormous energy throughout her career as an OB/GYN and in creating healthy new adventures. She explains, “To encourage other women physicians to stay fit, I created a boot camp in November 2011.” Then, with two colleagues, she launched the Ladydocscornercafe.com website, which features wellness blogs, medical news, nutrition and exercises for the public. “There is so much misinformation out there,” Dr. Tran exclaims. “We use our scientific knowledge to give people the right advice. At first, we aimed our information at women readers, but now men are reading our website too.”

PAYING IT FORWARD A supportive mother, a grandfather

Rethinking Private Practice Dr. Gaba completed both her internship and residency at GW, where her year as chief resident made her rethink going into private practice. She realized she was interested in developing curriculum and educational programs. “It was life-changing when I was offered a job as the assistant director of the residency program,” she recalls. She has remained at GW for her entire OB/GYN career. “I joke that they can’t get rid of me,” she laughs. “It’s been great and I’ve been given amazing opportunities.” While Dr. Gaba is in a specialty now dominated by women, there is only one other woman chair in her medical center.” I’m used to being with a room full of older white males. Women and men think about things differently. I like to be collaborative and hear other people’s opinions. Women also have competing priorities, such as family, and they’re sometimes judged negatively for it. Aggressive women are often viewed more negatively than aggressive men.” She acknowledges she couldn’t have done it alone, admitting, “One of the most important things for women physicians is having a supportive

partner. There’s no way I could have accomplished so much without my husband, who shares equally in raising our two sons.”

Mentors Matter Dr. Gaba credits the former director of the Division of General OB/GYN with shaping her leadership style and her own interest in mentoring. “She was a great mentor, and patients loved and respected her. I valued her research, which she allowed me to be a part of. I’m paying that forward – I lecture on mentorship and am making two videos on how to be a mentor and what’s expected of you.” She believes that reverse mentorship, where a younger person mentors an older one, is also important. “And having students keeps you on your toes,” she notes. “I would be lonely if I worked by myself. Today, I still have that memory of how important it is to be enthusiastic about what you do. I ask my students, ‘Do you see yourself as taking care of only women?’ to make sure that they’ve carefully considered their choice of specialty.” In addition to winning several prestigious teaching awards, Dr. Gaba was one of the creators of the Residents as Teachers program, which has been adopted by numerous other residency programs. She also has published numerous peer-reviewed articles, abstracts and book chapters. Further, she helped found the Society for Academic Specialists in General Obstetrics and Gynecology. She explains, “General OB/GYNs can get the short end of the stick in an academic setting, so I helped start a new society to support my colleagues around the country. I will spend the rest of my life supporting others’ careers.”

Angela Brodie, PhD, professor of Pharmacology and Experimental Therapeutics, University of Maryland Greenebaum Cancer Center Deborah Addo, MPH, CEO, Inova Mt. Vernon Hospital Thu Tran, MD, OB/GYN, Capital Women’s Care and founder of Lady Docs Boot Camp and Corner Cafe Nancy Gaba, MD, FACOG, chair of the Department of Obstetrics and Gynecology at George Washington University School of Medicine and Health Sciences

Clinical Features In each issue, Chesapeake Physician interviews some of the region’s top specialists to spotlight the latest clinical developments, including leading-edge diagnostic and treatment options.

Healthcare IT Chesapeake Physician explores ongoing major healthcare IT developments and the new care delivery models that depend on them, from interoperability issues to the latest on Meaningful Use, ACOs, Medical Homes, mobile health, hospital employment, mega groups, and more. Don't be left behind – read what Chesapeake physicians and healthcare IT experts have to say that keeps you abreast of the latest technology changes in every size and type of medical practice.

In Every Issue and Online Cases xSolutions xCompliance xPolicy

Jacquie Cohen Roth Founder/Publisher/Executive Editor 443.837.6948 xjroth@chesphysician.com chesphysician.com CHESAPEAKE

Physician YOUR PRACTICE. YOUR LIFE.

Maryland/DC/Virginia www.chesphysician.com

@chesphysician

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Rethinking Proper

Splinting and Concussion Treatment BY LI N DA H A RD ER

DOES REST HELP OR HARM CONCUSSIONS? With nearly half of all boys and a quarter of all girls fracturing a bone by age 16, this issue is a common reason for urgent-care visits. Yet splints for pediatric fractures in emergency departments and urgent-care centers are improperly applied in an astonishing 93% of cases, according to a recent study headed by Joshua Abzug, MD, assistant professor of Orthopaedics at the University of Maryland School of Medicine. The study examined 275 cases involving children under age 18 who were initially treated in community hospital emergency rooms and urgentcare facilities in Maryland. Dr. Abzug’s research was the result of personal observation that many children came to his office with improperly placed splints. “I observed a lot of cases where a splint was placed incorrectly, so I wanted to develop a rigorous approach to possibly fix the problem,” he explains. Dr. Abzug, who is also director of Pediatric Orthopaedics at the University of Maryland Medical Center, says improper splinting can result in excessive swelling, blisters and other skin complications, and poor immobilization of the fracture. In a few cases, skin grafts were even required. “Some pain is expected after a fracture, but pain that isn’t well controlled with a low-dose narcotic like Tylenol codeine indicates a problem,” he notes. “Swelling is the second symptom that physicians and parents should take seriously, as it indicates that the splint may be too tight.” The study found that the most common problem was putting an elastic bandage directly on the skin, which occurred in 77% of cases. Other top issues included improper immobilization of the joints, and splints that were either too long or too short, unnecessarily

Joshua Abzug, MD, assistant professor of Orthopaedics at the University of Maryland School of Medicine

immobilizing adjacent joints. For example, a splint for a fractured wrist should not immobilize the fingers. Splints should place the joint in a functional position and practitioners should ensure that bandages are not applied to the skin. Ideally, splints should be applied as soon as possible after an accident, and are intended to be on a child for only a day or two. However, there are unanticipated problems that can interfere with ideal timing on both ends. The majority of splints are applied by medical assistants, PAs and other non-physician personnel, but Dr. Abzug stresses that physicians can help to educate other staff to ensure that splints are properly applied to prevent swelling, pain and skin injuries. “Our findings indicate that healthcare professionals may need more extensive education and training on proper splinting techniques,” says Dr. Abzug. He plans a follow-up study working with healthcare providers in emergency departments and urgent-care centers on the correct way to apply splints.

“If there is any question, get in to see an orthopaedist as quickly as possible,” urges Dr. Abzug. As part of a follow-up study, he is creating educational signs that can be placed in community hospital emergency departments and urgent-care facilities.

DOES REST HELP OR HINDER CONCUSSION RECOVERY? Concussion remains a topic of intense clinical and lay interest, driven in large part by reports of possible neurodegenerative conditions and mood disturbances in professional American football players. The retirement of 49ers linebacker Chris Borland after only one year, due to his concerns about potential head trauma, is the latest. The resulting media attention has caused parents to rethink their children’s involvement in organized sports out of concern for avoiding concussions and long-term risk, and trends indicate a decline in participation. Marc DiFazio, MD, medical director of the Montgomery County, Md., Outpatient Center at Children’s

I observed a lot of cases where the splint was placed incorrectly, so I wanted to develop a rigorous approach to possibly fix the problem. —Joshua Abazug, MD

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National Medical Center, says, “As yet, there is no science to support prohibiting game play by children and adolescents, and most of the treatment recommendations for concussion remain based on expert consensus rather than evidence. Although it’s prudent to be attentive to brain protection, a uniform clinical algorithm does not exist for treating concussions.” He continues, “Athletic trainers and other caregivers often recommend unproven treatments such as cognitive and physical rest and withdrawal from activities. While rest intuitively makes sense to facilitate healing and prevent re-injury, this paradigm has not been proven to work for the brain. In fact, the brain cannot be “put to rest” volitionally, and thinking and concentration continue despite the fact that someone is taken out of school, work or play. “There is no evidence that daydreaming is less metabolically taxing for the brain than performing calculus,” notes Dr. DiFazio, “and in fact sleep, which is commonly recommended during concussion recovery, is an intensely metabolically active period for the brain.” A recent publication confirms this finding, demonstrating improved outcomes with shorter periods of recovery and activity restriction after concussion in adolescents. Dr. DiFazio explains, “We tend to think, ‘What’s wrong with taking patients out of their normal activities for a week or two to allow healing?’ However, the literature indicates that rest is contraindicated in a wide range of medical and surgical conditions, including brain injury after stroke. For example, prolonged bed rest after back injury was found to be less effective than shorter periods of rest.”

PROLONGED REST MAY TRIGGER ACTIVITY INTOLERANCE CASCADE Ironically, imposed rest can produce some of the very symptoms seen in post-concussive syndrome: fatigue, sleep disturbance, cognitive impairments and pain. An “activity intolerance” cascade may therefore occur in some individuals: First, rapid deconditioning after withdrawal from exercise results in a significant decrease in exercise tolerance. Caregivers then attribute continued 20 |

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symptoms to the concussion itself rather than withdrawal from activity, and consequently recommend more rest. When the individual resumes activities, symptoms are ascribed to the concussion rather than deconditioning, and still further rest is encouraged. Dr. DiFazio says, “At present, given that rest has never been proven to hasten recovery from concussion and may in fact be detrimental, a uniform recommendation for imposed rest should not be made until there is clear evidence of a benefit. Rest after concussion has been emphasized in part due to concerns regarding ‘second-impact syndrome,’

TREATMENT RECOMMENDATIONS Dr. DiFazio states, “We counsel parents and patients that at present there is no evidence linking concussion in childhood/adolescent sports to CTE, and we recommend a return to sports and regular exercise. For an uncomplicated concussion, we generally screen for pre-existing neuropsychiatric difficulties that may complicate recovery, such as anxiety, depression or attentional impairments. We also provide reassurance and early education, which the literature recommends.” He adds, “We allow for a return to exercise, and strongly recommend

Athletic trainers and other caregivers often recommend unproven treatments [for concussion] such as cognitive and physical rest and withdrawal from activities. —Marc DiFazio, MD in which diffuse and usually lethal brain swelling occurs soon after an impact. While a second injury does not appear necessary, training regimens often forbid returning to play until the person is ‘asymptomatic.’ “However, if a first impact explains this very rare phenomenon, prolonged withdrawal from play is probably unnecessary,” he continues. “It may be unrealistic to seek an “asymptomatic” status, since many people who have not suffered concussions may report similar symptoms. This goal may merely unduly delay a return to play/activity in the post-concussive patient.”

CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE) Researchers don’t yet know if CTE, a condition ascribed to the long-term effects of concussion in the brain, actually results from trauma, whether a single injury, or repetitive. Similar pathologic findings have been found in the postmortem brain tissue of chronic opioid abusers without chronic traumatic injury. This may therefore represent a condition caused by a number of etiologies, and in part maybe dependent on a genetic propensity after concussion or additional environmental stressors.

a return to school/work. If symptoms return, we offer reassurance and pain relief if necessary. Some patients continue to experience symptoms weeks or months after the concussion, but we do not believe this contraindicates exercise and re-engagement. Some patients with more debilitating chronic pain, depression or other symptoms need multidisciplinary interventions, including psychological support, medical therapy and facilitated rehabilitation.” Dr. DiFazio is one of a growing number of physicians believing that the benefits of sports far outweigh the risks. He concludes, “Modern concussion research remains in its infancy. Although the attention to brain injury is justified, a prudent and balanced approach to prevention, diagnosis and treatment is recommended, rather than interventions based on fear, hysteria and unfounded claims.”

Joshua Abzug, MD, assistant professor of Orthopaedics at the University of Maryland School of Medicine Marc DiFazio, MD, medical director of the Montgomery County Outpatient Center at Children's National Medical Center

COMPLIANCE

Physician Practices Should Brace for HIPAA Compliance Audits

HE SECOND PHASE OF THE HIPAA audit program will begin sometime in 2015. The Office of Civil Rights (OCR) within the US Department of Health and Human Services is the enforcement agency for breaches of protected health information (PHI). In light of the very public hacks and cyber terrorism acts against giant companies like Sony and Anthem, the agency is focused on auditing providers. The first phase of the OCR audit program launched in 2012. In 2013, the findings of the pilot program showed that only 11% of the audited organizations were fully compliant with HIPAA regulations and guidance. The OCR anticipates up to 17,000 complaints across the country in 2015, with a focus on those with “trigger events” and “high impact” breaches, where a large volume of patient information is disclosed. This means that small physician practices are as likely to be investigated as hospital systems and health plans.

Getting Ready

The second phase of HIPAA audits will include both covered entities and business associates – physicians, hospitals, clearinghouses, health plans and vendor partners alike. Under the federal stimulus bill (HITECH), business associates were expanded to include vendors that normally touch PHI, such as billing companies, collection agencies and EMR vendors, but also those that collect, transmit and store PHI. As a result, email and phone system vendors that store on their own servers’ health messages with sensitive patient data also must comply with HIPAA privacy and security protections. OCR intends to release a survey to aid the medical community in HIPAA compliance. The survey will encompass all aspects of privacy and security under federal regulations. Further, it will

By Jennifer Searfoss, JD, CMPE

request comprehensive lists of all hardware used by employees and contractors, and copies of agreements with business associates. The survey will act as the first step of the audit process and will identify for federal agents whether further investigation is required through a desktop audit (request for additional paperwork) or an onsite review. The request for additional information will allow the providers only 10 days to respond.

the repayment of Meaningful Use monies is that the risk assessment must be conducted during the attestation period each year. In 2015, physicians may choose which quarter they will attest (recommended before the fourth quarter due to the Oct. 1, 2015, ICD-10 implementation date). Thus, the risk assessment must be conducted during the calendar-year quarter that the physician chooses to attest. More Regulations to Come

Conduct Risk Assessment During Meaningful Use Attestation

HIPAA audits likely will dovetail with the Meaningful Use audits, which often uncover attesting physicians and hospitals that did not fully complete the core measure for HIPAA risk assessments. While the federal regulations do not specifically prescribe what a risk assessment is, there is sufficient guidance on what qualifies for meeting the Meaningful Use core measure. A few of those elements are outlined in the risk assessment elements. One thing we have learned through

Forthcoming rules may give individuals harmed by breeches a portion of fines recovered from the covered entity or business associate (RIN 0945-AA04), and provide guidance on cloudcomputing privacy and security considerations. The Fall 2014 Semi Annual Rule listing shows the notice of proposed rulemaking set for publication in June 2015. Jennifer Searfoss, JD, CMPE, is founder and CEO at SCG Health, a boutique consulting group focused on revenue cycle management and strategic planning. She can be reached at info@scghealth.com.

HOW TO PREPARE Physicians and their office staff should: z z z z z z z

Hold annual HIPAA training, documenting training content and exit-testing of all administrative and clinical staff, plus physician partners Remind staff of requirements and to contact the Privacy and Compliance officer(s) with concerns Review privacy and security procedures, breach notification protocols and disciplinary actions Make sure that the Notice of Privacy Practices is posted in a public area of each office, available in paper format, posted on the group’s website, and that acknowledgements are signed by all patients or guardians Validate that audit logs are created by software for all users, and review the logs to identify any abuse for unauthorized access (employee snooping and terminated employee access) Inventory and update IT systems’ software patches, firewall applications, malware detection and password protection Use encryption and remote-wipe software solutions for portable systems.

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Women’s Health ROUNDUP

Women today have a growing number of options for breast reconstruction, including free tissue transfer, and non-surgical options for cosmetic procedures abound. ere’s also growing awareness that complaints of pelvic pain should not be dismissed – it aﬀects about half of all women, and diagnosis may take perseverance. FREE TISSUE TRANSFER COMES OF AGE With more women choosing to have a mastectomy, sometimes prophylactically, having a range of good options for breast reconstruction has never been more important. Gabriel Del Corral, MD, a plastic surgeon at Carroll Hospital Center in Westminster, Md., who is fellowship-trained in microsurgery, is enthusiastic about the growing choices that women have today. “Free tissue transfer (FTT), in which a flap of tissue is detached from elsewhere in the body and reattached to the chest wall, has been around a long time but has become far more sophisticated. Very skilled microsurgical techniques are needed to reconnect blood vessels in the belly to those in the chest. It takes about five hours of surgery to do one breast.” A common type of FTT is the deep inferior epigastric artery (DIEP) flap, in which blood vessels, fat and skin attached to them are transferred from the lower abdomen to the chest without removing muscle. “FTT isn’t right for everyone, but longterm, it’s a better solution than implants for many patients,” Dr. Del Corral notes. “It provides natural reconstruction using a patient’s own tissue, with less pain. The tissue can be harvested from (in order of preference) the stomach, inner thigh or gluteal area. Gluteal fat is harder, so it 22 | CHESPHYSICIAN.COM

doesn’t feel as natural and the recovery process is a little longer.” Performed at the same time as the mastectomy, the FTT approach involves one long operation and a recovery time of about four to six weeks, compared to three to four weeks after an expander is inserted. However, patients choosing implants must then undergo a second procedure down the road. “It’s good for primary care physicians

to be familiar with alternatives to implants,” Dr. Del Corral says. “Because radiation can make it harder to correct deformities, making them more permanent, it’s important to perform reconstruction at the same time as a significant partial mastectomy.” He notes that smokers tend to do better with FTT than with implants, because they’re at higher risk for infection and implant failure.

Gabriel Del Corral, MD, a plastic surgeon at Carroll Hospital Center, Md.

SPECIAL ADVERTISING SECTION

The Future

CoolSculpting

On the horizon are fat transfers, where autologous tissue is removed through liposuction or other means. “We’re becoming more sophisticated in the way we harvest the flaps and with the imaging we use,” explains Dr. Del Corral, “and we’re finding new areas to harvest – such as ‘love handles.’”

CoolSculpting®, an FDA-cleared procedure, freezes and eliminates fat cells using controlled cooling that doesn’t entail surgery. “This procedure can take anywhere from one hour for a single area to 10 hours if there are many areas to address,” says Dr. Chappell. “While it doesn’t offer the same results as liposuction, it’s a viable procedure, and really works. It can take as many as six to 12 treatments – at a certain point, it can be more expensive and time consuming than liposuction, so a skilled plastic surgeon can help to guide patients to the most appropriate procedure.” He adds, “This procedure provides a great technique, solid results and very high patient satisfaction. It should be used in a setting supervised by a physician, which is often not the case at a medi-spa.”

EXPLOSION IN NON-SURGICAL COSMETIC PROCEDURES As more minimally invasive cosmetic surgery procedures become available and accepted, is the surgical part of this specialty’s name becoming an oxymoron? While plastic surgery is hardly at that point yet, James Chappell, MD, FACS, a plastic surgeon at Annapolis Plastic Surgery in Severna Park, Md., notes that there is no question that non-surgical approaches are exploding, and that such techniques are favored by men, who account for about one-quarter of all non-invasive cosmetic procedures, compared to only five to 10% of cosmetic surgical procedures.

Eliminating Double Chins The latest FDA-approved cosmetic treatment is ATX-101, which was unanimously approved in March 2015 after studies showed that injection of deoxycholic acid could break down the membrane of fat cells in the chin to reduce double chins. It takes only a few minutes to administer ATX-101, and only a few days for patients to heal, with mild to moderate short-term swelling, numbness and bruising. Dr. Chappell explains, “ATX-101 came out of mesotherapy, which has been available for about the last eight years. Mesotherapy involves injecting microscopic quantities of various agents into the skin for cosmetic purposes. It grew too quickly, and with limited oversight.”

Liquid Facelifts “‘Liquid facelifts,’ in the form of fillers and neurotoxins, are increasingly being used to avoid, delay or supplement facelifts,” Dr. Chappell says. “This includes VOLUMA® XC, an iteration of Juvederm that volumizes the cheeks. It’s a simple, popular procedure that takes only about 15 minutes and lasts one to two years. Fillers also can be used to blend in ‘subtle prejowl hollows,’ but are not appropriate for those with more obvious jowls. Laser resurfacing today offers more subtle results with less down time. It tightens skin to a point.”

Fat Injections vs. Breast Implants Dr. Chappell does not think that fat injections are appropriate for enhancing breasts unless a patient is undergoing reconstruction following a mastectomy. “I get calls from patients today who want to know if they can get a fat injection instead of a breast implant. I do these injections in breast cancer reconstruction cases to build a more normal-looking breast, but because we don’t know the long-term effects, they are not appropriate for cosmetic purposes. Implants got a bad reputation in the 1990s, but studies found no relation between them and diseases such as lupus.”

DON’T DISMISS PELVIC PAIN With nearly half of all women experiencing pelvic pain at some point in their lives, physicians need to better recognize pelvic venous insufficiency as a possible cause. Some 15% of women experience pelvic pain as a result of pelvic congestion syndrome, a condition in which there is dilatation of the ovarian vein with subsequent development of pelvic varices, often as the result of multiple pregnancies. Risk factors for pelvic congestion syndrome include: z z z z z

Two or more pregnancies Hormonal abnormalities Varicose veins in the thighs, vaginal area or buttocks Obesity Previous surgeries in the pelvic area

Symptoms may include pelvic pain, pelvic pressure, leg swelling, and painful intercourse, which can be debilitating. The pain may be worse upon sitting, standing, and during menses. Michael Malone, MD, a vascular surgeon at the Center for Vascular Medicine, explains, “Pelvic and lower-extremity venous ultrasound is the initial noninvasive study to be performed. If pelvic varicose veins are found on ultrasound, patients should be referred to a vascular specialist, who will perform a careful history and physical. Based upon those findings, the physician may order further invasive testing, including a venogram (catheterizing select veins and injecting contrast dye), which is considered the gold standard to confirm the diagnosis.” He continues, “Treatment typically involves closure of the abnormally dilated veins, which can be accomplished with chemical embolization. In addition, there may be patients who have a venous outflow obstruction compounding the pelvic symptoms. For example, when the right common iliac artery compresses the left common iliac vein, this condition is called May-Thurner Syndrome. Treatment may include insertion of a stent into the iliac vein to improve bloodflow. Treatment has an 85% or higher success rate, and patients say that the difference is ‘like night and day.’” Patients may experience soreness for a few days after these procedures, but they can return to their normal routine. Typically, there is no surgical incision and minimal need for general anesthesia. “It’s important for physicians not to dismiss complaints of pelvic pain, especially if it worsens during intercourse or as the day progresses,” Dr. Malone concludes. “This syndrome is real and treatable, and treatment provides tremendous relief and improved function for thousands of women.”

Gabriel Del Corral, MD, a plastic surgeon at Carroll Hospital Center in Westminster, Md., who is fellowshiptrained in microsurgery James Chappell, MD, FACS, a plastic surgeon at Annapolis Plastic Surgery in Severna Park, Md. Michael Malone, MD, a vascular surgeon at the Center for Vascular Medicine in Glen Burnie, Md.

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HEALTHCARE IT

Moving Toward Interoperability BY LIN DA H ARDER

EALTHCARE is perennially behind other industries where information technology is concerned. Today, people can switch cell phone providers without losing their data or phone number, and they can book an entire vacation on one website. But that seamless interface isn’t available in healthcare. According to a KLAS report, EMR Interoperability 2014: Where are We on the Yellow Brick Road?, 82% of providers believed they were moderately successful at interoperability due to their own efforts, not those of their vendor, while only 6% felt they had achieved advanced interoperability. Dan Haley, VP of Government Affairs for athenahealth, explains, “IT systems don’t talk to each other because the systems in prevalent use were built in the ’70s and were meant to connect departments within a hospital, not to connect with other physicians and other providers across the care continuum. These legacy systems were designed for intraoperability, not interoperability.” He goes on to say, “The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 created an artificial market that forced doctors to adopt new technology and told them what to buy to a large extent. The goal of Meaningful Use was to provide the dollars to install as much technology as possible, as soon 24 |

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as possible. A lot of federal-subsidized technology cannot enable easy, costeffective information sharing. It can be jerry-rigged individually to interoperate, but that’s like saying you have to hire a consultant to customize the latest app for your iPhone.” Peter Basch, MD, medical director of Ambulatory EHR and Health IT Policy at MedStar Health, says, “I like to inject some reality into the conversation. While moving towards full interoperability is important, much of the conversation surrounding interoperability is shaded by hyperbole and magical thinking.” He takes issue with the frequently repeated statement that, because systems are not fully interoperable, doctors cannot communicate with colleagues or patients or that they couldn’t effectively communicate before there were EHRs. “The notion that doctors didn’t talk to each other when they were reliant on

paper records is ridiculous. The medical record (paper or electronic) has always contained diagnostic, imaging and lab results, as well as other pertinent information from other doctors, providers and hospitals. “What was missing and what interoperability aims to resolve is the ability to have EHR systems seamlessly and efficiently share information with each other without special effort or added cost,” Dr. Basch continues. “Interoperability is just a component of infrastructure that can make moving structured data between systems easier and less costly. And as infrastructure, let’s not forget that interoperability doesn’t necessary lead to more effective communication; it can result in information overload, or in misinterpretation, where the volume of structured data moved obscures the patient narrative or rich clinical context.”

Emerging Approaches Offer Hope Application program interfaces (APIs) can help to bridge disparate IT systems, if vendors make them cost-effective to implement and clients use them. Haley explains, “APIs allow different software applications to understand each other, so that, for example, you can buy tickets from United Airlines on Kayak. But the key is willingness to use them. APIs don’t solve the problem without the will to share information.” In 2010, The Markle Foundation Work Group on Consumer Engagement created the Blue Button Initiative to give patients access to their own health data and improve patient-provider interactions. Initially available to VA patients, the initiative has expanded to Medicare and other payers, including United Health, Humana, and Aetna. By 2013, the ONC created the Blue Button+ Implementation Guide to specify structured data formats, transmission protocols, and APIs to provide trusted, automated data exchange to parse that data to make it more readable. Opinions about these and other new standards that are seeking to improve the ability of EHRs to talk to each other, such as the Consolidated Clinical Document Architecture (C-CDA) for document exchange and Fast Healthcare Interoperability Resources (FHIR), vary. Issues have included mismatches between codes, overly broad vocabulary and variations in how data was transmitted.

CommonWell: The Second Tier Haley believes that a cloud-based approach is part of the solution. “As one of the few cloud-based players in healthcare, athenahealth can provide updates and fixes to its 60,000-plus providers literally overnight, simultaneously. Unlike most of the software in use today we were built from the outset for an interoperable world. We use the term interoperation, which is an activity, not interoperability, which describes a capability. What doctors and patients need is the activity.” He describes three tiers of interoperability: z

Intraoperation, or sharing of data within a health system – HL7, which was developed in the 1980s, is good for this but little more Interoperation – in which providers can send or access electronic information outside their own system

when needed. We haven’t achieved this yet broadly yet, though every vendor claims to be able to do it A truly open platform, enabling patient-centered control of record availability

CommonWell Health Alliance – a group of some of the largest vendors, including athenahealth, Cerner, McKesson, Allscripts, CPSI, Greenway Health and Sunquest – was rolled out in 2014 to achieve the second tier. Its goal is to serve as an intermediary that provides patient matching and conduits for different players. “It’s effectuating active information exchange now among its members,” Haley claims. According to its website, CommonWell’s services include: z z z z

Patient identification and linking Record locator and retrieval Patient access, privacy and consent management Trusted data access

Bob Robke, board treasurer for CommonWell Health Alliance and VP for Interoperability Solutions at Cerner, notes, “I’ve been in the interoperability space for about 20 years. The goal is to serve data at the right place and time. In the past, with fee-for-service, there was no financial demand for interoperability. With the move toward pay-for-value, there is a need for systems to connect. We helped launch CommonWell because we realized we needed to cooperate with the competition to decrease costs and the variance of connecting with their

prevent wars. While interoperability can make the process of sharing structured data easier, without a concurrent shift in workflow and an aligned payment model that rewards health information review and management – and thus at least in some cases, a reduction in redundant testing and services – interoperability by itself does not necessarily lead to higher quality or decreased costs. What we need are payment, alignment, leadership and workflow changes.” He compares the enormous stream of data that full interoperability could unleash to trying to drink from a fire hose. “Without filters and new workflows that can make this torrent of data ‘digestible’ and understandable, the same people crying for interoperability now may be sorry they asked for it.”

The ONC Roadmap In January 2015, the Office of the National Coordinator for Health IT (ONC) released a draft roadmap for interoperability which outlined shortand long-term goals for the coming decade, with a 2017 deadline by which ‘a majority of individuals and providers across the care continuum should be able to send, receive, find and use a common set of electronic clinical information.’ Dr. Basch recommends that the ONC Roadmap avoid using the existing Meaningful Use approach of prescriptive process measures, with rigidly defined numerators and denominators. “The problem with this approach is that it creates such a narrow definition of accepted workflow that EHR usability has deteriorated.

…interoperability by itself does not necessarily lead to higher quality or decreased costs. What we need are payment, alignment, leadership and workflow changes. —Peter Basch, MD systems. CommonWell uses existing identifiers, such as drivers’ licenses, to link patients to their health data. We should have done this 10 years ago, but now we’re making progress.”

Not a Magic Potion “Interoperability is not a magic potion,” Dr. Basch observes, “but there’s magic thinking that it solves problems in and of itself. I compare it to thinking that speaking a common language will

“We’re suffering the consequences of this overly defined, process-driven approach,” he adds. “In Stage 2, the problems increased as expectations grew. In hindsight, it was a mistake to assume that the EHR should be used the same way by all providers in all specialties. Moving forward, continuing this same approach carries the risk that the benefits of interoperability may get lost in a poorly usable EHR; where the focus has been on compliance with a single MAY/JUNE 2015

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set of process measures â&#x20AC;&#x201C; rather than allowing for specialty-specific flexibility.â&#x20AC;? Haley agrees that Meaningful Use is a checklist that can have little to do with quality care. He concludes, â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m happy that weâ&#x20AC;&#x2122;re moving away from mandatory standards toward mandatory outcomes and behaviors.â&#x20AC;? â&#x20AC;&#x153;If we really want doctors to have the time to optimize the new data they may receive from fuller interoperability, we need electronic systems that help reduce administrative burden,â&#x20AC;? Dr. Basch notes. â&#x20AC;&#x153;Why? Doctors spend 43 minutes a day on administrative tasks, and half of that time is avoidable. For example, Iâ&#x20AC;&#x2122;d like to see payers figure out how to accept the structured output from an EHR rather than still making doctors fill out additional forms for prior authorization, durable medical equipment, etc.â&#x20AC;? Dr. Basch says, â&#x20AC;&#x153;Achieving and optimizing interoperability would be more successful if it was driven by actual need or business case, not by mandates. We need inter-operability that helps to reduce our burden, not increase it.â&#x20AC;?

Practical Interoperability â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;re killing our doctors â&#x20AC;&#x201C; they arenâ&#x20AC;&#x2122;t reaping any benefits from electronic data,â&#x20AC;? complains Dr. Basch. â&#x20AC;&#x153;EHRs take more time because they provide for, and often require capture of more information. I would agree with the ONC Interoperability Roadmap that enhances interoperability iteratively. And this indeed was the approach of what most would agree has been a successful model for interoperability, the Chesapeake Regional Information System for our Patients (CRISP). CRISP started with things providers would find useful, rather than trying to capture and share everything. CRISPâ&#x20AC;&#x2122;s model was to start slow and build on success.â&#x20AC;? Robke contributes, â&#x20AC;&#x153;We understand that interoperability needs to be simple for doctors. Alliance members agreed to a specific workflow to help with connectivity. Then the individual EHR deals with how data is parsed and displayed. Itâ&#x20AC;&#x2122;s similar to e-prescribing, which offers nationwide connectivity. It has to be on a national scale â&#x20AC;&#x201C; consumers are used to Visa and Mastercard, which wouldnâ&#x20AC;&#x2122;t survive if they only offered local networks.â&#x20AC;?

He adds, â&#x20AC;&#x153;Cerner is trying to stay in alignment with the ONC Roadmap, but not wait for them. We recognize that we need to get information to the physicians so they arenâ&#x20AC;&#x2122;t burdened, but we havenâ&#x20AC;&#x2122;t scratched the surface yet on usability. One barrier to interoperability is that competing hospital systems donâ&#x20AC;&#x2122;t want to share data. Our goal is to have the majority of our clients on the network within the next three years. Weâ&#x20AC;&#x2122;re starting with the C-CDA for lab values, medication lists, allergies, family history, and so on. We know that if a patient has had five encounters elsewhere, we have to find a way to put the five summaries together to give physicians a useful view of that information.â&#x20AC;?

Peter Basch, MD, medical director of Ambulatory EHR and Health IT Policy at MedStar Health Dan Haley, VP of Government Affairs, athenahealth Bob Robke, board treasurer of CommonWell Health Alliance and VP for Interoperability Solutions at Cerner in Chevy Chase, Md.

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POLICY

The Third and Final Stage of Meaningful Use BY LI N DA HA RD ER

N MARCH 2015, THE CENTERS for Medicare and Medicaid Services (CMS) rolled out the proposed rule for Stage 3, which they declared will be the final stage of its Meaningful Use (MU) EHR incentive program. This stage is scheduled to begin in 2017, with all participating providers, regardless of whether or not they have met prior stages, expected to report by 2018. CMS notes in its proposed rule that â&#x20AC;&#x153;Stage 3 of Meaningful Use is expected to be the final stage, and would incorporate portions of the prior stages into its requirements. In addition, following a proposed optional year in 2017, beginning in 2018 all providers would report on the same definition of Meaningful Use at the Stage 3 level regardless of their prior participation, moving all participants in the EHR Incentive Programs to a single stage of Meaningful Use in 2018.â&#x20AC;? The Stage 3 proposed rule, according to CMS, helps to simplify the MU program, improves health delivery through health IT and begins to align MU with other quality programs, including the Physician Quality Reporting System (PQRS). However, with a very small percentage of physicians and only about a third of hospitals currently meeting Stage 2 requirements, many providers have viewed the new rule as overly aggressive. 28 | CHESPHYSICIAN.COM

While Stage 3 has only eight objectives, it has 15 or more measures, most of which are updates to Stage 2 objectives. Half of these objectives focus on interoperability and data exchange. In response to pressure from various provider groups, CMS has agreed to reduce the reporting burden for providers and cut the Stage 2 EHR reporting period from a full year to 90 days. That would make it easier for physicians to comply with requirements, as well as allow them more time to implement EHR systems that are certified for Stage 2. However, it rejected other recommendations from

the American Medical Association (AMA) and other provider groups, including the provision that providers be allowed to fail any two objectives and still meet MU. Carrots and Sticks

Since 2011, the first year that providers could attest to MU, CMS has paid over $25 billion in incentive payments under this program. However, the new rule comes on the heels of the first penalties for providers who did not meet MU. In November 2014, over 250,000 physicians were notified that they would be subject to a 1% penalty to their

Medicare Physician Fee Schedule. In 2016, the penalty grows to 2% of the fee schedule. Some 28,000 physicians also were hit with a 2% penalty for not having an e-prescribing program in place. Interoperability

Objective 7 relates to health information exchange. The proposed rule states, “The purpose of this objective is to ensure a summary of care record is transmitted or captured electronically and incorporated into the EHR for patients seeking care among different

To make it easier for providers to share data with their patients, CMS is proposing to certify selected application program interfaces (APIs) for certified EHRs, to allow patients to use thirdparty applications, such as personal health records (PHRs). That would provide another route for patients to obtain their health information beyond provider portals. The rule states, “As some low-cost and free API functions already exist in the health IT industry, we expect third-party application developers to continue to create low-cost solutions

Beginning in 2018 all providers would report on the same definition of Meaningful Use at the Stage 3 level regardless of their prior participation. providers in the care continuum, and to encourage reconciliation of health information for the patient. This objective promotes interoperable systems and supports the use of CEHRT [certified electronic health record technology] to share information among care teams.” The three measures associated with this objective pertain to obtaining summary of care record during care transitions and for new patients, including a measure that requires providers to perform a clinical information reconciliation on 80% or more of new patients (for medications, medication allergies and a list of current problems). Growing Patient Engagement Requirements

Stage 2 built on Stage 1 by requiring the beginnings of patient engagement, including having at least 5% of patients access their medical records and receive secure messaging. The requirement increases to 25% in Stage 3 for both measures. Instead of four days, providers will have only 24 hours to make patient health information available electronically. New measures include a requirement that providers must receive provider-requested, patient-generated health information through secure messaging or a structured questionnaire.

that leverage APIs as part of their business models. Therefore, we encourage health IT system developers to leverage these existing API platforms and applications to allow providers no-cost, or low-cost solutions to implement and enable an API as part of their CEHRT systems.” Protecting Patient Health Information

Another key goal of Stage 3 is improving safeguards for patient data by requiring encryption of sensitive patient electronic health information, risk analysis and risk management processes, and contingency plans and training programs. Stage 3 also requires providers to have physical safeguards in place, such as facility access controls and workstation security. Clinical Decision Support

Stage 3 of MU also focuses on implementing clinical decision support systems for “interventions related to four or more clinical quality measures (CQMs) at a relevant point in patient care for the entire EHR reporting period.” The goal of these requirements is to go from process compliance to better clinical outcomes, although the provider community has expressed concerns that the current capabilities of most information exchange technology make this goal challenging at best.

Public Health Data

Adding to the requirements in Stage 2, Stage 3 requires providers to continue reporting health data to clinical data registries (CDRs) and public health agencies (PHAs), but the requirement provides some additional flexibility in that providers should have ‘active engagement’ in response to stakeholder feedback rather than ‘ongoing submission.’ The six measures in this objective include requirements that providers exchange data with an immunization registry and submit case reports of reportable public health conditions. Another change in Stage 3 is that, beginning 2017, hospitals will move to a calendar-year reporting period, consistent with the reporting period for physicians and other eligible providers. Comments on the new rule will be accepted through May 29, 2015. CMS has indicated that it expects MU to continue to be adjusted in future years, without adding additional stages. Whether providers will find it worthwhile to participate in the last stage(s) of MU, however, remains to be seen.

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