June 2017 Orlando Medical News by Orlando Medical News

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Health Care Team Experience with Integration of Behavioral Health Services into a Patient-Centered Medical Home By CERISSA BLANEY, PhD, JONATHAN C. MITCHELL, PhD and MARIA CANNAROZZI, MD

Over the past two years at UCF Health, UCF’s College of Medicine Practice, a major effort has been underway to introduce an integrated behavioral health (IBH) service into the existing patientcentered, collaborative environment. The

ON ROUNDS PHYSICIAN SPOTLIGHT PAGE 3 Walter Conlan, III

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impetus for this effort lies in the recognition that psychosocial dynamics often play a central role in treatment of illness. Although it is more challenging to address psychosocial needs in the primary care office, this endeavor has multiple benefits for patients and providers alike. It is a common misconception that behavioral health care is traditional mental health treatment located in the same site as

the primary care office. While addressing aspects of mental health are incorporated, behavioral health care actually focuses on a broader array of symptoms, many of which span cognitive, emotional, behavioral and physical domains. Services at UCF Health aim to increase access to care, improve health behaviors and mitigate the impact of chronic conditions. Behavioral health services also work to make tradi-

tional health care services more effective. IBH acts as a bridge to help patients obtain additional services, refine and expand our colleagues’ appreciation for the behavioral components of health care, and train the next generation of behavioral health and medical providers. Historically, this type of integration has received strong support from health (CONTINUED ON PAGE 4)

HEALTHCARELEADER

Love for Childhood Schoolmates Leads to Action TAMIKA GRUBBS, CYSTIC FIBROSIS FAMILY ADVOCATE By PL JETER ROSEMARY ANTONELLI

A pair of contrasting discoveries during childhood propelled Tamika Grubbs, RN, to find a much-needed way to positively impact cystic fibrosis (CF) patients and their families in Central Florida. As the grandchild of a military officer, Grubbs looked forward to the annual Oktoberfest, a special event that allowed children to explore military vehicles. Her favorite:

climbing on helicopters! Around the same time, Grubbs became aware of schoolmates with cystic fibrosis (CF) and recalled being horrified when her family gently explained that most CF patients didn’t live past their teens. Decades later, Grubbs combined her extensive military, nursing, pharmaceutical and entrepreneurial experience to establish Cystic Fibrosis Continuity of Care, an Orlando-based consulting and advocacy firm. Opened in 2015, the firm’s mission

is simple: to facilitate better connections of CF patient care via hospitals, pharmacies, home health organizations, specialist physicians and other healthcare services. “If you can’t breathe (easily), you can’t do anything else, and I believe we can do better connecting care for patients with breathing disorders,” explained Grubbs, (CONTINUED ON PAGE 6)

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PHYSICIANSPOTLIGHT

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Walter A. Conlan III, MD, CWSP

CEO, Florida Wound Care Doctors; Medical Director, Wound Care & Hyperbaric Medicine Center at Orlando Health-Health Central, Osceola Regional Wound Care Center and Orlando Health’s Lucerne Wound Center

By PL JETER

WINTER PARK – As CEO of Florida Wound Care Doctors, medical director of three fast-growing, hospital-based wound healing centers in Central Florida, visiting doctor at area skilled nursing facilities, researcher for clinical trials, and volunteer for community causes, Walter A. Conlan III, MD, CWSP, has time management down to a science. “My greatest goal is to dramatically decrease the incidence of amputation from diabetes,” said Conlan, whose practice is comprised largely of diabetes patients with circulatory complications. Most referral patients’ wounds are about a month old. “We focus on goal-directed wound healing, going beyond the standards of care. For example, we provide total contact casting for diabetic foot ulcers to take pressure off the bottom of the foot to allow healing.” Ironically, Conlan’s focus on wound care wasn’t on his radar until late in his academic life. While studying psychology at Emory University, he was mulling plans to pursue a doctorate in clinical psychology when an advisor suggested otherwise. He told Conlan that, quite frankly, he probably couldn’t get into the PhD program and should settle on a career in social work. That advice didn’t go over well with Conlan, who ultimately decided to pursue medicine. He aced pre-med classes and toiled an extra post-baccalaureate year of studies before being accepted to Thomas Jefferson Medical College, where he planned to specialize in psychiatry. He chose physical medicine rehabilitation because it combined components of psychology, neurology and orthopedics,

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a decision reinforced during a short stint at the University of Texas Health Science Center at San Antonio. He completed a four-year residency in physical medicine and rehabilitation at the Rehabilitation Institute of Chicago at Northwestern University Medical Center. When he married Kristin, a Bradenton native, in 1990, it was an easy decision to relocate to the warmer climate of Central Florida. Conlan, who lost his father at the age of five, had grown up in Pennsylvania with his mother and younger brother, and had tired of the long winters. Besides, Florida represented an ideal venue for his paddle boarding, sailing and surfing interests. His wife’s experience at Rollins College in Winter Park influenced their decision to settle down in the Orlando area. It also laid the groundwork for his son, Alex, now 22, and a junior at Eckerd College in St. Petersburg. After four years in private practice at a Central Florida rehabilitation center, Conlan established his own multi-disciplinary medical practice to concentrate solely on wound care. Florida Wound Care Doctors opened in 2000 as Central Florida’s only medical practice exclusively concentrating on wound care

around the clock. The practice flourished. Before long, Conlan and staffers Barry Cook, MD, and ARNPs Patrice Muse and Megan Chipman were routinely traveling between several outpatient hospital-based wound care centers, including Orlando Health-Health Central Wound Care & Hyperbaric Medicine Center in Ocoee, Osceola Regional Medical Center, and Orlando Health’s Lucerne Wound Center. In 2011, Conlan became a Certified Wound Specialist Physician (CWSP), one of only 68 physicians nationwide to achieve the elite designation. Around that time, he began sharing his expertise on wound care on Lillian McDermott’s Radio Show. Most recently, Conlan was named medical director of the Wound Care & Hyperbaric Medicine Center at Health Central in Ocoee, a part of Orlando Health which hired a fresh influx of wound care and hyperbaric medicine staff to accommodate the population spike in West Orange County. This center alone has doubled in volume in the last few months requiring Conlan’s expertise. “We’re striving for improved continuity of care between the inpatient and

outpatient wound care programs for better patient outcomes,” said Conlan. “For example, the doctors and nurse practitioners are promoting the wound healing program before patients are even discharged. Prior to the patient being discharged from the hospital setting, arrangements are made to ensure a smooth transition for their outpatient appointment. Improving communications between all disciplines involved in the patients’ care is essential to maximizing our patient outcomes.” Florida Wound Care Doctors are also trained to provide hyperbaric oxygen therapy, a life-saving or limb preserving therapy, and an adjunct component of wound healing. Hyperbaric oxygen therapy (HBO) treats a wide array of patients, including diabetic patients with a Wagner Grade III that have ulcers which show no measurable sign of healing for at least 30 days of treatment, underlying chronic refractory osteomyelitis, osteoradionecrosis, soft tissue radionecrosis, and actinomycosis. “My foremost desire is to improve the quality of life for my patients,” said Conlan. “We’re continuing to strive to improve every day with better advanced care.”

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Integrated Behavioral Health, continued from page 1

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UCF Integrated Behavioral Team members, back row, left to right; Cerissa Blaney, PhD, Chelsea Wiener, MA, Andel Nicasio, MA, Jonathan Mitchell, PhD. Front row Keri Dotson, MA, Chris Spender, MA

care leaders but has been difficult to operationalize. The most common barriers include restrictive payment methods, confidentiality procedures, traditional provider training and ingrained practice patterns that impede collaboration. Many of the organizations that have made significant progress in this area are larger payer systems, such as the VA. Smaller organizations often face unique and shifting obstacles that make integration even more challenging, further dividing medical and behavioral health treatment. At UCF Health, our clinical team saw an opportunity to offer IBH through partnership with the clinical psychology doctoral training program in the UCF College of

Sciences. This mutually beneficial collaboration trains students to work in a rapidly growing specialty area that is both in dire need of practitioners and often overlooked by many training programs across the U.S. Training in a clinical setting best prepares our students to take on these roles in other practice locations across the country. It is important to note that students are not the only beneficiaries in this model. The integration of behavioral health services also helps physicians provide the highest quality care possible. Primary care is typically the first stop for patients with mental health concerns, particularly those with symptoms of anxiety and depression. Often providers feel unprepared to treat

these conditions or have limited time to do so, leading to a referral outside of the practice. We have been able to close this gap, and help patients to achieve great improvements in their conditions. After two years of working together as a team, the physicians say that our services help make them more effective health care providers. It allows them to maximize their time with each patient, confidently refer patients for behavioral health care, or assist patients with mental health issues that lie outside their scope of practice. Maria Cannarozzi, M.D. is the medical director at UCF Health and an advocate for integrating behavioral health services in community primary care practices. “Our

physicians have learned so much regarding how to care for patients’ behavioral needs,” she said. “Prior to having onsite behavioral health services, we would refer patients for psychology/psychiatry services with no knowledge of the type of care they were receiving, their progress, or if they even got the care we recommended.” Dr. Cannarozzi says that through the integrated services, the physicians are co-managing illness and wellness initiatives for patients and seeing the measurable benefits such as improved blood sugar control, lower blood pressure, and weight loss. Beyond primary care, our team has also been able to provide care for patients (CONTINUED ON PAGE 6)

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Integrated Behavioral Health,

Tamika Grubbs, continued from page 1

continued from page 4

pointing out that CF also affects the digestive system and increases risks for infections, diabetes, osteoporosis and liver failure. Also, social isolation takes an emotional toll on CF families. “My goal is to (help healthcare organizations) create clinical, operational and advocacy efficiencies to increase their revenues. The larger goal is to decrease unnecessary hospital admissions by coordinating prescribed care.” The mother of two earned a nursing degree from Herzing University in Winter Park, followed by a community education health degree from Morgan State University in Baltimore, Md. “Most of my nursing school classmates wanted to be ER or flight nurses, and I was the odd man out” focusing on CF, she recalled. “After getting out of the military, I considered becoming a social worker or dietitian because I very much

wanted to be part of the core team that cares for the CF patient.” Another appeal of CF, Grubbs pointed out, stems from the disease being among the most studied populations. Since the time her awareness of the disease began, the average life span of the CF patient has doubled, thanks to new drug therapies. Grubbs wants CF families to know about the latest groundbreaking ways the lung disease is being studied that could improve their quality of life. “Most patients have been a part of research since childhood as they aggressively search for a cure,” she said. “The military and nursing are very similar service positions I used to coordinate training for soldiers and now I coordinate care for patients. Either way, the most important thing in both fields is taking care of people the way that you would want to be taken care of.”

After graduating from college via an ROTC scholarship, Grubbs was commissioned into the U.S. Army as an officer. In her role as a U.S. Army captain, Grubbs served as a logistics and human resources officer, coordinating new soldier training while also improving operational efficiencies. “The Army officer leadership training I received really helped sharpen me as a leader early on,” said Grubbs. “Leadership, integrity, service and teamwork are among just a few of the priceless experiences that I’m so grateful for.” For three years, Grubbs worked as a dedicated research assistant at the National Institute on Aging (NIA)/National Institutes of Health (NIH). At Central Florida Pulmonary Group, PA, she served as the CF nurse coordinator, and at Kroger Specialty Pharmacy (formerly (CONTINUED ON PAGE 10)

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of specialty care providers. For these providers, having team members whose expertise includes helping patients plan, enact and sustain lifestyle changes means they can practice with greater efficiency. “As a physician, my goal is to not increase a patient’s prescriptions but is to help them manage their medical condition as best as possible,” said Neha Bhanusali, M.D., a rheumatologist at UCF Health. “To do that requires a lot of patient education to teach patients about all the contributing factors. The behavioral health team does an excellent job at that.” Research has demonstrated significant improvements to patients’ access to and utilization of behavioral health services when they are offered on-site. Further, it has shown to produce improved patient outcomes and greater satisfaction with care. Some of these impacts can be seen through the patient’s perception of care at UCF Health. One of our staff members recently spoke with a behavioral health patient who agreed to share their story. During one brief visit with their primary care physician, the patient noted concern over severe depression. The doctor placed a referral to our team and the patient was able to be seen immediately. “At one point, I was frequently contemplating suicide” the patient said. “Just having someone to talk to helped a great deal. I’m not sure what would have happened to me if I would have been referred out- what kind of doctor I would have gotten, or if I would have even gone. I knew I needed help but didn’t know where to go.” This patient further reported that they are now an advocate for this team approach to health care and was especially glad to know that their case is helping to train future psychologists. Another patient reported their experience with the behavioral health team as life changing, stating, “The behavioral health team has changed how I function in the world. I could not have done it without them. It let me focus on my weight and creating happiness in my life.” The patient stated that they were often secretive about their problems, including drinking, but after discussing their concerns with their doctor, and with an introduction to the IBH services, the patient was able to work through multiple lifestyle changes. As medicine moves forward toward values-based reimbursement, the financial value of integrated care will become more evident. Until then, quality measures related to patient outcomes, patient and provider satisfaction and cost offset will help to demonstrate the value of IBH services. Our team plans to contribute to the growing research base that demonstrates the significant benefits of integration of behavioral health in a patient-centered medical home.

INFERTILITY MEDICINE

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Social Egg Freezing – No Longer an Experimental Insurance Policy By COREY BURKE

Women are increasingly waiting later in life to have children and start a family. While delaying having children is potentially helpful in building a career, it is often detrimental to reproduction. As the biological clock keeps ticking, many professional women are turning to assisted reproductive technologies (ART) to help them build a family. While ART can overcome many aspects of infertility, there are limitations; primarily a woman’s oocytes. As women age the number of oocytes remaining in the ovaries not only decreases, but the number of aneuploid (chromosomally abnormal) oocytes increases. This one-two punch is significant and evident in the live birth rate for women having IVF over the age of 40. The live birth rate for women using their own eggs decreases almost 50% per cycle for women who are over 40, and by age 45 the live birth rate is nearly 0. Until recently the only options available to women of advanced reproductive age was to use donated eggs or to adopt. While these remain the frequently used options, there is still a lack of a genetic connection between parent and child, which is of great importance to many. Technological advances now allow us to cryopreserve oocytes effectively and efficiently. Elective (social) egg freezing gives women the opportunity to preserve their fertility and have genetically linked babies when they are academically, professionally, and financially ready. Why has this option taken so long to

Corey Burke is the Tissue Bank Director at Cryos International Sperm and Egg Bank in Orlando, one of the industry leaders in reproductive technology. Cryos offers fertility preservation to the general public.

become widely available? Well, because prior to 2005, eggs could only be frozen using what embryologists call the slow freezing method. This method involves loading the cells with cryoprotectants and then slowly lowering the temperature to – 197 C. The problem with this method for freezing eggs is contained in the very name of the process, slow FREEZING. During freezing, liquids crystalize and in the transition phase, liquids and solids coexist. This process allows ice crystals to form and damage the tissue being frozen. In the case of embryos, some damage from ice crystals is ok because an embryo is multicellular and

can survive some cell loss. Sperm, similarly, can withstand some damage from ice crystals because most samples contain many millions of cells and killing a few million has little overall effect on a sample. Eggs, however, are single cells and consist of mostly cytoplasm; any damage from ice crystals almost always results in cell death – making the process incredibly inefficient. Now we have the process of vitrification! This is the transitioning of a liquid to an amorphous solid with no equilibrium between crystalline and liquid state, thus preventing the formation of ice crystals. Since there is no equilibrium state, vitrifi-

cation is not actually freezing in the sense we commonly think of. In this process, eggs or embryos are loaded with cryoprotectant, like the slow freeze method, and then plunged into liquid nitrogen. This rapid cooling method turns the eggs and the liquid they are contained in to glass. Improvements over the past 10 years have led to an egg survival rate of close to 100% in well trained hands. Pregnancy rates with vitrified eggs are similar to those of fresh eggs and provide an opportunity for women to “preserve” their fertility for medical reasons or to postpone starting a family. A woman who has her eggs vitrified in her twenties or early thirties will have an insurance policy of sorts if she finds she has fertility issues when she is ready to conceive. The vitrified eggs remain “frozen in time” at the age at which the woman was when the procedure was done. This is a huge advantage for women postponing childbirth when you consider that women under 35 undergoing IVF have a live birth rate of 54% and women aged 38-40 have a live birth rate of only 26%. (CONTINUED ON PAGE 10)

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Dr. Cerissa Blaney is a licensed psychologist and Director of Behavioral Health Services at UCF Health. She holds a joint appointment in the Department of Psychology and Internal Medicine. Dr. Jonathan Mitchell is a visiting assistant professor in the Department of Psychology and a postdoctoral fellow in clinical health psychology at UCF Health. Maria Cannarozzi is the Medical Director and a practicing physician at UCF Health and Associate Professor of Internal Medicine and Pediatrics at UCF College of Medicine.

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INFERTILITY MEDICINE

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Journey of the Egg and the Sperm By BRUCE I. ROSE, PhD, MD and SAMUEL BROWN, MD

Everyone knows that a man and a woman produce a baby using their eggs and sperm. This is a miraculous process shrouded in mystery and hope. Contemporary infertility care enables doctors to help couples conceive a child even when things are less than optimal. Our tools and techniques have grown out of our understanding of this physiological process after more than 30 years of performing in vitro fertilization (IVF). What follows is an attempt share some of the complexity underlying this process that so affects us all. All of the eggs that a woman ovulates in her lifetime were created as primordial follicles when she was a fetus. Each primordial egg has a single layer of specialized granulosa cells surrounding it. These cells play an important role in the future development of that egg. A woman’s body releases these eggs from their arrested state slowly over the course of the woman’s reproductive life. The process that triggers an individual egg’s release is not understood, but intra-ovarian androgens are likely a contributing factor. At birth, women start life with about a million primordial eggs. Women release

eggs from their arrested state during their childhood and during all stages of their growth and development. During a woman’s peak reproductive years (age 18-30), about 1000 eggs are released each month. Intra-ovarian growth factors and hormones cause some of these eggs to grow in the ovary for about five months. Most of the eggs that were released will wither away (apoptosis). During this time period, the egg increases its volume approximately 4-fold. Most of the volume increase is due to an increase in the number of energy producing mitrochondria. The granulosa cells that surrounded the primordial egg become multilayered and differentiate into two types of cells which nurture the developing egg and produce estrogen to prepare the lining of the uterus for implantation. During this time period, the egg secretes a shell (zona pellucida), which plays an important role at the time of sperm penetration into the egg. After about five months, fluid secretions from the granulosa cells begin to collect in a small sac surrounding the egg and some granulosa cells (follicle wall). When this cyst is 6 mm in diameter, the granulosa cells begin to develop receptors for FSH. This initiates exponential growth driven by the hormone FSH and augmented by the

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GOOD MEDICINE. estradiol produced. Granulosa cells and the egg work together to supply the eggs with the molecular products it needs to prepare for ovulation, fertilization and early embryo development. Fifty million granulosa cells are now contained in the follicle. When the follicular cyst has a diameter of 18-20 mm, egg is ready to leave the ovary. The estradiol produced by granulosa cells has also been acting on the pituitary to produce a trigger for ovulation: the release of a spike of LH. LH triggers ovulation in part by inducing collaginase production in the follicle which breaks down the follicle wall and frees the oocyte from its attachment to it. The egg contains four times too

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many chromosomes and LH causes changes with the egg that enable completion of the first meiotic division in which one-half of the chromosomes are pushed out of the egg (first polar body) in preparation for sperm penetration. In the natural cycle, as a woman moves around during her day, the tubes and ovaries move around in her body and the delicate ends of the tube locate the egg and move it inside. Sperm from intercourse has colonized the crypts within the cervix. As they swim out, a few will reach the end of the tube and find the egg. Most sperm are not capable of fertiliz-

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As a longtime Orlando resident, I’m privileged to have some of the best hospitals in the country located a $6 Uber ride away, a fact that I had never really taken stock of until recently. Through my work with Health Innovators, I’ve been given a behind the scenes peek at these monolithic institutions - and been afforded the opportunity to meet and develop meaningful relationships with many of the administrators and physicians who shape and drive those hospital systems. I have intimate knowledge that myself and my neighbors are in the hands of caregivers who are not only excellently trained, but deeply motivated to improve their patients’ outcomes. In other parts of the state the same cannot be said, a fact that many rural Floridians have been aware of for quite some time. A recent family emergency put me smack dab in the middle of the rural hospital experience. I was immediately troubled by how the most simple implementations of cost effective technologies would have drastically changed not just my family’s experience for the better, but the care providers’ experience as well. I knew I was in for a rocky ride from the start when the paramedics didn’t have an address for the hospital. I was literally unable to use GPS navigation in a town I knew nothing about. But it wasn’t until my loved one was discharged from ICU without a diagnosis or aftercare instructions that I realized how devastating these mediocre communication practices could be to a family struggling with a health crisis. There was a point in the ER as we were wheeling a gurney from radiology that I had to interrupt the technician and correct them as to what room we were supposed to be heading to. After a bit of back and forth, the technician laughed and said “Well, you seem to have the most up to date information, I’m listening to you!” My stomach dropped and a silly, panicked thought crept through my mind, “Toto, we’re not in Orange County anymore.” Although a majority of the care providers I encountered there were personable and hardworking, I was continuously struck by their utter lack of care coordination. It was rampant at every turn. There were simple communication problems like being told the patient was receiving previously prescribed medications during respiratory therapy, only to later be told by another team member that no one had ever ordered the respiratory therapist and thus no medications had ever been administered. There were also larger endemic orlandomedicalnews

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problems, like the attending physician telling me I needed to direct my questions to the patient and then ending the discharge conversation there. He made it very clear to me that he did not have time for me, or for that incredibly vital conversation. This is all a symptom of something larger, a malignancy in our system stemming from an ability to be complacent. To look away. To not worry about the physicians or patients in rural hospitals because we would never go there for care. While I cleaned up a long-ignored splatter of my loved one’s blood off of the ICU floor, listening to their ragged breathing as they slept, I began to think about what needed to happen to begin a forced change. Clearly Meaningful Use and HCAHPS surveys are not having the impact here that they should be. And then I realized something. What is there - truly - that an underfunded hospital can do? How accessible are technologies to a system that has one ICU doctor who is only contracted at the hospital for two hours a day, treating 24 ICU patients? At what point does the onus fall on us, the innovators in health technology, to begin approaching these ignored systems instead of constantly chasing the white whale of our fantasies? While I was there I met care providers and administrators who seemed just as frustrated as I was, and when my work with Health Innovators came up I found them incredibly eager to engage with technologies, they simply lacked access to them. So, I make a call to physician entrepreneurs and other innovators in healthcare — Reach out to Rural Hospitals! Work with them, and within their budgets, to solve simple problems we often forget still linger in some hospital systems. Research their administrators and reach out to them directly. I think you’ll be surprised at how eager they are to play ball. Does the hospital not have enough to finance the project? Find grants to help fund your efforts, or reach out to your state legislature and explore what initiatives you could participate in. Perhaps even take an un-capitalistic turn and knowingly take a loss on a system, so that patients may receive a standard of care we would all hope to have access to. We are the future of healthcare, we are what will bring about a new standard of care that we wouldn’t have dreamed of ten years ago. Let’s not leave behind entire populations just because they don’t live in the right ZIP Code.

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JUNE 2017

MEDICAL MARKETING

HEALTHCARELEADER

What is Your Digital Marketing Strategy? By ARLEN MEYERS, MD, MBA

use customer data and insights to create a superior end-to-end brand experience for their customers. Typically, these companies (such as financial-services companies, airlines, hotels, and retailers) build their business models around customer service. By reinventing how they interact with customers, and wowing them at multiple touch points, these companies hope to create an ongoing dialogue and build a loyal customer base.

Sick care clinicians need a digital health strategy combining brick and mortar with online touch points that build brand loyalty before, during and after the service or product interaction. Biomedical (medtech, techmed and biopharma) and digital health companies need the same thing to engage customers and drive sales. But, how and what are the ways to do it? The authors propose four basic digital marketing strategies. • Digital Branders are most often consumer products companies or other marketers that focus on building and renewing brand equity and deeper consumer engagement. These companies are shifting their investment from traditional linear advertising toward more immersive digital multimedia experiences that can connect consumers to the brand in new ways. They are reimagining how they engage consumers, with the primary goal of recruiting new consumers to the brand and driving loyalty through multiple experiences with the brand. • Customer Experience Designers

• Demand Generators (typically retailers) focus on driving online traffic and converting as many sales as possible across channels to maximize marketing efficiency and grow their share of wallet. All elements of the digital marketing strategy—website design, search engine optimization, mobile connected apps, and engagement in social communities—are tailored to boost sales and increase loyalty. Although Demand Generators also need to leverage content to drive engagement, they’re more focused on driving volume and efficiency than on curating the deep,

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There are 8 basic marketing capabilities, which are more or less relevant depending on which of the four digital marketing models a company applies. Here is what it looks like when you put them all together:

emotional branded experiences that Digital Branders pursue. • Product Innovators use digital marketing to identify, develop, and roll out new digital products and services. These companies employ digital interactions with consumers primarily to rapidly gather insights that can shape the innovation pipeline. By helping nurture new sources of revenue, the marketing group increases the value of the company. You should use one of these strategies to build your brand, create dissemination and implementation and convert prospects to leads to customers. Most independent clinicians do not have the resources or skills to do this nor are they willing to allocate the necessary time to do it because of the high opportunity costs when they are not seeing patients. Consequently, they ignore digital marketing or outsource it. Employed physicians rely on their employer to do. Some employers do it ef-

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Arlen Meyers, MD, MBA is President and CEO of the Society of Physician Entrepreneurs. Learn more about the Society of Physician Entrepreneurs at www.sopenet. org and on Twitter @SoPEOfficial

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Source: Peter Drucker, The Practice of Management, 1954

continued from page 6

TLC Rx Pharmacy), she was manager and regional clinical specialist of the CF clinical program. Her cumulative experience has impacted some 2,000 of the nation’s estimated 30,000 CF families. “I’m so driven because there must be a better way of solving patients’ problems with coordination of care,” she said. “People with a chronic illness like this should never feel they’ve been abandoned by the healthcare system.” In 2015, Grubbs joined Veteran Women Igniting the Spirit of Entrepreneurship (V-WISE), a premier training program in entrepreneurship and small business management that helps female veterans and military spouses turn an idea or startup into a viable business venture. Conferences focus on business practices, finances, technology and other resources for new companies. “I was inspired by the training I received from the North American CF conference, CF Foundation coordinator nurse mentor program, a quality improvement project with the foundation, and the Dartmouth Institute for Health Policy,” she said. “I began to formulate the idea around a business of taking care of CF patients, working for months with a consultant on my business plan. Once it was complete, I saw the opportunity to compete for investor insight.” Grubbs was selected from more than 100 competitors as one of 16 finalists to pitch her idea to investors at Rice University. Even though Grubbs wasn’t selected as one of five competitors who won $600,000 from the session, her spirit was undaunted. “The rest of us received an experience of a lifetime and a network of veteran-friendly business connections worth more than gold,” she said. The Cystic Fibrosis Continuity of Care advocacy board includes Daniel Layish, MD, of Central Florida Pulmonary Group, other healthcare experts, veterans and an advisory CF patient. “I’d like for the Central Florida medical community to know that if they are having trouble getting (CF patients) prescribed care … or if they’d like to guide their business in the direction in servicing this popu-

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Social Egg Freezing – No Longer an Experimental Insurance Policy continued from page 7

In 2012, the American Society of Reproductive Medicine (ASRM) removed the experimental label from oocyte vitrification, making it a routine clinical practice. This opened the door for fertility preservation for women. Prior to 2012 most egg vitrification was done for women with cancer or other disease states that impaired their fertility. In addition to the advantages already described, this has a social impact by leveling the reproductive playing field between men and women. Men have been able to freeze sperm since the 1950’s and couples could freeze embryos, but you have to have sperm to make embryos. For the first time in history, women can cryopreserve their gametes for future use and control their own reproductive future. The cost of fertility preservation ranges from $7000 - $15,000 per cycle. Depending on the age of the woman and her ovarian reserve, more than one cycle may be needed. The process takes approximately 2.5 weeks and involves several doctor appointments for ultrasounds and blood work to monitor the progression of the eggs’ mat-

continued from page 8 ing an egg even if they are lucky enough to find one. Those that can, will tightly attach to the zona pellucida composed of three proteins surrounding the egg. It takes sperm about two hours to penetrate this protective shell. After binding to the shell, the pattern of sperm tail movement changes, in part, beating more vigorously. Binding to the zona pellucida prevents a sperm from bouncing off as it tries to penetrate the shell. Motility changes convert the business of the sperm from finding the egg to directing their force into penetrating it. The head of the sperm contains a sac of digestive enzymes (acrosome). After binding to the zona pellicida, the sac fenestrates and leaks the enzymes into the zona to facilitate passage of the sperm into the eggs. As the first sperm that passes through the zona, the head is taken into the egg and fuses with the egg cell membrane. This in-

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uration. There are daily hormone injections that cause more eggs to mature than would in a natural cycle, allowing more eggs to be retrieved. The eggs are retrieved vaginally using an ultrasound guide and the procedure is completed in around 20 minutes. The egg retrieval is performed under IV sedation. After the procedure, some patients experience period-like symptoms, but most return to work the next day. Oocyte vitrification has many advantages, and while called fertility preservation, it is not a guarantee of children in the future. There are many factors involved in achieving a pregnancy and eggs are just one. Simply having eggs in the freezer does not assure a good uterus, sperm, or endocrinological support. It should also be noted that having stored eggs does not necessarily mean the woman will ever need them. Many women have children into their forties with little problem. Fertility preservation should be looked at as an insurance policy that may never be needed. For further details please call 407-203-1175

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fectively and most don’t. On the other hand, bio-entrepreneurs and digi-preneurs need to do it as soon as possible and their dissemination and implementation efforts should be as pressing as validating the value proposition and business model and generating revenue. In the end, as Drucker noted: I can recall, as if it was just yesterday, exactly where I was when I first read these profound words: “Because the purpose of business is to create a customer, the business enterprise has two–and only two– basic functions: marketing and innovation. Marketing and innovation produce results; all the rest are costs. Marketing is the distinguishing, unique function of the business.”

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duces a secretory reaction which causes the zona pellucida to harden and prevent further sperm penetration. If two sperm enter the egg before this reaction can take place, the resulting cell is not compatible with becoming life. The sperm’s entry into the egg causes the egg to reduce its chromosomes to the desired number as it produces a second polar body. The sperm head rearranges its chromosomes and becomes the male pronucleus which matches up with a similarly constructed female pronucleus. These structures fuse and we have a cell with the correct number of chromosomes. There are many more hurtles for this complex cell to overcome to become a baby. The early embryo will not implant into the uterus for seven days. It has stored all of the energy required to support its rapid cell division in preparation for implantation. These include the inherited components from the particular egg and sperm starting this journey and the environment in which this fertilized egg finds itself. The reproductive process can go wrong at many levels. As our understanding of the process of reproduction increases, we are able to diagnose and bypass these problems. Almost all couples have the potential to become parents using contemporary tools. Founded by Dr. Samuel E. Brown, Brown Fertility offers a fully comprehensive array of fertility treatments, including in vitro fertilization, egg donation and artificial insemination and is home to Florida’s most state-of-the-art IVF center, which produces some of the highest pregnancy rates in the country. With over 80 years’ experience, and the management of more than 7,000 IVF cycles, the providers at Brown Fertility have earned a reputation for not only producing excellent outcomes and offering affordable treatment options, but also for providing patients with the one-on-one attention and the compassionate care they deserve. Visit www.BrownFertility. com for more information.

PUBLISHER

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PL Jeter editor@orlandomedicalnews.com ——

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SOCIAL MEDIA DIRECTOR

Trish Murphy 863-899-3703 trish@tridentorlando.com ——

CIRCULATION

jkelly@orlandomedicalnews.com ——

CONTRIBUTING WRITERS

Cerissa Blaney, PhD Samuel Brown, MD Corey Burke, Jeremy R. Burt, MD Maria Cannarozzi, MD PL Jeter Arlen Meyers, MD Jonathan C. Mitchell, PhD Bruce I. Rose, PhD, MD Nina Talley ——

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Orlando Medical News is published monthly by K&J Kelly, LLC. ©2016 Orlando Medical News. All Rights Reserved. Reproduction in whole, or in part without written permission is prohibited. Orlando Medical News will assume no responsibility unsolicited materials. All letters to Orlando Medical News will be considered Orlando Medical News property and therefore unconditionally assigned to Orlando Medical News for publication and copyright purposes.

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JUNE 2017

Pacemakers and MRI Safety By JEREMY R. BURT, MD

Having been involved with research in the field of MRI and pacemakers/defibrillators (P/Ds) for many years, I’m very excited to announce that many patients with these devices can now safely undergo MRI. Our initial concern was that P/D patients placed in the magnetic field created by the MRI scanner would develop dangerous arrhythmias, leading to symptoms such as chest pain, shortness of breath, palpitations, or loss of consciousness. For this reason, P/Ds have been regarded as a near absolute contraindication for MRI. Over 2 million patients in the United States have implanted devices, including P/Ds. Estimates show that more than 50 percent of these patients will need an MRI while the device is in place. Many clinicians need their patients to undergo MRI and cannot order another exam because of concerns related to radiation exposure, allergy to iodinated contrast or require MRI to answer a specific question that cannot be resolved with other imaging modalities. An example would be a patient needing a cardiac MRI to evaluate for a potential cardiomyopathy. Other modalities such as echocardiography or cardiac CT angiography are generally insufficient for evaluating patients with cardiomyopathy. In the past, a patient with P/D in this situation would

not be able to undergo MRI. In 2016, two companies received approval from the Federal Drug Administration (FDA) for safe MRI of P/D patients. The devices are made by Medtronic and Biotronic (SureScan™ Revo MRI™ and Advisa MRI™; ProMRI®). Initially, only pacemakers were approved, and only under very controlled circumstances. For example, patients with defibrillators or those needing a cardiac MRI were not deemed as safe to undergo MRI by the FDA with these devices. Additional research in this arena led to removal of many of these restrictions. The current imaging protocol for MRI performed in these patients includes continuous monitoring of vital signs (heart rate, blood pressure, SpO2, single lead electrocardiogram), visual monitoring of the patient during the exam by an ACLS trained nurse or physician, and monitoring of the MRI machine and patient by the MRI technician. All P/D patients with MR conditional devices must be evaluated by a cardiovascular health care professional prior to and after the MRI with interrogation of the device and switching to “MR safe mode” during the MRI. Other makers of pacemakers and defibrillators are hoping to follow suit. Many implantable device companies are also evaluating the safety of performing MRI in patients with non-MRI conditional P/ Ds. A few investigators have published

smaller studies to determine the safety of these devices (Nazarian 2011 and Russo 2014). Patients with nonMRI conditional P/Ds must be closely monitored before, during and after the MRI by cardiovascular nurses, radiologists, and/or cardiologists and have interrogation of the P/Ds prior to and after the MRI. Many of these research projects are currently enrolling P/D patients as part of the MRI Diagnostic Imaging Registry. These trials are being performed at many centers in the country including Florida Hospital. Investigators are evaluating the safety, image quality, clinical impact and diagnostic utility of MRI in patients implanted with certain types of implantable devices. These studies are accepting eligible patients who have certain brands of implantable devices who require MRI imaging of the head, cervical spine, lumbar spine, pelvis, or extremities.

Although the research protocols may vary depending on the device being imaged, in most cases, a cardiac radiologist and/or electrophysiologist are on site to monitor patients who participate in the project before, during and after the MRI. ACLS certified nursing personnel are also present throughout each MRI to provide cardiac monitoring of the patient. Finally, the patient’s devices are interrogated before and after the MRI to monitor for any significant changes. Patients are followed by research personnel at a follow up visit to check the device and assess for any adverse events. Researchers in the field are actively trying to safely extend the unique diagnostic power of MRI to more patients, including those with pacemakers and defibrillators. Please reach out to your local radiologist to determine the appropriateness of MRI in your pacemaker and defibrillator patients.

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Jeremy R. Burt, MD, is a diagnostic radiologists sub-specialized in body imaging for Radiology Specialists of Florida/ Florida Hospital, Orlando. His expertise ranges from MRI, CT, Oncology, Cardiovascular to Genitourinary Imaging. He is currently the medical director of Radiology Research, the medical director of MRI Safety, GI/GU Imaging, and the Co-Chair of Radiology Residency, at Florida Hospital. He is also the Adjunct Professor of Research, Adventist University of Health Sciences, Orlando, the Assistant Professor of Radiology, at Florida State University, and the Assistant Professor of Radiology, at the University of Central Florida.

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JUNE 2017

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