St. Louis Medical News May 2013

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PHYSICIAN SPOTLIGHT PAGE 3

Robert B. Belshe, MD ON ROUNDS Part 5: Money Speaks Loudly Understanding the PCMH pillar of cost The important topic of cost of healthcare services represents the fourth pillar of the Patient Centered Medical Home (PCMH) model.

With the PCMH model fully implemented, cost will be commensurate with utilization and measured against payer cost benchmarks. ... 4

IT Acceleration MedEvolve finds ‘sweet spot’ niche providing PM and EMR software and RCM services to physician practices nationwide LITTLE ROCK – When Bill Hefley, MD, was a junior partner at a Little Rock orthopedic practice more than two decades ago, he was tasked with choosing a new information technology (IT) system to replace an antiquated one ... 5

Miles Against Melanoma Race founder anticipates record-breaking third annual race to raise funds for deadliest skin cancer

By LyNNE JETER

Amalyn Martin has clocked many miles in her mission to raise money for melanoma patients nationwide, a special project that began, oddly enough, with a tanning bed.

In 2010, Martin was spray tanning clients in a franchise salon she owned, Tans Are Now Safe, when “God planted the seed,” she recalled. Around the same time, her father was diagnosed with early-stage skin cancer and a Kansas City friend’s best pal died of melanoma at the age of 30.

“I just took (this idea) and helped it snowball,” said Martin, founder of Miles Against Melanoma, an annual race that raises money for research and patients with the deadliest form of skin cancer.

“An avid runner, I started by coming up with a name, Miles Against Melanoma,” explained Martin. “Then I realized people really would come on board. A city employee in Cottleville (also a melanoma survivor) helped me (CONTINUED ON PAGE 8)

PHOTO CREDIT: K. THAEMERT PHOTOGRAPHY

Mainstreaming Digital Dettmann and Kalkofen find success providing digital marketing expertise to healthcare leaders

By LyNNE JETER

When Kaysha Kalkofen and JoAnna Dettmann picked up their college degrees, social media marketing was not on any radar.

Yet both ladies came from very different backgrounds to become early adopters of digital marketing for the healthcare, legal and higher education industries.

Kalkofen earned a biology degree and worked on the human genome project at the Washington University School of Medicine before relocating to Las Vegas to pick up an MBA from the University of Nevada at Las Vegas (UNLV). There, she worked part-time for a media firm that managed digital marketing projects. Starting as a receptionist, she worked her way to an account manager position before meeting Dettmann, who had earned a broadcasting degree with an eye on landing an anchor role. Instead, (CONTINUED ON PAGE 6)

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PhysicianSpotlight

Robert B. Belshe, MD

By LUCY SCHULTZE

It would be easy to feel daunted by the process of pursuing new vaccines – were it not for the chance your discovery might change the world.

“You have to take that very long viewpoint,” said Robert B. Belshe, MD, director of Saint Louis University’s Center for Vaccine Development and the Dianna and J. Joseph Adorjan Endowed Professor of Infectious Diseases and Immunology.

“From start to finish, the development of a new vaccine often takes many, many years,” he said. “But when you have a success, it carries on for a long, long time and helps millions of people.”

It’s a calling to which Belshe has devoted his career, serving the past 24 years at SLU’s vaccine center. He spent the decade prior in a similar role at Marshall University School of Medicine in Huntingdon, W.V. Most recently, Belshe was named to the National Institutes of Health’s main advisory panel on allergies and infectious diseases, where his contributions will help shape NIH funding priorities in that area.

SLU hosts one of eight federally funded centers focused on the testing of new vaccines in human subjects. The center’s role involves developing laboratory data and protocol to test the vaccine in humans.

While much of the work is slow-andsteady, the center is also called upon to respond swiftly to national threats like the 2009 influenza pandemic and fears of biological terrorism in the wake Sept. 11, 2001.

“We’ve done a number of clinical trials with the new smallpox vaccine,” Belshe said. “Right after 9/11, we were able to show that the relatively small amount of vaccine the United States had could be diluted 1-to-10 – meaning we could vaccinate 10 times as many people and it would still work.”

High-profile projects aside, most of the work Belshe supervises deals with developing new vaccines and improving existing ones. While short-term successes like each year’s new flu vaccine are rewarding, it’s the long-term efforts that result in dramatic effects.

“The field has had enormous success in developing vaccines for hepatitis A, hepatitis B, influenza and meningitis,” Belshe said. “All these have been developed in the last three decades, and they’re spectacular successes.”

The field of vaccine development is one Belshe came to by way of physical chemistry, which he studied as an undergraduate at the College of William and Mary in Williamsburg, Va. Suddenly, in 1969, his career prospects took a nosedive.

“I was a junior in college when the United States succeeded in putting a man on the moon,” Belshe said. “The NASA budget collapsed, and tens of thousands of physical scientists were out of work – stlouismedicalnews

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because they had succeeded. It was clear physical chemistry was not going to be a good path to go into for a long time.”

Shifting gears, Belshe responded instead to the need for physicians with strong basic-science backgrounds. He continued his interest in chemistry as a medical student at the University of Illinois College of Medicine, where virology emerged as his chief focus.

“That led to vaccines, because it’s really the best way of controlling viruses, through prevention,” he said.

Belshe completed his training with an internship and residency at the University of Illinois Hospital in Chicago, followed by a fellowship in infectious diseases at the National Institute of Allergy and Infectious Disease in Bethesda, Md. Prior to joining SLU, Belshe led the Section of Infectious Diseases at Marshall University School of Medicine, where he spent 11 years on the medical faculty.

“It was a great place to get started,” he said. “But it was clear that, in order to expand our work and continue doing some cutting-edge research, I was going to need a medical school that had strong basicscience and laboratory research to complement the clinical-trials research.”

Belshe made several visits to St. Louis before negotiating an agreement to bring his entire research group to SLU, including three other doctors, his head lab tech, head nurse and office manager.

“It was a bold move, and carefully crafted so that both institutions would benefit,” Belshe said.

With the exception of a couple of retirements, the group remains largely still in-tact 24 years later.

Today, the staff of the vaccine center has grown to about 30 people, and ongoing studies may involve as many as 2,000

to 3,000 volunteers at any given time. Belshe’s role is heavy on administration duties as well as crafting manuscripts to share the center’s findings.

“One of the most important things we do is publish the information that we generate,” he said. “Unless we do that, the broader scientific world doesn’t know the information.

“It’s a tremendous effort to sit down and craft a scientific manuscript to be understood by other scientists in the field, with data that could be reproduced in another trial.”

Travel also takes up a good portion of his time, whether to take part in scientific meetings on behalf of SLU research or to attend panel gatherings for the National Advisory Allergy and Infectious Diseases

Council (NAAID).

The four-year appointment places Belshe as one of 12 health and science experts who join six lay members in advising the National Institute of Allergy and Infectious Diseases (NIAID) on long-term planning and broad research priorities.

The panel also evaluates NIAID programs and performs second-level reviews of some grants.

In addition to serving on the panel, Belshe is a member of the NAAID’s microbiology and infectious diseases subcommittee.

Outside of work, Belshe and his wife, Pat, tend to the cattle ranch they own in rural Missouri.

They also frequently travel to California to visit their two grown children, Robert and Bonnie, and two grandchildren.

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“The very positive experience with the MedEvolve PM software prompted our decision to expand their services to include Revenue Cycle Management, which has absolutely improved our billing services. Overall a very positive experience, with a few key contacts in the company that are always available and promptly responsive and accountable to our practice.

MedEvolve really does stand out not only in software performance, but particularly in customer service.”

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Part 5: Money Speaks Loudly Understanding the PCMH pillar of cost

By LYNNE JETER

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The important topic of cost of healthcare services represents the fourth pillar of the Patient Centered Medical Home (PCMH) model. With the PCMH model fully implemented, cost will be commensurate with utilization and measured against payer cost benchmarks. These costs impact healthcare premiums and also provide opportunities for better management of healthcare dollars, says Derrick O’Connell, RN, MBA, chief quality officer for Esse Health in St. Louis, a nationally recognized expert on PCMH models.

“Costs are commenDerrick surate with the utilization O’Connell of healthcare services for inpatient facilities, outpatient services and pharmaceuticals, including those aggregated and soon-to-be-reported in 2015 by the largest payer of healthcare, CMS,” said O’Connell.

Last year, the Centers for Medicare & Medicaid Services (CMS) began reporting QRUR (Quality Resource and Utilization Report) data to providers and physicians in four contiguous Midwestern states; Missouri is among the pilot states. The data

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reported to providers for their Medicare fee-for-service population with cost, utilization data and clinical performance data which also benchmarked physicians and providers across all four states. Every six months, CMS adds more states to the QRUR. In 2015, CMS will publish data for 2013 QRUR performance.

“I don’t think the results will initially have a dramatic impact on costs, but it’s the first time CMS is reporting publicly on a physician or provider level,” said O’Connell. “It’ll show us the risk-adjusted aspect of utilization attribution, related to the cost of services.” “This exemplifies the healthcare sector’s movement towards the transparency of performance data.”

The PCMH is the model to manage patients across the entire continuum of care to efficiently manage costs, explained O’Connell, adding that “the balance of the attributes and functions of the medical home model positively affects cost.”

Money for healthcare delivery is, of course, derived from premiums. Also, more of the system’s financial burden has been placed on the consumer because of the shift in the percentage of coverage for healthcare premiums from employer to employee.

“Fee-for-service payment has been in place since the 1950s, doing more of the same thing regardless of whether it’s efficient or effective,” said O’Connell. “We’re entering a world where fee-for-service won’t fit into the medical home model.”

Currently, premiums are negotiated within the context of contracts – single provider, provider groups, networks of providers, population-based, episode-of-care measurement and value-based payment, and the inefficient fee-for-service model.

“An example of the episode-of-care payment model (for high-dollar admissions) is the patient who falls at home and is taken to the ER – the anchor event,” explained O’Connell. “Let’s say a hip fracture is found, the hip is surgically repaired or replaced, and rehabilitation takes place inpatient and continues in the home setting. The patient eventually finishes rehabilitation and follows-up with their specialty provider (Orthopedic Surgeon) and primary care provider. The episodeof-care ends when the data, claims and clinical data stops being produced, i.e., the patient no longer has care any where in the continuum.

Risk-adjusted payments for the illness burden, or sicker subpopulations, are an important part of the attribution methodology for physicians and providers.

“If historical claims data for a patient show he’s 30 percent sicker than the population, then 30 percent more resources should be allocated to, and spent on, the patient,” he said.

Benchmarks are determined by lines of business – commercial, Medicare, Medicare Advantage, Medicaid, or geographical region. “Regional cost of living or economies of scale will continue to have

an impact,” said O’Connell. “In California, one might pay a higher cost per patient per month for the care of diabetes. In Tennessee, it might be a lower cost because the economies of scale are different.”

Among the opportunities to capitalize on the new era of healthcare delivery: managing costs through population management programs, expanded access to primary care, care management, care coordination, and enhanced communication.

“Population management programs involve using population data to understand opportunities for intervention before the patient has a poor outcome, leading to increased avoidable utilization and increased costs,” he said, noting a few opportunities: gaps in care detection, highrisk populations, vulnerable populations, medication compliance data, inappropriate utilization, and determining patients who haven’t been seen by their provider within a year.

“For example, I’ll turn 50 in October, and I should be told I need a colonoscopy, according to Evidenced Based Medical Guidelines, so that early-stage colon disease may be detected now rather than discovering it at a later, more costly, stage if it does arise,” he said. “If my primary care provider doesn’t tell me I need to have a colonoscopy, that’s considered a gap in care and should be detected through population management data.”

Medication reconciliation – a key element in the transition of care – can have a major impact in the new payment paradigm to avoid duplication, negative medication interactions, hospital readmissions, or even untimely death.

“It sounds simple, but it needs to happen consistently throughout all transitions of care,” he said. “It’s something the medical home model promotes greatly.”

As a result of the focus on cost, avoidable inappropriate utilization of services will be positively impacted, such as decreasing or eliminating non-emergent ER care, decreasing inpatient readmissions within 30 days, decreasing or eliminating frequent inpatient admissions, decreasing frequent ER visits, and decreasing frequent Urgent Care visits.

“Utilizing something more appropriate with EBM instead of using more of something that’s not working will make a significant difference in healthcare delivery,” he said.

For now, competing forces are hindering the full continuum of care.

“But once we get under populationbased payment, you’ll see those forces working together,” said O’Connell. “Then you’ll see overutilization of services level out.”

Editor’s note: This article represents the fifth and final part of our Lean Six Sigma series with Derrick O’Connell, RN, MBA, chief quality officer for Esse Health in St. Louis. O’Connell may be reached via doconnell@essehealth.com. stlouismedicalnews

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IT Acceleration

MedEvolve finds ‘sweet spot’ niche providing PM and EMR software and RCM services to physician practices nationwide

By LYNNE JETER

LITTLE ROCK – When Bill Hefley, MD, was a junior partner at a Little Rock orthopedic practice more than two decades ago, he was tasked with choosing a new information technology (IT) system to replace an antiquated one. After completing due diligence on various options, he played it safe and purchased a new system from the na- Dr. Bill Hefley tion’s largest vendor.

“It was a complete disaster,” recalled Hefley, noting the software was different than the demonstration version, the trainer was “preoccupied and disinterested,” and customer support was practically non-existent. “Our practice collections soon approached zero. I knew there had to be a better way.”

A hobbyist computer programmer, Hefley devoted his energies to filling the void in the marketplace. From it, he established MedEvolve as a truly collaborative industry partner to solidify the IT backbone of medical practices. The success of MedEvolve’s practice management (PM) software – it not only organizes patient databases, scheduling and billing, but also allows extensive data reporting – led to the launch of its revenue cycle management (RCM) division. In a fairly crowded field of practice management software companies, MedEvolve stands out not only in software performance, but especially in a vital yet often overlooked area – customer service.

The Drawing Board

In searching for a better solution in the early 1990s, Hefley connected with Pat Cline, president of Clinitec International Inc., then a startup company based in Horsham, Pa., and a pioneer in the emerging field of electronic medical records (EMR).

“Intrigued, I became an early investor and a development partner focused on orthopedic clinical content,” he said, noting that a small public company acquired Clinitec, which became known as NextGen Healthcare, now one of the world’s leading healthcare IT companies. Hefley, an orthopedic specialist in minimally invasive surgeries for the knee, hip and shoulder using arthroscopic and joint replacement procedures, became a development partner with NextGen in 1994, working on the development of clinical content for orthopedists. “By 1997, I felt opportunities still existed in the physician PM software industry. While most physician practices were utilizing computerized billing and scheduling, the available systems were DOS- or Unix-based and not taking advantage of the Windows GUI interface, much less the Internet. More importantly, healthcare IT vendors in the physician sector remained notoriously atrocious in delivering support and customer service. I frequently heard my physician friends and colleagues recount horror stories of flawed software stlouismedicalnews

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systems with dismal support that were making it impossible to run their practices successfully. I remembered my personal bad experience with the large national vendor and the stellar reputation of a small local firm, MBS (Medical Business Services Inc.), which I’d also checked out.”

In 1998, Hefley and Steve Pierce of MBS, a 9-year-old IT firm with a mature DOS-based PM software product, founded MedEvolve with the vision of becoming the first Windows-based physician PM system that employed the Internet and delivered impeccable support and customer service.

“My practice became the beta site for the first version of our new Windows-based PM system,” recalled Hefley, MedEvolve’s president and CEO. “We began to sell our product regionally initially and eventually throughout the United States. We integrated our PM product with several specialty-specific EMR systems to reach more physician practices. We continually worked to upgrade the software and deliver new, innovative functionality. By our tenth year, we had several thousand users nationwide.”

With the success of MedEvolve’s PM product, Hefley recognized a growing need among physician clients for expertise in RCM. “Physicians were struggling with increasingly complex third-party payor systems, growing documentation requirements, mounting government regulations, and threats of audits, fines and imprisonment,” said Hefley. “Practices were searching for a partner with expertise in these areas that could relieve them of the burden of constantly attempting to stay abreast of the ever-changing rules and regulations.

Physicians wanted to focus on the practice of medicine and leave the headaches to people that specialized in those matters.”

MedEvolve developed an RCM division, acquired three small RCM companies, and now has a division that includes experienced practice administrators and dozens of billing and coding specialists.

“With specialization, scale, and great software, we’ve been able to produce some of the best results in the industry – 97 percent first-pass claims success, 27 percent average increase in practice revenue, and a 38 percent average reduction in accounts receivable days through MedEvolve RCM services,” he said. “By switching to MedEvolve’s RCM service, providers immediately experience less hassle, lower costs and increased revenue that result in an improved bottom line and peace of mind.”

liver on the industry’s promise of a cutting edge, customized solution that helps practices save time and money and improve the quality of patient care,” said Hefley. “The resulting MedEvolve EHR is fully integrated with the MedEvolve PM system and is designed for the high volume practice with an emphasis on fewer clicks, fewer screens, faster data input and faster data retrieval.”

Hefley has placed a strong emphasis on customer service as the bedrock principle of MedEvolve. It’s not just a catchy slogan; he rewards employees for “outrageously excellent customer service” with WE (Whatever, whenever, Exceed expectations) awards. The WE Award comes with a cash bonus and a new title on the employee’s email signature. As a result, employees strive to achieve the distinction of a “Four-time Recipient of the MedEvolve WE Award.”

“In the software business, that means several operators are at the ready for periods of peak call volume,” he said. “We maintain support-to-client ratios above the industry norm. We design our software to be intuitive with online help so that less support is necessary. In the RCM division, we work claims as much as necessary to ensure our providers are fully paid for the services they’ve performed. We’re not some detached, impersonal entity; we partner

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The 2009 American Recovery and Reinvestment Act (ARRA) authorized the Centers for Medicare & Medicaid Services (CMS) to award incentive payments to eligible professionals who demonstrated Meaningful Use of a certified electronic health record (EHR) system.

“With the new criteria defined, MedEvolve saw a need for a modern EHR product designed from the ground up to meet Meaningful Use mandates and finally de-

with the practice in achieving their goals.”

Today, MedEvolve offers PM and EMR software and RCM services to physician partners, and also electronic prescribing, data analytics and other ancillary products and services. With four offices, the company covers all specialties and the entire United States, from solo practitioners to practices with more than 50 physicians. Commitment to service has garnered MedEvolve a reputation of trust among physician partners, allowing the company to rise above the scores of small physician IT companies nationwide.

By year’s end, MedEvolve will outgrow its new corporate headquarters in downtown Little Rock, a refurbished red brick bakery built circa 1919, necessitating yet another expansion.

“We’re now in that sweet spot where we have the expertise and resources to meet our clients’ every need, and yet we remain nimble and able to move quickly in a rapidly changing healthcare environment,” he said. “We’re proud to be privately held so that we aren’t a slave to our stock price and quarterly reports, but rather free to do what’s right for our client. Our foremost concern remains the principles upon which the company was founded – elegant, user-friendly software and unparalleled customer service.”

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Mainstreaming Digital, continued from page 1 Dettmann opted for traditional ad agency work with a firm that asked her to establish the digital side of the business. That firm was one of the first agencies worldwide to create a banner ad campaign; Anheuser-Busch was the client.

“We both have essential real experience in the field,” said Dettmann.

“We both came into the digital marketing industry JoAnna when it was in its infancy.”

Dettmann Dettmann and Kalkofen co-founded tSunela, a St. Louis-based digital marketing firm that specializes in search engine optimization (SEO), mobile search marketing, paid search marketing, local Kaysha search optimization, web Kalkofen analytics, and social media marketing. The company name is a nod to Dettmann’s favorite number and Kalkofen’s heritage. Pronounced with a silent “t,” tSunela is Cherokee for the number eight.

The firm also has an office in Portland, OR. “Digital marketing is a prescription for today’s marketplace,” said Dettmann.

“In 2011, roughly $1 in $4 of marketing budgets was allocated to digital marketing channels, as the shift to online marketing has been a natural progression that has fol-

Digital Marketing Tips: • Don’t ignore data. You’ll deliver the best possible user experience and be able to make the case for higher marketing budgets only if you use data.

• Do integrate. Have your teams work together. If you use multiple marketing agencies, don’t be afraid to have them all in the same meetings. Your agencies should communicate with each other and work together so that all of your messaging is consistent. This also goes for IT. Keep your IT department in the loop when it comes to your online marketing activities. Introduce them to your digital marketing agency.

• Do act as a factual resource.

Make your web properties resources for your target audience so that you are always top of mind. Do not be afraid to offer information that is not selfpromoting.

• Do understand that it’s better to not do it at all than to do it poorly.

This tip is especially true for social media. If you don’t have the resources to keep up with daily or weekly posting to social media pages, don’t do it.

It’s better to not have a Twitter page at all than to have one that you haven’t posted to in more than six months.

• Do respond to online reviews— positive and negative. You’ll find reviews on numerous sites across the web – Google Local, Yelp, HealthGrades, and more. Monitor them and respond.

SOURCE: tSunela.

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lowed consumer behavior.”

According to Forrester Research, U.S. digital marketing expenditures will reach $76.6 billion by 2016. This subset of traditional marketing includes online marketing tactics and strategies such as social media and blog creation and content, online advertising, and organic and paid search engine optimization on a national, local, and mobile basis.

“SEO local is one of our most popular requests,” said Kalkofen.

Even though prices vary, Kalkofen said a local search optimization package may cost approximately $1,500 annually.

With it, clients receive reporting and optional (online to offline) call tracking data.

Digital marketing services for the healthcare industry also include: • SEO to increase visibility for their institution when certain medical and surgical specialties are researched online.

• Online support group creation via social media channels as a value-added service for patients.

• YouTube channels featuring videos of procedures to inform current and future patients, potential donors, and the community.

• Social media channels as a venue for wellness-related tips to the community.

• Comprehensive monitoring of social media channels as a way to observe negative feedback and respond to the patient directly, providing both a reputation management avenue and enhancing their customer service standards.

“One of the first things potential clients want to know is the ROI (return on investment) on digital marketing services,” said Dettmann, noting that tracking software provides detailed information, such as keywords used in a search, pages most visited, and the length of time a person views a page.

Even though most industry leaders are well-versed on digital marketing, there’s a learning curve for non-traditional users.

“Younger doctors who come into hospitals and large healthcare systems and go proactively into the marketing department are driving much of the change,” said Kalkofen. “More established doctors aren’t necessarily proactive, but they’ll Google themselves and not see many results. Then they’ll go to the marketing department and ask why there’s not a broader internet presence. They’re falling into digital.”

So how have both ladies involved their healthcare industry partners so deeply in digital marketing efforts?

“Very small steps,” said Kalkofen. “A few years ago, many healthcare clients were hesitant to get into social media marketing because of HIPAA privacy regulations and concern about not being able to control incoming content. But they noticed the growing importance of social media and wanted a presence. We might start with a Facebook page or set up a doctor’s blog. Now, we have clients with a strong social media presence who benefit from us streamlining all of it and providing important data that allows readers to drive the content.”

With healthcare clients, videos and images are very important to consumers.

“Perhaps they’re trying to self-diagnose by comparing a picture of something on their arm with an image onscreen, or they want to see the surgeon who is going to operate on them in action via video,” she said. “We help clients get a lot of YouTube videos and visual images online.”

Marketing practices are rapidly changing internally to gain a digital presence.

“For example, traditional mailers are still being sent out, but that information is also being copied online,” she said. “QR codes are being added to print advertising

for consumers to scan into their smartphones. Also, we include a lot of URLs of articles online to push readers to view them for more information.”

Digital marketing continues to evolve at an accelerated pace, with early online tactics almost obsolete.

“Today, pop-ups are a big no-no,” said Dettmann. “It’s important for healthcare companies that haven’t yet made the leap to digital marketing to work with experts who do this daily and can advise them appropriately on a winning strategy.”

Nine Red Flags for Digital Marketing Firm Candidates: What should you look out for when choosing a SEO firm? A few things should raise red flags when choosing a firm. If you hear them, run!

1. The Keyword Confusion Red Flag. If you choose an SEO company that asks for your keywords, stop and turn around. Figuring out what your keywords are is their job, not yours. As a SEO company, they should be handling this and giving you a list of words to review. Additionally, the SEO company should have spoken to you in-depth about the mission of your company and also the product/service and message—and this should be conveyed in the keywords they provide.

2. The “We’re Web Programmers who also do SEO” Red Flag: This should catch your attention and turn on the warning light because SEO is not an IT function; it’s completely and absolutely a marketing function. Would you give an IT person the power to design your next marketing campaign? No, and you shouldn’t give them the power to SEO your website either. It just doesn’t make sense. While they can handle the SEO basics, IT programmers aren’t marketing professionals and SEO is a very different skill set from what they’re used to doing.

3. The Minimum Red Flag: “You just need to optimize a few pages.”If you hear this, you should probably find a new firm. Sure, maybe your terms and conditions page doesn’t necessarily have to rank in search engine results, but your title tags and descriptions should still be in place, simply because every page should be treated equally. In other words, every page should be treated as a homepage. What happens if you have a 5,000-page site? Truthfully, you might only want to focus on 500 pages.

However, if you have a smaller site, your firm should definitely be recommending that you optimize the entire site to get the best results.

4. The No References Red Flag: Like any new employee you hire, you should check for references. If your SEO firm cannot or will not give you references, chances are something is off. They may be trying to hide nonexistent or weak experience. You should get a portfolio of proven results and take note of the clients who stand behind their services.

5. The Guarantee Red Flag: “We guarantee it!” Sometimes an SEO firm will guarantee that your website will have high search engine results or a higher number of leads. If you hear this, chances are they’re lying. The truth is, no SEO company owns Google or Yahoo!—only they can decide if you get better results. No SEO company has complete control over Google or Yahoo!’s search engine algorithms. A good SEO firm knows what influences these algorithms and, while they can help you gain a significant ranking, they can’t guarantee a placement. If you hear “guarantee,” get out of there!

6. The Opaque Red Flag: The term, hidden practices, should tip you off. An SEO company should update you regularly about your progress and rankings. If you’re not being educated through these reports from your SEO firm, this is a bad sign. You should be working with your SEO company and the methods they use should be transparent. You should have complete understanding about what you’re paying for. It’s a good idea to set up status calls or check-in meetings with the firm you’re working with—be sure to ask plenty of questions about their methods and processes.

7. The “Get ‘er Done” Red Flag: Firms who say that SEO is a “one-time thing” and that your site is good to go once they’ve finished calibrating it have just ruined their credibility. While the start-up process (just the basics) can be a one-time thing, getting continual results requires long-term maintenance. Search engine algorithms change, and you don’t want your competitors changing their SEO practices while yours stay the same! A website is organic and should be adaptable to changes as your business changes and grows.

8. The Ultimatum Red Flag: An SEO firm should never give you an ultimatum; that means they have another agenda in mind. It’s not necessary to have a blog or a Facebook, Twitter, LinkedIn, or any other social networking profile. You don’t “have to have” anything. It’s also not necessary to be linked within certain pages to enhance search engine rankings. Don’t be forced into buying links. The SEO process does everything that it needs to do if done correctly—it focuses on your site, its brand, and the ranking amongst other sites. External factors aren’t requirements—they’re options and nothing else.

9. Non-transparent Pricing Flag. Pricing should be transparent. A set-up fee, followed by a monthly fee for ongoing maintenance, is a fair and honest pricing arrangement. Be sure to talk candidly about costs and pricing options with your SEO firm before accepting their services.

SOURCE: tSunela.

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Fear Not portability of their data to avoid lock-in or potential loss if the Cloud provider fails.

Is the Cloud a perfect situation for your practice? It may be closer to a perfect situation then what might be happening at your office right now.

Why?

By THOMAS VAN CLEAVE

ST. LOUIS—Simply thinking about putting critical business information in the Cloud may give some practice managers a scary feeling. With some of the news reports lately about security breaches, this is no surprise.

The word “Cloud” to most decision makers conjures up thoughts of some mystical beast that should be feared.

To this, I say, “not so fast”!

Let’s peel back the onion in non-technical terms.

Ensuring your practice can enjoy the many advantages of the Cloud requires two strategically important security measures: 1. Lock down information while in motion 2. Lock down information while being housed If these two measures are addressed properly, the Cloud can be a very pleasant and surprisingly fun experience that quickly becomes a business asset!

Locking down your information in motion and locking down your information being housed sounds simple…right?

Well….with the right tools and knowledgeable personnel, it is simple. Please take note, I said simple, I did not say easy, it takes a lot of skill and understanding to lock down information and keep it locked down…period. The simple part is the understanding that it can be done and is being done.

Of course, just like in any industry, good players and not so good players exist.

There are eight key components to look for when choosing a Cloud provider that has the ability to lock down information while it is in motion and locks down information while it is being housed.

1. Access privileges - Cloud service providers should be able to demonstrate they enforce adequate hiring, oversight and access controls to enforce administrative delegation.

2. Regulatory compliance – Your practice is accountable for your own data even when it’s in the cloud, you should ensure the Cloud provider is ready and willing to undergo audits.

3. Data provenance - When selecting a provider, ask where their datacenters are located (onshore only datacenters are appealing to the health industry), and if they can commit to specific privacy requirements.

4. Data segregation – Currently, most organizations (that use the cloud today) use clouds that are shared environments, and it is critical to make sure Cloud providers can guarantee complete data segregation for secure multi-tenancy.

5. Data recovery – Your practice must make sure the Cloud provider has the ability to do a complete restoration in the event of a disaster.

6. Monitoring and reporting stlouismedicalnews

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- Monitoring and logging cloud activity is hard to do, so practice managers should ask for proof that the Cloud provider can support investigations.

7. Network – Your practice needs a secure web connection to your critical information. The Cloud provider should own their own network (fiber optic) that enables your practice to have one secure “hop” to your data…think of this like the game you may have played as a kid, take 2 empty cans and one piece of string and tie each can at opposite ends of the string.

If the Cloud provider does not own their own network, the web connection is not as secure 8. Business continuity - Businesses come and go, and practice managers should ask hard questions about the

• Economics: How much does your practice spend on hardware? There is market research on how much a practice manager spends, but this article is about your practice, not research. So, go back in your books and add up the cost. Take this cost and wipe it from your books. The Cloud eliminates the need to spend money purchasing and maintaining most of the hardware you currently have at your practice.

How much does your practice spend on I.T. support to maintain the hardware?

Add this cost up and wipe it from your books.

Rather than having to account for software and hardware as a capital expense, and then having to depreciate those expenses over time, with the Cloud, those expenses are considered operational and can be deducted every year, rather than over several years.

• Compliance: Does your practice undergo audits to ensure business data compliance? As described earlier, a Cloud provider should take most of this burden off your practice by allowing audits and providing the results.

• Back up: How do you currently back up information? Do you use tapes or external hard drives? Where are those tapes and hard drives kept? In a vault? Someone’s house? (yikes). Forget about all this, the Cloud allows you to back up information without manual intervention and eliminates the greater risk associated with information that is manually taken off premise.

How often do you back up? Is this a manual process? No need to manually do this anymore, the Cloud allows for dynamic back up on a scheduled basis.

These are just a few examples, there are many more, including, gaining efficiencies and not falling behind the technology curve.

Hmmmm…..the Cloud is not so scary now, is it?

Tom Van Cleave is Vice President of Business Development with Cloud10 Global. His passion is educating business on how the Cloud strengthens business, increases security, improves cash flow, creates efficiency, offers access to current and future software as a service application(s), and provides a quick return on investment. His “Cloud and Coffee” discussions are popular, if you are interested in discussing the Cloud over a cup of coffee with Tom, he can be reached at tvancleave@cloud10global.com.

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Miles Against Melanoma, continued from page 1 get the race started at Legacy Park. I knew at that point, I had to go through with it to see if it was something I could grow.”

The inaugural 6.2K (3.8 miles) race – the distance determined by a death from melanoma every 62 seconds – was held at Legacy Park in Cottleville on May 14, 2011. The event drew 600 runners, two dozen sponsors, and raised $22,000.

“When more people contacted me with very sad stories of very young people who had suffered or passed away from this cancer, I knew,” said Martin, 35, of St. Peters. “I knew it was special when they thanked me for having an event where they could celebrate a life.”

To promote melanoma awareness, Martin pointed out that “so many people think (melanoma) is just a mole. It’s so much more than that! It can be a life sentence.”

Coincidentally, a lady named Pepsi from Washington, DC, contacted Martin via Facebook, challenging her to grow the race nationwide.

“So I did,” said Martin. “I became a cheerleader in a sense, giving people the encouragement.”

Kansas City jumped on board.

“Stephanie Liebengood was Mrs. Kansas 2010 and a basal cell carcinoma survivor,” she said. “I just keep praying I continue with the strength and wisdom to do this and someday my kids can take over for me! I love that one of my daughter’s first real topics of understanding was melanoma!”

The second race, changed to 5K, drew 1,077 participants, more sponsors, and raised more than $25,000.

In less than three years, the national 501(c) (3 ) non-profit organization has expanded to 14 cities.

In the St. Louis area, the third annual Miles 5K event will take place Saturday, June 8 in Chesterfield. More than 2,000 participants are anticipated at the local 2013 race. An important change this year: the race will start at 7:30 a.m. instead of the traditional 6 p.m. start time. Best Buy

Before

In the St. Louis area, the third annual Miles Against Melanoma 5K event will take place Saturday, June 8 in Chesterfield. More than 2,000 participants are anticipated at the local 2013 race. An important change this year: the race will start at 7:30 a.m. instead of the traditional 6 p.m. start time. Best Buy Mobile, Express Scripts, Gold’s Gym, Jordan Essentials, Saint Louis Physical Therapy, St. Charles Dermatology, and The Gap are among the sponsors.

Nationally known live bands, The Madison Letter and Acoustic Edge, will provide entertainment.

Mobile, Express Scripts, Gold’s Gym, Jordan Essentials, Saint Louis Physical Therapy, St. Charles Dermatology, and The Gap are among the sponsors. Nationally known live bands, The Madison Letter and Acoustic Edge, will provide entertainment.

“Miles is growing exponentially and without the help of committed volunteers, not just interested, but truly passionate, we wouldn’t prosper,” she said. “I just hope we continue to grow and develop and ultimately change the mindset of Americans.”

Along with providing financial assistance to families of late-stage or deceased melanoma patients, funds are given to The Foundation for Barnes-Jewish Hospital for melanoma research at the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine.

“Can you believe,” queried Martin, “melanoma is the most underfunded type of cancer there is?”

This year, Miles will host a lotus flower release in the pond behind the amphitheater to memorialize “our angels

After

and survivors,” said Martin, noting that among the families Miles has helped is that of Chris Weber, a 36-year-old who lost his life to melanoma on Aug. 15, 2011.

“Seven months earlier, Chris went to his dermatologist to check a mole that had begun to change,” recalled Martin of the rapid disease progression. “Two days later, he was told that the mole was melanoma. Chris had surgery on January 27 to remove the mole and affected lymph nodes … (and) learned that his cancer was (late stage) melanoma. During the months of February and March, Chris underwent four hard weeks of daily Interferon treatment to knock out all signs of cancer. Unfortunately, a PET scan on June 9 showed the cancer had spread into his bones. In July, a CT scan showed (it) had spread to his stomach, liver and between his lungs, and a tumor was growing again in the lymph node area that had been treated. Chris began radiation to help shrink the tumor in his lower back, which had been causing severe pain, along with the newly-growing tumor in his lymph node area.”

Weber, who had worked for a drywall supply company for nearly 17 years, left behind three children under the age of seven.

“We’re trying to help their family with burdensome medical bills that still exist,” said Martin.

Martin also focuses on sun safety, noting that only one in four children is protected by sunscreen on a regular basis. Her colleague, Deanda Cronin, established the Miles Against Melanoma Kids Marathon, in which children ages 5-12 cover 26.2 miles over a period of several months by walking, running, jogging or using a wheelchair in one mile increments. They complete the final 1.2 miles at the main event.

“Like all moms, I strive to protect my (two young) boys, including protecting them from the dangers of the sun,” said Cronin. “As a nurse, I frequently see families affected by melanoma. I never want

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my children to go through the trials these families have had to endure. It only takes one bad sunburn as a child to double your risk of developing melanoma later in life.

My hope is that if we protect our children while they’re small, we’ll instill in them the importance of applying sunscreen, wearing protective clothing, and avoiding tanning beds.”

The Research Component Exposure to ultraviolet light from tanning beds makes users 75 percent more likely to develop melanoma than nonusers, according to a study led by dermatologists at Washington University School of Medicine and Dr. Lynn the Siteman Cancer Cornelius Center.

A survey of tanning salon operators in Missouri, part of the study, shows that 65 percent would allow children as young as 10 years old to tan, despite evidence that tanning bed use increases the risk of all skin cancers, including melanoma, later in life.

(Missouri is one of 17 states with no minimum age restrictions on tanning bed use and doesn’t require parental consent.) The study also found many tanning salon employees across the state said indoor tanning had no associated risks.

“This should serve as a wakeup call for parents in Missouri and other states that don’t regulate tanning beds,” said study coauthor Lynn Cornelius, MD, chief of the Division of Dermatology and the Winfred A. and Emma R. Showman Professor in Dermatology at Washington University. “With the absence of logical age restrictions, we’re failing to protect our children, who are at an increased risk of developing skin cancer when exposed to the high-intensity levels of ultraviolet light that can be received in a tanning bed.”

Cornelius and her colleagues at Siteman and Washington University routinely see young, typically female, melanoma patients who report previous tanning bed use.

“Indoor tanning may seem innocuous at first,” she said. “Due to what’s called ‘tumor lag time,’ or the time between an exposure to a carcinogen such as ultraviolet and the development of a cancer, it may take a decade or longer for someone who has been exposed to artificial ultraviolet radiation from tanning beds to develop a skin cancer.”

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theEstatePlanner

BY STEVEN M. LAIDERMAN

Avoiding Disaster How to not leave it to someone else to mess up your estate plan Let me introduce you to my client; we’ll call her Joanna.

Like many clients, she’s a professional and very knowledgeable about her work.

She might even have her own estate plan.

Unfortunately, like many clients, she’s the unsuspecting participant of another person’s failure to plan.

Joanna and her brother, who we’ll call Jim, owned a family farm together. Jim died almost a year ago. Sadly, when Jim and Joanna acquired the real property, they titled it simply as “Jim and Joanna.” In many states, if they had been husband and wife, upon death the property would pass to the spouse. Because they aren’t, the ownership is considered “tenants in common.” This simply means each one owns one-half.

Joanna came to me wanting to acquire Jim’s share of the family farm. She knew he owned one-half, and had already negotiated a price with Jim’s second wife, who we’ll call Haley. Sounds simple, right?

Generally, if you die and own property in your own name, and there’s no named beneficiary for that property, the property will need to go through probate. Probate is the court process of transferring property to heirs. If you have a will, it simply indicates to whom the property will pass after it goes through probate.

Unfortunately for Joanna, Jim died without a will, or he might as well have because it could not be located. If Haley had located Jim’s will, the court would first determine if it was his last will and testament.

Missouri has the added requirement the will must be approved by the court within one year of Jim’s death. Even though family believed Jim had a will, it could not be located and admitted within the time limit.

Whether Jim had a will that wasn’t admitted, or he died without one, the property passes to heirs as determined by state law.

This is referred to as “by intestacy.” Essentially, the law says the property will pass only in part to the surviving spouse, and the balance to his children. As it turns out, Jim had children from a prior marriage, who as luck would have it, didn’t have a great relationship with Jim’s newer wife.

This situation created quite the dilemma.

Joanna already negotiated a purchase price from Haley for all of her interest, but Haley didn’t inherit all of Jim’s one-half. In Missouri, she would only inherit one-half of his one-half. This real property was located in another state, where the surviving spouse inherits a smaller portion. So Joanna was forced to negotiate with Jim’s children for a larger portion than Haley inherited as well.

Fortunately, there’s a simple process for transferring the real property, assuming everyone agrees on the sale to Joanna.

It’s called an Affidavit as to Heirship. This document sets forth the facts related to the ownership of the property and is recorded along with other real property records in the county in which the property is located. And if all of the heirs agree, they can then sign a deed to sell their share of the property to stlouismedicalnews

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Joanna.

If any one of the heirs objects, their share of the property cannot be transferred to Joanna. Further, any rent from the operation of the farm would need to be split proportionately among the heirs that do not transfer their interest to Joanna and Joanna.

Without an agreement as to how decisions are made, such as a partnership agreement, no one has the legal authority to bind the others to decisions affecting the farm, such as who to lease to and for how much.

In Missouri, we have an added complication; that even if the real property is titled in your name alone, you cannot transfer it, or pledge it as collateral for a loan, without the written consent of a spouse. So in Missouri, each spouse of an heir would need to agree to transfer the heir’s share of the real property to Joanna.

Because the real property is located in another state that does not require probate to begin within one year after death, if the heirs don’t agree to the transfer by Affidavit, the real property can be probated in that other state without the will. The executor could sell Jim’s one-half to Joanna, and eventually the proceeds would pass to Jim’s heirs as determined by that state’s law where the real property is located.

So, how could this have been avoided?

Jim and Joanna could have owned the real property as joint tenants with rights of survivorship. The survivor would automatically inherit the property upon the death of the joint owner. If Jim wanted the real property to pass to his wife, he could have left it to her in his will, and made sure someone could locate it. However, the real property would first pass through probate, which can be expensive and time consuming. But then the executor alone could sell his one-half to Joanna, and the proceeds pass to his wife or other heirs as he determines.

In some states, Jim could’ve had his one-half pass to Haley by the use of a life estate or beneficiary deed that transfers ownership upon his death. The best option would have been to create a trust and transfer his one-half of the real property to the trust before he died. With a trust, the transfer from Haley to Joanna could have already been completed without involvement of courts and other heirs.

By the way, did I tell you that Joanna and Jim previously went through a similar situation when they inherited the real property from a grandparent and were forced to buy out another sibling? They didn’t learn their lesson: to be sure all co-owners of real property have an estate plan.

Steven M. Laiderman, principal of The Laiderman Law Firm PC, an estate planning, probate, and business law firm based in St. Louis, has extensive experience in estate planning. His business practice focus also extends to business tax planning, entity creation, succession planning, and the negotiation of business sales and acquisitions. He also represents clients in the negotiation of real estate leases, sales and acquisitions. A frequent speaker, he also serves as an adjunct professor at the Washington University School of Law, teaching estate planning and family wealth management classes. He may be reached at Steve@ LaidermanLaw.com.

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Unconventional Wisdom Rethinking the approach to some autoimmune disorders

By CINDY SANDERS

What if the standard treatment approach was the wrong one? In the case of several autoimmune disorders, it’s a theory that is gaining traction bolstered by recent research findings.

Stephen A. Paget, MD, FACP, FACR, MACR, physician-in-chief emeritus at the Hospital for Special Surgery in New York City, has spent his career researching and treating a range of inflammatory and autoimmune A. disorders. The rheu- Dr. Stephen Paget matologist, who is also a professor of Medicine and Rheumatic Disease at the Weill Medical College of Cornell University, said the potential exists for a paradigm shift in how clinicians view and treat some disorders including reactive arthritis, Whipple’s disease and persistent Lyme disease.

Paget said the accepted concept has been “that in a genetically predisposed person, with some type of environmental trigger … probably virus or bacteria … they develop disease.” Although the initiation was from a microorganism, he continued, the conventional wisdom has been that the self-perpetuation of symptoms is due to the body’s subsequent response.

“What you were left with was an inflammatory problem that was no longer tied to the previous organism,” Paget explained.

A good example would be persistent Lyme disease. The infectious trigger is the Borrelia burdorferi, a bacterial species of the spirochete class, which is transmitted to humans through a tick bite. Skin rash in a bull’s-eye pattern (erythema migrans), fever, fatigue, chills and headaches are among early symptoms. Later symptoms could involve the joints, heart or central nervous system. For most, a prescribed course of oral or intravenous antibiotics takes care of the infection and symptoms.

However, in some patients, synovial inflammation persists even after the bacteria have been nearly or totally eradicated.

This has given rise to the belief that in predisposed patients, the initial Lyme disease triggers an ongoing autoimmune disorder.

In his 2012 paper, “The Microbiome, Autoimmunity and Arthritis: Cause and Effect: An Historical Perspective,” which was published in Transactions of the American Clinical and Climatological Association, Paget noted that for more than 100 years, there has been “tantalizing but often inconclusive evidence” about the role of microorganisms in autoimmune diseases. He wrote, “Current therapy focuses on the pathogenesis rather than the etiology of these disorders. In order 10

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to rein in the overactive immune system we believe to be causing the disease, we employ immunosuppressive drugs, an act that would be counterintuitive if infection were the root cause of the problem.”

A small but intriguing study out of the Division of Rheumatology at the University of South Florida College of Medicine published in the journal Arthritis Rheum in May 2010, found a six-month combination antibiotic regimen was effective in treating patients with the autoimmune condition Chlamydia-induced reactive arthritis. In the nine-month, prospective, double-blind, triple-placebo trial, researchers assessed a six-month course of combination antibiotics with a primary end point of the number of patients who improved by 20 percent or more in at least four of six variables without worsening in any variable.

At month six, the authors found significantly more patients in the active treatment group became negative for C trachomatis or C pneumonia. The primary end point was achieved in 63 percent of patients in the active arm of the trial, with 22 percent of those patients believing their disease had gone into complete remission. No patient in the placebo group achieved remission.

Pointing to this study, Paget noted that one of the failures of antibiotic regimens in the past in treating autoimmune disorders might be the duration of the therapy. “If you give long courses of antibodies, you may very well calm the problem down,” he said. However, he noted, physicians currently switch to steroids, T-cell inhibitors, and other immunosuppressive drugs to ameliorate the ongoing inflammatory issue after treating the triggering microorganism with antibiotics or antivirals for a relatively short course, “It may very well be we have to improve the immune system response instead of suppress it, and that’s the interesting twist,” Paget continued. If the root cause of an autoimmune condition is infection, “You’d want the army active,” he said of augmenting the immune system.

While much more research must be done, Paget said mounting evidence of the important connection between microorganisms and a number of autoimmune disorders provides ‘food for thought’ when it comes to the best course of action for treating these conditions and could ultimately portend a paradigm shift in the delivery of care.

“In some of these, the organism is slow, smoldering … but still there in a low-grade way that is triggering the inflammatory response. We have to be appreciative of the fact that we want to do the best thing for our patients … but what we’re doing (now) may be the worst thing,” he concluded. stlouismedicalnews

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Staving Off Mental Illness

UNC researchers discover mysterious links in two brain studies

By LYNNE JETER

CHAPEL HILL, NC— In a study to identify functional changes that may occur in the brains of adolescents at high risk of developing schizophrenia, Aysenil Belger, PhD, discovered that brain scans of those whose parents or siblings have schizophrenia reveal neural circuitry that is stressed by tasks their peers with no family history of the illness seem to manage with ease.

Belger, associate professor of psychiatry at the University of North Carolina (UNC) School of Medicine, performed functional magnetic resonance imaging (fMRI) on 42 children ages 9 to 18. Half of the study subjects had relatives with schizophrenia; the other half didn’t.

Because there’s no way of knowing for certain who will become schizophrenic until symptoms arise and a diagnosis is reached, Belger became acutely interested in studying individuals who have a first-degree family member with schizophrenia, and therefore have an 8- to 12-fold increased risk of developing the disease.

Study participants each spent an hour and a half playing a game in which they had to identify a specific image – a simple circle – from a lineup of emotionally evocative images, such as cute or scary animals. At the same time, the MRI machine scanned for changes in brain activity associated with each target detection task.

Belger found the circuitry involved in emotion and higher order decision making was hyperactivated in children with a family history of schizophrenia, suggesting the task was stressing out these areas of the brain.

“This finding shows these regions aren’t activating normally,” she said. “This hyperactivation eventually damages these specific areas in the brain to the point that they become hypoactivated in patients, meaning that when the brain is asked to go into high gear, it no longer can.”

Because these differences in brain functioning surface before neuropsychiatric symptoms – trouble focusing, paranoid beliefs, or hallucinations – scientists believe the finding could point to early warning signs or “vulnerability markers” for schizophrenia.

“The downside is saying that anyone with a first-degree relative with schizophrenia is doomed,” said Belger. “Instead, we want to use our findings to identify those individuals with differences in brain function that indicate they’re particularly vulnerable, so we can intervene to minimize that risk.”

The UNC study, published online March 6 in Psychiatry Research: Neuroimaging, is among the first to look for alterations in brain activity associated with mental illness in individuals as young as nine years of age.

“It may be as simple as understanding that people are different in how they stlouismedicalnews

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cope with stress,” said Belger. “Teaching strategies to handle stress could make these individuals less vulnerable to not just schizophrenia, but also to other neuropsychiatric disorders.”

The National Institute of Mental Health and the National Institute of Child Health and Human Development funded the research, which included co-authors Sarah Hart, PhD, postdoctoral fellow; Joshua Bizzell, MS, lab engineer; Carolyn Bellion, study coordinator; and Diana Perkins, MD, MPH, professor of psychiatry.

Potential New Mental Health Therapies

In a second UNC study, new research explains for the first time exactly how two brain regions interact to promote emotionallymotivated behaviors associated with anxiety and reward. The findings could lead to new mental health therapies for disorders such as addiction, anxiety, and depression. Nature published a report of the research online March 20.

“For many years, it’s been known that dopamine neurons in the VTA (ventral tegmental area) are involved in reward processing and motivation,” said senior author Garret Stuber, PhD, assistant professor in the departments of Psychiatry and Cell Biology and

Physiology, and the UNC Neuroscience Center. “For example, they’re activated during exposure to drugs of abuse and naturally rewarding experiences. On the one hand, you have this area of the brain – the BNST – that’s associated with aversion and anxiety, but it’s in direct communication with a brain reward center. We wanted to figure out exactly how these two brain regions interact to promote different types of behavioral responses related to anxiety and reward.”

Previously, researchers have tried to glimpse the inner workings of the brain using electrical stimulation or drugs, but those techniques couldn’t quickly and specifically change only one type of cell or connection. However, optogenetics, a technique that emerged about seven years ago, can.

In the technique, scientists transfer light-sensitive proteins, opsins – derived from algae or bacteria that need light to grow – into the mammalian brain cells they want to study.

Next, they shine laser beams onto the genetically manipulated brain cells, either exciting or blocking their activity with millisecond precision.

Initially, Stuber and colleagues used optogenetics for “photo-tagging,” to optically identify different types of neurons in vivo. This enabled them to identify a neuron in the BNST that’s projecting into the VTA. “So we know the neuron is directly interfacing with a reward-related brain region,” Stuber noted.

They also exposed mice to a mild aversive stimulus, a carefully controlled but anxietyprovoking foot shock delivered repeatedly and unpredictably. The BNST neurons projecting into the VTA showed changes in their firing rate, “but some cells would increase their activity and others would sup-

press their firing,” said Stuber, adding the results suggested functionally distinct populations of neurons within the BNST that are projecting to the VTA, therefore highlighting the complexity of this neural circuit.

Stuber and his team repeated the experiment, but this time optically identified BNST neurons that project to the VTA as either excitatory or inhibitory cells by integrating the approach they developed with the use of transgenic animals that allows for precise targeting of distinct neuronal cell types. The excitatory neurons were the cell population that increased their activity in response to the foot shocks; the GABAergic cells showed activity suppression during foot shock.

Finally, researchers found that stimulating either brain cell pathway had opposing behavioral consequences. The glutamate neurons provoked an aversive, avoidance behavioral response and promoted anxiety-like behavior in the mice. In contrast, when Stuber’s team activated the GABAergic pathway projections from the BNST into the VTA, the animals showed reward-associated behaviors and less anxiety. They preferred that stimulation and would spend more time in the area of the cage where they had received it.

“When we exposed them to foot shock and at the same time activated this GABAergic pathway, it actually reduced the anxietyassociated behavioral consequences of that otherwise ‘aversive’ stimulation,” Stuber explained. “Because these cells are functionally and genetically distinct from each other, our findings also point to new potential targets for therapeutic interventions in neuropsychiatric disorders associated with alterations in motivated states such as addiction.”

The National Institutes of Health, Whitehall Foundation, and Foundation of Hope funded the research, which includes study co-authors Joshua Jennings, Dennis Sparta, Alice Stamatakis, Randall Ung, Kristen Pleil and Thomas Kash.

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The Move from Social Media Marketing to Social Business Strategies

By CINDY SANDERS

Earlier this year, Andrew Dixon, senior vice president of marketing and operations with Igloo Software and the former chief marketing officer for Microsoft Canada, was invited to Dallas to share insights on how healthcare organizations can make the move from social media marketing to an integrated social business strategy during the CIO Healthcare Summit.

At the core of a social business strategy is the desire to deepen connections, engagement and collaboration within various communities touched by the company or industry. For healthcare providers, those communities might be other practitioners, researchers, payers, staff, and … of course … pa- Andrew Dixon tients.

“Social business is no longer just for early adopters,” said Dixon. “It really is a modern way to help connect members together.”

One of the first steps, however, is to understand the difference in social media and social business. “Social media is about analyzing how your brand is being received in the marketplace,” Dixon explained. “Social business is modern communications brought into the business for

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the purpose of end-user productivity, collaboration and engagement.”

He continued, “The most popular tool being used today to do that is email, but email was never intended to be a collaborative tool.”

In a typical scenario, he continued, one person would email an attached document to 10 people for comments and input, which leads to 10 different documents with notes that might be conflicting to compile into one master file … which is then sent back out for further review.

Ultimately, businesses need to connect three key elements together — processes, information and people. Dixon noted that while large investments have been made in processes, the chief tools of email and a word processor have been fairly stagnant for the last 20 years.

To address this issue, social business software designers have taken a cue from technologies like Facebook and Twitter, which started in the consumer realm.

Dixon said the beauty of these tools is that they are lightweight, easy to navigate, simple and very effective in keeping individuals connected to their social network, which is a sophisticated online community.

The concept of online communities, he continued, isn’t new to healthcare.

“Even back in the 1990s, people would have early dos-based discussion boards.

Around 2000 … 2002 … we started to see the emergence of heath information repositories like WebMD. For consumers, it was the first time they could easily get information outside of a doctor’s visit,” Dixon said. He added that by mid-2005, those repositories had become more like communities where people with a similar interest could connect with each other.

“Fast forward to where we are today, and what we really have are health networks. They really are communities, but they’ve introduced much richer communication and collaboration tools,” Dixon continued. He noted tools like microblogging, wikis and forums open the path to allow discussion around content within a community setting. “The reason social business tools are so popular is not only do they work they way you do, but you can choose the one that’s most appropriate for the task at hand,” he added.

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Dixon said the ability to engage and connect in a community setting is one of the most powerful aspects of a social business model. Today, patients with similar ailments can tap into a network to share experiences, information and support.

That said, he added the communities could be built with parameters to allow providers to monitor and moderate discussions.

“It’s open communication, but at the same time, you introduce controls,” he ex-

plained. Although it does take some time to manage, Dixon added, “The scale and the reach you get with an online community far exceeds what you could ever get from an in-person visit.” That element also allows physicians to disseminate messages about wellness and disease management to large, targeted populations, which will be increasingly important in new accountable care delivery models.

For physicians, the community setting lets providers who might not be geographically connected engage each other.

One of Igloo’s clients is the American Academy of Family Physicians. The organization launched the Delta Exchange as a way for physicians from across the country to become more aligned. “They were able to coordinate all the different best practices and overall learning that various physicians had and bring each other along. It was a great way to be able to coordinate a geographically diverse set of practitioners,” Dixon said.

Similarly, community settings that encourage discussion and idea exchange could work equally well for other groups including researchers, mid-level providers and practice managers. Internally, an intranet community allows for easy communication and collaboration. Using the same types of business tools employed in external communities, staff members can easily review documents, communicate information broadly across geographic locations, vote on policy, and share ideas.

Security

“Security has to be built in as a core set of requirements in any social business tool,” said Dixon. “The technology

is there,” he continued. “It’s one of the central things you look at when deciding which social business tool provider makes sense.”

He added, “Any enterprise-class social business software firm can not only lock down the individual permissions but also has the ability to audit everything that has happened in that community.”

Avoiding Information Overload

Dixon said email is in danger of becoming less and less useful because of information overload. The same caveat also applies to information imparted through social business tools. “If you don’t implement properly, you risk making that problem worse,” he said.

However, social business tools can be offered in a very targeted manner through channels. Individuals choose which channels are of interest to them and subscribe.

Drilling down even further, there are generally options within the channel to refine what information the subscriber receives and how.

The Bottom Line

With accountable care organizations and patient-centered models, supporting patients and colleagues by providing timely, pertinent information in an easilyaccessible manner has become even more critical, Dixon pointed out. “That means you need to be able to collaborate and communicate internally and externally.

From a common sense perspective, those that do that best will attract the most patients and keep the most patients … those who don’t will find the opposite.”

Three Trends Driving Change Three trends are driving change in the workplace – social, mobile and cloud. People want to be connected; they want to be able to access their information on the move; and they want access on a variety of devices so information can no longer be stored in one physical space.

“It’s incredible how powerful each of these trends are alone, and they are all converging,” said Andrew Dixon of Igloo Software. “By the end of 2013, 20 percent of all U.S. businesses will possess no IT assets whatsoever,” he said, quoting recent statistics. “All of their IT requirements will be outsourced and provided to them by the cloud.”

Citing recent research from business and technology research firms McKinsey & Company and Gartner Inc., Dixon underscored just how pervasive these three trends are. “Seventy-two percent of all organizations have already adopted at least one social tool,” he said, adding, “Your phone will outpace your PC as the most popular device to access the Internet this year.”

Although healthcare is sometimes criticized for being slow to adopt business technology, Manhattan Research’s annual Taking the Pulse® study of U.S. physicians’ digital use revealed 85 percent of physicians in 2012 own or use a smartphone professionally (up from 30 percent in 2001). Between 2011 and 2012 the number of physicians who own a tablet nearly doubled from 35 percent to 62 percent.

Furthermore, half of the tablet-owning doctors have used their device at the point of care.

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Totally WiFi?

Why it might not be prudent to have allwireless networks in hospitals

By LyNNE JETER

When Greg Copen joined MedWest Carolinas Health Care System in Western North Carolina as an information technology (IT) project manager, one of his first tasks was to evaluate and repair system issues in a totally wireless medical office building in rural Sylva.

On the day of a new software system deployment, clerical staff couldn’t register patients or access information. The entire building lost connectivity.

“I scratched my head and thought, this doesn’t make a lot of sense. I called the vendor and said something’s not right,” said Copen, now CIO of the 5-county health system that serves 160,000 people with a medical staff of more than 230 physicians and 2,100 employees on three main campuses – Haywood, Harris, and Swain. Hay- Greg Copen wood Regional Medical Center, a not-for-profit public hospital established in 1927 as the state’s first county hospital and licensed for 189 beds, anchors the MedWest network.

Copen learned the wireless network was oversaturated with devices, a problem that would require additional network equipment and rewiring the entire facility.

“Even the printers were on wireless,” he said. “A network engineer had gone the all-wireless route and the retiring CIO was unaware of the new network topology. The network contractor had neglected to properly engineer the wireless implementation. There was no oversight.”

A vendor inspection confirmed his suspicions: slowness, dropped connections.

“All wireless devices were being routed through a small number of access points and the network infrastructure was not capable of handling the traffic,” he said.

Copen conducted a wireless survey to verify the system was robust and reliable enough to ensure no dead spots, and to meet the required speed and connectivity standards for a highly demanding medical grade network.

“We discussed the environment with the vendor, and the fact that the wireless cards on printers couldn’t talk at the security protocols recommended by HIPAA,” he said.

Even though many industry analysts advocate all-wireless networks, Copen disagrees.

“As a general rule, wireless is slower and more unstable than hard-wired because of radiofrequency interference,” he explained. “You’ll hear that encryption is very good and sophisticated for wireless networks, but there’s no unbreakable protocol. Hard-wiring computers and monistlouismedicalnews

.com

HELP PATIENTS QUIT. toring devices provide better speed and reliability. Gaining access to a secured wired network is more difficult than a wireless network.”

To solve the problem, Copen hardwired all printers, stationary work stations, and other devices that could be considered stationary, such as doctors’ personal computers and IP-based IV bedside pumps.

Laptops and mobile devices remained accessible to the wireless network.

Like most hospitals, Medwest offers free wireless access to their guests. “Sometimes, the guest network gets oversaturated because the default session expiration time is two hours,” he said. “Many people log on for 15 to 20 minutes and then log off, but the certification stays active for two hours. ‘Active connections’ stay in limbo and may create an issue. We could do a mass expunge and reauthorize access, but we know it’s frustrating to the guest user who’s in the middle of something when their connection is lost. Gratefully, guests rarely complain. They just set aside their laptop or iPad and try again a few minutes later. Somebody’s session has usually expired by then.”

A year later, Copen continues working on connectivity issues at the medical office building.

“Not that it takes so much time, but it takes funding,” he said. “If money wasn’t an object, it could’ve been fixed in a month or two. These days, funding – or lack of – is hitting all hospital systems. We have to prioritize all of the issues and resolve them as funds are allocated.”

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GrandRounds St. Louis’s Only LenSx for Cataract Surgery Allows Patients to ‘See Like Never Before’

People in St. Louis now have a new option for cataract surgery – the LenSx laser procedure. The LenSx is located in the Surgery Center on the campus of SSM St. Clare Health Center is the only one in St. Louis, and one of only about 100 in the United States.

Patients of Dr. Brent Davidson who have undergone cataract surgery using the LenSx laser machine are saying now that they are “seeing like they never have before.” As opposed to traditional cataract surgery, the LenSx procedure reduces the ultrasound energy needed to remove the cataract by using a cutting laser as opposed to making the cut by hand. This leads to perfect cuts every time, the elimination of human error and reduced post-op swelling, which allows patients to see clearer, faster with fewer complications.

The LenSx is currently FDA approved to treat cataracts and astigmatism, but there are numerous applications currently being investigated by the FDA, including aiding in corneal transplants, glaucoma and refractive surgery.

The LenSx procedure began to be offered to patients in February, and since its inception, Dr. Davidson has performed the procedure on more than 50 patients, all with exceptional results.

Cancer Care at AMH Taking Giant Leap

The Cancer Care Center at Alton Memorial Hospital will be reopening in May after a $4 million technology upgrade and building renovation.

AMH will be breaking the boundaries of cancer care and radiation oncology. A new TrueBeam linear accelerator from Varian Medical Systems and a Phillips Brilliance CT Big Bore simulator will be installed along with other renovations

to the entire building.

Stereotactic radiosurgery, more specifically stereotactic body radiotherapy (SBRT), is a newer form of radiation therapy treatment that will be offered at Alton Memorial Hospital, according to Dr. Joel Simmons, medical director of Radiation Oncology at the Cancer Care Center. It’s unlike surgery in the sense that it is non-invasive and Dr. Joel doesn’t come with the poSimmons tential acute surgical complications, such as blood loss, infection or a lengthy inpatient hospital stay.

By using proper immobilization techniques, image guidance and multiple radiation beams, higher doses of radiation therapy can be pinpointed to the tumor and acheive more accurate results than ever before. Significant decreases in the number of treatments needed can be achieved by the increased dose per treatment. Dr. Simmons does stress that SBRT is only for a certain subset of cancers.

SBRT is already the standard of care for certain cancers such as inoperable non-small cell lung cancer and is showing promise in other areas as clinical trials are conducted.

Dr. Simmons compared the TrueBeam to other machines that deliver stereotactic treatments.

The TrueBeam machine will be able to deliver comparable treatments to the Gamma Knife and Cyber Knife,said Simmons. Those machines are stereotactic specific, whereas TrueBeam offers more versatility with the ability for traditional longer treatments as well as the shortcourse stereotactic treatments.

The TrueBeam will also come with the ability to deliver arc therapy. This allows for shortened treatment times.

Alton Memorial Hospital has forged a partnership with Washington University which allows for all of the planning of the

radiation treatments to be performed by Washington University staff. This means that the same expertise in developing the treatment plans and maintaining quality assurance of the treatments (e.g. safety checks) are the same standards for

Special Techniques Can Save Heart Tissue in Breast Cancer Patients

When patients are diagnosed with breast cancer they are focused on treating the disease at hand. However, according to recent studies radiation therapy could pose a danger to heart tissue leading to increased risk of ischemic heart disease for those with a left-side breast cancer.

Doctors with Mercy Cancer Services are leading the way in the St. Louis area with heart-sparing left breast radiotherapy using specialized techniques such as deep-inspiration breath holds and prone patient positioning to move the heart out of the radiation fields.

Standard 3D-conformal radiation for left-sided breast cancer often includes a portion of the heart and coronary arteries in the fields, which may lead to an increased risk for cardiac disease in longterm survivors.

For the deep-inspiration breath hold technique, patients breathe through a mouthpiece connected to an Active Breathing Coordinator (ABC) unit, which continuously monitors lung volume. The operator closes a valve at a specified lung volume to produce a breath hold.

A deep breath creates increased separation between the chest wall and heart by moving the breast outward and the heart and diaphragm downward. Radiation is delivered during these repeated short breath holds. While a standard breast radiation treatment may take 10-15 minutes to deliver, radiation using deep breath holds can take 15-30 minutes depending on the duration of each breath hold.

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PUBLISHED BY: SouthComm, Inc. CHIEF EXECUTIVE OFFICER Chris Ferrell PUBLISHER Jackson Vahaly jvahaly@southcomm.com ASSOCIATE PUBLISHER Larry Henry lhenry@medicalnewsinc.com Ad Sales: 314.917.6107 NATIONAL EDITOR Pepper Jeter editor@medicalnewsinc.com LOCAL EDITOR Lynne Jeter lynne@medicalnewsinc.com CREATIVE DIRECTOR Susan Graham susan@medicalnewsinc.com 931.438.8771 GRAPHIC DESIGNERS Katy Barrett-Alley Amy Gomoljak Christie Passarello CONTRIBUTING WRITERS Lynne Jeter, Cindy Sanders, Lucy Schultze ACCOUNTANT Kim Stangenberg kstangenberg@southcomm.com CIRCULATION subscriptions@southcomm.com —— All editorial submissions and press releases should be emailed to: editor@medicalnewsinc.com —— Subscription requests or address changes should be mailed to: Medical News, Inc. 210 12th Ave S. • Suite 100 Nashville, TN 37203 615.244.7989 • (FAX) 615.244.8578 or e-mailed to: subscriptions@southcomm.com Subscriptions: One year $48 • Two years $78 SOUTHCOMM Chief Executive Officer Chris Ferrell Chief Financial Officer Patrick Min Chief Marketing Officer Susan Torregrossa Chief Technology Officer Matt Locke Business Manager Eric Norwood Director of Digital Sales & Marketing David Walker Controller Todd Patton Creative Director Heather Pierce Director of Content / Online Development Patrick Rains St. Louis Medical News is published monthly by Medical News, Inc., a wholly-owned subsidiary of SouthComm, Inc. ©2013 Medical News Communications.All rights reserved. Reproduction in whole or in part without written permission is prohibited. Medical News will assume no responsibilities for unsolicited materials.

All letters sent to Medical News will be considered Medical News property and therefore unconditionally assigned to Medical News for publication and copyright purposes.

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GrandRounds Shane H. Peng, MD, Named President of SSM Health Care – St. Louis Physicians’ Organization

Shane H. Peng, MD, has been appointed to the newly-created position of president for the SSM Health Care – St. Louis Physicians’ Organization.

His responsibilities will include working with physicians and staff on continued improvement in H. quality and safety, as well Dr. Shane Peng as growing the Physicians’ Organization through exceptional services. Dr. Peng will also work to strengthen patient, physician, and employee satisfaction.

Dr. Peng joins the SSM Health Care Physicians’ Organization from Sentara Healthcare in Norfolk, Virginia. He most recently served as the vice president/senior medical director of Sentara Medical Group (SMG), where he was responsible for the clinical operations of 650+ primary care and ambulatory specialty providers.

Dr. Peng implemented over 34 National Committee for Quality Assurance Level III accredited medical home models and steered physician alignment with the Sentara quality clinical network. He has been the chair of the Quality Leadership Council for the American Medical Group Association since 2011 and was also appointed by the Virginia Secretary of Health and Human Resources to serve on the Virginia Center of Health Innovation.

Derdeyn appointed chair of AHA Stroke Council

Colin P. Derdeyn, MD, professor of radiology, of neurological surgery and of neurology at Washington University School of Medicine in St. Louis, has been appointed vice-chair and chairelect of the Stroke Council of the American Heart Association/American Stroke Association.

Dr. Colin P. Derdeyn The Stroke Council is one of 16 scientific councils within the association. It develops better ways to identify, treat and prevent strokes; awards scholarships; publishes the journal Stroke and organizes and conducts the International Stroke Conference.

Derdeyn earned his bachelor’s degree from the University of Virginia in 1984 and his MD from the University of Virginia in 1988. He came to Washington University as a resident in 1990.

Derdeyn is principal investigator of the Specialized Program for Translational Research in Acute Stroke Center at the school and the hospital. The center, now in its fifth year, is funded with a $9 million grant from the National Institute of Neurological Disorders and Stroke.

Derdeyn has been a leader in multicenter clinical trials of stroke treatments.

He was an executive investigator in a study in 2011 that found surgical bypass of a blocked carotid artery was no more effective in reducing stroke risk than drug treatments. stlouismedicalnews

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Kui Yang, M.D. Joins Vigilant

Vigilant Anesthesia Care & Pain Management, LTD is pleased to announce the addition of Kui Yang, M.D. to the practice.

Dr. Yang earned his Master’s Degree of Science from Dalian Medical University, Beijing University, China and his medical degree from Dalian Dr. Kui Yang Medical University, Beijing University, China. Dr. Yang completed a

general surgery residency and an orthopedic surgery residency at First Affiliated Hospital of Dalian Medical University. He then completed his surgical internship at University of Southern California and his second surgical residency at St. Louis University. He completed his anesthesiology and pain management residencies at Washington University School of Medicine.

He completed two research fellowships in trauma at the Trauma Division, Department of Surgery, at University of

Southern California and in Molecular and Medical Pharmacology at UCLA. Dr. Yang’s addition to the practice will ensure greater accessibility and increased services to our patients. Dr. Yang has broad clinical interests which include chronic/complex pain syndromes utilizing interventional modalities and multidisciplinary pain management. His clinical interest is interventional pain management procedures.

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The conference will feature more than 25 individual seminars on multiple business topics needed by health care providers for success in these changing times. Seminars will be presented by individuals from the local business community who provide services and expertise for the health care community. These health care business specialists will offer attendees knowledge and insight into solutions for the challenges facing today’s health care practices.

Detailed seminar information and registration information will appear in the July issue of St. Louis Medical News and on the St. Louis Medical News web site at www.StLouisMedicalNews.com

Conference Committee Seminars will address business issues practitioners face on a daily basis as well as arm practitioners with the tools to solve future challenges. Companies and Institutions involved in creating seminars for the conference include: Washington University Physicians New York Life | Missouri Professional Mutual Numerof & Associates | St. Louis University Sandberg, Phoenix & Von Gontard Keystone – IT | MD Real Estate Advisors Brown, Smith & Wallace | Evans & Dixon Clifton, Larson, Allen | Fifth Third Bank

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