TRIAD Online Winter 2018

The Award-Winning Journal of the Michigan Osteopathic Association W I N T E R 2018

IN THE MEDICAL FIELD MICHIGAN OSTEOPATHIC ASSOCIATION w w w. D O M O A . o r g

michiganosteopathic

MichiganDOs

m i c h i g a n - o s t e o p a t h i c- a s s o c i a t i o n

Michigan Osteopathic Association

119th Annual Spring

Scientific Convention

Thursday, May 17 - Sunday, May 20, 2018 30+ AOA Category 1-A Credits Anticipated SESSION HIGHLIGHTS: • Diabetes • Nutrition, Lifestyle & Wellness • Sleep Medicine • Cardiovascular Disease • Gastrointestinal Disease • Dermatology • Pulmonology • Venous Insufficiency SPECIALTY TRACKS • ER/Critical & Intensive Care • Stroke Session • Oncology LARA - Michigan State Osteopathic Licensing Requirements • Pain & Symptom Management • Human Trafficking

SPONSORED IN PART BY:

Includes new education requirements for Michigan License Renewal.

REGISTRATION OPENS JANUARY 2018

WWW.DOMOA.ORG/SPRING2018

Login required for member discount. By default, your username is your AOA number. If you experience difficulty logging in, please call 800-657-1556.

CONTENTS

FEATURE STORIES IN EVERY ISSUE 05 President’s Page 07 CEO’s Message 27 Advertiser Index

09 10

Population Health: A Journey to Value-Based Care

12 15

Autumn Convention Recap

16 18

Proton Beam Therapy: The Future Is Here

19 20

Putting an End to Human Trafficking

22

Technology: Problematic Terms in Purchase/Finance Documents

24

Cyber Attacks Threaten Patient Safety

Contributed by The Doctors Company

26

Building Stronger Communities

Telemedicine Continues Steady March Forward Origami Partners with MSU in $150,000 Brain Injury Research Study New App Promotes Antibiotic Stewardship Via Game Format Flu Shots at the Capitol

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MHA KEYSTONE CENTER. MEMBER HOSPITALS & HEALTH SYSTEMS. STATE & NATIONAL PATIENT SAFETY EXPERTS. Together, we are part of something important. We’re changing healthcare and improving patient safety and quality by implementing evidence-based, best practices that are supported by data. Our person-centered philosophy fuels our purpose and work. It drives us to continually improve and build safer and more reliable healthcare.

Michigan Health & Hospital Association (MHA) Keystone Center member hospitals are voluntarily participating in programs to improve the quality and delivery of healthcare by tackling big issues on a daily basis.

Every day, we’re exploring new and innovative ways to prevent harm, reduce healthcare costs, and improve patient safety.

TOGETHER, WE’RE MEETING THE CHALLENGES OF TODAY TO

Build a Safer Tomorrow and Beyond Read our 2017 MHA Keystone Center Annual Report and hear stories about how hospitals are improving patient safety and healthcare quality online at www.mha.org.

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PRESIDENT’S PAGE

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t this stage in my career it is easy to look back and be amazed at the changes I have seen. Medical advancements, patient knowledge and technology have all contributed to major progress in how physicians practice medicine and how patients receive care. This issue of the TRIAD is dedicated to technological advancements in the medical field. And while monumental discoveries have been made in past eras, it is hard to imagine an era with greater changes than I have seen in the course of my career.

JOHN SEALEY, DO, FACOS MOA PRESIDENT

The biggest transformation in the way we work is the “telephone.”

We may still call it a telephone, but with the popularity of smartphones most of us carry a device with computing powers that dwarf the Apollo missions.

Today’s phones are, in essence, powerful computers that help us manage our schedules and provide a world of research at our fingertips. For physicians, smartphones allow a degree of freedom. Gone are the days of beepers and searching for a pay phone.

Smartphones are also changing the way we treat patients. They have the ability to perform searches. Sometimes in the patient’s room. The “Google effect” is something most physicians have encountered, as patients can Google their symptoms and suggested treatment by searching the internet. The risks are apparent. But when physicians are aware their patients can access misinformation, they can be prepared to combat the self-diagnosis.

As the landscape of healthcare continues its rapid change, a key component will include retaining data in Electronic Health Records (EHR). EHRs epitomize the challenges of technology. In regard to the ability to have centralized records, a healthcare team can easily retrieve important information that can speed up a diagnosis and perhaps eliminate redundant testing. But data entry can consume valuable time. Especially when the physician is forced to enter data multiple times, into multiple systems. There is no doubt EHRs can provide a huge benefit. But there is much work to be done in terms of making systems streamlined and secure.

No matter what technologies evolve and advance in our profession, we must remain true to our philosophies. In my career, after seeing thousands of patients, I am certain of this: technology cannot replace the connection we have with our patients. We communicate with our patients and treat the body as a whole.

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Thank you to those who donated at Autumn Convention.

T H E I R F U T U R E D E P E N D S O N I T.

The importance of giving in the 2018 election cycle: • Of the 110 Michigan representative seats up for election, 24 are term limited.

• Of the 38 Michigan senate seats up for election, 26 are term-limited.

• Other Michigan races: Governor, Lieutenant Governor, Attorney General & Secretary of State.

You decide if we have a voice!

MOPAC M I C H I GA N O ST E O PAT H I C POLITICAL ACTION COMMITTEE

MAIL A CHECK: 2445 Woodlake Circle, Okemos, MI 48864 DONATE ONLINE: domoa.org/joinmopac

is in the company you keep.

Sparrow became the first health system in Michigan and one of the first five in the country to join the Mayo Clinic Care Network. This collaborative relationship is another way Sparrow continues to find innovative ways to deliver the finest healthcare to you.

Sparrow.org/Mayo

Choose Wisely. Choose Sparrow.

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CEO’S MESSAGE

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s we move into the year 2018, the TRIAD focuses on technology. Technology changes are impacting all of our lives and there are few professions experiencing that change faster than healthcare. Doctors have amazing diagnostic equipment and the means to share the results within the healthcare team almost instantaneously These Electronic Health Records (EHR) offer the ability for efficiencies in managing testing, tracking treatment and preventing complications. But as we embrace the advancements in technology, we need to have a measured approach in the implementation.

KRIS NICHOLOFF CEO AND EXECUTIVE DIRECTOR

In the realm of healthcare, the advancements are pushing forward at a blinding speed. My job as Executive Director is not to analyze the technologies, but to examine the impact on the physicians we serve and the requirements and policies the physicians must adhere to.

With all of the amazing things technology brings, it can also bring burden. The data entry required by physicians can consume valuable time. When data entry must be performed on multiple systems that do not “talk” to each other, a physician’s frustration can be understood. In my role, I work towards policies with responsible requirements and advocate on behalf of systems that eliminate double and triple data entry.

Recently, the MOA has launched a physicians’ organization—Healthcare Partners of Michigan (HCPM). HCPM will serve healthcare providers on many issues, including support in regards to technology.

HCPM will provide: • Infrastructure and technology support, including EHR and telehealth, to develop and sustain high performing, independent practices focused on patient health and wellness • A voice of leadership and support in the broader healthcare community, liaising with payers, health systems and policy makers • In office, multi-disciplinary clinical care teams that follow an advanced primary care approach to treat chronic conditions and teach self-management skills

The goal of HCPM is to offer support on many issues, including expert consultation on the hardware and software for a practicing physician. The MOA is focused on the benefits and challenges advancing technologies bring. In the end, it still comes down to a doctor’s dedication and the tools they use. We just want to make sure those tools accessible, intuitive and affordable.

For more information on HCPM, visit: www.domoa.org/hcpm

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GROWTH

PROGRESS

INNOVATION

Moving forward with McLaren As one of Michigan’s largest and growing health care systems with more than 52,000 contracted providers and a delivery network covering the entire lower peninsula of Michigan, our strength can be attributed to our ability to excel at the very human element of medical care.

We understand that health care must be provided by physicians and other medical professionals who are devoted to healing the sick, relieving pain and advancing research.

We are thankful for the dedication and service of the more than 9,000 osteopathic physicians in Michigan whose contributions make a difference each and every day in the quest to bring the latest technologies and innovations to the communities we serve.

Find out how you too can move forward with McLaren.

To learn more about opportunities around the state, visit JoinMcLaren.org.

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One of the largest health care systems in Michigan with 350 facilities, 12 hospitals and more.

POPULATION HEALTH A JOURNEY TO VALUE-BASED CARE

BY MICHAEL ZICCARDI JR, DO, CHIEF MEDICAL OFFICER, MCLAREN PHYSICIAN PARTNERS

T

he health care landscape is changing. Episodic-based fee-for-service payments are being replaced by value-based payments. Clinic visits are becoming more patient-centric and less physician-centric. The solo practitioner is being replaced by the health care team. Independent private practitioners are becoming less common, while physician employment by health systems or hospitals is becoming the norm.

Why are we seeing these changes?

Health care is currently failing to achieve the higher quality and value-based outcomes that patients, employers, and payers expect. “One major problem today is that the care is unregulated; in a fee-for-service world, we are paid for the services we provide whether or not they add value,” says McLaren Physician Partners President and CEO Gary Wentzloff.

What does value-based care mean?

In October of 2013, the Harvard Business Review defined value-based care as care that at its core maximizes value for patients: that is, achieving the best outcomes at the lowest cost. We must shift the focus from the volume and profitability of services provided—physician visits, hospitalizations, procedures, and tests—to the patient outcomes achieved.

How can physicians transition to value-based care?

Adopting concepts like population health management (PHM), which is described by the Institute for Healthcare Improvement (IHI) as the design, delivery, coordination, and payment of high-quality health care services to manage the Triple Aim for a population using the best resources we have available to us within the health care system. Much of the efforts today such as the accountable care organization, risk stratification methods, patient registries, patient-centered medical home, and other models of team-based care are all part of a comprehensive approach to population medicine. This is an excellent evolution for health care and an excellent place for health systems to be in. The Health Care Advisory Board, in April 2013, identified three key elements as the foundation of population

health management: information-powered clinical decision-making, a primary care-led clinical workforce, and patient engagement and community integration.

How can a practicing physician be expected to provide this level of care?

Physician alignment is an essential part of a successful, effective population health management model. Those health care systems that can successfully align with their communitybased physicians through a variety of mechanisms–including traditional medical staff membership, employment, joint venture arrangements and physician-hospital organizations (PHOs)–will be positioned for success. Another emerging option is the population health services organization (PHSO); McLaren Physician Partners is an example. A PHSO provides a business model with resources to manage risk and improve quality performance in the transition to value-based payment models. Providers and partners can obtain key services such as staffing, patient registries, care coordination, health analytics, quality monitoring and submission to health plans, and contracting support. These services are integral in future health care delivery. Another model has physicians joining accountable care organizations (ACOs) which are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high quality care to their Medicare patients. Providers within the ACO share responsibility for delivering primary preventive services, chronic disease management, and acute care to patients with multiple chronic conditions. McLaren Health Care’s ACO is called McLaren High Performance Network, LLC. The bottom line is that with accountability and risk more broadly shared, value-based care will require health care providers, health systems and payers to partner together for the patient’s benefit. A greater degree of clinical integration and data exchange, both within and outside of the health system, will be paramount to achieving success in the new world order of health care. Coordinated care models will be transformed, physician engagement and alignment will improve, and the IT infrastructure to improve data analytics will be built. These are all things that are occurring right now across the McLaren Health Care system.

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TELEMEDICINE CONTINUES STEADY MARCH FORWARD

BY PAUL NATINSKY

obtaining consent for treatment and allowing health professionals prescribed drugs, other than controlled substances, via a telehealth service.

According to the website, Telemedicine.com, the top three uses of telemedicine are: (1) radiology, (2) dermatology and

The VETS Act allows providers working for the Department of Veterans

(3) psychiatry.

Affairs to practice telemedicine at any location, in any state, regardless of where the professional or patient is located. Under current law, the VA can only waive state provider licensing requirements if both the physician and the patient are located in a federally owned facility, placing a burden on veterans who live in rural or underserved areas.

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mid myriad advances in telemedicine and growing pressure to expand its use, the VETS Act of 2017 continues its journey through Congress, having passed the U.S. House in November. The federal legislation is one of scores of bills under consideration and joins state-level legislation regulating telemedicine.

The VA implemented telemedicine nationally in 2003 and expanded the program in 2011, according to congressional analysis. Last year, the VA spent more than $1.2 billion providing telemedicine to 700,000 patients, according to the analysis.

In 2012 Michigan passed legislation that eliminated the condition for reimbursement many insurers had requiring face-to-face contact between a health care provider and patient, effectively creating a form of parity between traditionally delivered care and care provided via telemedicine.

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“Telemedicine offers an incredible opportunity to easily provide health care to Michigan’s elderly, disabled and rural communities.”

—Gov. Rick Snyder The law defines telemedicine as use of telecommunications technologies for medical diagnosis, care and education, according to a legislative analysis.

Generally, telemedicine uses interactive audio, video or other electronic media for diagnosis, consultation or treatment; but the term usually does not include services provided using audio-only telephone, email or fax transmissions.

More recently in Michigan Public Act 359 of 2016 provided the first comprehensive approach to regulating telemedicine in the state. Key provisions include prohibiting a health professional from providing a telehealth service without

A Becker’s Hospital Review article from November 2017 polling health care executives and providers revealed the top telemedicine services their organizations plan to offer as “Second opinions or specialty opinions, mental health services and remote patient monitoring.”

“The most promising use of telemedicine that I have seen and expect to continue to expand is within the field behavioral health,” said Dustin Wachler, an attorney with Wachler & Associates, P.C. “Specifically, the nationwide opioid epidemic and shortage of addiction medicine providers in certain areas has created a great opportunity for telemedicine in substance abuse and addiction treatment. Coverage and reimbursement for substance abuse and addiction medicine continues to expand.”

Wachler also thinks that many of the standard of care concerns often raised in opposition to telemedicine are not as prevalent in behavioral health, which often does not require a physical evaluation of the patient.

“Patients can go into clinics, where a medical assistant or nurse can take a urine sample, and then the patient can meet addiction medicine physician via telemedicine. This arrangement complies with most payer requirements and continues to expand,” said Wachler.

As the use of telemedicine continues to expand, changes in reimbursement policy, legal concerns and licensure continue to evolve.

In some cases, providing services through telemedicine is less expensive for patients and providers, but debate continues as, by one estimate more than 80 percent of the cost of telehealth services is generated by increased utilization of such services.

Questions remain about whether cost savings and access benefits outweigh the costs of increased utilization.

Generally, reimbursement for telemedicine is the same as for in-person visits, but government payers, Medicare and Medicaid, are more restrictive.

“Medicare limits reimbursement for telemedicine services to patients at eligible originating sites and providers at eligible distant sites,” said

Wachler. “Originating sites must be in a county outside a Metropolitan Statistical Area or in a rural Health Professional Shortage Area. Medicare reimbursement for telemedicine is also limited to certain services.”

Wachler said Michigan Medicaid has removed distance requirements previously imposed for telemedicine, however the policy is still that telemedicine should be used primarily when travel is prohibitive for the beneficiary or there is an imminent health risk justifying immediate need for services. Michigan Medicaid also limits telemedicine reimbursement to specific services.

On the legal front, providers have to be careful to meet the “standard of care” for a service when it is performed via telemedicine, as opposed to referring the patient to an in-person provider.

HIPAA patient privacy requirements

also present a challenge for telemedicine providers.

Michigan requires a full license to practice of medicine in Michigan in order for an out-of-state provider to provide a service via telemedicine to a patient located in Michigan. Wachler said some states offer a telemedicine license or other type of limited license.

Some states allow a non-licensed provider to practice telemedicine into the state at the request of or in consultation with a licensed provider that that primarily treats the patient. There is also the Federation of State Medical Board’s Interstate Medical Licensure Compact. Michigan is not a part of the compact.

The VETS Act is a big step forward for telemedicine and states are evolving their policies, but there is still a long way to go in the expansion of telehealth.

Celebrate the Spirit of the Season

by Supporting the A MOA Tree of Peace

The Advocates for the Michigan Osteopathic Association are presenting the Tree of Peace to remember that special person while supporting the programs of the Advocates. The tree will be displayed in the lobby of our beautiful MOA building for the month of December.

All proceeds of this fundraiser will benefit our ongoing projects in support of the Osteopathic Profession. One such project, the Distracted Driving Simulator, continues to gain attention, and we are to reaching out across the state to interested hospitals, service organizations and schools.

With your support, it will glow brilliantly throughout the holidays.

MORE INFO & DONATION FORM AT

http://bit.ly/2w3E5wN

Shining Light $10 A light is dedicated in Memory of Honor of your loved one.

Keepsake Ornament $40 Keepsake Ornament placed on the Tree.

Tree of Peace Sponsorship $100 Keepsake Ornament placed on the Tree, yours to keep when the tree is taken down in January.

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2017 AUTUMN CONVENTION RECAP

Evaluations and CME Information

The Michigan Osteopathic Association would like to extend a huge “Thank you!” to all of the attendees, sponsors, exhibitors and those who participated in the Science Research Exhibit competition at the 13th Annual Autumn Scientific Convention. The event drew record numbers in each of those categories.

• www.domoa.org/cmeinfo

Evaluation website link: • https://data.expressevaluations.com/eval/ 38060/web/ Link to CME information:

Speaker Presentations Some speakers have allowed us to share their presentations as PDF files via the following link: • www.domoa.org/ autumnpresentations

Online Photo Album There were many friendly faces and great events at Autumn Convention! Check out our Facebook page to see if your photo is among them!

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Yoga in the Physician Wellness Center Yoga is a great tool for the health and wellness of you and your patients. Remember to take some time for yourself - for a few minutes a day or a few times a week.

When referring patients to yoga, make sure you have a specific teacher, class or studio so feel comfortable as they continue healing.

Private yoga services are a way of tailoring each yoga practice to meet the needs of the individual client.

Contact Amanda:

November 16-18, 2018 Amway Grand Plaza Hotel Grand Rapids, MI

S

SCIENTIFIC CONVENTION

E AV

THE DAT E!

Many of you met Amanda at Autumn Convention. She is passionate about bringing yoga into people’s lives in a safe way to help them reach their goals. Please contact her if you are interested in her private yoga services for you or your patients, or to learn more about the benefits of private instruction.

Amanda1792@outlook.com OR Facebook.com/PrivateYoga KalamazooBattlecreek T R I A D | W I N T E R 2018

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CME: A NOTE FROM THE MOA EDUCATION COMMITTEE Your MOA Education Committee continues to develop CME programing to meet the needs of our members. The ongoing changes in CME requirements, by the AOA, by specialty boards, and various state mandates, makes this a very challenging effort.

At the MOA 2017 Spring Scientific Convention, two new programs were piloted with a focus on Emergency Medicine and Hospitalist Medicine specialties. From this experience, MOA will provide additional specialty-focused sessions during future conferences.

As many members know, in addition to the ongoing 150 CME hours per three year period required by the Michigan Board of Osteopathic Medicine and Surgery, the state of Michigan now requires two new educational requirements for osteopathic license renewals: (1) a one-time course on recognition and interventions for human trafficking and (2) three hours of pain and symptom management. The State has set specific standards for this education and MOA will include the necessary sessions in future conferences. These additional educational requirements have not been designated as CME; however, the MOA will design programs to also meet the standards to achieve CME credits.

New! State of Michigan Osteopathic License Requirements (per 3 year reporting cycle)

• Pain and Symptom Management

(effective December 2017) Min. 3 hours per 3-year period

• Human Trafficking

One-time requirement Courses will be offered during MOA 2018 Spring convention.

If you are interested in participating in development of specialty-focused programing at future MOA conferences, please contact Melissa Budd, MOA Educational Coordinator, at mbudd@domoa.org or by phone at 517347-1555 Ext. 112 for further information.

WHEN YOU NEED CARE, MAKE SURE YOU’RE COVERED. MOA members have the option to purchase a variety of insurance plans directly through the association at affordable rates.

Contact us today to recieve the latest insurance information.

MICHIGAN OSTEOPATHIC ASSOCIATION

MOA will develop a customized insurance program based on your individual needs. We offer: • Health Insurance • Vision service plan • Delta Dental options • Medical Malpractice, Professional Liability • Life insurance • Long-term care insurance • Long & short-term disability, group & individual options • Home and auto insurance • MOA Prescription Rx Drug Card

Get more info at DOMOA.ORG/INSURANCE • JRUEDISALE @ DOMOA.ORG • 1-800-657-1556 14

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ORIGAMI PARTNERS WITH MSU IN $150,000

BRAIN INJURY RESEARCH STUDY

BY REBECCA WYATT, DO

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ocated just outside of Michigan State University’s campus, Origami Brain Injury Rehabilitation Center is a CARF accredited, non-profit organization resulting from a unique alliance between Michigan State University College of Osteopathic Medicine and Peckham, Inc. Origami’s dynamic and innovative treatment team is committed to providing clients and their families with a holistic approach to recovery. Origami addresses the cognitive, physical, spiritual, psychosocial, and behavioral challenges that often occur following a brain injury.

Origami and their exceptional partners have been generating superb clinical outcomes with cost effective management for over twenty years.

William Strampel, DO, FACOI, Dean, Michigan State University, College of Osteopathic Medicine reflects on the twenty year partnership, “we are immensely proud of Origami’s success in helping patients and their families find healing, relearn skills, build new lives, and, most importantly, do so with dignity and grace.”

With a focus on maximizing recovery and restoring lives, Origami remains on the cutting edge of brain injury rehabilitation.

Most recently, Origami has partnered with Michigan State University for a two-year research study, during which Origami will act as the

“We are immensely proud of Origami’s success in helping patients and their families find healing, relearn skills, build new lives, and, most importantly, do so with dignity and grace.”

—Dean Strampel, MSUCOM

clinical site. Origami’s Medical Director, Rebecca Wyatt, DO, obtained $150,000 in grants from the American Osteopathic Association and AT Still Foundation to better understand and treat symptoms associated with mild to moderate brain injuries.

Wyatt is the primary investigator for The Effect of Osteopathic Manipulative Treatment (OMT) on Functional Outcomes and Anti-inflammatory Biomarkers in Mild- to Moderate Traumatic Brain Injury.

The focus of the study is whether survivors see improvements in headaches and other brain injury related symptoms through targeted manipulation of the muscles in the neck and back of the head. Headaches often plague clients with mild to moderate head injuries and are the number one complaint that Wyatt sees in her work.

Data collection began in September 2017 and is expected to involve

200 cases. Wyatt stated, “The impact of our proposed research lies in our attempt to establish a foundation for the basis of using OMT procedures to accelerate recovery of patients following mild to moderate brain injury and to find correlations between cognitive functions, biochemical markers, and self-reported assessments of quality of life.”

Origami’s Executive Director, Tammy Hannah, shares that, “providing exceptional brain injury care to our clients and their families has and continues to be our top priority. The more than a thousand clients we have served in the past twenty years motivates us to continue advancing and honing in on our ability to successfully treat brain injuries. Research studies, such as the one being led by our Medical Director, Dr. Rebecca Wyatt, truly help to make our vision a reality.”

To learn more about the services available at Origami or make inquiries about this research study, please call Amanda Carr at (517) 455-0274.

Additional information about Origami can be found online at www.

OrigamiRehab.org.

Rebecca Wyatt, DO, is the Medical Director of Origami Brain Injury Rehabilitation Center, and Associate Professor with the Department of Physical Medicine and Rehabilitation (MSUCOM).

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PROTON BEAM THERAPY THE FUTURE IS HERE

BY PEYMAN KABOLIZADEH MD/PHD, ROHAN DERANIYAGALA MD, PETER CHEN, MD AND KATE GOWANS, MD

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roton therapy is an advanced form of radiation therapy that can deliver precise and accurate radiation treatment to the tumor while minimizing the dose to the adjacent critical normal tissues. The technology uses accelerated subatomic positive particles called protons with the first patient treated at the Berkeley Radiation Laboratory in 1954. The concept behind this treatment is that is that the Bragg Peak characteristic of particle therapy is that the deposited dose increases quite sharply and yields a distinct, localized high-dose region.

therapy is that physicians

Pediatric Cancers

secondary cancer, cardiac dysfunction, neurocognitive deficits, hearing loss, infertility, etc. Maintaining outcomes while decreasing the toxicities has become a priority in cancer care and proton therapy can provide the means to this end. In striving to achieve such a therapeutic ratio, many trials have attempted to omit radiation, yet radiation therapy has been shown to remain an important part of the comprehensive treatment of many pediatric and adolescent patients.

Technical improvements in radiation therapy aim to deliver full dose to the tumor target while avoiding normal, uninvolved tissues. If done carefully with high precision, such advanced technology reduces toxicity without the risk of decreasing tumor control.

can direct where the proton

Proton therapy is an excellent choice for many adult cancers but it is particularly beneficial in the survival for pediatric cancer patients. It is estimated that currently close to 80 percent of pediatric patients will survive their cancer. Radiation therapy plays an important role in cancer therapy for many pediatric patients as the developing tissues are more sensitive to radiation therapy even at low doses. As a result, the late radiation side effects that can occur over the years can be significant with conventional photon radiotherapy.

These toxicities can consist of kidney damage, diminished bone growth,

As more childhood and adolescent cancer patients are cured, the number of survivors across the United States and worldwide will continue to increase. Such cancer survivors are recognized to be at risk for a myriad of late effects. Proton therapy has the potential to dramatically decrease these late morbidities.

Proton therapy has shown and will continue to demonstrate its ability to decrease late effects. Diligent studies of these long-term effects are needed through patient registries, in-house study protocols and perhaps most importantly through national cooperative groups.

The advantage of proton

releases its cancer fighting energy. Proton therapy will conform its energy to the tumor itself while sparing the adjacent healthy tissues and organs. The clinical benefit of proton therapy is its potential to decrease the treatment toxicities, which is especially important in the pediatric patient population.

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Beaumont Proton Therapy Center—the first of its kind in the country

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The Beaumont Proton Therapy Center has one of the most sophisticated, and precise proton therapy machines called ProteusONE. IBA is the manufacturer of the ProteusONE and also has the most experience in building the proton therapy machines. This machine’s cyclotron is the first of its kind built with superconductive materials and therefore using much less energy than older larger cyclotrons. This machine has the capacity to deliver intensity modulated proton therapy-pencil beam scanning with the highest precision and accuracy.

Proton Therapy Advantage Craniospinal radiation involves radiating the entire brain and spinal cord.

The excess radiation from photon radiation delivers long-term toxicity to the child’s organs of the mouth, neck, chest, abdomen and pelvis.

Proton therapy delivers essentially no dose to these structures.

Combining the most advanced technology in the world with specialized care, Beaumont’s proton radiation therapy system is state-of-the-art and will provide many benefits to patients requiring radiation for their cancers.

It delivers less radiation to healthy tissue and will reduce the risk of secondary cancers and developmental delays among the pediatric patient population.

THERE’S NO QUIT IN US.

BECAUSE THERE’S NO QUIT IN YOU. There’s no quit in a patient who runs a marathon after hip replacement. Battles back after open-heart surgery. Or overcomes a stroke. People who never quit deserve a health care system with the same philosophy. That’s Beaumont.

Thousands of medical minds working together as one—for one reason: you. Talk to a Beaumont Doctor. Beaumont.org

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NEW APP PROMOTES ANTIBIOTIC STEWARDSHIP VIA GAME FORMAT

BY ROSE RAYMOND

Every year, roughly 2 million people in the U.S. develop antibiotic-resistant bacterial infections and about 23,000 people die from them, reports the Centers for Disease Control and Prevention, which is recognized

O

veruse of antibiotics is the driving factor leading to increases in antibiotic resistance, notes the CDC, which also reports that up to half of all antibiotics prescribed are either unnecessary or not optimally effective when taken as directed.

U.S. Antibiotic Awareness

Prognosis SOMA: Antibiotics

Week Nov. 13-19.

To help combat the overprescribing of antibiotics that leads to antibiotic resistance, the AOA, A.T. Still University and the CDC have worked together to develop a custom medical app, Prognosis SOMA: Antibiotics, that educates clinicians and trainees on antibiotic stewardship via a game based on case reports. The app is available for Apple and Android devices and its case reports can be completed for CME credit.

The project is headed by Joy H. Lewis, DO, PhD, professor of medicine and public health at A.T. Still University, School of Osteopathic Medicine in Arizona (ATSU-SOMA), who explains that the game format was designed to entertain while educating.

“The game format of the app motivates users to read the explanation page where they can access valuable clinical information and warnings about antibiotic misuse.

—Joy H. Lewis, DO, PhD 18

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Promoting discussion “The game format of the app motivates users to read the explanation page where they can access valuable clinical information and warnings about antibiotic misuse,” Dr. Lewis says. “You can play again and again until you get a perfect score.

This deliberate practice helps reinforce the right clinical decisions and appropriate antibiotic prescribing behavior.”

In addition to learning about antibiotic stewardship, DOs who use the app can earn up to 1.5 AOA category 1-B CME credits for completing all six cases, at a rate of 0.25 credits per case.

Dr. Lewis is hopeful that the app will help start conversations among clinicians and trainees on the importance of antibiotic stewardship.

“We have a big problem with inappropriate antibiotic prescribing in the U.S.,” Dr. Lewis says. “Providers are prescribing antibiotics for conditions that don’t require them or they’re prescribing broad-spectrum antibiotics for conditions that could be better treated with narrow spectrum, targeted drugs.

“This app is a small step toward attacking a big problem. The cases it presents can teach some specific practices. I’m hoping the app can also help raise awareness and promote discussion of the importance of antibiotic stewardship.”

The Founders Reynard MD, PhD, FACP and LaClaire Green Bouknight, MD, FACP have over 80 years of combined medical expertise. Reynard Bouknight has been a faculty member of Michigan State University’s College of Human Medicine, Department of Human Medicine since 1980.

PUTTING AN END TO

HUMAN TRAFFICKING Human sex trafficking, as well labor trafficking, is a world- wide problem and a form of slavery that is found across the United States of America. No community is exempt from this travesty.

SexTraff was designed by two physicians to be a screening tool used by healthcare professionals. Use of this application will help them discern patients at risk for being sexual trafficking victims. Healthcare professionals are very likely to be the first to identify victims of human trafficking.

This app separates victims under 18 years of age from those 18 years of age or older. By answering questions about the index patient, a sum of points will be indicated. A total of eight or more points indicates that the patient is at significant risk for being trafficked. The professional should call the indicated human trafficking hot line for help and the local police department. Patients under 18 years of age with 8 or more point totals should be referred to local child protective services as well as the local police department. Patients with borderline totals likely need further evaluation by a professional with expertise in human sex trafficking.

Currently, he is the Chief of General Internal Medicine.

LaClaire Bouknight currently heads a community based, faith based wellness organization and is the regional chairperson of a tri-county regional antitrafficking Task Force (Capital Area Anti-trafficking Alliance) under the Michigan Human Trafficking Task Force. In that role, she is working to see the establishment of more specialty courts for trafficking victims in midMichigan where victims can receive the services that they need. Dr. Bouknight has trained over 1000 health care providers in that last year in the recognition of human trafficking.

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FLU SHOTS AT THE CAPITOL October 17, 2017 • Downtown Lansing

MOA once again partnered with Michigan State University College of Osteopathic Medicine (MSUCOM) and Michigan Association of Osteopathic Family Physicians Inc. (MAOFP) to administer flu vaccinations at the capitol on October 17, 2017.

Throughout the event, a total of 310 public officials, staffers and other attendees were vaccinated. The event was free and open to the public, as part of outreach to strengthen the awareness of osteopathic medicine and the importance of vaccinations.

Students participating in the event honed both their clinical and advocacy skills while giving the legislature a dose of osteopathic preventive care. More than 50 volunteer physicians and medical students from MSU, MOA and MAOFP assisted in administering the flu shots. All students were trained to administer shots through Community Integrated Medicine Public Health Systems.

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TECHNOLOGY PROBLEMATIC TERMS IN PURCHASE/FINANCE DOCUMENTS DANIEL J. SCHULTE, JD

Purchasing technology can come with less than obvious problems.

Most often these problems do not become apparent until after the agreements are signed and something goes wrong. The equipment does not function as represented, the software turns out not to be compatible with other software or another device that it must interact with, etc.

It is critical that you anticipate these scenarios before signing any agreement.

Following are examples of problematic terms that are frequently found in technology purchase/finance documents. You should consider the position these terms put you in when something goes wrong before signing any agreement.

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Financing/leasing technology from someone other than its developer/manufacturer

right to discontinue making payment to the lender or lessor even if the technology completely fails to operate.

Very often, the developer/manufacturer will have an arrangement with a finance or leasing company enabling you to finance the cost of the technology through a loan or leasing transaction. This may seem to be just a convenience for you but can be problematic if the technology does not perform as represented or for some other reason you desire to pursue a claim against the developer/manufacturer of the technology. The loan repayments or lease payments will be required to be made to the lender or lessor whether or not the technology actually functions as represented, is free of defects, properly integrates with your practice, etc.

The financing or leasing transaction is entirely separate and distinct from the purchase transaction. You will have no

Warranty Disclaimers Most technology developers/manufacturers provide no warranties that the technology will function as it has been represented to function or even that the technology is free of defects.

In addition, they routinely disclaim any warranty provided by law. You should carefully review your purchase agreement and/or your license agreement to determine the scope of the disclaimer.

Most agreements provide that unless expressly stated (and there is usually nothing stated in the agreements) the seller of the technology makes no warranty, representation or other promises regarding the quality of the technology, its fitness for your practice or otherwise. It is very likely that your technology seller will not contractually stand

behind the quality or fitness of their product unless you insist that you be provided some kind of warranty.

It is unrealistic to expect to be able to adequately protect

Damage Limitations

does not work as represented and/or is not a good fit for your

In addition to failing to provide/disclaiming any warranty, technology sellers developers/manufacturers usually disclaim liability for the expenses and other losses that you incur in any way connected with a failure of the technology to perform as represented and/ or be a good fit for your practice. The limitation provision is sometimes absolute (i.e. there is no obligation to compensate you under any circumstances).

Other times, the amount of the obligation is limited to what would be an unacceptably low amount that bears no relationship to the actual amount of the damages you have incurred (e.g. the amount you paid for the technology, six months of license fees, etc.).

practice due to how technology developers/manufacturers do

yourself against having to pay for technology that you discover

business. The only way to protect yourself is to thoroughly vet the technology prior to purchase.

It is unrealistic to expect to be able to adequately protect yourself against having to pay for technology that you discover does not work as represented and/or is not a good fit for your practice due to how technology developers/ manufacturers do business. The only way to protect yourself is to thoroughly vet the technology prior to purchase.

This vetting should include not only what the technology sales person is telling and showing you but must also

include discussions with references (e.g. speaking directly with representatives of practices similar to yours that have implemented the technology.) It is absolutely critical to do this due diligence prior to purchasing any technology. Given the contract terms described above, which are typically included in technology sales agreements, you will likely have little if any remedy upon your dissatisfaction with technology following its purchase.

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CYBER ATTACKS THREATEN PATIENT SAFETY

BY ROBIN DIAMOND, MSN, JD, RN, SENIOR VICE PRESIDENT OF PATIENT SAFETY AND RISK MANAGEMENT, THE DOCTORS COMPANY

The recent WannaCry ransomware attack that crippled the United Kingdom’s National Health Service (NHS) showed how more than money and IT security are at risk— patient safety is also compromised

the most frequently attacked form of business, more cyber threats to patient safety are certain to arise.

Our nation’s healthcare providers must approach cybersecurity as an organizational risk management and quality-of-care issue. And they must do it now.

by a cyberattack.

H

ospitals and doctors’ offices in parts of England had to turn away patients and cancel appointments because their IT systems were infected with ransomware. Electronic health records (EHRs) were not accessible, and entire communities were advised to seek medical care only in emergencies. The same scenario could play out here in the United States.

Ransomware is not the only risk to patient safety. As the use of computerized medical devices continues to grow, hackers may target these devices. And because healthcare is

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After WannaCry, I asked myself: Would physicians and hospital staff know how to respond to protect patient safety if all computer access suddenly vanished?

With 79,000 member physicians nationwide, The Doctors Company has access to experts in specialties that might be most affected by a cyber attack: obstetrics, emergency medicine, anesthesiology, and surgery. So I reached out to some of these experts to share their concerns as well as their plans to protect patients. Their insights are a wakeup call to be prepared.

Some physicians have considered the potential danger and prepared a response, which is often a return to paper records when EHR systems go down. But that might not always be easy, or even possible. Paper copies of patient medical records may not always be available, a situation that could jeopardize patient care when clinicians must act without sufficient knowledge of allergies, medications, and past treatment.

This is why Marcus Tower, MD, director of gynecology at Hillcrest Hospital (part of the Cleveland Clinic Health System), always keeps a paper backup of patient records that can be accessed

quickly in the event of a computer failure. While he said losing access to computer records would be devastating to patient safety, access to paper backups would enable him to continue seeing patients even if his system was offline. Without a computer system, Dr. Tower would keep notes with time stamps. Diligence with time stamping is particularly important in obstetrics, where so much hinges on exactly when decisions were made and care was provided.

Anesthesiologist Randolph Steadman, MD, MS, at the University of California, Los Angeles, said in case of computer failure, ordering labs, imaging, and other diagnostic tests would be done by paper form and transmitted within the hospital by fax and/or conveyed by phone with paper forms to follow. But that would only be a workaround. Patient care overall would be affected, with registration slowed, he noted. Many clinicians and staff would be challenged to adapt to non-digital processes, as happened in the March 2016 cyberattack on the MedStar Health system, which has 10 hospitals and more than 250 outpatient clinics.

When hackers seized control of their computer data, senior staff had to

assist their younger counterparts with learning how to use paper messages and recordkeeping.

The ER could be hit hard by a cyberattack, but the physicians and staff there might be best prepared to respond, says Roneet Lev, MD, FACEP, chief of emergency medicine at Scripps Mercy Hospital in San Diego, California, and president of the Independent Emergency Physicians Consortium.

“Emergency departments have all experienced downtime with computer systems,” Dr. Lev said. “At our facility, we call this ‘Code White.’ ” “When we hear ‘Code White’ on the speaker system, we know to get out the white board and the markers, and that things will be slower. It’s annoying and no one likes it, but we’d manage by keeping track of patients the oldfashioned way.”

Even so, a “Code White” still leaves clinicians without a way to refer to any medical records that are stored electronically. Not knowing a patient’s allergies or medical conditions is not

optimal, she said, suggesting that all patients should always carry a list of their medications, allergies, and pertinent medical history on paper or on their smartphone.

Workarounds can only accomplish so much, Dr. Lev noted. A cyberattack could affect all computer-related hospital activities such as labs, x-rays, patient tracking, operating room scheduling, access to previous medical records, and treatment recommendations.

“While the emergency department would function using ‘Code White’ procedures, this is not sustainable for long-term operation of a hospital,” she said.

What these experts all seem to agree on is that in the face of an attack, the best way to protect patients is to return to practices that worked before computers.

As Ralph Gambardella, MD, orthopedic surgeon and president of the Kerlan-Jobe Orthopaedic Clinic (affiliated with Cedars-Sinai) in Los Angeles, so aptly stated: “Rather than relying on computers, I still believe that talking to—and communicating directly with—my patients is the best way to impact patient safety.”

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BUILDING

STRONGER COMMUNITIES THROUGH HEALTHIER INDIVIDUALS Technology and innovation are the future of medicine, and they can be one of a physician’s most valuable tools to improve patient outcomes by getting patients the resources they need. Access is undeniably one of the biggest barriers to health among the low-income demographic, but even among more affluent populations, so many of our nation’s best health resources go shamefully underutilized.

T

here are wellness resources, nonprofits, and organizations in every shade of the rainbow, designed to serve so many of the community’s most desperate needs, but despite their best efforts, their services often do not reach those who need them most. There exists a myriad of factors that contribute to this, but the consistent reason we hear is a simple one: people did not know how to find them.

Lettuce Live Well is here to change that. Embracing the power of technology to bring our world within reach, we have partnered with thousands of organizations nationwide to create a comprehensive health database cataloging every resource one

could possibly need on their journey to wellness. Simple and user friendly, our website is so much more than a search engine, it is a solution. It is a place to find personalized, local support for every aspect of your health.

Simply type in your zip code or city to have a complete listing of local health and wellness resources at your fingertips. Find out what is going on for the kids this weekend, get maps to your local parks and trails, find a physician who shares your philosophy, or discover the perfect exercise class that finally helps you take the first steps toward a healthier you. Connect with the nonprofits who will help your patients get to their medical appointments if they lack transportation, or the ones who will provide nutritional

counseling for free if their insurance does not cover it. The benefits are as limitless as the possibilities.

By bringing every local health and wellness resource together into one convenient location, we are taking a major step towards getting those resources into the hands of those who need them most. There is an undeniable gap between our nation’s health resources and the people they are designed to help, and only by joining hands can we bridge that gap and ensure people access to the tools they need to build happier, healthier lives. ____________________________________ ABOUT LETTUCE LIVE WELL Here at Lettuce, we encourage healthy lifestyles through our free community programs and by connecting people with additional resources in their area. We offer individual and group health coaching, grocery store tours, children’s programs, employee wellness programs, and more. Each community provides differing programs, contact us to learn about what is offered near you!

333 Albert Ave Suite 212 East Lansing, MI 48823 Phone: (517) 898-1870 E-mail: info@lettucelivewell.org

Partner with us today at www.lettucelivewell.org 26

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ADVERTISERS TRIAD STAFF Stephen Bell, DO, and Larry Prokop, DO, Department Chairs Kris T. Nicholoff, CEO and Executive Director Lisa M. Neufer, Director of Administration Todd Ross, Manager of Communications Cyndi Earles, Director, MOA Service Corporation Marc A. Staley, Manager of Finance Virginia Bernero, Executive Assistant & Marketing Coordinator

2017-18 BOARD OF TRUSTEES John Sealey, DO, FACOS, President Lawrence Prokop, DO, FAAPM&R, FAOCPMR-D, FAOASM, President-Elect Craig Glines, DO, MSBA FACOOG, Secretary/Treasurer Bruce Wolf, DO, FAOCR, Immediate Past President Department of Socio Economics - Directors Andrew Adair, DO, FACOFP David Best, DO, MS, ABAM Department of Education - Directors Jeffrey Postlewaite, DO, MPH Patrick Botz, DO Mariam Teimorzadeh, DO, Resident Department of Membership - Directors Emily Hurst, DO Kevin Beyer, DO Augustine Nguyen, Student Department of Healthcare Technology & Informatics - Directors Lawrence Prokop, DO, FAAPM&R, FAOCPMR-D, FAOASM Stephen Bell, DO, FACOI The osteopathic profession in Michigan is made up of osteopathic physicians, osteopathic hospitals and an osteopathic medical school.

This TRIAD stands together to serve our patients and one another.

TRIAD, the official journal of the Michigan Osteopathic Association, serves Michigan’s osteopathic community, including its osteopathic physicians, hospitals, medical school and patients. The Michigan Osteopathic Association will not accept responsibility for statements made or opinions expressed by any contributor or any article or feature published in TRIAD. The views expressed are those of the writer, and not necessarily official positions of MOA. TRIAD reserves the right to accept or reject advertising. The acceptance of an advertisement from another health institution or practitioner does not indicate an endorsement by MOA.

COMMUNICATIONS DEPARTMENT Michigan Osteopathic Association Communications Department 2445 Woodlake Circle, Okemos, MI 48864

AMOA.................................................................................11 Beaumont............................................................................17 Kerr Russell.........................................................................23 McLaren Health Care.............................................................8 MHA Keystone Center...........................................................4 MOA Insurance...................................................................14 MOA Spring Convention.......................................................2 MOPAC.................................................................................6 Sparrow.................................................................................6 The Doctors Company........................................................28

For advertising inquiries, please email Todd Ross at tross@domoa.org or call 800.657.1556.

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90% YOUR MOA ANNUAL DUES ARE

TAX DEDUCTIBLE. Visit domoa.org/whatwedo to learn more about member features & benefits!

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Phone: 517.347.1555 Fax: 517.347.1566 Website: www.domoa.org Email: moa@domoa.org ©2017 Michigan Osteopathic Association T R I A D | W I N T E R 2018

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Tirelessly defending the practice of

GOOD MEDICINE. We’re taking the mal out of malpractice insurance.

By constantly looking ahead, we help our members anticipate issues before they can become problems. And should frivolous claims ever threaten their good name, we fight to win—both in and out of the courtroom. It’s a strategy made for your success that delivers malpractice insurance without the mal.

See how at thedoctors.com

www.DOMOA.org