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Physician YOUR PRACTICE. YOUR LIFE.
CRACKS IN MARYLAND MEDICINE’S GLASS CEILING Four Female Physician Leaders Discuss Their Non-Traditional Roles
THE CLOCK IS TICKING Three “Wired” Physicians Discuss the Why and How of Electronic Medicine
STARK COMPLIANCE CASE Happy Ending or Inauspicious Beginning?
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MAY/JUNE 2011 VOLUME1: ISSUE 1
LOVE THE SERVICE. APPRECIATE THE CONVENIENCE. TRUST THE NAME.
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Contents
May/June 2011 Volume1: Issue 1
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24
28
F E AT U R E S
20 Cracks In Maryland Medicine’s Glass Ceiling Four Female Physician Leaders Discuss Their Non-Traditional Roles
24 Perspectives From Women in Leadership Female presidents and CEOs on running a Maryland acute-care hospital
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Women’s Health Update From Botox® to Breast Biopsy
D E PA R T M E N T S
Cases | 7 | Managing Breast Cancer During Pregnancy Solutions | 9 | Improve Your Medical Practice Performance Policy | 11 | Health Care Issues in the 2011 Maryland General Assembly Session Compliance | 13 | A Stark Compliance Case – Happy Ending or Inauspicious Beginning? Medical Beat | 15 | News and Notes in the Medical Field Healthcare IT | 16 | Three “Wired” Physicians Discuss Medicine Going Electronic Good Deeds | 33 | Phyllis Campbell, M.D. Heritage | 34 | Sheppard Pratt – Part of Maryland’s Medical Heritage On the Cover: Gail Cunningham, M.D., chief of Emergency Medicine at St. Joseph Medical Center
MAY/JUNE 2011
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TRACEY BROWN, PAPERCAMERA PHOTOGRAPHY
JACQUIE ROTH, PUBLISHER/EDITOR-IN- CHIEF jroth@mdpracticelife.com LINDA HARDER, EDITOR lharder@mdpracticelife.com EDITORIAL STAFF Allison Eatough aeatough@mdpracticelife.com Tracy Fitzgerald tfitzgerald@mdpracticelife.com PHOTOGRAPHERS Tracey Brown, Papercamera Photography www.thepapercamera.com Mark Molesky, Molesky Photography www.moleskyphotography.com ADVERTISING Stephanie Day, Business Development Executive sday@mdpracticelife.com Liza Kimminau, Business Development Executive Eastern Shore
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lkimminau@mdpracticelife.com
VERY MEDICAL PRACTICE TODAY, no matter the size or specialty, is challenged by ever increasing complexities that impact the art of practicing medicine. It’s my passion and my goal to keep you informed, intrigued and inspired with information about cutting-edge treatments and practical advice for managing a clinical practice. Maryland Physician is dedicated to building a Maryland-based healthcare network with a commitment to achieving the highest standards of efficient and effective quality care. At our website, www.mdpracticelife.com, you’ll find fresh content and opportunity to interact with some of our contributors and subject matter experts. Maryland Physician events launch this fall, facilitating one-on-one conversations in both the clinical and practice management areas of a Maryland clinical practice. Life outside of medical practice is also an integral part of Maryland Physician. We all need to take time to enjoy the uniqueness of our Chesapeake region. Regular content will take you out of your practice confines, exploring Maryland's unmatched natural resources and intriguing you with stories of Maryland's rich heritage. Medicine is an inherent part of who and what I am. Growing up, I was routinely asked if I was going to be a nurse and help my dad, a physician. My answer was always a resounding “No! I’m going to be his boss!” While life took me in other professional directions, I never lost a passion for wellness and have grown a passion for Maryland. As Eleanor Roosevelt said, “The purpose of life is to live it, to taste experience to the utmost, to reach out eagerly and without fear for newer and richer experiences.” In that vein, Maryland Physician Magazine was born. Honoring lessons learned from my parents, a desire to inspire my own three daughters and with gratitude for the love and support of my husband, I invite you to be part of the Maryland Physician network. This first issue and those to follow cannot happen without a tremendous team of writers, artists, advisors, contributors and advertisers share a commitment to achieving the highest standards of quality care for all Maryland citizens. To life!
DIGITAL Andrei Palmer, Digital General Manager Aertight Systems andreip@aertight.com Maryland Physician Magazine™ is published bimonthly by Mojo Media, LLC. Corporate Office Mojo Media, LLC PO Box 1663 Millersville, MD 21108 Subscription information: Maryland Physician Magazine is mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $32.00. To be added to the circulation list, please email circulation@mdpracticelife.com or call 410.987.6667 Reprints: To order reprints of articles or back issues, please call 410.987.6667 or email jroth@mdpracticelife.com Maryland Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Maryland Physician. Advisory board members include: ERWIN ABRAMS, MBA, RET. CEO Hospice of the Chesapeake JOHN BARRY, M.D. Chesapeake Orthopaedic & Sports Medicine Center KAREN COUSINS-BROWN, D.O. Medical Director Ace, Maryland General Hospital HOLLY DAHLMAN, M.D. Greenspring Valley Internal Medicine, LLC MICHAEL EPSTEIN, M.D. Founder, Digestive Disorders Associates STACY D. FISHER, M.D. Director of Women’s & Complex Heart Disease, University of Maryland Medical Center REGINA HAMPTON, M.D. FACS Signature Breast Care DANILO ESPINOLA, M.D. Advanced Radiology GENE RANSOM, J.D., CEO MedChi Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources.
Jacquie Roth Publisher/Editor-in-Chief jroth@mdpracticelife.com
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LEARNING THE BUSINESS OF MEDICINE CHALLENGE: When Dr. Navalgund came out of medical school, he had all the right medical training. But when he decided to open his own practice, he needed something new — an education in the business side of medicine. SOLUTION: Dr. Navalgund had the Cash Flow Conversation with his PNC Healthcare Business Banker, who put his industry knowledge to work. Together, they tailored a set of solutions to strengthen his cash flow: loans for real estate and equipment along with a line of credit to grow his practice, plus remote deposit to help speed up receivables. ACHIEVEMENT: DNA Advanced Pain Treatment Center now has four private practices and a growing list of patients. And Dr. Navalgund has a place to turn for all his banking needs, allowing him to focus on what he does best. WATCH DR. NAVALGUND’S FULL STORY at pnc.com/cfo and see how The PNC Advantage for Healthcare Professionals can help solve your practice’s challenges, too. Or call PNC Healthcare Business Banker Les Pasternack at 1-866-356-6916 to start your own Cash Flow Conversation today. ACCELERATE RECEIVABLES IMPROVE PAYMENT PRACTICES INVEST EXCESS CASH LEVERAGE ONLINE TECHNOLOGY ENSURE ACCESS TO CREDIT
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Cases
Managing Breast Cancer during Pregnancy Regina Hampton, M.D., FACS
CASE: A 37-year-old female who is 17 weeks pregnant, presents with a lump in the right breast that has been present for 3 weeks. The mass is firm, non-tender and in the lower, inner quadrant of the breast. She denies nipple discharge. Her OB/Gyn sent her for an ultrasound (US) which showed a 1.1x1.4cm solid nodule. She had an US-guided core needle biopsy, which revealed an infiltrating ductal carcinoma. What treatment options are available for this patient? DISCUSSION: Breast cancer during pregnancy occurs in 1 in 3000 women. The recommendations and treatments for breast cancer have significantly changed in recent years. The physiologic changes that normally occur in the breast during pregnancy can make it difficult to palpate a mass. Tumors tend to be larger than in non-pregnant women. If a mass is suspected, traditional breast imaging can be used. Mammograms can be performed safely with the appropriate shielding. If the patient is a young woman with dense breasts, then it is appropriate to proceed to US. MRI with gadolinium is not recommended. At one time, therapeutic termination of the pregnancy was recommended in these instances. Today, there are a variety
of algorithms that can be used to deliver treatments during pregnancy that are safe for the mother and fetus. As with all breast cancer patients, a multidisciplinary approach should be employed with involvement from the surgeon, medical and radiation oncologists. A high-risk obstetrician should be included with the team. Surgery is a mainstay in the treatment of breast cancer in pregnancy. The timing of surgery may need to be delayed until after the 12th week. A consult with anesthesia should be employed to determine when best to proceed to decrease risks to the fetus. Both mastectomy and lumpectomy are options. For breast conservation (lumpectomy), the radiation will need to be delayed until after delivery. The axilla is important for staging. Axillary dissection has been traditionally performed safely. There are some studies that have utilized sentinel lymph node biopsy with Technicium 99 only (the blue dye-Isosulfan blue is not recommended). US-guided core needle biopsy can also be used with good results for preliminary staging. Chemotherapy can be given safely in women after the first trimester. It can be given preoperatively (neoadjuvant) or postoperatively. Neoadjuvant chemotherapy can be used to shrink the tumor or control disease if locally advanced. Many of the regimens can be used successfully with minimal effects to the fetus and resulting in a healthy delivery. Each regimen is personalized based on maternal weight and the timing of delivery. It is recommended that chemotherapy be stopped 4 weeks prior to delivery. Targeted agents, like Herceptin, are given after delivery. Hormonal therapy is also delayed until after delivery. Our patient above received a lumpectomy and axillary dissection at 22 weeks with general anesthesia. She tolerated the procedure without difficulty. Her pathology showed a 1.5cm infiltrating ductal
Regina Hampton, M.D., FACS
carcinoma, Elston grade 3. 1 out of 6 lymph nodes were positive for carcinoma. Her tumor was Estrogen receptor (ER) positive, Progesterone receptor (PR) positive and Her 2-neu receptor negative. She began chemotherapy at 30 weeks. She delivered a healthy full term baby girl at 38 weeks by cesarean section. She resumed chemotherapy. At 4 weeks postpartum, we ordered a breast MRI. A breast MRI is normally ordered prior to surgery to help determine the extent of tumor and to rule out other lesions in either breast. The MRI showed an abnormal area of enhancement. An US-guided core needle biopsy revealed a new infiltrating ductal carcinoma that was ER positive, PR positive and Her 2-neu positive. The patient had a mastectomy with TRAM reconstruction. She completed her last cycle of chemotherapy and then whole breast radiation and a one-year course of Herceptin. This patient is negative for BRCA1 and BRCA 2 mutations. Our patient is two years disease free with a healthy two-year-old girl. This patient is a shining example of how a multidisciplinary team approach can yield a healthy baby and cancer-free mother. Regina Hampton, M.D., FACS, is a board certified general surgeon with a special interest and established expertise in benign and malignant breast disease. Dr. Hampton is medical director of Signature Breast Care. She can be reached at office@signaturebreastcare.com. MAY/JUNE 2011
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When Franklin Squar Square e Hospital Center was named one of HealthGrades® America’s 50 Best Hospitals™ for 2011, we wer America’s were e very excited. e. Our ranking puts us among the nation’ nation’ss elite hospitals that deliver superior quality and excellent car care. In fact, for the past seven years, Franklin Squar Square e has been recognized recognized as a distinguished hospital for clinical excellence – not just among the nation’s nation’ community hospitals, but also major academic medical centers. Thank you to the doctors, nurses and associates who helped us achieve this milestone.
But what’s what’s even mor more e exciting than being rrecognized ecognized for quality care care is delivering it to the people who matter most — our patients.
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Solutions
Improve Your Medical Practice Performance By Nancy R. Smit, MBA, RPT, RRT
W
ITH THE MOUNTING complexities facing medical practices today, physicians and their practice administrators need to be more vigilant than ever in maximizing their operational performance. According to the Medical Group Management Association (MGMA) Annual Report - Performance and Practices of Successful Medical Groups, “better performing” medical practices collected at least 15% more revenue than similar practices within the same specialty, and many had profit margins that were more than 30% above their peers. In general, there are four key areas where the “better performing” practices excel: • • • •
Profitability and cost management Productivity, capacity and staffing Accounts receivable and collections Managed care operations.
The common denominator of the successful practices surveyed by MGMA was that they all shared a “culture of quality” within their organizations. Medical groups that have better financial performance than their peers typically exhibit a culture that focuses on the patient and on providing high quality services. They also focus on both physician and staff productivity, and their management is willing to invest in the resources needed to maximize it. This article examines some of these characteristics in more depth. Increasing Staff Costs Can Increase Profitability Regardless of the type of practice, the “better-performing” practices in the
MGMA survey consistently had: • Greater productivity • Higher employee-to-provider staffing ratios • Higher operating costs than their peers. While somewhat counter-intuitive, appropriate expenditures on non-provider costs can have a multiplier effect on practice revenues. Many physician owners focus solely on the cost of adding staff, without considering how additional staff can help to boost productivity and generate more income. For example, if a group with two doctors employs one medical assistant (MA), one of the doctors is likely to be less productive when the MA is not available to assist him/her. Hiring a second medical assistant should allow both doctors to see more patients, enhancing productivity as much as 50% and more than compensating for the cost of the additional employee. Further, when properly supervised, the MAs can expand their roles to take on functions such as patient education and intake, providing staff growth opportunities and higher job satisfaction. Investment in Technology and Facilities Boosts Profitability Compared with other practices, a higher percentage of the “better performing practices:” • Acquired equipment and materials to provide new services (40% vs. 33%) • Acquired new information technology or billing systems (32% vs. 29%) • Remodeled existing facilities (77% vs. 22%) • Their investment in their staff, facilities and technology paid off in: (continued on page 10)
Nancy R. Smit
Top 10 Reasons Why Medical Practices Fail To Maximize Physician Revenue 1 2 3 4 5 6 7 8 9 10
Front office systems and procedures are weak. Superbills contain inaccurate and outdated codes. Fee schedules have not been updated. Physicians/providers downcode their levels of service. Accounts receivable are not worked consistently. Financial reconciliation procedures are weak or absent. Staff to physician ratios are too low. Physician productivity is not maximized. Customer service is not “top priority”. Practices don’t formally plan and incorporate ancillary sources of revenue.
MAY/JUNE 2011
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Solutions (continued from page 9) • Increased productivity • Higher medical revenue • Higher practice profitability (total medical revenue after operating expenses per FTE provider) Many practices are still performing core business processes the way they’ve been performed for years, often greatly compromising staff efficiency. While EMR can take time to show results, more immediate changes can be reaped with small investments in technology. For example, many practices are still not using scanners to scan insurance cards. Investing in this equipment allows billing staff to access information through the computer rather than having to pull a chart. Better Billing Begins at the Front Office Many physician practices are also leaving significant revenue uncollected. While coding and billing practices are important
contributors, the problem often starts with the front office. Billing staff can generate reports to identify the primary reasons for denial and rejection of claims. With proper feedback loops, issues such as not verifying patient demographic information or obtaining up to date insurance information can be corrected up front. Other relatively easy “fixes” for
productivity or salary plus incentive, versus 75% of other practices. At the same time, “better-performing” practices emphasize the importance of satisfying their patients. Some 82% conduct patient satisfaction surveys and use those results to improve services, compared with 74% of other practices that survey patient satisfaction.
“Better-performing” practices are more likely to have compensation models based on productivity. maximizing revenue include having a certified coder review coding prior to claim submission and investing time to ensure that your practice is actually being paid the amounts reflected on the contracted managed care fee schedules. Productivity-Based Compensation and Patient Satisfaction Boost Performance The MGMA survey also found that “better-performing” practices are more likely to have compensation models based on productivity. More than 84% base at least 50% of their compensation methods on
The MGMA survey found that successful practices focus on patient care and maximizing productivity. They invest in their futures by adding technology, facilities and services that meet their patients’ needs and by staffing at a level that allows the physicians and their employees to be more productive. These strategies appear to pay off. These “better performing” medical groups have found success the old-fashioned way: they’ve earned it! Nancy R. Smit, MBA, RPT, RRT, is president of SHR Associates, Inc. (SHR). She can be reached at nsmit@shrassociatesinc.com.
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Policy
Health Care Issues in the 2011 Maryland General Assembly Session By Gene M. Ransom, III, Esq.
T
HE 2011 MARYLAND GENERAL Assembly Session moved at a slow pace as the result of the large number of newly elected legislators. The majority of work on health care issues resulted from the state reaction to recent federal actions. The O’Malley Administration worked to pass two bills to bring Maryland law into compliance with the new federal health care law, The Patient Protection Accountable Care Act (PPACA). The first of which, Senate Bill 182/House Bill 166 (Maryland Health Benefit Exchange Act of 2011) created an insurance exchange where individuals could secure health insurance. The federal health care legislation required states to set up such Insurance Exchanges and Senate Bill 182/House Bill 166 was Maryland’s attempt to do so. Senate Bill 183/House Bill 170 (Health Insurance – Conformity with Federal Law) was the second initiative designed to replicate provisions of federal health care reform as they now stand with respect to new legal requirements on insurance companies relating to such things as pre-existing conditions and loss ratio. Both initiatives were enacted, although the Insurance Exchange bill was extensively amended to accommodate concerns of a wide variety of stakeholders, including The Maryland State Medical Society (MedChi) and the health insurance agent and broker community. In addition, the final version requires that the Insurance Exchange, once operational, has to return to the General Assembly for additional authority to operate. The General Assembly also considered measures related to electronic health records (EHRs) that were initiatives of MedChi. Federal legislation in 2009 created incentives for physicians to adopt EHRs. The 2011 Maryland General Assembly passed House Bill 736/Senate Bill 722 (Electronic Health
Records – Incentives for Health Care Providers – Regulations) to improve the State incentive that complements federal law. These bills provide that the Maryland incentive program for EHRs must be paid in cash by insurance companies to a participating physician. This legislation is the completion of a MedChi initiative first begun in 2009. Maryland is the only state in the nation that requires health insurance companies to provide incentives for EHR adoption. As a result of the 2009 legislation, the Maryland Health Care Commission (MHCC) was detailed to establish a onetime payment to Maryland doctors for EHR adoption. The MHCC convened all stakeholders in this process in December 2010 to propose regulations that established a one-time payment to Maryland primary care doctors of $8.00 per patient (not to exceed $15,000 per practice) from each insurance carrier. However, these regulations did not require “up front” cash unless both the doctor and
(Exchange) from selling “de-identified” health insurance information prior to the issuance of regulations specifying privacy protections. The bill was amended to reflect a resolution of the MedChi House of Delegates designed to control the sale of health information by insurance intermediaries that have a business relationship with the exchange. A network for exchange of EHR records from one health provider to another is under development and under the supervision of MHCC. MHCC has designated Chesapeake Regional Information System for Our Patients (CRISP) to operate the Exchange. While CRISP is dedicated to the privacy of health information, it has relationships with groups such as Axolotl, a for-profit company in the business of selling health insurance data. While CRISP had amended its contract with Axolotl to provide for increased confidentiality, the passage of House Bill 784/Senate Bill 723 insures that such information will be pro-
“The majority of work on health care issues resulted from the state reaction to recent federal actions.” the carrier agreed. However, many small primary care practices needed “up front” cash in order to afford EHR adoption. House Bill 736/Senate Bill 722 changed the regulation to allow the doctor to demand “up front” cash. In addition, the legislation directed MHCC to study the expansion of the incentive beyond primary care and to deliver a report to the General Assembly on this issue on or before January 1, 2013. House Bill 784/Senate Bill 723 (Medical Records – Health Information Exchange) was another MedChi supported initiative which prohibited Maryland’s Health Insurance Information Exchange
tected by Maryland law over and above any contractual undertaking. The details of House Bill 784/Senate Bill 723 respecting the sale of health information were negotiated by CRISP representatives and MedChi. It is somewhat unusual that so much of the Maryland health policy debated before the Assembly relate to federal action. However, it may be the new normal, as many Maryland leaders have stated a strong desire to make Maryland a leader in the implementation of health system reform. Gene Ransom, III, Esq. is the CEO of MedChi. He can be reached at gransom@medchi.org. MAY/JUNE 2011
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YES, WE’VE REDESIGNED OUR BREAST CARE CENTER TO FEEL MORE LIKE A FOUR-STAR HOTEL. NO, YOUR IN-LAWS CAN’T STAY HERE WHEN THEY’RE IN TOWN. Call it transformation. A renovation. Or an extreme hospital makeover. But for those who haven’t experienced the hotel-like comfort of the newly redesigned Herman & Walter Samuelson Breast Care Center at Northwest Hospital, you will be pleasantly surprised. Led by Dr. Dawn Leonard, fellowship-trained breast surgeon, you’ll find a relaxing spa-like atmosphere, the latest in digital mammography and a staff of leading oncologists and surgeons. There is no finer setting in Baltimore for comprehensive breast care. To learn more, go to lifebridgehealth.org.
Northwest Hospital is located at the corner of Old Court and Liberty Roads.
Compliance
A Stark Case: Happy Ending or Inauspicious Beginning? By Charles B. Oppenheim, Robert L. Roth and Patricia H. Wirth
T
HE FEDERAL GOVERNMENT sued Joseph Campbell, M.D. for alleged false claims submitted not by Dr. Campbell, but by a hospital. Dr. Campbell had an employment contract with the hospital for 20 hours of service per week. However, although Dr. Campbell did everything the hospital requested, he actually provided far fewer services. The government claimed the contract was a scheme to pay Dr. Campbell for patient referrals in violation of the “Stark” Law. This violation would prohibit the hospital from billing Medicare for the services it provided to Dr. Campbell’s patients. Therefore, the hospital’s claims were alleged to violate the False Claims Act (“FCA”), which imposes civil liability upon any person who knowingly presents, or causes to be presented, a false claim for payment. Dr. Campbell argued that even if the hospital’s claims were false because they violated the Stark Law, he did not submit the claims or “cause” them to be submitted to Medicare. Rather, the hospital submitted the claims. The government argued Dr. Campbell knew these were Medicare patients and if he referred them to the hospital, the hospital would bill Medicare. However, after a recent trial, the jury found Dr. Campbell did not violate the Stark Law so there was no FCA violation. This seems like a happy ending since Dr. Campbell avoided harsh legal consequences such as substantial fines (which are not covered by malpractice insurance), potential exclusion from the Medicare and Medicaid programs, and possible suspension or termination of his license. However, Dr. Campbell actually paid a high price for this “victory.” He undoubtedly spent a lot of his own time, and money in legal fees, to defend this case. The case might have harmed Dr.
Left to Right: Charles B. Oppenheim, Robert L. Roth, Patricia H. Wirth. Campbell’s professional reputation and disrupted his practice as well. This prosecution could have been avoided. Dr. Campbell was an easy target because he did not provide the type or amount of services required by the contract. Instead of doing just what the hospital asked him to do, Dr. Campbell should have provided, and documented, 20 hours of service each week. Was Dr. Campbell’s prosecution an aberration? Will Dr. Campbell’s victory discourage the government from bringing similar lawsuits? While the answers remain to be seen, it is likely this case signals a more aggressive enforcement approach by the government to target physicians for prosecution in ways that were unthinkable a few years ago. For example, the Medicare Recovery Audit Contractor (“RAC”) audits are being extended to physician offices which could provide an easy avenue to discover potential false claims or overpayments. Also, under a new law, physicians could be targets of FCA cases if they fail to refund Medicare overpayments within 60 days of discovering the overpayment. Physicians should consider Dr. Campbell’s case a warning to prepare themselves for increased enforcement activity. While it is good practice for physicians to verify that they satisfy applicable Stark Law requirements, a document that on its face is in regulatory compliance is no defense if it is not carried out according to its
terms. Physicians must actually provide the services required, and verify the compensation they are receiving is fair market value for those services. Similarly, if physicians are renting space or equipment from or to hospitals, physicians should be sure the rental is at fair market value. Physicians also should review their office practices to be sure they have compliance programs and policies in place that respond to new regulatory matters. Again, physicians must actually be using and following these programs and policies. A compliance program that sits on a shelf and is not followed will be no help to defend an alleged violation. It might even be used against a physician to show knowledge of a particular problem. Finally, if a physician becomes aware that he or she is under investigation by a governmental agency, the physician should consult qualified legal counsel immediately. If another party is involved, such as a hospital, the parties could have adverse interests and should consider using separate legal counsel from the outset. Charles B. Oppenheim, Esq. is a principal in the Los Angeles office of Hooper, Lundy & Bookman. He can be reached at coppenheim@health-law.com. Robert L. Roth, Esq. is managing partner of the Washington, DC office of Hooper, Lundy & Bookman. He can be reached at rroth@health-law.com. Patricia H. Worth, Esq. is an associate in the Washington, DC office of Hooper, Lundy & Bookman. She can be reached at pwirth@health-law.com MAY/JUNE 2011
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Medical Beat
Cullen Named to National Cancer Board President Barack Obama recently selected Kevin J. Cullen, M.D., director of the University of Maryland Greenebaum Cancer Center, to serve on the National Cancer Advisory Board, an advisory committee to the U.S. National Cancer Institute (NCI). Dr. Cullen, a head and neck specialist and professor of medicine at the University of Maryland School of Medicine, is one of five people appointed to the board. The appointment is for six years. As a member of the National Cancer Advisory Board, Dr. Cullen will advise the secretary of the U.S. Department of Health and Human Services and the NCI director on issues that relate to institute activities. His role includes reviewing and recommending support grants and cooperative agreements.
New Case Management Program Coming to Shore Health Shore Health System will launch in July a new community case management program. The goal of the program is to prevent unnecessary hospital readmissions for people with chronic diseases through medication management, education and use of outpatient healthcare services. Led by Sharon Stagg, R.N., the program will serve residents in Talbot, Dorchester, Queen Anne’s and Caroline counties. For more information, call 410-822-1000 ext. 5212.
New Ear, Nose, Throat Center Opens in Lanham Doctors Community Hospital recently opened The Center for Ear, Nose and Throat, an otolaryngology facility in Lanham offering comprehensive ear, nose and throat treatment. Led by Otolaryngologist Bryan Ego-Osuala, M.D., the center specializes in managing disorders of the ear, nose and nasal passages, allergy conditions, sinuses, larynx, oral cavity and upper pharynx, as well as cancer of the head and neck. It treats patients ages two and up.
Hospice of the Chesapeake Names New Leader Lou Lukas, M.D., is the new chief medical officer of Hospice of the Chesapeake in Annapolis. Dr. Lukas, who previously worked as medical director of the palliative medicine program at Lehigh Valley Health Network in Pennsylvania, has more than 10 years of family medicine and palliative care experience. As chief medical officer at Hospice of the Chesapeake, she will work with current hospice teams to launch a new general inpatient care unit, expand the services provided for children and guide hospice’s medical future. Dr. Lukas received her medical degree from the University of Nebraska Medical Center. She completed a residency at Lehigh Valley Hospital and Health Network, where she also participated in a pilot palliative medicine program to help patients with advanced and complex conditions and their families focus on their quality of life. She recently completed a fellowship in health science research and leadership at the University of Michigan in the Robert Wood Johnson Clinical Scholars Program.
GBMC Doctor Receives Macular Medal The Macula Society has awarded Janet Sunness, M.D., medical director of Greater Baltimore Medical Center’s Richard E. Hoover Low Vision Rehabilitation Services, with its 2011 J. Donald M. Gass Medal for outstanding contributions in the study of macular diseases. Founded in 1977, the Macula Society is a forum for new research in retinal vascular and macular diseases.
New Guidelines in Treating Diabetic Neuropathy A new guideline for treating diabetic nerve pain was published in the April 11, 2011 online issue of Neurology, shows evidence that seizure drug pregabalin is effective in treating nerve pain and can improve a patient’s quality of life. But the guideline also found it may not be appropriate for all patients. Other treatments can be effective, including seizure drugs gabapentin and valproate, antidepressants such as venlafaxine, duloxetine and amitriptyline, and painkillers such as opioids and capsaicin. “Diabetic neuropathy is a painful and life-altering condition, so we need to find ways to help people who are suffering with it,” said James Russell, M.D., guideline author and professor of neurology, anatomy and neurobiology at the University of Maryland School of Medicine. Send news and announcements for publication consideration with high res photo (300 dpi) to news@mdpracticelife.com MAY/JUNE 2011
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Healthcare IT
The Clock is
Ticking
Three “Wired” physicians discuss why and how medicine must go electronic 16 |
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BY LINDA HARDER
S IF medicine didn’t already have more than its share of acronyms, the push to electronic information exchange, fueled by both technological advances and healthcare reform, is creating a bumper crop. What these terms - EMR, EHR, Meaningful Use, CRISP, HIT, CPOE, ACO and PCMH (Patient-Centered Medical Home) - have in common is a dependence on electronic technology. Knowing this new lingo and employing the technologic requirements it entails may soon be as critical to sustaining a viable medical practice as clinical skills. This Healthcare IT department of Maryland Physician will seek to help doctors understand the impact of health information technology (HIT) on their practices and meet Meaningful Use compliance deadlines. In this issue, we interview Holly Dahlman, M.D., an internist in solo practice, Sanford Siegel, M.D., president and CEO of Chesapeake Urology Associates and John Chessare, M.D., president and CEO of GBMC, to learn how they’re using technology to improve patient care and work more efficiently. With the clock ticking, the pressure is on. Electronic Practice from Day One Ahead of the curve, Dr. Dahlman’s Green Spring Internal Medicine practice
the MHCC Multi-Payor PCMH pilot program – one of two pilot programs in Maryland. My 2700 patients will be enrolled in the PCMH unless they opt out,” she comments. “The medical home is a teambased model that strives to provide centralized, coordinated care to help keep patients healthy. HIT is absolutely necessary for that. And in the end, it’s my final saving grace.” As a medical home, Dr. Dahlman will receive an additional payment of about $5 per patient per month to compensate her for the added responsibilities of coordinating care, helping patients set and keep health goals, collaborating with specialists and other health providers and keeping patients sufficiently healthy to avoid hospitalization. Specialists Were Early HIT Adopters Like Dr. Dahlman, Chesapeake Urology Associates was an early adopter of electronic information systems. Its CEO, Sanford (“Sandy”) Siegel, M.D., notes, “We started with EHR in 2004 and had fully implemented it by mid 2005. Our practice uses Allscripts and we decided to control the hardware, rather than using the cloud. We do all charting through the EHR and E-prescribe, which are compliant for PCRS (formerly PQRI) and which will get us ready for MeaningPAPERCAMERA PHOTOGRAPHY
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has never been paper-based. When she opened her doors in 2006, she launched her practice with the help of eClinicalWorks, an electronic medical record system. She extols the benefits of going paperless. “I can’t imagine practicing medicine on paper now,” Dr. Dahlman says. “I can fax a specialist a note, print off a copy for the patient, interface with lab and pharmacy electronically, and even instantly see my financial data. I’m currently transitioning from having servers in my office to using Software as a Service (SaaS), to have more services without spending more money. My patients can log into their secure web portal and access portions of their record online. The web portal is linked to the practice website. Using eMessenger, I will be able to access patient information securely from outside of the office.” Dr. Dahlman adds, “People in the U.S. are heavily interested in and invested in technology. If healthcare will start catching up, we can practice better medicine because we’ll improve both information and communication.” HIT not only saves Dr. Dahlman a full time employee, but its implementation is an essential step to achieve Meaningful Use criteria and become a PCMH. “Starting this July, I’m participating in
Holly Dahlman, M.D., reviews electronic health information with her patient. MAY/JUNE 2011
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ful Use. We just started using Phreesia, an electronic tablet where patients can enter their demographic data and medical history, verify their insurance and pay copays and balances. We’re also moving towards having a patient portal where patients can securely enter their demographic data and medicines online.” “Dr. Siegel continues, “The downsides of EHR are that it takes a lot of time, a lot of IT involvement and it’s expensive. With EHR, doctors are doing more typing and have more responsibility for completing the chart. As a result, we see fewer patients, but we collect more for each patient because we are able to code more accurately. EHR has been a learning curve for staff and doctors, but most would never want to go back to paper. Electronic communication is more accurate, provides more information and keeps us more organized. We get quick report turnarounds and dictation no longer takes weeks.” Dr. Siegel concludes, “EHR is perhaps not essential if you’re near the end of your career, but for all other doctors, it’s valuable and you have to do it to continue to be in practice.” Hospital CEO Drives HIT Reform At the hospital system level, Dr. Chessare is driving the shift to electronic information exchange not only within the walls of the hospital, but also with doctors and other providers in outside practices. “We’re rolling out EHR to all employed physicians,” he notes, “and establishing Greater Baltimore Health Alliance (GBHA), a vehicle for providing an integrated system of care that includes creating a patient-centered Medical Home and helping private practices affiliated with GBMC to meet Meaningful Use criteria.
We need to stop practicing what Elliott Fisher, the Dartmouth professor who coined the term Accountable Health Organizations, calls ‘hamster medicine’, where we have to run ever faster on the wheel. You don’t know how many wasteful steps you’re going through until you transition to electronic communication. It’s absurd, in the 21st Century, to be paper-based.” Dr. Chessare adds, “We will finish implementing CPOE (computerized provider order entry) by July, 2011. The surgeons and OBs will be the last to be added. We’re very excited about it – it’s cutting in half how long it takes from the time a drug is ordered until it is administered to the patient.” While a study from the Journal of the American Medical Association found that the use of CPOE cuts medication errors by 80 percent, Dr. Chessare cautions that electronic communication is not a panacea. “It’s an opportunity to move errors to another place,” he warns. “For example, we had a situation where a pharmacist accidently clicked on the wrong patient in the list. Thankfully, a nurse caught the error before the medication was given.” Finding a balance between protecting patient data and providing convenience is challenging. “We’re participating in CRISP (Chesapeake Regional Information System for our Patients), but frankly, it’s going to take too long,” Dr. Chessare notes. “The majority of Americans would rather have the information available in the ER, taking the risk that someone might misuse it. At GBMC, we’re going to create the most facile information sharing system we can legally provide.” Dr. Chessare notes that systems where doctors are employed, such as
HIT definitions ACO An Accountable Care Organization is an organization of physicians, hospitals and other healthcare providers that assumes the responsibility to provide the full range of medical care for a defined population of patients.
CPOE Computerized provider order entry is the process of entering physi18 |
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cian medication orders and other provider instructions electronically, rather than on paper.
CRISP The Chesapeake Regional Information System for Our Patients is a not-for-profit membership corporation and Regional Extension Center (REC) to promote health information exchange in Maryland and help 1000
primary care providers deploy EHR.
EHR and EMR Electronic health records or electronic medical records are systems that can store and access a patient’s medical history by computer or other electronic device.
HIT Health information technology refers to the comprehensive entry and exchange of secure
John Chessare, M.D., president and CEO of GBMC Mayo Clinic and Kaiser Permanente, are the farthest along and face the fewest challenges when implementing electronic data sharing. “We’re trying to create a Mayo Clinic without walls,” he states. “Luckily, our physicians understand the need to automate and our board is supportive, too. We’ll try to welcome as many primary care practitioners as we can and then add the specialists.” While coming from different backgrounds and practice settings, these three physicians all have come to the same conclusion about the many benefits to be reaped from HIT, while acknowledging the heavy investment of time and money it requires. With Meaningful Use deadlines looming, physicians don’t have the luxury of waiting for the perfect system or hoping the issue will go away.
electronic healthcare data among patients, providers, insurers and the government.
MEANINGFUL USE A requirement of the American Recovery and Reinvestment Act of 2009 (ARRA), providers must use certified EHR technology requirements by established deadlines in order to receive financial incentives (and later avoid financial penalties).
PCMH As defined by the AAFP, a patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology.
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BY LINDA HARDER • PHOTOGRAPHS BY TRACEY BROWN
Cracks In Maryland Medicine’s Glass Ceiling
Four Female Physician Leaders Discuss Their Non-Traditional Roles
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By 2005, female medical school applicants had edged out their male counterparts, with 50.4% of entrants being female, compared to only 29.5% in 1980. That and many other statistics demonstrate the progress women have made in what was once a male-dominated profession. Yet the vast majority of women still choose the traditional specialties of pediatrics, family practice or internal medicine, and OB/GYN. And discrimination, while waning, has far from disappeared. Nowhere is the distance that women physicians have yet to go more obvious than in medical leadership positions, where men dominate. Learn how four women physician leaders in non-traditional roles – Julie Frieschlag, M.D., Gail Cunningham, M.D., Stacy Fisher M.D., and Brooke Buckley, M.D., – have begun to crack the glass ceiling. Hurdles Women Leaders Faced While Pursuing Their Dreams Julie Freischlag, M.D., chair of Department of Surgery at Johns Hopkins, has perhaps climbed farther than any other woman physician in the country. One of only six female surgical chiefs in U.S. history, Dr. Freischlag has served as chief for eight years and is only the sixth
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surgical chief in the history of Hopkins. Ironically, she fell into a medical career only because “they basically had closed opportunities in education when I went to school. I was going to be a nurse but became pre-med by default because I didn’t want to move away.” “Women physicians often do have to work twice as hard as men,” Dr. Freischlag observes. “I didn’t notice a difference during training, but post training is harder because people are competing for power and control. A dean told me that he couldn’t have a woman chair and people talked when I was first appointed chief here at Hopkins.” Gail Cunningham, M.D., chief of Emergency Medicine at St. Joseph Medical Center and newly appointed president of the medical staff, faced a huge challenge early in her medical training when she found herself a single mother. “With family support and the determination that I could be both a parent and a doctor, I raised my daughter as a single parent. I’m a total believer that anything is possible for women in medicine.” However, Dr. Cunningham gave up her first choice of a surgical specialty to go into emergency medicine in order to
Julie Freischlag, M.D., chair of Surgery at Johns Hopkins, before her next surgical case.
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“My first mentor actually told me I’d be taking away a job from a man with three children... I learned to stand my ground. If you find a passion, stay with it.” — Stacy Fisher, M.D.
have a sufficiently predictable schedule. “Fortunately, I did a rotation in emergency medicine and loved it. I had to do a lot of night work while my daughter was young so I could be there for her.” Stacy Fisher, M.D., the newly appointed director of Women’s and Complex Heart Disease at University of Maryland Medical Center, wanted to be a physician since she was three years old, but she faced resistance throughout. She says, “I had strong support from my mother but not all family members believed that women should be doctors. And my first mentor actually told me I’d be taking away a job from a man with three children – so I just got another mentor. I learned to stand my ground. If you find a passion, you need to follow it and not let people take it away.” Younger women physicians have faced less discrimination, but still encounter few female colleagues when they choose a surgical specialty. Brooke Buckley, M.D., a surgeon at Shore Health System for four years and the chair of MedChi’s Public Health Subcommittee of the Legislative Council, comments, “In medical school, about half of my class were women, but for the majority of my residency, I was the only female. Many women choose radiology and anesthesia because the lifestyle is better.” The three male partners in her surgical practice have been extremely supportive. “Being a woman has never been an
Gail Cunningham, M.D., chief, Emergency Medicine and president of the medical staff at St. Joseph Medical Center, talks candidly about the issues female physician leaders face. 22 |
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issue in my practice,” Dr. Buckley continues. “I’m treated like a sister or daughter, not like a threat. In fact, some male patients seek out a woman physician because they feel we listen better.” She notes, however, that there are few other women in the room at the MedChi meetings she attends. “There are about 60 men and three women, including me. They are welcoming but I feel obvious.” Women Bring Special Traits to Patient Care and Leadership Positions All four physicians felt that women bring special qualities that can make for more effective patient care and leadership styles. “As a woman, I spend more time and listen more intently than many male physicians,” says Dr. Fisher. “I also understand women who have difficulty caring for themselves; I have that problem myself.” Dr. Cunningham comments, “Women are inherently responsible and multitaskers. Our compassionate nature influences how we interact with patients and colleagues. As a leader I have found it challenging to interact with the strong egos of many of my male colleagues and have had to learn how to integrate our inherent differences in communication styles into effective decision making. “Long before I became the ED Chief, I found myself upset when I didn’t feel we were providing timely care,” adds Dr. Cunningham. “I think my passion for quality care led people to seek me out as a leader. I am a strong believer in holding all of us who have chosen health care as our profession accountable to do the ‘right thing’ despite any personal sacrifice.” Dr. Freischlag observes, “Women are good multi-taskers, they’re fast and they’re good at teamwork. You need that to be an effective leader.” As chief, she has made significant changes to the surgical process, moving away from an individual focus to a team focus. She says, “You’re safer when more than one person is involved. We use teams and checklists, and get the patient involved, providing lots of education. We perform a briefing before each procedure and a debriefing afterwards. The entire team is on a first-name basis – it’s friendlier and it’s more efficient.” As Chair of the Public Health subcommittee, Dr. Buckley reviews all of
Brooke Buckley, M.D., surgeon at Shore Health System, consults with one of her nurses. the bills in the Maryland legislature that pertain to public health and helps formulate MedChi’s stance on issues. She strives to ensure that the physician’s point of view is heard. “I spent the first 32 years of my life training for this job and dedicating myself to making people’s lives better. I don’t want to see the government make us out to be uncaring. I didn’t miss dinner three days every week because I was trying to do the wrong thing.” Lifestyle Sacrifices Are Worth It All of the women interviewed noted the tremendous sacrifices that being a female physician, especially in a leadership role, necessitates. However, they felt it was worth what they had to give up. Dr. Fisher, who has two young children, comments, “This specialty has enormous lifestyle issues. My family makes a lot of sacrifices. At the end of the day, it has to be worth it because I’ve missed lots of holidays and birthdays. But if you’re motivated for the right reasons, it’s worth it because you have helped someone in a way that rationalizes the sacrifice that friends and family make.” “Even now that my daughter’s grown, it’s a challenge to balance home life and work life,” Dr. Cunningham notes. “My ‘in-box’ is always overflowing but I have a loving husband, daughter and family life that I want to attend
to. Balancing our commitment to patients and career with our commitment to our loved ones is very difficult.” One price many female surgeons pay for their career choice is difficulty becoming pregnant. Some 40% of women surgeons face infertility issues, likely attributable to the long hours and stress. Dr. Buckley remarks, “You give up so much – friends’ weddings, holidays and being home only a few nights of the week. You don’t realize how much it takes out of your soul.”
A Wonderful Time to Be a Woman in Medicine According to the 2000 Census Bureau, women physicians still earned only 63 cents on the dollar. And a survey of female physicians in 2000 found that nearly half of female academic physicians had experienced sexist comments or behavior. Further, women physicians were five times more likely to have experienced obstacles to career advancement than their male counterparts. While change is slow and uneven, it is occurring. “Four out of my six chief residents are women,” comments Dr. Freischlag. “In the next 10 years, change will occur more quickly because men are getting used to women leading. I tell women that you can only change things if you run it.” Dr. Fisher concludes, “There’s a definite trend to more women leaders. It’s a wonderful time to be a woman in medicine. There are more women mentors who provide a safe place to seek advice. The medical community also is more open to creating new models today, so that women can have both a family and a medical career. Women contemplating medicine today can create something that will work for them.” These four strong women are proof that there’s a growing role for women leaders in medicine, and that the increasing fissures in the glass ceiling may one day smash it completely.
Stacy Fisher, M.D., director of Women’s and Complex Heart Disease at University of Maryland Medical Center, in the cardiac electrophysiology lab. MAY/JUNE 2011
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BY TRACY M. FITZGERALD â&#x20AC;˘ PHOTOGRAPHS BY MARK MOLESKY
Perspectives from women in
Leadership Female Presidents and CEOs share their insights on the rewards and challenges of running a Maryland acute-care hospital
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I
N RECENT YEARS, THE role and value of gender diversity in the workplace has become increasingly apparent in the healthcare industry. Research shows that today, more women than men are submitting applications to medical schools nationwide. This means that in the near future, there will predictably be more females than males placing “M.D.” at the close of their signature lines. And it doesn’t stop there; more women are seated in executive leadership roles in hospitals today than ever before. In the state of Maryland, nine acute care hospitals are currently led by a female president or chief executive officer. Seven of the nine leaders recently joined Maryland Physician Magazine’s Publisher and Editor-in-Chief Jacquie Roth for a unique roundtable discussion, covering topics from personal career strategy and women in leadership, to physician relations, hospital operations, legislative issues in healthcare, and delivery of the one thing that matters the most – a top notch patient experience in today’s constantly evolving, technical and complex world. Joining the conversation: Adrienne Kirby from Franklin Square Hospital Center; Bonnie Phipps from St. Agnes Hospital; Joyce Portela from Washington Adventist Hospital; Karen Olscamp from Baltimore Washington Medical Center (BWMC); Sylvia Smith Johnson from Maryland General Hospital; Verna Meacham from Fort Washington Medical Center; and Victoria Bayless from Anne Arundel Health System. For each hospital leader, the journey that led them ultimately to the president’s chair was unique and personal. While Bayless’, Meacham’s and Portela’s stories implied that healthcare was part of their destiny, based on their passion or involvement in the field from very young ages, Kirby and Phipps originally pursued completely different career paths that diverted them to the field of healthcare. Olscamp began her career as a critical care nurse who eventually started picking up administrative and non-clinical projects as a way to learn and grow, leading ultimately to a leadership opportunity. And Smith Johnson actually started her healthcare experience in the Executive Office, serving as assistant to the president of University Hospital (known today
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as the University of Maryland Medical Center) as she was pursuing her undergraduate degree. “I wanted to keep challenging myself and a career in healthcare presented that opportunity,” said Phipps, originally a finance and accounting specialist who has served as president and CEO of St. Agnes Hospital for the past 15 years. “It’s a complex field that requires a balance between the business aspects of running an efficient organization and the fact that people are trusting you with their lives.” For every hospital president, the development, nurturing and growth of relationships with physicians is a vital component to running that efficient organization, Phipps references. Recruitment of physicians who offer the right skill set and a vision for the future that aligns with each hospital’s long-term strategic plan is a common priority. Getting the right docs in the door is the first step in the process; keeping them there is becoming increasingly important as each hospital expands or enhances its line of clinical services and also prepares for upcoming retirements of their most tenured physicians. “We are reorganizing the way we recruit, with a focus on finding more local doctors who will be loyal and want to stay here long-term,” said Kirby, president of Franklin Square Hospital. “Our strategy is defensive and involves constantly looking at the resources we have and how we can be more nimble in giving our physicians what they need and want in order to keep them here.” Bayless, president of Anne Arundel Health System, is seeing an increase in the number of physicians who wish to be
needs of Baltimore City’s population, as well as to support the hospital’s growth as facility enhancement projects are completed. “Medical residents are finishing their programs and need a place to work,” said Smith Johnson, president and CEO. “We are giving them new reasons to think about coming here.” For many hospitals in the state of Maryland, collaboration is the key to running an efficient operation while maintaining focus on patient needs. Franklin Square Hospital, St. Agnes Hospital, Ft. Washington Medical Center and Washington Adventist Hospital achieve this as members of health systems (Medstar Health, Ascension Health, Nexus Health and Adventist Health, respectively). Anne Arundel Medical Center, part of Anne Arundel Health System, has a partnership with Johns Hopkins Medicine to create broader access to clinical trials for patients and physicians. And, both BWMC and Maryland General Hospital are affiliates of the University of Maryland Medical System, allowing them to provide better access to tertiary care for patients stemming from their local communities. “Continuity of care, and the availability of sophisticated services in a community hospital setting was the key for our merger,” said Olscamp, president and CEO of BWMC. “It’s about looking at where your organization is today versus what the needs will be a decade from now, and creating strategies of alignment.” Technology in healthcare is another “hot topic” among hospital leaders, especially as the implementation of electronic
“I wanted to keep challenging myself and a career in healthcare presented that opportunity.” Bonnie Phipps, president and CEO of St. Agnes Hospital
employed by Anne Arundel Medical Center. “There is a lot of change happening now and forecasted for the future in healthcare, and for many it’s an unsettling time,” she said. “Doctors want stability, collaboration and protection.” Maryland General Hospital has implemented a similar strategy, “hiring their own” to staff new outpatient and ambulatory sites designed to best meet the
medical records becomes an increasingly important priority as a means of improving patient safety standards. While the benefits of these computer-based systems are clear, many hospitals have struggled to manage the process of implementation, for reasons ranging from the significant financial investment that is required, to the challenges of achieving compliance among physicians and clinical support
staff, some of whom are hesitant to embrace change in their work environment. “Once you implement it, you don’t know how you ever functioned without it,” said Portela, president of Washington Adventist Hospital. “You quickly are able to see how much was slipping through the cracks, and how the system works to improve process efficiency and patient safety.” Each hospital is also seeing unique trends in terms of how physicians, staff, patients and communities at large are using technology for everyday communications. Some physicians see text messaging as a quick and efficient way to share information with their colleagues. In fact, Portela shared that a cardiac physician on her medical staff recently used his cell phone to text an image of an open chest to a referring physician. And social media has given every hospital a new opportunity to gain knowledge and
“Social media is a channel of communication that replaces no other. It expands our audience and gives us new ways to reach people” Verna Meacham, president and CEO, Ft. Washington Medical Center
(Clockwise from top left) Bonnie Phipps, St. Agnes Hospital; Joyce Portela, Washington Adventist Hospital; Victoria Bayless, Anne Arundel Health System; Adrienne Kirby, Franklin Square Hospital; Jacquie Roth, Maryland Physician Publisher/Editor-inChief; Verna Meacham, Fort Washington Medical Center; Karen Olscamp, Baltimore Washington Medical Center and Sylvia Smith Johnson, Maryland General Hospital. insight about the “chatter” that is happening in their respective communities about their organization. “Social media is a channel of communication that replaces no other,” said Meacham, president and CEO of Nexus Health and Ft. Washington Medical Center. “It expands our audience and gives us
new ways to reach people.” Adds Smith Johnson, “It’s another way for us to listen to the people in our community.” The information that is gained through these evolving systems of communication is helping each hospital confirm what their patients need, what their
patients want, and how they can work to create a better and more appealing environment of care for those who have an abundance of healthcare choices. While “creating a culture of service” is an apparent priority among every hospital leader, many are integrating “little things that can make a big difference” into their overall patient care offerings. Private patient rooms have quickly transitioned from the “nice to have” to “expected” category, not only because patients want privacy, but also as a means of improving infection control practices. And, there is a lot more focus these days on caring not only for the patient, but for their loved ones as well. “No one knows the patient better than their family and we need to account for this as we think about the overall patient experience,” said Bayless, whose hospital now offers 24-hour-per-day visiting hours. “We need to engage families in the care process and make sure that the message isn’t about what we will do for you or to you, but instead what we will do with you.” Others have accounted for practicality in patient rooms, based on the types of patients admitted to a particular unit and their predictable needs. Inpatients at BWMC have a designated spot to place their laptops and obstetrical patient rooms were designed to create a “spa-like” environment, complete with Jacuzzi’s to comfort new moms. Obstetrical patients at Franklin Square Hospital will find cappuccino makers in their rooms. While patient comfort and the delivery of an excellent experience from the time of admission to discharge are important to every hospital leader, each faces similar challenges in terms of balancing and prioritizing good ideas that require investments. With many of the outcomes of healthcare reform and other current legislative issues pending, there is a consensus that hospitals and healthcare systems will operate and manage patient care in a drastically reshaped manner, in the years to come. “I believe the healthcare industry will need to be innovative over the next decade, because in the years to come, we will be responsible for care that goes on outside of our walls,” said Olscamp. “We all know these are challenging times but we can work together to shape the future of healthcare.”
MAY/JUNE 2011
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BY LINDA HARDER
Women’sealth H UPDATE
From Botox® to Breast Biopsy 28 |
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With the flood of new research on breast and urogynecology treatments, it can be hard for referring physicians to keep up with the latest women’s health issues. Our three experts — Neil B. Friedman, M.D., Daniel Aronson, M.D., and Robert Gutman, M.D. — provide a glimpse into some of the more exciting recent developments in this field. Needle Breast Biopsies – Less is More Several new studies demonstrate that less is better when it comes to breast cancer treatment. A recent Florida study found that far more surgical biopsies were being performed than necessary. Compared with an expected rate of 10%, researchers found that 30% of Florida women underwent surgical (open) biopsies from 2003 to 2008. While the reason for the higher rate was not known, the authors speculated that self-interest and/or lack of knowledge could have fueled overuse of the more invasive approach. Neil B. Friedman, M.D., medical director of Mercy’s Hoffberger Breast Center, finds these results concerning but not likely to be replicated in the Baltimore or D.C. area. “Needle biopsies are nothing new – we’ve been doing them for more than 15 years. As smaller needle sizes and improved technology were introduced, they became more trusted. Today, needle biopsies absolutely should be the standard of care. In our area, I expect that the rate of excisional biopsies is extremely low. With rare exception, such as an 18 year old patient with fibroadenoma, all women should be getting them.”
Axillary Lymph Node Dissection Not Essential in Early Breast Cancer A study in the February 9, 2011 issue of JAMA reported that 92% of women with breast cancers less than 2 cm. whose cancer spread to the lymph nodes were alive five years later, whether or not they underwent axillary lymph node dissection. Both groups of women received radiation and a lumpectomy. Both groups also had similar rates of cancer recurrence or metastasis after five years – 82% in those with axillary dissection vs. 84% in the group receiving more conservative treatment. “As a result of this study, we feel more comfortable than ever doing what we’re doing,” notes Dr. Friedman. “It highlights the need to individualize our treatment decisions - treating people less aggressively and more selectively – while getting results that are just as good.” “This is a time to individualize surgical care,” continues Dr. Friedman. “This study answers the question about the risk of recurrence in the axilla or of a distant metastasis if you do sentinel node biopsy alone.” The finding is good news for many women with early breast cancer, as removal of axillary lymph nodes can cause significant pain, lymphedema and sometimes infection, adversely affecting their quality of life.
3T MR Holds Promise for Breast Applications The higher spatial resolution of 3T MRI, now available in a growing number of Maryland inpatient and outpatient centers, holds promise for breast imaging. Some studies have shown higher diagnostic confidence for lesion depiction with breast MR at 3T. However, to date no prospective studies have demonstrated a definite clinical advantage of 3T breast MR compared to imaging at 1.5T. PEM-Guided Biopsies on the Horizon Another area of current research is Positron Emission Mammography (PEM) and PEM- guided breast biopsies. A study published in the March/April 2011 issue of Breast Journal reported 100% success in identifying areas with abnormal FDG uptake during 24 such biopsies. “Now that higher resolution PET breast imaging is being developed, it has the potential to provide biopsy guidance for lesions that are difficult to see with other conventional modalities,” observes Daniel Aronson, M.D., director of breast MRI at Advanced Radiology. Breast MRI is Underutilized Although commonly used in current clinical practice, breast MR imaging is frequently underutilized, and the
Neil B. Friedman, M.D., reviews breast treatment options with a patient. MAY/JUNE 2011
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MOLESKY PHOTOGRAPHY
appropriate clinical indications may not be well understood by referring physicians. Dr. Aronson notes, "If a suspicious lesion is well seen by mammography or ultrasound, MRI is not needed in the initial diagnostic work-up, but may be useful before treatment, depending on biopsy results." A recent study presented at RSNA 2010 confirmed the value of breast MRI as an annual screening tool for women with a personal history of breast cancer, augmenting existing evidence of its value for women with a strong family history or known gene mutation. Dr. Aronson reminds physicians of the following list of common indications for breast MR: ■ Problematic conventional imaging. In carefully selected cases, MRI may be helpful with equivocal or inconclusive mammographic or sonographic findings. ■ High risk screening for those with BRCA mutation, strong family history of breast or ovarian cancer, or history of chest radiation for Hodgkin’s Disease ■ Occult breast cancer in patients with normal conventional imaging, but with signs or symptoms of breast cancer and patients with axillary node metastatic disease, and unremarkable mammogram or sonogram ■ Assessment of response to neo-adjuvant chemotherapy ■ Patients with known breast cancer undergoing breast conservation surgery ■ Possible implant rupture. ■ Close or positive surgical margins at lumpectomy ■ Differentiation of post-op scar tissue from tumor recurrence ■ Newly diagnosed lobular breast cancer. Breast MR Spectroscopy Dr. Aronson sees a growing role for spectroscopy in breast diagnostic services. “Breast MR spectroscopy is also an area of current research,” he says. “By analyzing the chemical composition of a tumor, we can potentially increase specificity and decrease the number of benign biopsies." Botox® Found Effective for OAB For millions of women with incontinence, the emergence of Botox® as a therapeutic approach for overactive bladder (OAB) treatment is a welcome development. Not yet approved by the FDA but shown effective in a growing number of studies, Botox® 30 |
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The new development is that InterStim® received FDA approval for fecal incontinence in early 2011. —Robert Gutman, M.D.
Robert Gutman, M.D., discusses the latest urogynecology procedures. causes paralysis of the detrusor muscle by preventing the release of neurotransmitters from the cholinergic nerve endings. “There’s plenty of research to show that it’s safe and works well for women who have not had sufficient results from conservative therapy,” says Robert Gutman, M.D., fellowship director of the National Center for Advanced Pelvic Surgery at Washington Hospital Center. “Our experience has shown it can last at least nine to 12 months, and perhaps longer with repeated injections. However, until it’s FDA-approved, patients must pay out of pocket.” InterStim® Therapy now approved for Fecal Incontinence Sacral nerve stimulation (InterStim® Therapy), the minimally invasive implantation of a pacemaker-like device to stimulate the S-3 nerve root, has been FDA approved for 11 years for various urinary disorders, including urge incontinence. “The new development is that InterStim® received FDA approval for fecal incontinence in early 2011,” states Dr. Gutman. “It has 60 to 95% effectiveness for OAB and urge incontinence. We’re excited to have it as an option for this new application.” Improvements in Vaginal Mesh Procedures for Prolapse Dr. Gutman and his team have conducted research and published multi-center trials
on vaginal mesh for uterine prolapse. “We’re consistently analyzing products and implementing them when safe and appropriate,” says Gutman. “In vaginal hysteropexy, we have a new vaginal approach that uses less mesh and is lighter weight. Unlike most laparoscopic repairs, this approach allows women to keep their uterus.” Dr. Gutman received a generous grant from the Foundation for Female Health Awareness to perform a multi-center cohort study comparing vaginal and laparoscopic mesh prolapse repairs with uterine conservation. Tension Free Vaginal Slings Still Underutilized “Tension free vaginal slings, available since 1996, have revolutionized the way we treat stress incontinence,” says Dr. Gutman. “But because people are uncomfortable talking about incontinence, many of them don’t realize that these minimally invasive options exist. We can have a major impact on patients’ quality of life with a 20 to 30 minute outpatient procedure. Referring a patient directly to an urogynecologist may save them from undergoing repeat procedures, as can happen with less durable repairs.” In early 2011, Female Pelvic Medical and Reconstructive Surgery (aka urogynecology), was officially recognized by ABMS and ACGME as an accredited subspecialty. Neil B. Friedman, M.D., FACS, is medical director, The Hoffberger Breast Center at Mercy Medical Center. Daniel Aronson, M.D. is director, Breast MRI, at Advanced Radiology. Robert Gutman, M.D. is the fellowship director, FPMRS, National Center for Advanced Pelvic Surgery at Washington Hospital Center and associate professor, Departments of Ob/Gyn and Urology, Georgetown University Medical Center.
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Good Deeds
Phyllis Campbell, M.D.— On a Mission to Make a Difference By Tracy M. Fitzgerald
F
ROM THE TIME SHE WAS VERY young, Phyllis Campbell, M.D. dreamed of someday becoming a physician. Today, she considers it a blessing to practice medicine, using her knowledge and skills to positively impact people in her own community and also across the globe. Once a month, the Howard County General Hospital physician volunteers her time at the People’s Wellness Center in Montgomery County, which offers medical services to those without health insurance. Dr. Campbell provides free routine health exams to some of the Center’s patients, emphasizing the importance of prevention and early detection, and providing guidance and resources when more elaborate diagnostic testing and treatment are necessary. “The women who come into the clinic are so appreciative of what I am doing for them,” Dr. Campbell said. “I am very grateful for the chance to give back to my community.” In 2007, Dr. Campbell took her volunteerism to another level by participating in a medical mission trip to Haiti, providing health screenings and treatment. She worked from sun up to sun down each day, providing health screenings and treatment to people who do not ordinarily have access to medical care. The experience was so positive and personally rewarding that a year later, Dr. Campbell officially joined Dorcas Medical Mission, a faith-based volunteer organization that donates medical care to disadvantaged individuals across the globe. Dr. Campbell’s most recent mission trip was to St. Lucia, where approximately 2000 residents of the southern Caribbean island sought treatment for a full range of medical issues. “You go to these underprivileged parts of the world and see people that have so
On her recent medical mission trip to St. Lucia, Phyllis Campbell, M.D., helped provide care to more than 2,000 residents of the island, of all ages and scopes of need. much less than what you do. It really teaches you to appreciate the little things in life that are so often taken for granted,” Dr. Campbell said. “Hot showers and toilets that flush are a given in America. In many parts of the world, they are not.”
College of Obstetrics and Gynecology and served both obstetrical and gynecologic patients before transitioning exclusively to GYN care in 2005. After so many years in practice, she continues to be inspired by the evolving field of medicine.
“I love the challenge of the human body. To me, it’s an art.” While Dorcas provides the medical supplies necessary for each of its mission trips, Dr. Campbell is responsible for her own travel costs, which have been supported in part by donations from her church and the surrounding medical community. In the future, Dr. Campbell hopes to return to Haiti, where a significant need for medical care still exists in the aftermath of the 7.0 magnitude earthquake that devastated the island in January 2010. Dr. Campbell was born and raised in Baltimore and completed all of her medical training in Maryland, including a medical degree from the University of Maryland at Baltimore and a residency program at Sinai Hospital. She is a Fellow of the American
“I enjoy that medicine is always changing, and that my job requires me to be brave and constantly willing to learn,” Dr. Campbell said. “I love the challenge of the human body. To me, it’s an art.” Learn more about Dorcas Medical Mission and the opportunities that exist to contribute your time and talent to needy individuals worldwide. Call 718-342-2928 or visit www.dorcasmedicalmission.org. Maryland Physician Magazine would like to hear about your “Good Deeds.” Please share your ideas with us by contacting Jacquie Roth, publisher and editor-inchief, at 410-987-6667 or via email at jroth@mdpracticelife.com.
MAY/JUNE 2011
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Heritage BY BARTON COCKEY, M.D.
T
“The Sheppard and Enoch Pratt Hospital” by Elizabeth Cockey
HE SHEPPARD AND ENOCH Pratt Hospital, originally called the Sheppard Asylum, opened in 1891, twenty-nine years after the laying of the first cornerstone in 1862. Moses Sheppard (1771-1857) was one of those thrifty, practical Quaker merchants who did so much to create the prosperity that Baltimore enjoyed during the 19th century. In keeping with his prudent business practices, he stipulated that the institution be built and operated using only income, without touching the principal. Thus, construction went only as fast as the flow of income permitted. This slow-growing hospital became a model of its kind. Influenced by the reformer Dorothea Dix, Sheppard had insisted that patients should have “privacy, sunlight, and fresh air.” The purpose of this place was to cure, not merely to incarcerate. In 1893, the new asylum received a welcome infusion of cash from another generous Baltimore businessman, Enoch Pratt (1808-1896), who had made a for34 |
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tune in coal, iron, canals, railroads, and banking. “Sheppard Pratt,” as everyone calls it, soon became known as the region’s premier mental hospital. In 2000, the hospital enlarged and modernized, doubling the size of the facility. But they harmonized the architecture of the new structures with the lateVictorian buildings that give the campus so much charm. The stone gatehouse on Charles Street still invites the passing motorist to slow down and take a detour along the (sanely) babbling stream and through the wooded vale. Maybe a bit of that mental health will rub off.
ABOUT THE AUTHOR AND ARTIST Barton M. Cockey, M.D. is a native of Baltimore, an alumnus of Johns Hopkins University, and a diagnostic radiologist with Advanced Radiology. His wife, Elizabeth Cockey, from Washington County, New York, is an artist and art therapist. Together, they produce illustrative histories. Elizabeth paints the pictures, and Barton writes the text. Their last two books, Upstate New York, Towns That We Love and Drawn to the Land, The Romance of Farming, have been best-sellers in upstate New York. The accompanying image and article are excerpts from their upcoming book, Baltimore County, Historical Reflections and Favorite Scenes, scheduled for release in June, 2012. To learn more about their unique blend of beautiful paintings, carefully researched history, and curious anecdotes, log onto thepaintedword.info, or find them on Amazon.com.
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