Orlando Medical News November 2018

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Coming on Line: More Than $102-Million Invested in Healthcare Projects for Orlando Health in West Orange More on the way!

More than $102-million is being invested help meet the demand for healthcare services in West Orange County, the second fastest-growing area in Florida.

Projects include $29.7 million in funding

ON ROUNDS

PHYSICIAN SPOTLIGHT

Marygold L. Fernandez, MD ... 3

POSITIVE OUTCOMES

What really is Post-Acute Rehabilitation? ... 4

HEALTH INNOVATORS

Breathing New Life Into Purpose: It’s Never Too Early, Never Too Late ... 5 Prescribing Video Games for Better Health Outcomes ... 5 The HR Lady ... 9

RADIOLOGY INSIGHTS

What to Know about the Leading Cause of Cancer Deaths ... 21

CANNABIS CORNER

Interview With A Marijuana Patient ... 22

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PHYSICIAN VIDEOS

from the West Orange Healthcare District (The District) for a new freestanding emergency department and medical pavilion at Horizon West, $21 million for the recently opened Cancer Center and $24.5 million for a 110-bed skilled nursing facility currently under construction on the Health Central Hospital campus.

The Cancer Center opened in August, the first floor of the new emergency department opened at the end of September and the Pavilion is set to open in January 2019.

“We’ve been monitoring the potential healthcare needs in Horizon West for many years,” said Norma Sutton, chair of The District, which guides and invests in

healthcare facilities and programs throughout West Orange County. “It’s exciting to know we’re delivering this high level of access years ahead of what would have otherwise been possible. These three projects are (CONTINUED ON PAGE 2)

HEALTHCARELEADER

Venkatesh Nagalapadi, MD Health Central Park medical director led by respect for elders Older patients have more control than ever before.

There is one of those good-bad news jokes lurking in a discussion of medical care for older people: The good news is that people seem to be living longer. The bad news is that people are living longer; meaning they are living long enough to develop a variety of health ailments, sometimes needing multiple specialists. Fortunately, there is a special class of primary care physicians – gerontologists – who are able to help older patients by working hand-in-hand with the medical team to give them a stronger voice in the care they receive.

Meet Venkatesh Nagalapadi, MD, the medical director for Health Central Park, in

Winter Garden, part of the Orlando Health system, and several other skilled nursing facilities. Nagalapadi is a board-certified gerontologist, who has been practicing with Orlando Health for 15 years.

“In the past,” he said, “there was never any patient input in the outcomes they received. That has all changed now.”

Until recently, said Nagalapadi, medical care was built around tests and protocols for treatment without much attention to the actual benefit the patient received.

Now, the focus has changed to emphasize quality and outcomes. This is true throughout medicine, and it is especially true in geriatric care. This focus on outcomes is achieving improvements in patient longev-

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ity, according to Nagalapadi.

“I am seeing more functional, independent 90-year-olds than 15 years ago,” Nagalapadi, who is also an attending physician, said. “I am also seeing patients when they are sicker.” In general, people are living longer, healthier lives because they are receiving better care and advice on healthy living, said Nagalapadi. But sometimes patients are sicker because they have multiple health problems that have gone undiagnosed and untreated. For example, a 75-year old with diabetes may have had the condition for years, leaving him or her with several ailments, such as nerve pain and kidney disease, that now must also be treated.

(CONTINUED ON PAGE 6)

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Coming on Line: More Than $102-Million Invested in Healthcare Projects for Orlando Health in West Orange, continued from page 1 all part of our original vision. They help us boost access to healthcare, deliver the latest medical technologies and attract top-notch physicians to our community. We’re excited to be able to expedite these new facilities with our funding support.”

The Orlando Health Emergency Room and Medical Pavilion – Horizon West is a two-story, 78,000 square foot freestanding emergency department medical pavilion. The first floor, which houses the emergency department containing 24 patient beds, plus an additional six observation beds, is now open. Construction is expected to continue on the medical pavilion’s second floor through January 2019. Once complete, the medical office space will feature services that include primary care, family medicine, OB/GYN, general surgery, laboratory, orthopedics, neurology, urology, cardiology, pharmacy, outpatient rehabilitation and a center for health improvement.

“We are excited to open this new facility and offer its enhanced services to the Horizon West community,” said Mark Marsh, President of Orlando Health - Health Central Rick Smith Hospital. “Having the support of The District has been instrumental in our ability to keep pace with the population growth not only here, but all across West Orange County.”

Orlando Health UF Health Cancer Center – Health Central Hospital will offer expanded chemotherapy and radiation

treatment areas, medical oncology services, surgical oncology consultations, laboratory facilities, and Cancer Support Community programs. At 30,000 square feet, it almost doubles the size of the existing facility.

It will be the first cancer treatment facility in Central Florida to offer a new cancer-fighting technology called MRIdian®.

With this advanced technology, oncologists can view and track tumors during radiation treatments, allowing physicians to make immediate changes to treatment. The new technology uses magnetic resonance imaging (MRI) rather than computed tomography (CT) scans, reducing patient exposure to the damaging effects of radiation.

“This new facility is greatly needed and there’s no better place for it than right here on this campus, in this community, where families in West Orange County live, work, and play,” said Mark Roh, MD, president of Orlando Health UF Health Cancer Center. “In fact, evidence proves that patients battling cancer have better results when they are treated closer to home.”

Rick Smith, Chief Operating Officer, Orlando Mark Marsh Health UF Health Cancer Center–Health Central Hospital, said it will be a convenience to patients to have all three major services for oncology – surgical oncology, medical oncology, and radiation oncology – all under one roof.

“The other thing I would mention there is we have the latest technology in

the ray linear accelerator,” Smith said. “I think we’re number five or six in the country served with this technology. Those are the two key takeaway points, from my perspective, on the Cancer Center.”

Smith said the projects will easily be expandable in the future.

“I think each one of these projects, the cancer center, the skilled nursing facility, and the freestanding ED were all designed with an expansion portal already contemplated. Obviously, the cancer center, we built it almost double the size of our existing cancer center, because cancer is unfortunately so prevalent in our community. Same could be said for the center for rehabilitation. Obviously, with the land we have on our campus here, expansion would be easy to accomplish,” said Smith.

He also said a hospital is planned for the not-too-distant future.

“Although, we feel pretty confident that 110 beds will serve us for a number of years to come. Our plan all along has been to develop a hospital on that site at some point, and with the property we have there that won’t be an issue. I mean, obviously, we want to start as soon as it’s feasible. Our target has been in ‘18 or ‘19, to correspond to the population growth there,” he said.

The new Orlando Health Center for Rehabilitation will improve access and expand healthcare services provided, said Mark Marsh, President of Orlando Health - Health Central Hospital.

“This skilled nursing facility will allow our patients to receive the highly specialized levels of rehabilitative and post-acute care they require in a state-of-the-art facility here in the community they call home,” Marsh said.

The 95,000-square-foot Orlando Health Center for Rehabilitation will be a 110-bed skilled nursing facility capable of providing care to patients in need of either short-term outpatient rehabilitative services or patients in need of longterm care. A portion of those beds will be dedicated to inpatient rehabilitation for orthopedic/spine injury patients or postsurgery patients in need of additional care prior to returning home. The facility will also house a separate memory care unit, built to provide a secure and attractive setting to care for patients suffering from Alzheimer’s and/or dementia.

Sutton said this new facility is being welcomed with open arms.

“Our mission is to enhance the health and wellness of the residents of our community and this project brings high-quality healthcare right to our doorstep,” said Sutton.

“It’s a wonderful addition to the campus.”

Construction began late this year and is expected to take 12-14 months. Once fully operational, the new facility will staff 150 full-time employees.

Another new offering is the CareSpot Urgent Care/Orlando Health center in Ocoee which opened July 30, becoming the partnership’s tenth urgent care facility.

The District is an independent special healthcare entity created by the 1949 Florida Legislature that is governed by a 16-member Board appointed by the Governor of Florida. The District is a founding champion of “Healthy West Orange,” a grassroots movement to inspire west Orange County to become the healthiest community in the nation. More information at healthywestorange.org.

PARTNERS BREAK GROUND FOR NEW UCF-HCA HOSPITAL “You all ready to build a hospital?”

With those words — from Michael Joyce, president of HCA Healthcare’s North Florida Division – university and HCA leaders, faculty physicians, medical students and community leaders broke ground Thursday for UCF Lake Nona Medical Center.

The UCF-HCA joint venture hospital will open in late 2020 on 25 acres across from the UCF College of Medicine.

About 500 guests attended the groundbreaking event, which began with an early morning rainbow.

UCF President Dale Whittaker said the hospital embodies a bold, collaborative spirit that will “make Orlando a destination for how health and wellness should be taught and practiced in the 21st century.”

The hospital groundbreaking came eleven years and 22 days after university and community leaders broke ground for the UCF College of Medicine as the anchor of an emerging Medical

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City at Lake Nona.

“A teaching hospital was part of our dream that day,” said Dr. Deborah German, vice president for health affairs and founding dean. “On Oct. 3, 2007, we didn’t know who our partner would be or how we would build such a hospital.

But we knew then what we know today – that we needed a teaching hospital to accomplish our goal to be one of the nation’s premier 21st century medical schools, anchoring a Medical City that could one day be a global destination.”

The hospital will be just a few steps from a new UCF Lake Nona Cancer Center that will be created in the former Sanford Burnham Prebys research facility. And it will be the cornerstone for UCF’s new Academic Health Sciences Center that will eventually bring many of the university’s health-related programs to Lake Nona.

Wendy Brandon, the new CEO of UCF Lake Nona Medical Center, said the new academic hospital will incorporate medical education, research and patient care. “Our hospital

will be a place that not only provides healing for our patients but also educates the healthcare providers of the future and supports the work of brilliant researchers that will lead to lifesaving care,” she said.

UCF medical students applauded the role the hospital will play in preparing them as future physicians. UCF and HCA are already partnering to create residency programs across North Central and Central Florida and soon will expand those graduate medical education programs to Pensacola. Ultimately, the new hospital will have its own residents but will provide clerkship training for third- and fourth-year medical students from the time it opens.

“The UCF Lake Nona Medical Center will allow us to give back to and serve the community that has embraced us so warmly,” said medical student Kevin Petersen, Student Council president for the Class of 2021. “Today, we are one step closer to creating a healthier tomorrow… the UCF way.”

In preparation for his remarks, Petersen did an online survey of all 490 current UCF College of Medicine students and asked what the new hospital meant to each. He created a framed image of the hospital rendering with some of the students’ quotes and presented it to Dr. German “to thank you for believing in your dream and for believing in us… and also to remind you of the inspiration you provide all of us students on a daily basis.”

With the groundbreaking ceremony finished, construction of the hospital will begin. The hospital’s foundation will be poured by January. The three-story hospital will open at 204,079 square feet with 64 beds and shelled space enabling expansion to 80 beds. UCF Lake Nona Medical Center is authorized to grow to 500 beds without further state approval.

The hospital is a joint venture between HCA Healthcare and UCF Academic Health, a direct service organization of the university. HCA is spending $175 million to build and begin operating the hospital. No state dollars are being used.

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PHYSICIANSPOTLIGHT

Marygold L. Fernandez, MD: Staying in Tune with Patients Well-traveled compassion better serves patients As a child in Cuba, Marygold Fernandez often played with a toy stethoscope and dreamed of following in her family’s footsteps. Her sister was a family doctor, her uncle was a vascular doctor and her cousin was an anesthesiologist.

At 17, she went on a church mission trip with her uncle, and the experience only reinforced her desire to go into healthcare.

“My uncle was more than a doctor; he was a humanitarian,” she said. “His compassion is something I’ve always carried with me. I wanted to do the same for my own patients one day.”

As it turned out, music was the gateway to her career in medicine. Fernandez studied piano and earned a position as a choir director at the prestigious Escuela Nacional de Arte (National School of Arts) in Havana when she was 14 years old. There, she spent hours each afternoon practicing music, composition and choir.

With her sights set on opportunities in the United States, Fernandez moved to Florida at age 18. Having grown up under a communist regime, she arrived with little money and no grasp of English. So, she taught piano lessons, and along the way, she learned English from her students.

“Through my studies in Cuba, I learned to be dedicated and make a lot of sacrifices, which paid off when I came here,” she said. “Having the support of my parents and being a piano teacher

saved my life.”

After graduating from Nova Southeastern University with a bachelor’s in biology and then graduating from medical school, Fernandez completed her family medicine residency at East Carolina University. With relatives in Miami and Tampa, Fernandez decided to return to Florida to be closer to family. In 2017, she started serving as a family practitioner in Poinciana and is credentialed at Poinciana Medical Center.

EMPOWERING PATIENTS

As a primary care physician, Fernandez delivers regular exams, wellness education and preventive medicine. Many of her patients have significant comorbid conditions that have gone untreated for years, including obesity, diabetes, hypertension and hyperlipemia. Fernandez believes that by providing resources and accountability, she can help them adopt a new mindset toward their health.

“It’s critical that my patients feel comfortable and know I’ll be here to listen and care about them,” she said. “Sometimes, it’s hard for them to believe that getting a colonoscopy or mammogram, or taking cholesterol medication, is a good thing. We talk about why their health is so important, and we create a plan together.”

Fernandez said family medicine physicians bear a unique responsibility because they are on the front lines of caring

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for patients.

“We’re the first to say, ‘You’ve never had this type of test, so we’re going to refer you to a specialist,’” she said. “And sometimes, the patient will say, ‘I don’t want that.’ So, then we talk about our choices. What about getting a fecal stool sample instead of that other test? If you don’t want medicine, what else can you do to get those levels under control?’”

In many cases, a combination of diet and exercise can make a significant difference.

“When patients are committed and following the guidelines, they’ll come back two weeks later to review labs, and we’ll see they’ve lost some weight,” Fernandez said. “That’s very encouraging for them, and for me as their health advocate.”

When patients are very obese or have trouble losing weight, Fernandez often refers them to nutritionists. She stays in close contact with other specialists so her patients have continuity of care.

Fernandez said that speaking Spanish is an advantage for practicing in Poinciana, which has a significant Hispanic population.

“My patients don’t need a translator – they have a personal connection with me, and our cultures are very similar,” she said.

COMMUNITY EDUCATION

Along with sharing her expertise one-on-one, Fernandez takes it into the

community. She teaches an array of free classes and lectures at the hospital and in other settings.

“I love this area, and I’m happy whenever I have the chance to help people improve their health,” she said. “I’m proud to be practicing in P oinciana.”

Fernandez is also actively involved in her church, First Baptist Orlando, and said her faith strengthens her personally and professionally.

One day, she aspires to participate in medical mission trips, inspired by her uncle’s legacy. For now, she stays close to home, where she and her husband are raising two preschool-aged children.

“I’m very serious about spending quality time with family,” she said. “I love to build up strong relationships. That’s why I enjoy my work so much. My patients are an extension of my family, and I get to cheer them on toward good health.”

Dr. Marygold Fernandez is a board-certified family medicine physician credentialed at Poinciana Medical Center.

To learn more about Dr. Fernandez, search keyword “Fernandez” on the PoincianaMedicalCenter.com “Find a Doctor” page, or call 1.888.253.8117.

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POSITIVE OUTCOMES

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What really is Post-Acute Rehabilitation?

By MICHAEL SAMOGALA

In relation to health care in today’s world and economy, many facets of health care go undefined and are not considered to be truly consistent with standards of quality operation and outcome.

Post-Acute Care (PAC) is defined by the governmental agencies as the rehabilitation or palliative services that individuals receive after, or in some cases instead of, a stay in an acute care hospital. Depending on the intensity of care the individual requires, treatment may include a stay in a facility, ongoing individual therapy, or care provided at home. www.medpac.gov/-research-areas-/post-acute-care

After reading the above definition, we can conclude that anything that occurs after acute care services may be considered as post-acute care. This may certainly influence the decisions regarding discharge and continuation of care required by the individual after immediate or subsequent acute care services have been provided. We refer to these needs and this phase of care as transition. We must ask ourselves as health care providers why transition care and processes are so important to those we serve.

“The current process of care transitions for individuals with disabling conditions is both ineffective and inefficient. There is a need for clinicians with the necessary knowledge and skills to advocate and facilitate transitions that result in the greatest value to the individuals, their families, and the healthcare delivery system. A review of the literature reveals significant problems with

transition to post-acute care (PAC) settings. Care is fragmented, disorganized, and guided by factors unrelated to the quality of care or individual outcomes.” (Gage, 2009; Sandel et al., 2009).

As this statement communicates, the effects of fragmented care and services provided can and does affect the success and outcomes of those individuals needing and/or requiring complete post-acute rehabilitation services. We see these negative effects in all phases of the care continuum which include acute individual rehabilitation, skilled nursing facilities, the post-acute care arena and in the general community.

The negative results, and most importantly, formal outcomes of this, “fragmented care and services,” for those individuals requiring post-acute rehabilitation care, include everything from multiple rehospitalizations to the acute and subacute areas of the care continuum. This may also include incarceration due to the symptoms of the initial injury and the behaviors that may accompany that injury which may be occult during the acute phase of hospitalization and recovery (TBI).

Transition to post-acute facilities includes preparation and validation of services provided, ideally outside of a predetermined length of stay and progress parameters. Post-acute settings should focus on the individual and significant other/supportive care in relation to a rehabilitation process that includes, but is not limited to, a systemic comprehensive, multidisciplinary assessment in the development of realistic, measurable and functional goals.

In consideration of the multiple, specific, and often complex needs and barriers of this population, we are obligated to consciously validate and support facilities with accreditation and/or partnership status, reflecting the ability to provide all required services in the care of these individuals. Such accreditations/partnerships include, and may not be limited to, Commission on the Accreditation of Rehabilitation Facilities (CARF) (Brain and/ or Spinal Cord Injury Specialty), Agency for Health Care Administration (AHCA), Brain Injury Association of America and United Spinal Cord Association.

In reference to the services provided at NeuLife Post-Acute programs, a CARF accredited brain injury and residential rehabilitation program, which primarily encompass neurological disorders related to acquired brain injury (traumatic and nontraumatic) and spinal cord injury, the importance of barrier focused rehabilitation

NeuLife Rehab is one of the largest residential post-acute

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cannot be overemphasized. The identification of barriers affecting the outcomes after discharge from any post-acute facility begin with the admission process which must effectively and accurately identify the specific needs and services the individual will require. This includes all domains of the multi-disciplinary professions that would perform in concert to achieve the most functionally safe, independent and progressive outcome. Examples of the effectiveness relating to a truly accredited post-acute program are proven in the outcomes which in our case indicate approximately 80% of catastrophic injured clients return home or to their communities.

The results of the admission process and assessment must be evaluated by the rehabilitation team prior to admission to any facility ensuring the consistency and quality of all services provided. The Post-acute rehabilitation team having the essential components of care and services coordination which include: rehabilitation specific case managers, physiatry services (rehabilitation specific MD), board certified rehabilitation nurses, neurology services, psychiatry services, neuropsychology services, cognitive, dysphagia and speech therapy, neurobehavioral and behavior plan with supports as needed, physical therapy, occupational therapy/functional independence team, mental health counseling and support – clients and family members and individual and family education and training.

It is our understanding as many such neurologic injuries and illnesses develop so does the extensive and often exhausting demands of caring for these individuals in a multitude of “post - acute” settings.

This certainly leads all of us to realistically consider the financial impact of providing, what in some opinions should be, the universal standard of care. A publication citing the cost relationship between those individuals who were fortunate enough to receive comprehensive post - acute care as stated above actually proved to have more successful discharge outcomes (gains in (CONTINUED ON PAGE 6)

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HEALTH INNOVATORS

FLORIDA’S INNOVATION HEADLINES

Breathing New Life Into Purpose: It’s Never Too Early, Never Too Late

By STACIE RUTH, MedSpeaks Contributor

How can you find a new purpose after a significant life event, for instance, a layoff? It depends on how you spend the days, months, even the year that follows.

This week marks the one-year anniversary since I left a stellar career of promotions and payouts and trade-offs. I had every intention of rising like a phoenix from the ashes and going bigger and harder toward the achievements that had sustained me for my first professional twenty years. And then it changed, I decided to take my experience in leading healthcare innovation in a big company and funnel all that momentum into changing the lives of those suffering from respiratory diseases.

While I was busy setting a new path and planning for the future this past year, some people were unable to walk outside, leave the chair in their living room, or take a deep breath because they suffer so heavily under the weight of a disease such as chronic obstructive pulmonary disease (COPD). A severe, incurable lung disease,

COPD is marked by stressful and threatening symptoms of phlegm build-up, severe coughing and shortness of breath.

Although smoking is the leading cause of COPD, many patients have experienced socio-economic contributors such as poor indoor and outdoor air quality from toxins such as mold or smog, a history of uncontrolled asthma or being in a work environment that poses a respiratory health risk.

I personally come from a family tree of construction and factory workers and have been witness to the dramatic health toll from exposures to certain materials and chemicals.

Beyond a quality of life that deserves enhancing, this past year 120,000 COPD patients died from complications of their disease, a number that represents one of the leading causes of death in our country.

Sadly, according to the NIH, this impact is thought to be grossly underestimated because although 12 million people have been diagnosed, it is believed that an additional 12 million individuals in the US suffer without a formal diagnosis. We, as healthcare professionals and innovators

MD Live, a Sunrise-based virtual health service platform snags the top venture deal in South Florida for $50 million in 3rd quarter 2018. Ironically, the CEO of Papa Technologies, Andrew Parker, is the son of MD Live’s founder, Randy Parker!

can do better than this to improve prevention, diagnosis and management of this and similar respiratory diseases.

Perhaps if you have been impacted by, provided support for or have treated someone with COPD, you recognize the work of the Global Initiative for Chronic Obstructive Lung Disease, known as GOLD. Their mission is to improve the lives of those touched by COPD. Similar to my search, it is never too early, never too late to support the purpose and efforts of GOLD, by participating in World COPD day on November 21, 2018.

To show our support, let’s do the “straw test1.”

The straw test is easy and takes only a moment to literally breathe new life into your awareness about lung disease and the purpose of prevention. Its simplicity is eye opening. Here’s how it works: 1. Take 4 straws (preferably Earth(CONTINUED ON PAGE 8)

Prescribing Video Games for Better Health Outcomes

By TAYLOR DUFFY, MedSpeaks Contributor

The lack of adherence to prescribed medical regimens not only increases an individual’s overall healthcare costs, but often leads to fatal outcomes. Various studies have estimated that nearly half of all chronically-ill patients do not follow treatment plans as prescribed1. This nonadherence not only costs the U.S. health-care system from $100 billion to $300 billion a year, but also results in over 125,000 deaths each year2. This is especially prevalent among pediatric patients, where their environment, a lack of knowledge and understanding, comfort and enjoyment, all play critical roles in their final compliance to a given medical regimen. General Dr. C. Everett Koop once stated, “Drugs don’t work for patients who don’t take them.” Simply put, treatment plans are only effective if implemented properly. To improve the outcomes of pediatric patients and promote safe and effective therapy, it is imperative that health care providers strive to improve adherence from all angles.

One approach many innovators are beginning to capitalize on is the aura of fun. That’s right, fun. While this term 5

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rarely finds its place within medical terminology, it plays a critical role in the adherence to prescribed treatment plans, especially among children.

With surveys indicating over 90 percent of children play video games, many inventors are meeting practitioners and their patients half-way, creating interactive video games that serve as effective substitutions for otherwise monotonous treatment plans3.

One such video game, Re-Mission, takes players on a journey inside the human body to battle cancer at the cellular level. Armed with weapons and superpowers, such as chemotherapy, antibiotics, and the body’s natural immunity, one must fight off infections, nausea, and other threats to ultimately defeat cancer.

With the help of over 120 pediatric cancer patients and a variety of physicians and scientists, developers succeeded in creating a virtual reality that matches the many symptoms and treatments of the same cancer patients behind the screen4.

In a 2014 study of cancer patients playing Re-Mission, subsequent FMRIs displayed strong activation of the brain circuits involved in positive motivation, leading to shifts in attitude regarding chemotherapy and other cancer treat-

Papa Technologies, a Miami-based tech-enabled platform lets elders reach out to college students for transportation, household chores and companionship lands $2.4M in funding RepScrubs, a Central Florida-based vendor scrub management technology platform donated 888 packs of disposable scrubs to the Florida Hospital Foundation to support healthcare in Ethiopia, Haiti, Jamaica, Peru, and the Philippines.

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

FEATURED EVENTS: November 15-17, 2018 ments5. This shift in attitude as a result of playing Re-Mission was proven through a separate 375-subject study to improve adherence and self-efficacy to cancer treatment, in addition to newlyfound knowledge of their own disease state6.

“A lot of times we don’t really want to take our meds. We wonder, ‘What is this doing? Where is it going? I’m tired of it.

It’s just going to make me throw up,’” said Jose Guevera, an 18-year-old who went through cancer treatment and helped design the Re-Mission 2 games. But when you see on the screen and visualize what’s happening inside your body, and what the chemotherapy’s doing — you’re not looking at a PowerPoint, you’re playing a game, and you’re being chemo, and you’re killing your bad cells. I think Re-Mission 2 can really help a lot of us7.”

Re-Mission not only encourages its young players to understand the basic science and implications of their disease and (CONTINUED ON PAGE 8)

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HEALTHCARELEADER | Nagalapadi, MD, continued from page 1

Medical Marijuana: Treating

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And sometimes Nagalapadi sees patients after they have been transferred to a skilled nursing facility to recover following treatment in a hospital for serious ailments. In the past, those patients might have had longer and more expensive stays in the hospital without necessarily receiving better treatment, but the focus on outcomes has changed that.

Dr. Nagalapadi grew up in India in a family of engineers. His father had two doctorate degrees in engineering and his brothers and several other family members were all engineers of one sort or another.

“My decision to go into medicine was viewed as an act of rebellion,” he joked.

Medicine captured his imagination, and his grandmothers played important roles in his upbringing. He discovered that he enjoyed being with older people.

They were interesting, and he cared about them and the health challenges they were experiencing.

After studying medicine in India and Britain, Nagalapadi served his residency at the University of Arkansas in Little Rock, followed by a fellowship in geriatric medicine at the Donald W Reynolds Center for Aging at the University of Arkansas from 2003 to 2004.

At Health Central Park and the other skilled nursing facilities he directs, Nagalapadi emphasizes patient involvement and better management techniques, such as electronic medical record systems that ensure every member of the medical team

has the most current patient records.

While the management technology is very important – and something that many smaller practices are unable to afford – the most important element is still with the patient, and ensuring the patient has a clear understanding of their own health.

“I have a saying that I tell my patients,” Nagalapadi said. “The eye cannot see what the mind does not know.”

In other words, patients must understand what is happening with their bodies, so they can help the medical team identify conditions that might require treatment earlier. “Having patient involvement is the key to better health outcomes.”

Patients also need to be candid with their doctors not only about their physical health, but their financial health. “Medicare does not pay for everything, and many patients are on fixed incomes of $1,200 to $1,800 per month. If their doctor prescribes a medicine that costs $400 per month or more, they may just not take it.” If they don’t take their medicines – and don’t tell their doctor – the patient’s care will suffer. So, it is very important to have honest conversations with doctors about whether they can afford the medicine the doctor is prescribing.

“It is not about limiting healthcare,” Nagalapadi said, “but controlling it. The key to being able to do this is by taking ownership of your problem. And we are now better positioned to help patients do that than ever before.”

Post-Acute Rehabilitation, continued from page 4

functional status and level of independence) as well as overall financial cost savings over an extended period of time post injury. (COST/BENEFIT ANALYSIS FOR POST-ACUTE REHABILITATION OF THE TRAUMATICALLY BRAIN-INJURED INDIVIDUAL, M.J. Ashley, David K. Krych, Centre for Neuro Skills Bakersfield, CA Robert R. Lehr, Jr. Department of Communication Disorders and Sciences and Department of Anatomy, School of Medicine, Southern Illinois University, Carbondale, IL 1990).

In summary, post-acute accreditation, at its most effective level, not only includes, the maintenance and slow progression of an individual’s medical stability, functional and cognitive ability, but also includes a process that focuses on the individual and personal needs and barriers as related to the client, his/her environment and the ability to adapt to any actual or perceived deficit. The responsibility to acknowledge and meet this challenge lies with all of us who provide care and services for these individuals beginning at the onset of injury or illness and ending with the most successful and functional outcome.

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.

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The Business of Medical Marijuana (MMJ) Certifications

By MICHAEL PATTERSON

As of October 2018, there were over 170,000 Florida residents who are registered in the Florida Department of Health, Office of Medical Marijuana Use (OMMU) to legally receive MMJ. Also, there were over 1,700 physicians who have completed the 2-hour online training required to write MMJ Certifications for qualifying patients. That may sound like a lot of physicians, but just because a physician completed the MMJ training does not mean they are writing MMJ Certifications.

In fact, few Florida physicians advertise that they perform MMJ Certifications.

The numbers of qualifying MMJ patients continue to increase between 2,5003,000 patients per week, and with experts estimating the MMJ patient population being north of 600,000 upon maturation, Florida will soon become the largest MMJ market in the country.

As physician groups and medical practices look to new sources to increase revenue, MMJ Certifications could be an area to increase the bottom line of the practice, as well as provide quality healthcare to an ever-increasing demographic.

If you are considering writing MMJ Certifications in your medical practice, keep in mind the following recommendations.

1. What are you trying to accomplish?

- Your answer to this question will determine how to setup your MMJ Certification business. For example, are you looking to service your current patient population only? Do you want to create an entirely new division of your practice and service as many patients for MMJ Certifications as possible? Or, do you just want to make more money from services that do not require insurance?

Your answer to this question will guide you in setting up your business properly.

2. Setup a separate LLC to handle all of your MMJ Certifications- Marijuana is still considered illegal at the federal level. All health insurance companies must follow federal law, and most insurance providers have clauses which state that providers must follow the law.

This means that if you perform a MMJ Certification evaluation (recommending an illegal drug) and bill it to the patient’s insurance, you have the possibility of getting that money clawed back months or years later by the insurance company.

Now, I know some physician groups who currently write MMJ Certifications and bill their client’s insurance for the visit.

But these practices are playing Russian Roulette because it only takes one audit or claim to be scrutinized for all insurance payments to be denied and the medical practice to lose hundreds of thousands of dollars. Setup a different company and lease at least one room in your practice to perform all the evaluations.

Require patients to pay cash and/or 7

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using a separate merchant processing identification. Lease specific space in your practice for MMJ Certifications and code your current employees to the new MMJ Certification company for running the business.

3. Talk to other MD practices who currently handle MMJ CertificationsSee how they run their operation. Find out what problems you will face and challenges you will have to overcome to be successful before starting.

4. Determine your fee schedule for evaluations and required follow up recertification visits- Currently, MMJ Physicians in Florida are charging anywhere from $150-$350 for an initial MMJ Certification evaluation and $75$300 for required follow up visits. By law, patients must be recertified every 30 weeks and are not allowed to have more than one MMJ Physician at any time.

Therefore, do the math on how many patients you will need to see to break even, bring on more staff, and make a profit.

5. Have more than one certified Physician and staff member to work your MMJ Certification business- When patients

find out your practice is writing MMJ Certifications, patients will have a ton of questions, which will require a lot of time to answer. Most successful MMJ Physician groups have an online questionnaire that prospective patients can fill out ahead of time to see if they qualify (and save your staff time). If you plan on having existing support staff and one physician handling all of the new MMJ Certification business (as well as keep up all their current duties), then your business will be a very expensive and frustrating failure. Take the time to bring on at least one dedicated staff member and physician to start your MMJ Certification business, as well as cross-training other staff with plans to rapidly bring on more hires.

6. Get educated on MMJ products and dosing of products for your patients- Out of everything with starting a new MMJ Certification business, this is probably the easiest. All of the licensed Medical Marijuana Treatment Centers (MMTC) will be more than happy to provide your Physicians and staff with any training on dosing, products, technology, etc. for your

patients. Think of these companies like Big-Pharma and contact them and ask for training on their products. They will all fight to train you as much as needed for the hope of you recommending their products to patients.

7. If you write MMJ Certifications, you cannot have a financial interest in a Florida MMTC or MMJ laboratoryThis is similar to the “Starke Law” or inability to self-refer. Either you write MMJ Certifications or you can invest in a FL MMTC. Florida law does not allow you to do both.

8. Market your other services of your practice to potential MMJ patientsUse your MMJ Certification business to increase your patient base in your other practice areas (internal medicine, labs, x-ray, nutritional counseling, antiaging, etc.). If your new MMJ patients like your practice and have a good experience while they are on-site, they will be more likely to use your company for the other medical services you offer.

9. Have an “exit-strategy” or “step-down” strategy once recreational marijuana legalization becomes effective- It’s not a matter of if, but when recreational marijuana happens in Florida. Some think it will happen as soon as 2020. Whenever it happens, have a plan for your MMJ Certifications. We have learned in other states that when recreational marijuana is legalized, medical patients decline but do not go away. In 2012, when Colorado legalized recreational marijuana there were over 100,000 medical patients in the state. As of 2017, there are approximately 50,000 medical patients. However, with Florida having an older population and recreational mari(CONTINUED ON PAGE 9)

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continued from page 5

friendly paper straws) and breath “normally” through them with your mouth. This is what a stage one COPD patient feels when they breath.

2. Now drop to breathing through 3, then 2 straws and feel the difference.

3. When you reach breathing through 1 straw, you will have a similar sensation to what a stage four COPD patient feels with every breath.

By the final step of this experiment, I was moved to tears. For a moment I was transported, barely breathing through the lungs of a beloved grandmother who died of this terrible, preventable disease.

To bring this full circle, as physicians and care providers, perhaps this activity can be performed in your office with patients, their family caregivers, and your staff so that they too can experience what breathing, something many of us take for granted, feels like as COPD progresses.

And, maybe, this one simple activity will proffer a renewed purpose, awareness, empathy and motivation towards prevention and therapeutic compliance.

Support GOLD at www.goldcopd.org and make difference.

Prescribing Video Games,

continued from page 5

treatment, but empowers them to fight through each and every hardship they face outside of the game, just like they do as Roxxi, the protagonist, inside the game.

Less established than Re-Mission is the French start-up Ki-Breath. While still in its developmental phase, Ki-Breath aims to serve as an interactive diagnostic and therapeutic tool for children suffering from Cystic Fibrosis. Cystic Fibrosis (CF) is characterized by a defective gene that causes an influx of thick mucus within the lungs and gastrointestinal tract. While a cure has yet to be found for this genetic disease, aggressive medication and therapy has increased the average lifespan of those diagnosed with CF from 10 years old in 1962 to 37 years old today8. Even more promising, children born with CF in the 2000s are now predicted to live through to their 50s, if progress continues at a similar pace9.

Much of this increase in lifespan can be attributed to evidence-based treatments such as airway clearance techniques (ACTs)10. ACTs involve voluntary huffing, coughing, and deep breathing, often for hours, to ultimately loosen mucus from airway walls. Many children, however, adhere poorly to these daily ACTs and would much rather spend their time doing anything else. Ki-Breath sought to enhance the experience of pediatric ACTs by creating a series of iOS compatible games where your controller is a spirometer, and your choices are dictated by the varying intensities of breath you expire into the spirometer.

The prototype of Ki-Breath is detailed below through an interview at Microsoft Imagine Cup, a global competition for young innovators in the field of technology: Link: https://www.youtube.com/ watch?v=04sGoQKxNao The sensitivity of the spirometer, and therefore the difficulty of the game, can be adjusted by the caretaker in order to manipulate the aggressiveness of the treatment. In addition to promoting airwave expiratory maneuvers such as deep breathing and huffing, the spirometer also acts as a pulmonary function test, accu-

rately measuring a player’s forced vital capacity (FVC), slow vital capacity (VC), and forced expiratory volume in one second (FEV1). Research performed utilizing a spirometer and interactive respiratory video games has already shown to be just as effective of a pulmonary functioning test as any other existing method11.

With time and funding, platforms like Ki-Breath are capable of becoming standard forms of therapy for pediatric patients suffering from diseases that not only affect patients with mucus-filled airwaves, but patients with neuromuscular disorders requiring similar therapy due to weakened respiratory-related muscles12.

While medicine is certainly not all “fun and games,” we cannot deny that the enjoyment of a treatment has a direct correlation to its resulting compliance, especially among pediatric patients. We owe it to children to continue being creative and investing in all sides of medicine, even “fun and games,” to ultimately provide them with the best healthcare outcomes as possible.

1 Source: http://erj.ersjournals.com/content/48/suppl_60/PA2198

References 1. Brown, M. T.; Bussell, J. K., Medication Adherence: WHO Cares? Mayo Clinic Proceedings 2011, 86 (4), 304-314.

2. Benjamin, R. M., Medication Adherence: Helping Patients Take Their Medicines As Directed. Public Health Reports 2012, 127 (1).

3. Riley, D., The video game industry is adding 2-17-year-old gamers at a rate higher than the group’s population growth. NPD Group Press: 2011.

4. Saltzman, M. Re-Mission: Game sequel lets you blast cancer cells. https://www.usatoday.com/story/tech/columnist/ saltzman/2013/09/19/re-mission-cancer-therapy-app/2838945/.

5. Cole, S. W.; Yoo, D. J.; Knutson, B., Interactivity and Reward-Related Neural Activation during a Serious Videogame. PLOS One 2012, 7 (3).

6. Kato, P.; Cole, S.; Bradlyn, A., A video game improves behavioral outcomes in adolescents and young adults with cancer: a randomized trial. Pediatrics 2008, 122 (2), 305-317.

7. Takahashi, D. Re-Mission 2 games reimagine how to help kids survive cancer. https://venturebeat.com/2013/04/28/re-mission-2-games-reimagine-how-to-help-kids-survive-cancer (accessed October 23).

8. National Institute of Health. Cystic Fibrosis: Fact Sheets. https://report. nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=36 (accessed October 23).

9. MacKenzie, T., et al. Longevity of patients with cystic fibrosis in 2000 to 2010 and beyond: Survival analysis of the Cystic Fibrosis Foundation Patient Registry. Annals of Internal Medicine 2014, 161(4), 233-241.

10. Daniels, T., Physiotherapeutic management strategies for the treatment of cystic fibrosis in adults. Journal of Multidisciplinary Healthcare 2010, 3 (1), 201-212.

11. Bingham, P. M.; Lahiri, T.; Ashikaga, T., Pilot trial of spirometer games for airway clearance practice in cystic fibrosis. Respiratory Care 2012, 57 (8), 1278-1284.

12. Choi, J. Y.; Rha, D.; Park, E. S., Change in pulmonary function after incentive spirometer exercise in children with spastic cerebral palsy: A randomized controlled study. Yonsei Medical Journal 2016, 57(3).

REPRINTS: If you would like to order a reprint of a Medical News article in a PDF format or request an additional copy of an issue, please email: jkelly@orlandomedicalnews.com for information.

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THE HR LADY

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y d a HR L THE

By WENDY SELLERS

How do I handle marijuana use (recreational or medical use) for my employees?

In the state of Florida, medical marijuana use is legal, however, recreational use is not. Regardless, the use of marijuana is still federally prohibited. With that said, it is up to you (the employer) to decide what you will and will not choose as a policy for marijuana users. Obviously, some safety sensitive jobs should have more company regulations for use of marijuana on the job as well as alcohol or other drugs. The tricky part is deciding what happens when it is not used on the job but remains in the employee’s system and affects their ability to keep patients and other employees safe. My advice is to not make this decision lightly. Speak with both your liability insurance broker and workers compensation insurance broker who have experts on their teams and can provide you with the statistics to make an informed choice.

My employee has informed me that they are transgender.

How do I handle this information with my staff and with my patients?

This information should not be discussed without the transgender employees’ express permission and should only be discussed with the intent to create an inclusive work environment and medical practice. They should be treated the same as any other person working in your practice – free of discrimination including gossiping, rumors, unwanted teasing and/or bullying. Forget about the laws (or lack of) regarding transgender discrimination and focus on behaving humanely. If you use empathy and rational behavior and stick

to the job description, you should never be accused of discrimination. For more information, check out this great article on tips for working with transgender co-workers

I host office events once a month to show appreciation and gratitude to my team.

However, two of my employees claim I do not show them recognition. How do I deal with this entitled attitude?

First, kudos to you for hosting team events. Gatherings build team morale and friendships. People do business and work alongside those that they trust. In order to trust one another, they must get to know one another on a personal level in addition to their job role. You will notice as you continue to grow that not every event will satisfy every employee – because we are all unique with different desires and needs. It sounds to me that your two employees are asking for individual recognition in addition to the team gatherings. Second, my suggestion is to speak with all of your staff individually and ask them what their needs are. Some may want a one-on-one meeting with you monthly to discuss their career goals and current challenges. Others may simply desire an individual, or public “thank you” (which is free). You may also find that some are fine with the way things are, however you may want to make changes in order to motivate them to step it up. Just keep in mind that like your patients, your employees are individuals with different work and life experiences, learning capabilities and future goals.

What are the top HR challenges in healthcare?

Staffing and Leadership. Why? Because 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 con-

trol-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. If you have managers who manage tasks - call The HR Lady today to help get them from being a task manager to a leader people will follow.

“The HR Lady,” Wendy Sellers, is a leadership coach, author, speaker and COO of BlackRain Partners, a business consulting company focused on coaching, training, development and HR. She has a master’s in healthcare administration, a master’s in human resources, SHRM-SCP and SPHR certifications.

Wendy’s leadership book, “Suck It Up, Buttercup” is available on Amazon. com. Download the eBook today and learn how not to be a jerk leader. Why? You might be part of the problem. Visit http://www.blackrainpartners.com

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Do you want to Improve Customer Service?

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The Business of Medical Marijuana (MMJ) Certifications, continued from page 7 juana requiring a higher tax on purchase than MMJ (currently there is $0 tax on MMJ in Florida), there will continue to be a strong MMJ patient population for years after recreational legalization. Your MMJ Certification business will need to adapt. Patients like the security of seeing their physician but will do a cost analysis on staying with their physician or buying directly at a dispensary. You will have to offer more convenience and charge less for the same service. You will have to show value to your patients to keeping your service and expertise, rather than 9

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buying cannabis recreationally.

10. The MMJ Certification business can be a very profitable and beneficial business to your patients. If setup properly, your practice can reap the rewards of this new legal line of business for many years to come.

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.

Change Starts Today Call us 407.367.0883 #Leadership #Engagement

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The Opioid Crisis Can Be Solved It’s happening right here in Orlando

With Lotus Management Services as your strategic technology partner, you can:

By DAVE CHASE

The opioid crisis is the single greatest public health catastrophe in the last 100 years in the U.S., and the epidemic has reached epic proportions. According to the Centers for Disease Control and Prevention (CDC), more than 72,000 Americans died from drug overdoses in 2017 — a twofold increase in drug-related deaths over the past decade, which included overdoses from both illicit and prescription narcotics. In 2016, drug overdoses killed more Americans than the entire Vietnam War. And the cost isn’t just measured in human lives: the White House Council of Economic Advisers estimates that $504 billion was spent in 2015 on healthcare bills, criminal justice costs and lost productivity related to the opioid crisis.

Unfortunately, the entire U.S. healthcare system has been the biggest contributor to this catastrophe, from the doctors who overprescribe these drugs to the employers who skip out on decent primary care options within their health benefit offerings. As the largest benefits purchasers in the nation, employers in particular have become far too docile in negotiating the best deals for their workers — regularly accepting five to 20 percent increases on their annual healthcare costs, without seeing any improvement in the treatment their employees actually receive. In other words, we’re all paying more in order to get less.

And while short-term solutions can mop up the metaphorical spillage — the overall effects of the opioid crisis — we won’t ever truly eradicate the epidemic until we “turn off the spigot” and address its root causes. That means tackling the broader challenges of healthcare in this nation.

Recently, both the Senate and the House signed a bipartisan legislation package aimed at combating the crisis.

The package aims to stop the inflow of synthetic opioids while authorizing and expanding programs for addiction prevention, treatment and recovery. The package also allocates funding to the National Institute of Health for the research and development of new, potentially non-addictive painkillers. In addition, the CDC recently released new physician guidelines for prescribing and monitoring opioid use. The goal of these rules is to monitor all patients for signs of opioid tolerance or dependence in order to spot cases as soon as they begin. Some studies show that after seven days of opioid use, one in six individuals will become addicted.

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While the CDC’s guidelines are a step in the right direction, and this bill is a rare example of bipartisan cooperation on an important issue, this legislation alone isn’t enough to stop fix the problem. To enact real change, we must look to employers that can use their market power to catalyze a watershed change in healthcare.

Fortunately, we already have a number of real-world examples to which we can turn for guidance and motivation.

Hundreds of employers are charting a new course in benefits design, all in an effort to provide better care at lower costs, disincentivize opioid overprescription, fight addiction and combat misuse.

One of those employers is Orlandobased Rosen Hotels & Resorts, which was the focus of a TED talk in 2017.

Rosen’s story is one of our nation’s finest examples of how employers can rethink the boundaries of traditional employee benefits programs, and in turn, help their employees achieve the American Dream.

In an industry with a common employee turnover rate of close to 60 percent, Rosen’s turnover hovers in the low teens. Part of the reason employees stay is because of the company’s commitment to fully fund in-state college tuition for all full-time employees who have worked for Rosen for five or more years. In addition, Rosen also pays for the in-state college tuition of all employees’ dependents once employees have been with the company for three years.

How on earth can Rosen afford to keep such promises? The answer is simple: Rosen’s benefits’ design allows them to save millions on costs otherwise wasted on low-value, overpriced healthcare. Since adopting this approach, Rosen has saved approximately $315 million on healthcare costs, and their per capita spending on healthcare is half that of the average employer. By investing in proper primary care that includes physical therapy and other wise strategies, they not only have improved the health and

well-being of their employees, they’ve kept them out of harm’s way, shielding them from unnecessary levels of opioid prescriptions that are pervasive in most employer health plans. Despite physically demanding jobs, opioid prescription levels for Rosen employees are at one-sixth the level of a typical U.S. employer — roughly the same rate as Italy or France, where they have also avoided an opioid epidemic.

And Rosen doesn’t just put these savings back into employees’ pockets — they also redirect funds into the communities they serve. One of Rosen’s most creative philanthropic efforts focuses on the formerly crime-ridden neighborhood of Tangelo Park. By investing in free daycare, pre-K, after-school programs and free college educations, Rosen helped to cut crime rates by 67 percent and boost high school graduation rates from 55 percent to nearly 100 percent.

Rosen continues to fund a number of different programs aimed at helping Tangelo Park’s students thrive and become leaders in their community. And recently, Rosen took another move toward spreading the wealth of their healthcare savings further, now by “adopting” another underserved Orlando community, Parramore.

Rosen’s efforts, and those of countless employers like him, prove that when we make an effort to tackle the root causes of the opioid crisis (i.e. our feefor-service care model that’s driving more Americans to become addicted to these substances), we can effect powerful changes in our own lives and the lives of those in the communities we serve. That change starts with employers, and it can be in their own backyard.

Dave Chase is co-founder of Health Rosetta, which aims to accelerate the adoption of simple, practical, non-partisan fixes to our health care system. He is also the author of “The Opioid Crisis Wake-up Call:Health Care is Stealing the American Dream. Here’s How We Take it Back.” (Health Rosetta Media, September 2018).

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THE INDEPENDENT PHYSICIAN

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Surgeon Paul Shuler, MD, Finds Independent Practice Allows Him to Provide the Best Care Paul F. Shuler MD, an independent practitioner and founder of Provident Orthopedic & Sports Medicine Center and also practicing at the SportsMedicine Institute located behind the South Lake Hospital, was born with a club foot that was casted before his parents took him home from the hospital. The physician he saw the most growing up was an orthopedic surgeon.

“I had an interest in medicine from my childhood,” Shuler said.

Shuler graduated Summa Cum Laude from Michigan Technological University with a degree in electrical engineering. After working for General Motors for several years, he returned in 1992 to med school, earning his MD with honors from the Michigan State University College of Human Medicine in Lansing, Mich. He then completed an affiliated general surgical internship and orthopedic surgical residency in Michigan.

YOUR SOURCE FOR LOCAL HEALTHCARE NEWS

Throughout his career in orthopedics he has always looked for techniques and technology that can improve his patients’ experience and outcomes.

“It requires discernment at times to understand what can be a benefit and not just jump on every new and high-profile offering,” Shuler said. “Robotic arm assisted surgery truly appears to offer greater precision and reproducibility for select patients and procedures.

I have also integrated into my practice the lateral approach for total knee replacement and anterior approach for hip replacement. These techniques spare the muscles and allow rapid recovery of function making it easier for patients to go home the same day as their joint replacement surgery.”

Shuler has chosen to remain an independent physician which gives him greater latitude to provide the best care possible.

“For me, the reasons to maintain an

independent practice line up with the reasons I chose to go into medicine in the first place,” Shuler said. “Being independent provides me the best opportunity to solve the problems my patients face without competing interests. By definition it would seem physicians who are not in an independent practice are beholden to their employing entity. Consequently, they may experience pressures to place other priorities on their decisions other than the patient’s best interest.”

Studies show that many physicians have been forced to spend more time with computers than patients. There are also challenges with declining reimbursement, increased regulatory burden, patients who are unable to afford the care they need and an increasing pace of change.

“Independent practices are best positioned to advocate for the patients and provide care which is aligned with the patient’s best interest,” Shuler said. “Or-

thopedic surgery is at a time of transition.

Medicare has approved outpatient joint replacement and a growing number of our patients do not require hospital-based care. I believe this shift to outpatient care for an ever-greater number of surgical conditions provides us as physicians with both opportunity and obligation. We have an obligation to make sure that we understand how to identify patients for whom outpatient surgery provides improved care without increased risk. We have an opportunity to gain a greater voice in managing the patient care continuum. It is my hope that we can use this greater voice to encourage alignment of health systems and insurance companies to focus on highquality cost-effective care.”

Shuler and his wife, Pam, have four children. He is a very outdoors person and loves to downhill ski and water ski when he can fit those in as a private practitioner.

CALLING ALL INDEPENDENT PHYSICIAN’S INTERESTED IN

“PRESERVING & PROTECTING THE INDEPENDENT PHYSICIAN” VALUE BASED IQ PRACTICE ASSESSMENT ACHIEVE THE STATUS OF AN “IN DEMAND INDEPENDENT PRACTICE” ENJOY HIGH ACHIEVEMENT & ASSOCIATED BENEFITS IN HEALTHCARE REFORM

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LEVERAGE A COMPLETE INDEPENDENT HEALTHCARE DELIVERY SYSTEM orlandomedicalnews

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GrandRounds Three Orlando Health Hospitals Receive ‘A’ Grades for Patient Safety Orlando Health Dr. P. Phillips Hospital, Orlando Health Orlando Regional Medical Center and Orlando Health South Lake Hospital were awarded ‘A’ grades from The Leapfrog Group’s Fall 2018 hospital safety survey. The designation recognizes the hospitals’ efforts in protecting patients from harm and meeting the highest safety standards in the United States.

“By focusing on processes as well as our quality outcomes, patient care across our system has continually improved,” said Thomas Kelley, MD, vice president, quality and clinical transformation, Orlando Health.

“We are particularly pleased with these recent grades, not just for the hospitals, but also for patients. It reinforces the strides we are making in patient care.”

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 harm to patients. With more than 2,600 hospitals across the U.S., 855, or just over 30 percent, were awarded ‘A’ grades in the current rating period. The Leapfrog Group uses 28 measures of publicly available hospital safety data to assign grades.

The methodology is peer-reviewed and fully transparent, and the results are available at www.hospitalsafetygrade.org.

“We are pleased to have been recognized by the Leapfrog Group for our patient safety and quality outcomes,” said David Strong, president and CEO, Orlando Health. “Achieving these results requires commitment on the part of every team member and every physician to do their best every day.”

In addition to the three Orlando Health hospitals to receive ‘A’ grades, Orlando Health South Seminole Hospital maintained its ‘B’ score and Orlando Health – Health Central Hospital maintained its ‘C’ score earned during the spring 2018 rating period.

“Over the past five years, quality metrics at all Orlando Health hospitals have trended in a positive direction,” added Dr. Kelley. “So while we are mindful of the stable performance of these two hospitals, we are confident in our advancements in quality and the high level of care we provide to all patients.”

cologist Don Eslin, MD accepted the grant on behalf of the hospital. “We are so grateful to receive these crucial funds from St. Baldrick’s. We desperately need more early-phase clinical trials in Central Florida to provide hope for patients with relapsed disease,” said Dr. Eslin.

As the largest private funder of childhood cancer research grants, St. Baldrick’s gifts these infrastructure grants based on the need of the institution and its patients, anticipated results of the grant and local participation in St. Baldrick’s fundraising events and activities. To learn more about the foundation, visit www.stbaldricks.org.

Orlando's Stephanie Garris Awarded National Association of Free and Charitable Clinics and CVS Health Foundation 2018 Safety Net Health Care Champion To highlight the important work being done across the country to provide affordable, accessible health care to the medically underserved, the National Association of Free and Charitable Clinics (NAFC) has partnered with the CVS Health Foundation, a private charitable organization created

by CVS Health (NYSE: CVS), to present the Safety Net Health Care Champion Awards.

Stephanie Garris, CEO of Grace Medical Home in Orlando was one of 4 awarded.

These awards recognize individuals and organizations who through their actions have made an extraordinary impact in the Free and Charitable Clinic and Charitable Pharmacy community.

"The CVS Health Foundation applauds the 2018 Safety Net Health Care Champion awardees. Because of the work done by these champions, and so many free and charitable clinics across the country, more Americans are able to get access to the quality, convenient and affordable healthcare they deserve," said Eileen How-

Advanced Kids Care - Pediatric Practice, Pediatric Urgent Care and Pediatric Concierge Care Opens Advanced Kids Care has announced immediate availability of Pediatric Urgent Care services for walk-ins, after hours, weekends, Pediatric practices and Pediatric Concierge Care, enabling children in the area to have the highest pediatric services available to them.

Positive Customer Impact Many customers have already benefited from deploying Pediatric Urgent Care services for walk-ins, after hours, weekends, Pediatric practices and Pediatric Concierge Care. Dr Bernadette Antonyrajah founder and President of Advanced Kids Care was the former medical director of the Pediatric Intensive Care unit at Florida Hospital Orlando and is double board certified in Pediatric Critical Care and Pediatrics.

Pediatric Urgent Care services for

walk-ins, after hours, weekends, Pediatric practices and Pediatric Concierge Care Availability Pediatric Urgent Care services for walk-ins, after hours, weekends, Pediatric practices and Pediatric Concierge Care is an update driven by customer feedback and is part of Advanced Kids Care commitment to deliver the latest product updates in one convenient installation. Pediatric Urgent Care services for walk-ins, after hours, weekends, Pediatric practices and Pediatric Concierge Care is available for immediately download at www.advkidscare.com.

For more information on Pediatric Urgent Care services for walk-ins, after hours, weekends, Pediatric practices and Pediatric Concierge Care: www.advkidscare.com

Arnold Palmer Hospital Receives Grant to Support Childhood Cancer Research The St. Baldrick’s Foundation awarded Orlando Health Arnold Palmer Hospital for Children with a $50,000 grant, which will help ensure more patients can be treated in early-phase clinical trials, often their best hope for a cure. One of nearly 30 grant recipients (and only two in Florida), Arnold Palmer Hospital will use these funds to continue bringing the next generation of treatments for patients battling childhood cancer.

Arnold Palmer Hospital pediatric on-

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GrandRounds ard Boone, President of the CVS Health Foundation. "We are proud to be a longtime supporter of NAFC, who is helping us deliver on our purpose of helping people on their path to better health."

Stephanie Garris - Stephanie Garris is the CEO of Grace Medical Home in Orlando, Florida. Stephanie is a constant advocate for the medically underserved at a local, state and national level. Under Stephanie's leadership, Grace has been able to grow from a small, start-up medical home with a handful of staff to an organization with 31 staff and hundreds of physician and student volunteers who have served 4,000 of their uninsured neighbors with more than 11,000 patient visits annually, totaling an offered value of care of more than $20,000,000.

Complex and Rapidly Changing Payment Models Challenge Physician Practices, Study Finds Physician payment models are becoming more complex and the pace of change is increasing, creating challenges for physician practices that might hamper their ability to improve the quality and efficiency of care despite their willingness to change, according to a new joint study by the RAND Corporation and the American Medical Association.

“The complexity and pace of change in how physicians are paid for their services has required practices to spend substantial resources just to keep up with program details,” said Dr. Mark W. Friedberg, the study’s lead author and a senior physician policy researcher at RAND, a nonprofit research organization. “While the practices in our sample generally voiced support for the goals of alternative payment models, these implementation challenges could make it difficult to achieve them.”

The study is a follow-up to a similar one conducted in 2014 to assess how physician practices were responding to alternative payment models. These models are changing how physicians are compensated for the care of their patients to create stronger incentives for efficient, high-quality medicine. They often involve either bonuses for meeting quality goals or penalties for falling short.

Researchers from RAND examined 31 physician practices in six geographic markets to describe the effects of alternative health care payment models on physician practices. Whenever possible, researchers re-interviewed the same physicians and practice leaders that participated in the previous study.

The findings are intended to help guide system-wide efforts by the AMA, which sponsored and co-authored the study, and other health care stakeholders to improve alternative payment models and help physician practices successfully adapt to the changes.

“Physicians tell us that it’s more difficult than ever to understand the growing complexity of payment models and they are straining against a conflicting muddle of public and private value-based policies and rules that are continually in flux,” said AMA President Dr. Barbara L. McAneny.

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“The resulting administrative burdens take physicians away from patient care. Today’s report is a call to action to align multiple payers and payment models with consistent measures aimed at improving patient care. It is clear the long-term sustainability of payment reform hinges on value-based payment models that must be operationally and financially sound, sustainable over time, aligned across payers, and must work for physician practices and patients. The AMA is committed to spearheading and engaging these efforts.”

Across the markets studied, leaders perceived an acceleration in the pace of change in alternative payment models from both private insurers and government programs since 2014, at least partially driven by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program.

As in 2014, many physician practices -especially those that are small and independent -- reported that they lacked the skills and experience with data management and analysis that are needed to perform well in alternative payment methods, according to the report. Building in methods to help these practices master the use of health data would improve the potential success of many alternative payment methods.

The study found that medical practices increasingly were averse to the financial risks posed by alternative payment methods that include penalties for cost of care overruns. In some cases, practices renegotiated contracts with payers to reduce their excessive downside risk or transfer some of that risk to partners such as hospitals or device manufacturers.

In addition to finding ways to reduce the complexity of alternative payment methods, study findings suggest that a slower and more-predictable pace of change might benefit medical practices, payers and other stakeholders.

As in their previous study, researchers found that physicians were broadly supportive of alternative payment methods that enabled their practices to make noticeable improvements in patient care.

They voiced satisfaction with clinical improvements, even when they did not result in financial bonuses.

However, when the alternative payment methods created new reporting and documentation burdens or when they created no perceptible improvements in patient care, physicians reported disengagement and skepticism.

Allowing practicing physicians and other practice leaders to help design alternative payment methods might help improve physician engagement and improve the likelihood that such strategies will produce improvements in patient care, according to the report.

The project conducted interviews between January and June 2018, speaking with 84 people from 31 physician practices in six markets throughout the country: Little Rock, Arkansas; Orange County, California; Miami, Florida; Boston, Massachusetts; Lansing, Michigan; and Greenville, South Carolina. Researchers also spoke to leaders of eight health plans, 10 hospitals or hospital systems, 10 state and local medical societies, and four Medical Group Management Association chapters.

The report, “Effects of Health Care Payment Models on Physician Practice in

American College of Healthcare Trustees Appoints Irma Rastegayeva, MSc, MSEM to its Board of Directors The American College of Healthcare Trustees, a social enterprise that promotes good governance, leadership, and decision-making in healthcare, announces today that it has appointed Irma Rastegayeva to its Board of Directors.

“Irma is an outstanding addition to our Board of Directors,” said David Levien, MD, MBA, FACS, President and CEO of the American College of Healthcare Trustees. “She is a true healthcare visionary, tireless patient advocate and innovator committed to outstanding American and global health care.”

Irma’s professional career spans two decades in engineering, technology management and consulting in medical software, devices, life sciences and other industries. Irma left a successful 5-year tenure with Google in 2016 to fully indulge her passion for medical technology and healthcare innovation. She now combines deep technical expertise, product development and patient advocacy experience with storytelling and community engagement as a Chief Innovation Catalyst at eViRa Health, which she co-founded. Additionally, Irma is a consultant, entrepreneur coach, cofounder and co-organizer of TEDxBeaconStreet, and serves on the board of Ideas in Action.

Irma earned Master of Science degree in Systems and Software Engineering from Boston University and Master of Science degree in Engineering Management from Tufts University.

“I am honored to join the ACHT board and to partner with an outstanding Board of Directors and talented executive team, all committed to achieving the quadruple aim of high quality and safety, great patient and physician experience, and sustainable costs in healthcare,” said Irma Rastegayeva. “I

the United States: Follow-Up Study,” is available at www.rand.org.

Other authors of the report are Peggy G. Chen, Molly Simmons, Tisamarie Sherry, Peter Mendel, Laura Raaen, Jamie Ryan and Patrick Orr, all of RAND, and Carol Vargo, Lindsey Carlasare, Christopher Botts and Kathleen Blake, all of the American Medical Association.

CMS Proposes to Modernize Medicare Advantage, Expand Telehealth Access for Patients In a proposed rule issued today, the Centers for Medicare & Medicaid Services (CMS) took action to build upon the Administration’s ongoing efforts to modernize the

look forward to helping lead an organization with such a socially conscious mission and to be working with preeminent healthcare leaders towards shared goals.”

On November 7th, Irma will be joining many ACHT Board of Directors members, Fellows and attendees as a speaker at the Asilomar Health Innovation Conference, held on the magnificent Monterey Peninsula. Irma will also be leading the planning of ACHT conference on Integrative Medicine in the Great Southwest in the Spring of 2019.

The American College of Healthcare Trustees (ACHT) is a national professional association for health care boards of directors and other leaders.

We support both current and aspiring board members by providing education, networking, and documentation of their preparation. We provide education and training to all people of good character who wish to increase their knowledge, skills, and abilities to effect improvement in health care delivery.

Medicare Advantage and Part D programs, which provide seniors with Medicare health and prescription drug coverage through private plans. The changes proposed today would allow plans to cover additional telehealth benefits and would make other much-needed updates, including for individuals who are eligible for Medicare Advantage special needs plans.

“President Trump is committed to strengthening Medicare, and an increasing number of seniors are voting with their feet and choosing to receive their Medicare benefits through private plans in Medicare Advantage. Today’s proposed changes would give Medicare Advantage plans more flexibility to innovate in response to patients’ needs,” said CMS Administrator Seema Verma. “I am especially excited about proposed changes to allow additional telehealth benefits, which will promote access to care in a more convenient and orlandomedicalnews

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GrandRounds cost-effective manner for patients.”

Medicare Open Enrollment for 2019 is currently underway and runs through December 7, 2018, so seniors can review their coverage options and decide how they would like to receive their Medicare benefits in 2019. CMS offered new flexibilities to Medicare Advantage plans starting in the 2019 plan year, and plans are making additional benefits available including adult day care services, in-home support services, and benefits tailored for patients with chronic diseases like diabetes. The average Medicare Advantage premium will decline by 6.1 percent, enrollment is projected to grow by 11.5 percent, and there will be approximately 600 more plans available across the country next year.

Today’s proposed changes for plan year 2020 would leverage new authorities provided to CMS in the Bipartisan Budget Act of 2018, which President Trump signed into law earlier this year. With respect to telehealth, the proposed changes would remove barriers and allow Medicare Advantage plans to offer “additional telehealth benefits” not otherwise available in Medicare to enrollees, starting in plan year 2020 as part of the government-funded “basic benefits.”

This proposal will allow Medicare Advantage plans broader flexibility in how coverage of telehealth benefits is paid to meet the needs of their enrollees. As Medicare beneficiaries become more tech savvy, CMS is working across the agency to promote beneficiary access to telehealth, but the Medicare fee-for-service program telehealth benefit is narrowly defined and includes restrictions on where beneficiaries receiving care via telehealth can be located. The proposed rule would give MA plans more flexibility to offer governmentfunded telehealth benefits to all their enrollees, whether they live in rural or urban areas. It would also allow greater ability for Medicare Advantage enrollees to receive telehealth from places like their homes, rather than requiring them to go to a health care facility to receive telehealth services.

Plans would also have greater flexibility to offer clinically-appropriate telehealth benefits that are not otherwise available to Medicare beneficiaries.

Today’s proposed changes are a major step towards expanding access to telehealth services because the rule would eliminate barriers for private Medicare Advantage plans to cover such additional telehealth benefits under the MA plan. While MA plans have always been able to offer more telehealth services than are currently payable under original Medicare through supplemental benefits, this change in how such additional telehealth benefits are financed (that is, accounted for in payments to plans) makes it more likely that MA plans will offer them and that more enrollees will be able to use the benefits.

Additional changes proposed today would improve the quality of care for dually-enrolled beneficiaries in Medicare and Medicaid who participate in “Dual Eligible Special Needs Plans” or D-SNPs. These beneficiaries generally have complex health needs. Today’s proposed changes would unify appeals processes across Medicare and Medicaid to make it easier for enrollees in certain D-SNPs to navigate the system. The proposed rule would also require plans to more seamlessly integrate

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benefits across the two programs to promote coordination.

Today’s proposed rule also improves accountability and bolsters program integrity within the Medicare Advantage and Part D programs. The proposed changes would update the methodology for calculating Star Ratings, which provide information to consumers on plan quality. The new methodology would improve stability and predictability for plans, and would adjust how the ratings are set in the event of extreme and uncontrollable events such as hurricanes.

The proposed rule also includes critical updates with respect to program integrity. First, CMS is making revisions to an earlier regulation that made available to Part D sponsors and Medicare Advantage plans a list of precluded providers and prescribers that have engaged in behavior that bars their enrollment in Medicare. Under the earlier regulation, plans would be required to deny payment for any prescription, service, or item that is prescribed or furnished by an individual or entity on the Preclusion List.

Second, the proposed rule would take steps to help CMS recover improper payments made to Medicare Advantage organizations. CMS conducts Risk Adjustment Data Validation audits to confirm that diagnoses submitted by Medicare Advantage Organizations for risk adjusted payments are supported by medical record documentation. CMS recovers improper payments based on these audits. The proposed rule would strengthen CMS’s ability to return dollars to the Medicare Trust Funds as a result of these audits. If finalized, the proposed changes would result in an estimated $4.5 billion in savings to the Medicare Trust Funds over a ten year period, largely from the recovery of improper payments to Medicare Advantage plans through contract- level Risk Adjustment Data Validation audits. In addition, CMS released an analysis on the application of a Fee-For-Service adjuster in determining the Medicare Advantage payment recoveries. The analysis can be accessed at: https://www.cms.gov/ Research-Statistics-Data-andSystems/ Monitoring-Programs/Medicare-Risk-Adjustment-Data-ValidationProgram/Resources.html (the Fee-For-Service Adjuster executive summary and technical appendix are available in the “Downloads” section of the webpage).

For a fact sheet on the CY 2020 Medicare Advantage and Part D Flexibility Proposed Rule (CMS-4185-P), please visit: https://www.cms.gov/newsroom/factsheets/contract-year-cy-2020- medicareadvantage-and-part-d-flexibility-proposedrule-cms-4185-p.

The proposed rule can be downloaded from the Federal Register at: https:// s3.amazonaws.com/public-inspection.federalregister.gov/2018-23599.pdf And on 11/01/2018 and available online at https://federalregister.gov/d/2018-23599 CMS looks forward to feedback on the proposal and will accept comments until December 31, 2018. Comments may be submitted electronically through our e-Regulation website at: https://www.cms.gov/Regulations-andGuidance/Regulations-and- Policies/eRulemaking/index.html?redirect=/eRulemaking.

New Ocoee Cancer Center First in Central Florida to Offer MRI-Guided Radiation Therapy The newly-opened Orlando Health UF Health Cancer Center – Health Central Hospital is treating cancer patients with new, cutting-edge MRI-guided radiotherapy. The cancer-fighting technology is called MRIdian® and allows oncologists to see treatment areas in real-time while targeting them with precise radiation therapy.

The facility is one of nine in the country to treat cancer with MRI-guided radiotherapy and only the second in Florida.

With the MRIdian® Linac from ViewRay® Inc. (Nasdaq: VRAY), magnetic resonance imaging and radiation therapy are fully integrated during the course of treatment, allowing for a targeted approach. The technology allows specialists to track and adjust its beam delivery to any subtle changes in the tumor and surrounding tissue during treatment. As a result, cancer patients benefit from truly personalized radiation therapy while minimizing radiation exposure to surrounding tissue.

“Fighting cancer requires a constant search for the latest advances in treatment and the MRIdian system is another example of our commitment to provide our pa-

New study in STEM CELLS could lead to therapy that does away with joint replacement surgery A study recently released in STEM CELLS moves scientists a step closer to finding how to help the body regenerate joint cartilage ravaged by disease. Their work reveals a new method to quickly and efficiently produce virtually unlimited numbers of chondrocytes, the cells that form cartilage, from human skin cells converted to induced pluripotent stem cells (iPSCs).

For the 54 million Americans suffering from arthritis – the nation’s Number One disability – this could be great news.

While a May 2018 report by Modern Healthcare says that currently over 1 million joint replacement surgeries occur ev-

tients with personalized, exceptional cancer treatment,” said Dr. Daniel Buchholz, chairman of radiation oncology at Orlando Health. “Soft-tissue tumors have subtle, natural movement during treatment but this technology allows us to track and treat the tumor while sparing surrounding healthy tissue from radiation exposure, which may result in better outcomes and less side effects for our patients.”

The MRIdian® System is one of the advanced treatment options available at the new Orlando Health UF Health Cancer – Health Central Hospital. The 30,000 square-foot Cancer Center was funded primarily by a $21 million grant from the West Orange Healthcare District and almost doubles the size of the previous facility located near Health Central Hospital. In addition to MRIdian® MRI-guided radiotherapy, the new Cancer Center features expanded chemotherapy and radiation treatment areas, medical oncology services, surgical oncology consultations, laboratory facilities and Cancer Support Community programs.

ery year in the United States alone — and that number is expected to exceed 4 million by 2030 — many medical researchers believe that the future of arthritis therapeutics lies in the application of stem cells to grow new joint cartilage (a process called “chondrogenesis”). Human iPSCs (hiPSCs) are a promising cell source for cartilage regenerative therapies and in vitro diseasemodeling systems due to their pluripotency and unlimited proliferation capacity.

Furthermore, iPSCs provide a means of developing patient-specific or genetically engineered cartilage to screen for osteoarthritis drugs.

“That’s why finding methods to rapidly and efficiently differentiate hiPSCs into chondrocytes in a reproducible and robust manner is critical,” said Farshid Guilak, Ph.D., from Washington University’s Center of Regenerative Medicine and Shriners Hospitals for Children (St. Louis, Mo.). He is a co-senior author of the study in STEM

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GrandRounds CELLS along with Charles A. Gersbach, Ph.D., from the Department of Biomedical Engineering at Duke University (Durham, N.C). Scientists from Cytex Therapeutics (Durham, N.C.) and Stanford University (Stanford, Calif.) also participated.

Chondrocytes are the cells that produce and maintain the cartilage lining the surfaces of diarthrodial joints — the freemoving types of joints you find, for example, in the hip and knee. “However,” Dr. Guilak explained, “a disease like arthritis can destroy the cartilage in the joint and escalate inflammation. Ultimately, these changes lead to pain and loss of function that currently necessitates total joint replacement with an artificial prosthesis.”

In their study, the Guilak-Gersbach team demonstrated the development and application of a step-wise differentiation protocol validated in three unique and well-characterized hiPSC lines. They examined gene expression profiles and cartilaginous matrix production during the course of differentiation. To further purify committed chondroprogenitors, they used CRISPR-Cas9 genome engineering technology to knock-in a GFP reporter at the collagen type II alpha 1 chain (COL2A1) locus to test the hypothesis that purifying the chondroprogenitors could enhance articular cartilage-like matrix production.

Most differentiation protocols to date have been based on trial-and-error delivery of growth factors without immediate consideration of the signaling pathways that direct and inhibit each stage of differentiation. Accordingly, chondrogenic differentiation is often dependent on the specific cell lines used, and broad application of iPSC

chondrogenesis protocols has not been independently demonstrated with multiple cell lines and in multiple laboratories.

Recently, critical insights from developmental biology have elucidated the sequence of signaling pathways needed for PSC lineage specification to a number of cell fates.

“By reproducing these reported signaling pathways in vitro, in combination with existing chondrogenic differentiation approaches, we sought to establish a rapid and highly reproducible protocol for hiPSC chondrogenesis that is broadly applicable across various hiPSC lines,” said Chia-Lung Wu, Ph.D., the co-first author of the study.

“Since hiPSC differentiation processes are inherently unpredictable and can often produce heterogeneous cell populations over the course of differentiation, an important goal of differentiation protocols is to minimize variability in hiPSC differentiation potential, which may arise from characteristics of the donor and/or reprogramming method. Therefore, we hypothesized that purifying the committed chondroprogenitors would improve hiPSC chondrogenesis.”

The method obtained the desired results.

“The purified chondroprogenitors demonstrated an improved chondrogenic capacity compared to unselected populations,” Dr. Shaunak Adkar, Ph.D., co-first author of the study reported. “The development of processes for rapid and repeatable induction of iPSCs into joint cell tissue will hopefully enable the identification of novel therapies for joint diseases such as osteoarthritis.”

Jan Nolta, Ph.D., Editor-in-Chief of

STEM CELLS, said, “The elegant techniques used by the the Guilak-Gersbach team generated improved numbers of pure chondroprogenitors, a step that was crucially needed to propel the promising field of stem cellmediated cartilage repair forward.”

This work was supported in part by the Arthritis Foundation, the Nancy Taylor Foundation for Chronic Diseases, and the National Institutes of Health.

The full article, “Step-Wise Chondrogenesis of Human Induced Pluripotent Stem Cells and Purification Via a Reporter Allele Generated by CRISPR-Cas9 Genome Editing” can be accessed at https://stemcellsjournals.onlinelibrary.wiley.com/doi/ abs/10.1002/stem.2931.

“Night on Broadway” Famous Faces Masquerade Ball Brings Down the House The Great White Way was shining bright in Central Florida in October as 555 guests raised nearly $400,000 to benefit Shepherd’s Hope and its mission of providing free and compassionate healthcare to the uninsured.

This year’s Famous Faces Masquerade Ball transformed the Loews Royal Pacific Resort at Universal Orlando into the world’s most famous theater district in midtown Manhattan. The evening included interactive entertainment, gourmet dining, fine wine and spirits, costume contests, live and silent auctions, dancing and more. “‘Night on Broadway’ shined a light on our community’s increasing need for

free medical care for the uninsured,” said CEO/President Marni Stahlman. In Central Florida, an estimated 450,000 people are without health insurance, including 50,000 children.

“The proceeds from our annual Famous Faces Masquerade Ball have a profound impact on the lives of thousands of people each year,” Stahlman added. “In 2018, we are already seeing the number of provided primary care and specialty care visits to uninsured men, women and children surpass what was provided in 2017, with the help of an all-volunteer medical team and thousands of general volunteers.

The dollars raised at Famous Faces are essential in order for us to continue to provide these valuable services in the future.”

During the entertaining evening, Dom and Kalani Meffe were honored with the Maryanne Brown Award of Distinction. As the Chief Executive Office of Kroger Specialty Pharmacy, Meffe currently serves on the Shepherd’s Hope Board of Directors, returning after eight years when he was previously Chairman. He and his wife, Kalani, are immense community supporters who have given of their time, talents and resources to many organizations in Central Florida.

Generous community partners who contributed to the success of the Shepherd’s Hope Famous Faces Masquerade Ball included the event’s presenting sponsors, Kroger’s Specialty Pharmacy and Lucky’s Market, as well as a number of corporate sponsors, including Universal Orlando Resorts, Megan’s Moving & Staging, Orlando Health, Florida Hospital, SeaWorld, Nemours Children’s Hospital, Rae of Sunshine Foundation, Vaco, Bioclinica, Loews

Multidisciplinary Breast Cancer Clinic bring comprehensive care to Florida Hospital Altamonte Florida Hospital is taking an innovative approach to make breast-cancer care more convenient and less stressful for patients.

At Florida Hospital Altamonte, a team of breast cancer specialists, including medical oncologists, radiation oncologists and breast cancer surgeons, work together to develop targeted treatment plans for patients based on their individual needs. Patients can access all three specialties at one location, in a single visit, at the new Breast Cancer Clinic.

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provides patients the highest quality of care," said breast cancer surgeon Dr. Lisa Minton. "We can evaluate breast cancer patients in a comprehensive, single-day setting — helping to decrease the time between diagnosis and treatment."

Prior to a patient's appointment, the team reviews the case. The patient then meets with her or his care team, consisting of a medical oncologist, a breast surgeon and a radiation oncologist, to discuss the best treatment options for her specific diagnosis.

Additional appointments for imaging, labs or ancillary services such as plastic surgery can be discussed with the patient and scheduled as needed.

The Altamonte campus also offers advanced new technologies for breast cancer treatment, including the new TrueBeam system, which is designed to deliver precise radiation directly to a tumor site while sparing healthy tissue and reducing overall treatment time. The system will also incorporate a 64-slice CT scanner, which produces incredibly detailed, razor-sharp images,

and the Prone Breast Board, which ensures patient comfort, while also further minimizing radiation exposure to the chest wall, protecting healthy cardiac tissue and lungs.

“Undergoing cancer treatment is a difficult experience,” Minton said. “We want to do everything we can to make it easier for our patients. Our multidisciplinary approach allows us to do that.”

The new clinic is located in the Medical Plaza on the campus of Florida Hospital Altamonte, 661 E. Altamonte Drive, Suite 231.

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GrandRounds Royal Pacific Resort at Universal Orlando®, ABC Fine Wine and Spirits, City Beverage, Production Resource Group, VER, Sunbelt Rentals, Spectacular Themes, Quest Drape, Amazing Pictures by Colorvision International, Shephard Exposition Center, Orange Appeal and numerous other businesses and individuals.

AMA Applauds HHS for Revisions to Medicare E/M Policies Barbara L. McAneny, M.D., president of the American Medical Association issued a statement saying: “With physicians facing excessive documentation requirements in their practices, it is relief to see that the Administration not only understands the problem of regulatory burden but is taking concrete steps to address it. Patients are likely to see the effect as their physicians will have more time to spend with them and be able to more quickly locate relevant information in medical records.”

Specifically, the AMA is grateful that the Centers for Medicare & Medicaid Services: • Changed the required documentation of the patient’s history to focus only on the interval history since the previous visit.

• Eliminated the requirement for physicians to re-document information that has already been documented in the patient’s record by practice staff or by the patient; and • Removed the need to justify providing a home visit instead of an office visit.

• Declined to move forward on a proposal to reduce payment for office visits when performed on the same day as another service.

“Implementation of these policies will streamline documentation requirements, reducing paperwork burdens that interfere with a meaningful patient-physician relationship.”

“The AMA also is grateful that the Administration is not moving forward in 2019 with the payment collapse of E/M codes. A two-year window for implementation of the proposal will give the AMA-convened work group – comprised of physicians and other health professionals – time to make recommendations on this complicated topic. The panel members have deep expertise in defining and valuing codes, and as members of various specialties, they all use the office visit codes to describe and bill for services provided to Medicare patients. The group is analyzing these issues and plans to offer solutions to be provided to CMS for future implementation. We look forward to further dialogue with the Administration on the work group’s proposal.”

Florida Hospital – Soon to be Renamed AdventHealth – Will Be The Official Sponsor of DAYTONA Speedweeks Daytona International Speedway and Florida Hospital, which will soon be renamed AdventHealth, announced an expansion of their relationship, making the health system the official presenting

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sponsor of DAYTONA Speedweeks at the “World Center of Racing.”

With this expanded multi-year partnership, DAYTONA Speedweeks will now be referred to as DAYTONA Speedweeks Presented By AdventHealth, which is highlighted by the 61st annual DAYTONA 500, “The Great American Race.”

In 2014, Florida Hospital was named a Founding Partner and the Official Healthcare Partner of Daytona International Speedway. In addition, Florida Hospital provides the medical services at the facility. The new expansion of the partnership will further enable Florida Hospital to share its guiding philosophy of delivering wholeperson care for the mind, body and spirit on the DAYTONA Speedweeks’ international platform.

In August, Florida Hospital’s parent company, Adventist Health System, announced that it will change its name to AdventHealth on Jan. 2, 2019. As one of the nation’s largest health systems with more than 80,000 employees, nearly 50 hospital campuses and hundreds of care sites, the change to the AdventHealth name will unite the healthcare system under one connected and identifiable national system of care.

DAYTONA Speedweeks Presented

By AdventHealth includes the following events: * The Lucas Oil 200 Driven By General Tire, the ARCA Racing Series season opener: Saturday, Feb. 9 * DAYTONA 500 Qualifying Presented

By Kroger and the Advance Auto Parts Clash doubleheader: Sunday, Feb. 10 * The Duel At DAYTONA 150-mile qualifying races: Thursday, Feb. 14 * The NextEra Energy Resources 250, the season-opening event to the NASCAR Gander Outdoors Truck Series: Friday, Feb. 15 * The DAYTONA 300, the seasonopening event to the NASCAR Xfinity Series: Saturday, Feb. 16. * The DAYTONA 500, NASCAR’s biggest and most prestigious event that marks the start of the Monster Energy NASCAR Cup Series season: Sunday, Feb. 17.

“Florida Hospital has been an ideal partner for Daytona International Speedway,” track president Chip Wile said. “To be able to expand our partnership to now include the DAYTONA Speedweeks brand will provide another platform for Florida Hospital to amplify their new name.”

“The DAYTONA 500 and the associated races of Speedweeks are the nation’s premier racing events and present an amazing opportunity to introduce AdventHealth to race fans across the globe,” said David Ottati, president and chief executive officer of Adventist Health System’s Central Florida Division - North Region, which includes the Florida Hospitals located in Volusia, Flagler and Lake counties. “Since announcing our Founding Partnership with Daytona International Speedway four years ago, we have had the opportunity to share our message of health and wellness, focused on improving lifestyles and offering high-quality healthcare services. We are thrilled to have the opportunity to further expand upon our relationship with the Daytona International Speedway and are already looking forward to the upcoming Speedweeks.”

Oviedo Medical Center’s “Memorable Beginnings” Labor and Delivery unit is now offering Nitrous Oxide as an option for pain management in labor. Nitrous Oxide is a quick-acting gas that is inhaled through a mask. It is widely used all over the world as a safe alternative for labor pain relief. Many people may be familiar with its use in dentist office and may have heard it referred to as “laughing gas”. Nitrous Oxide, as with any medical intervention, does have risks but overall is considered safe to use during labor.

Dr. Rajan Wadhawan to lead Florida Hospital for Children, Florida Hospital for Women Dr. Rajan Wadhawan has been promoted to senior executive officer, and will lead both Florida Hospital for Children and Florida Hospital for Women.

Wadhawan previously served as chief medical officer of Florida Hospital for Children, as well as medical director of neonatology at Florida Hospital for Children.

During Wadhawan’s tenure as chief medical officer, Florida Hospital for Children has been named a Leapfrog Top Children’s Hospital and a top neonatology program by U.S. News & World Report. Also during this time, the hospital entered into affiliations with Duke Health and Children’s Hospital of Pittsburgh of UPMC. “Dr. Wadhawan has done an outstanding job bringing national prominence to our neonatal care, and he will now bring his proven leadership skills to oversee our women’s and children’s hospitals,” said Eric Stevens, Florida Hospital CEO of acute-care services.

“Dr. Wadhawan is the perfect choice to lead our programs as Florida Hospital takes a position on the national stage in the coming months as we become AdventHealth.”

In his new role, Wadhawan will oversee a wide range of women’s and children’s programs, including pediatric liver transplant, pediatric and congenital cardiology, four labor and delivery locations with more than 12,000 deliveries annually, advanced gynecology and urogynecology surgical services, and a host of extended care facilities supported by seven hospitals.

Wadhawan completed his training in pediatrics and neonatology at Brown

University in Providence, R. I. He was at All Children’s Hospital in St. Petersburg prior to joining Florida Hospital for Children in 2012.

He is board certified in pediatrics, neonatal perinatal medicine and medical management by the Certifying Commission for Medical Management as a Certified Physician Executive (CPE).

He obtained a master’s degree in medical management from Carnegie Mellon University in 2011.

Wadhawan is also an associate professor for pediatrics at the University of Central Florida.

“It is an honor to lead our exceptional women’s and children’s care teams,” said Wadhawan. “I look forward to building on the successes of our world-class team and to continue our work growing a leading network that is a destination for patients nationwide, and provides seamless care for a lifetime.”

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GrandRounds Transaction Data Systems Partners with Community Pharmacies to Fight the Opioid Epidemic with Release of NarcFacts OCOEE -- Transaction Data Systems, Inc., the leader in pharmacy management software including Rx30 and ComputerRx, is helping community pharmacies fight controlled substance abuse with integrated tools to streamline PDMP review.

"The launch of NarcFacts brings an innovative solution to a nationwide epidemic. Community pharmacy is uniquely positioned to impact substance abuse through daily patient engagement. Our pharmacy management platforms now help pharmacies facilitate change within the care continuum," Jude Dieterman, TDS President and CEO. "It's tools like these, which integrate PDMP review into the pharmacy's workflow, that are going to help community pharmacies make a big impact on the opioid epidemic."

Using the NarcFacts integration, pharmacies are alerted to overlapping pharmacies and prescribers, high doses, duplications or other potential problems directly through their pharmacy management platform. From the alert screen, they can learn more about warnings, access multi-state PDMP data records, and view an interactive prescribing graph and geomap of dispensing history.

"NarcFacts is an innovative solution designed to integrate seamlessly with the pharmacy management software to become part of the pharmacy's daily prescription filling process," explains Jeff Pohler, TDS Clinical Services vice president. "If there is a potential problem, the pharmacy is alerted through their pharmacy management system, saving time and effort while ensuring compliance."

NarcFacts is an exclusive solution available to community pharmacies only through Computer-Rx and Rx30 platforms.

NarcFacts gives nearly half of all community pharmacies the opportunity to remain compliant with their state's reporting requirements without leaving their pharmacy management platform, and, most importantly, the ability to impact lives of patients affected by the opioid epidemic. Visit www.NarcFacts.com to learn more.

For more than four decades, TDS has been dedicated to the success of community pharmacy. TDS, through its family of products including Rx30, Computer-Rx and Enhanced Medication Services, provides pharmacy management systems and other innovative technology to the pharmacy industry. Its proven software solutions and continually growing, evolving products and services offer pharmacies the technology and support they need to succeed. Proudly supporting the largest install base of community pharmacies in the industry with systems in all 50 states, TDS is the unquestioned leader in community pharmacy management software.

New initiative aims to protect hearts of breast cancer patients As a breast cancer survivor, the last thing Mary Lynn Brown expected to hear was the treatment that saved her life had inadvertently injured her heart. She wasn’t alone.

Breast cancer patients may be at increased risk of heart diseases, and now, Florida Hospital is launching a cardiooncology initiative designed to prevent or minimize the adverse effects of chemotherapy and radiation on these patients.

The initiative, made possible by a $100,000 grant from the Hearst Foundations, combines state-of-the-art cardiac software, a care coordinator and a multidisciplinary approach to treating breast cancer patients.

Physicians can monitor a patient’s heart function before irreversible damage occurs, and if there’s a sign of cardiac decline, the multidisciplinary team will be able to adjust cancer treatment or prescribe medications to protect the patient’s heart.

“When we care for patients, we can’t look at just the cancer or just the heart disease. We need to treat the whole person, and this new initiative strengthens our wholistic approach to healing,” said Dr. Patricia Guerrero, a cardiologist with Florida Heart Group and medical director of Florida Hospital’s women and cardio-

vascular disease program. “We are appreciative for the continued support the Hearst Foundations has offered to our cardiovascular program and are confident this will have a significant impact on our patients’ health.”

Guerrero treated Brown in 2016, six years after she was declared cancer free.

Brown thought her allergies caused shortness of breath, but Guerrero found heart disease was to blame.

Research shows up to 28 percent of women receiving chemotherapy will develop a weakening of the heart, according to a study published in the Journal of the American College of Cardiology in 2017.

“Florida Hospital has outstanding clinical programs, and we are pleased to support initiatives that further enhance their services and provide Central Floridians vital care,” said Ligia Cravo, senior program officer at the Hearst Foundations.

The new initiative launched at Florida Hospital Orlando and Florida Hospital Altamonte, and is expected to expand to the Apopka and Celebration campuses in the upcoming months.

The Hearst Foundations’ grant also includes ongoing support of Florida Hospital’s Heart Care Center — a program that seeks to improve the cardiovascular health of underserved and uninsured heart patients in Central Florida.

Orlando Health joins the Healthcare Financial Management Association Enterprise level program provides membership for all team members Orlando Health has joined the Healthcare Financial Management Association (HFMA), providing membership benefits to all of its more than 20,000 employees. Previously limited to individuals, HFMA’s enterprise membership was developed to provide entire organizational teams with cost-effective and easy-to-implement tools and educational resources that increase staff engagement and optimize organizational results.

"This membership gives our team members access to great tools and resources, along with valuable insights in healthcare finance,” says Michele Napier, vice president, Revenue Management, Orlando Health.

“We’ll be able to share knowledge and best practices with colleagues across the country at the chapter, regional and national level. We are very pleased to offer this HFMA membership to our team members to help meet the challenges of the

$5 Million Gift Expands Pediatric Neurological Care in Central Florida An Orlando woman with a long history of philanthropy is helping expand care for children with neurological conditions in Central Florida. At her 87th birthday celebration, Helen Leon, agreed to give $5 million to the newly created neuroscience center at Orlando Health Arnold Palmer Hospital for Children.

Ms. Leon’s gift will be used to facilitate and formalize initiatives that support the center, which will now officially be known as the Leon Pediatric Neuroscience Center of Excellence. The vision for the center includes providing comprehensive, coordinated care for a broad range of neurological disorders (such as spina bifida and epilepsy) and developing innovative treatment options through expanded research opportunities.

“My late husband, Eddie and I were very involved in supporting advancements

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in children’s healthcare for many years together,” said Ms. Leon. “Children are innocent, and deserving of our investment of time, love and resources.”

“We’re extremely grateful to Ms. Leon for her generous gift to help grow the highlevel of neurological care at our hospital,” said John Bozard, president of the Arnold Palmer Medical Center Foundation. “She has been a long-standing supporter and volunteer at Arnold Palmer Hospital and her kindness and generosity has and will continue to impact many young lives.”

In August, Orlando Health announced its new fetal surgery program to repair spina bifida, which is supported by the neuroscience center. As the first hospital system in the state of Florida to offer this kind of in-utero surgery, Orlando Health is prepared to become a destination medical facility in the southeast.

modern healthcare environment.”

The membership provides professional development opportunities, unlimited access to financial management education and organizational alignment for the entire organization.

“Enterprise membership helps organizations meet today’s challenges by bringing them educational and talent development resources that align with their goals,” said HFMA president and CEO Joseph J. Fifer,

FHFMA, CPA. “Through this membership, Orlando Health is equipping its entire team to succeed in the new era of health care.”

Specific enterprise membership benefits include access to online education, research reports, and white papers as well as discounted conference registrations and opportunities to connect with industry peers in virtual communities and at national and local levels.

More information about enterprise membership is available at hfma.org/enterprise

Helen Leon

“Ms. Leon’s seminal gift arrives at a very exciting time for us,” said Samer Elbabaa, MD, medical director of pediatric neurosurgery and director of the Leon Pediatric Neuroscience Center of Excellence at Arnold Palmer Hospital. “Her extremely important philan-

thropic support will help us become the region’s largest comprehensive pediatric neuroscience program with unparalleled physician and allied health expertise for the treatment of all children, newborns and fetuses with neurological conditions."

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Helen is a long-standing supporter of Arnold Palmer Hospital for Children, as well

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Florida Hospital Cancer Institute’s Sebastian de la Fuente, MD, Studies Outcomes and Treatments for Elderly Patients with Pancreatic and Liver Cancers Latest Study Published in Journal of Geriatric Oncology As the US population ages and life expectancies increase, the incidence of pancreatic and hepatic (liver) cancers are also on the rise. For the past seven years, Florida Hospital Cancer Institute (FHCI) surgical oncologist Sebastian de la Fuente, MD, has been studying the impact of these demographic changes on the treatment of patients.

Pancreatic cancer is a disease that predominantly affects the elderly with an average age of diagnosis at 70 and an average age of death at 72. Treatment with surgical resection followed by adjuvant chemotherapy offers the greatest chance of survival. Dr. de la Fuente and his colleagues at Florida Hospital and the University of Central Florida recently conducted a study to investigate if age alone, regardless of co-morbidities and pathologic stage of the cancer, affects the rate at which pancreatic cancer patients are offered adjuvant chemotherapy following resection surgery.

The results were published in the Journal of Geriatric Oncology.

For this study, they queried the National Cancer Database (NCDB) to analyze basic demographics and treatment characteristics and found that there was a statistical difference in age for patients who received adjuvant therapy following pancreatic resection and those who did not. The rate of adjuvant therapy in older patients was 35 percent — much lower than for all age groups which was 58 percent. This was regardless of postoperative complications and functional status.

Previous research has demonstrated that undergoing pancreatic resection alone without subsequent chemotherapy is a predictor of poor prognosis in older patients. Dr. de la Fuente and his team also found that 62 percent of those patients who received chemotherapy were given a single-agent regimen despite growing evidence that multi-agent chemotherapeutic regimens may provide better outcomes.

The research team concluded that older patients should be offered tailored treatment plans that would allow them to complete the intended extent of treatment for their cancer.

“We know that the only chance for someone to get cured of a pancreatic cancer is if they are able to undergo chemotherapy and surgery, and in some cases radiation, explains Dr. de la Fuente. “The sequence and timing of such therapies varies and depends on several factors, but if a patient cannot get one of the treatment arms for whatever reason, then that cancer will likely be fatal.”

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of surgical complications, but when age is taken into consideration, up to 80 percent of elderly patients will not be able to receive chemotherapy after surgery. Dr. de la Fuente believes one tailored strategy could be to treat all elderly pancreatic cancer patients with chemotherapy upfront prior to performing the surgery.

“We need to research the effectiveness of this approach along with others to see if we can develop customized treatment plans that take into consideration the specific needs and challenges of older patients to improve their care,” he says.

A previous study by Dr. de la Fuente published in HPB explored the safety of pancreatic resections in elderly patients by using the National Surgical Quality Improvement (NSQIP) database to analyze 30-day postoperative mortality and complication rates. That research concluded that age was a significant determinant of postoperative morbidity and mortality, and as a result, age and functional status should be taken into consideration when counseling pancreatic cancer patients about surgery.

Like pancreatic cancer, the US is also seeing an increase in hepatic cancers among patients over 65. In a third study that was published in the Journal of Surgical Oncology, Dr. de la Fuente examined hepatic resection surgical outcome measures of patients under 70 compared to patients over 70, also using the NSQIP. They found that the older patient group experienced significantly higher complication rates and mortality.

“What we continually find is that elderly patients with cancer are not usually treated in a multidisciplinary way and as a result, aren’t getting the same benefits of treatments used in younger patients,” explains Dr. de la Fuente. “In general, there is a lack of organized geriatric programs to treat these patients as well as a lack of understanding of how cancer affects older people.”

Dr. de la Fuentes believes there is a need to research new treatment options for the growing population of elderly patients, including care teams that encompass medical oncologists, surgical oncologists, radiation oncologists and geriatricians.

“At Florida Hospital, we are also currently exploring if less invasive techniques could benefit elderly patients with gastric cancers,” he explains. “My hope is to eventually develop a comprehensive geriatric surgery program for cancer patients.”

Recognized as “Who is Who in Emerging Leaders” in 2006, Dr. de la

Fuente is a surgical oncologist, board certified in general surgery and fellowship trained in advanced surgical oncology. He has written over 45 peer-reviewed scientific journal articles, 17 book chapters and was awarded The Conquer Cancer Foundation of the American Society of Clinical Oncology (ASCO) Merit Award for his work on esophageal cancer. Dr. de la Fuente also serves as the Director of Research at the Florida Hospital Surgical Residency Program and Director of the Hepato-Pancreato-Biliary (HPB) fellowship.

Dr. de la Fuente received his medical degree from University of Salvador in Buenos Aires, Argentina, and then completed a research fellowship in gastrointestinal surgery and a general surgery residency at Duke University Medical Center in Durham, North Carolina. In 2012, he completed a surgical oncology fellowship at H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida.

To learn more about care for pancreatic or hepatic cancer, visit the Florida Hospital Cancer Institute website.

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Provider Racial Bias Continues to Negatively Impact Community Health IMPLICIT VERSUS EXPLICIT RACIAL BIAS

By JOY STEPHENSON-LAWS, Stephenson, Acquisto & Colman

A recent study published in the Journal of the American Heart Association suggested that black patients hospitalized for heart attacks continue to receive different medical treatment than white patients. This is the latest in a series of reports of well-documented racial differences in medical care despite ongoing efforts by providers to eliminate or at least reduce them. These reports have wideranging implications for providers as well as the communities they serve.

In this particular study, researchers concluded that doctors were less likely to perform aggressive medical procedures or administer certain types of medications routinely prescribed under common treatment guidelines when it comes to black patients. It also found that black patients were almost 25 percent less likely to receive an antiplatelet medication that wasn’t aspirin and they were 9 percent less likely to get medication to reduce blood lipid levels. Perhaps even more alarming, on several levels, is that black patients had an almost 30 percent lower chance of getting an angiogram and were 45 percent less likely to undergo therapies such as bypass surgery or angioplasty.

This racial bias, and its negative impact on treatment outcomes and community health, are not limited to black patients. There are also disparities in healthcare between whites and Hispanics/Latinos, Native Americans, Asians and darker-skinned people in general. It can be readily seen in provider-patient interactions, treatment decisions, transplant decisions, pain management protocols, and treatment adherence as well as in disease incidence and prevalence, life expectancy and mortality. In fact, according to the National Center for Health Statistics, the mortality rates for blacks are about 20 percent higher than those of whites and this disparity has not changed since 1950.

The gap is so pronounced that some diseases, such as prostate cancer, have a higher mortality rate among black men than their white counterparts. And black women, who are less likely to develop breast cancer than white women, are 40 percent more likely to die from this disease.

Another study sugested that black men and women with early-stage breast or lung cancer were less likely to complete treatment than white patients. This statistic held true even when factoring in such variables as age, comorbid illnesses, income and health insurance status.

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Explicit racial bias is as unacceptable in healthcare much as it is in the rest of society. So if this is the case, then exactly what underlies the ongoing bias towards nonwhites? The answer is what is known as “implicit racial bias.” This is a bias that is often unconscious, unrecognized and that can be triggered by external situations and events.

There is evidence that this type of bias is present among many health care providers independent of their specialty area, education and years of experience. Given that close to 75 percent of physicians are white (and 72 percent are male), there is more than ample opportunity for this type of bias to impact all aspects of non-white patient care.

The difference in behavior exhibited toward Blacks, Latinos and other non-white individuals by healthcare providers with implicit racial bias is often very subtle although the patient can often detect – and react to – these bias cues. Some of the more common indications of implicit racial bias are: • Viewing Black patients as being less cooperative, less compliant, less responsible • Seeing a patient as being high-risk without any historical or empirical data to support this belief • Keeping Black and other non-white patients waiting longer for treatment • Spending less time with patients-ofcolor versus white patients • Approaching non-white patients with a dominant and condescending tone • Failing to provide interpreters when needed • Discounting what the patient reports about their pain or symptoms because of their color • Recommending different treatment options on assumptions about the patient’s ability to comply What is interesting is that many healthcare providers do not exhibit any type of racial bias in their routine, day-today interactions with patients but rather their biases seem to be “triggered” when they are busy, distracted, tired or under pressure. Unfortunately, many healthcare providers find themselves in these types of situations more often than not. And, in some settings such a trauma care, it is the norm. This can lead to a healthcare provider assuming that a Black patient reporting pain is drug-seeking rather than pain-relief seeking or that a non-white adolescent will not follow-through with safe sex guidelines and therefore should not be given counseling or STI prophylaxis.

Various studies suggest that health care providers are not intentionally treating people differently based on skin color or ethnic background but that they, like almost

everyone else, have unconscious stereotypes of people who are different than themselves. And when put in specific situations these stereotypes influence their behavior.

WHAT PROVIDERS CAN DO TO REDUCE RACIAL BIAS

Most experts agree that trying to eliminate all bias would be akin to trying to “get people not to breathe” given the unconscious nature of implicit bias. Furthermore, it appears that traditional, cultural or racial sensitivity training does very little to reduce racial bias (either explicit or implicit). Indeed, some suggest these types of training may create resentment on the part of the participants.

If this is the case, can providers realistically take steps to reduce racial bias with the aim of improving healthcare and treatment outcomes for their non-white patients?

It appears that providers can adopt approaches and techniques to achieve positive outcomes in addressing implicit racial bias. Some of these include the following: • Include potential implicit bias factors as part of a provider’s morbidity and mortality conferences to better identify when, how and what could have prevented the bias and its influence on treatment decisions • Make the effort – and train staff – to always practice evidencebased medicine and how to better recognize when their unconscious bias and stereotypes may be a factor in treatment or diagnostic decisions • Take time to see the patient as an individual rather than as a member of a specific ethnic or other group prone to generalizations and try to understand their point-of-view, life experience and day-to-day stresses • Make the effort to create – and take advantage of – opportunities to meet, talk with and know individuals of other racial and ethnic backgrounds to make

it easier to see patients as individuals rather than as racial or ethnic labels • Learn to recognize when body language during provider-patient interactions may be giving subtle cues of bias.

These include increasing interpersonal distance, not maintaining eye contact and having a closed posture (such as crossing arms or keeping hands in a pocket). All these body language signals can impact patient understanding of diagnosis, treatment options and compliance levels • Identify and correct individual provider and staff misconceptions that contribute to racial bias. These include such as false beliefs like those identified in one study among medical students and residents about biological differences between white and black patients (like black skin is “tougher” than white skin) • Aggregate patient treatment and treatment outcome data to be better able to identify possible racial disparities and ways, including more standardized treatment protocols, to reduce them The elimination of explicit racial bias in most settings may cause providers to become complacent. It is important to recognize the existence of implicit bias and avoid taking a “not at my hospital” approach to dealing with this important issue. Admitting that racial bias exists in many healthcare setting is neither easy nor comfortable. But doing so on an ongoing, objective basis is critical to the health and well-being of patients across the country. Their lives literally depend on it.

Joy Stephenson-Laws is founding and managing partner of Stephenson, Acquisto and Colman (www.sacfirm.com), the law firm of choice for the healthcare industry and the leader in healthcare reimbursement law. To date, the firm has recovered well over $1 billion in unreimbursed, denied or disputed medical claims. In this role, Ms. StephensonLaws leads a diverse team of over 100 professionals that includes attorneys, doctors, nurses, technology and healthcare provider operations specialists. She is a member of the American Bar Association.

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A Strategy to Conquer Burnout

By THOMAS P. BURNS, MD

I just spent two days at the Florida Medical Association Annual Meeting. We were there to help educate the physicians on real asset investing. I met many interesting people and likely started some new and exciting relationships. Many of the physicians stopped to talk to us about real estate investing and the benefits of passive cash flow, but there was a troubling undertone that permeated many of the conversations.

A startling number of these doctors admitted that they were “burned out” to some degree with the practice of medicine.

Often, I have had doctors confide in me that they are unhappy with medicine. One 58 y/o family practice doctor once told me that he “hated the business of medicine” but loved taking care of his patients. I have asked others if they would, or could, enjoy medicine if the documentation burdens and the micromanagement were removed. Almost 100 percent say

that they would love to practice medicine the way they were trained, which is to put the patient first.

While I am familiar with physician burnout, I was unaware of its pervasiveness. According to a 2018 Medscape survey, physician burnout has reached epidemic proportions and is above 50 percent. A 2015 Mayo Clinic article compared physician surveys from 2011 and 2014 and found that burnout increased from 45 percent to 54 percent during those three years. Work-life balance was also significantly decreased during that time. These are staggering numbers. How did this occur and what can be done?

According to a presentation given

by Tait Shanafelt, MD, the Director of the Stanford WellMD Center, there are structural defects in the system that must be addressed by the institutions and physician employers. The thesis was that the burden should not be placed on the individual physician, but should be addressed at the corporate, or institutional level. One solution, proposed in Diseases of the Colon and Rectum was, “...enable(ing) physicians to devote 20 percent of their work activities to the part of their medical practice that is especially meaningful to them.” How comforting that the doctor might now be “allowed” to enjoy one-fifth of his chosen vocation! I am not sure if it is worth ten years of medical school and residency only to have a 20 percent satisfaction ceiling!

While the structure and mindset does need to change, the healthcare system moves like the Titanic and will not change course eas-

ily. I do not see any short-term corporate solutions on the horizon.

Given that scenario, what can we do as physicians? Certainly, doctors can lobby for change, enter politics and try to change the system. In the long-run, this may have lasting effects. In the interim, we need to take care of our personal health and our families. If we cannot change the burdensome infrastructure and oversight that has infected medicine over the past 20 years, we must change ourselves. We may not immediately solve the systemic issue, but we can chip away at our own collective situation one doctor at a time.

What can individual practitioners do to counter the potential for burnout? Doctors need to learn to talk the language of money.

It sounds trite and simplistic, but none of us were taught that language in school. Many feel that it is reserved for the “experts” or the guys in the C-suites. That is simply not true.

A modicum of financial education could start you on a path to gain some control over your professional life and buy back a piece of the precious time that you are losing in front of a computer screen. A physician who is less dependent on income from a medical practice is less stressed and enjoys his profession more. I can promise that your patients will notice and they will receive more compassionate care.

In my case, I was slowly able to produce enough passive income outside of medicine that I have been able to mold my practice to my liking. In turn, this has, with all modesty, provided a much more pleasant and caring environment for

my patients. I still work within the same system, but I now have the power to eliminate or change conditions that affect my time, my income, or my patients’ care.

I love going to work each day. While I could have retired long ago, my practice is more fun now than ever. I have the freedom to spend as much time as needed with each patient and I can treat those without insurance for free without financial angst or external oversight. I believe that an army of doctors with control over their professional lives would create the best healthcare system in the world.

I created my freedom through a strategy that fit the lifestyle of a full-time practicing orthopedic surgeon. There is an infinite number of ways to buy back time and there are plenty of resources to learn them. It is not impossible, and it can be done within the time constraints of a busy medical practice. It is beyond the scope of this short article to lay out the strategy, but if you start looking, you will find seminars, articles and podcasts that will help you get started. Physicians are smart and have the capacity to do great things. Find a way to create some passive income. You don’t have to create enough to retire, you just need a little to take off some of the pressure!

Thomas Burns, MD is an orthopedic surgeon in Austin, Texas. He is a graduate of Southwestern Medical School and completed his sports medicine fellowship training at the Steadman Hawkins Clinic in Vail, CO. He is a member of the Forbes Real Estate Council and is frequently featured in nationally circulated print articles and popular real estate-oriented podcasts. Dr. Burns is Principal and Co-founder of Presario Ventures, a real estate investment management firm. tom@presarioventures.com ; www.presarioventures.com

Safeguarding Your Credentials from the Dark Web

By CURTIS PARTRIDGE

When someone describes the “dark web” it sounds like the stuff of a thriller novel or science fiction. Sadly, the dark web is all too real. It is the other “internet” for criminals and their activities. Access to the dark web is only available via a special browser and it is not indexed by search engines. Some of the things you can find on the dark web include credit card numbers, drugs, guns, counterfeit money, stolen subscription credentials such as Netflix, and software the helps you break into other people’s computers.

Where this becomes a problem for a practice owner or manager is those stolen subscription credentials. Imagine your employee left the front door keys on a park bench. Not a large security problem unless there is also a card attached with your practice name and the alarm code.

Those stolen subscription credentials are like those keys with that tag.

Many people have developed the habit of reusing the same login credentials

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across all their accounts. This could be their social media, Netflix, online banking, and your cloud-based EHR. Imagine all the places you use credentials and it easy to see why users re-use the same credentials. It is impossible to remember different credentials for every site and resource.

Online credentials have real value to criminals. According to a recent report

by NBC News, online bank account passwords cost on average $160.15. A set of Uber credentials can be obtained for just $7. Usually an individual’s personal identity can be purchased for about $1200.

When a criminal obtains stolen credentials, they can usually in a short amount of time figure out how to access the systems a practice uses via employee access. They can do this through some simple research or just guessing. There are only a few large providers of services such as email, etc. Once they access one system it allows them to burrow deeper into your practice systems by giving themselves permissions.

What can you do to stop this? The

first thing is to find out if you or your employees have exposed credentials on the dark web. There are organizations that can run a dark web scan periodically to find out if you have been exposed. They will generate a periodic report that lists the affected credentials, and some can also provide the password that was exposed so you can confirm if it current.

The second group of steps you can take is to institute good password practices and tools. There are basic requirements for a secure user password: 1. Random letters and numbers with no words 2. At least one each number, lowercase letter, upper-case letter, and a special character such as * & $ 3. Minimum of 10 characters – the more the better There are fortunately some good tools on the market to generate suitable passwords and manage your credentials.

A tool we have tested and approve is LastPass. It is available in every major browser

as well as mobile devices. The latest version of Apple’s iOS can even incorporate LastPass to assist you with access to your passwords securely.

It is critical to teach employees to never share credentials with anyone. This includes co-workers and supervisors.

Many credentials are leaked via social engineering in the form of a phone call or via email.

If you do need to change or update a co-worker’s password, be sure to do so in person if possible. If you must do so via telephone, be sure to confirm the caller’s identity. Be sure to never email a new password to a user.

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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RADIOLOGY INSIGHTS

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What to Know about the Leading Cause of Cancer Deaths

By LEENA KAMAT, MD

cancers are lung carcinoid tumors. They are also sometimes called lung neuroendocrine tumors and most of these tumors grow slowly and rarely spread.

Radiology with the use of imaging including but not limited to radiographs, CT, and PET/CT scans play a part in the detection and management of lung cancer. Not only is imaging used in staging of cancer once it has been diagnosed but also more recently is being used for the purposes of screening.

Lung cancer screening with low-dose CT (LDCT) is an imaging strategy that is being adopted for high-risk patients.

Since lung cancer is the common cause of cancer death worldwide, there is evidence

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November is Lung Cancer Awareness Month. Lung cancer is the leading cause of cancer deaths in the United States and worldwide, among both men and women. Lung cancer claims more lives each year than do colon, prostate, ovarian and breast cancers combined.

Cigarette smoking is the principal risk factor for the development of lung cancer. The risk of lung cancer increases with the length of time and number of cigarettes one has smoked.

Smoking cessation is the most important measure that can prevent the development of lung cancer. However, lung cancer can also occur in those who have never smoked too.

Symptoms of lung cancer can include coughing, wheezing, shortness of breath, and bloody mucus. Treatment includes surgery, chemotherapy, and/or radiation.

There are three main types of lung cancer; the type can affect treatment options and prognosis. Non-small cell lung cancer (NSCLC) is the most common type of lung cancer as it accounts for 85 percent of cancers. Squamous cell carcinoma, adenocarcinoma, and large cell carcinoma are all subtypes of NSCLC. Small cell lung cancer also known as oat cell cancer accounts for 10-15 percent of lung cancers.

This type of lung cancer tends to spread quickly. Lastly, fewer than 5 percent of lung

that a mortality benefit exists with the screening of carefully selected patients.

Furthermore, a Lung-RADS screening classification exists for the purpose of standardizing follow up and management.

The U.S. Preventive Services Task Force (USPSTF) issued a recommendation in favor of annual screening for lung cancer with LDCT in persons at high risk for lung cancer based on age and smoking history. Additionally, the Centers for Medicare & Medicaid Services (CMS) has issued a final national coverage determination that provides Medicare coverage of screening for lung cancer with LDCT. Medicare will now cover lung cancer screening with LDCT once per year for Medicare beneficiaries who meet all of the following criteria: age 55-77 and are either current smokers or have quit smoking within the last 15 years, have a tobacco smoking history of at least 30 “pack years” (an average of one pack a day for 30 years), and do not have signs or symptoms of lung cancer.

The advantages and benefits of lung cancer screening with LDCT include: diagnosing lung cancer at its earliest most treatable stage; CT scanning is fast, painless and noninvasive; low-dose CT scans of the chest produce sufficient image quality to detect many abnormalities using less ionizing radiation than a conventional chest CT scan; lastly, lung cancer screening with LDCT has been proven to reduce the number of deaths from lung cancer in patients at high risk.

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CANNABIS CORNER

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Interview With A Marijuana Patient – A Life Changed Forever What made you decide to make the move to Medical Marijuana?

I had a history of chronic pain, due to an auto accident, that medical doctors attempted to treat through narcotic use. I ended up spending 10 years on pain killers which left me feeling disconnected from life most of the time. Even though my pain was under control, having to rely on pills to combat it and feeling ever and ever dependent on them made me start looking for other possibilities. After a lot of research and talking to a couple of friends that were having success with medical marijuana, I decided to give it a shot and can gladly say I haven’t looked back since.

I’ve been a medical cannabis user for 8 years now since starting in Colorado, and I consider myself well versed on how to treat myself depending upon my needs at that time, like whether I am dosing for anxiety, or pain, or my mood.

How do you feel like your life has changed since becoming a patient?

I have the ability to treat myself knowing that I don’t have to break the law to do it and risk criminal action, which is sad for many that have done so for years before medical marijuana became available. To also know that I’ll never run out of medicine is very important, and I know that it’s coming from clean, regulated companies.

Being a patient also provides legitimacy

to my conditions and a community of individuals that have experienced similar failures from traditional medicine. I’ve also made so many new friends and met so many great people since becoming a patient. I’m talking people from all walks of life. I’m on the younger side of the patient spectrum from many I’ve met here in Florida at the dispensaries. I’m still amazed at times, especially meeting more elder patients, at how medical marijuana changed their lives also. Many have been able to cut down on their medicines since one thing was stacked on top of another to counteract side effects of the first thing and so on. Now they’re not only feeling better, but they’re out and about and more active which they say has helped tremendously in their overall well-being. I know it was true for me. When I was on pain pills from my accident, I just stayed numb most of the time. After switching to medical marijuana, that numbness went away, and I found myself living my life again.

Did you have any hesitation getting your card/seeing a doctor?

No, since I’ve been a card holder in other states, I didn’t have any hesitation at this point. A friend went with me the very first time I went to in to be evaluated by a medical marijuana doctor. It’s very helpful to talk to people who know and understand what the transition is like. There are so many questions people have when looking to transition into medical marijuana.

I read and read countless stories of how

other people were helped by the medicine and researched as much as I could before first giving it a chance. I remember thinking how strange it was at first, being able to have something that was going to help me but had been also been considered illegal and bad for most of my life. I also remember being worried about getting high and how would I be able to function in my life and career on marijuana? All of those questions went away the more I read. Like I didn’t have any idea that CBD negated the psychoactive effects of the THC without compromising the pain relief until I read about it back in my research phase. After all the reading and research, knowing that I was going to be seen by a doctor who is qualified by the state made it a process that I wasn’t afraid of trying. I’m happy to say that I’ve never looked back since.

What would you say to others in a similar situation who are apprehensive about trying out medical marijuana?

Research and discussion are your two best friends. Find people who have been through something similar, talk to the dispensaries, stop in to a clinic, Google it.

There is so much great information out there online to learn about how medical marijuana is helping people like me and others with different ailments also.

NORML of Florida and Florida for

Care have some great resources available to learn about the medicine. I’ve read a lot of great info on your website as well.

Taking a leap of faith and trying something different is far better than more of the same dysfunction. The more you learn about medical marijuana, the more it makes sense as an option for treating a bunch of different conditions.

What was your experience with Marijuana Doctor, and why would you recommend it over other clinics?

I had a great experience with Marijuana Doctor and the staff there. Their staff was very knowledgeable and thorough. They made sure I understood their process, how my orders would be handled, how I could come back for any follow-ups I might need, and how it was all covered for one flat price. I experienced issues with other clinics in refilling my orders or reaching the doctors. I never experienced that with Marijuana Doctor and those things make a huge difference! The process was seamless in comparison to a couple of the other doctor groups that I went to in the beginning. Once I found Marijuana Doctor, I knew I found the right place for me to continue my care in going through the re-evaluation process.

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Leading Cause of Cancer Deaths, continued from page 22

The radiologists from Radiology Specialists of Florida at Florida Hospital/ AdventHealth are very well trained and experienced. We have radiologists specifically trained in thoracic imaging who use imaging techniques to screen and stage lung cancer. 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 Somedaystartstoday.com 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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