December 2017 Orlando Medical News

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Like it or Not, The Green Rush is Coming: Are You Ready?

By BRETT PUFFENBARGER

Let’s cut straight to the point…Cannabis is the next “dot com” boom, or gold rush. The Orange County Commissioners just voted unanimously to allow dispensaries, and a similar story is playing out across the state as cities and counties discuss medical marijuana. Over half the country now has either a legal medical or recreational market, and recent polls suggest as much as 64 percent support for nationwide legalization. Here in Florida, 71.3 percent of voters supported the constitutional amendment that passed last November, and the patient count is the

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Srinivas Seela, MD PAGE 3

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fastest growing registry in the country. Basically, Cannabis is big business, and it’s easier to get involved than you may think.

For a medical provider to recommend “Medical Marijuana” here in the Sunshine State requires a two-hour course.

That’s about it. Any unrestricted license as a medical doctor or osteopathic physician qualifies you to take the course through the Florida Medical Association or Florida Osteopathic Medical Association depending on your license type. The course costs $250.00, and a passing grade of 80 percent on the final exam is required. The only other restriction is that you can’t work for any of the Medical Marijuana Treatment

Centers (MMTCs, Dispensaries), or have any direct or indirect financial ties to them.

This state required course is a very basic overview of the law and how to ensure you are following it as doctors, but it really doesn’t cover any of the hows, whys, and whats of being a medical cannabis qualified ordering physician.

HOW

The how is pretty simple: either begin offering cannabis recommendations at your current practice, start a second cannabis specific practice, or join one of the many “referral agencies” that allow providers to moonlight with them, separately

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HEALTHCARELEADER

Daryl C. Osbahr, MD, Sports Medicine From pros to the Joes – preventing sports injuries is the priority.

Daryl C. Osbahr, MD, is an internationally renowned orthopedic sports medicine surgeon serving as chief of sports medicine at Orlando Health, fellowship director for the Orlando Health Orthopedic Sports Medicine Fellowship, research director for Orlando Health Sports Medicine, and director of the Orlando Health Orthopedic Sports Medicine Residency Education.

Board certified in orthopedic surgery and sports medicine, Dr. Osbahr earned his medical degree from the University

of North Carolina in Chapel Hill, North Carolina. He completed an internship in general surgery at Weill Medical College of Cornell University at the New York Presbyterian Hospital in New York, and an orthopedic surgery residency at Hospital for Special Surgery in New York. He also completed an orthopedic sports medicine fellowship at the American Sports Medicine Institute in Birmingham, Alabama, a premier sports medicine program under the guidance of Dr. James Andrews who treats internationally recognized pro-

fessional athletes.

Dr. Osbahr currently serves as the chief medical director and head orthopedic team physician for a number of local and national sports teams and organizations.

He has particular expertise in treating complex orthopedic sports medicine pathology, including cartilage injuries, meniscal transplantation, multi-ligamentous knee injuries, bone alignment procedures (i.e., osteotomies), shoulder instability with bone loss (i.e., Latarjet (CONTINUED ON PAGE 8)

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from any of their other medical business.

Each one of these has their own pros and cons. Cannabis specific practices, and doctor groups seem to be the most popular options, though most advocates and patients are pushing for family practices and primary care clinics to start offering medical marijuana. When it comes to cannabis patients in Florida, the average age is 57 and most are suffering from terminal or incurable conditions. They don’t want to be associated with any of the false or negative stigmas attached to “weed” or “dope” any more than some doctors and

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PHYSICIANSPOTLIGHT

Srinivas Seela, MD

Gastroenterologist, Digestive and Liver Center of Florida IN OTHER WORDS with Dr. Srinivas Seela Srinivas Seela moved to Orlando after finishing his fellowship in Gastroenterology at Yale University School of Medicine. During his training, he spent a significant amount of time in basic and clinical research, and has penned several articles in gastroenterology literature.

His interests include advanced and therapeutic endoscopic procedures, colorectal cancer screening, Gastro Esophageal Reflux Disease (GERD), metabolic and other liver disorders.

Seela is board certified in both Internal Medicine and Gastroenterology. He is a member of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE), the American Association for the Study of Liver Diseases (AASLD), and Crohn’s Colitis Foundation (CCF).

In addition to an assistant professorship at the University of Central Florida School of Medicine, Seela is also a teaching attending physician at both the Florida Hospital Internal Medicine Residency and Family Practice Residence (MD and DO) programs. He is on the board of directors at the Orange County Medical Society and is a regular contributing writer for Orlando Medical News.

Digestive and Liver Center of Florida provides a wide range of services and treats gastrointestinal and liver conditions. The Endo-Surgical Center of Florida provides colonoscopy, upper endoscopy, advanced diagnostics, therapeutic procedures, and radiofrequency ablation for patients with Barrett’s Esophagus and non-surgical hemorrhoid treatment.

“We do everything we can to make sure that our patients have a positive, educational experience, because that’s what we would want if the roles were reversed,” said Seela.

The Endo-Surgical Center of Florida has been recognized by the American Society for Gastrointestinal Endoscopy for quality and safety and it is accredited

by The Joint Commission. Prevention of colon cancer is a top priority at the center In our forum segment, Dr. Seela shares with our readers diagnosis and new trends in treating H. pylori.

H. pylori is a spiral shaped, microaerophilic, gram negative bacterium. H. pylori infection occurs when a type of bacteria called Helicobacter pylori (H. pylori) infects the stomach. This usually happens during childhood. A common cause of peptic ulcers, H. pylori infection may be present in more than half the people in the world.

For most people, it doesn’t cause ulcers or any other symptoms. If H.pylori is present, medications are available to treat.

Infection with H. pylori is a cofactor in the development of three important upper gastrointestinal diseases: duodenal or gastric ulcers (reported to develop in 1 to 10% of infected patients), gastric cancer (in 0.1 to 3%), and gastric mucosa-associated lymphoid-tissue (MALT) lymphoma (in <0.01%). The risk of these disease outcomes in infected patients varies widely among populations. The great majority of patients with H. pylori infection will not have any clinically significant complications.

TREATMENT TRENDS

Helicobacter pylori treatment has changed the natural history of peptic disease in this country and around the world. In addition, such treatment has affected other consequences of H pylori, in particular some of the mucosa-associated lymphoid tissue (or MALT) lymphomas and other specific disease categories that

benefit from its eradication. But the treatment has changed.

Standard treatment involved a 7-day regimen of a proton pump inhibitor (PPI) plus amoxicillin and clarithromycin for patients who could tolerate it. Metronidazole was a substitute for amoxicillin in patients who were penicillin allergic. There has been a component alternative with bismuth-based therapies for patients who have amoxicillin allergy or clarithromycin resistance: a tetracycline/metronidazole/ bismuth combination plus a PPI. This is a 10-day regimen.

We have seen, however, that the efficacy of these regimens has declined. This prompted a group of primarily Canadian experts on H pylori and evidence-based medicine to convene a 2-year analysis that culminated in a final evaluation in Toronto, Canada—hence, the Toronto Consensus Conference on Helicobacter pylori Infection in Adults. This consensus conference resulted in several important take-home messages that should change the way we practice and treat H pylori.

First, recognize that drug-resistance patterns have changed during the past decade and a half. Clarithromycin resistance, which was initially quite low, at 1%-8%, has risen to 16%-24%. Metronidazole resistance was relatively high to begin with and has remained relatively stable at 20%40%. Tetracycline resistance and amoxicillin resistance are virtually unheard of at

less than 1% for tetracycline and 1%-3% for amoxicillin, and thus they remain incredibly good drugs.

Prevalence of secondary resistance for clarithromycin and metronidazole has gone up dramatically with the use of antibiotics for UTIs and URIs .Resistance is up to 67%-82% for clarithromycin and 52%-77% for metronidazole. Thus, the effectiveness of these drugs has been drastically reduced.

CONSENSUS RECOMMENDATIONS

It is recommended that extending the treatment from 7 or 10 days to 14 days is and should be the new standard. The eradication rates for the 7- to 10-day regimens have fallen to approximately 50%, whereas with a 14-day regimen by either intention-to-treat or per protocol, the eradication rates were in excess of 95%.

Therefore, a regimen lasting 14 days is the new rule across all treatment regimens for H pylori, regardless of which line of therapy is used.

If the initial regimen for a given patient included clarithromycin or levofloxacin and had failed, these drugs should not be used at all.

Similarly, levofloxacin has been used in patients whose initial triple therapy had failed; in that case, triple therapy would include levofloxacin, amoxicillin, and a (CONTINUED ON PAGE 8)

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Like it or Not, The Green Rush is Coming: Are You Ready, continued from page 1 politicians do, and being able to talk to their normal doctor about this option is much more comfortable for them.

WHY

For the why of medical marijuana, the most obvious is economic. The average cost of an appointment for a cannabis referral is between $120-$250, with biannual follow ups usually costing patients $75-$100. With the current patient count being just over 60,000 and a doctor count at under 500, the potential income is substantial to say the least. A less obvious, but more important why is part of your Hippocratic Oath, where all known measures are required for the benefit of the sick.

Here in Florida there is a list of 10 qualifying conditions: Cancer, Epilepsy, Glaucoma, HIV, AIDS, PTSD, ALS, Crohn’s disease. Parkinson’s, and Multiple Sclerosis. Similarly debilitating conditions are also qualifiers. The major take-away here is that these are sick people who are

tired of the pills, and treatments. They are looking for a more natural relief, and with cannabis being the most talked about subject of 2017, they will be coming to you for information. No business, least of all medical practices, want to leave their customers/patients high and dry when they come looking for the most popular single medical product in America.

WHAT

Last but not least is the what of medical marijuana. Most importantly, here in the land of Mickey, Cannabis is a constitutional right. Medical Marijuana is also a lot more than a right though; it’s the only medicine you can talk about without a list of side effects longer than the symptoms it relieves.

Marijuana is actually a negative term coined in the 1930’s to make a harmless and wild growing plant seem alien or foreign. The plant is actually Cannabis Sativa, and it’s related to Hops, Dogwood trees, and most other flowering trees and bushes. Ancient

Greek, Chinese, Middle Eastern, and Native American cultures all recognized the industrial and medical uses of Cannabis. Even the founding fathers have referenced the plant.

Here in Florida, you are limited to only extracts, tinctures, and concentrates. There is no “whole flower” cannabis, and patients can’t smoke any of the products. There are currently only 9 licensed MMTCs, with 5 currently dispensing products. Products are limited to two categories, and two general delivery methods. The categories are: THC/Medical Marijuana with any amount of the psychoactive agent TetraHydraCannabinol (THC) above 0.8 percent, and Low Strength/CBD with under 0.8 percent THC and comprised mostly of the other major agent in cannabis, Cannabidiol (CBD). Delivery Methods are split into inhalation and oral. The former is for any of the vape pens, inhalers, or other ingestion methods where the lungs are the major processing method. The latter is for any number of drops, tinctures, capsules, and sprays

where the stomach or mouth is the intake method. There is also a third method that covers balms, salves, suppositories, and other methods that are much less common given the current qualifying condition list.

Now that you know the basics of how to become a qualified physician, why you should consider it, and what is happening, the rest is on you. Whether it’s the economic incentive, a true love for your patients, or peer pressure, the time to jump on board is now. This article is just a start, just like the state course is only the very basics. Cannabis is only in it’s infancy as a medicine in the modern world, and the more qualified medical professionals who take the time to understand this phenomenon the better. Check with the Florida Department of Health and The Office of Medical Marijuana Use for more information on how, and get involved with any of the non-profits, groups, or consulting firms to really dig into why and what.

Steps After Qualifying as an MMJ Physician You’ve taken the two-hour course, and can now recommend medical cannabis here in Florida. That’s an important first step, but to really be a knowledgeable provider in the medical marijuana field, you must understand exactly what you’re dealing with. Over the next few paragraphs, we’re going to go over the delivery methods, the recommendation types, and some of the strains and varieties available here.

Let’s start at the very beginning, the recommendation. When you decide to offer cannabis as a medicine to a patient it isn’t a prescription. Most of you probably already know this, but just in case you don’t, I’ll repeat: It’s a recommendation, not a prescription. Prescriptions are federally regulated, and as we all know cannabis is illegal at a federal level, so a script for cannabis would cause a loss of license, and probably some hefty fines.

As far as what a recommendation entails, it is fairly simple. Recommendations come in two forms, CBD/LOW DOSE and THC/FULL STRENGTH. The two are not interchangeable, and will be

Physicians, Food, Fellowship and

displayed as grey for CBD, and green for THC in the state registry. The DOH has currently set the maximum daily dose at 400 mg, though very few patients will ever use more than 200 mg a day. When discussing these dosages, you are referring to the actual amount of the active ingredient, not the total amount of the container your patient purchases. For THC recommendations, patients can try either variety (Indica or Sativa), though most doctors recommend them one or the other depending on the individual patient’s situation. Very generally speaking Indica will produce a tired, relaxed feeling, whereas Sativas produce an energetic or creative feeling. Products also come in hybrids that share both characteristics.

Once you have made this recommendation, the patient will be able to purchase products that fall under this category, so there will be some trial and error for both of you as you set dosages, and recommended strains.

The second component of the recommendation is delivery method, and comes in three varieties: Inhalation, Oral, or Other.

• Inhalation comprises vape pens

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and inhalers, works nearly instantly, and lasts for as long as four hours.

Inhalation is the most common method, but most specifically is for breakthrough pain/anxiety, or for conditions that are sudden onset (seizure, panic attack).

• Oral can be sublingual drops, tinctures, capsules, or throat sprays, and takes as much as two hours to feel affects, but lasts as long as 8 or 10 hours. Oral is the second most common, and is for chronic conditions, or long-term relief.

Oral is also considered “stronger” since it doesn’t process through the lungs and liver, causing the active ingredients to change slightly.

• The final method is the Other category, and comprises salves, balms, oils, lotions, suppositories, and any number of creative methods the dispensaries develop. These methods are usually non-psychoactive, and are for localized pain or other conditions with the exception of the suppository, which works similarly to Oral as far as effects.

While on the subject of delivery methods, let’s touch on the final component of recommendations – maximum and recommended doses. As it currently stands, most patients use a maximum dose of 200 mg a day, but this can be as low as you want or as high as 400 mg a day. Some patients may only need 10mg, whereas experienced patients may need over 200mg. A prudent method is to follow averages, and allow your patient to work themselves up cautiously to an effective dosage.

There has been much discussion in activist circles about when a recommendation should go active – with some doctors seeing their patient and once the card is approved the recommendation is there, while other doctors require a second visit between the patient obtaining the card and making their first purchase. The sec-

ond method is generally not preferred, and really doesn’t make sense.

The follow up schedule is currently set at 7-month intervals, though some doctors require patients come in every 60-90 days for the first 7-month cycle so they can help patients adjust with the trial and error process.

I offer one last bit of advice learned from my time as a dispensary manager; please ALWAYS click the “Patient may purchase delivery device” when adding your patient’s recommendations. Here in the Sunshine State, a registered patient can only use dispensed medicine in a dispensed delivery method – otherwise the medicine is invalidated and becomes a felony to possess. If you don’t click this little button, patients can’t use the meds they buy legally.

So, now you have taken your two-hour course, and spent the last 5 minutes or less reading this brief explanation to what the next steps are. So where do you go from here? I would start by either pursuing a consultant, doing your own independent research, or going to one of the many CME courses offered throughout the state for providers on this subject. If none of these options work, all of the current active dispensaries have education departments and would be happy to send you an educator if you are willing to listen to the product sales pitch as well. Go out and start learning, because the registry is growing every day, and patients are begging for educated physicians to visit.

Brett Puffenbarger is a cannabis educator, activist, and consultant with Key & Support badges for the cannabis industry nationwide. He was the general manager for the first dispensary in Florida, and is currently serving as the Director for Public Relations for the charity: Buds for Vets. He’s a full-time consultant to physicians, their staff, and secondary markets through his business page: Professor Cannabis. You can find him on Twitter @ProfCannabis and FB @ProfCannabiz or online at professorcannabis.ml. Inquiries can be directed to Brett.ProfessorCannabis@gmail.com & for my charity work Brett@budsforvets.org

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On the road, something is happening again. For sporty drivers – and their sporty companions – our engineers and designers have created the next Panamera. With the courage of a new generation.

Our engineers have demonstrated their courage with the Panamera concept.

By continually re-evaluating and reinventing. By reconciling apparent contradictions: performance and comfort, dynamics and efficiency, career and family. And by forever remaining true to our roots, with shared traits like the ignition lock on the left and the rev counter in the middle – in short: typical Porsche DNA. Chassis control systems, such as Porsche Dynamic Chassis Control Sport (PDCC Sport), Porsche 4D Chassis Control, three-chamber air suspension or

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Alfa Romeo Giulia named Motor Trend’s 2018 Car of the Year® The editors of Motor Trend today named the Alfa Romeo Giulia as its 2018 Car of the Year®, best representing exceptional value, superiority in its class and impact on the automotive scene.

“The Motor Trend Car of the Year award acknowledges all of the hard work, dedication and passion that went into developing the entire Giulia lineup – including our record-breaking Giulia Quadrifoglio – which revolutionizes the segment and pays tribute to our storied heritage and racing pedigree,” said Reid Bigland, Head of Alfa Romeo. “We are honored to be the first Italian brand to ever receive this prestigious award and we’re excited for the future of Alfa Romeo here in North America and abroad.”

Motor Trend’s Car of the Year program is open to any all-new or substantially upgraded 2017 model year vehicles.

Rather than being compared against one

another, contending vehicles are first put through Motor Trend’s full battery of performance tests to measure acceleration, braking, and limit handling.

“Motor Trend’s judges agreed that the Alfa Romeo Giulia is the new ultimate driving machine,” said Ed Loh, Motor Trend Editor-in-Chief. “Alfa Romeo developed a car that is perhaps the finest handling sedan on the market.”

All “Of the Year” contenders were selected by Motor Trend judges and evaluated against six key criteria: advancement in design, engineering excellence, safety, efficiency, value, and performance of intended function. The 2017 Alfa Romeo Giulia best represents these six key elements, which also characterize what consumers most want in their next vehicle.

Contenders are put through a grueling battery of tests to determine which vehicles best represent exceptional value, superior-

ity in its class and impact on the automotive scene.

Alfa Romeo Giulia models feature an all-new, all-aluminum, 2.0-liter, directinjection turbo engine with an eight-speed automatic transmission that delivers a classleading, standard 280 horsepower and 306 lb.-ft. of torque, allowing it to launch from 0-60 mph in 5.1 seconds, and achieve a top speed of 149 mph*.

As the lineup’s “halo” model, the Giulia Quadrifoglio highlights Alfa Romeo’s performance and motorsport knowhow with its best-in-class 505 horsepower, 0-60 miles per hour (mph) in 3.8 seconds and a record-setting 7:32 lap time around the legendary Nürburgring – fastest ever by a four-door production sedan.

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HEALTHCARELEADER procedure), rotator cuff repair with and without graft utilization (i.e., superior capsular reconstruction), hamstring tendon injuries, and ulnar collateral ligament (Tommy John) injuries. He is also trained in the utilization of regenerative therapies, including platelet rich plasma and stem cell therapy.

As this month’s healthcare leader, Dr. Osbahr shares with us how to help patients prevent sports injuries no matter their level of performance.

IN OTHER WORDS

by Daryl C. Osbahr, MD

From pros to the Joes – preventing sports injuries is the priority.

As a team doctor for some of Orlando’s most prominent sports teams, including Orlando City Soccer Club, and as an orthopedic consultant to other teams such as the Atlanta Braves, Washington Nationals, USA Baseball, US Soccer, PGA, LPGA and others, I’ve had the pleasure of working with many of the world’s finest athletes – men and women who are at the top of their game.

If these athletes are injured, they can’t make a living. So keeping them healthy is the highest priority for me, the athlete, the team, and the fans.

But in addition to working with elite athletes, I also work with amateur athletes and average Joes – the weekend warriors who enjoy running a 5K or playing in a recreational soccer league. Regardless of the level of the athlete, the best way to keep them in the game is to focus on prevention. Over the course of my career as an orthopedic sports medicine doctor, prevention of sports injuries has become my passion and subsequently led to my role as Chair of the Education & Outreach Committee for the internationally

Daryl C. Osbahr, continued from page 1 renowned STOP Sports Injuries Program.

Therefore, I’m constantly asking myself what can we do to keep an injury from ever happening in the first place?

The New England Patriot’s Tom Brady has won the Super Bowl a record five times. He’s now in his 18th NFL season and this year he has the Patriot’s positioned once again for a deep playoff run. With all this success, it’s easy to forget the season-ending knee injury Brady suffered in 2008. He rehabbed during the off-season and came back stronger than ever. While much of this can be attributed to Brady’s legendary focus and determination, one of the keys to Brady’s successful recovery was knowing the many unique characteristics of his own body, his medical history and his overall health – and then developing a rehabilitation and maintenance plan specific to him.

Tom Brady is one thing, but what does this mean for you? Simply put, each athlete is different, and as sports medicine doctors we need to understand everything we can about the individual in order to prevent injuries whenever possible – and then to customize treatments if and when they’re needed.

This means all competitive athletes need to be properly screened though appropriate pre-season physicals to not only prevent injuries but also make sure that they have received appropriate recovery from prior activities and injuries. In addition to a thorough medical examination completed by a licensed orthopedic or primary care sports medicine physician, doctors need to ask questions such as: • What kind of past injuries and illnesses have you had?

• Have you ever had surgery?

• What’s your family’s medical history?

High blood pressure, early cardiac death, cancer, etc.?

• Have you broken a bone or seriously injured a joint, ligament or tendon?

• What’s your concussion history?

• Have you ever been admitted to a hospital? If so, why?

And on and on.

The answers to these questions will help the athlete and the doctor get on the same page when it comes to preventing injuries and staying healthy. But even more importantly, this essential early preseason screening can also be the difference between life and death.

We’ve all heard stories of seemingly healthy athletes collapsing and dying during practice or a game for sometimes preventable reasons. When I read stories like this, my heart obviously breaks for the families and the team. But like most doctors, I want to understand why. Why would someone in peak physical condition die? I’m hopeful that if we ask the right questions and perform the indicated tests beforehand – during an in-depth medical screening – we might be able to prevent this type of terrible outcome.

As a medical director and head orthopedic team physician, I try to create a great relationship with every player to build an environment of trust and respect.

The athlete at any level needs to know the biggest part of my job is to keep them healthy, not just get them healthy after an injury.

The athletes need to see their team doctor as a trusted professional who can help them properly prepare for their sport and prevent injuries that could take them off the field and out of the game. For me, being able to do my best for the team comes down to the three “A’s”: Affability, Ability, and Accessibility.

AFFABILITY. Always being pleasant, easy to approach and helpful.

ABILITY. Having the medical skills and knowledge to develop injury prevention strategies and provide treatments and solutions when injuries occur.

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ACCESSIBILITY. Being available – no matter when or in what circumstances.

While the holiday season is upon us right now, before we know it – spring sports will start up. With single sport specialization and overuse now commonplace at all levels of sports, we are seeing an increasing number of injuries during each season and over the course of the entire year. But this doesn’t have to be the reality of modern-day sports. Athletes at all levels – whether the well-known pro or a weekend Joe – should know their bodies and have an understanding of their vulnerabilities before they step onto the field. Along with athletic trainers, physical therapists, coaches, agents, teams, and teammates, orthopedic and primary care sports medicine doctors need to continually advocate for the prevention of sports injuries through good practice, communication, and education.

Orthopedic and primary care sports medicine doctors can better help athletes prepare, prevent and keep themselves on the field if proper attention and care are part of the game plan even before the game begins.

PHYSICIANSPOTLIGHT Srinivas Seela, continued from page 3

PPI for 14 days. Levofloxacin does have a fairly high resistance pattern.

Probiotics were not useful to attenuate side effects of the 14-day antibiotic treatment, nor were probiotics helpful proactively to improve the eradication rate.

14-DAY REGIMEN IS THE NEW APPROACH FOR TREATMENT

In conclusion, the consensus committee recommends a 14-day regimen and recognizes the high resistance patterns.

But be careful when prescribing the bismuth-based therapy. The standard packaging for the tetracycline/metronidazole/ bismuth combination drug is for 10 days.

The recommendation now is to use this regimen for 14 days. You would have to give a pack and a half.

Substitute one of the standard bismuth subsalicylate preparations, and prescribe two tablets four times a day plus the PPI, tetracycline, and metronidazole.

Think about new treatments, new options. Think about H pylori as a 14-day-treatment disease. This is the new standard, and we believe the consensus on this is quite strong.

The new guidelines also recommend that patients <60 years with dyspepsia be tested for Helicobacter pylori and treated if positive. H.pylori prevalence is ethnicity specific and pretest probability should be based on the risk factors of the population.

DR. SEELA practices at Digestive and Liver Center of Florida and can be reached at 407-384-7388.

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HEALTH INNOVATORS

FEATURED INNOVATORS:

Urgent Needs in Emergency Medical Education

By KELLI MURRAY, MedSpeaks

Life in 2017 is a real double-edged sword. On the one hand we have modern privileges like an open and free Internet, the ability to see and talk to our loved ones no matter where they are on the planet, and self-driving cars so close we can taste it. But on the other, we have the dark reality that we exist in a time when terror is being utilized on a global scale, most often surprising us when we least expect it.

Terror threats are a reality we must face and the weapons in use to cause harm involve bombs, semi-automatic guns, knives, and vehicles. Schools, churches, concert stadiums, parades, employers, and nightclubs are now targets; places where you’d least expect mass murders to occur. For us locals, the Pulse nightclub shooting in Orlando left the innocence of the “Happiest Place on Earth” marred by something sinister and unpredictable.

Last week, our Health Innovators’ event focused on how organizations are preparing emergency response personnel, from hospitals to the battlefield. We talked with Eric Alberts, Manager of Emergency Preparedness at Orlando Health about the field he works in and protecting those he serves. He’s responded to a variety of emergencies including a terrorist attack, 4 hurricanes, tropical systems, communicable diseases, wildfires, multi-type vehicle

accidents, and mass casualty incidents.

Eric iterated that Orlando’s risk for mass incidents is high and that teams have to be ready with a depth of knowledge to react when situations arise.

To prepare staff, mock tragedies are performed 3 times each year. One of these exercises recruits nearly 800 volunteers to stand in as injured victims and distraught family members to challenge the clinical and ancillary teams in as realistic setting as possible. Clinicians practice dynamic procedures on simulators while patients and families scream and yell in various dialects and languages.

The goal of scenario exposure, such as an active shooter exercise, is to move staff out of their instinctual flight mode and into a fight mode of response.

So what are some of the biggest hurdles when it comes to this new mindset and requirement for emergency response training? According to Eric, “you just cannot make things happen fast enough,” referring to the speed of learnings, converting knowledge into competencies, and also decision-making within Orlando Health and across involved agencies. David Rogers, CEO of Allogy, also added that within

organizations, “people are territorial and protective, and that really limits accessibility. Making information accessible to teams helps speed up the process to activate expertise and inform a lot of people at once.

It also helps debrief on new standards of care but that’s hard to do if bureaucracy is not compressed.”

To overcome these challenges, Eric and David surmise that what communities and organizations like ours need are: • 2-way mass communication tools for notifications and acknowledgements • engagement to move new standards, processes and procedures into practice • bring training to where people are through mobile technology; shifting away from classrooms and traditional learning management systems (LMS) • urgency and prioritization for decision-making • funding to support emergency preparedness infrastructures Before the Pulse tragedy, we didn’t have the idea to connect a network of police, fire department, hospitals, the FBI, and others... Eric Alberts (CONTINUED ON PAGE 10)

doing research in cancer, genomics, and proteinHello Innovators! I am excited to protein interactions, start a series on some of the wonderful she realized that innovations that are helping in the world learning programof cancer care. This particular innovaming was essential to tor recently spoke at our Miami event on bioinformatic analysis.

November 30, 2017 along with two other She then taught herself Florida-based cancer technologies, Dercomputer programmaSensor and DosiSoft. ming and got Anabetsy Rivero is the CEO accepted to the of Metastatic AI, a new company masters in computer that is changing the way that biscience at Nova Southeastopsy results are given to patients. ern University, where she specialAnabetsy has a really interesting ized in data science and artificial background - she was invited to intelligence. During her time at conduct cancer and stem cell reNSU, she met Dr. Saeed Rajput search at Dr. Robert Sackstein’s and, soon after, they started buildlab at Harvard Medical School. ing a deep learning library that The Sackstein lab further fueled Anabetsy Rivero would eventually become Metaher passion to cure cancer and imstatic AI. prove the human condition. During her years Let’s start with how biopsies usually 9

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DECEMBER 2017

4D HEALTHWARE Founded by Star Cunningham, this chronic condition management platform provides a dashboard with each patient’s care plan, a record of adherence and progress and exception reports when a patient needs intervention. The communication between the platform and the patient exceeds the 20-minute requirement of non-face-to-face care coordination/management and is reimbursed under CPT-99490. Learn more at www.4dhealthware.com

Disclosure: Readers, please take note that the companies featured in the Health Innovators section have not paid for or bartered for these acknowledgements. All companies are selected based on merit, intrigue, and their potential to move healthcare forward towards the Quadruple Aim. In a noisy and biased market, we believe this to be a valuable distinction.

UPCOMING EVENTS

Revolutionizing Cancer Care Part 1

By BETH RUDLOFF, MedSpeaks

DEPLOYED MEDICINE a platform in use by the Defense Health Agency to trial new innovative learning models aimed at improving readiness and performance of deployed military medical personnel.

The intent is to deliver personalized, dynamic learning using the most current and accessible technology, enabling a selfdirected and continuous study of learnings and medical best practices. Android and iOS apps available.

MACRA Year 2 Readiness Webinar UCF HealthARCH

work, using the example of breast biopsies since that is what Anabetsy is working with currently. Breast biopsies are usually done to determine if a mass that is palpable and/ or seen on a mammogram is cancerous.

A needle is inserted into the mass and cells are drawn out by the physician and sent to the pathology department for review. The pathologist looks at the size and shape of the cells and the cell’s nuclei in the biopsy as a factor in determining whether a patient has cancer. This is painstaking work that can take 24 hours, or up to a week depending on the testing the pathologist needs to do, because of course it is very important that (CONTINUED ON PAGE 10)

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HEALTH INNOVATORS Revolutionizing Cancer Care Part 1 continued from page 9

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the diagnosis is accurate.

At the University of California in Irvine, they have a database of 569 breast biopsies with these measurements and the final diagnosis. And that is where Anabetsy started to think about her hypothesis.

Could artificial intelligence and machine learning fast track the diagnosis from these pathology measurements? And how accurate would this diagnosis be?

As I have learned, artificial intelligence is when a computer does not just store and retrieve information, but it also mimics human learning patterns. Machine learning, a component of AI (artificial intelligence), occurs when “algorithms enable systems to take in new information, and apply those ‘learnings’ to make changes to its analytical engine. The more information fed into the system, the better it is at guiding decisions”, according to Frost and Sullivans’ 2017 white paper called The Artificial Intelligence Revolution has Arrived in Healthcare.

When Anabetsy fed a randomized sample of the pathology measurement data from the University of California’s

ncial contributions to suppor Center Managers Support of Our Health ect Dir rs rs er Towels gePap Center Manage altene na old Ma lti-F nterMu h Ce x and upport of Our •HeKle els Tow itizer Sanels ndTow Haer nex and Multi-Fold• Pap Wipes nt cta infe • Dis d Sanitizer esr Patients & Families t Fo orteri Bat A pp AA Su and AAect nfectant Wipes • Dir to make s Bus Passes and gas cards Bagtion e Op Ridge glerba SinGa Kitcxhen • Lyn and AAA Batteries • Tall ves Glo centers easier dicalhea lth Meour s n-L chixng • No reaate Kitchen Garbage Bag s mp Sta get Gift Cards g Tar ilin MaW almart or For •ves Pubr lix, n-Latex Medical Glo • eve and games for er Pap pyand DVD’s, Coloring books & crayons, eos ever Mailing Stamp•s Wh 10” x 13”) VidCo • ite and continued from page 9 12” x 9” 0, #1 e vider (Sizpro pesthe elosee Env g ilin Ma ite Wh er in to it Pla Pap • wa py o Co wh te ) children#1 13” es x vic 10” ser al and 12” ffssupport patient visits and medic 0,”)9” Cuto rens Prexssu x 13 ”Blo od 10ecia elo and(Siz Ultimately, the greatest challenge and g Env ” pes 12 x• Ma Aut 0,ilin9” Wheite#1 sn (Siz an l contributioTele Finatic er Trainings eer • om nte unt olu on for Vol visi een ffs Scr t Cu Fla re ssu unt opportunity in medical training is finding Pre Mo od allW Blo • omatic ffs er Trainings eer nte unt olu for Vol rs on ge visi na Tele Ma ways to reduce the friction and efficiently r een Scr nte t Ce gs Fla t h inin Healt ll-Moun er Tra

breast biopsy database into her machine learning tool and added mathematical calculations, the tool could learn how to predict which biopsies would have cancer. She then retested with another sample to help determine which measurements were most important, and verified the machine learning with a third sample, which predicted the biopsy results with a 99 percent accuracy.

The computer analysis of an individual biopsy takes nanoseconds to perform.

This discovery could change cancer diagnosing timeframes to minutes instead of days, alleviating a great deal of stress for the patients with negative biopsies and getting treatment faster for those with cancer. Also, the more data the tool learns from, the more specific it can get. It also would be exciting to integrate genomic data and other data (demographics, lab results, risk factors, etc.) that could give us more information about the correlations with a cancer.

Metastatic AI is another exciting tool to add to the fight against a deadly disease.

For more visit: http://metastaticai.com.

HEALTH INNOVATORS

Urgent Needs in Emergency Medical Education

hope

eer Direct Support of Our nte unt olu ision for Vol bridge information and knowledge with Paper Towels • Kleenex and Multi-Fold demonstrable competencies. At the top of • Hand Sanitizer Eric’s wish list is having a mass notification • Disinfectant Wipes system, but the solutions he has seen thus far has been price prohibitive. Perhaps, • AA and AAA Batteries gs Orlando Health, a nationally recognized • Tall Kitchen Garbage Ba ves Glo al dic Me star for emergency trauma management x ate n-L No • s mp and Allogy, the mobile learning platform Sta g ilin Ma r • Foreve behind the Defense Health Agency’s, er Pap • White Copy 9” x 12” and 10” x 13”) Deployed Medicine app which is used to 0, #1 e (Siz pes elo Env g • Plain White Mailin improve readiness and performance of Cuffs Volunteer your time at a er Trainings • Automatic Blood Pressure eer nte unt military medical olu Vol for n sio Every $ Makes a Difference: Visitpersonnel, can find a way and double your donation.

Televi Hope Health Center. t Scr Shepherd’s Volunteer yourFla time at aeen all-Mount • W to lead a new path to emergency training.

Every $ Makes a Difference: Visit e your donation. Selected items ShepherdsHope.org/DonateNow are shipped For more information, visit Shepherd’s Hope Health Center.

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As a community that sits at high risk for mass casualty incidents from both natural and manmade threats, we as citizens and healthcare leaders have a vested interest and role in helping push responsible solutions forward. As Eric flatly stated, “The threats are real. It’s not a matter of if it happens again, it’s a matter of when. We need to be ready.”

For more information about volunteering for Orlando Health’s mock trainings, go to www.orlandohealth.com and to learn more about Allogy’s mobile learning platform, go to www.allogy.com.

a Gift!

ShepherdsHope.org/DonateNow ms are shipped ShepherdsHope.org/Volunteers Volunteer yourdirectly time to at Shepherd’s a For moreHope.

Call 407-876-6699 Ext. 230. information, visit Every $ Makes a Difference: epherd’s Hope.

Hope Health Center.

ShepherdsHope.org/Volunteers CallVisit 407-876-6699 Ext. 230. hepherd’s

For more information, visit epherdsHope.org/Volunteers

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Selected items are shipped directly to Shepherd’s Hope.

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Every $ Makes a Difference: Visit ShepherdsHope.org/DonateNow Call 407-876-6699 Ext. 230.

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DECEMBER 2017

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CPASPEAK

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Charitable Giving

By DALIA CANTOR

As the holidays approach we are accustomed to making charitable contributions and usually don’t even think twice about it. After back-to-back storms pummeled Texas, Florida and Puerto Rico, many people are giving even more in 2017 than before. It is time to reap the tax benefits of those charities. Tax rates being at the all-time high, deductions become even more valuable than ever.

You may deduct charitable contributions of money or property made to qualified organizations if you itemize your deductions. Generally, you may deduct up to 50 percent of your adjusted gross income, but 20 percent and 30 percent limitations apply in some cases.

If you are contributing gently worn coats or jackets and other clothing your kids outgrew, you can only deduct the thrift shop or fair market value, which is less than retail. Other noncash donations can work as well, like cleaning out your closets and donating old clothing, books, toys, furniture and kitchen goods. All count toward your charitable contribution, as far as Uncle Sam is concerned. In order to get the deduction come next April, keep a receipt of the donation, a note of the organization’s name, and the date and fair market value of all noncash goods.

Out-of-pocket expenses, like driving, could also qualify if you volunteer

for a charitable organization, like Meals on Wheels, or travel to a soup kitchen. In that case, you must keep a log when you are providing services for a charity or nonprofit so you can deduct charitable mileage at the federal rate of 14 cents per mile.

High-income earners often benefit from giving stocks or other assets that have grown in value and this way avoiding capital gains tax on investments. If you have stocks that have lost value, by donating them you get a full deduction of the fair market value versus $3,000 capital loss deduction limitation if you were to sell them.

You cannot deduct contributions made to specific individuals, political organizations and candidates.

Below are charitable giving tips published by the Internal Revenue Service: • To deduct a charitable contribution, you must file Form 1040 and itemize deductions on Schedule A. • If you receive a benefit because of your contribution such as merchandise, tickets to a ball game or other goods and services, then you can deduct only the amount that exceeds the fair market value of the benefit received.

• Donations of stock or other non-cash property are usually valued at the fair market value of the property. Clothing and household items must generally be in good used condition or better to be deductible. Special rules apply to vehicle donations.

• Fair market value is generally the price at which property would change hands between a willing buyer and a willing seller, neither having to buy or sell, and both having reasonable knowledge of all the relevant facts.

• Regardless of the amount, to deduct a contribution of cash, check, or other monetary gift, you must maintain a bank record, payroll deduction records or a written communication from the organization containing the name of the organization, the date of the contribution and amount of the contribution. For text message donations, a telephone bill will meet the record-keeping requirement if it shows the name of the receiving organization, the date of the contribution, and the amount given.

• To claim a deduction for contributions of cash or property equaling $250 or more you must have a bank record, payroll deduction records or a written acknowledgment from the qualified organization showing the amount of the cash and a description of any property contributed, and whether the organization provided any goods or services in exchange for the gift. One

document may satisfy both the written communication requirement for monetary gifts and the written acknowledgement requirement for all contributions of $250 or more. If your total deduction for all noncash contributions for the year is over $500, you must complete and attach IRS Form 8283, Noncash Charitable Contributions, to your return.

• Taxpayers donating an item or a group of similar items valued at more than $5,000 must also complete Section B of Form 8283, which generally requires an appraisal by a qualified appraiser.

Dalia Cantor, CPA, has been practicing as an accountant and tax advisor since 1997. She is a Certified Public Accountant in the states of Florida and New York, and graduated Dowling College with a Bachelor’s Degree in Accounting. Dalia is a member of the American Institute of Certified Public Accountants and the Florida Institute of Certified Public Accountants.

Prior to establishing her own practice, Dalia worked in public accounting managing both domestic and foreign audit and tax clients. In private industry, she was involved in the regulatory environment, specializing in technical accounting, internal controls, and SEC reporting for publicly held companies. She can be reached at Dalia@mycpasolutions.com

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RADIOLOGY INSIGHTS

sponsored by

The New Year the New You! From Radiology Specialists of Florida The New Year is the right time of the year to try to start new and do things better.

Some of the most common – to lose weight, exercise more, and quit smoking – are healthy habits that can help you lower your cancer risk and benefit you for the rest of your life.

ACCORDING TO THE AMERICAN CANCER SOCIETY

• More than 40% of American adults make New Year’s resolutions, and almost half of them keep their resolutions for at least 6 months.

WHEN IT COMES TO EXERCISE

• Be specific about your exercise goal.

For example, instead of resolving to just get more, make a plan to walk 30 minutes every Monday, Wednesday, and Friday.

• Think you don’t have time to add any physical activity to your day? Try simple substitutions, such as using

stairs rather than an elevator, walking to visit co-workers instead of sending an email, and using a stationary bicycle or treadmill while watching TV. Studies show that getting even just 15 more minutes of exercise a day can help you live longer.

EAT BETTER

• Eat a little less by avoiding oversized portions. For example, the amount of meat recommended as part of a healthy meal is about 3 ounces, or the size of a deck of cards.

• Eat a little healthier by adding more vegetables, fruits, and fiber to your meals and leaving out some of the sugar, fat, and calories.

QUIT SMOKING

• Quitting smoking is the most important action you can take to reduce your cancer risk. Half of all smokers who keep smoking will end

up eventually dying from a smokingrelated illness. Additional important ways to lower your risk include getting to and maintaining a healthy weight, being physically active, and eating a healthy diet rich in fruits, vegetables, and whole grains. The evidence for this is strong: Each year, more than 589,000 Americans die of cancer; about one-third of these deaths are linked to poor diet, physical inactivity, and carrying too much weight.

Radiology directly impacts the care of a cancer patient. Cancer patients undergo a variety of different scans throughout the course of their treatment, including MRIs,

CT and PET scans, and x-rays. A radiologist will review these scans and inform oncologists if the current treatment is either helping or not beneficial to the patient.

If the current treatment is not effective, a radiologist, along with an oncologist, will recommend a different course of treatment.

Radiology Specialists of Florida at Florida Hospital are very well trained and experienced. We keep up to date on the latest technology and information so that we can offer patients the best care.

The Florida Hospital Care Network delivers seamlessly connected healthcare services for all ages. Quality Imaging and Diagnostic starts today.

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Accelerated Trauma Program for Treating Substance Use Disorder

By GREGG ARMSTRONG, LMHC, CAP

One of Coalition Recovery’s new treatment programs focuses on a trauma and cognitive based approach as the center of addiction recovery. It is best to understand substance abuse and addiction as a “mode of being.” The behavior of addiction stems from an underlying psychological condition that manifests as symptom relief for emotions or feelings that are disruptive to life. Depression and anxiety to name a couple. The psychological conditions that are driving the emotional base must have a point of origin, or root cause.

It begins in childhood. Adverse childhood experiences or childhood trauma. Trauma has ramifications on cognitive, emotional, and physical development that can persist into adulthood. Stress from a past trauma can be constant throughout an extended period of time. Science shows the longer stress exists from trauma, the more damage progresses in the brain in the parts that affect most processes of the person and their ability to make healthy decisions - consequently leading to harmful behaviors such as substance abuse and addiction. This approach to treating substance abuse is locating the origin of these stressors, coming to terms with this reasoning, and establishing a new way of thinking.

This is taking Cognitive Behavioral Theory as well as Dialectical Behavioral Theory and diving deeper into understanding the reasons behind dysfunctional behavior and emotions - something that has never been the clinical centerpiece in the substance abuse treatment industry.

C-PTSD AND CHILDHOOD TRAUMA

Post-Traumatic Stress Disorder (PTSD), is associated with seemingly di-

symptoms, such as hopelessness, despair, and depression, reside in the other side of high arousal symptoms. These symptoms typically result from living in a threatening environment with no escape. When you have no ability to change your situation, you may be left feeling ineffective, powerless, and helpless. Shame and unworthiness are signatures of depressive symptoms of C-PTSD.

TREATMENT A COGNITIVE BASED APPROACH TO TRAUMA

SYMPTOMS OF C-PTSD

• Avoidant symptoms: It is common to develop avoidance strategies to get away from memories or present manifestations of childhood trauma.

This involves avoiding people and the places that serve as reminders of the past. Avoidance can take the form of denying that past, repressing feelings, idealizing parents, minimizing pain or dissociating.

• Intrusive Symptoms: High arousal symptoms, characterized by feelings such as anxiety, aggression, and irritability, are often experienced by those individuals with C-PTSD. These often manifest in what is known as emotional dysregulation, or sweeping emotions of sadness, rage or fear. These can feel intrusive and hijack the relationship with yourself, your family, and your world and can result in feeling stuck in patterns of disconnection, resentment or abandonment with family and friends.

• Depressive Symptoms: Low arousal

DO NOT MISS this opportunity to hear, meet and ask questions with the subject matter expert

JAN

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sastrous events such as natural disasters, terrorist attacks, car accidents and any other occurrence that may flood someone with powerful emotions such as fear or sadness. These symptoms may be present well after the incident. However, there is another type of post-traumatic stress called Complex Post Traumatic Stress Disorder (C-PTSD) which occurs as a result of long-term exposure to traumatic stress, rather than a response to a single event. C-PTSD typically arises as a result of ongoing stress referred to as developmental trauma disorder (DTD).

Childhood Trauma is a common form of C-PTSD. Childhood Trauma can range from having faced or witnessed extreme violence, the loss of a parental figure in the family, being unwanted, abuse whether it be physical, emotional, sexual, or psychological, or growing up with substance abuse in the family. Both men and women who were victimized as children report more stressful events over their lifetimes suggesting that early child abuse and neglect is part of a broader constellation of life stressors. In the Adverse Childhood Experience Study (ACE) comparing the relationships of indicators of childhood abuse and neglect to changes in the symptoms of mental disorders over the period from early adolescence to adulthood, youths with an official record of victimization of child physical abuse showed elevated levels of disorders and symptom rates for almost every clinical disorder. The disorders carry forward through childhood into adolescence, and become the core emotional base for adulthood. Unresolved childhood trauma, as an adult, has significant consequences on mental and emotional health.

Physical health may also be impacted by illness or chronic pain.

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Treating the whole person, mind/ body/spirit will result in the best possible outcome for a healthy, long term recovery from addiction. This treatment philosophy has an accelerated trauma focus with a cognitive based approach. It is effective to develop a story-line of the individual in an effort to the find the root cause of their destructive patterns of behavior such as addiction and substance abuse. These root causes are the effect of trauma. Trauma can range from PTSD to C-PTSD such as childhood trauma. Using a Cognitive Behavioral Therapy technique (focusing on solutions, encouraging patients to challenge distorted cognitions and change their destructive patterns of behavior) is not enough because it focuses solely on how to handle these distorted and destructive patterns, but does not give reasoning to why these thought patterns exist. Trauma Focused, Cognitive Based Approach is formulated with the use of cognitive interventions, such as Cognitive Behavioral Therapy, Dialectical Therapy, Motivational Work, Interpersonal Interventions, Neurological Theory among other interventions. Educating the patient as to the root cause of their current clinical issues aids their understanding of “Why” and accelerates the healing process.

Accelerated Trauma programs are effective within the traditional 90-day period to establish a foreground for treatment and start changing cognitive behavior, while also treating these dysfunctional emotions and behaviors. Additional clinical hours and on-going care, built on the basis of programs such as these, will only improve outcome statistics. Aftercare programs that offer substantive ongoing resources such as connecting patients to ongoing clinical care with their local clinicians are essential. With aftercare resources like these in place, patients are able to continue trauma-specific clinical care far beyond traditional treatment.

Gregg Armstrong is an expert in trauma-focused care in accelerated settings and his work in the field spans over 16 years. He is a published author for his research, work, and studies examining instances of childhood trauma/c-ptsd and its correlation to substance abuse disorders and other maladaptive behaviors in adults. He currently serves as the Clinical Director for Coalition Recovery.

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The AutoNation Cure Bowl is more than a game.

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Billing Under Another’s Provider Number Can Cause Trouble

By EMMA CECIL, JD

An Oklahoma physician recently agreed to pay the government $580,000 to resolve allegations that he violated the False Claims Act by submitting claims to the Medicare program for services he did not provide or supervise. According to the government, the physician allowed a company that employed him and in which he had an ownership interest to use his NPI numbers to bill Medicare for physical therapy services that he did not provide or supervise. The government further alleged that after he left the company and deactivated his NPIs associated with the company, he reactivated those NPIs so that the company could use them to bill Medicare for services he neither performed nor supervised.

This case is another example of the risk involved in billing services provided to federal health program beneficiaries under another provider’s name and national provider identification (NPI) number. In 2011, the University of North Texas Health Science Center agreed to pay $859,500 for allegedly violating the Civil Monetary Penalties Law (CMPL) by submitting claims for physicians’ services provided to Medicare and Medicaid

beneficiaries using the NPI numbers of 103 physicians who neither provided nor supervised the services rendered. Other examples include a family practice physician who paid $133,880.50 under the CMPL for submitting claims to Medicare for nurse practitioner services as if he had personally performed the services; and a hospital that paid $706,090.46 for violating the CMPL by submitting claims for physicians’ services provided by a doctor to Medicare beneficiaries using the provider identification numbers of another doctor, who did not further the services.

Although these cases involve relatively small penalties under the CMPL, the Oklahoma physician’s settlement makes clear that more significant False Claims Act liability is a real risk for providers who bill under the incorrect provider identification number. As a reminder, services provided to Medicare beneficiaries should always be billed under the name and NPI of the provider who actually performed the services, and billing under one physician’s NPI for services that are in fact provided by another physician or non-physician provider may be viewed as fraudulent since there is little doubt that the identity of the person performing the service would be material to the government’s decision to pay the claim.

The most common exception to this general rule is when services provided by non-physician practitioners to Medicare beneficiaries are billed “incident-to” a

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physician’s services. While CMS has acknowledged in informal guidance that a physician’s services may be billed incident to another physician’s services so long as all of the incident-to requirements, including direct supervision, are satisfied, this practice is not favored and should be used sparingly. CMS has observed that billing a physician incident to another physician is warranted only in rare circumstances.

Importantly, the incident-to rules are a Medicare invention and may not apply outside the context of Medicare billing.

Many commercial plans prohibit the practice of billing the services of one provider under the name and NPI of another provider and explicitly require that all services be billed under the name of the rendering provider. Providers billing private payors must therefore review their provider contracts to determine whether billing the services of one provider under the name and NPI of another provider is allowed – and if so, under what circumstances – or whether it’s forbidden. If prohibited, billing under another provider’s name and NPI could result in criminal liability under the federal health care fraud statute, which makes it a crime to knowingly execute, or attempt to execute, a scheme or artifice to obtain, by means of false or fraudulent pretenses, representations, or promises, money or property owned by any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services.

Practices under pressure to pay noncredentialed physicians should think long and hard about billing the non-credentialed physician’s services under a credentialed physician’s NPI. Doing so without strictly complying with all of CMS’s stringent incident-to requirements, or in violation of private payor contracts, can spell big trouble, including penalties under the CMPL, treble damages under False Claims Act liability, and even criminal liability under the federal health care fraud statute.

Emma Cecil is MagMutual’s new Senior Regulatory Attorney and Policyholder Advisor. Prior to joining MagMutual, Emma spent 10 years in private practice defending individual and corporate clients faced with healthcare regulatory investigations and litigation.

Her defense work focused on alleged violations of the False Claims Act, AntiKickback Statute, Stark law, and other state and federal civil and criminal laws. Emma also defended physicians in peer review and credentialing disputes, as well as licensing board and other regulatory agency investigations.

Emma is an invaluable resource for MagMutual Policy Owners for all regulatory matters they face in healthcare today, including billing compliance, CMS investigations and RAC audits, HIPAA, HITECH, Stark law, Anti-Kickback Law, and the False Claims Act. If you have questions about Medicare incident-to billing requirements or billing for non-credentialed providers, please call MagMutual’s Senior Regulatory Attorney, Emma Cecil, at (404) 842-4670.

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GrandRounds Edyth Bush Charitable Foundation’s $100,000 Gift Honors President Hitt In the first announced gift honoring UCF President John C. Hitt, who is stepping down in June 2018, the Edyth Bush Charitable Foundation has donated $100,000 to support Grand Rounds at the College of Medicine. Grand Rounds are a ritual of medical education, where physicians and students gather to discuss unusual cases and treatments.

The Dr. John C. and Martha Hitt Grand Rounds Endowment will support Grand Rounds at the medical school and other community locations until the new UCF Lake Nona Medical Center opens in 2020.

With the gift, Edyth Bush has now donated $1 million to UCF. Foundation President David A. Odahowski said a Grand Rounds gift is an appropriate way to honor Dr. Hitt, UCF’s president for nearly 26 years, and the College of Medicine, which the president has called one of his biggest accomplishments. “I can think of no other leader who has made more of a difference in our community over such a length of time as John Hitt supported by his wife Martha,” Odahowski said.

“Grand Rounds are an opportunity to share knowledge and are part of the tradition of a medical school and a teaching hospital.

We thought this was a fitting gift to recognize all that the President and Mrs. Hitt have done.”

The foundation has been a generous supporter of UCF and its medical school.

Founded in 1973, the Edyth Bush Charitable Foundation provided its first grant to the university the following year, awarding $60,000 for the construction and equipping of a child care center on UCF’s main campus. In 2007, the foundation donated $160,000 to fund a full four-year scholarship to cover tuition and living expenses for a student in the medical school’s charter class. This gift was made in memory of Dr. Russell W. Ramsey, who was the personal physician to Mrs. Edyth Bush. Thanks to donations like Edyth Bush’s, the UCF was the first medical school in U.S. history to offer full scholarships to an entire class.

Edyth Bush has also donated funds to help M.D. students conduct and present original research. UCF’s College of Medicine is one of the few schools nationally that requires all students to complete a two-year research project on a topic about which they are passionate.

Dr. Deborah German, UCF vice president for medical affairs and founding dean of the College of Medicine, said she was thrilled with the gift.

“Grand rounds are a centerpiece learning experience for medical students, residents, faculty and all healthcare providers,” she said. “To have our first endowed grand rounds named for Dr. and Mrs. Hitt and generously given by the Edyth Bush Charitable Foundation is a dean’s delight.”

In its history, the foundation has awarded more than 3,833 grants to 872 organizations, primarily in Central Florida, totaling more than $110 million. Its most recent contributions have centered on Medical City, which Odahowski said is creating “a new

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era of diversity of Central Florida’s economy.” He said he hoped the Grand Rounds gift will encourage other foundations and groups to contribute to UCF’s current Ignite campaign.

“President Hitt made UCF the Partnership University®,” Odahowski said. “Philanthropy is a partnership between those who have the resources and those who have the ideas and needs.”

For more information on the Edyth Bush Charitable Foundation, please visit www.edythbush.org.

AMA Highlights Harmful Effects of Screen Time in Youth, Urges Better Balance Between Screen Time, Physical Activity Young people are increasingly using digital devices for both educational and recreational purposes. This increased use of devices such as tablets and phones is being associated with an uptick in harmful effects, including obesity, sleep problems, depression and anxiety.

“Mobile phones and tablets undoubtedly have educational and recreational benefits, but it is critical, particularly for young people, that screen time be balanced with physical activity and sleep,” said AMA Board Member Jesse M. Ehrenfeld, M.D., MPH. “Physicians can play an important role in educating patients and parents about this balancing act, at home and in schools. To improve the health and wellbeing of young people, all of us must do more to address the harmful effects of screen time.”

In addition to highlighting the harms of too much screen time, the AMA encouraged primary and secondary schools to incorporate into health class curricula the topic of balancing screen time with physical activity and sleep. Additionally, the AMA encouraged primary care physicians to assess pediatric patients and educate parents about the amount of screen time, physical activity and sleep habits.

New Policy Furthers AMA’s Efforts to Create Medical School of the Future The American Medical Association (AMA) adopted policy during its Interim Meeting this week that builds on its efforts over the past four years to help prepare future physicians to care for patients in modern health systems. The new policy calls for medical students, residents and physicians to receive training in both lifestyle medicine and social determinants of health in undergraduate, graduate and continuing medical education.

To help reduce disparities in patient care, the policy will also help medical students and residents receive training regarding implicit bias, diversity and inclusion.

Under the new policy, the AMA will work to identify and publicize effective strategies for educating residents in all specialties about disparities in their fields related to race, ethnicity, and all populations at increased risk, particularly regarding access to care and health outcomes. Additionally, the AMA will support research to identify the most effective strategies for educating physicians on

Toddler diagnosed with leukemia receives life-saving bone-marrow transplant from baby brother In September 2016, the Gibbens family — a newly pregnant Jessica, John and their 1-year-old son Grant — all became sick with a cold.

While the parents’ health improved within a week, Grant’s became worse. His lymph nodes became inflamed, and his right eye swelled shut.

Doctors wanted Grant to be evaluated for cancer. The family traveled from their Palm Bay home to Florida Hospital for Children, where physicians confirmed their young son had leukemia.

Grant was treated and returned home on Christmas Eve 2016. But it wasn’t long after that Grant’s leukemia relapsed, and doctors said he needed a bone-marrow transplant.

Doctors told the Gibbenses the cord blood from their unborn baby could be a life-saving option for their eldest son — if

it was a match. The odds: one in four.

On May 16, Jessica gave birth to her second son, Wyatt. His cord blood was tested, and was a match.

“We weren’t sure if it was going to take a while for him to be interested in a little kid, but Grant is the best big brother ever,” said Gibbens. “He has no idea what he’s done for him and for our family.”

Grant underwent a bone-marrow transplant July 17. Today, he’s cancer free.

“Only about a third of kids will have a match within the family,” said Dr. David Shook, medical director of the Pediatric Bone Marrow Transplant at Florida Hospital for Children. “We have a fair number of children who don’t have matches, so it’s unusual for it to work out this well where the donor is kind of made to order.”

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GrandRounds how to eliminate disparities in health outcomes in all at-risk populations.

“The AMA is committed to eliminating health disparities in our nation in order to achieve health equity. One critical component of our efforts is transforming medical education so that it keeps pace with our nation’s changing health care system,” said AMA Board Member and medical student Karthik V. Sarma, M.S. “By ensuring students and residents have proper training to address disparities in care from the outset of their careers, we can empower them to be the change agents that we need to achieve our mission to improve the health of the nation.”

Several medical schools that are part of the AMA’s Accelerating Change in Medical Education Consortium have been working on curricular innovations to address health care disparities, including University of California, Davis School of Medicine, A.T. Still University-School of Osteopathic Medicine in Arizona, Florida International University Herbert Wertheim College of Medicine, and Morehouse School of Medicine in Georgia.

New policy will also help medical students and residents understand the impact that sex and gender have on patient care.

Specifically, the policy calls for the AMA to collaborate with other organizations to disseminate the work produced by medical schools participating in the Accelerating Change in Medical Education consortium and distribute pertinent information and a comprehensive bibliography about the influence that sex and gender have upon clinical medicine. This would include literature showing that some clinical trials may have skewed representation of specific gender and sexual traits making it difficult to generalize their results.

The AMA launched its Accelerating Change in Medical Education initiative in 2013, providing $11 million in grants to fund major innovations at 11 of the nation’s medical schools. Together, these schools formed a Consortium that shares best practices

Poinciana Medical Center Nurse Esther Sanchez Colon – an Emergency Room nurse who has been with the hospital since 2014 – was recently presented with the DAISY Award® for Extraordinary Nurses. The award is given to nurses for providing exceptional patient care. Pictured (left to right): Chris Cosby, Chief Executive Officer; Sharon Dillard, Chief Nursing Officer; Esther Sanchez Colon, Emergency Room Charge Registered Nurse/Clinical Coordinator and DAISY Award® Winner; Kevin Saunders, Director-Emergency Services; Tom Eisel, Chief Financial Officer. with a goal of widely disseminating the new and innovative curricula being developed among all allopathic and osteopathic medical schools. The AMA expanded its Consortium in 2015 with grants to an additional 21 schools to develop new curricula that better align undergraduate medical education with the modern health care system.

Poinciana Medical Center Recognized by Joint Commission for Excellence in Three Areas Poinciana Medical Center was recently recognized by The Joint Commission for excellence in the areas of stroke, sepsis management and quality of care.

The Joint Commission has recognized the center as a 2017 Pioneers in Quality™ Data Contributor for its contributions to electronic clinical quality measure (eCQM) data for quality improvement in health care.

Until recently, most hospitals collected information to measure health care quality by manually abstracting data from patient records. Today, through eCQMs--which rely on structured, encoded data present in the

electronic health record--hospitals can electronically collect and transmit data on the quality of care that patients receive. The electronic data can be analyzed to measure and improve care processes, performance and outcomes.

In addition the center has announced that it has earned The Joint Commission's Gold Seal of Approval® for Sepsis Management Certification. The Gold Seal of Approval® is a symbol of quality that reflects an organization's commitment to providing safe and effective patient care.

Poinciana Medical Center underwent a rigorous on-site review in August 2017.

Joint Commission experts evaluated compliance with national disease-specific care standards as well as with sepsis management-specific requirements. Clinical practice guidelines and performance measures also were assessed.

Finally, Poinciana Medical Center announced that it has earned The Joint Commission's Gold Seal of Approval® and the American Heart Association/American Stroke Association's Heart-Check mark for

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Advanced Certification for Primary Stroke Centers. The Gold Seal of Approval® and the Heart-Check mark represent symbols of quality from their respective organizations.

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AMA Adopts New Policy to Increase Organ Donation Nationwide With the need for donated organs far exceeding the number available for transplantation in the U.S., the American Medical Association (AMA) adopted policy during its Interim Meeting this week aimed at increasing organ donation rates—particularly among minority populations with historically low donation rates.

While reports show that the vast majority of U.S. adults support organ donation, only about half are actually registered as organ donors and only three in 1,000 of those registered actually become donors after death. Given the significant need to increase the number of organs available for donation, the AMA’s new policy calls for the development of public education programs that are tailored to address the factors that most influence people’s attitudes toward organ donation in order to improve their willingness to donate.

“Although the numbers of organ donors and transplants has been growing slowly over the last two decades, there aren’t nearly enough donated organs to satisfy the number of people in need of transplants. We know this is due in large part to the factors that influence a person’s decision on whether to designate themselves as a donor—ranging from religious and cultural beliefs to family influence, beliefs about body integrity after death, and limited knowledge about organ donation,” said AMA Board Member Albert J. Osbahr III, M.D. “We will continue to support the implementation of programs aimed at improving the public’s willingness to donate and help identify other approaches to encourage more people to become organ donors.”

To help ensure sufficient organ donation nationwide, the AMA’s new policy also calls for educational programs targeted to populations with historically low organ donation rates. Of the nearly 120,000 people who are on the national transplant waiting list, the proportion of racial and ethnic minority patients is higher than the corresponding proportion of racial and ethnic minorities who are donors. In fact, African Americans make up nearly 30 percent of the waiting list and Hispanics make up approximately 20 percent, yet only about 16 percent of donors are African American and only 14 percent of donors are Hispanic.

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GrandRounds Innovaccer Announces the Launch of Datashop Beacon

Innovaccer Announces the Launch of Datashop Beacon - a product offering over 10 million data points for care research

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Innovaccer, Silicon Valley's fastest growing healthcare platform company, today announced the launch of Datashop Beacon— a new product that offers extensively researched, benchmarked and structured datasets for healthcare organizations and researchers to gather actionable insights on healthcare trends.

The datasets within Datashop Beacon were built keeping in mind the importance of having holistic care data, especially, in the era of healthcare information technology. But assimilating comprehensive care research data with socio-economic and demographics data included has been a major challenge for care teams. Datashop Beacon brings hassle-free access to diverse datasets to the consoles of healthcare experts.

• Datashop Beacon has a repository of more than 10 million data points.

• HEDIS benchmarks with utilization & quality benchmarks in one place for ACOs, hospitals, and other healthcare organizations.

• Access to various healthcare datasets like expenditure, demographics, Medicare, savings, and a lot more offered to support research needs.

• In totality, the tool has 16+ datasets including subcategories.

• The datasets within Datashop Beacon are divided into different levels such as county level, state level, and national level.

• Furthermore, these datasets have been subcategorized organization and yearwise to analyze trends.

The range of datasets will be extended in due course as Datashop Beacon will add in more specific data sets around hospital, health plans, Medicare, CHIP and benchmarks. Designed for favorable use by Payer Contractors, Managed Lines Directors, Researchers, Operational Leaders and ACOs, Datashop Beacon affords them time, money and base line numbers to gauge themselves on.

The availability of actual records and actual data would ensure easier negotiations between care organizations and payers as it will assist in making better judgments based on benchmark data and state and national averages. Besides, performance and benchmark data will help in keeping a tab on each other’s progress and enable healthy competition among them.

“We identified the need for Datashop Beacon while we were working with care teams spending a lot of time and money on obtaining datasets for care research” says Kanav Hasija, CTO & Co-founder at Innovaccer. “Through Datashop Beacon, the healthcare community can choose from data that has been collated, aggregated, and standardized to minimize effort and time-consumption. The datasets are presented in a way that they are ready to be visualized, analyzed and implemented for the benefit of users.”

FDA announces approval, CMS proposes coverage of first breakthrough-designated test to detect extensive number of cancer biomarkers The U.S. Food and Drug Administration approved the FoundationOne CDx (F1CDx), the first breakthrough-designated, next generation sequencing (NGS)-based in vitro diagnostic (IVD) test that can detect genetic mutations in 324 genes and two genomic signatures in any solid tumor type. The Centers for Medicare & Medicaid Services (CMS) at the same time proposed coverage of the F1CDx. The test is the second IVD to be approved and covered after overlapping review by the FDA and CMS under the Parallel Review Program, which facilitates earlier access to innovative medical technologies for Medicare beneficiaries.

“By leveraging two policy efforts aimed at expediting access to promising new technologies, we’ve been able to bring patients faster access to a breakthrough diagnostic that can help doctors tailor cancer treatments to improve medical outcomes and potentially reduce health care costs,” said FDA Commissioner Scott Gottlieb, M.D. “The FDA’s Breakthrough Device Program and Parallel Review with CMS allowed the sponsor to win approval for this novel diagnostic and secure an immediate proposed Medicare coverage determination within six months of the FDA receiving the product application.”

Compared to other companion diagnostics previously approved by the FDA that match one test to one drug, the F1CDx is a more extensive test that provides information on a number of different genetic mutations that may help in the clinical management of patients with cancer. Additionally, based on individual test results, the new diagnostic can identify which patients with any of five tumor types may benefit from 15 different FDA-approved targeted treatment options. Its results provide patients and health care professionals access to all of this information in one test report, avoiding duplicative biopsies. “The F1CDx can help cancer patients and their health care professionals make more informed care decisions without the often invasive process of extracting tumor samples multiple times to determine eligibility for a single treatment or enrollment in a clinical trial,” said Jeffrey Shuren, M.D., director of the FDA’s Center for Devices and Radiological Health (CDRH). “With the run of one test, patients and health care professionals can now evaluate several appropriate disease management options.” Today, CMS also issued a proposed national coverage determination of the F1CDx and other similar NGS IVDs for Medicare beneficiaries with advanced cancer (i.e., recurrent, metastatic or advanced stage IV cancer), who have not been previously tested using the same NGS technology and continue to seek further cancer therapy. The proposed national coverage determination provides coverage of NGS IVD tests to assist patients and their treating physicians in making informed cancer treatment decisions that improve health outcomes. Use of a test as a diagnostic also (CONTINUED ON PAGE 20)

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GrandRounds includes the ability to help patients and their treating physicians determine candidacy for cancer clinical trials.

“Through parallel review and collaboration, we speed access to innovative diagnostics, so that doctors are better able to deliver the best quality care to their patients and patients have access to these state-ofthe-art tests,” said Seema Verma, Administrator of CMS. “Our proposal establishes clear expectations, while at the same time delivering better outcomes for the people we serve.”

This determination was made under the FDA-CMS Parallel Review Program, where the agencies concurrently review medical devices to help reduce the time between the FDA’s approval of a device and Medicare coverage. This voluntary program is open to certain premarket approval applications for devices with new technologies and to medical devices that fall within the scope of a Part A or Part B Medicare-benefit category and have not been subject to a national coverage determination.

The F1CDx detects gene mutations that may be found in any solid tumor and this information can be used by physicians according to professional guidelines to manage cancer patients. Moreover, it can be used as a companion diagnostic to identify patients with specific mutations who may benefit from certain FDA-approved treatments for non-small cell lung cancer, melanoma, breast cancer, colorectal cancer or ovarian cancer. Importantly, the F1CDx can detect genetic mutations that are indicated for multiple FDA-approved treatments, which extends beyond the previous “one test for one drug” model.

The device works by sequencing DNA from a patient’s tumor sample to determine the presence of gene mutations and alterations. It also detects certain molecular changes (microsatellite instability and tumor mutation burden). Clinical performance of the test was established through a least burdensome means by comparing the

F1CDx to previously FDA-approved companion diagnostic tests that are currently used to determine patient eligibility for certain treatments. Results indicated that the test’s ability to detect select mutation types (substitutions and short insertions and deletions) representative of the entire 324 gene panel is accurate approximately 94.6 percent of the time.

Fountain Pharmacy Expands Services Fountain Pharmacy, a local, independently owned service located in Oviedo Plaza on W. Broadway announces its services are fully operational. Timi Alalade, PharmD, frustrated with a lack of customer interaction at large pharmacies has created a different kind of pharmacy experience focused on customer care with the following benefits: • Greater expertise and more personal attention • Shorter wait time filling prescriptions • Consistent access to needed medications • Accepts e-scripts from physicians • Free delivery and curbside pick up • Auto-refill prescription program • Medication therapy management by managing drug therapy and resolving medication problems • Medication synchronization Visit www.stores.healthmart.com/fountainpharmacy

CMS Office of the Actuary Releases 2016 National Health Expenditures In 2016, overall national health spending increased 4.3 percent following 5.8 percent growth in 2015, according to a study by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS) published today as a Web First

by Health Affairs. Following Affordable Care Act (ACA) coverage expansion and significant retail prescription drug spending growth in 2014 and 2015, health care

spending growth decelerated in 2016. The report concludes that the 2016 expenditure slowdown was broadly based as growth for all major payers (private health insurance, Medicare, and Medicaid) and goods and service categories (hospitals, physician and clinical services, and retail prescription drugs) slowed in 2016.

During 2014 and 2015, the health spending share of the economy increased 0.5 percentage point from 17.2 percent in 2013 to 17.7 percent in 2015. The increases in the health spending share of the economy in 2014 and 2015 were largely due to coverage expansion that contributed to 8.7 million individuals gaining private health insurance coverage and 10.2 million gaining Medicaid coverage over the period and to significant growth in retail prescription drug spending. Health care spending grew 1.5 percentage points faster than the overall economy in 2016, resulting in a 0.2 percentage-point increase in the health spending share of the economy – from 17.7 percent in 2015 to 17.9 percent in 2016.

Additional highlights from the report: Private health insurance spending increased 5.1 percent to $1.1 trillion in 2016, which was slower than the 6.9 percent growth in 2015. The deceleration was largely driven by slower enrollment growth in 2016 after two years of faster enrollment growth due to ACA coverage expansion.

Medicare spending grew 3.6 percent to $672.1 billion in 2016, which was slower growth than the previous two years when spending grew 4.8 percent in 2015 and 4.9 percent in 2014. The slower growth in 2016 was due to slower growth in spending for both Medicare fee-for-service (2.2 percent in 2015 compared to 1.8 percent in 2016) and Medicare Advantage (11.1 percent in 2015 compared to 7.4 percent in 2016).

Medicaid spending growth slowed in 2016, increasing 3.9 percent to $565.5 billion. State and local Medicaid expenditures grew 3.2 percent in 2016, while federal (CONTINUED ON PAGE 21)

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GrandRounds Medicaid expenditures increased 4.4 percent in 2016. The slower overall growth in Medicaid spending was much lower than in the previous two years, when Medicaid spending grew 11.5 percent in 2014 and 9.5 percent in 2015. The higher growth in 2014 and 2015 was due in part to the initial impacts of the ACA’s expansion of Medicaid enrollment during that period.

Out-of-pocket spending includes direct consumer payments such as copayments, deductibles, and spending not covered by insurance. Out-of-pocket spending grew 3.9 percent to $352.5 billion in 2016, faster than the 2.8 percent growth in 2015. Additionally, 2016 was the fastest rate of growth

since 2007 and was higher than the average annual growth of 2.0 percent during 200815. The faster growth in 2016 was due in part to a continued shift towards enrollment in high-deductible health plans, which was somewhat offset by a continued decrease in the number of uninsured in 2016.

Retail prescription drug spending slowed in 2016, increasing 1.3 percent to $328.6 billion. The slower growth in 2016 follows two years of significant growth in 2014 and 2015, 12.4 percent and 8.9 percent, respectively.

This significant growth in 2014 and 2015 was largely attributable to increased spending on new medicines and price growth for existing brand-name drugs, particularly for drugs used

to treat hepatitis C. Growth slowed in 2016 primarily due to fewer new drug approvals, slower growth in brand-name drug spending as spending for hepatitis C drugs declined, and a decline in spending for generic drugs as price growth slowed.

In 2016, the federal government and households accounted for the largest shares of spending (28 percent each) followed by private businesses (20 percent), state and local governments (17 percent), and other private revenue (7 percent). After two consecutive years of rapid growth (10.9 percent in 2014 and 8.9 percent in 2015), federal government spending for health

care slowed, increasing 3.9 percent in 2016.

The primary reason for the deceleration in federal spending growth in 2016 was federal Medicaid spending, which grew more slowly in 2016 as a result of less Medicaid enrollment growth.

The CMS Office of the Actuary’s report will appear on the CMS website at: https:// www.cms.gov/Research-Statistics-Dataand-Systems/Statistics-Trends-and-Reports/ NationalHealthExpendData/NationalHealthAccountsHistorical.html.

Osceola Regional Medical Center Brings Stroke Treatment Advancements With New Comprehensive Stroke Center

Cornerstone Hospice Breaks Ground on new unit at Orlando Health – Health Central Hospital in Ocoee

Osceola Regional Medical Center now offers a higher level of care for complex stroke cases and becomes the first and only Comprehensive Stroke Center in Osceola County. The addition of the AHCA Certified Comprehensive Stroke Center to its Joint Commission Certified Advanced Primary Stroke Center is part of a $50 million expansion plan announced earlier this year.

By achieving Comprehensive Stroke Center status, Osceola Regional is now providing more advanced stroke treatments than primary stroke centers located in Osceola and surrounding counties.

Scientific evidence shows that when a stroke, or also called brain attack occurs, immediate assessment and treatment will reduce the effects of stroke and lessen the chances of a permanent disability.

With the opening of the new Comprehensive Stroke Center, patients suffering from all types of strokes to include severe stroke cases such as large brain clots and hemorrhages, can now receive immediate care closer to home.

With 24/7 access to minimally invasive stroke procedures, on-site neurosurgeons, and dedicated Neuroscience Intensive Care Unit, the hospital’s new Comprehensive Stroke Center is staffed with a specially trained team of neurointerventionalists, neurologists, neurosurgeons and healthcare professionals with 24/7 coverage. Dr. Ankur Garg, Neurointerventionalist and Medical Director leads the program and advanced technologies such as Biplane Angiography which produces three-dimensional views of the brain to help diagnose and treat

A community-wide recognition of the need for critical patients facing lifelimiting illness to receive loving care in a comfortable home-like environment is a step closer to fulfillment.

Today, Cornerstone Hospice and Palliative Care leaders celebrated the groundbreaking of the Cornerstone Hospice Care Center at the new 110-bed Orlando Health Center for Rehabilitation. They were joined by representatives from Orlando Health-Health Central, the West Orange Healthcare District, the West Orange Health Alliance and members of the community.

Norma Sutton, chair of the West Orange Healthcare District, presented a check for $1.25 million as a generous lead capital campaign donation for the Cornerstone Hospice unit which will include ten private rooms and a family lounge. Each room will have a pullout bed, refrigerator and showers so family members can be with loved ones as much as possible.

Additionally, Mike Yoakum, who is the chair of the West Orange Health Alliance, announced a $440,000 donation to the project.

“The Cornerstone Hospice Care Center at Orlando Health-Health Central will help fill a gap in health care services available in West Orange County. Patients and their families will receive inpatient care in a homelike place, not an intensive care unit, when symptoms become too difficult to manage at home,” said Chuck Lee, President and CEO of Cornerstone Hospice. “We are grateful for the partnership of Orlando Health which designated space for the unit and for the generosity

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complex strokes.

“My goal is provide outstanding care to stroke and brain hemorrhage patients while bringing world-class treatment to Osceola and surrounding communities”, said Dr. Garg. Osceola Regional Medical Center’s CEO, Davide Carbone mentioned how the hospital’s multiple expansions and additions have extended the hospital’s commitment to providing advanced healthcare services to our community. “As a hospital with Comprehensive Stroke Care, we can seamlessly provide treatment to patients whose conditions require a higher level of stroke treatment expertise. We’re proud to be able to offer this service to our community.”

According the American Heart and Stroke Association, stroke is the No. 5 cause of death in the nation, accounting for approximately 795,000 strokes each year and is the leading cause of serious long-term disability. On average, someone has a stroke every 40 seconds in the US and every 4 minutes, someone dies of a stroke. Locally, Osceola Regional continues to see sicker patients in our community and reported they treated nearly 645 stroke patients since the beginning of this year.

In an effort to educate the community, the hospital urges the community to act fast to know the signs of stroke and to call 911 immediately. For more information on the risk factors, prevention and signs of stroke, visit OsceolaRegional. com/stroke.

of the West Orange Healthcare District and West Orange Health Alliance to kickstart the capital campaign.”

In November 2015, the 22-bed Cornerstone Hospice Unit opened at Orlando Health’s Orlando Regional Medical Center. More than 2,200 patients and their families have received loving care and end-of-life support at the downtown Orlando unit.

“Orlando Health is proud to expand our partnership with Cornerstone Hospice by providing the West Orange County community with this important facet of care,” said Mark Marsh, President, Orlando Health – Health Central.

“The West Orange Healthcare District is dedicated to ensuring that the residents have access to medical care and wellness services right in our community,” said Sutton. “The District is pleased to make an investment in the Cornerstone Hospice Care Center which will help fill a gap for families who want to provide comfort and dignity for their loved ones facing end of life.”

“Aside from meeting a critical need, having this resource in our community will help raise awareness about hospice care and the peace of mind it provides to patients and families facing life-limiting illness,” said Lynn Walker Wright who is a member of the West Orange Health Alliance and chairs the project’s $3.6 million campaign.

The 95,000 sq. Orlando Health Center for Rehabilitation and Cornerstone Hospice Care Center are scheduled for completion in 2019.

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GrandRounds More than 850 employees volunteer throughout Central Florida at annual “Day of Caring” Hundreds of Florida Hospital employees stepped out of the hospital and volunteered at nearly 20 nonprofits throughout metro Orlando to mark the organization’s annual “Day of Caring.”

From stocking shelves at food pantries to landscaping, employees — known as “Care Givers” — shared their time, talents and treasures with neighbors in need.

“It’s amazing to see our employees coming together in a unified way to help those who need it the most,” said Yamile Luna, assistant vice president of Florida Hospital Community Impact and Volunteerism. “Food insecurity, access to care and housing are some of the issues that our neighbors encounter every day. That’s why we decided to focus our efforts supporting local nonprofits that can help us fight these problems.”

For the first time, Florida Hospital extended its community efforts to an entire “Week of Caring,” which started with a meal packing event

Nov. 11 — in which employees and community members packed over 65,000 meals for hungry neighbors — and concluded with the annual “Day of Caring.”

“Having Florida Hospital employees giving us an extra hand means a lot to us,” said Eunice Carasas, a case coordinator at Kids House. “We are so busy taking care of the kids that we don’t have time to do landscaping or paint the building and it’s very important for us to have a pretty place to receive the kids every day.”

Earlier this week, employees from Florida Hospital Celebration Health and Florida Hospital Orlando, packed more than 60,000 meals that were then donated to No Child Hungry.

“It’s very fulfilling to be able to give back to the community,” said Elizabeth Espada, registered nurse at Florida Hospital. “Our mission is to extend the healing ministry of Christ and today we are taking it outside the hospital walls.”

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BEST PRACTICES

Surgeon Specializes in Robotic-Arm Assisted Joint Surgery Robotic-arm assisted hip and knee replacement has the ability to offer those suffering from osteoarthritis in their knees and hips almost immediate relief.

It is estimated that 15 million Americans suffer from osteoarthritis (OA) in their knees. The U.S. Census Bureau estimates that the 55 and older age group, who are peak knee replacement candidates, will reach 96 million by 2020. That age group is also the most susceptible to suffer from Degenerative Joint Disease (DJD) of the hip as well.

Abhijit Manaswi, MD, a specialist in joint replacement surgery, knows his robotic-arm assisted hip and knee replacement offers a solution to OA and DJD sufferers.

Heart of Florida Regional Medical Center, where Dr. Manaswi is the director of the Joint Replacement Center, is the only hospital in Polk County where the robotic arm joint replacement surgery is performed.

Dr. Manaswi uses a robotic arm interactive orthopedic system to map the area that will be operated on. Using a computer guided robotic arm, Dr. Manaswi can easily and quickly remove the osteoarthritis from the healthy bone and replace the knee or hip joint with the new joint.

“There is a smaller, less invasive incision than traditional surgery, and only the arthritic portion of the joint is removed, preserving the healthy bone and tissue,’’ Dr. Manaswi said. “There is less scarring, minimal hospitalization time and a more rapid recovery time.’’

When patients start having symptoms of DJD in the hip, for example, they notice they start limping to avoid putting weight on the affected hip, and that pain radiates down to the lower back, or thigh to knee. They also notice that pain medication is also no longer helping.

That is when the robotic arm joint replacement surgery provides the most relief.

“By using the robotic arm system to remove the damaged bone, I can reduce the risk of leg length discrepancy and improve the post-operative range of motion. There is also a rapid relief of pain and a quicker return to daily activities,’’ Dr. Manaswi said.

How It Works It all starts with a personalized plan. After a CT scan of the joint is taken a 3-D virtual model of area is generated. That model is loaded into the robotic arm system software and a personalized pre-operative plan is created.

During surgery, Dr. Manaswi uses that plan to

Robotic-arm joint replacement.

Original knee.

3-D map of hip for robotic-arm hip replacement surgery.

3-D map of knee for robotic-arm joint replacement surgery.

prepare the bone for the implant and the system guides him within the pre-defined arthritic area and keeps the machine from moving outside of the defined area for treatment. This helps provide a more accurate placement and alignment of the implant.

After surgery, the goal is to get the patient back up and moving around as soon as possible. At the Joint Replacement Center at Heart of Florida, the patients will be up and doing physical therapy within a few hours of the surgery. They also participate in group therapy with others who have had the surgery as well.

Patients also return home sooner than after traditional knee and hip replacement surgery.

Potential Benefits Improved surgical outcomes Optimal implant positioning Smaller incision, less invasive Minimal hospitalization Less scarring More rapid recovery Ligaments remain intact for a more natural feeling knee and hip • Ability to return to an active lifestyle quickly Dr. Manaswi offers several procedures including: robotic arm assisted total hip replacement, computer assisted total knee replacement, robotic arm assisted partial knee replacement, revision knee replacement, and revi-

sion hip replacement.

To find out more about the robotic arm joint replacement surgery, call Dr. Manaswi’s office today to make an appointment and come see how the robotic-arm assisted joint surgery can help your patients get their active lives back. For patients who would like to learn more about the surgery, please call Dr. Manaswi’s office at 863-419-8922.

Disclaimer: Before you decide on surgery, discuss treatment options with your doctor. Understanding the risks and benefits of each treatment can help you make the best decision for your individual situation.

Member of the medical staff at Heart of Florida Regional Medical Center. Heart of Florida Regional Medical Center is owned in part by physicians.

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Hip presentation

Abhijit Manaswi, MD, MS, FCPS, DNB, MNAMS, FRCS Board Certified | Fellowship Trained Total joint Surgeon Director, Joint Replacement Center

Robotic-Arm Hip Replacement