Orlando Medical News December 2018

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Artificial Intelligence Helps Protect New Mothers at Orlando Health A disturbing trend in American medicine over the past 15 years has been a steady increase in the number of women suffering serious injury or death following childbirth. In fact, the United States currently has the dubious distinction of the highest maternal death rate in the world among industrialized nations. While

ON ROUNDS

there does not appear to be any one cause for this trend, one of the most common problems appears to be the difficulty in accurately assessing blood loss during cesarean-section deliveries. To address this risk, Orlando Health invested in an artificial intelligence technology that removes the guesswork from calculating blood loss.

Now, Orlando Health Winnie Palmer Hospital for Women & Babies has become the first hospital in Central Florida and the largest-volume delivery hospital in the United States to use the technology in its labor and delivery rooms.

“This system takes what has historically been a subjective process – estimat-

ing how much blood has been collected by sponges and pads by eyesight alone – and makes the estimate much more accurate,” said Mike Schmidt, managing director of strategic innovations at Orlando Health.

Called Triton™, the new technology (CONTINUED ON PAGE 2)

HEALTHCARELEADER

Danielle Henry, MD: PHYSICIANSPOTLIGHT Dr. Maria Rosario Garcia and Dr. Jorge Londoño ... 3

INDEPENDENT PHYSICIAN Matthew M. Antonucci, DC, DACNB, FACFN, FICC ... 4

POSITIVE OUTCOMES The Silent Epidemic ... 5

ACOs, Medical Marijuana, and the Prohibition Hangover... 7 Helping Your Employees Protect Themselves and Your Practice ... 20

RADIOLOGY INSIGHTS

Asthma: A Silent Killer? ... 22 Human Epigenetics ... 23

The Unique Opportunity of Surgery Dr. Danielle Henry is able to combine warmth and directness in describing her approach to treating her patients. “Surgery is a specialty that gives you, as the surgeon, the unique opportunity to cure disease by removing it completely.” She says this when you ask her why she wanted to be a surgeon instead of practicing another type of medicine.

Henry is a board-certified general surgeon and fellowship-trained breast surgical oncologist with the Breast Care Center at Orlando Health UF Health Cancer Center. It is common among cancer surgeons to be direct and maybe a little simple when they are trying to explain to laymen

the very complex things they do: You find where the disease is and then remove it.

Aside from recovery and any long-term preventive measures, the patient is cured.

Simple, right? Except we all know that it is not simple.

The road to become any sort of medical doctor is a challenging one, no matter the specialty. But the road to becoming a surgeon has its own particular set of challenges. And some of those challenges are blamed for there being a significantly smaller percentage of women performing surgery. Although the number has risen steadily in recent years, the Association of American Medical Colleges reports that

women account for only about 20 percent of all surgeons.

But ask Henry if she feels like a “trailblazer,” and she laughs. “No,” is the answer. Her voice is warm, but direct. “No.” “I had always been interested in being in a field of medicine related to women’s health,” she said. “And then as I was doing my general surgery rotation in medical school (at Florida State University’s College of Medicine), I discovered that I was

(CONTINUED ON PAGE 3)

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Artificial Intelligence Helps Protect New Mothers, continued from page 1

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was developed by Gauss Surgical with significant investment support from Orlando Health Ventures. Nurses use special iPads loaded with the Triton™ app to take digital photographs of all the suction cannisters, surgical pads, sponges and other materials that are used to collect blood during a surgical procedure and weigh them on a scale that is Bluetoothconnected to the app. Using artificial intelligence similar to facial recognition software to read the digital images and analyze data from the scales, Triton™ can precisely calculate the amount of blood that has been collected and let the delivery team know immediately if unexpected blood loss is occurring.

“It allows us to catch hemorrhages much quicker,” said Schmidt.

The potential impact of this is huge.

Not only can it reduce the need for blood transfusions and shorten the length of hospital stays for patients, it can reduce the risk of serious complications which have been rising nationally.

According to separate studies by ProPublica/NPR and USA Today 50,00065,000 American women per year suffer some form of serious injury due to complications such as blood loss, increased blood pressure, blood clots or infections following childbirth. As many as 700 of these women die as a result of these complications. Because most deaths occur not in the delivery room, but days or even weeks later when the new mother is at home, the

scope of the problem has been slow to be realized, but every analysis seems to agree that it is growing. A recent article on the Harvard Medical School website by Neel Shah, MD, summarized the statistics this way: “This means that compared with their own mothers, American women today are 50 percent more likely to die in childbirth.”

With rising awareness of the problem, Gauss has been developing the Triton™ technology for several years, and an investment from Orlando Health Ventures helped to bring the technology into the delivery room. The next step will be to use Triton™ in other surgical settings as well.

Approximately 14,000 births happen each year at Winnie Palmer Hospital, making the impact of this technology immediately significant.

“Innovation is happening across healthcare, but it is not happening within hospitals themselves as much,” said Erick Hawkins, senior vice president of strategic management at Orlando Health. “Culturally, hospitals tend to be conservative in their approach and have been slow to adopt disruptive technologies. So, at Orlando Health we have made investing in new technologies part of our overall financial investment strategy. This was the perfect opportunity for us to combine a smart investment with technology to improve the outcomes for patients.”

The mission for Orlando Health Ventures is to find companies that can gener-

ate both a solid investment return for the foundation and that can deploy new beneficial technology into the hospital, said Hawkins.

This is part of an effort at Orlando Health to cultivate a culture of innovation, said Schmidt. The health system has also created an internal innovation incubator to encourage healthcare professionals within the Orlando Health system to turn their ideas into reality. The first team of innovators has been selected and the project is entering a second cycle with applications being reviewed.

“It’s exciting to watch,” said Schmidt.

“We are starting to see the whole ecosystem come together – technology, medicine, finance – and it will produce legitimate game-changing innovations that will improve patient outcomes.”

“It is a historic moment, too,” said Hawkins. “Orlando Health is 100 years old. For a century, patients have been able to rely on us for high quality, dependable healthcare. There is no better way that we could enter the next century than as a health system that also brings the best in patient-focused new technology and innovation.”

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PHYSICIANSPOTLIGHT

Husband and Wife Marry Their Passion for Community Service to Provide Health Care for Women in Need Volunteering is a family affair for Dr. Jorge Londoño, a board-certified obstetrician and gynecologist. Along with his wife Dr. Maria Rosario Garcia, a primary care physician, the duo have been providing gynecologic health services to uninsured and underinsured women at Shepherd’s Hope since 2010.

“The gynecologic services we provide are vital for these women in need, from pap smears and other preventive care, to more complex screenings such as colposcopies, endometrial biopsies and ultrasounds,” explained Jean Zambrano, vice president of clinical operations at Shepherd’s Hope. “Because of Dr. Londoño’s steadfast commitment, and the fact that the two of them always volunteer together, we have been able to help exponentially more people.”

Jorge Londoño, MD, FACOG, has been practicing for more than 20 years in the areas of operative gynecology, advanced laparoscopic surgery, pelvicrelaxation surgery, urinary incontinence, gynecologic ultrasound and infertility, in addition to well-woman examinations, obstetrics and high-risk pregnancy.

He attended medical school at the Pontifical Xavierian University in Bogotá, Colombia, where he also completed his first residency in Obstetrics and Gynecology and was named chief resident.

After moving to the U.S., Londoño completed a three-year research fellowship in Reproductive Ultrasound at the University of South Florida College of Medicine and a second OB/GYN residency at Orlando Regional Healthcare System, where he also was named chief resident.

For the last 13 years, he has served

arrange for the donation of a colposcopy machine for the health center that we use to examine patients for signs of disease.”

Is there a memorable patient encounter that is especially meaningful to you?

as medical director for the OB/GYN ultrasound department at Physician Associates (now Orlando Health).

Dr. Londoño shares his thoughts and experiences as a volunteer physician with Shepherd’s Hope to encourage other health care professionals to take up the cause and join him.

Why did you choose to volunteer at Shepherd’s Hope?

“I learned about Shepherd’s Hope from other physicians who were volunteering and heard about the great need for the health care services they provide.

My wife and I were both searching for a way to give back to the community to help those in need. Shepherd’s Hope was the perfect fit for us.”

Talk about the volunteer work you do with Shepherd’s Hope.

“My wife and I volunteer once a month, providing gynecology services at the Shepherd’s Hope health center in downtown Orlando. I bring a portable gynecologic ultrasound machine from my office to perform scans. I also helped

“Truly, all of the patients that come to Shepherd’s Hope are special in some way.

That’s what makes it so rewarding to volunteer there. Even after more than eight years.

However, one patient, in particular, comes to mind. It was a young Haitian mother with a small child who presented at the clinic with an infected breast mass that turned out to be breast cancer. I remember thinking at the time how lost and confused the young woman seemed.

But, thanks to Shepherd’s Hope and its Community Referral Provider Program, she was very well cared for throughout her entire treatment process from surgery to chemotherapy.”

What would you tell other physicians who may be interested in volunteering at Shepherd’s Hope?

“My wife and I have witnessed firsthand how many people truly need the medical care that Shepherd’s Hope provides and how much we can do for these patients.

Volunteering once a month may seem like a small contribution, but to the patients we see, it means a lot. Yes, we are tired at the end of our work day, but when we finish up our night shift at the clinic, there is always such a feeling of gratitude and gratification. It is very rewarding to know that you are providing real help and a real service for these patients.

You can really change a life by volunteering at Shepherd’s Hope. You can touch many, many lives and really make a difference.”

“Dr. Londoño goes above and beyond when it comes to the patients he and his wife see at Shepherd’s Hope,” Zambrano said. “If there is a patient he’s concerned about, he will always call to follow-up on the results of their diagnostics and where they are in their treatment process.”

Shepherd’s Hope is in need for more volunteer physicians like Dr. Londoño and Dr. Garcia to care for those in the community who need access to quality healthcare. Last year, 2,800 licensed medical and other professionals provided 44,000 volunteer hours and yet the organization still had to turn away 900 people due to capacity limitations.

To learn more about how to become a Shepherd’s Hope volunteer, contact Volunteer Program Manager Abby Seelinger at (407) 876-6699, ext. 233, or abby.seelinger@shepherdshope.org, or visit www.shepherdshope.org/volunteers.

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HEALTHCARELEADER Danielle Henry, MD, continued from page 1 really interested in surgery.” She knew that was the path she wanted to pursue. And the way she explains it, you know she did not dwell on the fact that she was entering a predominantly male field.

“More women are entering medicine, and more are starting to enter surgery,” she said. “It just so happens that I am one.”

Henry grew up in the South Florida city of Miramar. There she went to the local International Baccalaureate high school, a rigorous academic program that usually leaves its students with little time for extracurricular activities. But not Danielle Henry. She played soccer, and earned a varsity letter. In fact, she still plays soccer; she is a mid-fielder. And, the opportunity to do that as an adult is one of things she loves about Orlando.

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From Miramar she went to the University of Florida and then to medical school at Florida State University. She completed a general surgery internship and residency at Orlando Health, where she served as administrative chief resident and won “Best Resident Award.” She went on to complete a Society of Surgical Oncology breast surgical oncology fellowship at Moffitt Cancer Center and Research Institute, Tampa. While at Moffitt, Henry received the Junior Scientist Partnership Award for collaboration with the immunology lab to investigate local immunity within breast cancer tissue.

“It is really exciting to practice at the place where I did my internship and residency,” she said. Being part of the breast cancer treatment team is one of the things

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Henry likes about Orlando Health. She credits her partners at the breast care center with helping to mentor her and make her part of the team without regard to anything but her ability as a surgeon.

The approach to treating breast cancer at Orlando Health is multi-disciplinary, involving everything from the oncologist to radiologist, to surgeon, to nutritionist and genetic counselors. And the specific treatments vary according to the individual.

“And all of these things combined make it interesting,” she said.

Among the advances in treating breast cancer that Henry finds most interesting are those which limit surgery on patients, advancements that minimize the (CONTINUED ON PAGE 4)

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THE INDEPENDENT PHYSICIAN

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Matthew M. Antonucci, DC, DACNB, FACFN, FICC Lessons learned early Matthew M. Antonucci, DC, DACNB, FACFN, FICC, learned an important lesson as a youngster from his grandfather.

After learning how to use a nail and hammer, his grandfather handed him a screwdriver and a cup full of screws to play with, which he had no idea how to use.

“Where’s my hammer and where are my nails? And he said, ‘sometimes life isn’t going to always give you a hammer and nails, so you have to learn to use different tools.’ And from there, I just tried to learn as many different types of tools that I could use to help my patients. And what I realized is that the more tools you have in your toolbox, the more people you can help.”

Now, Antonucci is the lead clinician and Director of Neurological Performance and Rehabilitation for Plasticity Brain Centers. He completed undergraduate studies on an academic scholarship at Central Connecticut State University and received his Doctorate in Chiropractic Medicine from Life University in Atlanta, Georgia.

His post-graduate studies in neurology were completed at the Carrick Institute for Graduate Studies, where he also had the great fortune to complete a 2-year fellowship residency under the direction of Pro-

fessor Frederick R. Carrick. He received both his diplomat in Chiropractic Neurology, as well as his fellowship in Functional Neurology, in 2009. He has completed additional fellowship training and is board certified in the specialties of: Childhood Developmental Disorders, Vestibular Rehabilitation, Neurochemistry and Nutrition, and Brain Injury Rehabilitation.

In 2015, Antonucci was awarded the highest honor in the chiropractic profession, a lifetime induction as a fellow to the International College of Chiropractic for his outstanding service to the chiropractic profession.

With almost a decade of clinical experience, he has attended over 1,500 patients with complex neurological conditions, and has held private practices in Charleston, South Carolina and Atlanta. He currently attends patients at Plasticity Brain Centers and is a tenured Associate Professor of Clinical Neuroscience at the Carrick Institute, regularly lecturing both nationally and internationally on neurological rehabilitation. He has contributed to and published numerous research abstracts, and studies on the quantification of neurological function, efficacy and accuracy of

technology, as well as clinical outcomes of functional neurology interventions.

When not attending patients or lecturing, Antonucci enjoys continuing his education, researching, traveling, fine dining, photography, writing, electronic dance music, and spending time with family. He and his wife Tricia have 3 children, Tedy and identical twins Brady and Boston.

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Danielle Henry, MD, continued from page 3

invasiveness of invasive procedures.

“These advancements limit the complications for the patients, not the outcomes,” she said.

While there is no typical day for a surgeon, the hardest part is always telling a patient that she has cancer.

“You have to be direct, but you also have to take the time to explain all of the options, and to make sure the patient knows that you are there to help them get better,” she said. “Breast cancer is a very intimate diagnosis, and that is an advantage women surgeons might have. We can understand what the patient is going through.”

Although new to her practice at Orlando Health, Henry is a familiar speaker on breast cancer topics. Her clinical interests include high-risk breast cancer groups, like genetic carriers and minorities, in addition to adapting new technology in the operating room.

Henry is a member of several professional societies including the American Society of Breast Surgeons, Society of Surgical Oncology, American College of Surgeons, Association of Women Surgeons, Association of Academic Surgeons and Society of Black Academic Surgeons. She is active on committees in the Florida Chapter of the American College of Surgeons and the Association of Women Surgeons.

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POSITIVE OUTCOMES

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The Silent Epidemic

By MICHAEL SAMOGALA, RN, CRRN, CBIS

As we know, brain injury in its multiple forms, continues to be a major health issue in the United States and is becoming consistently more complicated as time and effort continues to define its complexity. Brain injury as many of us understand today, is also known as, “The Silent Epidemic.” In spite of its staggering number of occurrences, the true effects of a brain injury are often invisible to a common observer. We must understand that someone who has sustained a brain injury appears the same and often completely “normal,” however, there are many different occult effects of brain injury that cannot be specifically, conclusively and consistently observed by the untrained eye.

Keeping in mind that in 2013, the CDC stated in the U.S approximately 2.8 million traumatic brain injuries resulted in emergency department visits, some resulting in hospitalization, or death. Brain injury effects all age groups in every social and economic status; this cannot be ignored.

In discussing brain injury in a basic, systematic fashion, we can define what is universally referred to as Acquired Brain Injury. An Acquired Brain Injury (ABI) is further subclassified by relative causes (Traumatic or Non-traumatic). Traumatic brain injury (TBI) is a nondegenerative, noncongenital insult to the brain from an external mechanical force. (Medscape 2017). As defined, we must also include inertial injury within the cranial vault. Nontraumatic ABI most often occurs due to CVA; however, injury can be caused by any form of impending or sustained cellular hypoxia (Inflammatory or Physical) or other various causes including substance/ chemical abuse and/or exposure, and infective processes.

The mechanisms of ABI are often thought of as primary which include the injury itself whether mechanical as in coup-contrecoup and/or diffused axonal injury. Secondary mechanisms and their process are now becoming the focus of research with the known concept of secondary cascade, including the action of free radical release originated by the cells of initial injury into the surrounding cells and tissues. Current literature targets this process as progressive and is possibly considered to be unpredictable. Specifically, this process influences apoptosis and random cell death.

Understanding these processes may allow us to consider those latent effects of brain injury which we as health care providers so often attribute to non-compliance or blatant refusal to conform to medical or social regimen. Recent statistics show that if an individual sustains a brain injury, the likelihood of a second injury is three times that of the general population and after the second injury, is eight times more likely 5

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DECEMBER 2018

to occur again; thus, we have a reoccurring injury by initial occurrence.

In further discussing ABI, familiarity with the levels of severity, mild, moderate and severe, are consistently scrutinized. The categorization/determination of severity is currently initiated utilizing three main factors relating to the incident of injury. These include the initial Glasgow coma scale, the period of post-traumatic amnesia and the length of any period of unconsciousness. As we know, in current practice, often the information received on initial assessment may be tainted. Failing to consider, “the injured individual not being able to remember what they don’t remember?” simply stated is what happened actually what occurred, or is it what the individual was told throughout questioning, transport and/or the initial treatment process? “Since there was no loss of consciousness!”

This question also generates attention to what we now know regarding concussion as a true form of a mild brain injury.

The health care system of the past considered concussion as an incident that frequently occurred within the context of sports, athletics or minor incidence of impact – having your “bell rung.” We now know concussion in itself is defined as an injury characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma (2017 AANS).

Post concussive syndrome as defined

by NIH 2012, refers to cognitive deficits in attention or memory and three or more of the following symptoms: fatigue, sleep disturbance, headache, dizziness, irritability,

As we understand behavior in general as a response to stimuli, the present acute health care arena at times focuses on over efficient treatment and discharge.

As often behaviors and deficits associated with ABI are not always immediately observed, these individuals fail in their homes and communities, sometimes long after the initial injury. In addition, these individuals often become involved in our corrections systems due to the corrections systems’ no-fault inability to screen and recognize brain injury related behaviors and functional deficits in many of these individuals.

In summary, as health care providers, we must be diligent in advocating for the individual who has sustained an ABI in any form. Due to the ongoing research and continued definition of acquired brain injury and results of that injury as related to the individual’s specific needs within our community, it is imperative this advocation begin on the onset of the individual’s assessment and care and progress throughout what might be a life change vs an injury. As new information is discovered and processed, the communication and recognition of brain injury as the silent epidemic, to and by all health care providers, is essentially everyone’s responsibility. We, at NeuLife Neurological Services, fully support this concept.

affecting disturbance, apathy or personality change (behaviors).

Conclusively, the risk of post-concussion syndrome doesn’t appear to be associated with the severity of the initial injury.

There does not have to be any loss of consciousness. In most individuals, symptoms occur within the first 7-10 days and resolve within 3 months, however, we now know they can persist for a much longer period of time, exceeding a year or more.

(Mayo 2017) In fully assessing an individual with a possible ABI our thoughts need to be not only focused on immediate care but also on the discharge sequelae. In doing so, we must relate what is known about the area or areas of brain injury and the relative basic function as related to what could be great challenges to the individual’s significant others/caregivers or the community in general, primarily safety issues and impulsive behavior.

NeuLife Rehab is one of the largest residential post-acute programs in the country offering personalized rehabilitation plans ensuring successful outcomes; as approximately 80% of our clients return to their home or communities.

Michael Samogala RN, CRRN CBIS has been directly involved in providing professional nursing and education services to the healthcare community for over 40 years.

Most notably receiving board certification in rehabilitation nursing and as a brain injury specialist, he continues to provide professional credited continuing education programs to multiple professionals across the country, and remains in the position of Director of Corporate Education, NeuLife Neurological Services.

DIAGNOSES INCLUDE: • Acquired Brain Injury Traumatic/Non-Traumatic including Stroke • Spinal Cord Injury • Amputations • Multiple Trauma, Orthopedic & Challenging Medical Diagnoses

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THE HR LADY

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Top HR Challenges in Healthcare: Staffing & Leadership

By WENDY SELLERS

The healthcare industry is complex, challenging, severely understaffed and lacking effective leadership. The massive shortage of qualified healthcare staff continues to be an issue - in nursing, specialists, clinicians and even general physicians to name a few. High turnover also plagues the industry - and will continue to do so as long as employees have “better options”.

Money is not their only motivating factor.

According to Gallup, being satisfied, trusted and engaged at work is more important than money to 50 percent of employees who quit their job because of a bad manager. Now more than ever, it is vital to build a reputation to attract and retain these sought-after staff members. In order to do so, your brand and culture must be enjoyable - which means your leadership team must learn to lead rather than simply manage.

Review the National Library of Medicine study and results on commitment vs control approaches for yourself https:// www.ncbi.nlm.nih.gov/pmc/articles/ PMC5029057/. The findings reveal a control-based approach to people management does not work for the long term. In fact, this approach actually negatively affects staff attitude and operational efficiency.

The best HR approach to retain top healthcare talent AND improve long term operational efficiency is a development of mutual commitment between the employer and the employee. This commitment is based on a high level of trust and empowerment - which comes from great leadership. This starts with engaging your employees. So, what the heck does this mean? Definition: Employee engagement is the emotional commitment the employee has to the organization and its goals. (Forbes.com) Why is it important for your employee to have this emotional commitment? Can’t they just do their job? Sure, they can do the minimum requirements of the job to avoid being fired. But let’s be honest, almost everyone is doing more with less time and less employees since the economy tanked. The economy flourish that followed brought a crunched operating budget with revenue flow that is tight and highly regulated. For some specialties the budget is flowing and so is the revenue - yet experienced, loyal and dedicated employees are no longer a dime a dozen. See, this is where the emotional com6

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DECEMBER 2018

mitment comes in. When your employee is dedicated to the job and to you, they will be less likely to be swept away by a competitor, they will be more likely to stay late/ come in early and put in extra (paid or unpaid) hours to make sure the job is not only done - but done right, and they will be much more likely to tell their experienced, loyal and dedicated friends to come work for you and alongside them.

According to Towers Perrin research companies with engaged workers have 6 percent higher net profit margins, and according to Kenexa research engaged companies have five times higher shareholder returns over five years. (Forbes.com).

I’m in! How do I better engage my employees?

Here are 8 steps to getting your staff to give a darn – today!

First, remember the answer to this question: Who is responsible for communication? You are! Repeat after me: I am responsible for communication. If someone did not understand your message, you must take responsibility. Always ask yourself or even the employee for that matter ~ how could I have handled that differently?

Then handle it differently next time.

Communicate often. Schedule weekly team meetings and stick to them!

For some employees, you may need to meet more often or on an individual basis - especially if there is a challenging project and fast approaching or changing deadline. Employees whose managers hold regular meetings with them are almost three times as likely to be engaged than those with no meetings.

Respond to your employee’s emails, phone calls and voicemails. This shows that you respect and value them. You expect that of them and should give them the same effort.

Set priorities for your employees so your expectations are clearly known. Osmosis does not work! If priorities change, as they often do, communicate with the team.

Show sincere appreciation. If you fake it, employees know! Be specific in your gratitude. “You did great” Is not specific.

“The way you handle the ABC customer complaint was inspiring. You saved the day.

Thank you, John,” Bonus: Thank you is free!

Provide feedback often – do not wait for an annual performance review meeting.

Often those meetings feel forced and super-

ficial and let’s face it, no one likes giving or getting an annual review. when performance management is done well, employees become more productive. Feedback can be as informal as a conversation over coffee or as formal as notes jotted down on paper discussing goals and even a reverse review ~ ask them questions about your performance!

Get to know your employees as humans. You do not have to be best friends, but you do spend a lot of time together so being friendly makes those difficult conversations much easier for all involved.

Find out what they do outside of work and engage them in those conversations.

Finally, assist your employee in growing their strengths. Do not assign them

to projects that will highlight their lesser strengths. Mentoring and coaching are extremely important to build confidence their trust, respect, and happiness. Happy employees are productive employees! Building someone up is called being a leader. Putting someone down is called being a bully.

Wendy Sellers “The HR Lady” has a master’s degree in Human Resources, a master’s degree in Health Care Administration, is a passionate HR Consultant, Leadership Coach, author, and speaker. She has worked with hundreds of corporations and associations conducting management training, leadership development and HR advisory services. Wendy is authentic and transparent - above all, she keeps it real.

She is honest, loyal and direct - there is never any sugar coating! See more at https://youtu.be/hXqsb2lnQ3Y

Dedicated to You and Your Practice!

ATTENTION INDEPENDENT PHYSICIANS & PRACTICE ADMINISTRATORS & MANAGERS

Enjoy a complimentary book from The HR Lady an HR expert, speaker and author.

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ACOs, Medical Marijuana, and the Prohibition Hangover See what happens when data is captured

By MICHAEL PATTERSON

ACOs, or Accountable Care Organizations, are a growing influence on current healthcare. Their power over decision making will continue to increase for the goals of streamlining healthcare costs, improving communication between all healthcare settings (Medical practices, hospitals, surgical centers, nursing homes, home health care, outpatient providers, etc.), and improving the quality of healthcare.

If you have been in healthcare long enough, you know the only constant is change. ACOs are just the beginning.

Bundled payments for services across multiple providers are here. In 2019, nursing homes will be dealing with outcome-based payments, rather than service-based payments and home health care will be soon to follow.

With all this change in reimbursement, some providers will get left behind.

Those who are not willing to change, or do not want to change, will not make it.

They will hold on, put their head in the sand, and keep “milking” the current system telling their employees to do “more with less” and expect the same financial returns.

One of these areas of change, which is already happening, is Medical Marijuana (MMJ) in Florida. Unless you have been living under a rock, it’s been legal now for almost 3 years. We will surpass over 200,000 active MMJ patients in Florida in early 2019, and that number will continue to increase at 3,000-5,000 patients per week. Now the question, “Why should I care if patients use MMJ? I don’t have anything to do with MMJ in my ACO, so it doesn’t affect me.” Your patients are already using MMJ, they are just not telling you! By capturing the data from these patients, you will begin to see how MMJ is saving your company lots of money indirectly now and will save millions more by using the data to better patient outcomes.

Right now, I know of ZERO healthcare providers in Florida tracking MMJ data. If you want to be ahead of all your competition, start doing the following:

1. Start asking your patients about MMJ use. Medical Marijuana has been proven to decrease prescription drug use each month. (https://www. cboutlook.com/bradford2016. pdf ). It has been proven to decrease depression, increase appetite, kill cancer cells, cure colitis, improve Alzheimer’s symptoms, decrease chronic pain, decrease the effects of a stroke, and the list goes on, and on. (https://www.businessinsider. com/health-benefits-of-medicalmarijuana-2014-4#animal-studiessug gest-that-marijuana-mayprotect-the-brain-after-a-stroke-18) 2. Track the data. Start “connecting the dots.” All these positive effects will help your patients and your bottom line ONLY if you know what is happening. Why are they using MMJ? Is it providing them with benefits in their health? What other benefits are they finding by using MMJ? Are they less depressed or anxious so they can exercise more? Do they now have the ability to eat better so they can put on weight and decrease potential skin tears and wounds? (which are tremendously expensive to treat). Have they been able to stop taking costly prescription medications and have better outcomes and less side effects? At first your patients may not trust you enough to tell you – the current FL MMJ law does not protect patients from losing their job if they use MMJ. However, over time if you continue to show that your ACO or company is looking to learn how MMJ will help their condition and it will help you provide better care, they will slowly warm up and answer the questions truthfully.

3. Educate your ACO on the findings of your data. Once you start collecting enough data on MMJ, you will begin to extrapolate results.

For example, you may find that your patients who are using MMJ for chronic pain are less likely to get addicted to

opiates – which means the ACO will have to pay for less drug dependency treatment over time. Or, your patients using MMJ for colitis or IBS don’t need expensive prescription meds for their condition anymore, which will save your ACO millions of dollars. Or, your Alzheimer’s patients are not getting worse, actually better, and are less likely to fall and break a hip requiring costly surgery, hospital stay, nursing home care, and home health.

In the new age of blockchain, super computing power, and data analytics, a wise man once told me, “Whoever has the data wins.” Regardless of your opinion of MMJ, this new legal medicine is a treasure-trove of data that can begin to lower costs, improve outcomes, and put more money in your pocket without having to recommend the medicine.

The “prohibition hangover” is alive and well. The “prohibition hangover” is the inability to come to grips with

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Michael C. Patterson, founder and CEO of U.S. Cannabis Pharmaceutical Research & Development of Melbourne, is a consultant for the development of the medical marijuana industry nationwide and in Florida. He serves as a consultant to Gerson Lehrman Group, New York and helps educate GLG partners on specific investment strategies and public policy regarding Medical Marijuana in the U.S. and Internationally.

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Medical Marijuana being legal and refusing to learn anything about it. If you have not noticed, our neighbors to the north (Canada), have legalized cannabis across the entire country. Currently, over 27 countries in the world have legalized Medical Marijuana and that list continues to grow every month. Germany has legalized MMJ and it is paid for through the national healthcare system. The use of MMJ in Florida and globally will only increase over time. Savvy healthcare operators will use the data of this new legal medicine to jump ahead of the competition because whoever gets rid of their prohibition hangover last, will lose.

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GrandRounds Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019

The Centers for Medicare & Medicaid Services (CMS) has issued its final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.

The calendar year (CY) 2019 PFS final rule is one of several final rules that reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation.

Background on the Physician Fee Schedule Payment is made under the PFS for services furnished by physicians and other practitioners in all sites of service. These services include, but are not limited to, visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services.

In addition to physicians, payment is made under the PFS to a variety of practitioners and entities, including nurse practitioners, physician assistants, and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities.

Payments are based on the relative resources typically used to furnish the service. Relative Value Units (RVUs) are applied to each service for physician work, practice expense, and malpractice. These RVUs become payment rates through the application of a conversion factor. Payment rates are calculated to include an overall payment update specified by statute

PAYMENT PROVISIONS Streamlining Evaluation and Management Payment and Reducing Clinician Burden

CMS is finalizing a number of documentation, coding, and payment changes to reduce administrative burden and improve payment accuracy for office/ outpatient evaluation and management (E/M) visits over several years. For CYs 2019 and 2020, we are implementing several documentation policies to provide immediate burden reduction, while other changes to documentation, coding, and payment would be implemented in CY 2021.

For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits and practitioners should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare. For CY 2019 and beyond, CMS is finalizing the following policies: • Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit; • For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed,

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and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so; • Additionally, we are clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information; and • Removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians.

Beginning in CY 2021, CMS will further reduce burden with the implementation of payment, coding, and other documentation changes.

Payment for E/M office/outpatient visits will be simplified and payment would vary primarily based on attributes that do not require separate, complex documentation. Specifically for CY 2021, CMS is finalizing the following policies: • Reduction in the payment variation for E/M office/outpatient visit levels by paying a single rate for E/M office/ outpatient visit levels 2 through 4 for established and new patients while maintaining the payment rate for E/M office/outpatient visit level 5 in order to better account for the care and needs of complex patients; • Permitting practitioners to choose to document E/M office/outpatient level 2 through 5 visits using medical decision-making or time instead of applying the current 1995 or 1997 E/M documentation guidelines, or alternatively practitioners could continue using the current framework; • Beginning in CY 2021, for E/M office/ outpatient levels 2 through 5 visits, we will allow for flexibility in how visit levels are documented— specifically a choice to use the current framework, MDM, or time. For E/M office/outpatient level 2 through 4 visits, when using MDM or current framework to document the visit, we will also apply a minimum supporting documentation standard associated with level 2 visits. For these cases, Medicare would require information to support a level 2 E/M office/outpatient visit code for history, exam and/or medical decision-making; • When time is used to document, practitioners will document the medical necessity of the visit and that the billing practitioner personally spent the required amount of time face-to-face with the beneficiary; • Implementation of add-on codes that describe the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care, though they would not be restricted by physician specialty. These codes would only be

Nemours, UCF Transform Education For Hospitalized Children Nemours Children’s Hospital and UCF has announced a first-of-its kind program that provides highly specialized schooling to chronically ill children in a way that’s tailored to their specific disease. Called UCF’s PedsAcademy at Nemours Children’s Hospital, the new joint program involves more than 50 UCF faculty and student teachers working closely with Nemours physicians daily to deliver STEM education to hospitalized patients using virtual reality, robotics and other high-tech learning tools.

“These children can miss out on weeks, months or even years of schooling,” says Megan Nickels, a UCF assistant professor in the College of Community Innovation and Education and the College of Medicine, and PedsAcademy faculty director. “Our goal is to provide a rich, meaningful, educational experience so they aren’t just keeping pace with their healthy, typically developing peers, but they are actually getting extraordinary educational opportunities while in the hospital.”

The program launched in August and uses robots, immersive virtual reality, telepresence, 3D printers and MakerSpaces to deliver lessons that range from basic computer programming to learning about undersea worlds.

Lessons are personalized to a child’s interests by incorporating themes such as superheroes, animals, or sports. Teaching methods are based on Nickel’s research into cognitive development and the effects of certain diseases on learning, so patients are taught in ways that are conducive to their physical limitations and sensory conditions.

For example, a child with cancer who likes superheroes might have a math session that features Spider-Man and uses robots to prompt engagement. Because chemotherapy can cause problems with focus, working memory, and identifying visual and spatial relationships, the assignment might center around an activity that involves mental rotation, repetitive programming and small increases in task difficulty.

“It’s such a nontraditional way of delivering education and is tailored in a way that is as fun as it is intellectually stimulating,” says Norman Jeune, director of Patient and Family Centered Care at Nemours Children’s Hospital in Orlando.

“No one has done anything like this before.”

Instruction takes place at the bedside of inpatient children, and will soon begin in outpatient settings such as the Nemours’

Infusion Center where cancer and blood disorders, kidney disease, and immunesystem disorders are treated. In some cases, the virtual-reality goggles and scenarios are such an effective distraction that they are used as an alternative to sedation during treatments.

On an average day, up to 60 children are taught through PedsAcademy at Nemours. Patients can receive at least three hours of instruction per day and may begin participating in the program as soon as they are admitted. Instruction is for children up through 12th grade and also is available for siblings of the patients.

The PedsAcademy team is comprised of UCF faculty members, student researchers, postdoctoral scholars and dozens of student interns. The students, all pre-service teachers, complete a semester of study at Nemours and provide instruction to patients under the supervision of a faculty member. This gives them the opportunity to learn new skills for teaching special populations such as hospitalized children.

For UCF student Julisa Vinas, the mission of PedsAcademy hits home. In her third year at UCF as an accounting student, a mixture of illnesses led to her medically withdrawing from school and undergoing an extensive procedure to have a stem-cell transplant. Upon her recovery, she vowed to continue her education in something she felt would make an impact. She’s now in her senior year at UCF studying elementary education and a PedsAcademy intern.

“When this opportunity [PedsAcademy] came up, I thought this is perfect for me because I know what it feels like to be extremely ill and want to have an education, to want to go to school and not be able to. Being able to now go to these kids and provide that for them – it’s an amazing experience,” Vinas says.

The program was inspired by research that shows children who face lifethreatening illnesses or suffer from chronic health conditions will have their education disrupted, often resulting in an inability to keep pace with their peers and perform at their grade level. This disruption in education can affect children into their later years by limiting their achievements and social mobility. Each year, eight out of every 100 children are hospitalized in the United States.

The program is funded through grants and private donations.

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GrandRounds reportable with E/M office/outpatient level 2 through 4 visits, and their use generally would not impose new pervisit documentation requirements; and • Adoption of a new “extended visit” add-on code for use only with E/M office/outpatient level 2 through 4 visits to account for the additional resources required when practitioners need to spend extended time with the patient.

CMS believes these policies will allow practitioners greater flexibility to exercise clinical judgment in documentation, so they can focus on what is clinically relevant and medically necessary for the beneficiary. CMS intends to engage in further discussions with the public to potentially further refine the policies for CY 2021.

After consideration of concerns raised by commenters in response to the proposed rule, CMS is not finalizing aspects of the proposal that would have: (1) reduced payment when E/M office/ outpatient visits are furnished on the same day as procedures, (2) established separate coding and payment for podiatric E/M visits, or (3) standardized the allocation of practice expense RVUs for the codes that describe these services.

Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services

CMS is finalizing our proposals to pay separately for two newly defined physicians’ services furnished using communication technology: • Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012) and • Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010) Practitioners could be separately paid for the brief communication technologybased service when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed. This would increase efficiency for practitioners and convenience for beneficiaries. Similarly, the service of remote evaluation of recorded video and/ or images submitted by an established patient would allow practitioners to be separately paid for reviewing patienttransmitted photo or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed.

CMS is also finalizing policies to pay separately for new coding describing chronic care remote physiologic monitoring (CPT codes 99453, 99454, and 99457) and interprofessional internet consultation (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449).

the Medicare program. CMS sought comment on methods for identifying nonopioid alternatives for pain treatment and management, along with identifying barriers that may inhibit access to these non-opioid alternatives including barriers related to payment or coverage. CMS received many comments on these solicitations with detailed information to help inform future rulemaking.

Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder and Other Substance Use Disorders

Through an interim final rule with comment period, CMS is implementing a provision from the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act that removes the originating site geographic requirements and adds the home of an individual as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019.

Additionally, the SUPPORT for Patients and Communities Act establishes a new Medicare benefit category for opioid use disorder treatment services furnished by opioid treatment programs (OTP) under Medicare Part B, beginning on or after January 1, 2020. We note that there is a 60-day period to comment on the provisions of the interim final rule discussed earlier, during which we are requesting information regarding services furnished

by OTPs, payments for these services, and additional conditions for Medicare participation for OTPs that stakeholders believe may be useful for CMS to consider for future rulemaking to implement this new Medicare benefit category.

Providing Practice Flexibility for Radiologist Assistants

CMS is revising the physician supervision requirements so that diagnostic tests performed by a Radiologist Assistant (RA) that meets certain requirements, that would otherwise require a personal level

of physician supervision as specified in our regulations, may be furnished under a direct level of physician supervision to the extent permitted by state law and state scope of practice regulations. This is in response to stakeholder comments that the current requirement of personal supervision that applies to some diagnostic tests is overly restrictive when the test is performed by an RA, and does not allow for radiologists to make full use of RAs, and that reducing the required level of supervision will improve efficiency of care.

Discontinue Functional Status Reporting Requirements for Outpatient Therapy

Since January 1, 2013 as required by the Middle Class Tax Relief and Jobs Creation Act of 2012, all providers of outpatient therapy services have been required to include functional status information on claims for therapy services. CMS implemented a system that collects data using non-payable HCPCS G-codes and modifiers to describe a patient’s functional limitation and severity at periodic intervals during outpatient therapy services. In response to the Request for Information on CMS Flexibilities and Efficiencies that was issued in the CY 2018 PFS proposed rule, CMS received comments requesting burden reduction related to the functional status reporting requirements.

The data from the functional reporting system was to be used to aid CMS in recommending changes and reforming of Medicare payment for outpatient therapy services that were subject to the statutory therapy caps. Going forward, the functional status reporting data that would be collected may be even less purposeful because the Bipartisan Budget Act of 2018 repealed the therapy caps while imposing protections to ensure therapy services are furnished when appropriate. As a result, CMS is finalizing our proposal to discontinue the functional status reporting requirements for services furnished on or after January 1, 2019.

Outpatient Physical Therapy and Occupational Therapy Services

Furnished by Therapy Assistants

The Bipartisan Budget Act of 2018 requires payment for services furnished in whole or in part by a therapy assistant at 85 percent of the applicable Part B payment amount for the service effective January 1, 2022. In order to implement this payment reduction, the law requires us to establish a new modifier by January 1, 2019 and CMS details our plans to accomplish this in the final rule.

CMS is finalizing our proposal to establish two new modifiers – one for Physical Therapy Assistants (PTA) and another for Occupational Therapy Assistants (OTA) – when services are furnished in whole, or in part by a PTA or OTA. However, CMS is finalizing the new modifiers as “payment” rather than as “therapy” modifiers, based on comments from stakeholders. These will be used alongside of the current PT and OT modifiers, instead of replacing them, which retains the use of the three existing therapy modifiers to report all PT, OT, and Speech Language Pathology services, that have been used since 1998 to track outpatient therapy services that were subject to the therapy caps. CMS is also finalizing a de minimis standard under which a service is furnished in whole or in part by a PTA or OTA when more than 10 percent of the service is furnished by the PTA or OTA, instead of the proposed definition that applied when a PTA or OTA furnished any minute of a therapeutic service. The new therapy modifiers for services furnished by PTAs and OTAs are not required on claims until January 1, 2020.

Conversion Factor

With the budget neutrality adjustment to account for changes in RVUs, all required by law, the final 2019 PFS conversion factor is $36.04, a slight increase above the 2018 PFS conversion factor of $35.99.

Practice Expense (PE): MarketBased Supply and Equipment Pricing Update

Practice expense (PE) is the portion of the resources used in furnishing a service that reflects the general categories of

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Comment Solicitation on Creating a Bundled Episode of Care for Management and Counseling Treatment for Substance Use Disorders

In the CY 2019 PFS proposed rule, CMS sought comment on creating a bundled episode of care for management and counseling treatment for substance use disorders. Comment was also sought for regulatory and subregulatory changes to help prevent opioid use disorder and improve access to treatment under

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GrandRounds physician and practitioner expenses, such as office rent and personnel wages, but excluding malpractice (MP) expenses. CMS develops PE RVUs for each physician’s service by considering the direct and indirect practice resources involved in furnishing each service. Direct expense categories include clinical labor, medical supplies, and medical equipment. Indirect expenses include administrative labor, office expense, and all other expenses.

CMS worked with a contractor to conduct an in-depth and robust market research study to update the PFS direct PE inputs for supply and equipment pricing for CY 2019. These supply and equipment prices were last systematically developed in 2004-2005. A report from the contractor with updated pricing recommendations for approximately 1300 supplies and 750 equipment items currently used as direct PE inputs is available as a public use file displayed on the CMS website under downloads for the CY 2019 PFS final rule.

CMS is finalizing the proposal to adopt updated direct PE input prices for supplies and equipment. While CMS is adopting most of the prices for supplies and equipment as recommended by the contractor and included in the proposed rule, in the case of particular items, CMS is finalizing refinements to the proposed prices based on feedback from commenters. CMS is also finalizing our proposal to phase-in use of these new prices over a 4-year period beginning in CY 2019 to ensure a smooth transition.

Payment Rates for Non-excepted Off-campus Provider-Based Hospital Departments Paid Under the PFS

Section 603 of the Bipartisan Budget Act of 2015 requires that certain items and services furnished by certain offcampus hospital outpatient providerbased departments are no longer paid under the Hospital Outpatient Prospective Payment System (OPPS) and are instead paid under the applicable payment system. In CY 2017,CMS finalized the PFS as the applicable payment system for most of these items and services.

Since CY 2017, payment for these items and services furnished in non-excepted off-campus provider-based departments has been made under the PFS using a PFS Relativity Adjuster based on a percentage of the OPPS payment rate.

The PFS Relativity Adjuster in CY 2018 is 40 percent, meaning that non-excepted items and services are paid 40 percent of the amount that would have been paid for those services under the OPPS. CMS is finalizing that the PFS Relativity Adjuster remain at 40 percent for CY 2019. CMS believes that this PFS Relatively Adjuster encourages fairer competition between hospitals and physician practices by promoting greater payment alignment between outpatient care settings.

Medicare Telehealth Services

For CY 2019, CMS is finalizing our proposals to add the following codes to the list of telehealth services: • HCPCS codes G0513 and G0514 (Prolonged preventive service(s)) CMS is also finalizing policies to implement the requirements of the Bipartisan Budget Act of 2018 for telehealth services related to

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UCF Nursing Students Get Hands-On Anatomy Training “Look how small the esophagus is,” she said, examining her patient’s neck. “Now I’m definitely going to chew my food a bit more knowing that it’s going down this small pipe into your stomach.”

Her “patient” was a cadaver, a person who had donated their body to help train medical students, and her “clinic” was the UCF College of Medicine’s Anatomy Lab. Dos Anjos was one of 10 UCF College of Nursing students who trained in the lab with thanks to medical students who organized a one-day workshop Nov. 28.

“It’s been absolutely phenomenal,” dos Anjos said of her first experience learning from real humans.

“I’ve learned so much, knowing how the different organs look and how they work inside the body instead of just looking at pictures in a textbook. It’s definitely going to do wonders for me in helping me be a better nurse, because I’ll have a fuller understanding of how everything actually works when I’m explaining procedures to my patients.”

The workshop was the brainchild of former critical-care-nurse-turned-UCFmedical student Will Pruitt. After getting trained in the Anatomy Lab during his first year of medical school, Pruitt realized how valuable such a learning experience would have been during his nursing education.

“So much of what I learned during the gross anatomy module would have been tremendously helpful in multiple facets of my nursing practice,” said Pruitt, who is now in his second year of medical school. “So, I wanted to give UCF nursing students, starting with this small group, a unique learning experience that gives them an opportunity to bridge the gap between what they have learned in nursing textbooks and the actual human body.”

Only a handful of nursing schools utilize cadavers for their students’ learning.

While the College of Nursing employs advanced simulation technologies, such as high-fidelity mannequins and virtual or screen-based patients, cadaver-based learning experiences are not yet part of the curriculum.

“The most exciting thing for me as an educator was the absolute total engagement and enthusiasm of both the nursing and medical students during this teaching and learning experience,” said Dr. Joyce Burr, associate lecturer at the College of Nursing who accompanied the students to the workshop.

beneficiaries with end-stage renal disease (ESRD) receiving home dialysis and beneficiaries with acute stroke effective January 1, 2019. CMS is finalizing the addition of renal dialysis facilities and the homes of ESRD beneficiaries receiving home dialysis as originating sites, and to not apply originating site geographic requirements for hospital-based or critical access hospital-based renal dialysis centers, renal dialysis facilities, and beneficiary homes, for purposes of furnishing the home dialysis monthly ESRD-related clinical assessments. CMS is also finalizing policies to add mobile stroke units as originating sites and not to apply originating site type or geographic requirements for telehealth services furnished for purposes of diagnosis,

“It’s clear from listening to the student interactions that there is much to learn and share between disciplines. The medical students are teaching but they are also learning from the nursing students, and it shows that each partner on the team has something valuable to contribute, and the end product is a healthy patient.”

Pruitt worked with three other medical students and Dr. Daniel Topping, the Anatomy Lab’s director, to design a workshop curriculum that allowed nurses to see and touch core parts of the anatomy and common pathologies and review common clinical scenarios like hernias and lung damage while peering into the human body. The nurses also flushed central lines, inserted tracheal tubes and used manual resuscitators to inflate balloons as simulated lungs with medical devices donated by the Osceola Regional Medical Center.

“Nurses are at the bedside helping to place and monitor these devices, but they never really get to see what lies beneath the skin,” Pruitt said. “So we want them to get a better understanding of where these devices are traveling and how they work once they are in the body, so it will assist them when putting these devices in, and also be able to picture exactly what happens when a device fails or migrates out of place.”

Before studying in the lab, nursing students watched a videotape about the experience and the impact of their

evaluation, or treatment of symptoms of an acute stroke.

Clinical Laboratory Fee Schedule

The Clinical Laboratory Fee Schedule (CLFS) final rule entitled “Medicare Program: Medicare Clinical Diagnostic Laboratory Tests Payment System” implemented Section 1834A of the Social Security Act (the Act), which required extensive revisions to the Medicare payment, coding, and coverage for clinical diagnostic laboratory tests (CDLTs) paid under the CLFS. Beginning January 1, 2018, the payment amount for a test on the CLFS is generally equal to the weighted median of private payer rates determined for the test, based on the data of “applicable laboratories”

patient’s gift to medical education. At UCF’s medical school, cadavers are considered the student’s first patient.

Medical students talked to their nursing colleagues about honoring and respecting the person’s gift to their training. Pruitt will be analyzing the impact of the experience in a research study, and hopes his results will help make the program a staple for UCF nursing students.

With the development of UCF’s new Academic Health Science Center, which will ultimately bring many UCF health programs to Lake Nona and encourage more interprofessional education, research and patient care, Dr. Topping said the Anatomy Lab workshop can be a model for future collaborations between healthcare disciplines.

“Anatomy is fundamental to any discipline involved in direct care of patients, whether nursing, speech therapy, or pharmacology. And we have such a wonderful facility and resources here, which makes perfect sense for us to collaborate and begin partnerships,” he said.

“I also feel that our donors would want as many healthcare professionals as possible to benefit from their gift,” he added. “And what better way to do it than through these interprofessional collaborations.”

that is collected during a specified data collection period and reported to CMS during a specified data reporting period.

The first data collection period was from January 1 through June 30, 2016, and the first data reporting period was from January 1, 2017, through March 31, 2017, including an additional 60-day enforcement discretion period.

In determining payment rates under the private payer rate-based CLFS, one of our goals is to obtain as much applicable information as possible from the broadest possible representation of the national laboratory market on which to base CLFS payment amounts without imposing undue burden on those entities.

In the interest of facilitating this goal, CMS proposed a change to the way Medicare orlandomedicalnews

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GrandRounds Advantage payments are treated in our definition of “applicable laboratory.” CMS is finalizing this proposal, which we believe may result in additional laboratories of all types that serve a significant population of beneficiaries enrolled in Medicare Part C in meeting the majority of Medicare revenues threshold and potentially qualifying as an applicable laboratory and report data to CMS. In addition, CMS sought public comments on alternative approaches for defining an applicable laboratory, for example, using the Form CMS 1450 14X Type of Bill (TOB) or CLIA certificate number to define an applicable laboratory. Based on comments we received and further analysis of the various options, we are amending the applicable laboratory definition to include hospital laboratories that bill for their non-patient laboratory services on the CMS 1450 14X TOB bill. CMS also sought public comments on potential changes to the low expenditure threshold component of the definition of an applicable laboratory, and will consider those comments as we continue to evaluate and refine Medicare CLFS payment policy in the future.

Ambulance Fee Schedule Payments

The Bipartisan Budget Act of 2018 extended the temporary add-on payments for ground ambulance services for 5 years. The three temporary add-on payments include: (1) a 3 percent increase to the base and mileage rate for ground ambulance transports that originate in rural areas; (2) a 2 percent increase to the base and mileage rate for ground ambulance transports that originate in urban areas; and (3) a 22.6 percent increase in the base rate for ground ambulance transports that originate in super rural areas. These provisions were set to expire on December 31, 2017, but have been extended through December 31, 2022. The Bipartisan Budget Act also increased the payment reduction from 10 percent to 23 percent for nonemergency basic life support transports of beneficiaries with end-stage renal disease for renal dialysis services furnished other than on an emergency basis by a provider of services or a renal dialysis facility. This provision is effective with ambulance services furnished on or after October 1, 2018. CMS has revised the applicable regulations to conform with these requirements.

Recognizing Communication Technology-Based and Remote Evaluation Services for Rural Health Clinics and Federally Qualified Health Centers

For CY 2019, CMS finalized payment for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for communication technology-based services and remote evaluation services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit. These services will be payable for medical discussions or remote evaluations of conditions not related to an RHC or FQHC service provided within the previous 7 days or within the next 24 hours or at the soonest available appointment. RHCs and FQHCs will be able to bill for these services using a newly created RHC/FQHC Virtual Communication Service HCPCS code, G0071, with payment set at the average

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of the PFS national non-facility payment rates for communication technology-based services and remote evaluation services.

Wholesale Acquisition Cost-Based Payment for Part B Drugs: Finalizing a Reduction of the Add-on Amount Most Part B drug payments are based on Average Sales Price (ASP) methodology and, by statute, include an add-on payment of 6 percent of the ASP amount. Some Part B drug payments, are based on the wholesale acquisition cost (WAC). WAC-based payment amounts typically exceed amounts based on ASP. CMS has finalized a policy that, effective January 1, 2019, WAC-based payments for Part B drugs determined under section1847A of the Social Security Act, during the first quarter of sales when ASP is unavailable, will be subject to a 3 percent add-on in place of the 6 percent add-on that is currently being used. This change in policy will help curb excessive spending, especially for new drugs with high launch prices, and will also decrease beneficiary cost sharing.

The reduction of the add-on percentage for certain WAC-based payments for new Part B drugs is consistent with the Fiscal Year 2019 President’s Budget Proposal and MedPAC’s June 2017 Report to the Congress. In addition, CMS will also update manual provisions to permit Medicare Administrative Contractors to use an add-on percentage of up to 3 percent, rather than 6 percent, when utilizing WAC for pricing new drugs. We would also like to reiterate that these changes only apply to WAC-based payment for new Part B drugs.

and subsequent years.

Reducing the Shared Savings Program core quality measure set by eight measures; and promoting interoperability among ACO providers and suppliers by adding a new CEHRT threshold criterion to determine ACOs’ eligibility for program participation and retiring the current Shared Savings Program quality measure on the percentage of eligible clinicians using CEHRT.

Request for Information on Price Transparency

Under current law, hospitals are required to establish and make public a list of their standard charges. In an effort to encourage price transparency by improving the public accessibility of price information, CMS included a Request for Information related to price transparency and improving beneficiary access to provider and supplier charge information in the CY 2019 PFS proposed rule. CMS appreciates the input provided by commenters.

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging

For CY 2019, CMS is finalizing the revision of the significant hardship criteria in the AUC program to include: 1) insufficient internet access; 2) electronic health record (EHR) or clinical decision support mechanism (CDSM) vendor issues; or 3) extreme and uncontrollable circumstances. CMS is also finalizing allowing ordering professionals experiencing a significant hardship to self-attest their hardship status. In

addition, CMS is adding independent diagnostic testing facilities (IDTFs) to the definition of applicable setting under this program. This will allow the AUC program to be more consistently applied to outpatient settings. CMS is also allowing AUC consultations, when not personally performed by the ordering professional, to be performed by clinical staff under the direction of ordering professional. This will allow the ordering professional to exercise their discretion to delegate the performance of this consultation.

UCF Student Health Services Receives AAAHC Accreditation

UCF Student Health Services (SHS) has achieved accreditation by the Accreditation Association for Ambulatory Health Care (AAAHC) once again. SHS was first accredited in October of the year 2000. Accreditation distinguishes UCF Student Health Services from many other outpatient facilities by providing the highest quality of care to its patients as determined by an independent, external process of evaluation.

Status as an accredited organization means SHS has met nationally recognized standards for the provision of quality health care set by AAAHC. More than 6,000 ambulatory health care organizations across the United States are accredited

by AAAHC. Not all ambulatory health care organizations seek accreditation; not all that undergo the rigorous on-site survey

Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organizations (ACOs)

This final rule also addresses a subset of changes to the Medicare Shared Savings Program for ACOs proposed in the August 2018 proposed rule “Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations Pathways to Success” and other revisions designed to update program policies under the Shared Savings Program. In order to ensure continuity of participation, finalize time-sensitive program policy changes for currently participating ACOs, and streamline the ACO core quality measure set to reduce burden and encourage better outcomes, CMS is finalizing the following policies.

• A voluntary 6-month extension for existing ACOs whose participation agreements expire on December 31, 2018, and the methodology for determining financial and quality performance for this 6-month performance year from January 1, 2019, through June 30, 2019.

• Allowing beneficiaries who voluntarily align to a Nurse Practitioner, Physician Assistant, Certified Nurse Specialist, or a physician with a specialty not used in assignment to be prospectively assigned to an ACO if the clinician they align with is participating in an ACO, as provided for in the Bipartisan Budget Act of 2018.

• Revising the definition of primary care services used in beneficiary assignment.

• Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 orlandomedicalnews

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GrandRounds process are granted accreditation.

“We believe our patients deserve the best,” stated Dr. Michael Deichen, Executive Director of SHS. “When you see our certificate of accreditation, you will know that AAAHC, an independent, not-for-profit organization, has closely examined our facility and procedures. It means we as an organization care enough about our patients to strive for the highest level of care possible.”

Ambulatory health care organizations seeking accreditation by AAAHC undergo an extensive self-assessment and on-site survey by AAAHC expert surveyors – physicians, nurses, and administrators who are actively involved in ambulatory health care. The survey is consultative and educational, presenting best practices to help an organization improve its care and services.

“Going through the process challenged us to find better ways to serve our patients, and it is a constant reminder that our responsibility is to strive to continuously improve the quality of care we provide,” said Deichen.

Three Orlando Health Hospitals Earn Top Hospital Designations

Orlando Health Dr. P. Phillips Hospital, Orlando Health Orlando Regional Medical Center (ORMC) and Orlando Health Arnold Palmer Hospital for Children have been designation as Top Hospitals in the country by the Leapfrog Group, an independent hospital watchdog organization. Performance across many areas of hospital care is considered in establishing the qualifications for the award, including infection rates, maternity care, and the hospital’s capacity to prevent medication errors.

"This prestigious award affirms the dedication to excellence of all of our clinical and non-clinical teams,” said David Strong, president and CEO, Orlando Health. “To be recognized nationally for our high quality care and patient safety is an honor that we all are happy to share.”

The Top Hospital designation recognizes the highest performing hospitals in the Leapfrog Hospital Survey and is widely cited as one of the nation’s most competitive quality awards. Dr. P. Phillips Hospital is one of only 35 hospitals in the country to be designated a Top General Hospital. ORMC is one of only 53 hospitals to be named a Top Teaching Hospital. And Arnold Palmer Hospital is one of only 13 in the nation to earn the Top Children’s Hospital designation.

For hospitals to receive the designation, they must meet the Leapfrog Group’s high standards that are established and defined in each year’s Top Hospitals Methodology.

To qualify for the Top Hospitals distinction, hospitals must submit a Leapfrog Hospital Survey. The selection of Top Hospitals 2018 is based on surveys from nearly 1,900 hospitals.

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CMS Office of the Actuary Releases 2017 National Health Expenditures

Overall national health spending grew at a rate of 3.9 percent in 2017, almost 1.0 percentage point slower than growth in 2016, according to a study conducted by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS) and published as a Web First by Health Affairs. Medicare spending grew at about the same rate in 2017 as in 2016, while Medicaid spending grew at a slower rate in 2017 than in 2016.

According to the report, overall healthcare spending growth slowed in 2017 for the three largest goods and service categories – hospital care, physician and clinical services, and retail prescription drugs. Details from the slower spending growth in these three largest goods and service categories are: • Hospital spending (33 percent of total healthcare spending) decelerated in 2017, growing 4.6 percent to $1.1 trillion compared to 5.6 percent growth in 2016. The slower growth for 2017 reflected slower growth in the use and intensity of services, as growth in outpatient visits slowed while growth in inpatient days increased at about the same rate in both 2016 and 2017.

• Physician and clinical services spending (20 percent of total healthcare spending) increased 4.2 percent to $694.3 billion in 2017. This increase followed more rapid growth of 5.6 percent in 2016 and 6.0 percent in 2015. Less growth in total spending for physician and clinical services in 2017 was a result of a deceleration in growth in the use and intensity of physician and clinical services.

• Retail prescription drug spending (10 percent of total healthcare spending) slowed in 2017, increasing 0.4 percent to $333.4 billion. This slower rate of growth followed 2.3 percent growth in 2016, which was much slower than in 2014, when spending grew 12.4 percent, and in 2015, when spending grew 8.9 percent. These higher rates of growth in 2014 and 2015 were primarily the result of the introduction of new, innovative medicines and faster growth in prices for existing brand-name drugs.

Retail prescription drug spending growth slowed in 2017 primarily due to slower growth in the number of prescriptions dispensed, a continued shift to lower-cost generic drugs, slower growth in the volume of some high-cost drugs, declines in generic drug prices, and lower price increases for existing brand-name drugs.

The 3.9 percent growth in healthcare spending was slightly slower than growth in the overall economy (4.2 percent) in 2017. As a result, the healthcare spending share of the economy (17.9 percent) was similar to the share in 2016 (18.0 percent).

Growth in overall healthcare spending slowed for the second consecutive year, following elevated rates of growth in 2014 and 2015 that were affected by expanded Medicaid and private health insurance coverage and increased spending for prescription drugs, particularly for drugs used to treat hepatitis C.

Nemours Announces New Leader and Vision Private health insurance spending (34 to percent of total healthcare spending) Advance Pediatric increased 4.2 percent to $1.2 trillion Research in Health 2017, which was slower than the Additional highlights from the report regarding the source of funds include:

6.2 percent growth in 2016.

The Nemourswas Children’s Health deceleration influenced

by System slower announced the benefits appointment Mary growth in medical and a of decline Enterprise in M. feesLee, and MD, taxesasresulting fromChief the Scientific Officer for the multi-state Consolidated Appropriations Act 2016, pediatric healthcollection system. Dr. Lee, who which suspended of the health has served Nemours as an Enterprise insurance provider fee in 2017.

Vice President and Physician-inMedicare spending (20 percent of Chief of Delaware Valley Operations total healthcare spending) grew 4.2 since April, is being tapped in this percent to $705.9 billion in 2017, which new role to oversee and lead the was about the same rate as in 2016 organization’s efforts in developing when spending grew 4.3 percent. In better treatments and new cures to 2017, slower growth in fee-for-service help tomorrow’s children.

Medicare (Medicare FFS) spending (1.4 “We have a strong foundation of percent in 2017 compared to 2.6 percent pediatric research at Nemours. The in 2016) offset faster growth in spending appointment of a scientist of Dr. Lee’s for Medicare private health plans (10.0 stature underscores our deepening percent in 2017 compared to 8.1 percent commitment to research excellence,” in 2016). The trends in Medicare FFS and said R. Lawrence Moss, MD, president Medicare private health plan spending are and CEO of Nemours Children’s attributed in part to an increasing share Health System. “Dr. Lee’s leadership of all Medicare beneficiaries enrolling in will usher in Nemours’ next phase of Medicare Advantage. growth in academic medicine and Medicaid spending (17 percent help to expand the impact of our of total healthcare spending) growth research program.” slowed in 2017, increasing 2.9 percent Nemours’ research operations have to $581.9 billion following growth of 4.2 been a pillar of the organization’s percent in 2016. The slower growth in efforts in battling disease and total Medicaid expenditures in 2017 was improving the lives of children by influenced by a deceleration in enrollment helping to advance life-changing growth and a reduction in the net cost of medical care. In addition to a strong Medicaid health insurance resulting from commitment to basic science and an increase in recoveries from Medicaid clinical research, Nemours has been managed care plans for favorable prior a leader in digital health, with nearly period experience. State and local 30 years of continuous electronic Medicaid expenditures grew 6.4 percent, health records, and a telemedicine while federal Medicaid expenditures infrastructure. While these tools have increased 0.8 percent in 2017. In 2017, been primarily tapped for clinical states were required to fund 5 percent care, Nemours’ research has begun of the costs of the Medicaid expansion to identify novel ways to utilize these population, while in prior years these tools to make pediatric research costs were funded entirely by the federal more efficient, as well as reduce the government. burdens on patients and families.

Out-of-pocket spending (10 percent of “In order to provide the best care total healthcare spending) includes direct possible for children and to be a consumer payments such as copayments, world-class children’s health system, deductibles, and spending not covered we need to couple the delivery of by insurance. Out-of-pocket spending state-of-the-art patient centered care grew 2.6 percent to $365.5 billion in 2017, with rigorous scientific inquiry and which was slower than the 4.4 percent discovery research,” said Lee. “I am growth in 2016.

Sponsors of Healthcare. In 2017, the

federal government’s spending excited to advance these efforts on healthcare slowed, increasing 3.2 percent and further embed discovery and after 4.9 percent 2016. The innovation in ourgrowth clinicalin practice deceleration largely associated to help us was to transform pediatricwith slower federal Medicaid spending due healthcare.” to Prior lower to Medicaid joining enrollment Nemours, growth, Dr. a reduction thePhysician-in-Chief, federal government’s Lee servedinas share of funding newly Chair eligible and Professor and for Stoddard Medicaid enrollees, and a decline in the of Pediatrics at UMass Memorial net cost of insurance Medicare Children's Medical for Center andand Medicaid in private plans in University enrollees of Massachusetts Medical 2017. in household spending on School.Growth She brings strong operational, healthcare also slowed in 2017, increasing financial and strategic leadership 3.8 percent following having growth of 4.8 experience to Nemours, served percent in 2016.

The slowdown for 13 years in academic, clinical andwas mainly driven byleadership slower growth in out-ofadministrative roles.

Dr. pocket Lee hasspending. a significant history of funded Thepublished National research, Health Expenditure and faculty estimates haveand been revised to reflect recruitments promotions and isthe most recent and up-to-date data nationally recognized for her source research that is field available (and may not and haveher been in the of endocrinology available for inlast year’s vintage keen interest mentoring others. of the National B e y o nHealth d hExpenditure er p r o f eAccounts). ssional The 2017 National Health appointments, Dr. Lee hasExpenditures invested data andand supporting her time energy in information the scientificwill appear on the CMS chaired website at: https:// community having several www.cms.gov/Research-Statistics-Datastudy sections at the National and-Systems/Statistics-Trends-andInstitutes of Health (NIH) and served Reports/NationalHealthExpendData/ on the Scientific Advisory Council for National National HealthAccountsHistorical.html.

Institute of Environmental Health Sciences at NIH. She is the immediate past-president of the Reemphasis Of Pediatric Endocrine Society, a pastHepatitis A Vaccination president of the American Society of Recommendations After Andrology, and is an active member of the Association of Medical Substantial Increase School PediatricAcquired Department Chairs, In Locally American Pediatric Society, and the Infections Society for Pediatric Research. She has also routinely been recognized Pursuant to the authority granted in among the Best Doctors of America Section 381.00315, Florida Statutes, (2005-2018), andM.D., Top Pediatricians in Celeste Philip, M.P.H., as State America General (2012-2015).

Surgeon and State Health Officer, determines that a public health advisory is necessary to protect the public health and safety, and hereby issues the following

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GrandRounds Public Health Advisory Since January 2018, 385 cases of hepatitis A virus (HAV) infection have been reported in Florida. This is more than three times the previous five-year average of 126 cases. The increase in hepatitis A cases to date is predominantly in the Tampa Bay and Orlando metropolitan areas. Most of the cases do not involve international travel exposures. Although infections have occurred across all demographic groups, approximately 68% of the recent cases are among males. The median age of cases is 37 years and the highest rates of disease are among persons 30-49 years. Common risk factors include injection and noninjection drug use, homelessness, and men having sex with men (MSM).

Local and state health departments across the country have worked closely with the Centers for Disease Control and Prevention (CDC) to respond to similar outbreaks since March 2017. This year, health departments in Arkansas, California, Indiana, Kentucky, Massachusetts, Michigan, Missouri, North Carolina, Ohio, Tennessee, West Virginia and Utah, have investigated more than 8,000 outbreak associated cases of hepatitis A among persons who are homeless, persons who use drugs, men who have sex with men, and their close direct contacts.

HAV is transmitted person-to-person through fecal-oral route, which may include, but is not limited to, some types of sexual contact, and poor hand hygiene after going to the bathroom or changing diapers. HAV can also be spread through fecal-contaminated food or water. While most patients with HAV infections will fully recover, 77% of recent cases in Florida have required hospitalization.

Health care providers are also reminded to immediately report all cases of hepatitis A to your county health department to ensure a prompt public health response in order to prevent disease among close contacts.

South Lake Hospital to Fully Integrate with Orlando Health

Strengthening the commitment to provide quality healthcare services in South Lake County, Orlando Health and South Lake Memorial Hospital have signed an agreement that will soon make South Lake Hospital a controlled subsidiary of Orlando Health. Complete integration into the Orlando Health network will provide the scale necessary for South Lake Hospital’s long-term relevance in today’s rapidly changing healthcare environment.

“In 1995, Orlando Health assumed full management responsibility over the dayto-day operations of the hospital and 50 percent board representation,” said Paul Rountree, who served as chairman of the South Lake Memorial Hospital Board of Directors when the agreement was consummated. “This agreement is the final phase of that very successful relationship.”

“Over the years, Orlando Health has helped increase south Lake County residents’ access to emergency medical care, world-class oncology services and state-of-the-art rehabilitation therapies,” said David Strong, president and CEO, Orlando Health. “We’re excited about

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building on that success by enhancing outpatient services for infants, children and women through our renowned Arnold Palmer Medical Center, and further expanding oncology care by developing a more comprehensive cancer center that is a satellite location of our Orlando Health UF Health Cancer Center.”

The agreement coincides with South Lake Memorial Hospital’s creation of the Live Well Foundation of South Lake County, a new grant-making organization formed to help fund healthcare services in the south Lake community. Orlando Health will provide initial funding of $128 million to the new foundation after it is granted 501(c)(3) status, which is expected in a few months. South Lake Hospital will become a controlled subsidiary of Orlando Health upon the transfer of those funds, and South Lake Memorial Hospital will relinquish its board seats on the South Lake Hospital board.

“The new foundation will ensure that residents in Lake County will have access to quality health and wellness services close to home, now and well into the future,” commented Dr. Kasey Kesselring, who will serve as chairman of the Live Well Foundation of South Lake. “All services and facilities funded by the Foundation are required to be in south Lake County, so we will work closely with Orlando Health and South Lake Hospital leadership to continue to grow strategically and efficiently to meet the community’s healthcare needs.”

South Lake Hospital will continue to have a significant impact on the south Lake County community. Revenues generated by the hospital will remain in and be reinvested into the community. In 2017, the hospital provided $40 million in value to the region; $5 million of that in the form of charity care. South Lake Hospital is the third largest employer in the county and the largest employer in south Lake County with 1,600 team members. In 2015, the hospital reported an overall financial impact to the community of $229 million.

“This agreement represents a defining moment in south Lake County healthcare,” said John Moore, president, South Lake Hospital. “It allows us to strategically plan for the future with one of the top healthcare organizations in the region, while maintaining the culture of South Lake Hospital.”

In conjunction with the agreement, Orlando Health has committed more than $99 million over five years for capital improvements throughout the Lake County region.

Retired Officer Thanks Clinical Team after Surviving Three Rare Heart Procedures Tom Morrarty spent his life fighting crime and the past year fighting for his life.

Last Thanksgiving, Morrarty was in critical heart failure. Doctors kept him alive via a machine that took over for his heart and lungs. Soon after, he was given an artificial heart. Then, Morrarty suffered two strokes.

Months passed, and finally, Morrarty underwent a heart transplant.

On Monday, Morrarty returned to the intensive care unit at Florida Hospital Orlando where he stayed for so many months. But this time, he was walking, breathing and his own heart strongly beating.

Just in time for Thanksgiving, he stopped by to deliver a special message of thanks to the clinical team that saved his life and helped him survive the series of rare, critical procedures and surgeries.

We Need Your Help!

Shepherd’s Hope, the largest free and charitable clinic in Florida, is seeking an Endocrinologist to provide volunteer care for our patients (one three hour shift per month) at one of our five convenient locations in Central Florida.

For volunteer information contact Abby Seelinger, Manager of Volunteer Programs (407) 876-6699, ext. 233 | abby.seelinger@shepherdshope.org or visit www.shepherdshope.org/volunteers.

New Foundation Forms to Support Healthcare Services in South Lake County

A new organization has been formed to support health care services in South Lake County. The Live Well Foundation of South Lake, Inc., which was formed by the South Lake Memorial Hospital, Inc. (SLMH), officially incorporated in late September. It is currently developing guidelines and processes to enable it to begin operations.

“With the October 2019 dissolution of the South Lake County Hospital District,

“They got me through it. It’s amazing.

I’m very grateful for all they did,” said Morrarty, who retired to Florida in 2017 after serving 27 years in law enforcement in Connecticut.

Physicians were quick to point out they aren’t the ones deserving of thanks.

“It´s not me or our team giving them this gift,” said Dr. Scott Silvestry, surgical director of thoracic transplant at Florida Hospital, which will become AdventHealth in January. “The gift comes from a nameless, faceless stranger in the community whose thoughtfulness enables them to have their life back.”

Morrarty agrees and said he has much to be thankful for.

“I got a second chance at life, and that makes this Thanksgiving even more special,” he said.

SHARE YOUR PASSION: Help those in need of hope and healing in our community by joining our clinical and non-clinical volunteers at Shepherd’s Hope.

More volunteer doctors and nurses needed now more than ever to help fill the immense demand for healthcare services to the uninsured and under-insured men, women and children in Central Florida.

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GrandRounds we felt it necessary to create an ongoing funding source to address healthcare needs in our community,” said Paul Rountree immediate past chairman of the SLMH Board of Directors. “All funds generated by the Foundation will remain in south Lake County.”

“We’re excited about what the Foundation will mean to south Lake County,” said Kasey Kesselring, EdD, chairman of the Live Well Foundation of South Lake. “It will ensure that residents will continue to have access to high quality health and wellness services in our community, now and into the future.”

Dr. Kesselring, who is headmaster of Montverde Academy, is one of three current Foundation board members.

Other members of the all-volunteer board are Rodney Drawdy, senior vice president and director of consumer lending for CenterState Bank, and Linda Smith, cofounder of New Beginnings of Central Florida, a non-profit organization that serves the homeless through shelter, food and professional counseling including job counseling. A search is currently underway for an executive director for the Live Well Foundation of South Lake who will be responsible for its day-to-day and strategic operations. The position is currently posted on the Glassdoor.com and Indeed.com recruiting websites.

Initial funding to the Live Well Foundation of South Lake is being provided by Orlando Health, which currently manages South Lake Hospital.

Orlando Health will provide $128 million to the new foundation once it is granted 501(c)(3) status, which is expected in a few months. The contribution coincides with the hospital becoming a controlled subsidiary of Orlando Health per an agreement between Orlando Health and the South Lake Memorial Hospital organization, which results in South Lake Memorial Hospital relinquishing its seats on the board of South Lake Hospital.

“Our commitment to the South Lake County community dates back more than 20 years,” said David Strong, president and CEO, Orlando Health. “We have helped increase residents’ access to emergency medical services, state-ofthe-art rehabilitation therapies and worldclass oncology care. We’re excited about building on that success by adding and enhancing additional services.”

Orlando Health Oncology Program Ranked Among The Best in the Nation

Becker’s Hospital Review has named Orlando Health UF Health Cancer Center one of the 100 best programs for cancer treatment and research in the country.

Becker’s Hospital Review, the leading source of cutting-edge business and legal information for healthcare industry leaders, has been publishing rankings since 2012. Hospitals and cancer centers that are selected are leading the charge in cancer treatment and research. The list includes institutions with busy research institutes, multiple clinical trials and safety designations that exceed national benchmarks.

Orlando Health UF Health Cancer Center treats more than 80,000 patients annually.

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In 2017, the Cancer Center conducted more than 66 clinical trials and enrolled nearly 4,000 patients. With one of only 24 proton centers in the United States, the Cancer Center is also the only institution in central Florida to hold the Florida Cancer Center of Excellence Award. The Cancer Center expanded its reach this year with the opening of new facilities in the Dr. Phillips-area and Ocoee.

Leesburg Regional Medical Center Awarded Advanced ReCertification for Primary Stroke Centers

Leesburg Regional Medical Center announced that it has earned recertification and The Joint Commission’s Gold Seal of Approval® for Advanced Certification for Primary Stroke Centers. This also includes the American Heart Association/ American Stroke Association’s HeartCheck mark. The Gold Seal of Approval® and the Heart-Check mark represent symbols of quality from their respective organizations.

Leesburg Regional Medical Center has been accredited since 2011 and provides rapid treatment to more than 500 area residents who suffer a stroke annually.

“Stroke is a brain attack and we should think of it in the same way we think of a heart attack. You need to seek medical treatment quickly,” said Don Henderson, president and chief executive officer of Central Florida Health—the not-for-profit parent company of Leesburg Regional Medical Center. “Being a certified advanced primary stroke center means we have trained staff and leading-edge technology in place to make an accurate diagnosis and provide our patients with the right care in a timely manner.”

Leesburg Regional Medical Center underwent a rigorous on-site review to achieve its recertification. An expert from The Joint Commission reviewed the hospital’s compliance with strokerelated standards and requirements, including program management, the delivery of clinical care and performance improvement.

“We congratulate Leesburg Regional Medical Center for achieving this designation,” said Nancy Brown, chief executive officer, the American Heart Association/American Stroke Association.

“By adhering to this very specific set of treatment guidelines, LRMC has clearly made it a priority to deliver high quality care to all patients affected by stroke.”

“We are pleased to be recertified by The Joint Commission and the American Heart Association/American Stroke Association,” continued Henderson.

“Due to the hard work and dedication of our stroke care clinical team, including our physician partners, this designation provides us with an opportunity to highlight the exceptional stroke care we deliver as well as to continually strive to further advance the quality of our care.”

PMC Recognizes Employee Limary Montanez was recently selected by the leadership team at Poinciana Medical Center as the hospital's employee of the month. Montanez, a dietitian in the hospital’s Food and Nutrition Services Department, was nominated for going above and beyond in her job and embodying the hospital’s motto: “Every Patient Every Time.” Pictured: Chris Cosby, CEO of Poinciana Medical Center (left), Limary Montanez (right).

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GrandRounds Two Orlando-Area HCA Hospitals Receive Leapfrog ‘A’ Grades For Patient Safety

Two local HCA North Florida Division hospitals – Osceola Regional Medical Center and Central Florida Regional Hospital – were awarded ‘A’ grades from The Leapfrog Group’s Fall 2018 Hospital Safety Grade. The designation recognizes the hospitals’ efforts in protecting patients from harm and meeting the highest safety standards in the United States. The Leapfrog Group is a national organization committed to improving health care quality and safety for consumers and purchasers. The Safety Grade assigns an A, B, C, D or F grade to hospitals across the country based on their performance in preventing medical errors, infections and other harms among patients in their care.

“We are thrilled to once again receive an ‘A’ rating from The Leapfrog Group,” said Davide Carbone, CEO of Osceola Regional Medical Center. “This score is a great representation of our team’s commitment to providing high-quality care to every patient that comes through our doors.”

“Ensuring patient safety is our staff’s top priority, and is a responsibility we take seriously,” said Wendy Brandon, CEO of Central Florida Regional Hospital.

“It is an honor to receive recognition for exemplifying HCA’s dedication to the care and improvement of human life.”

“Leapfrog’s Hospital Safety Grades recognize hospitals like Osceola Regional Medical Center and Central Florida Regional Hospital that focus on advancing patient safety. This ranking provides an important resource for patients, and a benchmark for hospitals, to determine how care at one hospital compares to others in a region,” said Leah Binder, president and CEO of The Leapfrog Group. “Hospitals that earn an A Hospital Safety Grade deserve to be recognized for their efforts in preventing medical harm and errors.”

Developed under the guidance of a National Expert Panel, the Leapfrog Hospital Safety Grade uses 28 measures of publicly available hospital safety data to assign grades. Out of more than 5,500 hospitals nationwide, approximately 2,600 facilities were recognized and only 855 received ‘A’ grades this fall.

New Online Tool Displays Cost Differences for Certain Surgical Procedures

New Online Tool Displays Cost Differences for Certain Surgical Procedures The Centers for Medicare & Medicaid Services (CMS) launched a new online tool that allows consumers to compare Medicare payments and copayments for certain procedures that are performed in both hospital outpatient departments and ambulatory surgical centers. The Procedure Price Lookup tool displays national averages for the amount Medicare pays the hospital or ambulatory surgical center and the national average copayment amount a beneficiary with no Medicare supplemental insurance would

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pay the provider.

“Price transparency in health care is a priority for the Trump Administration.

Working with their clinicians, the Procedure Price Lookup will help patients with Medicare consider potential cost differences when choosing where to have a medical procedure that best meets their needs,” said CMS Administrator Seema Verma.

The Procedure Price Lookup tool is launching as required by Congress in the 21st Century Cures Act. Medicare’s statutes require that CMS maintain separate payment systems for different types of healthcare providers, meaning both CMS and patients may pay different amounts for the same service, depending on the site of care.

“The different payment rates are a prime example of Medicare’s misaligned financial incentives, under which providers can make more money if they see patients at one location as opposed to another,” Administrator Verma said.

Procedure Price Lookup, part of the agency’s eMedicare initiative, joins other patient-oriented transparency tools, including an overhauled version of the agency’s drug pricing and spending dashboards, which provide patients with Medicare and Medicaid spending information for thousands more drugs than ever before and, for the first time, list the prescription drug manufacturers that were responsible for price increases.

CMS recently launched the eMedicare initiative to empower beneficiaries with cost and quality information. This announcement included the launch of an enhanced interactive online decision support feature to help people better understand and evaluate their Medicare coverage options. eMedicare also offers a mobile-optimized out-of-pocket cost calculator to provide beneficiaries with information on overall plan costs and prescription drug costs.

For a blog post on the Procedure Price Lookup took by Administrator Verma, please visit: https://www.cms.gov/blog/ you-have-right-know-price.

The Procedure Price Lookup tool is available at: https://www.medicare.gov/ procedure-price-

Florida Hospital Celebration Health achieves Magnet® recognition

Florida Hospital Celebration Health attained Magnet recognition as testament to its dedication to highquality nursing practice. The American Nurses Credentialing Center’s Magnet Recognition Program® distinguishes health care organizations that meet rigorous standards for nursing excellence.

This credential is the highest national honor for professional nursing practice.

Receiving Magnet recognition is a great achievement for Florida Hospital Celebration Health, as it now belongs to the global community of Magnetrecognized organizations. Only 6.65 percent of U.S. health care organizations — 419 out of over 6,300 U.S. hospitals — have achieved Magnet recognition.

“Magnet recognition is a tremendous honor and reflects our commitment to delivering the highest quality of care to

this community,” said Doug Harcombe, administrator of Florida Hospital Celebration Health. “To earn Magnet recognition is a great accomplishment and an incredible source of pride for our nurses. Our achievement of this credential underscores the foundation of excellence and values that drive our entire staff to strive harder each day to meet the health care needs of the people we serve.”

Research demonstrates that Magnet recognition provides specific benefits to health care organizations and their communities, such as: Higher patient satisfaction with nurse communication, availability of help and receipt of discharge information.

Lower risk of 30-day mortality and lower failure to rescue rates.

Higher job satisfaction among nurses.

Lower nurse reports of intentions to leave their positions.

Magnet recognition is the gold standard for nursing excellence and is a factor when the public judges health care organizations.

U.S. News & World Report’s annual showcase of “America’s Best Hospitals” includes Magnet recognition in its ranking criteria for quality of inpatient care.

The Magnet Model provides a framework for nursing practice, research, and measurement of outcomes. Through this framework, ANCC evaluates applicants across a number of components and dimensions to gauge an organization’s nursing excellence.

The foundation of this model comprises various elements deemed essential to

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delivering superior patient care. These include the quality of nursing leadership and coordination and collaboration across specialties, as well as processes for measuring and improving the quality and delivery of care.

Health care organizations must reapply for Magnet recognition every four years based on adherence to Magnet concepts and demonstrated improvements in patient care and quality.

An organization reapplying for Magnet recognition must provide documented evidence to demonstrate how staff members sustained and improved Magnet concepts, performance and quality over the four-year period since the organization received its initial recognition.

Axolotl Biologix Launches New Axolotl Shot™ For Wound Care

Axolotl Biologix, an innovative biotechnology leader in regenerative medicine, is proud to announce the launch of Axolotl Shot™, an ambient temperature regenerative fluid preloaded into a syringe for ease of use by physicians.

Axoltol Biologix is the first to market a pre-loaded syringe containing a regenerative fluid that is manufactured using the proprietary BioSym™ process to yield growth factors and cytokines known to stimulate cellular growth and repair. It offers significant therapeutic benefits to help facilitate repair and regeneration of damaged cells and tissues

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GrandRounds “Our new Axolotl Biologix treatment option uses the latest advances in biotechnology to improve patient outcomes while making it more convenient for physicians,” said Dr. Robert Kellar, Chief Science Officer. “The Axolotl Shot is pre-loaded in 1mL and 2mL volumes, terminally irradiated for use in surgical applications, and since it can be stored at room temperature there is no storage concerns or down time waiting for product to thaw.”

This new option benefits consumers because it can be applied during a sameday outpatient visit, helping patients avoid the costs, pain and downtime associated with surgery.

“Axolotl Biologix is excited to introduce the Axolotl Shot which has potential clinical benefits in a variety of applications that will help physicians, orthopods, and wound care specialists save time and money treating patients,” said Phillip Larson, President of Axolotl Biologix.

Axolotl Shot is a regenerative fluid derived from the amniotic components of the placenta to promote regeneration and repair of damaged or degenerated tissues. Donor tissue is recovered and processed aseptically in accordance with all FDA guidelines and quality assurance standards in a controlled environment.

AMA Study Offers First National Estimate Of Telemedicine Use By Physicians

The American Medical Association (AMA) today presented the first nationally representative estimates on how many physicians use telemedicine, and what functions it serves in their practices.

Based on a 2016 survey of patient care physicians from all corners of the medical profession, the results gauge the emergence of telemedicine and its integration into health care delivery. The AMA’s benchmark telemedicine study was published in the December issue of Health Affairs.

“While regulatory and legislative changes have been implemented to encourage the use of telemedicine, there are no nationally representative estimates on its use by physicians across all medical specialties,” said Carol K. Kane, study co-author and AMA director of economic and health policy research. “To fill this information gap, the AMA study surveyed 3,500 physicians to provide needed data that will help assess potential barriers and create strategies to promote telemedicine adoption.”

Key findings from the AMA study include:

Overall Use of Telemedicine

Fifteen percent of physicians worked in practices that used telemedicine for patient interactions, such as diagnosing or treating patients, following up with patients, or managing patients with chronic conditions.

Eleven percent of physicians worked

in practices that used telemedicine for interactions with health care professionals, such as having a specialty consultation, or getting a second opinion.

Telemedicine Use by Specialty

Radiologists (39.5 percent), psychiatrists (27.8 percent), and cardiologists (24.1 percent) had the highest use of telemedicine for patient interactions. In other specialties, the use of telemedicine for patient interactions ranged from 6.1 percent to 23.0 percent.

Emergency medicine physicians (38.8 percent), pathologists (30.4 percent), and radiologists (25.5 percent) had the highest use of telemedicine for interactions with health care professionals. In other specialties, the use of telemedicine for interactions with health care professionals ranged from 3.3 percent to 14.9 percent.

Telemedicine Use by Modality

Videoconferencing was the telemedicine modality with the most widespread use. Videoconferencing was used in the practices of 12.6 percent of physicians. Use of videoconferencing was most common among emergency medicine physicians (31.6 percent), psychiatrists (25.8), and pathologists (24.1 percent).

Store and forward of patient data for analysis and diagnosis was used in the practices of 9.4 percent of physicians. Using telemedicine to store and forward patient data was most common among radiologists (42.7 percent), pathologists (22.7 percent), and cardiologists (14.9 percent).

Remote patient monitoring (RPM) was used in the practices of 7.3 percent of physicians. Use of remote patient monitoring

was most common among cardiologists (17.9 percent), nephrologists (15.4 percent), and neurologists (12.8 percent).

Telemedicine Use by Practice Characteristics

Physicians in smaller medical practices and physician-owned medical practices had a lower rate of telemedicine use than physicians in larger medical practices and ones that were not physician-owned. The findings suggest the financial burden of implementing telemedicine may be a continuing barrier, especially for that segment of practices.

The AMA is committed to making technology an asset, not a burden, and continues to invest in resources that provide physicians with a proven path for integrating telemedicine and digital health technologies into patient care.

A module in the AMA’s STEPS Forward™ collection of practice improvement strategies can help physicians use telemedicine in practice. In the module, physicians will learn the four steps to adopting telemedicine and how to navigate the benefits and challenges of remotely monitoring patients.

The AMA’s Digital Health Implementation Playbook offers a 12steps process for adopting RPM using devices, trackers and sensors to capture and record patient-generated health data outside the traditional clinical environment.

Through RPM, physicians can apply patient-generated health data to improve the management of chronic disease, while engaging patients in their own care.

Shepherd's Hope Announces Resignation of President/CEO Shepherd's Hope has announced the resignation of President and CEO Marni F. Stahlman, Ph.D., ABD, who has accepted an appointment to join the Make-A-Wish® Foundation of Central and Northern Florida as its President and CEO. Stahlman's last day with Shepherd's Hope will be Jan. 4, 2019.

The leadership of Shepherd's Hope Board of Directors has begun a nationwide search for a new CEO. In the meantime, the organization will continue to execute its strategic 2019 plan under the interim leadership of Jean Zambrano, vice president of Clinical Operations.

"On behalf of the Board of Directors of Shepherd's Hope, we congratulate Marni on her exciting new role with Make-AWish, one that comes with significant state and national responsibilities," said Board Chairman Chirag B. Kabrawala. "We expect she will help Make-A-Wish grow and excel as she did with Shepherd's Hope.

More importantly, we thank Marni for her dedication to Shepherd's Hope during her tenure and wish her much success."

Stahlman joined Shepherd's Hope in 2013 during a significant turning point in its history when patient needs were significantly outpacing the capacity of the organization. Stahlman joined the organization to help it achieve (and surpass) numerous goals, including streamlining operations, reducing and realigning clinic locations, expanding operating hours,

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establishing electronic recordkeeping, cultivating new donor and business relationships, recruiting new Board members, and assisting in the selection and development of a new clinic and administrative office for the organization.

A few of Stahlman's many accomplishments during her five-year tenure with Shepherd's Hope include: System-wide implementation of the Cerner electronic health record software; Newfound partnerships and collaborations with numerous training institutions, including Seminole State College, UCF College of Nursing, Adventist University and UCF College of Medicine, each of which include training within clinics as part of each student's matriculation; and Overseeing the financing, construction, development, and staffing of the organization's new facility in Winter Garden (which is scheduled to open this upcoming February).

Said Founder and Past President of Shepherd's Hope Dr. William S. Barnes, who is also the Teaching Pastor of St. Luke's United Methodist Church, "Marni has been a stalwart custodian of the vision I shared from our beginning, and watching her expand the scope and healing outreach of Shepherd's Hope over the years of her leadership have been a true gift that both honors the past and embraces the future. As for her own

future, I couldn't be happier for her and for the Make-A-Wish Foundation."

Stahlman said, "Five and half years ago, I was called to Shepherd's Hope and received a clear directive from the Board that a transformative vision and action plan was needed if the organization was to rise to its next elevation in the community. My decision to transition to this new opportunity is based on a similar calling. It has been an honor to lead thousands of 'Caring People, Caring for People,' and I firmly believe that this essential 'caring' characteristic of every team member, board member, volunteer, community partner and donor makes Shepherd's Hope unique and special. I am proud of the progress of the entire Shepherd's Hope team and am committed to a seamless transition and uninterrupted execution of the Board's vision."

Added Chairman Kabrawala, "I cannot argue with that reasoning; Marni has helped change the trajectory of this organization, which is on the cusp of opening the doors of its new facility, and is very much part of the conversation locally, state-wide, and nationally with regard to the healthcare continuum, thanks to the 'brand recognition' enjoyed

by Shepherd's Hope."

Orlando Medical News is proud to be a strong supporter of Shepherd's Hope and appreciates the leadership shown by Marni and is excited for her opportunity.

We also look forward to the excellent choice we know the Board will make to continue their mission.

Shepherd's Hope is the leading voice for the uninsured and underinsured in Central Florida. Founded in 1997, the faith-based nonprofit organization provides free primary care and specialty care medical services to uninsured men, women and children from five free standing health centers in Orange and Seminole counties.

In 2017, Shepherd's Hope provided 19,575 free patient visits and medical services thanks to partnerships with 2,800 licensed medical and general volunteers, three community hospital systems, 100 diagnostic/secondary providers and 23 multi-faith partners. To learn more, visit www.shepherdshope.org

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Four Ways the Marriage of Telehealth and AI Will Transform Virtual Care in 2019 Telehealth and AI are making strides in leaps and bounds, greatly enhancing services and patient care in the field of medicine. With technology taking on such a paramount role in the system, the healthcare climate is shifting gears, focusing its efforts on patient services by enabling individuals to monitor their own health, access their medical records and share critical information in a convenient, safe and efficient manner.

Thanks to improved legislation and positive trends in reimbursement, telehealth is rapidly gaining a newfound momentum. New bills have been recently signed to further the progress of telehealth implementation on a nationwide scale by removing previously established barriers.

As the U.S. faces the real possibility of experiencing shortage of up to 120,000 physicians by 2030, telehealth is quickly being recognized as a valued and cost-effective means of providing healthcare to patients with mobility, geographical or financial limitations.

The technology will also be instrumental in improving disease detection, diagnoses and treatment plans in rural areas where accessibility is limited due to underdeveloped facilities and physician shortages.

A variety of institutions, such as hospitals and clinics, are beginning to adopt telehealth technology as an affordable, quality complement to their existing services. Artificial Intelligence (AI) is bringing healthcare solutions to an entirely different level, enhancing the functionality of telehealth platforms and devices.

Following are some of the ways telehealth and AI are working together to transform virtual care in 2019: REMOTE HEALTH MONITORING Online platforms, applications and devices for monitoring chronic diseases have existed for years, but AI is making it easier to report, track and forecast patterns in real-time, facilitating the ability to take preventive measures and more effectively manage health for improved outcomes. Algorithms also now have the ability to uncover detailed insig hts and predict patterns, facilitating diagnostics and enabling the customization of care plans.

As the trend toward preventive healthcare and home monitoring grows, more people are embracing systems that incorporate predictive analytics to monitor conditions and transmit patient readings to clinics, hospitals, physicians’ offices and even family members.

Emerging AI is now making it possible for consumers to self-diagnose by evaluating their vital signs though tele17

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health’s diagnostic tools. Doctors can then analyze the readings and consequently take the necessary follow-up measures by scheduling a virtual visit or prescribing medication.

New medical-grade apps and platforms are also hitting the scene, enabling the detection of a variety of conditions ranging from skin cancer to heart disease.

As research and technology progress, devices will be increasingly sophisticated and tailored to the market’s needs.

MEDICATION MANAGEMENT The smart pill box, a system that monitors medication adherence through Bluetooth technology, has been on the market for some time, but a new forward-thinking technology is hitting the scene in the form of digestible pills equipped with sensors. Abilify MyCite has introduced a digital sensor-based version of Ariprazole, an anti-psychotic medication used to manage conditions like schizophrenia and bipolar disorder. The sensor is activated when mixed with a specific stomach fluid.

The data is then transmitted to a wearable patch, which is consequently submitted to a patient’s online data portal for review by a healthcare professional. This system is a major breakthrough, helping to monitor a patient’s medication compliance in order to achieve peak mental health.

VIRTUAL PHYSICIAN VISITS Te l e h e a l t h p l at fo r m s a re in full swing, allowing patients to schedule visits with primary care physi-

cians and specialists in the convenience of their own home, at a fraction of the cost. This accessibility not only helps patients become more proactive with their health, but also extends care to people who live in remote locations or have mobility issues.

The incorporation of AI into virtual visits creates a realistic environment for the patient thanks to the use of advanced diagnostic technologies that can monitor specific conditions. The benefits of these virtual visits are many, with patients relishing the convenience of managing their health remotely, as well as the comfort experienced from avoiding the sometimesunhealthy setting of a hospital. In addition, telehealth is extremely cost-effective.

Virtual telehealth is also gaining popularity in the psychology segment, allowing patients to access a wide array of behavioral healthcare providers through video conferencing.

Because of the shortage of mental health professionals, telehealth allows those with psychiatric problems to meet in a virtual setting without geographical boundaries. Schools, prisons and health centers are quickly integrating telehealth as a key component of behavioral healthcare management that can treat patients in a faster, discreet and more comfortable manner, thus lessening the burden placed on hospitals.

because of its proven ability to improve patient treatment times, reduce costs, and enhance patient outcomes. One such example is the introduction of a new smart technology that allows ambulances to send a patient’s digital vital readings to the hospital prior to arrival. Emergency departments are also enhancing their services by logging patients’ data at the triage center and then digitally transferring the information to an on-site physician or a healthcare professional at another hospital.

Intensive care units are using AI telehealth platforms to monitor patients around the clock. This is especially valuable for rural hospitals because it enables them to submit patient readings to larger, specialized hospitals without transferring the patient.

Telehealth technology streamlines processes in the health industry and helps amplify the effectiveness of the services provided by healthcare professionals.

The implementation of advanced telehealth solutions in mainstream healthcare is progressing at a satisfying rate, and while some challenges remain, barriers are slowly breaking down, paving the way to a bright future for the global healthcare industry.

Mary Gorder is the founder and president of Drs. On Calls , a virtual health technology company whose mission is to make healthcare accessible to all through compassionate, convenient and affordable telehealth services.

EMERGENCY CARE Emergency care is welcoming the partnership between telehealth and AI

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U.S. Surgeon General Discusses Public Health Issues From The Doctor’s Company

The Doctors Company’s 2018 Executive Advisory Board meeting—a gathering of some of the leading figures in medicine in the United States—featured a conversation between The Doctors Company Chairman and Chief Executive Officer Richard E. Anderson, MD, FACP, and the United States Surgeon General, Vice Admiral Jerome M. Adams, MD, MPH. In this second of two articles highlighting key excerpts from the conversation, Dr. Anderson and Dr. Adams discuss the dangers of e-cigarettes and the movement to population health.

DR. ANDERSON: The Surgeon General’s office has been relentless in highlighting the dangers of cigarette smoking. My impression is that despite a decades-long reduction in the overall incidence of smoking, the percent of smokers in the United States is still very high—I think something around 20 percent, which leads us to a major controversy—and that is the role of e-cigarettes, vaping, and nicotine substitutes for cigarettes. It’s a complex issue with a lot of tentacles, but we would be grateful if you would give us some of your thoughts about that.

DR. ADAMS: This is a very important and personal topic for me. I’ve got three young kids. I’m not just dealing with this as a surgeon general or as a physician; I’m dealing with it as a dad.

Respectfully, I think that folks are purposely making it a complicated issue. I don’t think it’s that complicated.

We know that the combustible cigarettes are bad. We know that nicotine is addictive. E-cigarettes and vaping can be two things at once. There can be harm reduction compared to combustible cigarettes for current smokers, but they can also be a dangerous initiation into the world of smoking.

I believe, and I hope all of you in the audience can say it loudly: No young person should be vaping. No young person should be using e-cigarettes. No one should be marketing these products with flavors like cotton candy and bubble gum to young children.

I’m working with the FDA and Commissioner Scott Gottlieb on this issue. We know the brain continues to develop up until age 26, and we know the folks are susceptible to developmental delays and effects on the brain, which prime it.

well as different ways of accessing care throughout the system.

But an important part of the conversation in that transformation is the discussion of population health versus the traditional doctor-patient and the individual patient and the individual office.

It’s really struck me that this conversation is very much akin to the entire discipline of public health, which after all is focusing primarily on population health. How do you find that your background in public health helps you? How does it affect the way you see this national transformation?

DR. ADAMS: A lot of our problems stem from the fact that we don’t teach enough about public health and population health to our medical students or nursing students. We don’t teach enough about how to discuss proper diet, how to talk about exercise, or how to talk about smoking cessation—all things that are promoted as part of public health.

That said, we’re all quickly being forced to get to grips with that because of changes in payment models. We found that in paying for procedures and cutting things up piecemeal and then reimbursing for them is not only ineffective, it’s costlier.

And so now when we look at paying for outcomes, we’re having to embrace population health. The good news is doctors, nurses, and healthcare professionals are all more satisfied when they’re able to do that. When systems are put in place that give them that freedom, flexibility, and the tools they need, it allows them to serve the patient.

JEROME M. ADAMS, MD, MPH It empowers professionals to refer patients or to write a prescription for food; it allows them to refer patients to community recreation centers where they can exercise—and ultimately, that patient becomes healthier because of something that you’ve been able to facilitate as a medical practitioner. So, we’re shifting in that direction; some people are kicking and screaming, others are embracing it.

Dr. Adams is the 20th Surgeon General of the United States, a post created in 1871. He holds degrees in both biochemistry and psychology from the University of Maryland. In addition, the Surgeon General has a master’s degree in public health from the University of California at Berkeley, and a medical degree from the Indiana University School of Medicine. Dr. Adams is a board-certified anesthesiologist and associate clinical professor of anesthesia at the University of Indiana. He has been active in a number of national medical organizations, including the American Society of Anesthesiologists and the American Medical Association.

DR. ANDERSON: The healthcare delivery system in the United States is undergoing a kind of once in a hundredyear cycle of change in the way care is delivered in almost every parameter of care; there are new technologies, new medications, new surgical potential, as 18

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Helping Your Employees Protect Themselves and Your Practice

By CURTIS PARTRIDGE

Failures in cybersecurity are continuing to garner front page news coverage.

The latest is the fear that hackers have accessed more than 500 million customer records in Marriott International’s data systems. Cybersecurity needs to be a real concern for businesses of all sizes.

According to a recent Enterprise Phishing Susceptibility and Resiliency Report 91 percent of cyberattacks begin with a phishing email. A Phishing email is a message that directs a user to visit a web site to update personal information or credentials such as bank account numbers, passwords, credit card information, or social security numbers.

Another form of attack is “vishing” or voice phishing scams where a convincing criminal calls an employee to obtain secure information. Voice scams can be more insidious because people tend to believe a phone call a “secure” form of communication. Either way it comes down to criminals taking advantage of the general trusting behavior of humans.

The cybersecurity experts have developed many tools and practices that protect practice data, but the most essential element of any good security protocol is employee training. Employee training can feel time consuming, but it doesn’t have to be expensive. The cost of one cybersecurity breach will be far more time consuming and much more expensive.

What do you share with your employees to protect themselves and your practice?

• Encourage employees to consider their own safety as well as the security of the company. Criminals are searching for employee personal information as well as company data.

Create a privacy culture in your organization.

• Ask employees to be open and question any odd-looking emails 20

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or phone calls with supervisors or practice IT professionals.

• Make your cybersecurity training steps actionable. A training program with one to three practical actionable tips on what people should or should not do will make it more memorable.

A follow up later will help to cement the tips in user’s minds.

• Don’t cover more than three topics in a training session. Continue to revise and improve training material and offer follow up training every 90 days or so.

• Make cybersecurity training mandatory for everyone. Today everyone receives email and phone calls and it is best to not leave anyone behind.

• Be creative and have fun with the process. Prizes and games are a fantastic way to keep the conversation lively and interesting.

• Utilize tools available to test your employees. There are free or low-cost tools to send test emails to employees available from Microsoft and others.

Don’t call out individual employees for failure but use it to gauge the overall readiness of your staff. This also assists you in finding training subjects for future sessions.

It is important to not assume your employees know. Frequent reminders also keep security top of mind. You can also stress the importance of employee cybersecurity by providing a personal data plan as an employee protection. Personal information plans can be purchased inexpensively in a group setting.

Curtis Partridge has over 20 years of experience in information technology focused on small to medium businesses. He has been a corporate IT manager as well as a consultant. He is currently Senior Systems Engineer for Lotus Management Services consults with businesses to implement and manage technology solutions.

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Health Plans and Providers Turn to Comprehensive, Flexible and Efficient Solutions to Mitigate Data Breaches, Optimize Value-Based Strategies

By JAY BAKER

Data breaches continue to burden health plans and providers at an alarming rate. While healthcare providers’ sites, such as hospitals and physician offices, are the largest target, health care plans account for the greatest number of health plan member records stolen over the past several years.

Centralized databases offer a wealth of health records that can be used to improve healthcare, but it’s critically important for all stakeholders to balance the risks of being hacked against the benefits.

Breaches represent one area where providers and health plans must focus their attention, while also navigating the increasingly complex regulatory and risk management environment -- especially for those striving to adopt value-based models of care. Toward that end, a fully equipped health information management solution has become essential for organizations seeking to improve care, member outcomes and ROI. Mitigating the Risks of DataSharing While better policies and procedures and the use of encryption have helped reduce easily preventable breaches, more should be done to protect patient/member privacy and mitigate associated costs.

Therefore, healthcare organizations should seek a technology-enabled platform that optimizes operational viability, helps to improve member outcomes at reduced costs, and ensures data security and privacy. The first step is to look for a vendor that has earned the Health Information Trust Alliance (HITRUST) Common Security Framework (CSF) certification.

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Key HITRUST Advantages As healthcare data shifts from local infrastructure to the cloud, the ability to control and secure data weakens, creating substantial challenges for health plans and hospitals that need to assess third-party vendors and ensure that data complies with HIPAA and other regulations.

HITRUST was founded on the belief that information security should be the core pillar of the broad adoption of health information systems and exchanges.

HITRUST CSF certification can be used by all organizations to guide them in selecting and implementing the appropriate controls to protect the systems that create, access, store or exchange personal health and financial information. Certification gives organizations detail and clarity related to information security controls tailored to the healthcare industry.

Certification carries key advantages: • Ensures a level of consistency from one assessment to another • Offers a gap analysis to help further assess a vendor’s security posture, which saves substantial resources • Cross references the requirements from legislative, regulatory, HIPAA, NIST, ISO, state laws and others for one comprehensive framework • Provides a framework that prepares organizations for new regulations and security risks once introduced • Ensures compliance and security protection to clients • Assures payers working with vendors that the platform is compliant, private and secure and meets the necessary requirements of HITRUST CSF certification Bottom line: Certification means a

third-party assessed the platform and attests to its compliance with globally recognized standards, regulations and business requirements, ensuring data security, privacy and compliance.

Full-spectrum, End-to-end Solution Healthcare organizations should look for an integrated risk adjustment optimization and quality improvement solution that has HITRUST CSF certification as validation of a commitment to improving the health of healthcare and providing innovative solutions for health plans across the country.

It should also provide a comprehensive risk adjustment solution that plays an integral role in helping health plans and risk-bearing entities improve measured quality. Furthermore, the solution should combine risk adjustment and quality improvement services and provide real-time visibility and reporting for risk adjustment

analytics, medical record retrieval, HEDIS abstraction, risk adjustment coding, claims and data validation, prospective health assessments, clinical abstraction, member engagement/outreach and provider education. It should also be designed to integrate risk adjustment and quality services to deliver fully transparent insights.

Success in value-based approaches pivots around delivering on total member health, cost, and quality rather than relying on the traditional model of maximizing relative value units, revenue and downstream referrals. Ultimately, patients reap the greatest benefit by being guided toward more preventive care and selfmanagement early in the care process while their information and privacy remain protected.

Jay Baker is the senior vice president of product management for Advantmed, LLC, providing risk adjustment and quality improvement solutions for health plans, provider groups and ACOs. Visit Advantmed.com

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Asthma: A Silent Killer?

Winter can be a hazardous time of year for those with asthma. Hospital admissions for asthma typically peak in the winter months, December and January.

Falling temperatures and cold and flu viruses are just two of the dangers that put people with asthma at risk during the winter months.

According to the Asthma and Allergy Foundation of America, 7.6 percent of adults and 8.4 percent of children in the U.S. have asthma. In 2015, 3,615 people in the country died from it.

Asthma is a condition in which the airways narrow and swell and produce extra mucus. This can make breathing difficult and trigger coughing, wheezing and shortness of breath. For some, asthma symptoms can be minor; for others, it can be a major medical problem that interferes with daily activities and may lead to a lifethreatening asthma attack.

Signs and symptoms of asthma include: shortness of breath, chest tightness or pain, trouble sleeping caused by shortness of breath, and wheezing when exhaling. For some, asthma signs and symptoms can flare up in certain situations. Exposure to various irritants and substances that trigger allergies can trigger signs and symptoms of asthma. Asthma triggers can include: airborne substances (pollen, dust mites, mold spores, pet dander), respiratory infections, physical activity (exercise-induced asthma), cold air, air pollutants and irritants

(ie, smoke), etc.

There are diagnostic tests that can be performed to diagnose asthma including: lung function tests such as spirometry and peak flow. Lung function tests are done before and after taking a bronchodilator to open the airways. If lung function improves with use of a bronchodilator, it’s likely asthma.

Imaging can also be used for diagnosis. A chest X-ray and high-resolution computerized tomography (CT) scan of the lungs and nose cavities (sinuses) can identify any structural abnormalities or diseases (such as infection) that can cause or aggravate breathing problems.

Asthma is classified into four general categories: mild intermittent (mild symptoms up to two days a week and up to two nights a month), mild persistent (symptoms more than twice a week but no more than once in a single day), moderate persistent (symptoms once a day and more than one night a week), and severe persistent (symptoms throughout the day on most days and frequently at night).

Prevention and long-term control are key in stopping asthma attacks before they start. Treatment usually involves recognizing triggers and taking steps to avoid them. In case of a flare-up, a quick-relief inhaler such as albuterol can be used.

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Under the direction and guidance of Florida Hospital, Radiology Specialists of Florida is fully dedicated to providing our community with excellent medical imaging services.

Leena Kamat, MD, is a board-certified diagnostic radiologist, sub-specialized in breast imaging for Radiology Specialists of Florida at Florida Hospital. She earned her medical degree at the University of Florida, College of Medicine and following graduation completed her residency at the University of South Florida and a fellowship in breast imaging at the Moffitt Cancer Center.

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Long-term asthma control medications, generally taken daily, are the cornerstone of asthma treatment. These medications keep asthma under control on a day-to-day basis.

Types of long-term control medications include: inhaled corticosteroids, leukotriene modifiers, and long-acting beta agonists.

The radiologists from Radiology Specialists of Florida at Florida Hospital soon to be Advent Health are very well trained and experienced. We have radiologists specifically trained to read high resolution CT, which may assist in the diagnosis of asthma. 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. For more information visit www.Somedaystartstoday.com

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Human Epigenetics

By SAM ATALLAH, MD Digestive and Liver Center of Florida

DNA can lead to silencing of tumor suppressor genes. Bottom line: the 3-D shapes are expressed, and important implications for tumorigenesis.

Over the past 50 years, significant progress has been forged in the science of genetics. Yes, we’ve come a long way from counting wide-type fruit flies in the biology lab! Let’s take a second to list some of the important milestones that have been achieved:

IMPLICATIONS FOR CANCER THERAPEUTICS:

1865: Gregor Mendel, a monk, studies the inheritance of the garden pea. From this, we learn that all life forms have traits that can be passed on in a predictable way. In Mendilian genetics, genes can be dominant or recessive. For some autosomal genes, simple math can predict the chances of offspring phenotypes. An excellent example of this is the inheritance of the ABO and Rh blood types.

AN INTERESTING FINDING IS THAT TUMOR CELLS DEMONSTRATE GLOBAL HYPOMETHYLATION.

1915: Thomas Morgan introduces the chromosomal theory of inheritance, for the first time indicating that chromosomes are what contain genetic information.

SECONDARY CHANGES TO DNA (i.e., methylation) do not

1953: Francis Crick, James Watson and Maurice Wilkins share the Nobel Prize for elucidating the double-stranded helical structure of deoxyribonucleic acid (DNA) using X-ray crystallography. Essentially, the findings suggest that DNA is simply a code of only 4 base pairs: adenine (A), guanine (G), cytocine (C), and thyamine (T). Our entire genetic makeup is based on a very long sequence of A, G, C, and T. Learn the sequence, and theory has it, you should hold the blueprint of a human.

LATTER HALF OF 20TH CENTURY: Prokaryotic and eukaryotic DNA translation become understood, as does gene replication. It’s learned that DNA express their genes with seemingly machinelike, molecular precision. In true factory style, DNA strands are first enzymatically separated and then translated by messenger ribonucleic acid (mRNA). The translated mRNA is then “read” by ribosomes and, from this, proteins are manufactured by the step-wise transfer of one amino acid at a time to a growing protein chain.

That’s done with the help of transfer RNA. These sophisticated molecules are able to decode DNA’s string of A, G, C, and T. As it turns out, three base pairs (codons) code for a specific amino acid, which are linked together in a chain, eventually forming a functional protein. In a nutshell, specific genes make specific proteins.

2003: The Human Genome Project is completed, in effect determining the 3 billion base pair sequence of the entire human genome. Great! Every last A, G, C, and T sequenced! The Holy Grail! The Human Genome Project is completed, in effect determining the 3 billion base pair sequence of the entire human genome. Great! Every last A, G, C, and T sequenced! The Holy Grail! The human blueprint! But, did this provide all the answers we were looking 23

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This happens in noncoding segments of DNA (introns), but also in the genes themselves. Even more intriguing, as neoplasms progress from benign to malignant, the degree of DNA hypomethylation also increases!

alter the sequence and are therefore considered reversible. The question is, can we control DNA methylation—particularly in cancer cells? for? Well, not exactly…

2003-2009: Surprisingly, once the human genome was decoded, it was discovered that most of our DNA doesn’t code for anything. It’s so called “junk” DNA. Only an estimated 1.5 percent of the human genome codes for genes. Even more confounding is the observation that an astonishing 99 percent of these genes are identical to the DNA of the mouse.

This leaves puzzling questions. What’s the purpose of having all this DNA if it doesn’t code for anything? How can we account for the vast phenotypic difference among man and mouse when these “blueprints” are nearly identical? Why is it that cloned animals are not phenotypically identical? Why do monozygotic twins experience different susceptibility to disease and cancer?

Part of the answer to these perplexing questions lies in the rapidly evolving field of epigenetics, which is defined as the heritable change in gene function that occurs without changes in DNA sequence. Perhaps the best-studied example of this is DNA methylation. In the human genome, DNA methylation occurs in a specific way. That is, methylation of cytosine—but only when it precedes guanine in a repeat CGCG sequence. Often near the regulatory, 5’ end of many genes, repeat patterns of noncoding CG exist (the dinucleotide is linked by a phosphodiester “p” bond). These are referred to as CpG “islands.” Upstream methylation of CpG islands can affect the degree of activity of its downstream gene.

Methylation has been implicated in genomic imprinting, whereby only one of two alleles inherited is active. In most cases, both alleles are functional. When genomic imprinting occurs—secondary to CpG methylation—then either the allele inherited from the mother or from the father is turned off. Having genetic machinery operating with only one allele

“off” is analogous to a twin-engine plane flying with only one engine working. In effect, imprinted genes are susceptible to gene-based disease and malignant transformation. Genomic imprinting has been implicated in Prader-Willi syndrome, Alzheimer’s disease, leukemia, BeckwithWiedemann syndrome and many others.

TUMORS AND EPIGENETICS: An interesting finding is that tumor cells demonstrate global hypomethylation.

This happens in noncoding segments of DNA (introns), but also in the genes themselves. Even more intriguing, as neoplasms progress from benign to malignant, the degree of DNA hypomethylation also increases! While global hypomethylation in gene-poor regions results in a propensity toward malignant transformation, hypermethylation of CpG islands has been found to be an important genetic alteration leading to many cancers. This is because CpG repeats are in the promoter region of tumor suppressor genes, thus hypermethylation leads to down regulation of these cancer-preventing genes. This deactivation mechanism has been implicated in retinoblastoma, Hippel-Lindau disease and BRCA-1-associated breast cancer, colon, lung, esophageal, ovarian, liver, bladder, kidney and stomach cancer.

Perhaps one of the most interesting concepts in epigenomics is that methylation doesn’t act only as “a giant master switch” turning on and off cancer-related genes, but that it actually results in changes to histone proteins, which are important in packaging DNA into chromatin. Histones can be modified by methylation and acetylation—the result of which a conformational change in the shape of DNA itself.

This global, conformational change in

Secondary changes to DNA (i.e., methylation) do not alter the sequence and are therefore considered reversible. The question is, can we control DNA methylation—particularly in cancer cells?

Demethylating agents are a new and exciting area in cancer research. It has been demonstrated in vitro that it’s possible to re-express shut off, DNA-methylated genes when these cell lines are treated with demethylating chemotherputics. Vidaza (5-azacytidine) and decitabine (5-aza 2’deoxycytidine) are demethylating agents that have been approved for treating leukemia and the myelodysplactic syndrome.

There is also interest in histone deacetylase inhibitors, which have been shown to induce cell-cycle arrest and even tumor cell apoptosis. Vorinostate (suberoylanilide hydroxamic acid) is now FDA approved for treating cutaneous T-cell lymphoma. Interestingly, valproic acid (depakote), which is a common antiseizure medication, is also a histone deacetylase inhibitor! There are more than 10 other agents currently being investigated in Phase I/II trials. The efficacy of epigenetic inhibitors is yet to be determined in this young but rapidly expanding field.

Dr. Atallah is among the most wellknown colorectal surgeons in the world. He moved to Orlando in 2007 after completing training at Houston’s Texas Medical Center with Surgical Oncology training at MD Anderson Cancer Center where his training had earned him double-board certification in General Surgery and Colorectal Surgery.

Two years to the day after completing fellowship training in colon & rectal surgery, Dr. Atallah performed the world’s first TAMIS operation in Winter Park, FL on June 30, 2009. This created a new approach to treating rectal cancers and polyps, that is now being practiced in more than 50 countries. Dr. Atallah pioneered robotic transanal surgery and was the first in the world to perform this technique. He is one of the leaders in advanced technology for rectal cancer surgery and has developed the technique of stereotactic navigation for transanal total mesorectal excision (taTME) — an important step forward in the evolution of computer-assisted surgery. Complex treatment of rectal cancer and surgical management of this disease through the new techniques of TAMIS and taTME represent Dr. Atallah’s principal interests in colorectal surgery; and he is currently producing a textbook on these topics scheduled for 2019 publication by Springer Nature.

He is also actively involved in the design and assessment of next-generation robotic systems that will be smaller, sleeker, and able to work in places and spaces never before imagined. See www.dratallah.com

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