M A RY L A N D
Physician YOUR PRACTICE. YOUR LIFE.
MANAGING PAIN, AVOIDING ADDICTION: MARYLAND’S PDMP NEW CARE DELIVERY MODELS PUT PHYSICIANS BACK IN THE DRIVER’S SEAT NEW INSIGHTS INTO AUTISM
mdphysicianmag.com
VOLUME 4: ISSUE 6 NOV/DEC 2014
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Contents 8
VOLUME 4: ISSUE 6 NOV/DEC 2014
20
F E AT U R E S
8 Managing Pain, Avoiding Addiction 12 New Insights into Autism D E PA R T M E N T S
Cases
| 5 | Current Awareness and Treatment of Critical Limb Ischemia
Solutions HIT
| 6 | Are Your Medical Records Safe?
| 20 | Primary Care in the Driver’s Seat
Policy
| 24 | Creating More Coordinated Care: An Interview with Donna Kinzer, Executive Director, HSCRC
Living
| 26 | Maryland’s Beer Industry: Tradition, Science and Craft
Compliance
| 29 | Don’t Be a HIPAA-CRIT: Are You Unintentionally Exposing Your Practice?
Good Deeds
| 30 | Walking with the Spirits
On the Cover: Farzad Mostashari, MD, MSc, CEO of Aledade, Inc., and former national coordinator for health information technology at the DHHS
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JACQUIE COHEN ROTH PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com JACKIE KINSELLA, MANAGER OPERATIONS, SOCIAL & DIGITAL MEDIA jkinsella@mdphysicianmag.com
Each issue of Maryland Physician is planned early in the respective year with a clinical theme linking our cover story and feature(s). Throughout the production process, each issue develops its unique life, with my publisher’s letter as the last piece produced. My goal with each letter is to introduce you to, and weave together, our content. When it was “my turn” for this issue’s letter, a clear theme presented itself: care coordination, which is part of just about every piece in the following pages. Care coordination, as identified by the Institute of Medicine, has the potential to improve the effectiveness, safety and efficiency of our healthcare system. Delivered to targeted vulnerable populations, and enabled through the meaningful use of healthcare information technology, care coordination can improve outcomes for all: providers, payers and most importantly, the patients. Underscoring the role of physicians as drivers of care coordination, we doubled up our usual Healthcare IT department to make it this issue’s cover story (see Primary Care in the Driver’s Seat, page 20). There’s powerful evidence that emphasizing preventive care and population health management, sometimes with the inclusion of high-tech approaches, is a win-win. Here in Maryland, policy makers are working with providers to ensure that patients are gaining access to better care and the right care (see Policy, page 24). Maryland’s Prescription Drug Monitoring Program (PDMP – see Managing Pain, Avoiding Addiction, page 8) highlights the critical role of healthcare IT in care coordination. Providers that participate in PDMP know what their patients are taking and what other providers are prescribing, which preserves care quality and legitimate patient access to pharmaceutical-assisted care. Clearly, PDMP is of paramount interest to our readers. Since we first featured it in the November/December 2011 issue of Maryland Physician, “PDMP” has remained the #1 search engine keyword that leads online readers to mdphysicianmag.com. In this same pain care feature, one of our experts raises the need to distinguish between possible mental health and physical care needs. In every issue, we also take you away from your clinical demands. We have delivered two such pieces in this issue. Our Living section focuses on Maryland’s burgeoning craft beer industry (see page 26) and Good Deeds features a piece that is certain to transport you to the holiday season upon us (see page 30). Wishing you and yours a joyful and peaceful holiday season…. To life!
Jacquie Cohen Roth Publisher/Executive Editor jroth@mdphysicianmag.com @mdphysicianmag
CONTRIBUTING WRITERS Tracy Fitzgerald, Susan Walker COPY EDITOR Ellen Kinsella PHOTOGRAPHY Tracey Brown, Papercamera Photography Gary Marine Photography Maryland Physician Magazine – Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC, a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 949 Annapolis, MD 21404 443.837.6948 mojomedia.biz Subscription information: Maryland Physician is mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52. 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 jroth@ mdphysicianmag.com. Maryland Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Maryland Physician. Advisory Board members include: PATRICIA CZAPP, MD Anne Arundel Medical Center HOLLY DAHLMAN, MD Greenspring Valley Internal Medicine, LLC PAUL W. DAVIES, MD, FACS KURE Pain Management MICHAEL EPSTEIN, MD Digestive Disorders Associates STACY D. FISHER, MD University of Maryland Medical Center REGINA HAMPTON, MD, FACS Signature Breast Care 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 JAMES YORK, MD Chesapeake Orthopaedic & Sports Medicine Center 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. Printed on FSC certified, 100% PCW, chlorine-free paper
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Cases
Current Awareness and Treatment of Critical Limb Ischemia John A. Pietropaoli, Jr., MD, RPVI, FACS
CASE: A 59-year-old male laborer presented with a non-healing, left great-toe ulcer. He also described severe rest-pain in his same forefoot. His past history was significant for insulin-dependent diabetes mellitus (IDDM), hypertension, dyslipidemia, renal insufficiency, obesity and 40 pack/ years of smoking. The patient was recently evaluated at a remote wound center where he underwent serial wound debridement and ongoing wound assessment. Plain radiographs were obtained, which demonstrated no evidence of subcutaneous emphysema or osteomyelitis. The patient was offered ongoing debridement or toe amputation. He presented to us for further evaluation and to discuss additional therapeutic alternatives. On examination the foot was cool with delayed capillary refill, atrophy of the skin and hair loss. There was a normal femoral and popliteal artery pulse, and a monophasic posterior tibial artery doppler signal with dependent rubor and pallor with elevation. The ankle-brachial index was at rest. The deep partial-thickness ulcer was on the distal great toe, measuring 1.5 cm in diameter, with clean, sharp margins. There was no odor, purulence or erythema. Serum creatinine was 2.3. Duplex revealed normal findings to the level of the popliteal artery. The anterior tibial and peroneal arteries were visualized in their proximal third with monophasic flow and chronic total occlusion (CTO) distally. The posterior tibial artery had monophasic flow at the level of the medial malleolus and into the plantar arch, but a CTO was present proximally, preventing continuity with the tibial-peroneal trunk.
DISCUSSION: Critical limb ischemia (CLI) from limb-threatening peripheral arterial disease (PAD) is approaching epidemic levels in the United States1. Patients suffering from CLI with ischemic ulceration can be among the most challenging patient demographic to treat, due to the advanced level of their PAD and the host of cardiopulmonary and other severe comorbidities that frequently accompany this disease. An effective approach to treating PAD begins with education. Patient, as well as physician, education is imperative to the success of any program. The therapies and technologies involving endovascular techniques are rapidly evolving. It is incumbent upon the vascular team to provide ongoing education to both the referring physicians and the lay public in order provide safe and appropriate care to PAD patients. Additionally, maximizing nonsurgical management – including smoking cessation, dietary/nutritional instruction, supervised exercise programs, hypertension control and antiplatelet therapy – is paramount in this patient population. This patient underwent successful endovascular reconstruction of his left posterior tibial artery via a retrograde posterior tibial artery access at the medial malleolus, utilizing ultrasound for the majority of imaging. Laser atherectomy and balloon angioplasty were performed to reconstruct the artery. Completion angiography demonstrated continuity of flow through the reconstructed segment
from the popliteal artery through the plantar arch with no residual stenosis. Less than 10 cc’s of contrast agent and two minutes of ionizing radiation were used due to the utilization of duplex imaging. At one month after revascularization, the patient had resolution of his rest-pain and his toe ulcer was completely epithelialized. Major limb loss has profoundly devastating consequences affecting the physical, emotional and occupational qualities of life. The negative economic impact on the GNP of the United States from amputation is well described2,3. Although the financial benefit of amputation avoidance is indisputable and must be considered, it has even greater value from the patient’s perspective. As one of the greatest minds of the 20th century advised, “Not everything that counts can be counted, and not everything that can be counted counts.”4 John Pietropaoli, MD, FACS, RPVI, is board-certified and re-certified in Vascular Surgery and General Surgery. He is also board-certified with the American College of Phlebology. Dr. Pietropaoli completed his fellowship training at the Mayo Clinic. He can be reached at 888.702.2711.
1) Dillingham TR, Pezzin LE, Mackenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med. J. 2002; 95:875- 883. 2) Gaziani, L. Comprehensive approach to management of critical limb ischemia. Curr. Treat. Options Cardiovasc. Med. 2014 Sep; 16(9):332. 3) Yin, H., Radican, L. King, SX. A study of regional variation in the inpatient cost of lower extremity amputation among patients with diabetes in the United States. J Med Econ. 2013;16(6)820-7. 4) Albert Einstein
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Solutions
Are Your Medical Records Safe? By Nathalie Griffin-Ames
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CCORDING TO Redspin, a leader in healthcare IT security, a total of 804 large breaches of protected health information affecting over 29.2 million patient records were reported to the secretary of Health and Human Services between August 2009 and December 2013. The 2013 statistics reported by Redspin are alarming: z z z z z
Over 7 million patient health records were breached. There was a 137% increase in the number of patient records breached vs. 2012. 83% of patient records breached resulted from theft. 22% of breach incidents resulted from unauthorized access. 35% of incidents were due to the loss or theft of an unencrypted laptop or other portable electronic device.
Medical record protection is an important part of today’s medical practice. Although the switch to electronic record keeping has many advantages, it also entails many new risks. The reasons that so many medical records are at risk include: z
z z
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Hackers – the number of attacks on hospitals, private clinics and medical practices has substantially increased to where it accounted for 33% of all medical record theft in 2013. Lost or stolen electronic devices Failure to delete – equipment used by medical practices are being discarded without fully deleting the sensitive information they contain. Third-party error – many healthcare organizations outsource medical MDPHYSICIANMAG.COM
z z
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record storage and management to third-party vendors, but in some cases these vendors are not qualified to secure this information. Open Wi-Fi networks that are not properly secured Insider access – examples include employees that leave a file open on their computer or allow an unauthorized person to view a medical record. The ‘Cloud’ – more healthcare organizations are moving their patient health records to the cloud. However, very few are confident that they can protect this information from thieves.
z
z
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How Can You Protect Your Medical Records?
Security tips to combat some of the risks listed above include: z z
z
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Install USB locks on computers, laptops and other mobile devices to prevent unauthorized data transfer. Install Geolocation tracking software on mobile devices, which allows for tracking, locating and wiping a mobile device of all data in the event it is lost or stolen. Encrypt all mobile devices and USB drives that will be used remotely and that contain sensitive data. Even if you allow employees to use their own tablets, laptops and/or smart phones, you should require encryption. Turn all computers completely off when not in use, even if you have installed full-disk encryption. Most leading encryption products are configured so that once the password has been entered, the laptop is unencrypted and unprotected until
z
z
it is booted down. Simply putting the laptop in “sleep” mode does not trigger encryption protection. Educate your employees about security awareness. Discourage them from downloading applications and free software that may contain malware, turning off security settings and not encrypting data in transit or at rest, as these are all behaviors that put you at risk. Provide frequent IT security awareness training for your staff. Before disposing of equipment, including copiers, smart phones, laptops and ultrasound machines, wipe hard drives of all data. Implement Electronic Protected Health Information (EPHI) security. As electronic medical records are being accessed more frequently from mobile devices, the risk of contamination from a virus increases significantly and makes investing in a proactive data management strategy even more critical. Conduct an Annual HIPAA Security Risk Analysis – periodic risk analysis is a requirement of the HIPAA Security Rule, and practices should plan and budget for it in advance. Assess security risk by identifying real vulnerabilities and developing a solution to those vulnerabilities. It is recommended that healthcare organizations engage in ongoing vulnerability scanning and remediation by implementing a monthly or quarterly test schedule. Ensure your business associates are effectively safeguarding your electronic medical records.
Nathalie Griffin-Ames, CPA, is a manager at KatzAbosch. She can be reached at ngriffinames@katzabosch.com.
SPONSORED CONTENT
Managing Pain with a Comprehensive Approach to Treatment By Susan Walker
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ROWING UP IN NEW Jersey, Sudhir Rao, MD, founder of Pain & Spine Specialists of Maryland, would travel to rural India with his family to visit his grandfather. Those trips had a big impact on Dr. Rao. “My grandfather was the first doctor in our family,” he explains. “I visited his clinic and watched him treat very sick people with limited financial resources. His work was difficult and his patients often paid him on the barter system or with a thank-you. That was enough for him, knowing he was able to help people who really needed care.” That ability to make a difference in a patient’s life was one of the things that led him to pursue a medical career in pain management. Dr. Rao received his BS in Biopsychology from the University of Michigan and his MD from St. George’s
University. He completed his internship in Internal Medicine at Greater Baltimore Medical Center, a residency in Anesthesiology at Albert Einstein College of Medicine/Montefiore Medical Center and a fellowship in Interventional Pain Medicine at Mt. Sinai College of Medicine. He is double board-certified in Anesthesiology and Pain Medicine. “Anesthesiology blended all the aspects of medicine that I was interested in – the pathology and pharmacology of internal medicine, and the procedural aspects of surgery – but I didn’t have my own patients,” Dr. Rao says. “Pain management gives me the opportunity to build relationships with my patients.” A Full Range of Options for Treatment Tailored to Each Patient’s Needs
After teaching as an assistant professor
Profile
in pain medicine at Baylor College of Medicine, and helping start a pain medicine clinic at Ft. Hood, Dr. Rao spent several years as the medical director of the Spine Center in Frederick. In 2012 he opened his own practice, Pain & Spine Specialists of Maryland, in Mt. Airy. Dr. Rao and his new partner, Suhas Badarinath, MD, an experienced pain medicine specialist, offer patients suffering from back-related pain and chronic pain conditions, including fibromyalgia, neuropathy and failed back surgery syndrome, a full range of treatment options. Treatments include spinal cord stimulation, radiofrequency neuroablation, and ultrasound and fluroscopically guided injections. In addition, Dr. Rao, who holds a fellowship in Anti-Aging, Regenerative and Functional Medicine, offers patients integrative and functional medicine approaches to pain management that complement the allopathic treatments the practice provides. All procedures are performed in the state-of-the-art Pain & Spine Specialists Center, where Dr. Rao and his staff treat each of their patients with respect, and provide them with the individual time they deserve, to express all concerns, as well as review their treatment plan. With the recent addition of Dr. Badarinath, patients referred to Pain & Spine Specialists of Maryland can usually be scheduled to be seen in less than a week. The practice accepts all insurance, including Medicaid. “We take a comprehensive approach to pain management,” says Dr. Rao. “Medications alone may not provide optimal benefit. Most of our patients have seen several physicians and gone through physical therapy, but are still in pain. We encourage our patients to be active participants in their care, and tailor treatment to the path they want to follow. Our goal is to get our patients as functional as possible with as little pain as possible.” For more information on Sudhir Rao, MD, and Pain & Spine Specialists of Maryland, or to refer a patient, please visit painandspinespecialists.com or call 301.703.8767.
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MANAGING PAIN, AVOIDING ADDICTION How do you manage patients in pain without risking them becoming addicts? Maryland’s Prescription Drug Monitoring Program and these tips can help. BY LI NDA H A RD ER • PH OTOGRA PH S BY TRAC EY BROW N
>>> OPIATES ARE POWERFUL AND useful pain relievers, but they too often are abused. More Americans have died from opiate overdoses in recent years than from heroin and cocaine overdoses combined. The CDC reports that more than half of the 41,340 drug overdose deaths in the country in 2011 were related to pharmaceuticals, and that drug overdose death rates increased 118% between 1999 and 2011. Prescription drugs are often a gateway to heroin, with some 80% of heroin addicts first addicted to a prescription drug. PRESCRIPTION DRUG MONITORING PROGRAM One way Maryland physicians can now reduce abuse is with the new Maryland’s Prescription Drug Monitoring Program (PDMP), which went live December 2013. Doris Cope, MD, a pain specialist at Kure Pain Management, is thrilled with this resource. She notes, “Physicians can go online, put in a patient’s name, and track all of their 8|
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controlled substances, as well as the pharmacy at which their prescriptions were filled. Maryland was one of the last states to implement such a program, but with the state experiencing increasing death rates from overdoses, this is a highly needed tool.” Laura Herrera, MD, MPH, deputy secretary for Public Health Services, explains why Maryland was later than many states in implementing this program. “Beginning in 2006, several legislative attempts failed. A bill authorizing PDMP was signed into law by the O’Malley administration in 2011. It took about two years to develop the PDMP system that is integrated into our state health information exchange (HIE).” “Over 40% of the deaths from overdose in Maryland since 2007 are connected to prescription pain pills, according to the CDC,” Dr. Cope observes. “Based on the experience from other states, having the monitoring program in place should significantly
reduce the number of prescriptions and ‘doctor shopping.’”
PDMP PROVIDER ACCESS As of September 2014, roughly 4,500 PDMP accounts had been established by pharmacies and prescribing providers, with over 12,000 visits per week. However, the program is still far short of its goal to credential all appropriate providers. To access the PDMP, providers must register, watch an educational video, and sign a participation agreement. Some hospital-based providers have single sign-on to the CRISP (Chesapeake Regional Information System for our Patients) portal, in which case their EHR log-in credentials are automatically relayed to the CRISP HIE. Patient information is also relayed to prevent having to re-enter patient search criteria and to access data with a single click. Interested providers can contact alert.hie@crisphealth.org or call 1.877.95-CRISP.
Laura Herrera, MD, MPH, deputy secretary for Public Health Services
THE MEDICINE ABUSE PROJECT FOR TEENS Another resource for Maryland providers, aimed at helping to prevent drug abuse in teens, is the Medicine Abuse Project. It includes a locator for area abuse and mental health services and a standardized Drug Abuse Screening Test (DAST) that contains a 10-item and 20-item format physicians can use in their practices.
CREATING AN OPIOID AGREEMENT WITH PATIENTS To help monitor opiate use and educate patients about their potential risks, doctors can ask patients to sign “pain contracts” or “opioid treatment agreements” that outline a set of conditions patients must follow to stay in the practice. The goal is to discourage opiate abuse that could include excessive medication usage or the selling of medications. The American Academy of Pain Medicine, the American Pain Society and the Federation of State Medical Boards all recommend the use of opioid agreements in certain circumstances. The agreements may require patients to consent to some or all of the following: z z z z z z z While PDMP is an excellent tool for prescribing physicians, there is a lag time of up to three days from the time data is entered until it is available to other providers. “The program is just one aspect of our overdose prevention program,” says Dr. Herrera. “The PDMP allows participating providers to know what their patients are taking and how many other providers are prescribing. Our goal is to promote balanced use of prescription data that preserves the professional practice of healthcare
providers and legitimate patient access to optimal pharmaceutical-assisted care. About 100 providers are signing on each week, and anyone who has a Controlled Drug Substance (CDS) and DEA number should participate.” If patients are abusing or diverting drugs, Dr. Herrera encourages physicians, “Bring them in to discuss what the signs of abuse are, and provide referral to treatment. Our website contains links to resources for providers and patients. If a physician is not sure what to do, we’ll be happy to advise them.”
Submit to random blood or urine drug tests Fill their prescriptions at a single pharmacy Refuse to accept pain medication from any other doctor Keep the medication out of other people's reach Keep the medication in a locked container Not request early refills Refuse to share their medication
Providers can also include a requirement that patients have their pills counted to make sure they’re the only ones taking them. Providers should note that law enforcement can access the PDMP only if an investigation is underway.
AVOID NARCOTICS WITHOUT A SPECIFIC DIAGNOSIS Dr. Cope acknowledges, “Primary care physicians are under a lot of pressure to see a high volume of patients, and the easiest thing to do is write a prescription NOVEMBER/DECEMBER 2014
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has been using opioids for years and still has severe pain and untoward side effects. We suddenly tell them they should consider tapering their opioids. If we had started earlier giving them healthier options such as weight-loss guidance, injections, acupuncture, or body-core strengthening exercises, it would have been far better for the patients. They do best if they feel in control of their bodies. If they are passive in managing their own health, it’s a poor prognostic sign.” Some patients fixate on their body as a way of avoiding mental health issues. Dr. Cope explains, “They insist that they are depressed because they have pain, and blame the pain for their dysfunction. I recommend that, rather than directly confronting the patient, physicians say something like, ‘the pain is causing you stress, so you’re not able to enjoy your family. After a while, your friends and family may get tired of hearing about your pain, but a counselor can take the time to listen to you.’” Dr. Cope recalls that one of her most challenging patients was an anesthesiologist who had charted her pain every hour for years. “She was an example of a patient who needed to change her focus from pain to something more positive. I ask patients what they really want to be able to do again. You also have to modify some patients’ expectations. If they no longer have a 20-year-old body, they have to be realistic. We are likely not able to completely cure all of their pain or difficult life problems.”
Doris Cope, MD, a pain specialist at Kure Pain Management
ISSUES WITH MEDICAL MARIJUANA
for a patient. But when someone has a non-specific diagnosis, especially if they’re young, you don’t want to go down the path of prescribing narcotics. It’s important to take the time at the beginning and consider the long-term impact of opioids.” She notes that diagnosing pain can be challenging. “An MRI is like a photo of someone in a particular position. It doesn’t show the body when it’s moving so it’s not totally diagnostic. Pain experienced due to body mechanics may not show up in an MRI. Physicians need to keep in mind what the goal is – to decrease pain and increase function. If a patient is sitting on a couch, life is not better. The treatment could be worse 10 |
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than the disease. You can’t cure ‘sadness’ with opiates.” Dr. Cope continues, “Opiates are a useful tool when other options don’t work; however, you need to have a clear diagnosis first. If a patient has cancer or major back surgery, for example, they aren’t going to get better. The key is how well they function and how bad the side effects from the opiates are for that patient.”
MANAGING MANIPULATIVE PATIENTS Dr. Cope cautions physicians, “If you feel like a patient is manipulating you, they probably are. As doctors, we have to do the right thing, not the popular thing. The hardest patient is one who
Medical marijuana has the potential to alleviate pain for many patients with cancer, chronic pain and nausea. One study indicated that whole-plant extract of cannabis that contained specific amounts of cannabinoids, sprayed under the tongue, relieved pain and improved sleep for patients with advanced cancer. Yet prescribing the substance presents a number of thorny issues. A Journal of the American Medical Association article on June 18, 2014, discussed the pros and cons of the medicalization of marijuana. One drawback is that most users ingest marijuana by smoking. “THC, which is believed to be the chief psychoactive component of marijuana, is available in pill form, but does not provide the euphoria that marijuana provides,” states Dr. Cope. “Further, marijuana is not standardized,
as are all other FDA-approved drugs. Also, there are potential legal issues. There’s no defined optimal dose and we know there’s withdrawal. Furthermore, marijuana contains more than 100 active products. It likely has utility, but it’s like bootleg liquor in its variability. The concept is good, but it needs to be refined, subjected to scientific randomized prospective studies and approved by the FDA for a specific dose, application and protocol.” In Maryland, the 2014 state legislature passed a revised marijuana bill after the prior law, which was focused on limiting distribution to teaching hospitals, failed to sign up any hospitals. The Natalie M. LaPrade Maryland Marijuana Commission was charged with filling in the details of the new law’s general framework for up to 15 approved growers, regulating distributors and creating/issuing ID cards for qualified patients. Wrestling with a number of details and facing criticism at a public hearing for their first draft, they had to delay the September 15, 2014, deadline for delivering their final draft regulations. Their goal is to provide marijuana to qualifying patients by early 2016.
EARLY TREATMENT, NEWER APPROACHES DETER ABUSE Dr. Cope notes, “Treating pain early is one way to deter later abuse and help patients avoid the path to chronic pain. Another approach to control pain is the growing use of transdermal patches, which provide a steady dose of longacting compounds. Tamper-proof opioids that are not crushable, agonist-antagonist medications, adjunct medicines, and implantable spinal cord stimulators and intrathecal pumps are additional alternatives.” In July 2014, the U.S. Food and Drug Administration approved Targiniq ER, a new form of OxyContin that was designed to deter abuse by combining a long-acting form of oxycodone with naloxone. “If the pills are crushed, naloxone blocks the euphoric effects of oxycodone,” says Dr. Cope. However, some experts warned the drug could wind up with unintended consequences, as the naloxone doesn’t take effect when the pills are swallowed intact.
GANGLION IMPAR NERVE BLOCKS A newer treatment for pelvic and perineal pain is a sympathetic nerve block to the ganglion impar (also called ganglion of Walther), a collection of
nerve cells near the coccyx that relay pain signals to the brain. It can sometimes be used diagnostically to pinpoint pain in the perineal area, which can be difficult due to the variety of anatomic structures that share common nerve pathways. “For patients with a history of sexual abuse, counseling plus these injections can give them hope and keep them on a positive track,” notes Dr. Cope. “They can learn to function better in their activities of daily life.”
“Treat this condition early to avoid chronic pain,” recommends Dr. Cope. Sympathetic nerve blockage, physical therapy and adjunctive medications are the first line of treatment. In refractory cases implantable spinal cord stimulation can help patients who don’t experience relief through more conservative measures, including pain medications and physical and psychotherapy. Interestingly, one of my patients with CRPS had a mild stroke that eliminated her pain.”
RELIEF FOR FIBROMYALGIA Fibromyalgia is diffuse myofascial pain that leads to chronic fatigue and depression and that often shifts from place to place. Dr. Cope comments, “When they get a fibromyalgia diagnosis, about half of the patients are happy to find that they aren’t ‘crazy,’ while the other half will give up. With this disorder, stress leads to muscle tension and pain, and increases insulin and body fat. The best treatment is physical exercise several times a week to get increased blood flow to the muscles, as the areas where muscles connect to bone have become ischemic. That can be combined, where appropriate, with a mild antidepressant. Increasing the heart rate increases blood flow, and exercise stimulates the brain chemistry.”
PULSED RF FOR DISC PAIN Patients with disc pain may benefit from a newer approach – using pulsed radiofrequency (RF) at the dorsal root ganglion, branches that carry pain signals into the spinal cord and central nervous system. Dr. Cope notes, “We have been using pulsed radiofrequency in these patients with good results. Studies in the Netherlands have demonstrated the efficacy of this approach. Newer studies in the U.S. and Canada are underway.”
INPATIENT PAIN PROGRAMS In addition to existing inpatient programs at The Johns Hopkins Blaustein Pain Treatment Center and Kennedy Krieger Institute’s Pain Rehab Program, a new inpatient pain program is now available at Father Martin’s Ashley in Havre de Grace. This nonprofit inpatient treatment center provides care for drug and alcohol dependency, chronic pain and other co-occurring disorders.
WHEN TO REFER TO A SPECIALIST Referral to a pain specialist is appropriate when: z z z z
The pain is not improving Function is not increasing The patient is manipulative or you are concerned that they may be You want to know if the patient is diverting
“We can do drug screens and often determine if the patient is diverting their medications,” comments Dr. Cope. “Physicians can also refer to pain specialists just for a consult, to make sure they didn’t miss anything, if they suspect that opiates are being misused or if they just want confirmation that their opioid therapy is indeed appropriate.”
COMPLEX REGIONAL PAIN SYNDROME Complex Regional Pain Syndrome (CRPS), formerly known as Reflexive Sympathetic Dystrophy, typically occurs after an injury or surgery to a limb. It typically is characterized by extreme pain, swelling, and/or changes in skin color and temperature. Symptoms can differ widely among patients, but most experience prolonged pain experienced as ‘pins and needles’ or a burning sensation, and light touch can be painful. The pain can spread along the extremity or even to the opposite extremity.
Doris K. Cope, MD, a physician at Kure Pain Management, is double-boarded in Anesthesiology and Pain Medicine. She has served as an examiner in both specialties, and previously was professor and vice chair of the Department of Anesthesiology and Pain Medicine at the University of Pittsburgh Medical Center and director of the largest pain fellowship in the U.S. Laura Herrera, MD, is a family physician and deputy secretary for Public Health Services.
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NEW INSIGHTS INTO
AUTISM B Y LINDA HARDER
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According to recent data from the CDC, about 1% of the world population has autism spectrum disorder (ASD). Prevalence in the U.S. is about 1 in 68 births and is growing at an alarming rate, some 6-15% per annum. Boys are almost five times as likely as girls to have ASD. Maryland experts discuss the latest insights into these trends.
Desmond Kaplan, MD, service chief, Child and Adolescent Inpatient Neuropsychiatric Unit at Sheppard Pratt Health System and clinical assistant professor at the University of Maryland, admits, “We don’t fully know why autism is increasing. We suspect it’s a combination of more cases being diagnosed, increased awareness, changing criteria, genetics and environmental factors. Autism is not a simple Mendelian inheritance – there are likely hundreds of genetic variants that interact with each other. There is high concordance among identical twins, and the incidence is related to increased parental age, especially increased paternal age. We know that the DNA in sperm is less stable with increasing age. Depakote, a seizure medication, may also be implicated.”
DSM-5 REVISED DEFINITION The new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains a revised definition of ASD that identifies levels of severity based on the amount of support required. It defines ASD as consisting of 1) persistent deficits in social communication and social interaction across multiple contexts and 2) restricted, repetitive patterns of behavior, interests or activities. These symptoms must be present in early development and cause clinically significant impairment.
SIGNS OF ASD The National Institute of Child Health and Human Development considers the following five behaviors to warrant further evaluation by a multi-disciplinary team:
z z z z z
Absence of babbling or cooing by 12 months Lack of pointing, waving or grasping by 12 months Not using single words by 16 months Not using two-word phrases on his or her own by 24 months Any loss of language or social skill at any age
“Younger children with autism typically lack ‘shared attention,’ for example, when the mother points to an object, the child looks at the object, or vice versa,” says Dr. Kaplan. “Eye contact and interest in faces is typically diminished. Older children may exhibit repetitive behaviors such as lining up blocks and becoming upset if their arrangement is changed. Or, they may become obsessed with spinning fans or flushing toilets. Autistic children don’t pick up social interactions instinctively. A minority of them have what’s called a ‘splinter function’ where they have superior abilities such as exceptional visuo-spatial abilities.” He adds, “About two-thirds of children with ASD have intellectual impairment, while the remaining third do not. Children with ASD might also have comorbid behavioral problems or disorders such as, ADHD, anxiety, agitation, aggression, or self-injury.”
EARLY SCREENING IS CRITICAL Research suggests that early developmental screening during wellbaby or well-child visits is important. The American Academy of Pediatrics recommends that all children be screened at 18 and 24 months. One of their recommended tools is the Modified Checklist for Autism in ToddlersRevised (M-CHAT-R™), a validated tool that screens children 16 and 30 months of age for ASD risk. Dr. Kaplan comments, “The M-CHAT screening interview can be used by pediatricians and family practitioners in their offices.” “The Autism Diagnostic Observation Schedule (ADOS) is the gold standard for the diagnosis of ASD,” he continues. “This instrument involves trained examiners engaging the child in a series of structured play activities to make the diagnosis. We have a behavioral specialist on our unit who has been
trained to administer the ADOS. It generates a lot of false positives but few false negatives. We refer children with possible autistic or other developmental disorders for outpatient services.” The Autism Diagnostic InterviewRevised (ADI-R), a companion instrument, is a structured interview conducted with parents that covers the child’s full developmental history.
EXCITING NEW RESEARCH Both Dr. Kaplan and Deepa Menon, MBBS, assistant medical director, the Center for Autism and Related Disorders (CARD) at Kennedy Krieger Institute, are excited about several recent research papers on autism. The first, a small study by Sally Rogers and Sally Ozonoff
some areas of their brains. Dr. Kaplan comments, “That would suggest a deficit in the pruning of synapses in those with ASD. In other words, those with ASD have brains that don’t prune out excess connections in adolescence, which may cause chaotic signaling.” Dr. Menon concurs. “Animal trials indicate that dysfunction at the synaptic level tweaks the function of the genes and disrupts neuronal migration during early development. We think that multiple mutations are linked to autism. Certain genes need to get turned early in development. Cells may not be moving to the right place.” Dr. Kaplan adds, “We know that autism is not caused by vaccines. It’s strongly genetic. Immunologic and other
This study suggests that early intervention, At under one year of age, can change the developmental trajectory for children with severe autism symptoms. – Deepa Menon, MBBS
at the UC Davis MIND Institute was published online in the Journal of Autism and Developmental Disorders. “This study suggests that early intervention, under one year of age, can change the developmental trajectory for children with severe autism symptoms,” says Dr. Menon. Treatment involved six months of parental intervention based on the Early Start Denver Model (ESDM) that Rogers and colleagues developed. Dr. Menon observes, “Parents were trained to work on eye contact and play skills in babies aged 6 to 15 months who exhibited marked autism symptoms, such as decreased eye contact, social interest or engagement, and a lack of intentional communication. Six of seven children were able to bring their learning language skills up to normal by age two or three. It gives us hope that early intervention makes a difference. Of course, these findings need to be replicated in larger scale studies.” A second study, published in the September 3, 2014, issue of Neuron, examined tissue from the brains of children and adolescents who had died by age 20. It found that those with autism had an excess of synapses in
factors seem to be important as well. I think that we also need to look at adverse events during pregnancy, such as bleeding and exposure to toxins.” Dr. Kaplan’s unit, at Sheppard Pratt, is one of six premier, national inpatient units dedicated to studying the management of patients with ASD in crisis. “The national research consortium was awarded a $1.2 million grant over two years to create this consortium to address the fact that severe autism has had very limited research involving bigger sample sizes. We started about a year ago to study severe ASD, which until now has been inadequately studied.”
COMPLEMENTARY AND ALTERNATIVE THERAPIES A November 2009 article in the Annals of Clinical Psychiatry reviewed emerging therapies for autism and concluded that melatonin, acetylcholinesterase inhibitors, naltrexone and music therapy were “Grade A” interventions. The authors of a review of complementary and alternative therapies for autism published in 2012 recommend only melatonin and an RDA/RDI multivitamin/mineral supplement for those with diet issues. They note that NOVEMBER/DECEMBER 2014
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a third intervention that was published after their review, N Acetylcystein (NAC), showed promise in a random double-blind trial of 33 autistic children. Notes Dr. Menon, “A third of the children with ASD have loss of developmental milestones (regression). Dr. Richard Kelley found that children with autism and regression could have a mitochondrial dysfunction that caused
initiations and motivation instead of targeting individual behaviors to create widespread improvement.” “We get the child to interact and play in smaller, one-to-one settings so they can learn and practice skills under guidance,” advises Dr. Menon. “Communication is often the biggest deficit, so we can teach sign language, use pictures or a tablet to help them
Those with ASD have brains that don’t prune out excess connections in adolescence, which may cause chaotic signaling. – Desmond Kaplan, MD
the regression and that, in these children, providing a formula containing vitamins, Q10 and Carnitine stopped the regression. We hope to get this research into a clinical trial.”
ADVICE FOR PHYSICIANS: EARLY REFERRAL “Parents today are more aware of autism,” comments Dr. Menon. “I find that they really do know their babies. The best advice I can give primary care physicians is to pay attention to any concerns the parents may have, especially if they’ve also had developmentally normal children. It’s better to have too many false positives than to ignore a child who could benefit from intervention. Looking for these deficits and referring to specialty centers is preferable to waiting to see how the child develops.” She adds, “Regrettably, I still see a few eight- or nine-year-olds who were recently diagnosed, but there’s a clear history of ASD. It’s far better to send children early to be assessed than to wait.”
TREATMENT FOR ASD Treatment chiefly involves behavioral therapy, supplemented by medications when children have concomitant issues with ADHD, depression and the like. Dr. Menon states, “Based on the theory that behavior is learned and shaped by one’s environment, Applied Behavior Analysis (ABA) breaks desired skills down into smaller parts to help children learn. Drs. Robert and Lynn Koegel developed Pivotal Response Therapy® based on ABA. It targets pivotal developmental areas such as social 14 |
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communicate. Teaching them to communicate their needs decreases maladaptive behaviors.” Many families have tried gluten-free and/or casein-free diets. “The research hasn’t demonstrated the value of this approach,” says Dr. Menon, “so the evidence at this time is anecdotal. I refer to a gastroenterologist for an allergy panel if there’s a history of constipation, diarrhea or other gastric issues. The problem with a diet, however, is that most kids with ASD are picky eaters and may only eat a few things. You have to do one thing at a time. I tell parents to be thorough about their interventions – try eliminating one food for four to six weeks and then try reintroducing that food again.”
ASD RESOURCES Maryland is fortunate to have several major autism centers. Kennedy Krieger offers research, clinical services, a therapeutic day program, day schools in Baltimore and Washington, D.C., partnerships with public schools, and training programs. Sheppard Pratt’s special education schools provide services to more than 300 students with ASD. They also offer a Child & Adolescent Neuropsychiatric Inpatient Unit that cares for children and adolescents with co-occurring developmental and psychiatric disorders, including ASD. Sheppard Pratt’s autism resource guide is visible online at autisminfoatsp.org. Mt. Washington Pediatric offers consults, diagnostic evaluations, social skills and individual and family treatment. “Both Kennedy Krieger and Mount
Washington Pediatric Hospital perform autism evaluations, and University of Maryland Medical Center conducts educational batteries,” says Dr. Kaplan. In theory at least, the state offers autism services under the Autism Waiver Services Registry, including in-home, respite, residential and other services. Contact them at 866.417.3480. “However,” cautions Dr. Kaplan, “The waiting list is years long, and families can become exhausted and isolated while waiting.” Dr. Kaplan is also the medical director of the Sheppard Pratt Behavioral Telepsychiatry Program, which was launched in 2005. Telemedicine units at both Sheppard Pratt and Kennedy Krieger are helping families in rural areas get developmental screening for their children without traveling for hours. “We have a telemedicine pilot that started in December 2013 with Atlantic General Hospital,” notes Dr. Menon. “We’ve had two clinics per month and have seen about 50 children, and we’re now expanding. Children with suspected ASD can then be evaluated in depth at one of our facilities.” Sarah Wayland, PhD, who has two sons with Asperger’s Syndrome, offers parents Relationship Development Intervention® (RDI), a family-based, behavioral treatment designed to improve the ability to think flexibly for individuals with autism. She supports parents through a website (guidingexceptionalparents.com) and parenting classes. Autism Speaks (autismspeaks.org) offers an Autism Treatment Network (ATN), a collaboration of medical centers dedicated to providing families with state-of-the-art, multidisciplinary care. The ATN was established to provide a place for families to go for high-quality, coordinated medical care for children and adolescents with autism and associated conditions.
Desmond Kaplan, MD, service chief, Child and Adolescent Inpatient Neuropsychiatric Unit at Sheppard Pratt Health System Deepa Menon, MBBS, assistant medical director, Center for Autism Related Disorders (CARD) at Kennedy Krieger Institute
Did You Miss the Last Issue of Maryland Physician Magazine? Visit www.mdphysicianmag.com Maryland Physician Magazine spotlights the critical clinical, business and policy issues that impact patient care and practice management in Maryland. Available in print and online, Maryland Physician is dedicated to building a Maryland-based network of physicians and healthcare stakeholders, with a commitment to achieving the highest standards of quality patient care.
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INCIRCULATION NOV/DEC 2014
The Official Publication for Center For Vascular Medicine™ VOLUME 1
ISSUE 1
Sanjiv Lakhanpal, MD, FACS Founder/CEO
C E N T E R
F O R
Pelvic Pain ™
o f Va s c u l a r O r i g i n
A Division of the Center for Vascular Medicine
UNDERSTANDING VASCULAR PELVIC PAIN CONDITIONS BY VINAY SATWAH, DO
T
here are several vascular conditions that cause women to experience ongoing pain that can interfere with their ability to take part in and enjoy daily life. Pelvic Congestion Syndrome (PCS) causes chronic pain in the pelvic area, lower abdomen, and thighs. May-Thurner Syndrome (MTS) causes leg pain and increases the risk of deep vein thrombosis (DVT), a potentially life-threatening condition. Using state-of-the-art technology, the physicians at the Center For Vascular Medicine (CVM) can treat these conditions, helping women find relief from vascular pain. Varicose Veins in the Pelvic Area May Lead to Pelvic Congestion Syndrome. PCS affects more than onethird of all women. Sometimes suffering with this condition for years, many women are told the problem is not due to a specific medical cause and may be psychological. However, recent advancements have allowed physicians at CVM to show that the pelvic pain may be due to varicose vein reflux causing pelvic venous insufficiency. The symptoms related to PCS include pelvic pain associated with standing and sitting, which worsens throughout the day. This chronic pain is typically dull and aching in nature. Patients often experience relief from pain when lying flat and when legs are elevated. The symptoms may worsen following intercourse, during menstrual periods, and during pregnancy. Associated symptoms in-
clude heaviness/fatigue/aching of the legs with varicose veins on the vulva and/ or buttocks. Similar to varicose veins in the legs, in PCS the valves in the pelvic veins that help return blood to the heart against gravity become weakened and don’t close properly. This allows blood to flow backwards and pool, causing pressure and bulging veins in the pelvis and vulva, which can affect the venous drainage of the uterus and ovaries. PCS typically affects women in their childbearing years. As the uterus expands during pregnancy, increased pressure is
ASK THESE QUESTIONS IF YOU THINK YOU HAVE A PATIENT WITH PELVIC CONGESTION SYNDROME
1 Have you been evaluated by a vein center for varicose veins of the leg/groin? 2 Do you have pelvic pain? 3 Is your pain worse at the end of the day? 4 Does your pelvic pain decrease when you are lying flat on your back? 5 Do you have visible varicosities in the area of the groin or labia? 6 Does your pelvic pain affect your daily quality of life or normal daily activities? If the answer is ‘YES’ to any of these questions, you may have a patient with PCS. Refer your patient for an appointment with a Center For Vascular Medicine specialist, who can work with you to get your patient the help she needs. www.cvmus.com
exerted on the pelvic floor and veins. Postpartum, the uterus eventually contracts and although the pressure on the pelvic floor is relieved, there is residual damage to the pelvic veins. Ovarian veins increase in size with each subsequent pregnancy, which means women who’ve had two or more pregnancies are at particular risk. Many women with PCS spend years trying to find out why they have chronic pelvic pain. Living with this pain is difficult and affects not only the woman, but also her interactions with her family, friends, and her general outlook on life. To help uncover the cause of their chronic pelvic pain, CVM patients undergo a thorough history and physical. Those with a high likelihood of the condition may also undergo pelvic ultrasound and venography. Considered the most accurate method for diagnosis, a venogram is performed by injecting contrast dye in the veins of the pelvic organs to make them visible during an X-ray. Once a diagnosis is made by, if the patient is symptomatic, a pelvic venogram with embolization should be performed. Embolization is a minimally invasive procedure performed by the interventional team using imaging for guidance. During the outpatient procedure, the faulty, enlarged veins are sealed to relieve the painful pressure. After treatment, pa-
tients should expect a low level of postprocedure pain and to spend a few of days off their feet as they recover. May-Thurner Syndrome Increases Risk of Deep Vein Thrombosis. MTS, sometimes called Iliac Vein Compression Syndrome, primarily affects women between the ages of 20 and 50.The name comes from the two physicians who are credited with first describing the condition in the late 1950s. Women diagnosed with MTS have compression of the left iliac vein leading to a decrease in drainage of the left leg. If left untreated, this may lead to the formation of a deep vein thrombosis (DVT). The clot restricts blood flow, which in turn causes pain, swelling and often varicose veins in the left leg. The condition usually presents on the left side, though cases where the right side is affected have been reported. When left untreated, MTS may progress through three stages: s Stage 1: Iliac vein compression, which often causes no symptoms. s Stage 2: Formation of venous spurs, which eventually become fibrous shelves. The spurs develop in the vein, restricting blood flow and increasing disposition for DVT. s Stage 3: DVT formation occurs when a clot forms in the vein and blood flow is severely restricted, leading to pain and swelling in the legs and the formation of varicose veins. Patients with mild narrowing of the vein will often experience no symptoms. As MTS progresses, however, the following symptoms are common: s 'ENERALIZED PAIN IN THE LOWER abdomen and pelvis. s 6ARICOSE VEINS IN THE UPPER THIGH (usually left leg). s 3WELLING IN THE LEG USUALLY LEFT LEG s #HRONIC PAIN IN THE LEGS THAT worsens as the day goes on. Treatment Can Help Women Live Pain-Free. The physicians at CVM offer a complete range of diagnostic and therapeutic services for women suffering from pelvic pain of vascular origin. To refer a patient to any of our Maryland centers, call 866-916-9202.
LEADERS IN OUTPATIENT-BASED TREATMENT FOR PERIPHERAL ARTERIAL DISEASE (PAD)
A
ccording to a recent report from the American Heart Association, peripheral arterial disease (PAD) affects approximately 8 million people in the United States. Unfortunately, only 25% of these individuals are aware that their symptoms are readily treatable. They live with leg discomfort that prevents them from enjoying everyday activities. During consultations, so many patients have said they believed their leg discomfort was just a result of “getting older.� This statement couldn’t be further from the truth. Typical symptoms of PAD include discomfort in the legs with exertion, such as walking or climbing stairs, which is relieved by stopping and resting. However, up to 40% of individuals with PAD may have no leg pain. They may experience a dull ache or cramp with walking (called claudication) that can occur in the buttock, hip, thigh, or calf. If the disease is not treated, they may develop skin color changes, which may progress to open wounds or ulcers. The physicians at CVM strive to prevent patients from getting to the point where the only option is amputation. CVM physicians believe that individuals who come to be evaluated are not just patients, in fact, they are our family members. CVM’s highly skilled and dedicated team evaluates and thoroughly explains the disease process and pertinent findings to each patient. Patients and their families are given the time to ask questions and discuss all treatment options. The referring provider will receive a personal phone call from a clinician if there are any urgent findings. CVM has three conveniently located, state-of-the-art, outpatient-based angiography suites located in Central, Eastern and Southern Maryland. After thorough noninvasive studies, symptomatic patients may require further invasive evaluation. This includes angiography, which requires the injection of contrast dye in the arteries to make them visible under fluoroscopy. Because any needed additional invasive studies and interventional treatments can be performed as a same day procedure at these centers, the process is more convenient for patients and reduces the anxiety they might feel in a hospital setting. CVM’s staff is also able to be more attentive to patients and their families because the nurse to patient ratio is far lower than in a hospital. In an economy WHERE EVERY DOLLAR SPENT IS CLOSELY SCRUTINIZED THE OUTPATIENT BASED LAB SAVES PATIENTS a significant amount of money while maintaining a high level of quality of care and patient outcomes. Published data supports the significant reduction in Medicare spending that outpatient-based procedures deliver. With advances in technology and new interventional diagnostic and treatment options, CVM is able to provide cutting edge, minimally invasive services to patients. To refer a patient with PAD to any of CVM’s locations, call 866-916-9202. www.cvmus.com
Sanjiv Lakhanpal, MD
Vinay Satwah, DO
Rakesh Wahi, MD
Shekeeb Sufian, MD
John Pietropaoli, MD
Gaurav Lakhanpal, MD
Tom Militano, MD
Krutiben Patel, PA-C
Call today to make a referral:
866-916-9202 ww w. cv m u s. co m
I M ME D I AT E APPO I N TM EN TS AVAI L A BLE Annapolis | Glen Burnie | Greenbelt | Prince Frederick | Silver Spring
Healthcare IT
Primary Care in the Driver’s Seat Physician Leadership of New Care Models Benefits All
Farzad Mostashari, MD, MSc, Aledade, Inc., CEO and former national coordinator for health information technology at the Department of Health and Human Services (HHS)
BY LI NDA H A RD ER • PHOTO GRA PHS BY TRAC EY B ROW N
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HYSICIANS OFTEN HAVE been the recipients, not the initiators, of healthcare changes. However, two new Marylandbased companies – Aledade, Inc., and Evergreen Health Co-operative – are demonstrating that, when physicians are at the helm, care innovation can follow.
This should not be surprising, given that physicians are oriented to less expensive outpatient care, while hospitals have been oriented to filling their beds and emergency departments. Clinicians also have direct patient relationships and are better positioned to understand what it takes to meet patients’ healthcare needs.
PHYSICIAN-LED ACOs The Centers for Medicare and Medicaid Services (CMS) has launched three different ACO models: Pioneer, Shared Savings and Advanced Payment models (designed for physician-based and rural providers). Participants in the Pioneer ACO group, which is subject to greater risk than the Shared Savings group, are dwindling from the initial 32, to 19 participants. Sharp HealthCare, The Franciscan Alliance, Genesys PHO and Renaissance Health Network are the most recent ACOs to drop out. But some of the Pioneer members are migrating to the Shared Savings model. Participants in the latter have grown from the first cohort of 27 ACOs to about 340, with more expected to join in January 2015. One will be a Marylandcentered ACO run in partnership with a new company, Aledade. Recent CMS data on the performance of 220 of these ACOs showed that, as a whole, they had higher scores on most comparable quality measures than other providers, and that 53 of them shared $300 million in bonuses. However, the National Association of ACOs points out that the more than $1 billion invested by ACOs has generated only $372 million in returns, and that 167 ACOs will get no returns this year. Initially, due to the high capital required to start an ACO, pundits expected the model to be led chiefly by hospitals. However, physicians are emerging as the primary leaders in ACOs, regardless of the model, and they were somewhat more successful in holding down costs than their hospitalled counterparts. And a January 13, 2014, Businessweek article noted that over half of the country’s 367 ACOs were led by physicians and did not include hospitals. 21 |
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Demand Destruction
Farzad Mostashari, MD, MSc, Aledade CEO and former national coordinator for health information technology at the Department of Health and Human Services (HHS), observes, “For most hospitals, population health is ‘demand destruction,’ where keeping patients healthy has a negative impact on their bottom line.” Believing that more physician-led ACOs were needed, Dr. Mostashari launched Aledade in June 2014 with a $4.5-million investment led by venture capital group Venrock. The Bethesdabased company initially is signing up independent primary care physicians in Maryland, Delaware, Arkansas and the New York-metro area. On July 31, 2014, Aledade submitted an ACO application with a total of 25,000 attributed Medicare patients in these states. Electronic Record Challenges
Dr. Mostashari recalls the enormous challenge HHS faced when it first sought to digitize the healthcare industry.
ACOs are not exempt from that challenge. A 2014 survey of 60 ACOs by Premier, Inc., and the eHealth Initiative, found that they are struggling with sending and integrating data they receive, and are under pressure to integrate their analytics into their workflow, with high investment costs and little to show for those investments to date. Rather than require that physicians change to a single EHR, Aledade will work with practices to bring them up to the higher 2014 Edition Standards and Certification Criteria established by the Office of the National Coordinator of Health IT (ONC), which fosters better data exchange. Dr. Mostashari comments, “Today, EHR systems can talk to each other, though not well. We can get medication, immunization and procedure data. It’s painful but possible. We can even do predictive modeling from disparate systems.” Flipping the Incentives
Dr. Mostashari explains why EHRs were slow to be adopted. “When I was the assistant commissioner for the Primary Care Information Project at the New York City Department of Health and Mental Hygiene, the major challenge for digitizing healthcare was that there wasn’t a business case for it under fee-for-service reimbursement. Doctors didn’t want to be slowed down if there was no incentive to use an EHR.”
The waiver changes the rules of the game so that each player’s enlightened self-interest benefits society, too. – Farzad Mostashari, MD, MSc “When we started, only 17% of doctors and 9% of hospitals were using electronic records to care for patients. We’re in the throes of rapid, jarring transformation, but a few short years later, it’s the norm to capture data electronically. The continuing challenge is how to change workflows and processes to make healthcare productive and decrease the burden on providers. That can take years.”
Dr. Mostashari cites the impressive outcomes of a group of 18 primary care physicians in McAllen, Texas, who formed the Rio Grande Valley ACO Health Providers in 2012. In 2009, the area had some of the highest healthcare costs in the nation, yet the population was less healthy than nearby El Paso. By emphasizing preventive care and population health, the ACO saved over $20 million in the next year and a half NOVEMBER/DECEMBER 2014
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while improving patient health. He exclaims, “That ACO demonstrated that, with physician organization and leadership, we can achieve magic. When you flip the incentives, the care changes. This is an important pocket of sanity in the healthcare system. It’s very exciting now that doctors can make money with population health. It’s good for patients, doctors and society at large. “The problem is,” Dr. Mostashari adds, “that there are too few physicianled ACOs. Doctors can’t do it on their own, but Aledade can help them do it. We create the vessel that makes it easy for physicians to come in and participate. “You can’t save money by seeing patients for shorter and shorter times during an office visit,” he continues. “However, if you prevent one hospitalization, you can save $10,000. We want to create a concierge experience for patients to save money, not see them less. The trust relationship between a physician and patient is powerful and we’re facilitating that. We want to be like the “Easy Button” for doctors by helping them make the shift to valuebased care.” A Model Aligned with Primary Care
“Aledade’s business model is totally aligned with the primary care physician,” Dr. Mostashari explains. “We’re not paid on a consulting basis, where the interests aren’t always aligned.” Physicians pay a small fee up front to ensure that they are serious about participating, but Aledade’s main revenue source won’t come until early 2016, when they will be reimbursed if they save CMS money. Physicians will receive 60% of those savings, and Aledade will get the remaining 40%. Aledade staff will meet monthly with physicians in the ACO to review best practices and figure out what’s not working. To help manage population risk, Aledade works with physicians to provide predictive modeling and integrated claims and clinical data. Notes Dr. Mostashari, “We learned that we can’t achieve change without going to the physicians’ offices and being there week after week. There are advantages if the practices are tightly clustered geographically, but a lot of it is about the patient and physician relationship, not the location.” He adds, “It’s not just about taking care of the patients who were in the 22 | MDPHYSICIANMAG.COM
Peter Beilenson, MD, chairman of the board of Evergreen Health Care and founder and CEO of its affiliated insurance company, Evergreen Health Co-operative
office recently, but about the 99% of those who weren’t. We identify the top ones needing the physician’s attention and work to improve their care.” Dr. Mostashari describes the advantage of moving from his position at HHS to head of Aledade. “The successes and failures are clearer. We’ll save money for doctors and save patient lives, or we won’t.” He predicts that the ACO model will spread to the commercial population and younger patients. And in Maryland, where a new Medicare waiver took effect
at the beginning of 2014, Dr. Mostashari sees an even broader opportunity to flip the incentives. He says, “The waiver changes the rules of the game so that each player’s enlightened self-interest benefits society too.”
PHYSICIAN-LED CO-OP Peter Beilenson, MD, is chairman of the board of Evergreen Health Care and founder and CEO of its affiliated insurance company, Evergreen Health Co-operative. In 2013, his plans to launch the co-op were stymied by the
difficulties with the state’s online health insurance marketplace, Maryland Health Connection. The exchange enrolled only about 72,000 members in 2013 – half of the number it had planned to enroll in private plans like Evergreen or CareFirst. CareFirst offered the lowest premiums in 2013, and ended up with the vast majority of enrollees. Beilenson expects this year to be different, as CareFirst premiums will increase while Evergreen’s will go down. “In April 2014, only 450 members were enrolled in our co-op, and today we have 5,000 enrollees. Our goal for the end of 2015 is to break even with 20,000 enrollees, which we expect to come from 12,000 small-group members and 8,000 individuals.” He adds, “We did poorly last year because of the exchange failure and because CareFirst underpriced its premiums. I’m very bullish about 2015. Our rates are very competitive and considerably less than CareFirst’s cheapest plan.” The co-op’s physicians come from two key sources: z z
Four Evergreen Health Centers, located in Columbia, Greenbelt, White Marsh and Baltimore City About 20,000 leased providers that are enrolled in MultiPlan (PHCS). Founded in 1980, MultiPlan is one of only a handful of large leased networks in the country, with almost 900,000 healthcare providers under contract.
The Evergreen Health model was based on Healthy Howard Health Plan, which was launched in 2008 when Dr. Beilenson was the county health officer. Healthy Howard, which delivers healthcare to uninsured residents of Howard County, also provides health coaching and care coordination with primary care. Health Centers Employ PCMH
Evergreen’s health centers employ a Patient Centered Medical Home (PCMH) model of care, which includes wellness services that vary depending on the community’s interests. “One may offer acupuncture and Zumba, while another offers nutrition and therapeutic massage,” Dr. Beilenson notes. “All of them have healthcare coaches that develop wellness programs for patients. Each center is staffed by a primary care
physician, nurse practitioner, nurse and licensed social worker.” Dr. Beilenson describes the benefits of working in Evergreen’s centers. “We pay physicians employed in these centers a salary of $180,000 to $200,000, with outcome-based incentives. Physicians see 12 to 13 patients a day, not 30. They spend quality time with their patients. It’s primary care the way it should be. “Co-op enrollees are encouraged, but not required, to use the health centers,” he states. “Network primary care physicians are paid fee-for-service, and we work with preferred specialists who are open to innovative financial approaches, including carve-outs and bundled payments.” High-Tech Telehealth
Evergreen is employing some high-tech approaches to care, including telehealth services. “We started with telepsychiatry in September 2014, then we’ll expand to cardiac telehealth in January 2015, and later to dermatology. “We have developed relationships with certain specialists so that, for example, a patient with non-urgent chest pain
presenting at our health center can be seen within 30 minutes via teleconference by the cardiologist on call,” Dr. Beilenson explains. “For cardiology, we’ll use a Bluetooth stethoscope to transmit the patient’s heartsound to the specialist, and for dermatology, we’ll use a special camera so the specialist can clearly view skin conditions.” Old Fashioned Service
Another feature that differentiates Evergreen from its competitors is a throwback to the old days when a human being actually answered a telephone, in contrast to the typically lengthy on-hold times for most major insurers. “We offer personalized member services,” promises Dr. Beilenson. “We pledge that a real person will talk to you within 30 seconds. “I came to this model from a public health background with a patientcentered philosophy, not a business approach,” he reflects. “I want to know how the average person will be affected. I don’t assume they understand what a PCMH or a copay is. Having a physician at the helm creates credibility.”
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Policy
Creating More Coordinated Care Donna Kinzer, executive director, HSCRC
In mid-2013, thenconsultant Donna Kinzer set out to help find a new executive director for the Health Services Cost Review Commission (HSCRC) and ended up being asked to serve in the role herself. A little over a year later, she talks about how the sea change in Maryland healthcare is impacting providers.
Q:
You previously worked as a healthcare analyst at Berkeley Research Group and were appointed acting executive director in June 2013 after Patrick Redmon departed. Was this move unexpected, and how did you prepare for your new role? Yes,
it was a surprise. I started as the acting executive director the day of the June Commission meeting. I had worked as a consultant my whole career. When Patrick left, the Commission was left with no director in the midst of negotiating a new waiver. I tried to help recruit someone but there weren’t any takers. Then I told (HSCRC Chair) John Colmers that I could do this job. I saw this as my opportunity for public service. 24 | MDPHYSICIANMAG.COM
Q:
You have been credited with jumping in quickly to help forge the new waiver. To what do you attribute your success? There are some very
dedicated people here. We put our heads down and negotiated hard. I have a lot of respect for Joshua Sharfstein, MD, (secretary of the Department of Health and Mental Hygiene) and John Colmers, who are very dedicated to Maryland healthcare, and are skilled, experienced policy leaders. And I’ve trained to support payment transformation my whole life, with lots of rate-setting, payment and delivery reform, as well as other related experience, for the last two decades.
Q:
How do you see hospitals adapting in the next few years under the waiver? We expect hospitals to
focus on better care to drive needed change under the new waiver. The goal
is to reduce utilization that can be avoided with better care, and to provide better care outside the hospital, while holding hospitals responsible for providing needed services. We won’t stand by and let hospitals benefit from not providing needed care. We’re being very analytical and data driven. We started focusing on readmissions a few years ago, which is a great example of our ability to decrease costs by improving care. If someone is readmitted because they didn’t take their medications correctly, or because they got an infection after a surgical procedure, that’s bad for the patient and also bad for the hospital under the new waiver.
Q:
What do you think will be the biggest challenges for hospitals and providers under the new waiver? Can such massive change be accomplished
in just five short years? If so, discuss what you see unfolding. Hospitals
will be doing even more work in the community to keep people with chronic conditions healthier and out of the ER. The goal is to focus on community resources to help people maintain better health. We have some great examples from the TPR (Total Patient Revenue) hospitals, all of which now have case managers in their ERs. These case managers help people get a primary care physician and set up office visits where necessary, assist with medications and transportation, and the like. Hospitals were doing some of this work already, but the waiver has accelerated that. Better quality care can decrease costs because we currently don’t have good care coordination. Increasing that is one of the main goals of the waiver. We have three main strategies. A first strategy is working with primary care and other community-based physicians to avoid hospitalizations in the first place, especially for those with
for the state. The HSCRC worked with the hospitals to establish global budgets to fix the revenue growth at the hospital level and also to allow hospitals to change and improve care delivery without experiencing revenue losses. Hospitals can adjust their rates up and down as volumes change, but they have to stay within a 5% rate ‘corridor’ or request an exception if volumes fall more than 5%.
Q:
How will the waiver impact physicians? Hospitals won’t be
successful under the waiver unless they work with physicians. Hospitals will want to make sure there are primary care physicians in the right geographic locations and that care is being coordinated among primary care, specialists, hospitals and specialized programs, especially for individuals with chronic conditions. For example, several hospitals analyzed where most of their low-intensity ER patients and avoidable conditions came from, and worked to place care providers in those areas
Hospitals won’t be successful under the waiver unless they work with physicians. – Donna Kinzer, executive director, HSCRC
chronic conditions. Medical home models are also focused on this objective. The second strategy is better care coordination. Commercial patients actually have better care coordination through their insurers than Medicare patients – the people who need it the most – do. Third, we’ll need to work with long-term care providers. Medication reconciliation is a huge issue. Several hospitals are sending nurses to nursing facilities to reconcile patients’ medications. Doctors and nurse practitioners are beginning to follow patients across settings from the hospital through the nursing facility for specialized care such as pulmonary and cardiology. We’re focusing on re-using the dollars that hospitals save by decreasing utilization for care coordination and care improvement. The new waiver locks revenue growth
to provide more outpatient care and also to reduce hospital utilization. Nationally, ACOs (Accountable Care Organizations) and PCMHs (Patient Centered Medical Homes) are driving primary care acquisition, so those models will mean that hospitals are still focused on practice acquisition.
Q
: What advice do you have for physicians in practice to help them thrive under the waiver? Physicians and hospitals need to work together to provide better primary and follow-up care and help patients navigate the healthcare system. The Chesapeake Regional Information System for our Patients (CRISP), the state’s health information exchange, and some other tools are helping physicians with this, but we need more. Care coordinators and case managers
have been added under the medical home models. Hospitals are adding care coordinators. Web-based tools and EHRs will facilitate creating care plans and having the right people access the patient’s information.
Q
: In June 2014, the HSCRC also updated its uncompensated care policy, cutting payments to hospitals from slightly over $1 billion in FY 2014 to $958 million in FY 2015. Discuss why uncompensated care is decreasing, and whether you think this trend will hold in coming years. Uncompensated care is clearly decreasing with the expansion of Medicaid. We had our first rate adjustment as a result in June 2014. There’s a lot of evidence that uncompensated care rates will continue to decrease, since many of the new Medicaid enrollees have mental illness, asthma, and other chronic conditions that created uncompensated care in hospitals. We’re bullish on thinking that expanded Medicaid coverage will decrease hospitalizations, as newly insured patients gain access to better community-based care. The expansion on the commercial side has been important too.
Q
: Discuss the work to date of the HSCRC Work Groups and how you expect their work might impact physicians going forward. Physicians have been involved in all of our Work Groups. They recommended improving care-coordination resources and focusing on alignment models. We started the planning process with the Work Groups to explore what those models should be and what common tools we could employ. On the alignment front, we are focusing on care coordination and infrastructure as well as pay-forperformance and shared-savings approaches. We are hoping to accomplish this in an organized, physician-friendly way, so that we can align efforts and incentives around care coordination and care improvement. At the HSCRC, we really want to hear from physicians. We’re serious about acting on their complaints and suggestions. NOVEMBER/DECEMBER 2014
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Living
Maryland’s Beer Industry Tradition, Science & Craft
JACQUIE COHEN ROTH
By Jacquie Cohen Roth
A
FTER MY ADVENTURES exploring the state of Maryland’s wineries (Maryland Physician September/October 2014 Living) I started to think about our craft beer industry. Is it as robust as the wineries I visited? How do our local beers stack up against other states’ products? After attending a couple of Octoberfests and renowned beer-lovers’ bars, I found that in the great state of Maryland, our selection of local ales, lagers, stouts, and hybrids may well knock your lederhosen right off. My next great investigative mission was born, and it underscores Ben Franklin’s observation, “Beer is proof that God loves us and wants us to be happy.” Beer recipes have been found in the temples and tombs of pharaohs, so obviously fermented malt-style beverages have been around for a while. In Maryland, the first known brewer was Ben Fordham, who, as early as 1707, had a respected establishment in downtown Annapolis. His efforts are memorialized by Fordham Brewing, which, unfortunately, is now in Delaware. Even our venerable National Bohemian is no longer brewed in Maryland. But no worries, Hon, some very fine Maryland craft beers have stepped up to fill those ale and lager voids. The two classic “beer” categories are ales (warm fermented beverages), and lagers, (cold fermented beverages), with a side of hybrids, specialties and session beers to bridge the gap. Ales and lagers break down further into all those esoteric groupings the waiter at the brew pub will throw around to impress you. Ales include “name your favorite UK style” (English, Irish, Scottish), India 26 | MDPHYSICIANMAG.COM
Plates of fries and Maryland's favorite bivalve with a couple of cold Maryland craft lagers make for a great way to spend a fall afternoon.
Pale Ales (IPA), Porters, Stouts, Belgian and French. Lagers include Pilsners, Light, European Ambers, Dark and Bocks. Breweries are another piece of beerknowledge to integrate. No longer are they only the giant operations from far-away places like St. Louis, or Golden, Colorado. The trade journal Beer Advocate segments them into nanobreweries (very, very small operations, three barrels or less, just a step up from home brewers), brew pubs (small operations, and they sell 25% or more of their product on the premises), micro-breweries (small operations, generally 15,000 barrels or less) and regional breweries (over 15,000, and up to 6 million barrels). I needed some guidance at this point, because there are a lot of beers out there, and more seasonal brews are being introduced every day. Hello (and goodbye) pumpkin beers. I turned to the experts. Annually the Baltimore Sun ranks the best of Maryland’s beers. First
of all, hats off to the hardworking, lucky staff at the Sun who committed themselves and their resources to this kind of in-depth investigation. I was pleased to see that the Eastern Shore's Evolution Craft Brewing Company and Public House (201 E. Vine Street, Salisbury) was representing. This little establishment has been making some big Chesapeake Bay waves in brewing and dining. They have a fine farm-totable restaurant that’s well worth the visit to the Eastern Shore. And the Baltimore Sun will back me up since Evolution’s Lucky 7 Porter was ranked #18, and their Lot No. 3 IPA ranked #7 on their best-of list. Not bad for two brothers who started their brewery with just high hops. For a little geographic variety, and a lot of beer variety, head to Baltimore for The Brewer's Art (1106 North Charles Street), and try #4 on the Sun’s list, Resurrection. This abbey brown ale has become the signature Brewer's Art
beverage, and it’s quickly becoming the Baltimore draft. Still, leave room for their Beazly ale, named after Mark Barcus – a bartender of the Mount Vernon bar for nearly 17 years – #1 in the eyes of the Sun’s intrepid reporters. It’s a golden-colored, Belgian-style, strong pale ale that will put that extra conviction in your cheers for the home teams on a blustery day. Also in Baltimore is well respected brewer Hugh Sisson and his Heavy Seas Brewery (4615 Hollins Ferry Road, Halethorpe). Sisson is a popular advocate of local
the gold for their Plank III, and bronze for their Gold. Frederick has proudly nurtured several breweries, including 1994 Colorado transplant Flying Dog Brewery. With about 80,000 barrels of beer produced annually, Flying Dog has ranked as high as #28 on the Brewers Association’s Top 50 Craft Brewing Companies based on sales. But don’t let that overshadow a hometown favorite like Monocacy Brewing Co. and their restaurant Brewer’s Alley, also in Frederick (1781 N. Market St.).
Beer is proof that God loves us and wants us to be happy – Ben Franklin brewing, and was a founding member of the Brewer’s Association of Maryland. His brewery’s production quality, number and variety dominate many a discussion about good, local craft beers. As proof, in the 2014 Maryland Comptroller’s Cup Competition, they dominated with Best of Show – Best Overall Maryland Beer category, earning
Looking a little more broadly, the 2014 Great American Beer Festival, selfidentified as “The largest commercial beer competition in the world!� awarded several medals to Maryland’s craft beers. The ‘ones’ to keep an eye out for are: Gold Medal winners “Gold� (again), from Heavy Seas Beer, in the Golden or Blonde Ale category, and “Rauchbeir�
from Gordon Biersch Brewery Restaurant in Annapolis, in the smoke beer category. Silver Medals went to Gordon Biersch Brewery Restaurant in Rockville, for their “Belgian IPA� and Union Craft Brewing in Baltimore for their “Old Pro Gose� in the German Style Sour Ale. One of the most consistent messages I got from the representatives at the breweries and the associations is that these small breweries encourage creative instincts. Using local resources and local inspiration, brewers are producing wonderfully creative beers. This trickles down even to the homebrew category. There are stores, clubs and associations that can launch the creative homebrewer such as Homebrewers Association and The Freestate Homebrew Guild. It wasn’t too long ago that at my local farmers market I was beat out of boxes and boxes of blackberries by a home brewer intending to ferment a blackberry stout hybrid; I asked him for an invitation to his tasting. This could be interesting. For more information on Maryland's craft beers, visit marylandbeer.org
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Compliance
Don’t Be a HIPAA-CRIT: Are You Unintentionally Exposing Your Practice?
M
OST PHYSICIANS are technologically savvy and provide quality healthcare in today’s cuttingedge, fast-paced practice of medicine. While you are likely taking precautions to protect your practice from the threat of a privacy breach, there are privacy risks that may not be so apparent. Protecting your practice requires planning, preparation and thinking outside of the box. Believing that you are protected from a breach because you have implemented privacy and security policies, while remaining unaware of everyday practice situations and circumstances that violate HIPAA, could make you a HIPAA-CRIT. The following scenarios will illustrate some of these hidden threats in order to help you avoid a HIPAA violation.
By Jamie Lynn Meier, Esq.
Responding to comments, even those that are blatantly false, can compound a physician’s troubles by setting the stage for a privacy complaint. This is not to suggest that a physician has no recourse, but rather to encourage a path to resolution that does not involve public response. For example, you could request that either the site or the patient agree to voluntarily remove the post. Control Office Chatter
Check Responses to Web-Based Health Review Posts
On a typical day, your office staff probably answers the phone within earshot of patients sitting in the waiting room. Disclosures of PHI in this environment are generally considered incidental; however, if voices are raised above a conversational level, or staff are having an unnecessary side conversation and disclose PHI, this would not be considered incidental, and could subject you to a HIPAA breach.
With websites like Healthgrades and Yelp receiving millions of unique visitors a month, it’s understandable that a negative review would be a source of stress for physicians. It might even be tempting to respond to such a post if for no other reason than to explain an alternative theory for an unfavorable review. Before you try to set the record straight, however, you should consider the potential unintended consequences. While patients are free to publicly discuss whatever they wish about their own healthcare experiences, physicians are limited – by the law and a patient’s express authorization – from disclosing protected health information (PHI).
When evaluating privacy protection and security, consider: z Avoiding the use of patients’ names in public areas such as hallways, elevators, etc. z Ensuring that voice levels are appropriate for the office setting. Where do your patient calls and staff conversations take place? The more compact your office and waiting room space, the quieter you will want to be if you need to have a discussion that involves PHI. z Communicating with your patients about how they want you to deal with their PHI. You need to do what
z
is necessary to reasonably accommodate their requests. Posting signs in the office to remind staff members to remain vigilant in their responsibility to protect patient confidentiality.
Encrypt Emails
Healthcare providers are increasingly using email to communicate with patients about their medical conditions. HIPAA does not expressly prohibit the use of email for sending electronic PHI in the Security Rule. However, it includes standards for access control, integrity and transmission security that require practices to implement policies and procedures to restrict access to, protect the integrity of, and guard against unauthorized access to PHI. It is critical to understand that many health and medical professional liability insurance carriers may require software encryption as a prerequisite to receiving coverage. Regardless of how a breach occurs, compliance in its aftermath can be timeconsuming and costly – not to mention the damaging effect a breach can have on your practice’s reputation. In addition to understanding your potential vulnerabilities, you can further mitigate your risk by purchasing a Privacy Breach policy in conjunction with your Medical Professional Liability policy. These steps will help you combat the hidden threats to the security of your practice. Jamie Lynn Meier, Esq., is an associate in the legal department of the Medical Mutual Liability Insurance Society of Maryland. She can be reached at jmeier@weinsuredocs.com.
NOVEMBER/DECEMBER 2014
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Good Deeds
Walking with the Spirits: A Journey through a South Dakota Sun Dance Ceremony By Thu Tran, MD, FACOG
T
HIS PAST SUMMER, I JOINED my son on a community service project in South Dakota to help the Lakota Native Americans prepare for their sun dance ceremony, an event that has occurred regularly for several years. Our destination was a track of land within the Pine Ridge Reservation, outside of Rapid City. Sun dance ceremonies, the most sacred in the Lakota culture, were previously outlawed, but as a result of “The Wounded Knee Incident” in 1973, they have experienced a revival. Participants dance, gazing at the sun, stepping in rhythm to drums and eaglebone whistles. The purpose of their dance is to pray for the world, their families and their community. To be a sun dancer is to “sacrifice” oneself for the good of others, with each step carrying spiritual meaning. Dancers follow many purification rituals before the actual sun dance. Sweating in the “Inipi” (a sweat lodge) is one of the most important pre-dance sacred ceremonies. The Inipi, which is shaped like a turtle, or the “womb of Mother Earth,” is the spiritual place for prayers. It was our job to build two new inipis using willow branches. We gathered sage, one of the four sacred medicines used for ritual cleansing in Native American cultures. It symbolizes strength, wisdom and clarification of negative energy. The other three medicines are tobacco, cedar and sweetgrass. The dancers hold sage fans braided with red strings, and wear sage crowns on their heads. The day before the dance, we awoke early to make wishes for a new “tree of life.” Our wishes were made of colorful fabric with tobacco inside, carefully tied into a bundle. Tobacco is believed to be 30 | MDPHYSICIANMAG.COM
Our group gathers sage, one of four sacred medicines used for ritual cleansing in Native American cultures.
Native American families join the Lakota for their sacred sun dance.
our connection to the spirit world, with the smoke thought to be the method of carrying prayers to God. The day of the dance, the dancers wore traditional ceremonial dress and had their wrists and ankles wrapped with sage and red ribbons or strings. Holding sage fans, wearing sage crowns and gazing at the sun, they blew eaglebone whistles while stepping in rhythm with the drumbeat and ancient songs. Around the arbor, fellow supporters and I watched, mesmerized, and some of us joined in. With the tree of life’s colorful wishes standing against a blue sky, the scent of burned cedar, the instruments and singing, dancers with their silent gazes to the sun, and a community of supporters all praying for peace and good will, you can imagine the magic of the event. It’s those moments that help us realize what’s truly essential in our lives. I found I had much in common with our new Native American friends. We care about our families, the world, the
environment and our health. We might not worship the same God, but our level of spirituality is not different. We all have the same goal in life: being joyful and peaceful. My time with the Lakota taught me how simply I could live, how rich my life is, and how wonderful it is being part of a close-knit community where everyone is focused on building the common good. I wish you Peace, or in Lakota, “WoLakota!” Thu Tran, MD, FACOG, is an OB/GYN with Capital Women’s Care in Rockville; a founding member of ladydocscornercafe.com, and a member of Maryland Physician Magazine’s Advisory Board. The full blog post of “Walking with the Spirits” can be found on Ladydocscornercafe.com.
Maryland Physician would like to hear about your “Good Deeds.” Please share your ideas with us at news@mdphysicianmag.com.
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