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ORTHOPEDIC UPDATE: JOINT TUNE UPS ARE ALTERNATIVE CARE DELIVERY MODELS RIGHT FOR YOUR PRACTICE? MAKING MARYLAND HEALTHIER WITH HEALTHCARE IT
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VOLUME 2: ISSUE 2 JULY/AUG 2012
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Contents 10
July/August 2012 Volume 2: Issue 2
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24
F E AT U R E S
10 Joint Tune Ups Lifestyle Changes, Shoulder & Hip Replacement
14 Alternative Care Delivery Models Are They Right For You?
20 Can Healthcare IT Make Maryland Healthier? DHMH Secretary Sharfstein Reveals the Challenges and Potential of Using IT D E PA R T M E N T S
Cases
| 6 | Limb Lengthening with a New Internal, Controllable Device
Compliance
| 7 | If You Accept Plastic, Then ...
Living
| 24 | Maryland on the Water: Summer Fun Along the Waterways
Policy
| 30 | Cardin Comments on the Affordable Care Act, Supreme Court, Health Priorities
Solutions
| 33 | Seven Reasons to Consider a Cloud-Based EMR
Good Deeds
| 34 | Life After War:Walter Reed National Military Center Helps Soldiers Get Back to Living
On the Cover: Maryland Department of Health and Mental Hygiene Secretary Joshua M. Sharfstein, M.D.
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JACQUIE ROTH, PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com CONTRIBUTING WRITERS Tracy Fitzgerald Jackie Kinsella CONTRIBUTING PHOTOGRAPHY Tracey Brown, Papercamera Photography www.papercamera.com Mark Molesky, Moleskey Photography www.moleskyphotography.com ADMINISTRATION Ginger Jenkins
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AS WE WENT TO PRESS FOR THIS ISSUE, America’s patients, healthcare providers and politicians – everyone – were bracing for the Supreme Court’s ruling on the constitutionality of the Affordable Care Act (ACA). Political philosophical differences aside and despite having some of the world’s leading-edge providers here in Maryland, most agree the American healthcare delivery system is broken and needs to be fixed. The “train has already left the station” in many of the ACA’s intended reforms with a number of states having been forward thinking, already undertaking and implementing some of the goals of the ACA. Maryland is one of the leaders, helping patients and their providers gain information via technology, with the intention of allowing all to be empowered, educated and involved in making informed care decisions. Informed decisions provide better outcomes and save us money. That’s what the system needs: improvements and accountability in quality and value. Maryland Physician Magazine Managing Editor Linda Harder and I had interviews with two of Maryland’s healthcare leaders, Department of Health and Mental Hygiene Secretary Joshua M. Sharfstein, M.D. and U.S. Senator Ben Cardin (D-MD). To learn what they are doing to support your practice and how you deliver care to your patients, see Healthcare IT (page 20) and Policy (page 30). If you’re a private primary care physician reading Maryland Physician, you’re well aware of the strains reimbursement rates create on the way you practice medicine and manage your practice. There are options available. Are they right for you? Are they right for your patients? See our feature, Alternative Care Delivery Models (page 14). Clinically, our issue spotlights updates in orthopedics with a focus on the hips and shoulders. I had to laugh when one of this issue’s ads was delivered – an image of a bicycle rider feet over his head on his way to meet the road. I’ve been that guy; I was hit by an SUV late last fall while on my own bike and have been in treatment for a variety of issues since then. I shudder to think what would have happened had I not been in good physical condition when my body made contact with the SUV and then the road. Via that experience, I’ve been a bit too “up close and personal” with both Western and Eastern treatments but I’m back biking and living the Chesapeake lifestyle – on the water – as much as I can. Learn about one of the fastest growing and inexpensive watersports, stand up paddling (SUP), in Living (page 24). Enjoy some time away from your practice this summer and be sure to share the road and waterways!
EXECUTIVE ASSISTANT/WEBMASTER Jackie Kinsella Maryland Physician Magazine™ is published bimonthly by Mojo Media, LLC. a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 1663 Millersville, MD 21108 443-837-6948 www.mojomedia.biz Subscription information: Maryland Physician Magazine is mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52.00. To be added to the circulation list, call 443-837-6948. Reprints: Reproduction of any contact 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: KAREN COUSINS-BROWN, D.O. Maryland General Hospital PATRICIA CZAPP, M.D. Anne Arundel Medical Center HOLLY DAHLMAN, M.D. Greenspring Valley Internal Medicine, LLC PAUL W. DAVIES, M.D., FACS KURE Pain Management GAUROV DAYAL, M.D. Adventist HealthCare MICHAEL EPSTEIN, M.D. Digestive Disorders Associates STACY D. FISHER, M.D. University of Maryland Medical Center REGINA HAMPTON, M.D. FACS Signature Breast Care DANILO ESPINOLA, M.D. Advanced Radiology GENE RANSOM, J.D., CEO MedChi
To life! Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources.
Jacquie Roth Publisher/Executive Editor jroth@mdphysicianmag.com 4 |
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Green logo here
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NOW MARYLAND PHYSICIANS CAN ENJOY A NEARLY 90% WINNING RECORD IN LIABILITY CASES. Maryland physicians love winning liability cases even more than they love crab cakes. That’s why it’s so exciting that Coverys’ medical professional liability coverage is now available here. For more than three decades, Coverys has been aggressively defending good medicine. Over 75% of our cases are closed without indemnity payments and we enjoy a win rate of nearly 90% for those that go to a verdict at trial. Finally, Coverys’ winning record, financial strength, and wide range of expertise can be yours. Delicious.
Medical professional liability coverage in Maryland is provided by ProSelect Insurance Company, a member company of Coverys. Claim data for Coverys member companies Medical Professional Mutual Insurance Company and ProSelect Insurance Company
Cases
Limb Lengthening with a New Internal, Controllable Device John E. Herzenberg, M.D., F.R.C.S.C., Shawn C. Standard, M.D., and Stacy C. Specht, M.P.A.
CASE: A 15-year-old boy presents with limb length discrepancy that resulted after damage to the growth plate of the femur. The injury occurred during a football game 3 years earlier. Physical exam showed a healthy young man who walked with a limp and had full range of knee motion. The right femur was 3 cm shorter than the right. Surgical and non-surgical options were discussed with the patient and his family.
DISCUSSION Limb length discrepancy may result from congenital, posttraumatic, and developmental etiologies. Differences greater than 1 to 2 cm can cause a limp, back pain, hip pain, and/or arthritis. External shoe lifts can alleviate these issues but are not typically accepted by young adults. Surgical lengthening of the short limb offers a permanent solution. Classically, the method to lengthen a short leg required using an external fixator for many months. Potential complications include pain, scarring, infection, and fracture after lengthening. Wearing the external fixator for months at a time can be difficult to tolerate both physically and
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psychologically. Recently, alternative methods for limb lengthening have been developed that use fully implantable telescopic intramedullary rods. In 2001, the first generation intramedullary telescopic rod was introduced in the USA. This was the Intramedullary Skeletal Kinetic Distractor (ISKD). The ISKD lengthened via a one-way mechanical ratchet mechanism. After the bone cut was performed and the ISKD was implanted, the leg was rotated back and forth. This movement caused the ISKD
In this case, the patient opted to have his femur lengthened with the Precice rod. Seven days after the Precice rod was inserted, he started the lengthening process at a rate of 1 mm/day. This rate was increased to 1.5 mm/day when rapid bone healing was seen on follow-up radiographs. Pain was well controlled with oral analgesics. Joint range of motion was maintained throughout the lengthening process during physical therapy sessions five times a week. Radiographs were obtained weekly to ensure that the Precice rod and the external magnetic
The femur lengthened 3 cm uneventfully over the course of four weeks. It was fully healed six weeks after lengthening was complete. and the limb to lengthen through the bone cut. Having implanted more than 280 of these devices, we have had generally good results, but the mechanism was difficult to control accurately. As a result, many limbs inadvertently lengthened too quickly or too slowly. Lengthening too quickly may prevent the bone from healing and can cause joint contractures, excessive pain, and even peroneal nerve stretch injuries. More recently, second generation technology has been released. The Precice rod, approved by the FDA in January 2012, contains a tiny internal magnetic motor, gearbox, and telescopic mechanism. Although similar in external appearance to the ISKD, the Precice rod lengthens only when an external magnetic field generator is placed against the leg. The external magnetic field generator is held next to the leg for a few minutes to power the magnetic motor inside the rod in a precisely controlled fashion.
field generator were working properly. The femur lengthened 3 cm uneventfully over the course of four weeks. It was fully healed six weeks after lengthening was complete. At this time, the patient was allowed to fully weight bear without assistive devices and has returned to full activity. Since January 2012, we have implanted 17 Precice rods. Although our experience is still early, the Precice rod appears to be a significant improvement over the first generation ISKD technology, providing a more accurate rate of lengthening and less pain than with the ISKD. John E. Herzenberg, M.D., F.R.C.S.C., director, Shawn C. Standard, M.D., head of pediatric orthopedics, and Stacy C. Specht, M.P.A., research program manager—all at the International Center for Limb Lengthening, Sinai Hospital of Baltimore. Contact Dr. Herzenberg at jherzenberg@lifebridgehealth.org.
Compliance
If You Accept Plastic, Then ... By Barry F. Rosen and John C. Morton
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HILE DOCTORS, hospitals and other medical facilities are patently aware of the numerous federal and state laws and regulations that govern the use and protection of patient information, they may not be aware of certain industry privacy standards applicable to medical providers that accept or process credit and debit card payments from patients. PCI Security Standards
The Payment Card Industry Security Standards Council (PCI SSC) was created jointly by most of the major credit card companies. It establishes technical and operational requirements, known as the Payment Card Industry Data Security Standards (PCI DSS), which apply to all “merchants” (including medical providers) that accept or process payment cards. The PCI DSS is, in turn, enforced by the individual credit card companies through their dealings with any entity that accepts payments from that card company. Compliance with the PCI DSS is important now, more than ever, because of the increasing number of transactions involving credit and debit cards, the potential liability that can arise from a security breach and subsequent compromise of payment card data, and the potential revocation of card processing services by banks and card companies. A security breach can have farreaching consequences, including notification requirements, litigation costs and potential financial liabilities. A data breach can also have an impact on goodwill, potentially resulting in a loss of reputation and patients. Medical providers are vulnerable to data breaches at various stages of payment card processing. For example, point-of-sale devices, personal computers or servers, wireless hotspots, paper-based storage systems, and unsecured transmission of cardholder data to service providers, all present potential points of vulnerability.
Compliance with the PCI DSS can help alleviate these potential vulner- abilities and protect cardholder data. Three Steps
There are three steps for adhering to the PCI DSS: assessment, remediation, and reporting. A medical provider should assess its data security by: 1. identifying cardholder data 2. taking an inventory of its information technology assets and the business processes it utilizes for payment card processing 3. analyzing them for vulnerabilities that could expose cardholder data. Generally, small practices may use a self-assessment questionnaire as a selfvalidation tool to assess PCI DSS compliance. The self-assessment questionnaire is provided by the PCI SSC, and requires varying levels of information depending on the manner in which a medical practice accepts payment cards. Remediation can be accomplished by (i) fixing vulnerabilities, and (ii) most importantly, not storing cardholder data any longer than absolutely needed to process a transaction. Finally, required reports should be compiled and submitted to the acquiring bank and/or card brands with which a medical provider does business.
Protect Cardholder Data Protect stored cardholder data – in general, no cardholder data should ever be stored unless it is necessary to meet the needs of the business. Encrypt transmission of cardholder data across open, public networks. Maintain a Vulnerability Management Program Use and regularly update anti-virus software or programs. Develop and maintain secure systems and applications. Implement Strong Access Control Measures Restrict access to cardholder data by need-to-know. Assign a unique ID to each person with computer access. Restrict physical access to cardholder data. Regularly Monitor and Test Networks Track and monitor all access to network resources and cardholder data. Regularly test security systems and processes. Maintain an Information Security Policy Maintain a policy that addresses information security for employees and contractors.
General Requirements
The PCI DSS also establishes 12 general requirements: Build and Maintain a Secure Network Install and maintain a firewall configuration and router configuration to protect cardholder data. Do not use vendor-supplied defaults for system passwords and other security parameters.
A medical provider’s compliance with these requirements, and with its specific bank and/or card company assessment and reporting requirements, can help protect patient cardholder information, and help prevent a damaging data breach. Barry F. Rosen, Chairman and CEO of the law firm of Gordon Feinblatt LLC, can be reached at brosen@gfrlaw.com. John C. Morton, an associate , can be reached at jmorton@gfrlaw.com.
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Profile
SPONSORED CONTENT
MSK Imaging from Shoulders to Toes A Guide to Ordering the Right Imaging Study for each MSK Problem
High strength MRI reveals underlying issues in small joints, from shoulders to toes.
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USCULOSKELETAL (MSK) issues are some of the most common clinical problems necessitating an imaging study. With a wide range of disorders, it can be challenging for referring physicians to order the right study for a given problem. What if the X-ray does not demonstrate a problem but the patient continues to experience pain? When is 3T MRI appropriate? When is ultrasound an acceptable substitute? When should arthrography be ordered?
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Advanced Radiology offers comprehensive and complete imaging options for your patients. Its MSK experts have prepared this guide for your convenience and are available to answer any of your questions about a specific patient. Physicians can call 888-972-9700 and ask to speak to one of its many subspecialty musculoskeletal radiologists. The practice also offers treatments, including steroid and anesthetic injections for painful joints.
X-rays
Radiographs should always be the first test for suspected bone or joint injury or pain. They often are sufficient to monitor non-complicated healing for fixation procedures, initial evaluation of arthritis and nonspecific pain localized to a joint. Most suspected fractures can be imaged with plain X-rays or CT. MSK CT
Musculoskeletal CT can be reliably used to evaluate suspected fractures
or as an alternative to MRI for patients with pacemakers or other contraindications to MRI. It also can be helpful for surgical planning in the setting of complex fractures, evaluating for avascular necrosis following fixation procedures or assessing complications after hip replacement. 3D volumetric rendering images are available upon request to assist clinicians in management. MSK Ultrasound Ultrasound (US) is appropriate for evaluating select soft tissue conditions, including: Tendon tears – especially rotator cuff, biceps, quadriceps and Achilles tendons Pain in joint with metal implant Soft-tissue masses such as lipomas Bleeding or fluid collections in muscles, bursae and joints, including popliteal cysts Early rheumatoid arthritis changes “Ultrasound can be an appropriate first modality in many clinical situations, especially for elderly patients,” comments Advanced Radiology's ultrasound expert, Thayer Simmons, M.D., MSK ultrasound expert. Nuclear Medicine
Three phase bone scans are an excellent modality for the early diagnosis of shin splints, pars interarticularis defects and stress fractures following a negative X-ray and unexplained bone pain. Other indications include the evaluation of painful joint replacements and determining if osteomyelitis is present. Danilo Espinola, M.D., nuclear medicine and PET/CT specialist, states, “If a bone scan is non-diagnostic for osteomyelitis, then a physician should order a labeled white blood cell scan.” MSK MRI
When an injury with a negative X-ray is not healing after two weeks, further evaluation with a second modality, such as MRI, is warranted. Loralie Ma, M.D., Ph.D., Medical Director of GBMC, MRI and PET CT and expert in MRI imaging advises, “For most musculo-
3T and Cartilage Mapping
skeletal indications, MR contrast is generally not required, except for inflammatory arthritis, suspected abscess or neoplasm.” High field (1.5 to 3T) MRI plays a crucial role in MSK diagnosis and treatment planning when other imaging modalities are insufficient. With its superb spatial resolution and soft tissue visualization, MRI is ideal to:
Dr. Ma observes, “Cartilage mapping is now available at two of our 3T locations – at GBMC and Crossroads. It is ideal for patients with ligament or meniscal tears and suspected articular cartilaginous injuries. This software can aid clinicians in detecting subtle occult trauma and help in operative planning. It can also evaluate cartilage following autologous osteochondral grafts.”
Evaluate patients with pain who
MR or CT Arthrography
have negative radiographs. It is especially useful for athletes with an unresolved soft tissue injury, or to confirm a diagnosis prior to surgery Guide therapeutic management and help patients avoid longterm consequences such as osteoarthritis Diagnose tears in the labrum, cartilage, menisci, ligaments and tendons, as well as tendinitis and tenosynovitis Visualize stress fractures, masses and congenital anomalies
A common use for MR arthrography is providing fine detail to evaluate glenoid or acetabular labral tears. It is particularly useful in athletes of all ages, whose pain is not resolving after an injury. By joint, common indications include:
Robert Van Besien, M.D., a musculoskeletal MRI expert, comments, “MRI often shows that the problem is not what was suspected on clinical examination. For example, in the ankle, patients referred to rule out a tendon tear may instead have a ganglion or osteochondral injury, which can change their management.”
When to Use 3T
Generally speaking, 3T MRI should be considered for patients with damage or injury to the small joints – wrist, hand, ankle, foot or elbow. 3T is also useful for diagnosing small tendon tears and grading articular cartilage abnormalities in the shoulder, knee and hip to improve pre- and post-surgical treatment planning. As the continued leader in outpatient imaging in Maryland, Advanced Radiology has four 3T MRI machines, more than any other outpatient imaging provider in the state. Its Crossroads center in Columbia/ Ellicott City now offers one of the region’s first wide-open 3T MRIs.
Shoulder - labroligamentous abnormalities, capsule and rotator cuff pathology Hip - acetabular labral tears Wrist - TFC or scapholunate ligament tears after a fall or workrelated injury Elbow - ligaments and articular cartilage defects Knee - recurrent meniscal tears after prior meniscal repair Ankle - talar osteochondral injuries, loose bodies
Alison Oldfield, M.D., arthrography expert, notes, “Arthrography can provide the finer detail needed to determine whether surgical intervention would benefit the patient or when regular MRI is not definitive. CT is an alternative when MRI is contraindicated or for more specific bone detail. We also perform indirect arthrograms, where contrast is injected intravenously.” Joint Pain Treatments
Advanced Radiology can perform injections of steroids or anesthetics to treat patients with pain in any joint. “This service, which is most commonly used to treat hip and shoulder pain, is available in many of our centers,” notes Dr. Espinola. Call 888-972-9700 to speak to an Advanced Radiology subspecialty musculoskeletal radiologist.
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Joint Tune Ups LIFESTYLE CHANGES, SHOULDER & HIP REPLACEMENT
An aging but active population of baby boomers is fueling an explosion in orthopedic problems.To learn the latest, Maryland Physician spoke with Maryland experts in shoulder and hip joint replacements – plus a physiatrist who specializes in lifestyle changes that help patients prepare for surgery. BY LINDA HARDER PHOTOG RAPHY BY TRACEY BROWN
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Surgical “Tune-Ups” Improve Outcomes While the critical factor in orthopedic surgery outcomes is the skill of the surgeon and the technology, physicians are becoming aware of another important factor – nutritional status and lifestyle choices. That’s where Frederick T. Sutter, M.D., M.B.A., a physiatrist who founded Lifestyle Medicine Consultants, Inc. in Annapolis, comes in.
Michael Anvari, M.D.
“When I get a referral for someone who may need surgery,” says Dr. Sutter, “it’s a superb opportunity to spark meaningful patient cooperation to optimize their nutrition and exercise habits. Poor lifestyles contribute to poor surgical results. Many people think that they need to change their lifestyle after they have surgery, but we like to intervene early on.” To determine the most effective interventions for the often-intractable problems of obesity, sedentary lifestyle and poor sleep and nutrition habits, Dr. Sutter spent years combing the literature. “For example, more than 100 peerreviewed studies have shown that nutritional factors influence surgical outcomes,” he notes. “We ask patients how long they want to take to recover. Then we tell them there are about a dozen things they can do to speed that recovery. We evaluate their sleep and exercise habits, nutritional deficiencies and stress.”
“That led to us develop our Weight Loss 5x5® lifestyle medicine program,” Dr. Sutter says. “People take five steps, five weeks at a time – they get their training wheels so to speak. We build in a lot of accountability, then expand the intervals in between visits and at the end ask participants to commit to a one year maintenance plan to help them keep their good new habits. Diets fail – our program is oriented to lifestyle changes supported by accountability. “Many overweight people have arthritic problems,” he continues. “Sometimes the surgeon won’t operate if the patient doesn’t lose some of that weight. We provide exercise prescriptions, rather than just telling them to “do more.” We check for nutritional deficiencies and imbalances since the targeted use of nutrients has been shown to favorably influence surgical outcomes. We also prescribe exercise to improve muscle tone. We discuss sleep hygiene, since pain can lead to sleep disruption and even a Vitamin D deficiency, since patients stop going outside. Following the No-White Diet to eliminate refined foods can help reduce inflammation and promotes healing.” Dr. Sutter reminds primary care physicians that they play a more critical role than they perhaps realize. “What can primary care physicians do? Most important is that they ask their patient to lose weight or make other healthy lifestyle changes. Studies have shown that patients are three to four times more likely to make a positive change if their physician asks them. “Then, patients need accountability and support – such as working out with a friend or having a holiday party where everyone brings a healthful dish, then
disorders. In that time, he’s performed more than 600 shoulder replacements, making him one of the highest volume surgeons in this area. Yet shoulder arthroplasty continues to be eclipsed by hip and knee replacements, which are now each performed in over 600,000 patients a year throughout the country. Given the lower profile of shoulder arthroplasty in the community, it can be overlooked as an option in the treatment of shoulder arthritis. Why is shoulder arthoplasty performed so much less frequently and what are the advances in the procedure? Dr. Petersen says, “The shoulder joint is subject to stresses equal to body weight, while the hip and knee carry three to five times that burden. Arthritis may be as common in the shoulder as it is in these other joints, but it often is much less symptomatic given these lesser stresses. Shoulder replacement has proven to be the gold standard treatment for severe shoulder pain and disability from arthritis.” Ideal Candidates
Surgery is not considered an option until more conservative approaches, including NSAIDs, physical therapy, heat/cold and injections have insufficiently improved pain and range of motion (ROM). Arthroscopic surgery may be an attractive option in someone with mild to moderate arthritis. “The ideal candidate for shoulder arthroplasty is someone with an intact rotator cuff, severe, poorly controlled pain, and limited range of motion,” states Dr. Petersen. “Most candidates are in their late 50s to early 70s, with ages ranging from 30-90 plus years.” Dr. Petersen continues, “While the procedure is not appropriate for someone with ROM limitations without significant
“The ideal candidate for shoulder arthroplasty is someone with an intact rotator cuff, severe, poorly controlled pain, and limited range of motion.” - Steve Petersen, M.D.
shares recipes,” concludes Dr. Sutter. “We say to patients, ‘Let’s take a stand together.’”
Shoulder Arthroplasty: Often Overlooked For the past 25 years, Steve Petersen, M.D., orthopedic surgeon, Johns Hopkins Orthopaedic & Spine Surgery at MedStar Good Samaritan Hospital, has focused his entire orthopedic practice on shoulder
pain, it’s important that physicians not wait until the patient has begun to wear away glenoid bone, which can compromise outcomes. If a patient has rheumatoid arthritis with progressive loss of bone, it’s a good time to refer to an orthopedist because glenoid bone loss compromises our ability to improve motion and stability. With osteoarthritis, posterior glenoid bone loss can become a JULY/AUGUST 2012
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concern, creating a challenging situation if surgical treatment is delayed.” Reverse Shoulder Arthroplasty
Appropriate for some elderly and sedentary patients with advanced arthritis and an irreparable rotator cuff tear (rotator cuff arthropathy), reverse total shoulder arthroplasty enables experienced shoulder surgeons to treat patients with previously insoluble conditions. By using special techniques and prostheses designed to replace the humeral head with a socket and the glenoid socket with a ball, qualified surgeons can improve the stability of the shoulder and increase motion that is provided by the deltoid. Downsides to Robots and MIS
Dr. Petersen is cautious about advocating minimally invasive surgery (MIS) or robotic approaches. “If a patient has to have a partial shoulder replacement revised, the results are not as predictable or durable as they would have been with a total shoulder replacement. “The classic total shoulder replacement has the best outcomes, supported by 20 years of data,” Dr. Petersen adds. “Different resurfacing options have been developed for younger patients, but long-term follow-up data is not yet available.” CAD/CAM and robotics techniques have not been proven more effective than traditional techniques. “We need to provide reproducible techniques and alternative products that are durable and cost effective. There are some things on the horizon – using 3D models and computer software for more accurate replacement of components. This attractive innovation needs further testing
and well developed clinical studies prior to its release for use,” Dr. Petersen envisages. “I believe that the future of shoulder replacements will need to focus more on the materials used than new techniques. Polyethylene is the most vulnerable material we use and there may be alternative materials in the future that will allow us to develop more durable arthroplasty components,” Dr. Petersen concludes.
Anterior Hip Replacement: Better Stability Michael Anvari, M.D., joint replacement specialist, Carroll Hospital Center, is bullish about the anterior approach to hip replacement; he now performs this procedure on virtually all appropriate patients. He notes, however, “This approach is not ideal for patients with significant anatomic dysplasia or a Body Mass Index approaching 35 to 40.” While not a new procedure, the anterior supine inter-muscular approach to hip replacement is not yet widely available. It requires significant training, and a special radiolucent OR table that improves access to the femur is helpful. The table allows supine positioning and permits precise positioning of the proximal femur. The approach permits more accurate and consistent component positioning and lower dislocation risk, and the table facilitates the use of intraoperative fluoroscopy, which increases the accuracy of implant placement and leg lengths. The approach is less invasive because it takes advantage of the natural gap between the gluteus medius and rectus femoris muscles to enter the hip capsule. Dr. Anvari observes, “Traditional hip replacement is already a very good
Frederick T. Sutter, M.D., M.B.A.
procedure, with 95% patient satisfaction, but the anterior approach is an improvement. In the short term, patients typically reduce their length of stay, use of narcotics and rehab time, and they can return to activities more quickly. Over the long term, the biggest advantage is better stability.” From the health system approach, the cost of the anterior approach is slightly less than the traditional approach; for patients, it’s roughly equivalent. While the surgical table costs about $100,000, it can be used for other procedures such as hip arthroscopy and fractures, and the hospital stands to gain by discharging patients earlier and requiring less nursing care. “In my practice,” notes Dr. Anvari, “I have patients who get two weeks of home therapy; half of them then need no outpatient therapy, while the other half need it for less time than normal.”
Advantages of Anterior Hip Replacement
Intraoperative fluoroscopy - precise positioning of implants, leg lengths
No muscle cutting Faster recovery Less post-operative pain/decreases use of narcotics
Quicker return of normal function Superior stability Eliminates traditional hip dislocation precautions
Steve Petersen, M.D.
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Lower dislocation risk long-term
Training Investment
For surgeons, however, learning the anterior approach requires a significant investment of time that should include education, training programs and cadaver work. “For me, it was a three to four year process to complete my study and training,” says Dr. Anvari. “I don’t believe in being an early adopter of anything. I’m conservative, and don’t want my patients to be one of the first. You have to prove that the new approach is better than the current standard.” As a result, he took a conservative approach to the new procedure. “My patients have had a genuinely better experience with the anterior approach,” he adds. “Some of them had the posterior approach for their first hip and the anterior approach for the other hip, so they can directly compare.” A study published in the Journal of Bone and Joint Surgery in 2009 found significantly improved early recovery of patients who underwent the anterior approach, with a higher rate of discharge directly to home, as well as improved Harris hip scores and lower-extremity activity scale scores at six weeks. While an advantage of the anterior approach is reduced risk of dislocation post operatively, Dr. Anvari again strikes a conservative tone. “I believe that the skill of the surgeon most affects the dislocation risk. For experienced surgeons, the risk is less than 1 percent, regardless of which approach is taken.” However, the anterior approach does preclude having to take the post-op precautions necessary following the posterior approach – including using abduction pillows and avoiding crossing the legs, deep bending or sleeping on the side for six weeks. Instead, patients can immediately resume normal activities without restrictions.
Michael Anvari, M.D., orthopedic surgeon, joint replacement specialist, Carroll Hospital Center Frederick T. Sutter, M.D., M.B.A., specialist in Physical Medicine and Rehabilitation and founder, Center for Wellness Medicine Steve A. Petersen, M.D., Johns Hopkins Orthopaedic & Spine Surgery at MedStar Good Samaritan Hospital, co-director for the division of shoulder surgery and associate professor, Orthopaedic Surgery, Johns Hopkins University School of Medicine
MORE ORTHOPAEDIC LOCATIONS
WITHIN THE STATE Introducing University of Maryland Faculty Physicians, Inc. at Columbia, where University of Maryland faculty physicians provide diagnosis and treatment of all orthopaedic problems. Just like the other orthopaedic locations in Baltimore, Timonium and Woodlawn, this new orthopaedic site offers patients access to the expert care available through an academic medical center, yet in the comfort and convenience of a community setting.
SPECIALTIES INCLUDE:
. TOTAL JOINT RECONSTRUCTION . SPORTS MEDICINE . SPINE CARE . SHOULDER, ELBOW AND HAND . ORTHOPAEDIC TRAUMA . PEDIATRIC ORTHOPAEDICS . MUSCULOSKELETAL ONCOLOGY . FOOT AND ANKLE The University of Maryland is available to referring physicians for consults or transfers at OneCall 1-800-373-4111. For orthopaedic appointments, please call 410-448-6400 or visit umortho.org.
University of Maryland Faculty Physicians, Inc. at Columbia 5500 Knoll North Drive / Columbia, MD 21045
umm.edu umm. edu
M MEDICINE ON A MISSION
Official Medical Provider
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Alternative Care DELIVERY MODELS
Are they right for
YOU? 14 |
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WRITTEN BY LINDA HARDER
MOLESKY PHOTOGRRAPHY
Strains on care access and delivery have led some physicians to create or participate in different models to meet patient needs – from urgent care to concierge medicine. Are any of these approaches right for you and your patients? Maryland Physician spoke with some local practice innovators to find out.
Stephen Katz, M.D.
HYBRID CONCIERGE CARE The concept of concierge medicine, where patients pay an additional fee for enhanced services, originated in Seattle in the late 90s. While it has grown steadily over the years, no hard numbers of the number of physicians engaged in this practice are available. The American Academy of Private Physicians estimates that as many as 2000 physicians (about 1%) offer concierge care nationwide. A much
smaller subset is estimated to provide hybrid concierge care, where only some patients in the physician’s practice participate in the model. Critics contend that concierge medicine could exacerbate the challenge of finding a primary care physician for patients, especially those with limited funds, while proponents tout the benefits to both physicians and patients. The hybrid model appears to be a way that physicians can improve their practice viability while keeping their existing patients. Concierge Choice Physicians (CCP), based in Rockville Centre, NY, has 200 practices in 20 states, concentrated on the East Coast. Nine physicians in Maryland offer their hybrid concierge model. Stephen Katz, M.D., based in Severna Park, is one of their participating physicians and an advocate for the model. “The insurance industry hasn’t raised reimbursement since 2002. It’s difficult to make a living in traditional private practice. We initially looked at the full concierge model, but I didn’t feel comfortable turning away a lot of
my patients. When I learned about CCP, it seemed crazy at first, but it turned out that many patients wanted a more personalized experience and were willing to pay for it, and I didn’t have to displace anyone.” Wayne Lipton, founder and managing partner of CCP, agrees. “The hybrid model is a way for many doctors to convert a small portion of their practice – typically 3% to 8% – to this model, while increasing their revenue by 30% to 100%. It’s a wonderful solution to keep doctors in the community while addressing their financial problems.” Dr. Katz, a participating doctor with CCP since 2009, has about 140 patients in his concierge practice and about 2700 in the traditional delivery model. Patients pay $1600 per year for a physical that is not covered by their regular insurance. The fee also includes the guarantee of same day appointments and access to their doctor by cell phone. Covered services continue to be billed to the patient’s insurance plan. CCP receives about one-third of the concierge revenues for
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the first three to four years. Providers have been somewhat surprised by the demographics of patients who sign up for concierge services. Most are middle aged and older, upper-middle-income people with medical issues, but they tend not to be the oldest or the highest income patients in the practice. Dr. Katz notes that a partial concierge model is somewhat like the Medical Home model (see Patient Centered Medical Homes Become a Reality, Jan./Feb. 2012 issue at www.mdphysicianmag.com), which he could not make work in his practice. “We applied for CareFirst’s Medical Home but found that we couldn’t participate because many of our patients were employed by firms that selfinsured. The cost of hiring a coordinator as required by the model would have cost more than we would have received in additional reimbursement.”
Wayne Lipton
“My patients love it. People have used it appropriately and I only get a few calls a week after hours – only slightly more than before.” – Stephen Katz, M.D.
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A Painless Process
The company stations a person in the office for four to six months prior,” notes Dr. Katz. “They talk with patients and also hold some group meetings for those who are interested. Then we had a few months’ orientation process for staff. The practice didn’t change that drastically – we work about the same number of hours with slightly less financial pressure. We have certain time slots scheduled for these patients and it hasn’t been a big challenge for our staff.” Is Hybrid Concierge Right for You?
Dr. Katz believes, “There’s no reason not to consider it, and nothing to lose. However, it’s probably not ideal for physicians with only a few years left in practice or for physicians who are just getting started.” Mr. Lipton observes, “You can rarely put up a shingle and start practicing by only offering concierge, but some doctors can start one or two years into their practice. We discuss where the practice is and how long they’ve been in practice. The number of patients has to be significant enough to be meaningful to the doctor – at least 50 concierge members if you’re a solo practitioner. “Hybrid concierge services are a kinder, more socially appropriate approach,” he continues. ‘It’s a way to tap into private revenue sources to support a physician in practice. It bridges, not severs, the relationships with patients. It’s even appropriate for larger groups and certain specialists. In a group, doctors can have different numbers of concierge patients without a problem. The model can also work for specialists who deliver some primary care, such as a clinical cardiologist or gynecologist.” “My patients love it,” exclaims Dr. Katz. “People have used it appropriately and I only get a few calls a week after hours – only slightly more than before.”
URGENT CARE In contrast to the fairly slow growth of concierge medicine, urgent care centers seem to be sprouting up like weeds, Nationally, there are roughly 8700 centers, with about 75 in Maryland. A growing number of primary care practices (including Severna Park Medical Associates) are adding an urgent care component and a little-known
Primary Care After-Hours Bonus Payments In 2010, MedChi fought for and got passed House Bill 435 (Health Insurance – Reimbursement of Primary Care Providers – Bonus Payments), which requires reimbursement for after-hours care. The legislation requires that an insurer must specifically address bonus payments for primary care physicians when they provide services to insureds between the hours of 6 p.m. and 8 a.m., weekends and holidays. The amount of the bonus payment is subject to negotiation with the insurer but must be specifically addressed in the contract.
Maryland law requires bonus payments for after-hours care (see sidebar). Howard Haft, M.D., medical director of Maryland Healthcare and Shah Associates, states, “From my perspective, urgent care arose to fill an unmet demand for primary care and in response to overcrowded and inappropriately used Emergency Departments. The ideal situation is for patients to receive all of their care within one tightly integrated care system, led by a single primary care provider. All other systems tend to fragment care. Once there is sufficient supply on the primary care side, with physicians and physician extenders, an urgent care support system should no longer be needed.” Appointment-Oriented Urgent Care
Robert G. Graw, Jr., M.D., a pediatrician still in practice, started a small pediatric urgent care center in 1989. Now called Righttime Medical Care, the company has grown to nine centers in Maryland that receive more than 250,000 visits per year from patients of all ages. Dr. Graw recalls, “Pediatric urgent care became needed about the time mothers went back to work. I began the business with eight other pediatricians working in our first center called ‘Nighttime Pediatrics’. In 1995, we added a second site and realized that parents coming in with their children also wanted our care, so we added adult urgent care. And over the years, we’ve expanded to operate from 7 am to midnight.”
TRACEY BROWN
Robert G. Graw, Jr., M.D.
In Dr. Graw’s view, the centers complement primary care with better access and reduced cost compared to
we can watch patient flow in real time. If a patient has been in the waiting room for more than 15 minutes, we call over.
“I don’t see traditional primary care going away, I just think there will be more options. Demand for non-appointment care is growing.” – Pete Sowers, M.D. Emergency Room visits. “We’re very tied to primary care physicians,” continues Dr. Graw. “I still practice, so I know how important that relationship is. We have a physician access line and understand that physicians want the information right away. Some of our competitors are soliciting primary care patients, but not us. “Physicians do a good job,” he adds, “but we don’t have enough primary care physicians in Maryland and we have growing numbers needing medical care. Healthcare reform will only increase that.” Righttime Medical Care has a central call center with 47 employees who answer the phone and triage patients. “Some 85% of our patients book an appointment, so we control the patient flow, though we also accept walk-ins,” says Dr. Graw. “We have a central command center where
“Our model is different because we focus on the retail experience of the patient. We don’t want people waiting for two hours. In fact, we have no waiting room in our centers. My advice to primary care physicians who want to see their own patients has been to make sure you offer availability and convenience. Leave some appointments open for sick visits.” Walk-in Urgent and Primary Care
Pete Sowers, M.D., founder and CEO of Patient First QUOTE , opened the company’s first center in 1981 in Richmond, Virginia. Today, the company operates 39 centers in Virginia, Maryland and Pennsylvania. “The first center was an outgrowth of my personal experience as an ER doctor,” says Dr. Sowers. “I saw that patients hated the long ER waits and discovered a model in Rhode Island that operated a full-fledged private ER
in a shopping center. So our model offers extended hours, no appointments, lower costs and quicker service than an ER.” In contrast to Righttime Medical Care, Patient First does not take appointments. Like Righttime, however, they seek to provide good communication back to the primary care physician. “We work together,” notes Dr. Sowers. “About 20 years ago, we added primary care because of pressure from the insurance companies to manage patients who did not have a primary care physician.” Nonetheless, he doesn’t believe his centers compete with doctors or hospitals. “I think we’re generally seen as benign. Most doctors and hospitals are as busy as they can be. We refer appropriate patients to the ER and inpatient services and go out of our way to establish relationships with physicians. I don’t see traditional primary care going away, I just think there will be more options. Demand for non-appointment care is growing.” Urgent Care as an Extension of a Primary Care Practice
Some primary care physicians have begun offering extended hours in their practices to increase patient access and practice revenues. Patricia Czapp, M.D., family practitioner at Annapolis Primary Care, says, “Some primary care practices are actively trying to recapture the patient visits that go to urgent care centers. These are typically quick, easy visits that do not generate a lot of overhead costs. Care-wise and economically, it makes sense to accommodate them. Patient satisfaction soars when that happens. “Our doctors designed and implemented a Rapid Access feature that mimics the Minute Clinic no-wait experience, with great success,” she adds. “Patients are seen by their own practice, with their own medical records already available. This effort is one example of the enhanced access model within the Medical Home concept. A patient of ours who works at a local urgent care center reacted by saying, ‘We wondered when primary care practices were going to figure this out!’"
Stephen Katz, M.D., internist, Severna Park Medical Associates. Wayne Lipton, founder and managing partner of Concierge Choice Physicians. Howard Haft, M.D., MMM, FACPE, medical director of Maryland Healthcare and Shah Associates, a multi-specialty group practice in Southern Maryland with multiple locations. Robert G. Graw, Jr., M.D., founder and CEO of Righttime Medical Care urgent care centers. Pete Sowers, M.D., founder and CEO of Patient First neighborhood medical centers. Patricia Czapp, M.D., family practitioner at Annapolis Primary Care.
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Profile
SPONSORED CONTENT
The Hodes Liver & Pancreas Centers Complex Care for the Deadliest Cancer
T
Mark Fraiman, M.D. and Richard Mackey, M.D. expand service area with second location.
HE HODES LIVER & PANCREAS Center, established in 2005 at St. Joseph Medical Center, was built from the ground up with the support of specialtytrained physicians handpicked from the world’s top academic hospitals. The Hodes Center was the first communitybased liver and pancreas center in Maryland to offer a multidisciplinary program for the treatment of patients with complex diseases related to pancreatic, liver, colorectal and bile duct cancer. Saint Agnes Hospital recently joined St. Joseph Medical Center by launching a second location of The Hodes Liver & Pancreas Center, expanding the access of this advanced cancer treatment to people in the Mid Atlantic Region. The new Center at Saint Agnes is led by Mark Fraiman, M.D., M.B.A, F.A.C.S., a hepatobiliary and pancreatic surgeon 18 |
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who is one of the few doctors in the area performing highly complex procedures for the treatment of liver and pancreas diseases, and is regionally recognized as an expert in the Whipple surgery. Richard Mackey, M.D., F.A.C.S., who also specializes in liver and pancreas surgery, will serve as the medical director of the Center at St. Joseph and the assistant director of the Center at Saint Agnes. “We’ve established a reputation for offering academic tertiary care for the community,” says Dr. Fraiman. “We can care for the most complex situations; at the same time, our staff are very experienced and provide a personalized experience that is comforting to patients.” Dr. Mackey adds, “We are the primary decision makers. These two hospitals have a reverence for patients’ rights, providing a holistic, patient-centered
approach where patients are not treated as just a number.” A Team Approach
The Hodes Liver & Pancreas Centers also have a highly experienced team of endoscopic gastroenterologists, interventional radiologists and pathologists who perform the tests needed to diagnose and/or treat liver and pancreatic cancer. These skilled doctors can make an early, accurate diagnosis to speed an effective treatment plan and they can perform advanced therapeutic procedures such as chemo-embolization of liver tumors. Endoscopic ultrasound (EUS) enables the detection of small tumors and biopsies of abnormal areas or cysts. Endoscopic retrograde cholangiopancreatography (ERCP) is also available to visualize the pancreatic ductal
system and relieve obstructions. “Patients want to be seen quickly and we can typically book a clinical evaluation within a day or two,” says Dr. Fraiman. “We offer highly experienced nurses, including a stable, skilled team in the OR, private rooms and attentive pre and post-op care. Yet patients can still participate in the latest liver and pancreatic clinical trials.” High Volumes, Broad Expertise
As with other specialties, selecting a hepatobiliary surgeon with high volumes is important. “We perform more than 100 pancreatic cases a year,” Dr. Fraiman notes. “That compares favorably with some ‘high volume’ centers that are only doing 15 or fewer cases annually. Over half of what we do at our Centers is to treat malignancies. That translates to the experience and focus cancer patients need.” “Patients with liver or pancreatic lesions should also have a surgical evaluation,” says Dr. Mackey. “Today, many of these patients do well when treated in a multi-disciplinary fashion at an experienced center.” Beyond the treatment of malignancies, the Centers provide the gamut of diagnostic and therapeutic care for an array of liver and pancreatic disorders. They also diagnose and provide medical/surgical treatment for pancreatitis, disorders of the bile duct, injuries of the bile duct and more. Latest Treatment Advances
“Patients with new-onset diabetes are now known to be at higher risk of underlying pancreatic tumors,” Dr. Mackey states. “When these patients have abnormal liver function tests or abnormal imaging results, they should be referred early.” He adds, “There are now expanded
indications for laparoscopic procedures. We are doing a growing number of minimally invasive pancreatic and liver resections, which offer a faster return to activities, plus less pain and blood loss.” The most common referrals for hepatic resection are patients with metastatic colon cancer to the liver and patients diagnosed with primary hepatocellular carcinoma (HCC). Radiofrequency Ablation (RFA), the latest technique can be used when a liver tumor is not resectable or as an adjunct to surgery when multiple malignancies exist. Whipple Procedure Extended to More Invasive Cases
Pancreaticoduodenectomy, known as the Whipple Procedure, is a complex, intra-abdominal operation to treat malignancies involving the pancreas, duodenum or common bile duct. “With the Whipple, we’re giving patients a better quality of life and the chance for a cure. Aggressive surgery in combination with chemotherapy and radiation offers patients with pancreatic cancer the best chance for long-term survival,” says Dr. Fraiman. “The vast majority of our patients return to normal gastrointestinal function within a few weeks.” Drs. Fraiman and Mackey perform the Whipple operation together, reducing what is typically a six-hour operation at many university hospitals to a three-hour surgery. They are now extending that surgery to many patients who previously would have been considered inoperable or borderline resectable. Tumors with invasion of the superior mesenteric vein, portal vein or smv-pv confluence can now be considered for resection by performing resection and reconstruction of the portal venous system. Dr. Fraiman says, “When the cancer is invading the portal vein, which used to be a criterion of inoperability, we use a very
The Hodes Liver & Pancreas Centers Advantages
Experienced, high-volume surgical team with training at top-five academic centers Superior outcomes (less than 1% mortality for Whipple procedures) State-of-the-art techniques and technology, including EUS and ERCP Expanded options for minimally invasive laparoscopic pancreatic and liver surgery Central and distal resections of the pancreas and benign liver resections A team approach that includes GI, pathology, medical and radiation oncology, and interventional radiology Personalized care with high patient satisfaction
Hodes Services at a Glance Evaluation and Diagnosis > Endoscopic Ultrasound (EUS) > Endoscopic Retrograde Cholangiopancreatography (ERCP) > Spyglass (biliary endoscopy) Advanced Surgical Treatments > Open and Laparoscopic Hepatic Resection > Open Surgical Radiofrequency Ablation > Laparoscopic Radiofrequency Ablation > Whipple procedure > Pancreatic resections > Laparoscopic distal pancreatectomy > Surgical procedures for complex acute and chronic pancreatitis > Biliary reconstruction for bile duct injuries > Shunt surgery for Portal Hypertension Chemotherapy & Interventional Radiology > Trans-Hepatic Arterial ChemoEmbolization (TACE) > CT-Guided Radiofrequency Ablation > SIRspheres > Portal vein embolization > TIPS > Percutaneous transhepatic biliary decompression
aggressive approach in cases that are now considered borderline resectable.” Prior to surgery, patients receive chemotherapy and radiation to neutralize the edges of the tumor. Then, in conjunction with the Whipple surgery, Drs. Fraiman and Mackey remove the portal vein, occasionally replacing it with a portion of internal jugular vein transplanted from the patient’s neck. “We’ve had good results with the resection and reconstruction of these formerly inoperable tumors, allowing more patients to undergo a potentially curable operation,” explains Dr. Mackey. “The only way to cure these cancers is to combine chemotherapy, radiation and surgery. For those patients whose malignancy remains unresectable, the Centers still play a major role in offering palliative care, an important part of our treatment algorithm.” For more information or to refer a patient to either center, call 1-855-88-HODES.
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Healthcare IT
IT
CAN MAKE MARYLAND HEALTHIER? DHMH Secretary Sharfstein Reveals the Challenges and Potential of Using Health IT BY LI N DA H A RD ER • PHOTOGRAPH Y BY TRACEY BROWN
Maryland Physician recently sat down with Department of Health and Mental Hygiene (DHMH) Secretary Joshua M. Sharfstein, M.D and Scott Afzal, program director, HIE, Chesapeake Regional Information System for our Patients (CRISP) to discuss the state’s Health IT progress and challenges on multiple fronts.
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Interoperability Challenges
Maryland is ahead of many states in creating a system where healthcare providers can share patient data to treat disease and keep people well – a fairly daunting task given the myriad issues connecting disparate data systems. Dr. Sharfstein comments, “The governor set a goal of having Maryland be a leader in health IT, part of which is the Health Information Exchange (HIE), where hospitals can query other institutions for
information. We now have millions of lab and radiology records, so it’s a tremendous resource.” Afzal reflects, “The goal of CRISP’s first two years was getting the HIE organization up and running, deploying the technology and making connections to data sources. We now have basic connectivity to permit sharing encounter data, such as an admission message, for all Maryland hospitals. Additionally, we have rich connectivity
(labs, radiology, history and physicals and discharge summaries) for half of them.” Describing the challenges of connecting physicians with hospitals and other providers, Dr. Sharfstein notes, “Regional networks are developing and some hospitals are providing significant communication and support to primary care doctors. But it may be difficult to have every system fully integrated with every possible model of EHR out there. The goal is to have common interoperability across the state. For example, doctors can find out when their patients have been admitted if they get credentialed through CRISP. If we tried to set all of the specifications for every network, we’d probably slow things down. “Maryland is the first state to set up this level of interoperability with the hospital data,” he continues, “but we realize there’s a long way to go. In the next few years, I think we’ll see explosive growth in access to electronic health information.” CRISP Query Portal
Afzal concurs. “Maryland is the first state to connect all the hospitals through an HIE, but we still need substantial data to make it worthwhile. The CRISP Query Portal, currently used in many hospital and ambulatory settings, enables authorized users to access a patient’s clinical data from many sources. Right now, most data available through the HIE has come from hospitals and large radiology centers, but the amount of data is growing quickly. Log onto http://crisphealth.org/ ForPatients/ParticipatingProviders/tabid/2 41/Default.aspx to see which facilities are sharing data. Afzal notes, “CRISP is only the conduit for the data, which continues to belong to the hospitals and providers.” “We have a technology that links together all of the disparate medical record numbers a patient might have,” continues Afzal, “so we can enable services like real-time alerting of a physician when a patient is hospitalized. At the same time, we know that the
technical and cost barriers to sharing data from an ambulatory EMR have been high.” The Direct Project
The Direct Project is a national effort to create common standards to send direct, secure messaging among providers to make healthcare communication more efficient. It specifies a simple, secure, standards-based way for participants to send encrypted health information directly to known, trusted recipients over the Internet. Maryland is taking advantage of this to help providers connect. “CRISP began offering direct secure messaging in mid May,” notes Afzal. “It enables participating providers to have an email inbox and share clinical data with their referral relationships by simply attaching it to an email message, like a normal email service. However, this service is encrypted and will likely involve a broadly used messaging standard.” Pay for Value, Not Volume
It’s no secret that fee-for-service fails to incentivize providers to keep patients healthy. Dr. Sharfstein observes, “The big picture is aligning the healthcare system for health. We have a lot of high quality care, but if you ask if the population is as healthy as it should be
Centered Medical Homes (PCMHs) and new hospital incentives for positive outcomes are a step in the right direction. Different kinds of smart payfor-performance incentives will help.” State Health Improvement Process
Dr. Sharfstein observes that one part of the DHMH website, the State Health Improvement Process (SHIP), aims to facilitate integrated public health planning. “SHIP now has 39 measures for what Healthy MD looks like,” he says. “We have planning coalitions in almost every county – they put together their priorities for how they’ll move those measures. There are lots of doctors, hospitals and health centers as part of those coalitions. They deliver care and also create a partnership between providers and public health.” Fostering Innovation
In partnership with CRISP and the Abell Foundation, the DHMH recently sponsored a Health Data Innovation Contest that encouraged innovative uses of electronic health data to promote a healthier Maryland, with winners announced in late May. Information is posted at https://themarylandprize. maryland.spigit.com/Page/Home. Dr. Sharfstein explains, “One winning idea was to track adverse blood transfusion reactions to prevent
“CRISP BEGAN OFFERING DIRECT SECURE MESSAGING IN MID MAY. IT ENABLES PARTICIPATING PROVIDERS TO HAVEAN EMAIL INBOX AND SHARE CLINICAL DATA WITH THEIR REFERRAL RELATIONSHIPS... – SCOTT AFZAL for the money we spend, the answer is clearly ‘no.’ Instead, we spend a lot of time and money on treating the complications. There’s a huge gap in access to primary care, particularly. We need to better align incentives and planning so that we get health value out of the state’s investment. I don’t believe fee-for-service aligns well with good outcomes.” He adds, “In the future, incentives should pay more for the value than for the volume of services. Patient
problems, some of which can be fatal. Another submission proposed using the data to provide an algorithm to doctors to better identify patients at risk of adverse medical complications from Alzheimer’s disease. Based on the patient’s pattern of hospitalizations, the doctor could identify a very high-risk patient; the HIE could provide both the data and some analysis to help the doctor triage and make decisions. “We also have an Innovations section on our website,” Dr. Sharstein JULY/AUGUST 2012
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continues. “There, we’ve brought together the hospitals, addictions, pharmacy, nursing and statewide delivery reform group and we’re putting up different kinds of models up on the web. It includes model payment structures that aren’t fee-for-service, and
the Maryland Health Care Commission have been great partners of ours and we work with them on public health uses of the data, such as tracking outbreaks of disease in real time to speed intervention.” “There’s been a real effort to get primary care doctors connected and we’ve exceeded all of our goals for both funding and number of participating doctors,” concludes Dr. Sharfstein. ‘The original goal of 1000 physicians has been well exceeded. I think people realize that the future requires EMRs and understand the advantages they offer for patients and providers.”
(MSOs) to help providers meet Meaningful Use. Additional REC funding is available as providers move towards the Meaningful Use goal. “It’s important to provide funding and other assistance to get as many doctors as possible using EHRs,” Dr.
“WE HAVE A LOT OF HIGH QUALITY CARE, BUT IF YOU ASK IF THE POPULATION IS AS HEALTHY AS IT SHOULD BE FOR THE MONEY WE SPEND, THE ANSWER IS CLEARLY ‘NO.” model programs that can accomplish the Triple Aim concept of improving the healthcare experience, improving the health of populations and reducing per capita costs. To learn more, visit http://dhmh.maryland.gov/ innovations/SitePages/Home.aspx. Support for Physician EHRs
CRISP, supported by DHMH, is also involved in the Regional Extension Center (REC) program. This program provided roughly $1600 to each of 1580 primary care providers that signed up, and partnered with 15 state-designated Management Service Organizations
Sharfstein remarks. “While a lot of physicians have signed up for the program, they then face implementation issues and we want to be as supportive as possible. One of the exciting challenges is figuring out what the EHR can do to truly advance health.” Afzal adds, “We’ll naturally see some level of attrition among that group, as some doctors decide pursuing Meaningful Use doesn’t make sense for their practice. While we don’t have more funds to support sign-ups with the REC program, interested physicians can still work with our group of trusted MSOs. Dr. Sharfstein, DHMH and the team at
For more information on PCMHs, see Maryland Physician Magazine’s article, “PCMH in Maryland: Public and Private Models,” in the January/February 2012 issue.
Joshua M. Sharfstein, M.D., Secretary, Department of Health and Mental Hygiene (DHMH). Scott Afzal, program director, Health Information Exchange (HIE), Chesapeake Regional Information System for our Patients (CRISP).
Clinical Features Maryland Physician focuses on the latest cancer developments. We talk with top Maryland specialists to get their take on the effectiveness of the latest treatments for prostate, breast and blood cancers.
Healthcare IT In every issue, Maryland Physician explores a different facet of the race to implement EHRs to meet Meaningful Use and other e-health government incentives. Don’t be
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left behind – read what Maryland physicians and healthcare IT experts have to say that eases the pain of transition to an electronic world.
In Every Issue and Online
Cases Solutions Compliance Medical Beat Policy Jacquie Roth Publisher/Executive Editor 443-837-6948 jroth@mdphysicianmag.com www.mdphysicianmag.com
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Living
JACQUIE ROTH
Maryland on the Water: Summer Fun Along the Waterways Tracy M. Fitzgerald
I
T’S A SATURDAY MORNING IN the dead of summer and you are wracking your brain, trying to think of a fun way to spend your day. What to do, what to do … Then it dawns on you. You live in Maryland. Water is … well, everywhere! The Chesapeake Bay is accessible from many points across the state. You really don’t need to drive all the way to the Eastern Shore to take advantage of the fun and adventure along Maryland’s waterways. There are plenty of opportunities available, much closer to home. You lucky Marylander! There are simply so many options to choose from!
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Walking on Water – Paddle Board Included
Some people see the water as a place to relax. Others see it as the spot to get active. Those looking for outdoor adventures will find a plethora of options at Ultimate Watersports, located alongside the Gunpowder Falls State Park in Baltimore County, in the Hammerman beach area. Visitors come here for kayaking, windsurfing, sailing, and to get on the bandwagon with the latest outdoor enthusiast trend: stand up paddle boarding (SUP). “Stand up paddle boarding is popular because it can be done in any kind of water, it does not require a lot of
The fast growing sport of stand up paddle boarding (SUP) and kayaking on Chesapeake Bay waterways – terrific options for great workouts and scenic adventures.
equipment and the learning curve is very short,” said Tylor Streett, Operations and Safety Manager at Ultimate Watersports. “First timers are usually up and feeling comfortable within an hour.” And, the benefits just go on. In addition to giving your body a thorough workout, it will expose you to some of the area’s most scenic wildlife. Through Ultimate Watersports, you can explore on your own or participate in a guided wildlife excursion, via stand up paddle board or kayak, with sunset and moonlight tour options available. “We give people the opportunity to enjoy the water in new and different ways, and see wildlife that they never
would see otherwise,” Streett said. “It’s easy to get hooked.” Local Scuba – It Really Does Exist
Many people think that their only opportunity to go scuba diving will come about when they hop on an airplane and head to the Caribbean islands, Hawaii or some other tropical destination. Wrong! These days, locals are suiting up with scuba tanks and diving into quarries and bodies of water such as the Chesapeake Bay and Potomac River. Matt Skogebo, Retail Manager and Master Scuba Diver Trainer at the Annapolis Scuba Center, has led groups in oyster diving excursions, fossil diving adventures and shipwreck explorations in Maryland and its surrounding states. His company offers training, equipment and organized travel programs, making it easy for Marylanders to make scuba diving part of their everyday lives rather than just their vacation plans. “Eighty percent of divers become certified in fresh water and then take their skills to travel and scuba dive in places all over the world,” Skogebo said.
“If you can tread water for ten minutes and swim continuously for 200 yards, you can become certified.” Scuba certification is acquired through three phases of training, starting with online academic courses, then moving on to confined water training, which includes two four-hour sessions focused on use of scuba equipment and emergency preparedness. The third and final phase takes trainees to the open waters for four open dives. Once certified, divers are prepared to explore the underwater world to a depth of 60 feet. Skogebo says that going on a scuba dive is like taking a trip to a different world. “There is no other sport that allows you to go into your own world in a way that is truly unique to only you,” he said. “Even if you dive side-by-side with another person, you will each see different things. This is a sport that is relaxing, therapeutic and something you can truly enjoy doing your entire life.” Sail Away – A Day (or More) at Sea
If you are eager to get out on the water but not necessarily interested in owning
a boat of your own, look no further than South River Boat Rentals. The company’s fleet of sailboats and powerboats, available for rent or charter, make it easy for you to hop on board for a half day, full day, or multiple day journey along the waterways of the east coast. The Annapolis-based company allows those with boating experience to take vessels out on their own, or can provide captained charters for parties that are more interested in sitting back, relaxing and enjoying the ride. Food and drinks can be brought on board, and fishing gear is available for those who wish to toss a line or two overboard while at sea. “Every single week, I see people come in here stressed out and looking for a way to quickly break away,” said Griff Bell, owner of South River Boat Rentals. “They go out on a boat for a few hours, and come back looking like they hung out with Jimmy Buffett all day long. This is a great way to take a break from reality; folks come back in as different people after a fun and relaxing day on the water.”
Travels with Eli
JACQUIE ROTH
I
picked up a 2012 Lexus CT 200h F Sport Package from Sheehy Lexus of Annapolis for a weekend free of commitment and full of sunny skies, with Chesapeake Beach as the day-trip destination. Sheehy’s service consultant couldn’t have been more patient while he walked me through what Lexus has named its sporty hybrid, the “Black Sheep of Green.” The first test: enough room for 70 lb. Eli, my set of golf clubs, a full beach bag and a two-legged traveling companion? No problem! The drive home gave me the chance to test the drive mode options – from a nearly silent battery power designed for short distances and ECO optimization to a full tilt sport mode where performance and steering feel are maximized. FUN! Saturday’s forecast proved true and off we went on an easy drive down Solomon’s Island Road to Southern Maryland. While I was busy customizing the performance of the CT and my interior space, my companion navigated the 10-speaker sound system with a very cool automatic sound levelizer, switching back and forth from Sirius Satellite radio to an iPod. We headed straight to Chesapeake Beach Resort & Spa and were struck by the breadth of the Chesapeake Bay. We enjoyed a walk around the grounds and strolled along the dock offering charter fishing. Eli presented a problem for lunch at the Boardwalk Café, but Resort owner Wes Donovan suggested a takeout lunch from the Rod n Reel. While waiting for our very friendly bartender Larisa to bring us our delicious soft shell crab lunch, we had the opportunity to briefly visit The Chesapeake Beach Railroad Museum located on Resort grounds. What a history! Trains ran from 1900 until 1935, bringing summertime visitors from Washington DC, Baltimore and nearby Southern Maryland (more on that in the September/October issue’s Living). I enjoyed the CT for some Sunday eco-friendly errand running and terrific parking maneuverability. I was a bit sad to return it on Monday, but happy to climb back into my convertible. The only negative on the CT? The sunroof was too small! –J.R.
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Profile
SPONSORED CONTENT
MAKOplasty Only at Mercy Medical Center A More Precise Partial Knee Replacement
With nearly five million Americans – almost 5% of the population age 50 and older – getting knee replacements at a younger and younger age, a procedure that can improve outcomes is significant to keeping more boomers active. Three of Mercy Medical Center’s orthopedic surgeons – Marc Hungerford, M.D., Joseph Ciotola, M.D. and Kamala Littleton, M.D. – have performed more than 150 MAKOplasty® procedures since mid2011, and all are enthusiastic about its benefits. As of summer 2012, Mercy remains the only place in Maryland performing the procedure.
FDA-APPROVED IN 2005, THE procedure is appropriate for many patients with uni or bi-compartmental osteoarthritis of the knee who have failed conservative therapies. Orthopedic surgeon Hungerford, director of Joint Replacement and Reconstruction at Mercy, explains, “MAKOplasty’s RIO Robotic Arm Interactive Orthopedic System uses a three-dimensional model of the patient's knee to help precisely resurface the diseased area. During surgery, the RIO provides the surgeon with real-time visual, tactile and auditory feedback for optimal joint resurfacing and implant positioning. This optimal placement can result in more natural knee motion following surgery. “Essentially, we are replacing the worn, damaged and missing cartilage with an implant made out of metal
the nerves, the muscles – and what we’re doing is putting a new bearing surface on the damaged part of the knee.” Dr. Ciotola likens the MAKOplasty® to remodeling a kitchen or bathroom instead of
Marc Hungerford, M.D.
A total knee replacement removes 72% more bone than the bi-compartmental MAKOplasty. Obviously, that makes a difference in patients’ recovery and post-op use of the knee. - Kamala Littleton, M.D.
and plastic,” he says. “You can think about it like capping a tooth instead of putting in an implant. The basic structure of the knee remains – most of the bone, the ligaments, the skin,
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tearing an entire house down. “Patients do dramatically better and are back exercising in about six weeks.” Dr. Littleton has similar praise
- Kamala Littleton, M.D.
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Benefits of MAKOplasty Partial Knee Resurfacing Versus the traditional knee replacement, the new MAKOplasty partial knee resurfacing allows patients to typically experience: Preservation of healthy bone and tissue A shorter hospital stay Minimal blood loss Quicker rehabilitation Smaller incision Return to active lifestyle within weeks
for the robotic technology. “Prior to MAKOplasty, we were hesitant to perform a bi-compartmental knee replacement or patella femoral replacement because the design and instruments were not as good as we thought they should be. With the robot, we can get much more accurate placement of the implant. The robot allows us to do it well every time. A total knee replacement removes 72% more bone than the bicompartmental MAKOplasty. Saving this bone is advantageous in younger patients where revision surgery will eventually be likely.” Precision Mapping Includes 3D CT
Following evaluation, patients who are good candidates are sent for a 3D CT that allows surgeons to create a precise pre-op plan determining: Component size Orientation of the components and bone Component alignment “Once we’re in the OR, we validate the plan and make fine adjustments intraoperatively,” observes Dr. Hungerford. “That virtually guarantees that the parts
Marc Hungerford, M.D.
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will be in the proper position and the ligamentous balance will be correct. The robot maps the cartilage and bone removal precisely to the CT.” Dr. Littleton agrees, noting, “With the robot, we have the advantage of doing patient-specific surgery with off-the-shelf implants. We can assess the ligamentous tension in the knee throughout the range of motion and make adjustments to ensure good tension. Then, we insert the femur implant and check the articulation between the femur and the center of the tibial component. We have a total knee
...the RIO provides the surgeon with realtime visual, tactile and auditory feedback for optimal joint resurfacing and implant positioning... result[ing] in more natural knee motion following surgery. — Marc Hungerford, M.D.
Hungerford. “With MAKOplasty, we can treat patients at an earlier stage of their disease and take care of uni-compartmental or bi-compartmental disease. Patients have been able to go back to their everyday activities of walking, shopping, climbing stairs and those who previously played golf or tennis can often resume those sports. “We don’t perform surgery on patients who are doing well with injections, bracing, and other conservative measures,” he adds. “We reserve surgery for patients for whom those approaches are not working.” Typically, MAKOplasty patients share the following characteristics:
Joseph Ciotola, M.D.
implant on hand in case the arthritis is worse than expected, but only one in 20 patients has needed this.” With this approach, all of the ligaments remain intact, maintaining proprioception. That stands in stark contrast to a total knee procedure in which the ACL and sometimes the PCL are removed. “The greatest pain in total knee replacement results from the incision through the quadriceps tendon, so a partial replacement avoids that pain,” Dr. Littleton says. “Patients come back two weeks later on Tylenol and you can’t tell from their walk which knee had the procedure.” “Where this procedure really shines is when you put more than one component in,” Dr. Hungerford adds. When/Who to Refer
“The best time to refer is when the patient is having pain and difficulty with activities of daily living, but conservative measures are not working,” advises Dr.
Knee pain with activity, usually on the inner knee and/or under the knee cap, or the outer knee Start up knee pain or stiffness when activities are initiated from a sitting position Failure to respond to non-surgical treatments or non-steroidal antiinflammatory medication “The younger the patient, the worse their clinical situation has to be to consider surgery,” says Dr. Ciotola. “We consider the risk versus the benefit. Depending on their situation, patients between the ages of 30 and 90 may be appropriate candidates.” Dr. Littleton observes that patients with mild to moderate arthritis typically do best. “Patients can almost point to the specific area causing them pain. Weight plays an important role, too. Those with morbid obesity and severe mal-alignment are not appropriate candidates. “With tools like this,” she comments, “we realize we don’t need to give patients injections and twice daily ibuprofen for the rest of their lives. And instead of enduring pain for years before getting a procedure, they can do things like play tennis again. In the last decade, we’ve realized that we have the tools to allow patients to enjoy themselves now.”
Candidates for MAKOplasty Mercy's orthopedic surgeons work with each patient experiencing knee pain to provide an individualized treatment plan. Potential candidates for MAKOplasty typically have the following characteristics: Knee pain with activity, on the inner knee, under the knee cap, or the outer knee Start up knee pain or stiffness when activities are initiated from a sitting position Failure to respond to non-surgical treatment such as rest, weight loss, physical therapy, and non-steroidal anti-inflammatory medication
Data/Results
Through June, 2011, about 8000 MAKOplasty procedures had been performed in the country; as of April, 2012, that number had rapidly grown to more than 12,000. While more than 50 studies of the procedure are being conducted nationally, outcome data is not yet available. Dr. Ciotola concludes, “The procedure makes a partial knee replacement more accurate and therefore more reliable. There’s no need for uni-compartmental knee patients to suffer. Before MAKOplasty, it was absolutely unheard of for people to go back to the gym within a month. I would want this procedure for myself, my family and my friends.” For more information or to make an appointment to determine if your patient is a candidate for MAKOplasty at Mercy Medical Center, call 410-539-2227.
Bel Air Grandmother Bowling Again Theresa M., an active 66-year-old grandmother from Bel Air, read about MAKOplasty in a newspaper article and was intrigued. “I had had several arthroscopies over time but got to the point where I couldn’t handle the pain anymore,” she recalls. After Dr. Hungerford evaluated her knee, they jointly determined that MAKOplasty was an appropriate option. “Before the procedure, I sat down with the coordinator, had all my questions answered and got a binder called the Joint Journal that had everything I needed to know. Everything was planned and all of the staff was so caring. I only took pain medications for four days after my procedure and I came home with minimal pain.” Ms. M. was so happy with her first MAKOplasty in September 2011 that, when her second knee needed a partial replacement in March 2012, she was thrilled to learn that it was again a good option for her. She jokes, “I think my other knee got jealous.” Only a few months later, Ms. M. is busy running after her two-year-old grandchild and resuming normal activities. “Now, I’m bowling again, doing aerobics and walking with my friend,” she exclaims.
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Policy
Cardin Comments on the Affordable Care Act, the Supreme Court and Health Priorities LINDA HARDER • PHOTOGRA PHY BY TRACEY BROWN
Maryland Physician recently interviewed U.S. Senator Ben Cardin, a key champion of healthcare reform, about the potential impact of the upcoming Supreme Court decision and his healthcare priorities for 2012/13.
Q:
If the Supreme Court dismantles the ACA, what can Congress do?
It would be a very difficult circumstance…it would be the Supreme Court substituting itself for the Congress. It would call into question whether Medicare and Social Security are
Q:
What have been the key benefits of the Affordable Care Act (ACA) for Maryland physicians?
The number one advantage is that you have everybody in the system – everyone has coverage so everyone is paying their fair share. Physicians, like all healthcare professionals, are providing care to a lot of people who don’t pay their bills. Now, we’ll have a much stronger presence in preventive care, which means we’ll have a more cost effective system. And hopefully, we won’t have to go through what we’ve been going through for the past 15 years with the Medicare SGR (Sustainable Growth Rate) formula and worry every year whether physicians’ reimbursement will be slashed. There are some specific provisions that affect physicians such as in the Patient Bill of Rights. Emergency physicians supported our efforts to enact the prudent layperson standard for all persons with health insurance coverage, so that insurers would have to pay for emergency care based on the patient’s symptoms rather than the final diagnosis. Other parts include the right of patients to select their own OB/GYN and family care provider. We were also able to do other things that help orderly healthcare, such as making some parts of the reimbursement structure more predictable, which should help physicians. The unfinished business was the flawed Sustainable Growth Rate formula. In 2005, when I introduced a bill to 30 |
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U.S. Senator Ben Cardin (D-MD)
repeal the SGR with my Republican colleague, Clay Shaw, it was estimated to cost $50 billion over ten years. This year it was estimated to cost $300 billion. If we don’t do anything for the next five years, the cost will jump to $600 billion. We’ve got to get that fixed.
Q:
How will you fix Medicare’s SGR?
To me, [repeal of the SGR] should be part of our baseline, we should correct this. We’re not going to allow a 30% reduction in payments to physicians under Medicare – that would be catastrophic. We should acknowledge that in our budget and just move forward.
constitutional and it would deny the Congress the ability to deal with 40 million people who have no health insurance in a rational, effective way. The immediate impact would be on the 40 million people sitting outside the healthcare system. How do we get them covered and make it less costly for all? By and large, these are workers who should take responsibility for their healthcare needs. Instead, they get sick and don’t pay their bills. That’s just fundamentally wrong. If you can’t do an individual mandate, your options become more limited. There are options we can explore but it would be a major step backwards.
Q:
Is there anything physicians can do?
Physicians in America are the best trained and provide the highest quality service in the world. The first thing we want to do is make sure we preserve that. If the Supreme Court throws the ACA out, we will look to provide incentives for our brightest to go into healthcare and treat patients in underserved areas. We can create positive incentives for improving our system and predictability for those going into medical school. But we will have lost a valuable tool and a rational healthcare system.
Q:
What has Maryland already accomplished and how would that be affected?
Maryland has expanded eligibility for Medicaid and set up Enterprise Zones. We would still try to fund federally qualified health centers. Maryland is progressive – for example, we have an all-payer rate structure for hospital care and we now have the best results in the nation on pediatric dental care. Maryland is leading the country in Health Insurance Exchanges and will be ready in 2014 to have functional exchanges that will allow small companies and individuals to buy an affordable healthcare plan. This would be at risk because, if people only come into the plan when they’re in need, you’d have adverse risk selection. It’s hard to see how universal coverage works without the individual mandate. Yet, Maryland has offered so many incentives to expand coverage that I think we’re in better shape than most states.
Q:
Since the ‘train has already left the station’ in many areas, what is at risk if part of the ACA struck down?
The fundamental risk is that the Supreme Court would use its power to substitute its judgment for the legislature in a way that moves the nation backwards in dealing with significant social issues. It would remind me of the Dred Scott decision, when the Supreme Court misused its power to prevent the advancement of civil rights. Of course, the closest analogy is
Medicare in the 1960s, which required participation in a health insurance policy based on age or disability. [Seniors] must be in Part A; what’s the difference between that and the individual requirement passed by Congress in 2010 as part of the ACA? Will the court be saying that Social Security or Medicare is unconstitutional? If the court rules in this direction, it would be taking away the flexibility of Congress to carry out its constitutional power to deal with national problems… [But] all we can do is initiate constitutional amendments and work within the parameters of the decision. I would hope that if they rule any part of it unconstitutional, they would give us clear guidance as to what we can do and enough time to get it done.
Q:
What are your healthcare initiatives and goals for 2012/2013?
I’m going to continue with the healthcare priorities I’ve already championed. Physicians are very impacted by whether our system’s working right. If it’s working right, we can talk about how we’ll improve quality. In healthcare, we pay a very heavy price because of lack of access and racial and ethnic health disparities. In the Affordable Care Act, one of my amendments established the National Institute on Minority Health and Health Disparities at the National Institutes of Health, and Offices of Minority Health throughout the Department of Health and Human Services. I want to follow that through to make sure we reduce, and one day eliminate, disparities in America, I also want to make sure we continue our commitment to dental care for children. A major indicator of how well we’re doing is how children show up in emergency rooms for dental care. You talk about a waste of resources! All children are now covered for dental services through the Children’s Health Insurance Program and the ACA, and we want to make sure they have facilities in their community to get quality dental care. I sponsored an amendment that established the national benefit for pediatric dental care. This is one of several prevention-oriented measures we want to move forward. In 1997, I sponsored the first major
expansion of Medicare to include preventive services, including screening for breast, cervical, prostate, and colon cancer, diabetes, and osteoporosis, and a few years later I authored a provision that allows the list to be expanded without Congress needing to come back and amend the law. I want to deal with some of our most costly and difficult healthcare challenges – diabetes, heart disease, obesity – at the earliest stages to save money for the system. Further, I want to work with the physician community to be more effective in providing preventive care. I’ve heard from a lot of physicians about how healthcare IT is going to help; so there will hopefully be a busy affirmative agenda with the healthcare community to maintain excellence, expand access, and reduce administrative costs.
Q:
What can physicians do to support your efforts?
The first thing I would say to a primary care physician is ‘thank you for your commitment.’ You’re a special person to go into primary care. There are more lucrative specialties, and the amount of responsibility that falls on your shoulders is increasing every year. The primary care physician is the key to our system working right. We want to ensure adequate numbers of primary care providers and allied health professionals, plus the right allocation of higher-cost specialists. But comprehensive healthcare all really revolves around primary care. We want the professionals to make the judgments and keep things moving the right way. Ben Cardin has been a national leader on healthcare and other issues as a member of the U.S. Senate and House of Representatives. In 2006, he was elected to the Senate, where he currently serves on the Environment and Public Works (EPW), Finance, Foreign Relations, Budget and Small Business & Entrepreneurship committees.
See Maryland Physician Magazine’s interview with Lt. Governor Anthony Brown in the January/February 2012 issue for more information on Health Enterprise Zones.
JULY/AUGUST 2012
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Solutions
Seven Reasons to Consider a Cloud-Based EMR By Tim Smelcer
P
HYSICIANS FACE MANY OPTIONS when choosing an electronic medical record (EMR) system. One of the most important decisions is whether to implement a cloud-based system or server-based system (one that requires hardware and software installed in the practice). Cloud-based systems can make high-end systems that were previously only in the reach of hospitals or large practices affordable for smaller practices. They offer an efficient, worry-free and secure way to meet Meaningful Use. Here are seven reasons a small to midsized medical practice should consider the cloud model.
1 Lower Upfront and Overhead Costs The cloud-based system reduces upfront and overhead costs. The initial cost of installing a server-based system with hardware and software can cost $60,000 and up. A cloud-based system will save at least half on these expenses. Physicians no longer have to invest what can add up to hundreds of thousands of dollars for their EMR system. With the cloud-based EMR, all the functionality is contained in the cloud.
upgrade or a security patch, there’s no need to tie-up medical office staff; the vendor will handle it.
3 A Greener Approach with Minimal Space Requirements
With a cloud-based system, valuable office space is not taken up with bulky hardware. This saves floor space as well as energy and cooling costs. Some doctors’ offices have space-consuming systems installed in closets or break rooms that become overheated, affecting office temperature and requiring additional air conditioning. A second way in which a cloud-based system is environmentally friendly and efficient is that cloud service in a regional data center maximizes the hardware’s usefulness by providing it for other medical offices as well.
4 Enhanced Data Security and Availability
Physicians often worry about the security of a cloud-based system and are concerned about hackers and HIPPAprotected information. If the practice chooses the right cloud-based system,
Physicians no longer have to invest what can add up to hundreds of thousands of dollars for their EMR system. 2 Ease of Implementation Having the EMR in the cloud spares a practice from the labor-intensive installation, configuration and maintenance of an internal server, which often disrupts staff routines and delivery of care. Plus, since the EMR vendor handles the continuing care and maintenance of the system, there is no need to hire an IT specialist to maintain software. When the system requires an
its security will be more sophisticated than in-house server systems. Make sure the vendor selected can house the cloudbased system in a reputable data center. Data centers provide services such as security, power redundancy, bandwidth and firewalls to protect the EMR system.
5 Access Anywhere, Anytime Providers can access medical information on a cloud-based system from any
medical office the physician is affiliated with, on the road, or from home. Some systems can also be accessed from any smart phone such as an iPhone. To rely on a cloud-based system, a stable Internet connection is necessary, but offices rarely experience an Internet disruption. To ensure peace-of-mind, there are many good, cost-effective ways to provide backup, such as a cellular 4G connection or an i-Pad with cellular data capabilities. Both options involve a minimal cost.
6 Ready Scalability It’s important for patients to be confident that their physician’s EMR supports their diagnosis and care. Cloud-based EMRs offer this peace-ofmind. For a reasonable purchase price and a small monthly fee, practices can get an extremely powerful, robust, cloud-based EMR system to boost profitability and patient care services.
7 High-End Systems Customized for Smaller Practices
Thanks to attractive pricing and the cloud’s desirability, many vendors are offering the cloud model to physician offices. This means that smaller practices can now afford more costly, high-end systems such as GE’s Centricity, AdvancedMD, athenahealth, Bizmatics and MedPlus/Quest Diagnostics. Look for vendors that offer robust, high-quality products that include an integrated practice management component and responsive customer support. Tim Smelcer is an IT expert and CEO of MED Cloud. He partners with GE Healthcare to provide Centricity Practice Solutions in the cloud as a Software-as-a-Service (SaaS) solution to practices in Maryland, Delaware, Pennsylvania, New Jersey, New York, Virginia and Washington, D.C. www.medcloudemr.com JULY/AUGUST 2012
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Good Deeds
Life After War: Walter Reed National Military Center Helps Soldiers Get Back to Living WALTER REED NATIONAL MILITARY MEDICAL CENTER
By Tracy M. Fitzgerald
E
ACH TIME A SOLDIER arrives at Walter Reed National Military Medical Center after being injured in combat, Paul Pasquina, M.D., and his team develop a treatment plan to address much more than their patient’s physical needs. Here, there is as much focus on mental and emotional healing, for those whose lives may be forever changed by what they saw, heard and felt while at war. At Walter Reed, it’s about caring for the patient as a whole, and helping each get back to living and doing the things they enjoy the most. “Every patient we see has different physical and emotional needs,” said Dr. Pasquina, Chief of the Department of Orthopedics and Rehabilitation at Walter Reed. “Some are here for as long as six month or even a year, undergoing multiple surgeries or rehabilitation. It’s important that we give our patients hope and make them realize they will be able to go on and enjoy the things they love in life, whether it’s sports and recreation, creative arts or just being able to go out in the community to do everyday activities like going to a ballgame, museum or movie theater.” Recovering soldiers with a love for sports have been able to participate in activities ranging from skiing, kayaking, fishing and horseback riding to golf, cycling, swimming and basketball (and so many more). Others have gone down a more creative path, focusing on writing, painting or even learning how to play musical instruments. And on plenty of occasions, Walter Reed’s recreational therapists have organized group outings for patients to attend professional sports events, take tours of Washington D.C. or just hit the town for dinner and a movie. 34 |
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Paul Pasquina, M.D. and his team take a very hands-on approach and focus on treating the physical, mental and emotional needs of their patients.
Pasquina says that without a doubt, keeping patients active can make a significant impact on their overall recovery process. “These activities help patients with their physical recovery, but go a really long way to support their emotional wellbeing,” Dr. Pasquina said. “Making soldiers realize that they can return to their communities and giving them outlets to learn and experience new things is an extremely important part of our mission.” Walter Reed partners with the U.S. Departments of Defense and Veterans Affairs, as well as various non-profit organizations, to make this program possible. Some organizations, such as Project Healing Waters, devote themselves entirely to supporting wounded military personnel and disabled veterans. Project Healing Waters is a national initiative that provides fly fishing, fly casting, fly typing and rod building classes at no cost to its participants. It’s one of many programs that has been well received by soldiers undergoing treatment at Walter Reed. “It’s these types of activities that help
our patients think ahead, rather than dwell on their injury or disability,” Dr. Pasquina said. “Our service members have told us that it helps them reset their goals and focus on moving forward.” Having the opportunity to help and give back to those who have volunteered to serve America, willingly putting their lives on the line, is something that staff at Walter Reed consider a privilege, Pasquina included. “Every day, I get to witness amazing resiliency and spirit as these patients take small steps to recover,” he said. “Seeing someone go on to do great things and be happy in life is something I cherish.” Those interested in making a donation to support the continued growth and availability of recreational programs for wounded soldiers are encouraged to do so by visiting the Walter Reed Society web site at www.walterreedsociety.org.
Maryland Physician would like to hear about your “Good Deeds.” Please share your ideas with us at news@mdphysicianmag.com.
Good intentions or bad judgment?
There are times we do crazy, misguided things; feats that shouldn’t be possible, and sometimes aren’t. So when you push yourself past your limits, it’s nice to know there’s a place like the Rubin Institute for Advanced Orthopedics – where doctors perform more total hip and knee replacements and progressive procedures like hip resurfacing – all combined with the latest rehabilitation services. Nice work knees and hips – the dynamic duo – when we ask too much of you! www.lifebridgehealth.org
The Ride of His Life Chris Barritt's 5,000 Mile Journey Began at Washington Adventist Hospital The Cardiac team at Washington Adventist Hospital offers the most advanced treatments in heart care, including: r .JOJNBMMZ *OWBTJWF $"#( r .JOJNBMMZ *OWBTJWF "PSUJD PS .JUSBM 7BMWF 3FQBJS PS 3FQMBDFNFOU r 5SBOTSBEJBM $BSEJBD $BUIFUFSJ[BUJPO r $BUIFUFS "CMBUJPO GPS "USJBM 'JCSJMMBUJPO
To refer a patient for a cardiac surgery consult, call 301-891-6101. For priority transfer of your cardiac admissions, call Cardiac One-Call at 866-684-8460. Chris Barritt, 57, Mount Airy, Heart Tumor Surgery