Medical Voyce Magazine - Colorado Edition (2012-02) by Bellandi Group South

C on tents 4

colorado edition | February 2012

WELCOME LETTER

From the Medical Voyce CEO

MEDICINE & POLITICS

Q & A With U.S. Senator Bennet

C OV E R F E AT U R E

No Boundaries

M E D I C A L V OYC E N E W S

Springs City Council Endorses UCH’s, Partners’ Bid

O P - E D : M E D I C I N A L M A R I J UA N A

Medical Marijuana: Where Do We Stand? Part II

CLINICAL FEATURE: ONCOLOGY

With Cancer, The Battleground Can Shift

PEOPLE ON THE MOVE

CHF Names Two to Board Directors

C L I N I C A L F E AT U R E : U R O L O G Y

First Patient Enrolled in HER2+ Bladder Carcinoma Study

C L I N I C A L A DVA N C E S

Freezing Out A-Fib at St. Anthony Hospital

Q UA L I T Y I N H E A LT H C A R E

How to Be Better

H E A LT H S Y S T E M P R O F I L E

About Us: Chilren’s Hospital

S P E C I A LT Y D I S C I P L I N E F O C U S : P E D I AT R I C D E N T I S T R Y

Aren’t They Just Baby Teeth?

SOCIAL MEDIA & MEDICINE

#1 Key to Facebook Marketing Success

C L I N I C A L F E AT U R E : C Y S T I C F I B R O S I S

Complex Care Needed for CF Survivors

F I N A N C I A L I N V E S T M E N T M A N AG E M E N T

Retirement Planning: Does Your 401(k) Plan Work for You?

S E RV I C E L I N E PRO F I L E

Penrose Cardiac, Thoracic and Vascular Surgery – Hearts Connected

CLINICAL GUIDELINES

New Guideline Supplement Helps Providers Prevent RX Drug Abuse

M E D I C A L R E A L E S TAT E

Is the Economy Improving?

Dear

Physician Welcome Physicians: Now that the holiday distractions are behind us, getting back into a good flow seems almost attainable. We’re pleased to present Centura Health on our cover this month. This feature takes a look at Centura’s approach to coordinated system of care within the cardiac care group. Doctors Karyl VanBenthuysen, MD and Sam Mehta, MD discuss this approach.

D i r k R. H o b b s , CEO M ed i c a l V o y ce , LLC

Medicinal Marijuana - Part Two: You may recall Part One in our inaugural edition by Dr. Ken Finn from Colorado Springs. This final segment will complete this op-ed, at which time we’d like to welcome other points of view to round out this conversation and other controversial issues among providers. Rx drug abuse is on the rise across the country and Colorado is no exception. HealthTeamWorks, formerly Colorado Clinical Guidelines Collaborative, provides us a look at the prescribed guidelines for Rx Drug Abuse in this edition. United States Senator Michael Bennett (D) shares his experience and point of view regarding why Congress always seems to wait to the very last possible moment to avoid cuts to the SGR. Don’t miss the finance article from Jeff Jensen and the clinical features from St. Anthony and Penrose-St. Francis, plus our feature from the University of Colorado School of Medicine. All great stuff… Next month our edition will focus on pulmonary care, asthma and allergies, and the cover will feature National Jewish Health. We’ll have more specialty showcases from the systems throughout Colorado. If you’d like to submit an article to the entire physician community in Colorado, please request a copy of our editorial calendar for 2012; please email us at info@medicalvoyce.com. Specialty practices and Hospitals: Do you want to reach patients? Medical Voyce is releasing Healthy Colorado in April – a lifestyle publication for those seeking health, wellness, diet, preventative medicine, exercise, nutrition and fitness resources throughout the state. Our cover features will showcase a health and wellness journey story, as well as Colorado’s best medical and wellness destinations and venues. If interested, please contact us at info@medicalvoyce.com. Until next month,

Dirk R. Hobbs CEO, Medical Voyce Sciences & Multimedia, LLC

Medical Voyce Magazine Colorado Edition Executive Publisher: Dirk R. Hobbs Medical Direction: Bhaktasharan C. Patel, MD Senior Medical Editor: Jeanne Davant Graphics, Layout & Design: Marta Podkul Printing Consultant: Marcum Group Media Contributing Writers: Marty Banks; Matthew Blum, MD; Martin Beggs, MD; John Mehall, MD; Dan Hyman, MD; Carla Carwile, Bill Sonn; Josh Erickson, DDS, MSD; Kirk Skidmore, DDS; Rita Zamora; Jeff Jensen; Jan Friedlander; Dan Meyers; Lynn Clark; Kenneth Finn, MD; and HealthTeamWorks. State Sales Executives: Chris Riley, Scott Steele and Denise Coughlin Medical Voyce Sciences & Multimedia, LLC Chief Executive Officer: Dirk R. Hobbs Chief Operating Officer: Scott W. Casey Chief Medical Officer: Buck C. Patel, MD Associate Medical Director: Sheldon Ravin, MD EVP Communications: Kim Ronkin EVP SEO Services: Greg Walthour Director of Web Services: Winn Jewitt Ask-My-Doc VP Development: Abhay Natu Ask-My-Doc Project Manager: Arun Raval Territory Managing Directors, NM: Michele Sequiera and Michael Westphal Medical Voyce Magazine is published by Medical Voyce Sciences & Multimedia, LLC 212 Washington Street, Suite E Monument, Colorado 80132 PO Box 2942, Monument, CO 80132 Phone: 719.884.1184 | Fax: 719.884.1189 Email: info@medicalvoyce.com Web: http://www.medicalvoyce.com To advertise, reprint or submit sponsored content in Medical Voyce, contact us at info@medicalvoyce.com, 719.884.1184, ext 1 Copyright 2012 ÂŠ Medical Voyce Multimedia, LLC POSTMASTER: Use form 3579 to 212 Washington Street, Suite E Monument, Colorado 80132 PO Box 2942, Monument, CO 80132.

Every attempt is made to ensure accuracy of published materials. Medical Voyce cannot be held responsible for the opinions, facts, or ideas expressed by its authors or contributors. Medical Voyce Magazine â&#x20AC;&#x201C; Colorado Edition is availabe in a digital edition at: www.medicalvoyce.com/medical-voyce-magazine

Cover f e a t u r e

N o B oundaries

C entura H ealth ’ s C a r d i o va scu l a r S y s t e m BY MARTY BANKS

Summary Cardiac care is beginning to transcend geography and physical walls under Centura Health’s new coordinated system of care.

ardiac care that is coordinated across facilities and physicians is a new goal at Centura Health, and the implementation is changing the landscape for patients and medical professionals across the Rocky Mountain region. Boundaries between hospitals, clinics, specialists and general practitioners are becoming transparent; expertise is available within minutes in outlying areas; and methods of administration are evolving into a more streamlined process. The changes are part of a larger strategic plan for Centura. Given the national climate for health care change and the forces of a competitive market, in recent years Centura has taken bold steps to commit to long term strategies that affect the very core of patient care. One facet of this overall strategic plan is to move from the traditional method of separate care at each hospital, clinic, doctor’s office and home into a system that allows cooperative care and expertise. The initial focus is in areas with the highest impact on families and patients: cardiovascular services, neurosciences and trauma care. “It makes sense to attack the costliest and most serious problems first,” says Dr. Karyl VanBenthuysen of South Denver Cardiology Associates. He explains that cardiac disease is common in our population, affecting 30 percent of the population, is responsible for 30–40 percent of inpatient work, and is the number one cause of death in the country, with more than 750,000 deaths annually. And, he says, “It’s expensive, with estimated annual direct and indirect costs of hundreds of billions in the U.S.” Given these facts, and with Centura’s broader strategic plan as the catalyst, in the fall of 2011, Centura Health’s cardiovascular medical directors held a ground-breaking meeting. The discussion focused on the premise that health care providers and facilities must collaborate more than has been seen in the past if they are to both survive in

Care

today’s market and continue to deliver exceptional care. The “cardiovascular system of care” is a collaboration that will change the way cardiac care is expected and delivered within every facet of Centura Health. The use of collaboration as the main agent of change makes sense given today’s technologies and systems. It also makes good business sense. Says Dr. VanBenthuysen, “As models of payment change, it will be increasingly important to find efficiencies in the health care delivery. The alignment of providers and facilities/hospitals will facilitate that process.” Centura Health currently has Colorado’s largest health care network with 13 hospitals, 55 medical clinics, nine imaging centers and seven surgery centers, among others. This puts it in the unique position to share and access the bulk of the state’s expertise and information. By utilizing the best practices, newest technologies and most innovative tools, the cardiovascular system of care is primed to improve overall efficiency and communication system-wide. Ideally, it will even lead to a healthier population through more accessible and cohesive prevention and long term care.

The Plan in Action

Although in beginning stages, there are concrete changes underway. “One of the most exciting aspects of the new cardiovascular system of care is the adoption of a CV Information System (CVIS),” says Dr. VanBenthuysen. “This will enable the immediate availability of multiple diagnostic tests – ECGs, echocardiograms, nuclear stress tests, cardiac catheterization – in much the same way that hospitals currently use ‘PACS’ systems for all X-ray services. We expect that the new CVIS will significantly improve the quality and efficiency of care.” Some of these new systems have been implemented. Dr. VanBenthuysen says his practice currently has “...the ability to interpret diagnostic studies such as echocardiograms and from multiple sites, speeding the time of interpretation. We can solicit for interpretation from our partners.” Future plans at South Denver Cardiology Associates involve the integration of their current office-based information system with that in the hospital. Dr. VanBenthuysen says this

7 will allow office visit notes and lab testing to be immediately available. In addition, all hospital documentation will be immediately available. Fast and easy access to information are attributes also envisioned by Dr. Sam Mehta, director of cardiovascular research and interventional cardiologist at Colorado Heart and Vascular, PC. “Moving to a coordinated system of care will allow easier transfer of information between cardiologists and primary care physicians. As such, duplications in testing can be avoided, as we all will have ready access to the same patient data.” He says he expects this will allow cardiologists to focus more on the cardiovascular issue at hand. “Long term patient care may then be discharged back to the primary care physician if the patient’s cardiovascular issues become stabilized, with long term recommendations for care,” he says. “Thus, time and resources will be saved.” Avoiding duplication of services is a crucial advantage of a more coordinated system. Says Dr. VanBenthuysen, “Key cardiac services may be more strategically placed, avoiding duplication of expensive services such as open heart programs and sophisticated electrophysiological procedures.” Dr. VanBenthuysen points out another possible advantage of a more collaborative system. “Providers of cardiac services (MDs, nurse practitioners, physician assistants, etc.) and facilities (hospitals, clinics, etc.) will become more aligned, decreasing competition and facilitating care,” he says. “Centura prioritizes physician alignment as a key strategic goal.” This change also appears to offer the financial benefit of lower costs. Says Dr. VanBenthuysen, “We anticipate... a net reduction in office personnel made possible by the improved efficiencies.”

Rural Outreach

A major component of this new system is the level of support and outreach it potentially offers to rural communities. Jeff Woods, director of cardiovascular services for Centura Health, says that cardiologists now have a stronger presence in outlying areas. Since 47 of Colorado’s 67 counties are rural, this is no small matter. For instance, Woods reports that clinics in Summit County, Alamosa and Goodland, Kansas are opening and/or improving cardiac care clinics in existing facilities. Woods says

specialized expertise also will be more readily available to outlying areas with tools such as CenturaConnect. Already active, this program guarantees that general practitioners in outlying areas can get a cardiac specialist on the phone within five minutes – so if timely questions arise, timely responses can be provided. The philosophical move from cardiac care based on geography to care based on collaborative information has further ramifications. Says Dr. VanBenthuysen, “Cardiac services will increasingly be performed in the outpatient sector. This will emphasize the importance of coordination of care and communication of findings–processes that are optimally handled in an integrated system of care.” The integration of information is perhaps most important with the newest information and treatments. Says Dr. Mehta, “Cardiac intervention has been an exciting field that has been evolving... there has been an exceptional amount of newer treatments that are evolving for entities such as atrial fibrillation, valve disease and peripheral vascular disease that all fit in the realm of the cardiac interventionalist, and as such, growth will likely occur in different disease subsets.” Having access to this information and treatments will be key. With Centura Health’s new cardiovascular system of care, access is what it’s all about.

Op-ed m e d i c i n a l m a r i j ua n a

M edical Marijuana: Where Do W e S tand ? By kenneth Finn, MD

C ontinued This article continued from Medical Voyce Magazine November 2011 Edition. Please go to www.medicalvoyce.com/medical-voyce-magazine to read the first part of the article.

here are physical effects related to marijuana use. Babies born to marijuana users tended to weigh less, have smaller heads than other infants, both of which are related to problems with thinking, memory and behavioral problems in childhood (Reuters, January 2010). Smoked marijuana during pregnancy has effects on the fetal brain (Sweden Karolinska Institute, May 2007). Heavy marijuana use contributes to gum disease and bullous lung disease (JAMA, Vol. 299, No. 5, February 6, 2008, Respirology (2008), 13, 122-127). Ammonia levels are 20 times higher in marijuana smoke than tobacco smoke and hydrogen cyanide, nitrous oxide, and certain aromatic amines were three to five times higher in the marijuana smoke (American Chemical Society, Chemical Research in Toxicology, December 17, 2008). Smoking cigarettes and marijuana together increased the odds of developing COPD by three and a half times of someone who smoked neither (American Thoracic Society, Science Daily, May 23, 2vv007). According to a Yale School of Medicine study, marijuana smoke exposure is linked to many of the same health problems as those experienced by long-term cigarette smokers (Arch. Int. Med. 2007:167:221-228). More tar is deposited in the lungs from marijuana smoke than cigarette smoke and if rolled with tobacco, a person will inhale twice the amount of benzene and three times as much toluene as if they were smoking a regular cigarette (April 2006 and UCLA, Monaldi Archives for Chest Disease 63(2):93-100, 2005). Marijuana smoking has been implicated in tumors of the head and neck and of the lung (Medical College of Georgia, Stanford University). Frequent or long-term marijuana use can significantly increase a man’s risk of the most aggressive type of testicular cancer, nonseminoma (Science Daily, February 9, 2009). Eighty-eight and a half percent of younger patients with transitional cell bladder cancer had a history of smoking marijuana (Medical News Today, January 26, 2006). According to the 2009 Drug Abuse Warning Network (DAWN), of the 973,591 ED visits involving an illicit drug, marijuana was involved in 376,467 of

Kenneth Finn, MD Board Certified, Physical Medicine and Rehabilitation Board Certified, Anesthesia Pain Board Certified, Pain Medicine Exam Committee, American Board of Pain Medicine

K e n n e t h F i n n , MD

these visits, second only to cocaine (December 2010). Among ED visits by patients 20 or younger from drug misuse or abuse, marijuana was second only to alcohol. Marijuana is a “gateway” drug. JAMA reported, based on a study of 300 sets of twins, that “marijuana-using twins were four times more likely than their siblings to use cocaine and crack cocaine, and five times more likely to use hallucinogens such as LSD” (Office of National Drug Control Policy, October 2003). Columbia University’s National Center on Addiction and Substance Abuse reported that teens who used marijuana at least once in the last month are 13 times likelier than other teens to use another drug like cocaine, heroin, or methamphetamine and almost 26 times likelier than those teens who have never used marijuana to use another drug (March 2007). Adults who were early marijuana users were found to be five times more likely to become dependent on any drug, eight times more likely to use cocaine in the future and fifteen times more likely to use heroin later in life. A substance abuse counselor in Idaho noted that “in almost all cases, meth users began with alcohol and pot” (2005). People can become dependent on marijuana. As a drug becomes more available in a society, there will be more use of the drug and as use expands, there will be more people who have problems with the drug (Dr. Thomas Crowley, University of Colorado, Department of Psychiatry, Division of Substance Dependence). Marijuana is often associated with behavior that meets the criteria for substance dependence established by the American Psychiatric Association (Office of National Drug Control Policy, January 2006). As of 2009, marijuana was the most commonly used illicit drug. Among all ages, marijuana was the second most common illicit drug responsible for treatment admissions in 2008, after opioids and ahead of cocaine. Of all illicit drugs, marijuana had the highest level of past-year dependence or abuse. Nearly 80 percent of adolescent treatment admissions involved marijuana as a primary or secondary substance. There is, on average, 6,500 new users every day (Department of Health and Human Services, National Survey on Drug Use and Health, 2009).

9 Marijuana is associated with juvenile crime. The earlier an individual begins to use marijuana, the likelier he or she is to be arrested (CASA, 2006). The Community Anti-Drug Coalitions of America outlined some data from the 2006 Pride Survey that was concerning: of those students carrying a gun to school, nearly 64 percent report also using marijuana; of those hurting others with a weapon at school, 68 percent had used marijuana; of those being hurt by a weapon at school, 60 percent had used marijuana; of those threatening someone with a gun, knife, or club, etc, 27 percent reported using marijuana. Marijuana users are twice as likely as non-users to report they disobeyed school rules. Marijuana use among youth is rising as perception of risk decreases. Other crimes are also noted by the media. According to the Denver Post, “Man sentenced to 40 years in pot-provider slaying (July 26, 2011), “Police discover 49 pounds of marijuana in woman’s car after accident in Colorado Springs” (June 2, 2011), as well as “Dad who gave pot to daughters sentenced to prison” (August 11, 2011). There have been several killings linked by law enforcement to the increased market for marijuana. In 2008, according to the United States Sentencing Commission, marijuana accounted for 25 percent of people sentenced in federal court for drug crimes under six offense categories. Only a small number (1.6 percent) were for “simple possession. Marijuana is the most commonly detected drug at the time of arrest (2008 Arrestee Drug Abuse Monitoring System). The issue of drugged drivers is another concern of marijuana use. It is well known that marijuana, which impacts the brain, can impact motor skills, reaction time and judgement (NIDA, September, 2009). In Colorado, although alcohol has been responsible for the majority of impaired driving fatalities, the percentage of drug-related deaths in Colorado continues to increase. Between 2005 and 2009, the percent of drug-related deaths increased from 35 percent to 48 percent (nearly half) and half of the time, the involved drug is marijuana (Impaired Driving

Fatalities Chart, Colorado Department of Transportation). Also, according to CDOT in July 2011, there are more drivers who are either under the influence of marijuana or are carrying it in their car. The number of positive drug tests increased between 2009 and 2010 by 50 percent (from 391 to 599). Nationally, the percentage of fatally injured drivers testing positive for drugs increased over the last five years. In 2009, 33 percent of 12,055 drivers fatally injured in MVA with known test results tested positive for at least one drug compared to only 28 percent in 2005. Marijuana was the most prevalent drug in those drivers (28 percent) (National Highway Traffic Safety Administration, 2009). University of Maryland’s ShockTrauma Unit found over 26 percent of injured drivers tested positive for marijuana (June 2007). Driving under the influence of marijuana almost doubles the risk of a fatal road crash (British Medical Journal, December 2005). The DEA and FDA are not the only organizations to view smoked marijuana as having no documented medical value. The American Medical Association, The American Society of Addiction Medicine, The American Cancer Society, The American Glaucoma Society, The American Academy of Pediatrics, The National Multiple Sclerosis Society, and The British Medical Association also denounced its use. The Institute of Medicine in 1999, released their study reviewing the supposed medical properties of marijuana. All organizations felt that further study and research is necessary. As of December 2010, there are 111 researchers registered with the DEA to perform studies with marijuana, marijuana extracts, and non-THC derivatives. These studies include evaluation of abuse potential, physical/psychological effects, adverse effects, therapeutic potential, and detection. At present, the evidence supports that smoked marijuana is harmful. The “medical” marijuana issue is not an easy one to dissect. Other issues we cannot predict are lurking around the corner (“medical” marijuana in the workplace, physicians with a “medical” marijuana card, traveling overseas with your “medicine”, physician-owned dispensaries, among others). This article is not an issue of legalization. It is an issue that affects all physicians in El Paso County, across the state of Colorado, and across the United States. Why would we, as a group of scientists, endorse a “medication” or chemical that is showing that harm appears to outweigh benefit, especially in the nonterminally ill? It is time we get the issue of “medical” marijuana off our plate. If science eventually proves that the benefits outweigh the harm, we could certainly change our position. As of this writing, there are 22 Starbucks and 27 McDonald’s restaurants registered in Colorado Springs (El Paso County Public Health, September 2011), and 152 marijuana dispensaries (Colorado Department of Public Health, September 2011, July 2010). That equates to nearly seven times as many Starbucks and over five times as many McDonald’s. It is a close second to the 166 liquor stores in the city.

C l i n i c a l F e at u r e o n c o l o g y

W i t h C a n c e r , T h e B at t l e g r o u n d Can Shift By Lynn Clark

ntil about 40 years ago, cancer was a death sentence for most children. Today, about 80 percent of children diagnosed with cancer will be alive five years later, and some will live for decades.

of pediatric cancers. The result is a collaboration between the cancer center, a children’s hospital and an adult hospital, called Thriving After Cancer Treatment is Complete, or TACTIC clinic.

But there’s a catch. They have survived only to face what are called late effects: stroke, heart problems, infertility issues, secondary cancers and more. The National Cancer Institute estimates there are 270,000 survivors of childhood cancer alive in the United States.

The planning team decided that patients would see one of two pediatric oncologists, an internist, a cancer psychologist and a nurse educator. If they needed help with nutrition or community resources, those experts were on hand at the Cancer Center. The team sees up to four patients each month. TACTIC is unusual in that it’s set in an adult care primary care environment rather than a pediatric oncology clinic.

“Survivors of childhood cancer have unique health care needs,” Kerry Moss, MD, a pediatric oncologist now in Connecticut who helped create the University of Colorado Cancer Center’s clinic for survivors of childhood cancers. “Many people who had cancer as a child don’t remember it, or if they do, may not consider it important to their health today. After all, they survived, right? Or, they may simply not know where to turn for follow-up care.”

“That’s because we are dealing with adults here—adults who had cancer as children but adults nonetheless,” Overholser says. Many patients don’t know what effects specific childhood treatments may have on them, according to Overholser.

In the spring of 2007, Moss was looking for a project to finish her pediatric oncology fellowship at CU. She had been working in the Children’s Hospital Colorado HOPE Clinic for young adult survivors of pediatric cancers, one of the oldest cancer survivorship clinics in the nation. There she noticed that a lot of people were coming in who were in their 30s and 40s, and there even was a 60-year-old.

“For example,” she says, “girls who are treated with chest radiation for Hodgkin’s lymphoma have a much higher risk of breast cancer and may need to start having mammograms at age 25, depending on when they finished treatment, and they might also want to consider having children earlier because of a risk of early menopause related to having received chemotherapy.”

“The HOPE Clinic is staffed by people who know about the late effects of pediatric cancer treatment, but no one who is an expert in a 50-year-old’s heart problems,” Moss says. “Our network usually extends to other pediatric specialists who also don’t have expertise in adult medicine.”

Kristin Kilbourn, PhD, a health psychologist, finds that pediatric oncology survivors often report traumatic memories associated with their cancer treatment:

She and her mentor, Brian Greffe, MD (Professor, PediatricsHematology/Oncology) saw a need for something different. Moss put out a call for internists and others at the University who were interested in adult survivors of childhood cancers. Responding were Dr. Alison Jones, director of the CU Cancer Center’s LIVESTRONG Cancer Survivorship Center of Excellence, and Linda Overholser, MD, assistant professor of internal medicine with the CU medical school and an internist at University of Colorado Hospital. Greffe and UC Denver’s section head of internal medicine, Jean Kutner, MD, joined the team to cement the vision of a clinic for adult survivors

People

on the

move

C o l o r a d o H e a lt h F o u n d at i o n N a m e s Two to Board of Directors Russ Dispense, President of King Soopers/City Market Dispense is President of The Kroger Co.’s King Soopers division, based in Denver. He oversees 143 King Soopers and City Market stores in Colorado, New Mexico, Utah and Wyoming. Combined, these stores employ more than 19,000 employees. Dispense began his supermarket career when he joined King Soopers in 1965 as a courtesy clerk. He earned a bachelor’s degree in business administration from Western State College of Colorado and is a graduate of the University of Southern California’s food industry program. In addition to the Foundation’s Board, he serves on the board of directors for the Western Association of Food Chains, Children’s Hospital Colorado and the Mountain States Employers Council.

in Colorado. Ginger’s understanding of the link between school health care services, food and nutrition education, physical activity and academic achievement also will contribute significantly to our work. Together, with our talented incumbent Board members, they offer the knowledge and commitment needed to make wise investment decisions and help us achieve the goal of making Colorado the healthiest state in the nation.”

Robert Nathan, MD

Maloney leads the University of Denver’s Marsico Institute for Early Learning and Literacy, a research and social policy institute dedicated to improving learning environments and outcomes for children from birth to age eight. Her interests include education reform, early childhood education, and education policy on the local, state and national levels. She received her bachelor’s degree from Yale University as a member of its first graduating class to include women. Later, she earned a master’s degree in education and human development and a Ph.D. in public administration from George Washington University. Previously, she served as the dean of DU’s Morgridge College of Education and prior to that, executive director of the Sturm Family Foundation. “Russ and Ginger bring to the Board a depth of leadership representing two sectors that are instrumental to advancing the work of the Foundation — business and education,” said Anne Warhover, president and CEO of the Colorado Health Foundation. “Russ provides valuable insights to expanding access to healthy and affordable foods, which are at the heart of healthy communities

Diplomat of the American Board of Allergy and Immunology Clinical Professor of Medicine Board of Directors, American Academy of Allergy, Asthma and Immunology President, Joint Council of Allergy, Asthma and Immunology

•

Virginia “Ginger” Maloney, Ph.D., Director, Marsico Institute

• •

•

Daniel Soteres, MD, MPH

Board Certified Asthma, Allergy & Immunology Award-‐Winner, American Federation of Medical Research

• •

Staff Debra Walters, ANP-‐C Jamie A. Allen, PA-‐C

C l i n i c a l F e at u r e u r o l o g y

F irst P atient E nrolled in HER2+ B ladder C arcinoma S tudy

endreon Corporation has announced that the company has begun enrolling patients into a Phase 2 trial for DN24-02, Dendreon’s investigational active cellular immunotherapy being evaluated for the treatment of HER2 positive cancer. The multicenter trial called Neu-ACT (NEU Active Cellular immunoTherapy) is expected to enroll approximately 180 patients to evaluate the safety and efficacy of DN24-02 as adjuvant therapy in patients with high risk HER2 positive invasive urothelial carcinoma, including bladder cancer, following surgical resection. “We believe that our active cellular immunotherapy platform may have applications in the treatment of other cancers, and are pleased to offer patients and physicians access to DN24-02 through our Phase 2 Neu-ACT clinical trial,” said Mark Frohlich, M.D., executive vice president of research and development and chief medical officer. “Initiating a Phase 2 clinical trial to evaluate immunotherapy outside of the treatment of prostate cancer is a significant milestone for Dendreon, and we look forward to the outcome of this important study.” Neu-ACT is a multicenter, open-label, Phase 2 study. Patients will be randomized to receive either the investigational product,

DN24-02, or standard of care. The primary endpoint of the trial will be to evaluate overall survival between these two groups of patients. Other objectives of the study are to evaluate safety, diseasefree survival, and immune response to treatment with DN24-02. Additional information is available at http://clinicaltrials.gov. “Immunotherapy has great potential to offer breakthroughs in cancer care. In fact, bladder cancer recurrence rates have already seen a profound impact by immune manipulation. We are pleased to continue to lead this evolving field by participating in this Phase 2 clinical trial of DN24-02,” said John Corman, M.D., Medical Director of the Virginia Mason Cancer Institute in Seattle and clinical investigator for the Neu-ACT program. “Given the promise of immunotherapy, this is an important step forward for patients with this complex disease.” Approximately 30 sites across the U.S. will participate in the Phase 2 Neu-ACT trial, including TUCC currently enrolling patients: • The Urology Center of Colorado, Denver, Colorado Contact: Candice Fortuna-Smith, 303.421.5783, cfortuna@tucc.com Principal Investigator: Lawrence Karsh, M.D.

Clinical a d va n c e s

F reezing O ut A-F ib

by Carla Carwile

early a year has passed since J. Thomas Svinarich, MD, performed the region’s first ArcticFront Cardiac Cryoballoon ablation procedure to correct the heart arrhythmia known as atrial fibrillation. The patient in the electrophysiology suite of the new St. Anthony Hospital this early morning, January 2012, is barely 50—younger than most of the 3 million Americans coping with “A-Fib.” But a lengthy course of medication has not resolved his problem fully. He’s dealt with the heart palpitations, the “fluttering” feeling and the dizziness at altitude. He’s well aware, too, that about 15 percent of strokes occur in people with A-Fib, due to the pooling and clotting of blood that can result. And that number rises sharply with age. The leading-edge procedure Dr. Svinarich has advised will improve his symptoms significantly by freezing the tissue that’s causing his heart’s upper chambers to quiver instead of beating normally. Fast-forward a few hours and he’ll learn that the correction was a success. Here’s what happened in between. A small catheter—like the one shown here—was guided through the femoral vein (located in the groin area) and up into the heart. In the catheter tip was a liquid coolant that— when injected expanded to a gas, causing the tip to cool to an extremely low temperature.

S t . A nthony H ospital The balloon remained deflated until it was precisely positioned just outside the pulmonary vein opening (there are four at the back of the heart) identified as contributing to the atrial fibrillation. It was then expanded, so that the entire “circle” of tissue it touched was frozen, thereby blocking the abnormal electrical activity. In the past, specialists often used the extreme heat of radiofrequency (RF) ablation to destroy the tissue sending the abnormal electrical signals. This new cold procedure offers a faster, more efficient and comprehensive treatment, and is a potentially safer alternative. While St. Anthony Hospital is the first in the region to provide the innovative option, the technology is well-proven. To date, more than 15,000 patients in more than 250 centers worldwide have benefited from Arctic Front cryoablation for the treatment of A-Fib. Dr. Svinarich, of Colorado Heart & Vascular (303-595-2727), has performed the procedure well over 75 times. He discusses the advantages in a brief video at www.stanthonyhosp.org/cryoablation.

M ore H eart St. Anthony Hospital merges state-of-theart technology and the expertise of skilled cardiologists, cardiothoracic surgeons and electrophysiologists to provide a comprehensive, award-winning cardiovascular program. This range, plus the compassionate attention of select staff, assures Rocky Mountain residents a full range of preventive care, diagnostic services, advanced interventions and cardiac rehabilitation. A prime indicator of this strength is the fact our response times for cardiac emergencies are among the nation’s fastest. Currently, our heart attack intervention rates (based upon the opening of a blocked artery) are 38 minutes faster than the national average.

(photo courtesy of Medtronic)

Q ua l i t y

How

h e a lt h c a r e

B e B ett er

By Dan Hyman, MD, MMM

ifteen years ago, when I first started quality improvement work, I learned that the reasons we didn’t achieve what we wanted in my practice back then and the reasons we sometimes fall short in the hospital today are never about personal motivation, effort, knowledge or desire. Instead, the reasons are always about complex systems that depend on many people effectively communicating among themselves and with families, and doing so in the setting of a busy, technology-dependent, high-stakes environment with competing priorities, and in an industry of imperfect art and ever-advancing science. Achieving reliability, safety, effectiveness and efficiency in that world is our great challenge and it is a challenge that we embrace. My journey into the world of quality and patient safety started quite by happenstance and, to be truthful, as a result of misplaced confidence in how good a group of doctors we actually were. Erdenheim Pediatrics, a then sixperson private pediatric practice in suburban Philadelphia was well-respected, thriving and – as we would come to learn – broken.

Dan Hyman, MD, MMM Chief Quality Officer, Children’s Hospital Colorado He can be reached at daniel. hyman@childrenscolorado.org or (720) 777-8019. Dan Hyman, MD, MMM

our effectiveness in providing care to children with asthma surprised us would be a tremendous understatement. Not only were we not adhering to the then five-year-old guidelines for diagnosing and treating childhood asthma, we were not even consistent across our group in what we called asthma, how we treated it, or who we diagnosed and treated. Terms like “WARI” (Wheezing Associated Respiratory Infection), “RAD” (Reactive Airways Disease) and “bronchitis” were scattered across our sometimes legible, unstructured

In 1996, we were offered the opportunity to participate in a pilot project that the American Academy of Pediatrics was running with 20 practices; like ours, they were members of the Pediatric Research in Office Settings Network. As the partner leading that initiative, I traveled to Chicago with two of our office nurses to learn the principles of the Model for Improvement and how we would, during the project, test its implementation in our primary care pediatric practice. The Model for Improvement has been extensively used and taught by the Institute for Healthcare Improvement and the National Initiative for Children’s Healthcare Quality in their national programs and is one of the simpler frameworks for pursuing change in healthcare and other settings. It asks three simple questions: 1. What am I trying to accomplish? (Aim statement) 2. How will I know that a change is an improvement? (Measures) 3. What changes can I make that will result in improvement? (Changes)

Practice improvement journey

Our first project was improving asthma care in our practice. To say that our initial, objective assessment of CHILDREN’S HOSPITAL COLORADO

15 notes on unlined white paper, which were mostly but not always, available at the time of the office visit. There simply had to be a better way. Our practice’s improvement journey started with better communication: gaining consensus on actually using the term “asthma,” agreeing on when we would use the word and then eliminating the use of other language that served to both confuse and delay effective treatment. We ultimately modified our charts with structured notes for all visits (starting with asthma follow-up notes) that dramatically increased our rates for classifying disease severity, treating children with antiinflammatory therapy and giving them written treatment plans. In subsequent years, we performed additional quality improvement work at Erdenheim Pediatrics in treating attention deficit/hyperactivity disorder and in providing preventive services in general. I moved on several years later to pursue work in quality improvement as a full-time endeavor. That is how I came to Colorado, where I am proud to be the chief quality officer for an excellent hospital that seeks to continuously improve all aspects of the care we provide to patients and families.

Quality and Patient Safety at Children’s Hospital Colorado

As a life-long East Coaster, Colorado was nowhere on my professional radar screen in 2007. That year, Dr. Jim Shmerling arrived at Children’s Hospital Colorado (as CEO) and soon thereafter initiated, with Dr. Joan Bothner (chief medical officer), a search for a chief quality officer, a new position that would lead the organization’s efforts to improve the safety and quality of care we provided to our patients. I had traveled to Colorado for many wonderful winter vacations since college and thoughts of Vail and Winter Park/Mary Jane surely played a role in my decision to pursue the opportunity. But the main draw for me was the chance to work in a hospital that – although already viewed as exceptional – also recognized its need to improve and wanted to invest in a program to do just that. I have been at Children’s Colorado since September 2008, and feel privileged to work for an organization that is entirely committed to helping our providers and staff achieve their goals: providing the best care to children and families every day.

Q ua l i t y

h e a lt h c a r e

Quality initiatives

We focus on improvement goals in a number of ways; I invite others to join us in these efforts. The Quality and Patient Safety Department at Children’s is comprised of a number of components, including: • • • • •

Clinical and Operational Performance Improvement Patient Safety (including medication safety) Accreditation Readiness and Policy Compliance Clinical Decision Support Clinical Informatics and Analytics

This team of professionals works together and with providers and staff across the hospital to achieve a range of goals. Over the past several years, we have focused on a number of goals, including:

Reducing hospital acquired infections including surgical site infections, viral nosocomial infections, infections caused by multi-drug resistant organisms, and especially, central line associated-blood stream infections.

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Reducing falls, pressure ulcers and other complications of care.

We are, of course, also focused organizationally on improving access to our services and improving the patient and family experience while receiving care here.

Ongoing commitment

We have improved our results in many of these areas and continue this work today. Our improvement results are increasingly available across the organization on our intranet sites and we publish some results on our external website. We know that we are accountable for our results to our patients, their families, and to the physicians whose trust and referral decisions can (and should) be based upon the outcomes that we achieve (in terms of effectiveness, safety, patient satisfaction, timeliness, equitability and efficiency). We know we must earn others’ trust every day and with every patient, and it is my job and privilege to help us do that. There are a number of ways that we are and will be collaborating with community based primary care physicians in the area of quality and patient safety. These include:

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Improving medication safety using dosing limits and alerts, protocols for treatment with high-risk medications and improvements in dispensing and administration of medications in the pharmacy and at the bedside. Improving the reliability of patient identification in order to eliminate episodes of care being provided to a patient other than for whom it was intended. Improving team work and communication, starting in high risk settings like the operating room and other procedural areas and now spreading across the organization. We have incorporated team communication strategies such as Crew Resource Management and structure communication tools like SBAR to reduce the risks of miscommunication resulting in patient harm. Improving the efficiency with which patients are treated, starting with reducing delays between the emergency department and the inpatient units, and now focusing both on access and throughput in outpatient clinics and care planning on inpatient units.

Reducing the rate of “codes” outside the intensive care unit through the use of rapid response teams (which families can also activate) and assessment tools to help nurses recognize and communicate signs of clinical deterioration.

Developing collaborative care models between primary care practices and specialty clinics that improve the effectiveness and efficiency of providing care to families when and where they want that care.

Managing populations of patients with chronic conditions like asthma using registries and other tools that can reduce the impact of that illness for these children and their families. Building Clinical Decision Support tools in EPIC that assist those physicians using the electronic health record in their practices (and continuing to expand PedsConnect to more practices so as to better integrate care and communicate across the delivery system).  Assisting physicians with their Maintenance of Certification requirements.

Finally, I would welcome physicians who are interested in serving as members of various committees that oversee our quality and patient safety work at Children’s or participating as a member of a project team. I appreciate the opportunity to share the efforts we at Children’s Colorado are making to objectively measure and improve the care we provide and would be happy to dialogue about any aspect of this article. I’m also happy to visit a practice and talk with caregivers there about practice-based improvement efforts.

H e a lt h S y s t e m p r o f i l e

A bout U s: C hildren’s H ospital

t Children’s Hospital Colorado, we see more, treat more and heal more kids than any hospital in our sevenstate region. We’re experienced and forward-thinking when it comes to the latest methods for diagnosis and treatment. This translates into less invasive treatment, less time, and less stress on you and your children. Since we are always pioneering new ways of curing childhood diseases, your child will receive the most effective care years before it may become available at other hospitals. We are doing everything we can to help you get your child healthy and home faster than at any other hospital. Our specially trained pediatric experts recognize that families are our partners, which is why we deliver family-centered care. By making the hospital very family-friendly, we make it easier for parents and siblings to be involved in the day-to-day medical, emotional and social needs of their child. Our hospital at I-225 and Colfax on the Anschutz Medical Campus in Aurora was designed and built to enhance our care for kids. Using data from an innovative type of study called evidence-based design, everything about our hospital was built to help us speed kids to recovery. From 100 percent private patient rooms to healing color therapy and views of nature, every detail of Children’s Hospital Colorado was built to help kids get better faster and reduce stress on the whole family.

Our mission

When it was founded in 1908 in Denver, Children’s Hospital Colorado set out to be a leader in providing the best healthcare outcomes for children. That calling has consistently made us one of the top 10 children’s hospitals in the nation and a place parents across the Rocky Mountain region have come to trust. Read more about our top ranking by U.S. News & World Report and other awards at http://www.childrenscolorado.org/about/awards.aspx Our modern-day mission is to improve the health of children through the provision of high-quality coordinated programs of patient care, education, research and advocacy. In addition to providing the best possible care for kids who need it, we also work hard to keep kids out of the hospital. Through medical research and advocacy efforts, we are working toward a world where kids are safer and healthier and will one day have less need for a hospital.

Patient care

As a private, not-for-profit pediatric healthcare network, Children’s Hospital Colorado is 100 percent dedicated to caring for kids at all ages and stages of growth. We have more than 1,000 pediatric specialists and more than 3,000 full-time employees helping to carry out our mission. We provide comprehensive pediatric care at our main campus and at our 15 regional locations. No matter which location you visit, you’ll receive the best possible care for your kids with our specially trained staff and facilities designed just for kids. Unlike other hospitals and urgent care locations, we partner with your child’s pediatrician or your family doctor to make sure you receive integrated care.

• Children’s Hospital Colorado at I-225 and Colfax is the only dedicated Level 1 trauma center in our seven-state region, handling the most challenging emergencies. • We offer two additional emergency locations: Children’s Colorado at Saint Joseph Hospital and Children’s Colorado at Parker Adventist Hospital. • We offer two urgent care locations: Children’s Colorado North Campus and Children’s Colorado Wheat Ridge. • We offer numerous specialty care centers and clinics.

Our healing hospital for kids

Children’s Hospital Colorado is an amazing blend of art, design and state-of-the-art technology. Every detail – from

layout to patient flow, design to decor, landscaping to color schemes -- was built to help kids heal faster, based off data from evidence-based design. Should you need us, we will provide you and your child with outstanding pediatric care at our main campus. Our campus is adjacent to The University of Colorado Hospital and School of Medicine. The University is home to worldclass education and research facilities and doctors from the prestigious Department of Pediatrics. This means our doctors and your children have access to some of the best minds, hands and hearts in pediatrics from across the country. We envision a world where no child needs a hospital. Until we make that happen, we’re here for your kids.

Medicine & p o l i t i c s

Q & A With U.S. Senator Bennet

Q A

: Why does Congress continually wait until the last minute to prevent cuts to the sustainable growth rate?

: There is a canyon between the conversations going on in Washington and the ones happening in Colorado and the rest of the country. The dysfunction in Washington continues to get worse. Congress is legislating by crisis. It seems the only way to get things done is to come up against a deadline or for the next crisis to strike. As you might know, on December 15, 2010, President Obama signed into law an SGR extension that averted a 23 percent cut in the Medicare physician reimbursement rate. I am pleased that we were able to prevent those devastating cuts, and that the one year fix was fully paid for and did not add to the deficit. However, we found ourselves in the same situation again this past December. Congress backed up against another 11th hour deadline.

Q A

: What is your position on the SGR?

: We must prevent cuts to the SGR that have the potential to limit Medicare and TRICARE beneficiaries’ access to their medical providers. Over half a million Colorado seniors on Medicare and our military personnel are at risk of finding that their doctors can no longer afford to treat them. Congress has blocked the cuts every time they’ve come up since 2003. I voted to prevent them in 2009, December 2010, and again last month.

Q A

: Do you support a permanent fix?

: The Medicare physician payment system needs to be permanently fixed, and I support fixing it in a way that does not add to our deficit. We can’t continue to pile mounds of debt onto our kids and grandkids because we aren’t willing to make difficult choices. As you may know, the 12-member bipartisan Joint Select Committee on Deficit Reduction that was tasked with finding $1.5 trillion in deficit reductions announced its failure to reach a bipartisan compromise on November 21, 2011. I share the complete frustration of most Coloradans with Washington and its inability to do the work it is supposed to do. Our national debt, which now stands at approximately $15 trillion, represents one of the greatest challenges that we face as a nation. If we do not act decisively, and in a comprehensive and bipartisan manner, our kids will not have the same opportunities that our parents and grandparents made available to us.

The bill I supported was a paid-for measure that prevented these devastating cuts from taking effect on January 1. I have supported preventing these cuts every time they’ve come up in the short time I’ve been in the Senate. Although short-term fixes to the SGR are important to ensure that Medicare and TRICARE beneficiaries continue to have access to their doctors, they are unsustainable in the long run for physicians, who cannot continue to work month to month without being certain that they will be adequately reimbursed for their services. This is especially a problem during open season for health coverage plans - when doctors must make decisions about whether or not to continue seeing Medicare and TRICARE patients.

Having said that, I do not believe that budget cuts should disproportionately target programs that invest in our future medical and economic progress. Coloradans tell me they want a deficit reduction plan that materially addresses the problem, ensures we’re all in it together, and is bipartisan. It was my hope that the Joint Committee could create a plan that met this three-part test.

Q A

: In 2010 you passed into law the Care Transitions Act as part of the affordable care act. Are there any updates?

: Yes. The Department of Health and Human Services announced in November the first site selections for the Community Based Care Transitions Program, which as you might know is based on work in Grand Junction and Denver that reduced hospital readmission rates among Medicare patients and could save hundreds of millions of dollars. It represents an important step toward bringing an innovative Colorado program to improve patient care and save taxpayers money to the national level. Colorado has shown the country that better-coordinated care and community collaborations can lead to higher-quality outcomes at a much lower cost to patients, hospitals and our health care system as a whole. Now, other communities across the country will have the same opportunities.

The Community Based Care Transitions Program is now part of the HHSâ&#x20AC;&#x2122; Partnership for Patients initiative, which incentivizes collaboration at the community level that will improve patient safety, lead to higher-quality care and bring down costs. According to the Department of Health and Human Services (HHS), the Partnership for Patients has the potential to save up to $35 billion in health care costs, including up to $10 billion for Medicare. Over the next ten years, it could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings. As part of the partnership, this program is committing $500 million to community-based organizations partnering with eligible hospitals to help patients transition from hospitals to other settings of care.

M e d i ca l V oyc e n e w s

S prings C ity C ouncil E ndorses UCH’ s , P artners ’ B id BY BILL SONN

ears after it first began talking about taking the city out of the hospital business, the Colorado Springs City Council unanimously voted Jan. 10 to approve the bid by University of Colorado Hospital, Poudre Valley Health System, Children’s Hospital Colorado and the University of Colorado’s health sciences schools to lease and operate Memorial Health System for the next 40 years. The council also appointed a team to begin negotiating the exact terms of the lease, a process that promises to take months. The partners themselves, meanwhile, will also be doing a detailed “due diligence” examination of Memorial’s assets as well as its liabilities and relationships with community groups and vendors. After that, the city council currently plans to submit the deal – or at least the conceptual framework of a deal – to a municipal vote, perhaps as late as June. “We’re honored and excited by the city council’s vote,” UCH President and CEO Bruce Schroffel said in the aftermath of the council’s action. As he had through the four-month process of shaping and offering the proposal, he maintained that “I believe we share our very strong values with southern Colorado, and we’re now looking forward to continuing our conversation with the people of Colorado Springs.”

If approved, the Memorial deal would cost the partners some $1.7 billion during the next 40 years. City Attorney Chris Melcher will head the Springs’ negotiating team, along with council members Merv Bennett and Brandy Williams. Schroffel will head the partners’ team. The process of spinning Memorial off from the city, which has owned it for 68 of its 108-year history, began as long as four years ago, but heated up in 2009 after a series of controversies about hospital policies and investments. During the fall of 2011, officials decided to look for new operators. Five bidders, including UCH and its partners, submitted proposals to a task force charged with grading them. In midDecember, the task force unanimously chose the UCH/Poudre Valley plan, and recommended it to the City Council.

A sense of urgency. At the same time, he expressed hope that the process could proceed quickly. Memorial – which boasts more than a dozen facilities throughout El Paso County, including its anchor, the level II trauma center, 600bed Memorial Central near downtown Colorado Springs – has been losing money and market share in recent quarters. Through November 2011, it lost $9.7 million, and its numbers of both admissions and emergency room visits have declined precipitously. It has also lost a number of clinicians to competitors in recent years.

Meanwhile, UCH’s and Poudre Valley’s as-yet-unnamed new system is reportedly close to being finalized, perhaps by the end of January. If the agreement to lease Memorial is consummated, Memorial would become the southern hub of a new not-for-profit system that would stretch north along the I-25 corridor into southern Wyoming.

Schroffel said providing stability for Memorial’s clinicians and staff are prerequisites to sparking a recovery, and that finalizing an agreement would ease a lot of the anxiety generated there during recent years and especially during the recent period of uncertainty.

Dr. Patricia Gabow, CEO of Denver Health for the past 20 years, announced that she will retire Sept. 1, 2012. Her successor is expected to be named within the next 10 months, according to an e-mailed news release from Denver Health.

T hank Y ou

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New Realities In Health Care Events From EPCMS Bring Information To Physicians Attendees then went to breakout sesAs health care reform engulfed us all, the El Paso County Medical Society reached out to sions, getting right to grappling with issues stakeholders across the state and brought them raised by payment reform. Each group disto Colorado Springs for a panel discussion titled cussed what participants would need to do if they had to act within a proposed system. This New Realities in Health Care Event: Understanding the Pieces, Understanding the Whole. was followed by discussion of outcomes and fuThis event proved so popular, that it led to a se- ture possibilities from the breakouts. ries of events on topics from Health Information Exchange, meaningful use, payment reform, and securing your place in integrated care. While each event features presenJeffrey, Moody, M.D., moderates the panel at the first New Realities in Health Care Event tations and question and The most recent event was a problem solving answer sessions with leading subject area experts, many also include breakout and work ses- work session to build the El Paso and Teller sions. Event number four, Payment Reform: County medical neighborhoods. At the New RePutting Transforma- alities event on medical neighborhoods, particitions Into Practice, pants related that they currently lacked consisNew Realities In Health Care featured presenta- tent clinical information on referred patients, and Events from EPCMS are open tions from Drs. spent too much time running down information to all, and many award COPIC Mark Laitos, CMS critical for patient care and coordinating care. ERS points or CME credit. Immediate Past The next New Realities in Health Care Event adPresident, and dressed these issues. Attendees rolled up their To attend the next New RealiMarjorie Grazi Harsleeves and came together to create a commuties in Health Care Event, visit epcms.org, go to “About Us”, brecht, Chief Exnity standard for communication and care coorand click on “Events and Meetecutive Officer of dination, and identified areas for prioritization to ings” from the drop down list. HealthTeamWorks. build local medical neighborhoods. Medical Voyce is a print media sponsor of EPCMSnews and publishes this excerpt free of charge so that the Colorado medical community may receive relevant information and resources in one convenient publication. The El Paso County Medical Society is solely responsible for the subject matter included in its newsletter, and is not responsible for the content of articles found in other sections of Medical Voyce. Neither the EPCMSnews nor Medical Voyce is responsible for the opinions expressed or facts presented by the authors of articles.

El Paso County Medical Society 730 Citadel Drive East, #206 Colorado Springs, CO 80909 www.epcms.org 719.591.2424

S pe c i a lt y D i s c i p l i n e F o c u s p e d i a t r i c d e n t i s t r y

A ren â&#x20AC;&#x2122;t They Just Baby Teeth?

By Joshua B. Erickson, DDS, MSD and Kirk A. Skidmore, DDS

.J. is awaking calmly in the recovery area after an in-office intravenous sedation and full-mouth dental rehabilitation. She is four years old and just had 12 of her 20 baby teeth treated. The cost is $500 for anesthesia and $3,150 for dental restorations, extractions, and a space maintainer. Today, there are three other patients scheduled for sedation because of the amount of work needing to be completed, their age, and their inability to cooperate or hold still to receive quality dental work. Unfortunately, this happens weekly in our Colorado Springs pediatric dentistry and orthodontics practice. For the first time in 40 years, dental caries in children is on the rise, nationally. It occurs in every racial and socioeconomic group. Research by the Center of Disease Control and Prevention found that dental caries is the most prevalent disease in children. It is five times more prevalent than asthma and seven times more prevalent than hay fever. Almost half of all children in the U.S. exhibit symptoms of the disease by the time they reach kindergarten. In the state of Colorado, 16 percent of two to four year-olds have untreated decay and the statistics only get worse as the population increases with age.

Joshua B. Erickson, DDS, MSD, is a unique dual specialist having been residency trained in both orthodontics and pediatric dentistry. University of the Pacific Arthur A. Dugoni School of Dentistry Dental School University of Washington Orthodontics University of Tennessee Pediatric Dentistry

J o s h u a B. E r i c k s o n DDS, MSD

tissue, and infection of the alveolar bone surrounding teeth. The health and preservation of cavity-free, primary teeth is important for chewing food, proper development of the facial structures and jaw relationships, eruption sequence and position of permanent teeth, and an increase in self-esteem. Unfortunately, once teeth decay, they become a source of significant infection and pain.

Dental caries is a disease where there is loss of calcium and phosphate from the enamel and dentin of teeth. Dental decay or a cavity is the primary symptom of the disease, but there is an increasing spectrum varying from a white spot lesion to actual loss of tooth structure, necrosis of the nerve

Gross Decay

White spot lesions

The disease of dental caries characteristically starts due to the presence of cariogenic bacterial organisms that, when combined with simple sugars in the diet, form acid. These organisms only colonize on teeth and are not present at birth. Infants get the bacteria transferred from their care takers via an orally-cleansed spoon or pacifier. Individual prevention as well as providing prenatal, oral-health guidance to pregnant mothers can minimize the motherâ&#x20AC;&#x2122;s bacterial count and delay the transmission and colonization of the bacteria in the infant.

Kirk A. Skidmore, DDS, spent a year in advanced general and hospital dentistry after dental school and then two years in pediatric dentistry. University of Washington Dental School

K i r k A. S k i dm o r e DDS

University Hospital at the University of Utah General Practice Residency Lutheran Medical Center, Hawaii Pediatric Dentistry

Ironically, this disease is almost completely preventable. The most successful strategies have not changed for many years. These include; establishing and maintaining good oral hygiene, optimizing fluoride exposure, and the elimination of simple sugars in the diet. Advances in prevention include dental sealants and, most recently, the support of the American Dental Association (ADA) and the American Academy of Pediatric Dentistry (AAPD) for the establishment of a dental home by the child’s first birthday. This idea follows the ‘medical home’ model. A dental home is a place where children can receive comprehensive care, dental anticipatory guidance, and establish a dentist-patient relationship allowing the patients to have confidence in dental professionals for continuing and emergency care. In America, there are approximately 30 times more general dentists than pediatric dentists, and thus the majority of children will be treated by the former. Unfortunately, most dentists do not want to see children until age three, about two and a half years after the child has teeth. That is too late. In our practice, we follow the recommendations of the AAPD and want to see children by their first birthday to establish a dental home. Most children only have four to six teeth at this age but a focus on anticipatory guidance, an oral screening, placement of fluoride varnish, and most importantly, parental education is critical. Parent’s own dental health, attitudes regarding dentistry and oral hygiene, and their anxiety significantly affect the child’s dental health. Often parents were traumatized by a dentist in their childhood because of outdated, behavior-modification techniques or the need to restore numerous decayed teeth. By starting at a young age, trust is garnered and anticipatory guidance practices prevent decay and difficult restorative procedures, resulting in children who love to see the dentist and have good oral health. If children are cavity-free by the age of three, the likelihood of that child experiencing dental decay in the future decreases significantly.

All health care providers can be advocates for the dental health of children. Family physicians and pediatricians most often see children during the age of the initial eruption of the primary teeth and traditionally see them seven to eight times before the first dental visit. Direct dental anticipatory guidance from medical providers is very beneficial. There are great resources found on the websites of the American Academy of Pediatrics (AAP), ADA, and the AAPD on how to perform an oral screening, provide fluoride, and evaluate risk. Establishing a dental home by age one with a pediatric dentist will also be vital and should be recommended at the early wellbaby visits. The age-one dental visit is so important in our practice – if the child is not covered by insurance – exams and preventive procedures are complimentary until the age of two. A.J.’s parents certainly experienced a more difficult and expensive path for restoration of good oral health and will now be more proactive in the prevention of oral disease with their younger son in the future. Early and frequent evaluation of dental health will lead to prevention of dental caries and improve overall health. Children can and should grow up with a positive image of dentistry. Pediatric dentists are best equipped to handle this burden but based on the sheer number of children in America, they need help from their general dental and medical colleagues. Erickson Pediatric Dentistry & Orthodontics 8580 Scarborough Drive, #220 | Colorado Springs, CO 80920 719.282.6666 16055 Old Forest Point, #202 | Monument, CO 80132 719.488.1101

S o c i a l M e d i a & medicine

#1 Key to Facebook Marketing Success BY Rita Zamora

re your practice Facebook marketing efforts flailing? If so, chances are you may not have a Facebook champion in place. Social marketing is all about people, growing relationships, and interaction. Without the right champion in your practice, your Facebook efforts may go nowhere. An effective champion can help to motivate patients to like your Page and build excitement around your online community with both staff and patients. So what traits make for an ideal Facebook champion? See the list below for several important qualities:

Enjoys talking with people.

This is a person on your team who can connect with just about everyone. They are gregarious, friendly, cheerful, and may smile a lot.

Is a life-long learner.

The one thing that will remain constant moving forward is change. You want your champion to be open to new ideas and technologies. This person enjoys learning and exploring new opportunities.

Is web 2.0 comfortable.

An ideal champion will not fear digital conversation and interaction, whether it be via Facebook interaction, email or live online chat. Here is where some practices are struggling, but rest easy, you can always train and educate

Rita Zamora is a leader in social media marketing for dental, medical and veterinary professionals. She trains doctors, teams, and corporate clients to “do social media themselves.” To learn more visit www.RitaZamora.com.

R i ta Z a m o r a

your champion. This trait will continue to become even more critical with internet marketing taking over a growing portion of many practice marketing budgets. And while some social marketing activities can be outsourced, even the best social media program will fail without internal participation at some level.

Is a natural at nurturing relationships.

Remember you can teach someone technology skills, however there are some traits that you can never change. People who connect well with others and can nurture those relationships—whether online or in-person—are naturals at what they do. You’ve heard the term “hire for personality.” and the same holds true for your champion. Just because someone “loves Facebook and has hundreds of friends in their network,” doesn’t mean they will be effective at asking patients to like your Page. Natural relationship builders also often have an internal sensor that guides them on the right or wrong thing to say. In working with numerous practices across the United States and internationally, I’ve heard many team members say, “None of our patients are on Facebook” or “Facebook isn’t working for us.” However with the right person, training, and tools in place, their Facebook Page efforts skyrocketed resulting in amplified engagement and word of mouth. Who is your Facebook Champion?

C l i n i c a l F o c u s cystic fibrosis

Complex Care Needed for CF Survivors BY Dan Meyers

the age of eight,” Allen Wentworth, director of respiratory therapy and pulmonary diagnostics at UCH, recalls. “Now, many survive longer.”

There are psychological dimensions to this progressive killer as well.

What changed? Better medications to deal with the lack of pancreatic enzymes. Improved ways to clear the mucous, such as a vest that thumps the mucous loose. Lung transplants to extend life. Superior ways to fight infections.

he patients themselves have many needs as they battle a disease that clogs the lungs with mucous and that also can wreak havoc with the GI tract because it affects pancreatic enzymes.

But thanks to medical advances, many patients who might have died in their teens now live into their 30s and 40s. This realm of care is an example of how improved medicine allows people with congenital conditions to live longer. But with Cystic Fibrosis (CF), there are outpatient needs and intense inpatient demands. In the Denver area the network of care might look like this: A child with CF is treated at Children’s Hospital Colorado. He or she then graduates to outpatient care at National Jewish Health. But for inpatient treatment, the patient likely would go to University of Colorado Hospital, Colorado’s only source of adult specialized CF inpatient care. So, three hospitals (and CU medical school faculty who work there) have to work together on behalf of people with CF. “The first cystic fibrosis patient I cared for in the 1980s died at

This progress creates new demands on UCH, where the average number of CF patients has more than doubled in five years. In Wentworth’s unit, other patients might require 15 minutes of therapy while a growing number of CF patients might need two hours’ worth—for several weeks. UCH recently delegated a respiratory therapist to work with National Jewish. One of her key missions will be coordinating the scheduling of interventions so the hospital can ensure enough staff is on hand to provide the intense care CF patients often need. Wentworth says relationships with Children’s Colorado are good but he wants to explore ways to make the care discussions more formal. “We communicate a lot,” he says. “But we can collaborate better. We just need to make it happen.”

Financial & Investment m a n a g e m e n t

R etirement P lanning : D oes Y our 401( k ) Plan Work for Y ou? By Jeffrey L. Jensen, Senior Vice

President/Corporate Retirement Director

S ummary Retirement planning can be daunting. As a medical practitioner, your goal is to practice medicine; and for most medical professionals, the thought of dealing with retirement plan design can be mind-numbing. But with the right plan design, you may be able to reduce your practice’s costs and increase the amount you are able to defer for your retirement needs.

Jeff Jensen, Principal with The Jensen Group, provides financial service advice to medical practice groups and medical professionals located throughout Colorado. Contact him at 719.577.6321 or jeffrey.l.jensen@mssb.com.

J eff L. J e n s e n

Tax laws are complex and subject to change. MSSB does not provide tax or legal advice and we are not “fiduciaries” (under ERISA, the Internal Revenue Code or otherwise) unless otherwise agreed to in writing. Individuals are urged to consult their tax or legal advisors before establishing a retirement plan and to understand the tax, ERISA and related consequences of any investments made under such plan.

Plan review helps you plan for the future.

he design of your retirement plan can either work for you or work against you unnecessarily taking money out of your pocket. With changing options in retirement planning, the plan design you put in place 5 or 10 years ago (and have not thought about since), may not be the best design for your practice in today’s retirement planning landscape. Not every financial advisor can help you maximize your plan options. Just as you would not refer a patient with orthopedic needs to a heart surgeon, you should not use a financial advisor who primarily does private equity or stock trading for your retirement plan design needs. Your best option is to hire a retirement plan consultant. To conduct a thorough plan review and optimize the plan design for your practice, there are a number of steps that we consider in designing a plan. Most importantly, we gather census data about your employees including the employees’ names, dates of birth, dates of hire, ages, and W-2 income. We look at how your employee census has changed from the inception of your plan to your current situation. We look at your practice goals and how your plan can support those goals. From that, we generate a number of plan design models to see what plan will work best for the medical practice’s group with a focus on reducing employer costs and maximizing owner contributions. The following are illustrations of an actual plan design review we conducted in 2011 for a medical practice group with 12 employees: 3 physician-owners (Tier A) and 9 non-owner employees (Tier B) his results.

4 0 1 ( K ) P L A N | PRO - R ATA A L LO CAT I O N F O R M U L A Tier B 37% Tier A 63%

Total Employer Contributions Tier A Employees

$97,500

Total Employer Contributions Tier B Employees

$57,061

Maximum Contributions by Employer

$154,561

Total Tier A Contributions

$163,500

Total Tier B Contributions Total Retirement Plan Contributions

$71,561 $235,061

Illustration 1 shows a common plan design used by many medical practices. In a 401(k) Pro-Rata Allocation, the physician-employers are not able to maximize their deferrals under existing 401(k) rules and they make a substantial contribution to non-owner employees in order to meet testing requirements. As this model demonstrates, this group had employer contributions of $154,500 with 63% of the employer contributions going to the owner physicians and 37% going to non-owner employees.

Additional Plan Savings.

4 0 1 ( K ) P L A N | N E W C O M PA R A B I L I T Y A L LO CAT I O N F O R M U L Aâ&#x20AC;&#x201C; M A X I M U M Tier B 18% Tier A 82%

Illustration 2 is a plan design developed and recommended to the medical practice. The goal was to maximize the physicianowner benefits and reduced plan costs. Under the 401(k) New Comparability design, the physician group still receives $97,500,but their employer cost is reduce from $57,000 to $21,500, a $35,500 (23%) savings. Additionally, 82% of the benefit is to physician-owners. Total Employer Contributions Tier A Employees

$97,500

Total Employer Contributions Tier B Employees

$21,500

Maximum Contributions by Employer

$119,000

Total Tier A Contributions

$163,500

Total Tier B Contributions

$36,000

Total Retirement Plan Contributions

$199,500

4 0 1 ( K ) P L A N | N E W C O M P CA S H BA L A N C E C O M B O P L A N Tier B 12% Tier A 88%

The savings donâ&#x20AC;&#x2122;t simply stop with employer contributions. In any plan design review, you need to analyze how you can save money in administrative costs. As a part of our consulting process and plan review, we get copies of your plan adoption agreement and plan contract to assure they comply with changes in ERISA and to find savings in vesting provisions, eligibility requirements, last day provisions, automatic enrollment, participant loans and a variety of other considerations where savings might be available. We also assess whether there are outsourcing options that can save you money by freeing you and your staff to perform the jobs you do best. These savings may reduce your plan costs, liabilities and administrative fees and make your practice more productive.

Saving You Money - Maximizing Your Benefit.

With almost every medical practice retirement plan I review and analyze, I am able to find cost savings for the practice owners. As medical practitioners, you work hard for the money you make and you should look to maximize your benefits. While the actual percentages will vary based upon your plan design, I am often able to save the medical practice groups that become clients 20% or more in their planâ&#x20AC;&#x2122;s annual cash outlay by making some thoughtful, practical plan design changes. As the illustrations above demonstrate, plan design is important. The group in the illustrated case decided to use the 401(k) New Comparability Allocation reducing employer contribution costs by 23% while maximizing physician-owner deferrals. This saved the group $35,500. As is evident from this actual case illustration, optimal plan design may save you money.

The Time is Now to Review Your Plan.

Illustration 3 is a plan design that focuses on deferrals beyond those allowed in a traditional 401(k). Under the New Comp Cash Balance Plan, physician deferrals go from a total of $97,500 to $314,000 ($126,000 per physician) with a small total cost of $41,250 to non-owners. This results in physicianowners receiving a greater benefit and 88% of total employercontributed dollars. Total Employer Contributions Tier A Employees

$314,100

Total Employer Contributions Tier B Employees

$41,250

Maximum Contributions by Employer

$355,350

Total Tier A Contributions

$380,100

Total Tier B Contributions Total Retirement Plan Contributions

$55,750 $435,850

While there is never a bad time to review your retirement plan, early in the year is one of the best times to determine whether your plan is optimized and meeting your practice goals. If your plan is not maximizing your benefits and minimizing your costs, you have time to make changes that can be funded over the better part of the year. Those changes could help with your tax burden and increase the benefits available to you in your retirement plan. The Jensen Group at Morgan Stanley Smith Barney offers any prospective client a complimentary plan analysis with a commitment to providing feedback in three business days. We are happy to extend this service to Medical Voyce readers who would like to have an analysis of their plan to see if they might find cost savings both now and into the future. To discuss a complimentary plan review, please call Ann Ries at 719.577.6333 or e-mail Ann at ann.marie.ries@mssb.com.

Service Line p r o f i l e

Penrose Cardiac, Thoracic and Vascular Surgery - Hearts Connected By Dr. John Mehall, Dr. Matthew Blum, Dr. Martin Beggs

he cardiovascular and thoracic surgery program at Penrose-St. Francis Health Services ranks among the top 10 percent of programs for heart and chest surgery in the nation. For years, patients have been traveling from Pueblo, La Junta, Trinidad and even Alamosa to Penrose-St. Francis for cardiac and thoracic surgery. Some patients choose PenroseSt. Francis because they don’t want to travel “all the way” to Denver and deal with the hassles of the big city. Others stop

at Penrose because they found out that it is one of the best cardiac surgery programs in the nation. (Consumer Reports ® Top 50 Heart Bypass Surgery Program, 2010 and 2011) We’ve heard over and over from our patients about the stress they are experiencing and the time they are spending traveling for their pre- and post-operative appointments. To address these concerns, we recently began seeing patients in Pueblo

FROM LEFT TO RIGHT: MATTHEW BLUM, MD, MARTIN BEGGS, MD, AND JOHN MENHALL, MD

one day each week. New patient consults in heart disease, lung and thoracic disease and aortic disease can be done at St. Mary Corwin Medical Center. Following surgery at Penrose Hospital, patients can complete their post-op, follow-up and cardiac rehabilitation in Pueblo. We use the term Hearts Connected to talk about cardiovascular and thoracic disease in southern Colorado. Our goal is to offer cardiac and thoracic patients the care they need within the southern Colorado group of Centura Health facilities (Penrose-St. Francis, St. Mary Corwin Medical Center and St. Thomas More Hospital) and then get them back to their home community as quickly as possible. As a physician, you can be confident that your patient is getting the highest quality care without the stress of traveling for the pre- and post-operative care. You can also feel confident that your patient will return to you for their future care, which we will support with timely and appropriate communication from the surgeons at Penrose. We have also

found that patients are more likely to comply with cardiac rehabilitation if the class locations are convenient. Know that we approach each case with an individualized plan, and the surgical and technological tools that we believe will create the best outcome. Whether it be minimally invasive heart valve repair, aortic aneurism surgery or lung cancer resection, we take the extra time to explain the options and proposed plan to the patient and family. You can be comfortable sharing your patients with us because our practice has achieved the highest possible ranking for outcomes and quality from The Society of Thoracic Surgeons. We are the only program in southern Colorado that publicly reports our results online (www.sts.org). You want to provide the best possible care for your patients. So do we. Please feel free to call our office at 719.776.7600 if there is anything we can do to help you.

Clinical g u i d e l i n e s

N e w G u i d e l i n e S u pp l e m e n t H e l ps Providers Prevent Rx Drug Abuse

rescription medications relieve all sorts of ills, but they are increasingly being misused or abused. In 2002, the National Survey on Drug Use and Health reported that an estimated 29.6 million Americans had used pain relievers for nonmedical reasons; by 2005, the number had risen to 32.7 million. 1

In 2009, 45 percent of the nearly 4.6 million drug-related emergency room visits nationwide were attributed to abuse of pharmaceuticals. 2 The Drug Abuse Warning Network estimates that of the 2.1 million drug abuse visits, 27.1 percent involved nonmedical use of medications. 3 Prescription drug abuse means taking a prescription medication that is not prescribed for you, or taking it for reasons or in dosages other than as prescribed. Abuse of prescription drugs can lead to serious health effects, including addiction. Commonly abused classes of prescription medications include opioids, central nervous system depressants and stimulants. HealthTeamWorks, formerly the Colorado Clinical Guidelines Collaborative, has developed a new clinical guideline supplement on prescription drug abuse prevention to assist primary care providers and other healthcare professionals. The supplement was developed through the statewide SBIRT program — Screening, Brief Intervention and Referral to Treatment. HealthTeamWorks is a partner in this project, which is funded by the Substance Abuse Mental Health Services Administration. SBIRT promotes prevention and early identification of unhealthy alcohol and drug use. HealthTeamWorks provides training and support to primary care and other healthcare organizations throughout the state to integrate the Alcohol and Substance Use Screening Guideline into clinical practice. The new Prescription Drug Abuse Prevention Supplement includes screening questions, information about responsible opioid prescribing, behavioral health considerations, tips for patients and care-givers and resources for prescribers. Printed front and back on an 8 ½ x 11-inch page, the supplement, like all HealthTeamWorks guidelines, is concise and easy to use in the clinical setting.

HealthTeamWorks is mailing the revised guideline to more than 7,500 healthcare providers across Colorado. All HealthTeamWorks’ clinical guidelines and supplements are available for free download. If you have questions about the guidelines or would like laminated copies, contact HealthTeamWorks at 303-446-7200 or e-mail egingerich@healthteamworks.org

How the guideline supplement was developed

In April 2011, HealthTeamWorks convened a committee of experts and practicing clinicians to revise the Alcohol and Substance Use Screening Guideline. That group worked over five months to update and streamline a guideline that summarizes the current evidence on putting SBIRT into practice. The guideline is intended for a wide audience, including primary and specialty practices, public health, emergency departments and hospitals. A subcommittee of the SBIRT guideline development committee comprised of physicians, mid-level providers, public health professionals, mental health professionals and researchers, and other experts provided input on the Prescription Drug Abuse Prevention Supplement during the course of the main guideline revision. The subcommittee reviewed published evidence and determined the key issues that providers need to know to prevent prescription drug abuse. In building the guideline, subcommittee members decided what is not now being done that could make the most difference to improve care.

Every healthcare contact is an opportunity to spot, prevent risky substance use

The United States Preventive Services Task Force recommends alcohol and tobacco screening and brief interventions – both are high-priority recommendations endorsed by the

Partnership for Prevention. These organizations recognize that every contact an individual has with the healthcare system â&#x20AC;&#x201D; whether in a primary care clinic, public health clinic, emergency room or hospital â&#x20AC;&#x201D; is an opportunity to detect risky substance use. Providers in any setting can use standardized questions to elicit information and intervene with a brief motivational conversation. The aim of SBIRT strategy is to provide feedback, advice and assistance to reverse risky substance use and prevent serious health and other consequences. SBIRT is effective for both youth and adults. HealthTeamWorks provides free training and technical assistance to healthcare organizations to help implement and sustain SBIRT in practice. See the HealthTeamWorks website (www.healthteamworks.org) for further information or to request training.

sources

1. Maxwell JC. Trends in the abuse of prescription drugs. The Center for Excellence in Drug Epidemiology, the Gulf Coast Addiction Technology Transfer Center, the University of Texas at Austin. http://www.utexas.edu/ research/cswr/gcattc/documents/ PrescriptionTrends_Web.pdf, accessed Sept. 20, 2011. 2. National Institute on Drug Abuse. NIDA InfoFacts: Drug-Related Hospital Emergency Room Visits. http://drugabuse.gov/infofacts/ HospitalVisits.html, accessed Sept. 20, 2011. 3. Ibid.

Medical r e a l e s t at e

Is the Economy Improving? by Jan Friedlander, CCIM

ll of us are looking for signs the economy is improving. With that in mind, I am pleased to share some good news that should be particularly welcome at this time of year. Below are quotes from various articles I have read recently.

Jan Friedlander, CCIM, specializes in Healthcare Real Estate. Contact her at 303.885.9200 or janfriedlander@comcast.net. J a n F r i ed l a n de r

Labor Department:

Capital Economics:

“The Labor Department said the seasonally adjusted figure of actual initial claims for the week ended Nov. 12 decreased by 5,000 to 388,000 from 393,000 the previous week, which was revised upward 3,000.

The Denver Post, Dec. 17, 2011, quoted CAPITAL ECONOMICS as saying, “The continued resilience of manufacturing is encouraging, since this should be the sector most exposed to the global economic showdown.”

Analysts surveyed by ECONODAY expected 395,000 new jobless claims last week with a range of estimates between 382,000 and 400,000. Most economists believe weekly jobless claims lower than 400,000 indicate the economy is expanding and jobs growth is strengthening. Initial claims have now been lower than this threshold for a month.

National Association of Realtors (NAR):

The four-week moving average, which is considered a less volatile indicator than weekly claims, declined by 4,000 claims to 396,750 from the prior week’s slightly revised 400,750. The seasonally adjusted insured unemployment rate for the week ended Nov. 5 remained unchanged at 2.9 percent, according to the Labor Department. The total number of people receiving some sort of federal unemployment benefits for the week ended Oct. 29 fell to 6.77 million from nearly 6.84 million the prior week.”

“Lawrence Yun, NAR chief economist, said the marker is holding fairly even. ‘Home sales need to recover first – only then can prices stabilize. Existing-home sales are little changed from the second quarter but are notable higher than a year ago,’ he said. ‘The good news is inventory levels have been trending gradually down.’”

Healthcare Industry:

All of us have read articles about higher employment in healthcare than other industries. This is attributable to several factors happening at the same time and that do not seem to be stopping: increasing population, longer lives, healthier lifestyles and advancements in medicine that keep us healthier, longer. These factors coupled with what appears to be an improving economy, allow us to be at least cautiously optimistic about our future.