The Triangle Physician January 2010 by TTPLLC

JANUARY 2010

P R E M I E R E

I S S U E

Wake Radiology Musculoskeletal Imaging Tackling Sports Injuries with a Team Approach

Also in this Issue

The Second Leading Cause of Blindness Preventing the Recurrence of Neural Tube Defects

YOUR LOCAL CARDIOLOGY PROFESSIONALS IN JOHNSTON COUNTY DEDICATED TO QUALITY, SERVICE, AND INTEGRITY Add a pinch of spice,

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and you’ll get Robert.

Robert suffered from unexplained fainting spells. His physicians couldn’t figure out why. To find answers, they implanted a Reveal® Insertable Cardiac Monitor (ICM) to see if his spells were heart rhythm related.

(Actual size)

Benjamin G. Atkeson, MD, FACC

Matthew S. Forcina, MD

Christian N. Gring, MD, FACC

The Reveal ICM is a long-term heart monitor that may help you rule in or rule out an abnormal heart rhythm as the cause of unexplained fainting spells. In Robert’s case, they were, and now he has a pacemaker.

Matthew A. Hook, MD, FACC

Possible risks associated with the implant of a Reveal Insertable Cardiac Monitor include, but are not limited to, infection at the surgical site, device migration, erosion of the device through the skin and/or sensitivity to the device material. Results may not be typical for every patient.

For more information, visit www.fainting.com.

Diane E. Morris, ACNP

Ravish Sachar, MD, FACC

2 LOCATIONS TO SERVE OUR PATIENTS Smithfield Heart & Vascular Associates 910 Berkshire Road Smithfield, NC 27577 Phone: 919-989-7907 Fax: 919-989-3147

Wake Heart & Vascular Associates 2076 NC Hwy 42 West, Suite 100 Clayton, NC 27520 Phone: 919-359-0322 Fax: 919-359-0326

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Brief Statement Indications 9529 Reveal® XT and 9528 Reveal® DX Insertable Cardiac Monitors – The Reveal XT and Reveal DX Insertable Cardiac Monitors are implantable patient-activated and automatically activated monitoring systems that record subcutaneous ECG and are indicated in the following cases: • patients with clinical syndromes or situations at increased risk of cardiac arrhythmias; • patients who experience transient symptoms such as dizziness, palpitation, syncope, and chest pain, that may suggest a cardiac arrhythmia. 9539 Reveal® XT and 9538 Reveal® Patient Assistants – The Reveal XT and Reveal Patient Assistants are intended for unsupervised patient use away from a hospital or clinic. The Patient Assistant activates one or more of the data management features in the Reveal Insertable Cardiac Monitor: • To verify whether the implanted device has detected a suspected arrhythmia or device related event. (Model 9539 only); • To initiate recording of cardiac event data in the implanted device memory. Contraindications: There are no known contraindications for the implant of the Reveal XT or Reveal DX Insertable Cardiac Monitors. However, the patient’s particular medical condition may dictate whether or not a subcutaneous, chronically implanted device can be tolerated. Warnings/Precautions: 9529 Reveal XT and 9528 Reveal DX Insertable Cardiac Monitors – Patients with the Reveal XT or Reveal DX Insertable Cardiac Monitor should avoid sources of diathermy, high sources of radiation, electrosurgical cautery, external defibrillation, lithotripsy, therapeutic ultrasound and radiofrequency ablation to avoid electrical reset of the device, and/or inappropriate sensing. MRI scans should be performed only in a specified MR environment under specified conditions as described in the device manual. 9539 Reveal XT and 9538 Reveal Patient Assistants – Operation of the Model 9539 or 9538 Patient Assistant near sources of electromagnetic interference, such as cellular phones, computer monitors, etc., may adversely affect the performance of this device. Potential Complications: Potential complications include, but are not limited to, device rejection phenomena (including local tissue reaction), device migration, infection, and erosion through the skin. See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. For further information, please call Medtronic at 1 (800) 328-2518 and/or consult Medtronic’s website at www.medtronic.com. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.

Eric M. Janis, MD, FACC

January 2010 Contents

COVER STORY Wake Radiology Musculoskeletal Imaging

Tackling Sports Injuries with a Team Approach

FEATURES

GLAUCOMA

Second Leading Cause of Blindness Can Strike at Any Age.

DEPARTMENTS FOLIC ACID

Can The Wonder Drug Prevent Recurrence of Neural Tube Defects (NTDs)?

Glaucoma is often called the “sneak thief of sight” because half of all patients have it and do not know it. Although some may consider the eye disease something that only happens to older people, the truth is, even children and teenagers can be diagnosed with it.

11 ELECTROPHYSIOLOGY

12 WOMEN’S HEALTH Heavy Menstrual Bleeding: A Comprehensive Strategy

17 CARDIOLOGY Are Small Elevations in Cardiac

Troponin Clinically Significant?

Folic acid taken prior to conception and in early pregnancy prevents most neural tube

Ablation of Atrial Fibrillation

18 Q & A

defects (NTDs) such as Spina Bifida. But

what about women who have already had a

19 NEWS Welcome to the Area

baby and want to have another child?

Uterine Fibroid Embolization

Events & Opportunities to Connect

New and Relocated Practices

20 PRACTICE MANAGEMENT Revenue Cycle Management in Physician Practices: What it Takes to Get Paid!

23 INSURANCE Evaluating the Lease on Your Business Life

24 GOOD BUSINESS

Medical Communication

26 LOCAL INTEREST The Right Stuff:

The North Carolina Museum of Natural Sciences

Cover Photo: Wake Radiology Musculoskeletal specialists Left to Right: Peter Leuchtmann, MD, Russell Wilson, MD, Lyndon Jordan, MD, William Vanarthos, MD, Joseph Melamed, MD, Charles Pope, MD and Nik Wasudev, MD. Photographed in the mammal research department of the North Carolina Museum of Natural Sciences. Special Thanks to Lisa Gatens and Jon Pishney.

The Triangle Physician | JANUARY 2010

27 ROUNDS

Pick Out Flu-Fighting Foods

From the Editor

e’re new, but we’re not. The folks behind The Triangle Physician are familiar faces—editors, writers, photographers, graphic designers and marketing specialists—with one goal: To continue to provide the Triangle medical community with a quality publication that’s a source of professional pride.

Times are changing in the publishing world. This compelled us to create The Triangle Physician. Our mission is to preserve the editorial and marketing integrity you’ve come to expect in a magazine that covers the tremendous medical advances happening in our region. With The Triangle Physician, there are no gray areas. Delineation between paid advertising and professionally written, thoroughly researched articles is clearly distinguished. Yes, advertising is our lifeblood. So we offer an exceptional conduit to an exclusive market at competitive rates. This, too, is to our readers’ advantage. Our focus for The Triangle Physician is clear, which also is represented in our bold graphic design. And by design, in this inaugural issue we explore advances in the treatment and prevention of glaucoma and birth defects. Within the Triangle, medical pioneers are developing and delivering advanced care that preserves vision later in life and that increases one’s advantage at the earliest stages of life. Each month, you can expect timely news presented in a variety of columns that are designed to satisfy your need to know. “Medical Research” will keep you in touch with advances in medical technology and treatment here in the Triangle. “Rounds” is the venue for hospital news. “Docs” and “New Practices” report on what’s new in town. “Moves” tracks recent changes. “Events” and “Opportunities to Connect” will keep you posted on the latest goings on. To be sure, all that The Triangle Physician is and becomes is designed to earn your trust and respect. We are delighted to continue a proud publishing tradition and appreciate your ongoing support.

Until next month,

Editor Mark Westphal

mark@trianglephysician.com

Contributing Editors Heidi Ketler heidi@trianglephysician.com Mateen Akhta, MD; Timothy Donahue, MD; Stephen P. Loehr, MD; Allen Mask, MD; John Reidelbach; Mike Riddick; Mark Wiener Photography Jim Shaw Photo

jimshawphoto@earthlink.net

Creative Director Dan Early Van Early

dan@trianglephysician.com van@trianglephysician.com

Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com

The Triangle Physician is published by Early Design Group 982 Trinity Road | Raleigh, NC 27607-4940

Subscription rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Tucson, AZ 85726 Every precaution is taken to insure the accuracy of the articles published, The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography.

Mark Westphal Editor

Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.

The Triangle Physician | JANUARY 2010

From the Cover

Bone Density Screening Helps Save Lives

Wake Radiology Musculoskeletal Imaging

People who have low bone density are at high risk of death as a consequence of osteoporotic fractures.* That established medical fact is the driving force for Wake Radiology’s comprehensive approach to high-quality DXA screening, a key to preventive care. “Osteoporosis is a silent disease; I compare it to hypertension. You don’t necessarily know that you have it until you experience some of the negative outcomes as a result of it,” says Joseph W. Melamed, M.D., who has led Wake Radiology’s DXA program for a dozen years. Today, the practice performs more than 6500 scans annually. Osteopenia and osteoporosis are preventable and treatable, Melamed points out, yet DXA is under utilized by those most at risk: post-menopausal women. Through Melamed’s leadership, Wake Radiology has become the nation’s only multi-site DXA provider to be certified by the International Society for Clinical Densitometry (ISCD). Patients can receive the same high-quality DXA screening at any of seven Wake Radiology locations. Equally important, all of Wake Radiology’s DXA technologists are dual-certified by both the ISCD and the American Registry of Radiologic Technologists. The quality of the test is vital, Melamed emphasizes. “With DXA, if the test is done wrong, you may get the wrong answer and not even realize it. You may tell the patient they’re normal when in fact they have osteoporosis. The legitimacy of numerical data is dependent on whether or not the study is done correctly. So we are very dependent upon the technologists, and Wake Radiology’s technologists are second to none.” Improving the screening even more, Wake Radiology’s DXA reports now provide FRAX® data based on the World Health Organization’s fracture risk assessment tool. This takes into account not simply bone mineral density, but also key demographic information.

Tackling Sports Injuries with a Team Approach

Men as well as women can benefit from DXA screening, as can younger people with diseases such as malabsorption, chronic steroid use (patients with asthma), anorexic patients, and those who are immobilized. * Research literature seem to indicate that for every 1 standard deviation decrease in bone density, there is approximately a 10 percent to 40 percent increase in mortality. Also, according to the National Osteoporosis Foundation, “The rate of hip fractures is two to three times higher in women than men; however, the one year mortality following a hip fracture is

Radiology’s MSK radiologists team with the

but also a high-grade musculotendinous

developed a painful mass in the gluteal region,

area’s physicians to help treat athletes who

injury that had occurred at the same time.

the condition was being clinically treated as

include Olympic hopefuls; professional

“It was unanticipated. After an ACL tear, the

probable bruising or hematoma. But Russell

hockey players; and college, high school, and

knee is always big and swollen. I was surprised

(Rusty) Wilson, M.D., director of imaging for

recreational players. Gymnasts and dancers

because the degree of soft tissue injury

over specific cuts on the computer while the

Wake Radiology’s musculoskeletal (MSK)

have their share of problems, too.

exceeded my expectations,” Martini says.

radiologist is reviewing them with me over

section, didn’t see it that way. “We were more

Wake Radiology’s sizable MSK group

“The soft tissue injury could have delayed

the phone. This allows me to make confident

concerned that it was actually a solid mass or a

includes seven radiologists, all with in-depth

his ultimate rehabilitation. So we waited,

decisions about when these athletes are

cancer,” he recalls. He believed the mass should

musculoskeletal experience, who are headquartered

prior to performing surgery, until this had

allowed to return to play or what treatments

be biopsied. Yet, as an athlete himself, he was

in a state-of-the-art musculoskeletal and sports

healed. We eliminated that as a possible

they are going to require.”

mindful of the timing. “You are dealing with a

imaging center at 4301 Lake Boone Trail in

complicating factor.”

patient who has reached a very short-term

Raleigh. At that office, two fellowship-trained

The combination of a precise history

occasion when I have needed to talk to someone

window in her life. She has dedicated extensive

musculoskeletal radiologists are always

and physical examination with a high-quality

that they have not been available. In doing

training and wants desperately to compete.

available for consultation and for real-time

MRI scan is enormously helpful in fine-tuning

this, the folks at Wake Radiology allow me to

monitoring of complex cases. All MSK cases

management decisions, especially when

provide high-level care for high-level athletes,

be nothing lost in allowing this athlete to

are filtered to this office for review.

considering surgery, Martini says. “For instance,

as well as for my weekend warriors.”

complete what she had prepared for. The main

“What makes Wake Radiology such a

there’s a partial rotator cuff tear versus a high-

thing we wanted to emphasize was that this

unique group is not only the quality of the scan,

grade tear. Even though both are incomplete

come crashing to earth, their extended hand

patient should not be lost to care.”

but the quality and precision of their reading

tears, one can be managed much more

often takes the impact. That is when orthopaedic

Wilson learned later that the mass was

of the scan, which is really appreciated in a

successfully non-operatively than the latter. So

surgeon Wallace F. (Wally) Andrew Jr., M.D.,

cancer, and the athlete was undergoing the

high-volume sports medicine practice,” says

often it [MRI] can set the treatment options.”

a partner at Raleigh Orthopaedic Clinic,

appropriate treatment. He was relieved.

orthopedic surgeon Douglas J. Martini, M.D.,

Pro athletes are frequently on Wake

may see them. He treats injuries to the hand,

“If you’re able to use your experience and

of Cary Orthopaedic & Sports Medicine

Radiology’s roster, and time is usually of

wrist, and upper extremities below the

training to have implications not just for a

Specialists. “The MSK group is by far the most

the essence. “As the team physician for the

shoulder. If he has a choice, Andrew says,

patient’s quality of life — participating in a

superb group I’ve ever worked with. A quality

Carolina Hurricanes, there have been many

he sends his patients to Wake Radiology. “I

sport they enjoy — but for the patient’s life

MRI is one thing, but skilled people reviewing

occasions when I have needed an MRI

think they’re outstanding. I’d compare them

itself, that’s rewarding.”

it for the subtleties of some of these complex

scheduled quickly for one of our players as

favorably to any academic group anywhere.”

injuries is incredibly helpful in making a

well as a quick read from the radiologist,” says

diagnosis and considering treatment options.”

William M. (Marty) Isbell, M.D., an orthopaedic

have been exceedingly easy to work with

odd — it doesn’t fit the clinical information

question. We know what they are looking

Often, he says, the subtleties make a

surgeon at Raleigh Orthopaedic Clinic, a

over the years, Andrew says. “I’d call Charles

or this, that, or the other — they pick up the

for because we’ve become familiar with our

big difference in preoperative planning and

practice that cares for North Carolina State

Pope and say, ‘The patient has this, this, and

phone and give you a call. Which is, I think,

orthopedic colleagues and we speak their

execution of the surgery. “Examples would be

University and Carolina Hurricanes pro hockey

this. You do whatever imaging you feel is

very unusual and very helpful, to get you thinking

language,” says musculoskeletal radiologist

identifying subtle intraarticular pathologies.

players, among many others.

appropriate to make the diagnosis.’ He’d say,

what they’re thinking—that type of approach.”

William (Bill) J. Vanarthos, M.D.

That may give you a chance to talk to your

“Often times, the scan is integral to

‘Let me have him over at West Raleigh where

patient in preoperative planning — which is

formulating a rehab or surgical plan for these

I can do an MRI or a CT scan or whatever.’ Then

Radiology nurtures. “Certainly, the surgeons

far superior to reacting to it when it’s found

athletes as well as to give some idea of how

the patient comes back with the appropriate

often have very specific clinical questions.

MSK imaging can be key to a young athlete’s future

at the time of surgery.”

long a player might miss. The musculoskeletal

study and the correct diagnosis.

Sometimes, however, the history provided

In another case, an MRI of a recreational

radiologists at Wake Radiology are always

“The other thing I like is that if they’re

is simply “pain” or something vague. In that

including gymnasts and dancers, MSK

soccer player revealed not only an ACL tear,

more than willing to stop what they are doing

doing a study and something looks a little

case, we can typically anticipate the clinical

imaging, especially MRI, is advancing by

“The trials were quite near—there would

PHOTO BY BRYAN REGAN

This is but one example of how Wake

Under ultrasound guidance, a needle is advanced into the calcific deposit for aspiration and medication injection (needle represented by the linear structure).

The Triangle Physician | JANUARY 2010

PHOTO BY BRYAN REGAN

When an Olympic-level track athlete

Dr. Bill Vanarthos injects a patient’s shoulder using a fluoroscope for guidance.

to discuss these often-complicated cases. There have been many times that I have gone

He continues,“There has never been an

When athletes fly through the air and

nearly twice as high for men as for women.”

A practice highly attuned to the needs of physicians and their patients Wake Radiology’s musculoskeletal section has fine-tuned its procedures to dovetail effortlessly with the needs of area doctors. Here is a bird’s eye view. • On a daily basis, more MSK radiologists providing outpatient and hospital-based diagnostic and interventional services than at many tertiary care institutions • Cross-consultation, thanks to having at least two MSK radiologists at all times in the reading room at a state-of-the-art musculoskeletal and sports imaging center in West Raleigh. The overall size of the practice – more than 50 radiologists – is also beneficial, as the broad experience they bring from training at the nation’s finest universities and teaching hospitals. • Standardized reports that always present the same information in the same spot. Both ready-read summaries and detailed reports are provided. • Highly experienced technologists who offer a welcome combination of compassionate care and wise efficiency. Patients experiencing pain are especially grateful.

The MSK radiologists at Wake Radiology

That’s the kind of rapport Wake

Luckily for many younger athletes,

JANUARY 2010 | The Triangle Physician

FRAX® Fracture Risk Assessment Tool The FRAX tool was developed by the World Health Organization to help physicians evaluate fracture risk of their patients. It is based on individual patient models that integrate the risks associated with clinical risk factors as well as bone mineral density (BMD) at the femoral neck. The FRAX algorithms give the 10-year probability of a hip fracture and the 10-year probability of a major osteoporatic fracture (clinical spine, forearm, hip, or shoulder fracture).

with and will therefore probably not make routinely. The radiologists

a patient to have an MRI. “It was not a widely

and if you’re treating just one of the bursa

the machine rather than the patient to achieve

in our section look for it. We have optimized our protocols to fully

practiced procedure,” Pope recalls, but “it was

and not others that are involved, it’s likely that

the most optimal angle.” Vanarthos explains.

characterize it whenever necessary.” Making a diagnosis like that, he

really good for the patients and orthopedists

you’re going to get an incomplete response,”

adds, is “one thing I find particularly satisfying about sports imaging.”

because it’s a relatively quick exam, it’s not

Wilson says. “We can use MRI to identify

peripheral joint injections on virtually every

extensive, it doesn’t cost a lot, and we could

inflammation around specific tendons and

joint in the body, including the small joints of

Wasudev recalls a 12-year-old dancer with persistent hip pain.

The MSK radiologists also provide

The initial imaging workup was negative, and an MRI was grossly unremarkable. But Wasudev found “a very subtle abnormality in her quadratus femoris muscle, which has recently been recognized as a manifestation of ischiofemoral impingement.” The good news for the dancer was that there are effective treatments for the condition.

“That’s an example of why we think it’s important to have sub-

specialty reads on all our MSK MRIs,” Wasudev notes. Particularly

“A quality MRI is one thing, but skilled people reviewing it for the subtleties of some of these complex injuries is incredibly helpful in making a diagnosis and considering treatment options.” Douglas J. Martini, M.D.

Orthopaedic Surgeon Cary Orthopaedic & Sports Medicine Specialists

in the context of sports injuries, expert imaging can help establish a diagnosis that was unsuspected clinically. “Not infrequently, we’ll

accurately screen patients who needed to

bursae, and then we can go in with ultra-

the feet and hands, which proves especially

pick up an osteochondral lesion in the talar dome, an injury to the

have surgery.”

sound or fluoroscopy and specifically target

helpful for patients suffering from arthritis.

bone and cartilaginous portion of the ankle joint. This can be a cause

those fluid-filled sacs so that people can get

of persistent pain following an ankle sprain, but may not have been

orthopedic surgeon Andrew says. “I think most

more optimal pain relief.”

can get some relief with a steroid injection,”

suspected clinically, particularly if the plain film is normal.”

radiologists would just do an MRI. You can

Success with pain relief is gratifying.

says Pope. But very few practices have offered

In the case of a football injury to the knee, he says, “The orthopedist

bill more for an MRI and make more money,

“You hear feedback from the patient, ‘I slept

therapeutic injections of the joints. “We’ve

may know there is a medial collateral ligament tear. But he or she may

FRAX Available Online

whereas the Wake Radiology guys will do

for the first time without waking up with

built a large following of people who need

not have suspected that the ligament has retracted and is now in a

an ultrasound, if that’s the thing to do, and

significant pain,’ or ‘I walked around the block

to have hip replacement surgery, but either

For your convenience and that of your patients, we have made access to the FRAX available right from our Website at wakerad.com. By simply clicking this button, the user will be directed to follow easy to read instructions to calculate his or her fracture risk.

position in which it may not heal down.”

then you get the appropriate information for

and was able to be outside in nice weather.’

aren’t quite ready to have the surgery or can’t

much less expense than an MRI.”

Those are rewarding comments to hear. The

have it. Those people are good candidates for

providing more specific characterizations of an injury with MRI. “The

Ultrasound also can help patients avoid

high-end athletes are glamorous and fun,

choice of an autogenous graft for an ACL repair could be influenced

surgery, Dr. Wilson points out. “In calcific

but it’s the everyday patients that really keep

by how we characterize the patellar tendon. If the patellar tendon

tendonitis, or hydroxyapatite deposition

us invigorated.”

looks abnormal or short, it may guide them to use a hamstring graft

disease, a buildup of this type of calcium in,

rather than a patellar tendon graft,” Wasudev explains.

say, a rotator cuff, can be debilitating and be

interventional pain management procedures

very painful. We are one of the few practices

not common to most practices. Among them

where we can go in under ultrasound guidance,

is a caudal epidural injection for patients with

put a needle into the calcium and try to

unexplained low back, sacrococcygeal, or hip

When an Olympic hopeful experienced Achilles tendon and

aspirate or get out as much of the calcium as

pain, or sciatica. The procedure is performed

leaps and bounds. MRI can uncover structural and functional sports-related

heel problems, MSK radiologist Charles V. Pope, M.D., helped the

possible, then locally target it with therapeutic

at the West Raleigh MSK office with the aid

problems that are otherwise very difficult to distinguish. “We are

orthopedist localize the abnormality and then perform the least invasive

medication to offer pain relief.” Otherwise, the

of a specialized C-arm fluoroscopy unit.

picking up abnormalities that were largely unrecognized by both

surgery. “We basically showed him where the problem was and exactly

patient has to endure the pain for perhaps

radiologists and orthopedists until recently,” explains MSK radiologist

where to go, so he wouldn’t have to explore up and down the tendon.

six to 12 months, or undergo surgical

space through an opening or hiatus in the

Nik P. Wasudev, M.D., a joint intervention specialist. “A good example

He could go right where he needed to, do what he needed to, and get

debridement. “Lots of people would love to

sacrum,” says Vanarthos, who specializes in

would be active people in their teens or twenties who will present to

back out without having a big invasive procedure,” says Pope.

have the option of something in between.”

joint and spine intervention. “This is very

their orthopedist or to their primary care doctor with hip pain. They are

often referred for MRI to rule out a stress fracture or a labral tear.

uncommon in much of the country, but a valuable procedure that Wake

“In some of these patients, the MRI shows normal marrow signal

Radiology began offering when Pope initiated the MSK section in

and is otherwise unimpressive. But some of these patients will have

1986. Soon, they were performing 200–300 MSK ultrasounds a year.

relatively subtle anatomic abnormalities such as in the femoral neck,

which can cause femoroacetabular impingement. Recognizing this

rotator cuff tears,” he remembers. “Unfortunately, prior to MRI,

abnormality, if it is appropriately managed and is treated early on,

Fracture Risk Assessment Tool Available online at wakerad.com

MSK radiologists can also help orthopedists in surgical planning by

Ultrasound guides surgery— or helps athletes avoid it

In that case, Pope used musculoskeletal ultrasound techniques,

Ultrasound has been very helpful,

Wake Radiology offers uncommon procedures to help patients find pain relief

“Patients who have an arthritic joint

Wake Radiology offers a number of

“We put a needle right into the epidural

effective for pain related to the lower lumbar spine, pelvis, and hips.” The procedure is not

Mechanical phase of rotator cuff calcific tendinitis: oval black focus represents the calcific deposit, within the supraspinatus tendon, elevating the bursa with associated inflammation (surrounding white).

well known except among pain management

corticosteroid hip injections for pain relief.

groups and anesthesiologists.

Usually reserved for hospital settings or

frequently treat are those with arthritis in

Ultrasound and MRI make a powerful

high-end angiography, C-arm fluoroscopy is

their feet. If you’ve got a painful foot, you

the only way to diagnose those was to perform a dye injection in the

combination in identifying the source of

an extraordinarily useful tool for procedures

don’t have many options.”

can prevent accelerated degenerative joint disease later in life. Or it

shoulder and do an arthrogram. A lot of people with painful shoulders

chronic pain. A good example using both

related to the spine and the low back. “The

can help preserve an otherwise limited athletic career,” Wasudev says.

were not up to having someone stick a needle in their shoulders.”

imaging modalities is for chronic lateral hip

patient lies flat on his or her belly and doesn’t

Orthopedic Surgery of the Foot and Ankle in

Moreover, “it is generally a diagnosis that a non-MSK radiologist is unfamiliar

pain. “There are multiple bursae in the hip,

have to move. The C-arm allows us to rotate

Raleigh, are among those who have benefited

The Triangle Physician | JANUARY 2010

“Probably the first thing I did was shoulder ultrasounds for

Used as a screening tool, ultrasound can obviate the need for

“ The other g roup of patient s we

Patients of Sarah E. DeWitt, M.D., of

JANUARY 2010 | The Triangle Physician

Electrophysiology

from therapeutic joint injections. “If you

staff are really nice to my patients. That

our ortho conferences, so they are actively

diagnose the problem correctly, patients

makes our job so much easier,” she says. “It’s

involved in the care of our patients.

respond beautifully to the injections,” she

also convenient to get someone scheduled

says. She has been working with Wake

because they have so many radiologists and

benefit to me with their skill and knowledge.

Radiology’s MSK team for the last decade.

locations. And they’re just really skilled at

I am very grateful to have such competent

“They are a pleasure to work with, and their

what they do. The MSK radiologists attend

MSK radiologists in this community.”

by Timothy Donahue, MD Education: Undergraduate: Louisiana State University 1992 Medical School: Louisiana State University 1996 Internal Medicine: Emory University 1999 Fellowships: University of Florida 2002 (Cardiovascular Medicine); 2003 (Cardiac Electrophysiology) Certification: Internal Medicine; Cardiology; Electrophysiology Interests: Cardiology, Diagnosis and treatment of heart rhythm disorders Joined Triangle Heart in Durham, NC in August 2009

“The Wake Radiology doctors add huge

FRAX is a registered trademark of the World Health Organization Collaborating Centre for Metabolic Bone Diseases

Meet the MSK Physicians CHARLES V. POPE, MD

RUSSELL (RUSTY) C. WILSON, MD

Musculoskeletal Radiologist Joint and Spine Intervention Specialist

Musculoskeletal Radiologist Director of Musculoskeletal Imaging Joint Intervention Specialist

Dr. Pope joined Wake Radiology in 1986 and founded the MSK imaging program. He holds a certification in diagnostic radiology from the American Board of Radiology. A native of Mooresville, NC, Dr. Pope received his medical degree from the University of North Carolina School of Medicine. He served as chief resident in diagnostic radiology at Duke University Medical Center in Durham.

JOSEPH W. MELAMED, MD Musculoskeletal Radiologist Joint Intervention Specialist

WILLIAM J. VANARTHOS, MD Musculoskeletal Radiologist Joint and Spine Intervention Specialist

LYNDON K. JORDAN III, MD Musculoskeletal Radiologist Joint Intervention Specialist

fibrillation remains the most enigmatic of cardiac

recurrent episodes of atrial

arrhythmias. Currently, atrial flutter,

fibrillation. In the early 1990s, it was described that many of these patients have abnormal

reentry, atrial tachycardia and many forms

Dr. Wilson, who joined our practice in 2005, is director of musculoskeletal radiology at Wake Radiology. Dr. Wilson is board certified in diagnostic radiology by the American Board of Radiology. He is a native of Dallas, TX, and a graduate of Duke University School of Medicine. Dr. Wilson was a resident in diagnostic radiology at Brigham and Women’s Hospital in Boston, and he completed a fellowship in musculoskeletal imaging at the University of California at San Francisco. He is a certified Clinical Densitometrist through the International Society for Clinical Densitometry (ISCD).

of ventricular tachycardia can be safely

triggers located in the left

treated with radiofrequency ablation

atrium. These triggers are foci, usually just inside the

techniques. Success rates generally top

pulmonary veins as they join left

95% with a risk of major complication

atrium, which periodically fire

of less than 1%.

Musculoskeletal Radiologist Joint and Spine Intervention Specialist

rapidly and irregularly. This rapid

A curative procedure for

firing can send the atria into the

atrial fibrillation has been much

Dr. Leuchtmann joined Wake Radiology in 2006. He is board certified in diagnostic radiology by the American Board of Radiology. Dr. Leuchtmann is a native of Florissant, MO, and he received his medical training at Indiana University School of Medicine in Indianapolis. He completed a residency in diagnostic radiology at the University of Maryland School of Medicine in Baltimore and a fellowship in vascular/interventional radiology at Johns Hopkins Hospital in that city. He also was a fellow in musculoskeletal radiology at University of North Carolina Hospitals. Dr. Leuchtmann is a certified Clinical Densitometrist through the International Society for Clinical Densitometry (ISCD).

NIK P. WASUDEV, MD Dr. Vanarthos has clinical interests in musculoskeletal imaging and emergency radiology. He joined our practice in 1999 and is board certified in diagnostic radiology by the American Board of Radiology. A native of Forest Hills, NY, Vanarthos received his medical degree from New York Medical College in Valhalla, NY. He was a resident in diagnostic radiology at Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL. Dr. Vanarthos was a fellow in musculoskeletal radiology at North Carolina Baptist Hospital, Bowman Gray School of Medicine, Winston-Salem, NC. He is a certified Clinical Densitometrist through the International Society for Clinical Densitometry (ISCD).

seemingly normal atria, who have

In spite of a tremendous amount of research, atrial

Wolf-Parkinson-White syndrome, AV node

PETER L. LEUCHTMANN, MD Dr. Melamed is chairman of the Department of Radiology at Maria Parham Medical Center in Henderson. His special clinical interests include bone densitometry and musculoskeletal imaging. He is board certified in diagnostic radiology by the American Board of Radiology and also is a certified clinical densitometrist. Dr. Melamed joined Wake Radiology in 1996. He is a native of New York City and a graduate of Yale University School of Medicine in New Haven, CT. At Duke University Medical Center in Durham, he completed his residency and a fellowship in musculoskeletal radiology. Dr. Melamed is a certified Clinical Densitometrist through the International Society for Clinical Densitometry (ISCD).

Ablation of Atrial Fibrillation

Musculoskeletal Radiologist Joint Intervention Specialist Dr. Wasudev joined our practice in 2007 and is certified in diagnostic radiology by the American Board of Radiology. Dr. Wasudev was born in London, England. He is a graduate of the University of Pennsylvania School of Medicine in Philadelphia. Dr. Wasudev trained in orthopedic surgery at University of Michigan Medical Center in Ann Arbor and his residency in diagnostic radiology at the University of California San Francisco. He was a fellow in musculoskeletal magnetic resonance radiology at National Orthopedic Imaging Associates in San Francisco. Dr. Wasudev is a certified Clinical Densitometrist through the International Society for Clinical Densitometry (ISCD).

more elusive, but significant

electrical chaos of atrial

progress has been made.

fibrillation. If the atrial substrate

The last 2 decades have

is normal, fibrillation is usually

seen a paradigm shift in

short-lived, but after years of this

the understanding of

periodic rapid firing, the atria undergo

this arrhythmia. A key

changes which make them more

branching point in the

accepting to atrial fibrillation. The

treatment of patients

atria may become enlarged and

relates to the etiology of

scarred, thus the tendency for atrial fibrillation to propagate itself.

the atrial fibrillation;

Currently, ablation strategies

specifically, whether it is

focus on delivering a series of burns

occurring due to abnormal left atrial substrate or abnormal

around the pulmonary veins as they insert

triggers contained within the left

Dr. Jordan, whose expertise is in musculoskeletal imaging, has been with Wake Radiology since 1999. He is board certified by the American Board of Radiology and is also a certified clinical densitometrist. He serves on the liaison committee of the North Carolina Industrial Commission. Dr. Jordan is a native of northern California and a graduate of Duke University School of Medicine in Durham. He completed his residency in diagnostic radiology and a fellowship in musculoskeletal imaging at Duke University Medical Center. Dr. Jordan is a certified Clinical Densitometrist through the International Society for Clinical Densitometry (ISCD).

into the left atrium. This creates an electrical disconnect between the pulmonary

atrium. This difference has important

veins (and the abnormal foci within them) and the

implications for what treatment strategy

left atrium. The foci still fire, but the abnormal

is likely to be effective.

electrical impulses cannot reach and disrupt the

Examples of patients with abnormal substrate

remainder of the left atrium. Ablation’s cure rate is perhaps

can be found in those who have mitral regurgitation or

70% in the structurally normal atrium. In patients with enlarged

Wake Radiology Muculoskeletal & Sports Imaging 4301 Lake Boone Trail, Suite 104 Raleigh, NC 27607 Scheduling: 919-232-4700

Musculoskeletal & Sports Imaging Physician Hotline: 919-782-4830 10

The Triangle Physician | JANUARY 2010

wakerad.com

uncontrolled hypertension. Chronically elevated left heart pressures lead to enlargement and scarring of the left atrium, both of

atria, additional burns are performed to “debulk” the left atrium. In this

which predispose to atrial fibrillation. Scarring of the atria is difficult

patient group, however, the cure rate is in the 50% range.

to appreciate clinically, but left atrial enlargement is readily seen

echocardiographically. Small increases in atrial volume lead to an

be brought to the 95% range achieved in other arrhythmias, but

exponential increase in the risk of atrial fibrillation.

for many patients, ablation is an attractive alternative to a lifetime of

medical therapy.

For years, researchers were baffled by a subset of patients with

It is debatable whether the cure rate of atrial fibrillation can ever

JANUARY 2010 | The Triangle Physician

Women’s Health

Heavy Menstrual Bleeding: A Comprehensive Strategy The prevalence of patient-perceived heavy

menstrual bleeding (HMB) is high, with as many as one-quarter of menstruating © ISTOCPHOTO.COM/ROLLOVER

women reporting HMB annually.(1) Given this high prevalence, health care providers should ask all women about their periods. There are many options for women that have emerged over the past decade that can treat, improve and resolve HMB. An international meeting regarding HMB was

These are the simple questions that we use on

investigator on a study coordinated by the

held in Washington DC in 2005 which

our intake form as part of the menstrual history.

Center for Disease Control (CDC) (with 5

examined taking a menstrual bleeding history

The advantage of using these questions are that

leading hematologists within the United States)

and was summarized by Fraser et al(2).

both provider and patient understand them;

that evaluated healthy adult women with HMB

Recommendations from this meeting include

whereas, menorrhagia can be confusing—

for potential underlying bleeding disorders.(3)

specific proposals for new terminology to

and as indicated above, the term menorrhagia

The first publication relating to this study

describe menstrual bleeding. Both Dr. Andrea

is not used the same way worldwide (within

appeared in the British Journal of Hematology,

Lukes (Women’s Wellness Clinic) and Dr. Marc

the US it is used to describe regular heavy

and noted that 73% (170/232) of women

Fritz (University of North Carolina at Chapel

periods whereas outside the US it is used to

evaluated had some type of hemostatic

Hill) were participants in this meeting along

describe irregular periods).

disorder when comprehensive hematologic testing was done. This highlights the

with over 30 experts on menstrual disorders. A summary of the new terminology includes

After identifying a woman with HMB, providers

importance of considering this possibility in

the following recommendations:

may appropriately refer to gynecologists for

women with heavy menstrual bleeding.

menopause (Depo Lupron®), hemostatic agents

bleeding. Furthermore, we are currently

to reduce bleeding (DDAVP or Stimate®),

doing a study on PMS symptoms and the

and a new medication just approved by

NovaSure® endometrial ablation. Our group

the FDA called tranexmic acid (Lysteda®);

presented data at the November, 2009,

by Amy Stanfield

2) LNG-IUS—or the Mirena® which also

meeting of AAGL showing that preliminary

Dr. Stanfield completed her undergraduate and medical degrees at the University of North Carolina at Chapel Hill, followed by residency in obstetrics and gynecology at Carolinas Medical Center in Charlotte, NC. In 2009, she completed the Fellowship in Integrative Medicine through the University of Arizona, founded by Dr. Andrew Weil. Dr Stanfield has a particular interest in women’s wellness and utilizes both conventional and alternative approaches for her patients.

has recent FDA approval for treatment of

results show a reduction of PMS symptoms

HMB; 3) surgical—this can include

at 6 months follow-up following NovaSure®

hysteroscopy and resection of endometrial

endometrial ablation.

endometrial ablation (now performed within

In conclusion, I would encourage all health

opportunity to discuss with women the

our office—see below), uterine fibroid

care providers — especially primary care

likelihood of an underlying bleeding disorder.

embolization (UFE). ExAblate,® a new

providers — to discuss menstrual bleeding with

Further, Dr. Lukes is working with the group

investigational Doppler Uterine Artery

their female patients. There are many advances

of hematologists coordinated by the CDC to

Occlusion procedure, as well as the definitive

in both evaluation and treatment for this

publish further screening evaluations to

cure for HMB, a hysterectomy (using

condition. We look forward to referrals for

determine which women with HMB should

minimally invasive techniques). Our approach

evaluation and treatment of heavy menstrual

be further evaluated for an underlying

at the Women’s Wellness Clinic is to present

bleeding, as well as any other gynecologic

bleeding disorder.

a comprehensive list of all potential medical

issues your female patients may have.

pathology (endometrial polyps or fibroids),

and surgical options and then work with our Ideally, the cause of HMB will drive the

patients to make the best treatment plan for

treatment, but this is not always the case since

each individual woman.

in up to 50% of cases, the cause of HMB is not determined. The treatments of HMB can

In terms of office based treatments for HMB,

be classified into three general categories:

we offer several endometrial ablations which

1) medical—which largely includes hormones

we do within our clinic: Her Option®

(combined oral contraception, progestin

cryoablation, NovaSure® and Thermachoice®.

alone, estrogen alone, medications to induce

All of these are effective in reducing menstrual

References: (1) Shapley M, Jordan K, Croft PR. An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract 2004;54:359-63. (2) Fraser IS, Critchley HOD, Munro MG, Broder M, A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding, Fertility & Sterility, Vol 87, Issue 3, p 466-476. (3) Kouides, PA, Byams, V, Philipp CS, Stein SF, Heit JA, Lukes AS, Skerrette NI, Dowling NF, Evatt BL, Miller CH, Owens S, Kulkarni R, “Multisite management study of menorrhagia with abnormal laboratory haemostasis: a prospective crossover study of intranasal desmopressin and oral tranexamic acid”, British Journal of Hematology, Volume 145, Number 2, April, 2009, p 212-220(9).

further management or they may appropriately order a pelvic ultrasound. We

Given that I have a strong interest in

perform transvaginal ultrasound within our

understanding and managing HMB — the

clinic and review findings with women as we

Women’s Wellness Clinic works closely with

for regularly occurring periods that are

perform the ultrasound. This provides

hematologists in the community (Durham,

heavy, see below)

information on the cause of HMB. In addition,

Chapel Hill and Raleigh) to diagnose and

in some women we recommend doing a saline

evaluate women for hemostatic disorders.

infused sonogram and/or office hysteroscopy.

I encourage any provider to refer to me for

The evaluation of the uterus and endometrium

evaluation if they would like to have this

may help determine a cause of the HMB

done (see website HYPERLINK

to be light, normal, or heavy?

such as leiomyomata (fibroids), adenomyosis,

“http://www.cwrwc.com” www.cwrwc.com

Regularity: Do you consider your periods

endometrial polyps, endometrial hyperplasia,

under heavy menstrual bleeding). In addition,

ovarian cysts, and more.

we will refer and help coordinate appoint-

STOP using the term menorrhagia (replace with Heavy Menstrual Bleeding

Four terms for describing the menses include: Volume:

Do you consider your periods

to be irregular or regular?

ments/evaluations to both Duke University

Frequency: Are your periods infrequent, normal in frequency, or come

In addition to considering uterine and

Medical Center and the University of North

too often

endometrial causes of HMB, we encourage

Carolina when indicated. Dr. Lukes offers

providers to consider other causes of HMB:

expertise in this area, having been the former

hemostatic disorders such as von Willebrand

Director of Gynecology and co-founder of

disease and platelet dysfunction. While at

the Women’s Hemostasis and Thrombosis

Duke University Dr. Lukes was the principal

Clinic at Duke University. We welcome the

Duration: Do you consider your periods to be too few, normal, or too long

The Triangle Physician | JANUARY 2010

JANUARY 2010 | The Triangle Physician

Glaucoma

Glaucoma Fact Sheet • The 2008 update to Prevent Blindness

blindness in African-Americans between

Diabetes: People with diabetes have a higher

America’s Vision Problems in the U.S.

the ages of 45-64 than in whites of the

risk (40 percent) of developing glaucoma.

report states that close to 2.3 million

same age group.

Nearsightedness: People who are very

Americans age 40 and older, or about 1.9

• In the early stages, glaucoma has no

percent of that population, have glaucoma.

symptoms, no noticeable vision loss, no

Eye Injury or Surgery: Those who have

• Prevent Blindness America’s 2007 research

pain, which is why it is called the “sneak

had eye surgery or eye injuries may develop

study, “The Economic Impact of Vision

thief of sight.” By the time symptoms start

secondary glaucoma.

Problems” states that glaucoma costs the

to appear, some permanent damage to the

Steroid Medication: Steroids may in-

eye has usually occurred.

crease the risk of glaucoma when used for

U.S. economy $2.86 billion every year

Second Leading Cause of

in direct medical costs for outpatient,

In Rare Cases, Children and Teenagers May Have the Disease

inpatient and prescription drug services. © ISTOCPHOTO.COM/CHOJA

Blindness Can Strike at Any Age

nearsighted are at greater risk.

• Glaucoma that is undiagnosed or poorly

extended periods of time.

controlled can lead to damage of the optic TYPES OF GLAUCOMA:

• The same study found that glaucoma

nerve, visual field loss, and ultimately sight

patients between the ages of 40 and 64

loss. People with glaucoma usually lose

years of age can expect to pay $3,352

peripheral vision first. Over time, glaucoma

annually per person in direct medical costs

may also damage central vision. Once lost,

Chronic (Open Angle) Glaucoma: This is the

for outpatient, inpatient and prescription

vision cannot be restored.

most common type. In open angle glaucoma,

Types of Glaucoma

• Prevent Blindness America recommends that

aqueous fluid drains too slowly and pressure

annual costs jump to $5,243 per person.

older people get regular, comprehensive

inside the eye builds up. It usually results from

drug services. For those 65 and older, the

Glaucoma is often called the “sneak thief of sight” because half of all

“Although having glaucoma at such a young age is rare, I think A.J.’s

• Juvenile open angle glaucoma (JOAG) is

eye exams, even if they have no signs of

aging of the drainage channel, which doesn’t

patients have it and do not know it. Although some may consider the

story demonstrates the need for everyone, including those young and

a rare form of glaucoma that accounts for

vision problems. The earlier glaucoma is

work as well over time. However, younger

eye disease something that only happens to older people, the truth is,

more mature, to receive an eye exam,” said Dr. Olivier. “There is no

approximately one percent of total cases.

detected, the better the chances are of

people can also get this type of glaucoma.

even children and teenagers can be diagnosed with it.

cure for glaucoma, but with early treatment, we can lessen the risk of

The clinical features of JOAG are the

preserving sight.

Normal Tension Glaucoma: This is

severe vision loss.”

same as those of more common forms of glaucoma.

A.J. DeGeorge is now 27 years old but has been receiving treatment

• Prevent Blindness America, with support

a form of open angle glaucoma not related

from Alcon, Inc., provides “The Glaucoma

to high pressure. People with normal tension

for juvenile open-angle glaucoma since he was 13. At the time of his

As of today, there are more then 2.2 million Americans over the

• Approximately 120,000 people are blind from

Learning Center,” a comprehensive online

glaucoma may be unusually sensitive to

diagnosis, he exhibited no signs or symptoms of the potentially blind-

age of 40 who have been diagnosed. Unfortunately, once glaucoma

glaucoma, accounting for 9-12 percent of

tool to educate consumers on a variety

normal levels of pressure. Reduced blood

ing eye disease. His glaucoma was only discovered because of a rou-

takes away sight, it cannot be restored. That is why Prevent Blind-

all cases of blindness in the U.S. (National

of topics related to the disease at

supply to the optic nerve may also play a role

tine eye exam.

ness America, the leading volunteer eye health and safety organiza-

Eye Health Program/National Institutes

www.preventblindness.org/glaucoma.

in normal tension glaucoma.

tion, has joined other leading eye care groups in designating January Glaucoma causes loss of sight by slowly damaging a part of the eye

as National Glaucoma Awareness Month in an effort to educate the

called the optic nerve. When the optic nerve becomes damaged,

public on the disease.

it usually begins to damage peripheral vision. Without treatment, central vision becomes diminished. It is the second leading cause of blindness, second only to cataracts. “There were no warning signs. I had very close to 20/20 vision and never had any pain,” said DeGeorge. “But, when the doctors checked the pressures in my eyes, they were unbelievably high and my optic nerves had shown signs of damage.” After his diagnosis, DeGeorge began treatment with a glaucoma specialist, Mildred M.G. Olivier, M.D. of the Midwest Glaucoma Center. Initial treatment included medications but later a Trabeculectomy (surgery) was needed in the right eye to lower the eye pressure so that no further damage would occur. Today, thanks to the early detection and consistently following his doctor’s directions, DeGeorge needs only to take eye drops in his left eye once a day. 14

The Triangle Physician | JANUARY 2010

Prevent Blindness America offers free informational resources, including treatment options and general information through its Web site and toll free number. “The Glaucoma Learning Center,” at www.preventblindess.org/glaucoma, contains a variety of resources including an adult vision risk assessment and an interactive guide on how to take eye drops. The Web site also includes “The Glaucoma Web Discussion Forum” that allows patients and caregivers the opportunity to discuss online all subjects related to the disease. Prevent Blindness America also offers free printed materials including the “Guide for People with Glaucoma.” This comprehensive booklet serves as a handbook for patients and includes information on what to expect during treatment and even a list of questions to ask the eye doctor. And, Prevent Blindness America offers a resource directory for those who may require financial assistance. And, consumers can obtain free printed materials on glaucoma in either English or Spanish by calling 1-800-331-2020. Additional information can be found online at www.preventblindness.org/glaucoma.

ABOUT PREVENT BLINDNESS AMERICA Founded in 1908, Prevent Blindness America is the nation’s leading volunteer eye health and safety organization dedicated to fighting blindness and saving sight. Focused on promoting a continuum of vision care, Prevent Blindness America touches the lives of millions of people each year through public and professional education, advocacy, certified vision screening and training, community and patient service programs and research. These services are made possible through the generous support of the American public. Together with a network of affiliates, divisions and chapters, it’s committed to eliminating preventable blindness in America. For more information, or to make a contribution to the sight-saving fund, call 1-800-331-2020 or visit us on the Web at www.preventblindness.org.

• Everyone is at risk for glaucoma from

Acute (Angle Closure) Glaucoma: This causes

• It is estimated that as of 2000, at least 66.8

young to old. Although older people are at

a sudden rise in eye pressure, requiring

million people in the world have glaucoma.

higher risk, approximately 1 out of every

immediate, emergency medical care. The signs

(Glaucoma Service Center to Prevent

10,000 babies born in the United States is

are usually serious and may include blurred

Blindness).

diagnosed with the disease (according to

vision, severe headaches, eye pain, nausea,

the Glaucoma Research Foundation).

vomiting or seeing rainbow-like halos

of Health).

• Glaucoma is the second leading cause of blindness in the world after cataracts, (according to the World Health Organi-

GLAUCOMA RISKRisk FACTORS Glaucoma Factors

zation), and the leading cause of blindness

around lights. Occasionally, the condition may be without symptoms; similar to open angle. Secondary Glaucoma: Another 10

in African-Americans (according to the

Age: Those that are 40 and older are more

percent of glaucoma cases come from certain

National Institutes of Health).

likely to develop glaucoma. The older you are,

diseases and conditions that damage the eye’s

the greater your risk.

drainage system. These include diabetes,

• According to the National Eye Institute,

Race: People of African or Afro-Caribbean

leukemia, sickle-cell anemia, some forms

• Five times more likely to occur in

heritage are more likely to get glaucoma than

of arthritis, cataracts, eye injuries or

African-Americans than in whites.

the rest of the population. They are also more

inflammation of the eye, steroid drug use

• About four times more likely to cause

likely to develop glaucoma at a younger age.

and growth of unhealthy blood vessels.

blindness in African-Americans than

Family History: If you have a parent or

Post-surgical

in whites.

sibling who has glaucoma, you are more

surgeries, such as retinal reattachments,

likely to develop the disease.

increase the chance of getting glaucoma.

glaucoma is:

• Fifteen times more likely to cause

Glaucoma:

Some

JANUARY 2010 | The Triangle Physician

Birth Defects

Cardiology

Are Small Elevations

Can the

‘Wonder Drug’

Dr. Mateen Akhtar is a clinical and invasive cardiologist in Johnston County with Wake Heart & Vascular Associates. He welcomes referrals, same day appointments, and your comments/questions. Phone: (919) 989-7909. Email: mateenakhtarmd@gmail.com

Prevent Recurrence of Neural Tube Defects?

Clinically Significant?

A 65 year old man with diabetes mellitus,

myocardial oxygen demand due to increases

If suspicion for ACS is low and demand

long-standing hypertension, and stage 2 chronic

in preload, afterload, myocardial contractility,

ischemia is suspected, then treatment is

kidney disease is admitted to the hospital with

or wall stress. Since myocardial oxygen

tailored to the underlying cause of increased

three days of progressive dyspnea and has a

supply is insufficient to meet the increased

myocardial oxygen demand (i.e. infection,

Here’s what we know: Folic acid taken prior

right lower lobe infiltrate by chest radiograph.

oxygen demand, ischemia (“demand ischemia”)

tachycardia, pulmonary embolism, dehydration,

to conception and in early pregnancy prevents

The nurse tells you, “Doctor, the troponin-I is

may occur. Demand ischemia often reflects

etc.). Once the acute illness has resolved,

most neural tube defects (NTDs) such as

elevated to 0.104.” The patient is not having

underlying obstructive coronary artery

further risk stratification is recommended.

Spina Bifida.

any chest pain. What would you do next?

disease.

Aspirin is also usually advisable if there are no contraindications.

But what about women who have already

The introduction of ultra sensitive troponin

had a baby with Spina Bifida or another NTD

assays has increased our ability to diagnose

COMMON CAUSES OF ELEVATED Table 1: Common Causes of Elevated CardiCARDIAC TROPONIN IN THE ABSENCE ACUTEinCORONARY ac OF Troponin the AbsenceSYNDROME of Acute Coro-

and want to have another child? The NTD

myocardial infarction with a high degree of

nary Syndrome

term studies have shown that patients who

sensitivity. This increased sensitivity, however,

Chronic kidney disease

have elevated cardiac biomarkers without

has come at the cost of reduced specificity.

Left ventricular hypertrophy

ACS typically have a worse overall clinical

Small elevations in cardiac troponins are now

Congestive heart failure

prognosis, compared to patients who have

recurrence risk is 2 to 3 percent in the United

Are Recurrence Prevention Programs Cost-Effective?

States. Can folic acid help prevent an additional NTD in a subsequent pregnancy? Previous research implies the answer is “yes”.

• Chronic kidney disease • Left ventricular hypertrophy • Congestive heart failure • Trauma

Interestingly, numerous short-term and long-

said Dr. Collins. That’s why women need to

The cost for the South Carolina program was

detected more frequently but their

Trauma

normal cardiac biomarkers. Therefore, patients

take a daily multivitamin containing folic acid.”

comparable to other types of preventative

significance is often not well understood by

Sepsis • Hypovolemia

with minor troponin elevations in the

programs—about $4,500 per protected

clinicians. I would like to take this opportunity

Hypovolemia • Pulmonary embolism

absence of ACS represent a higher risk

pregnancy for one particular year.

to review the pathophysiology, differential

Pulmonary embolism • Coronary vasospasm

subgroup. It is not uncommon to discover

diagnosis, and clinical significance of small

Coronary vasospasm • Myocarditis

severe single-vessel or multi-vessel CAD

troponin elevations.

Myocarditis • Pericarditis

upon further investigation in these patients.

This research looked at NTD recurrence (both randomized trials and observational

Dr. Collins assists the South Carolina NTD

studies) and showed reductions in the NTD

Recurrence Prevention Program, which was

recurrence risk ranging from 83-100 percent.,

started in 1992 by the Greenwood Genetic

Different types of recurrence prevention

• Sepsis

• Tachyarrhythmia Tachyarrhythmia

according to Julianne Collins, PhD, a genetic

Center because of the high rate of NTDs in

programs throughout the country are now being

epidemiologist at the Greenwood Genetic

that state. The program contacted enrolled

studied to determine their cost-effectiveness.

Cardiac troponin-I and troponin-T are cardiac-

Center in South Carolina.

women with a previous NTD-affected fetus

Both the March of Dimes and the Centers

specific proteins that are involved in regulation

My approach to a patient with small elevations

troponin are clinically important. It is

frequently by phone and provided counseling

for Disease Control and Prevention (among

of the calcium-mediated interaction of actin

in cardiac troponin is to first determine

abnormal for patients without structural

It has been 17 years since the Public Health

and free folic acid supplements. All enrolled

other agencies) have previously funded efforts

and myosin. In acute coronary syndrome

whether the clinical picture is consistent

heart disease or chronic kidney disease to have

Service published the recommendation

women were monitored to track supplement

to deliver recurrence prevention services to

(ACS), plaque rupture with thrombotic

with ACS. It can be challenging in the early

elevated cardiac biomarkers. In these patients,

that all women of childbearing age take 400

use and pregnancy outcomes.

women whose pregnancies were affected by

occlusion of the coronary artery leads to

stages to determine whether a small cardiac

acute coronary syndrome needs to be

neural tube defects.

myocardial necrosis with release of troponin

biomarker elevation represents ACS vs.

excluded, followed by a search for treatable

into the bloodstream. Prolonged ischemia

demand ischemia. The history, electrocardio-

causes of demand ischemia. Elevated cardiac

can also lead to myocyte necrosis.

gram, and additional biomarker information

troponin predicts a worse overall clinical

(including CK and CK-MB isoenzymes)

prognosis and often signifies underlying

micrograms of folic acid daily, and 10 times

Dr. Mateen Akhta

in Cardiac Troponin

In conclusion, small elevations in cardiac

that for women who have had a child with a

The results were positive: 85 percent of the

neural tube defect.

women took folic acid during subsequent

A national survey of these types of activities

pregnancies, and there were no NTD

was conducted during 2005.“Only 15 states have

“It’s pretty hard to get 400 micrograms of

recurrences among the 364 pregnancies

or are planning recurrence prevention projects,”

Elevations in cardiac troponin may occur

provide useful clues. If suspicion for ACS

obstructive CAD or structural heart disease.

folic acid through your diet—much less the

protected by folic acid, as compared to a 1.9

said Dr. Collins.“These programs should continue.

in the absence of ACS in several commonly

persists, treatment is initiated with aspirin,

Further risk stratification and/or consultation

4,000 micrograms recommended for women

percent recurrence rate among the pregnancies

The research proves recurrence prevention

encountered clinical situations (see chart).

heparin, beta blockers, and statins and early

with a cardiologist is recommended in these

who have already had a baby with Spina Bifida,”

that were not protected by folic acid.

programs work and are cost-effective.”

These situations typically cause increased

risk stratification is pursued.

situations.

The Triangle Physician | JANUARY 2010

JANUARY 2010 | The Triangle Physician

News

Q&A

Uterine Fibroid Embolization by Stephen P. Loehr, MD

Medical Director, Regional Vascular Associates and Triangle Interventional Services.

Medical School | Wake Forest University (Bowman Gray School of Medicine). Residency | Diagnostic Radiology, Mallinkrodt Institute of Radiology and Wake Forest University School of Medicine. Fellowship | Vascular and Interventional Radiology, Alexandria Hospital. Board Certification | American Board of Radiology with Certificate of Added Qualification in Vascular and Interventional Radiology.

Welcome to the Area

Feb. 5, 2010

MATEEN AKHTAR, MD

CATHERINE B. LERNER, MD

NATIONAL WEAR RED DAY

Echocardiography, Nuclear Cardiology, Cardiac Catheterization

Pediatric Radiologist

Show your support for the fight against heart disease in women and the American Heart Association’s Go Red For Women movement by sporting your best red outfit Feb. 5th. For a free downloadable Wear Red Day kit, visit GoRedForWomen. org/WearRedDay or contact the AHA at 919-463-8307.

Joined Wake Heart and Vascular 2009 Medical School | M.D. University of California, San Diego School of Medcine; B.S. University of California, San Diego, Summa Cum Laude Fellowship | Fellowship in Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH; Residency in Internal Medicine, University of California, San Francisco Medical Center; Internship in Internal Medicine, University of California, San Francisco Medical Center Certification | North Carolina Medical License Board Eligible, Cardiovascular Disease Board Certified, Internal Medicine, 2006

LESLIE H. BOYCE, MD Pediatric Neurology and Pediatric Sleep Medicine Joined Raleigh Neurology Associates 2009 Medical School | M.D. University of Medicine and Dentistry of New Jersey Residency | Pediatrics and Neurology/Child Neurology, Columbia Presbyterian Medical Center, New York City Certification | American Board of Psychiatry and Neurology, Neurology with Special Competence in Child Neurology 1997, Sleep Medicine 2007

Triangle Physician:

are always available 24 hours-a-day, 7 days a

Can you now do UFEs (uterine fibroid

What is the pain management program, and

week to our patients and referring physician

embolizations) in an outpatient setting?

when can patients return home?

to address any questions or concerns.

Dr Loehr:

Triangle Physician:

The UFE procedure has traditionally been

Patients are treated early in the morning

Post procedure, do you have any follow-up

performed in a hospital setting for many

and the UFE takes about 1 hour. Our pain

imaging done?

THOMAS M. CUNNINGHAM, MD

years. As we have become more skilled in

management protocol begins before the

Dr Loehr:

Interventional Radiologist

performing the procedure and managing

procedure with I.V. antiotics, anti-inflam-

I generally do not order pre-procedure imaging

the expected after-effects (namely nausea

matories, and narcotics.

if patients have a good quality ultrasound

and cramping), many patients can be safely

Following the procedure, we provide a

or MRI. I also do not order post procedure

treated in outpatient facilities without an

personal nurse for the recovery period

imaging in most patients now because the

overnight hospital stay. The efficiency of this

and continue a medical regimen to control

vast majority are asyptomatic and pleased with

approach is supported by several large case

nausea and cramping which are the most

the results. Imaging post procedure patients

studies in the literature.

common after effects post procedure. Our

does not affect their UFE management. If a

Triangle Physician:

protocol is identical to what we use in the

patient has recurring symptoms after UFE, I

Do health care insurance companies cover

hospital setting. Patients remain at our center

usually order enhanced pelvic MRI.

this procedure in an outpatient setting?

until later afternoon when nausea has resolved.

Triangle Physician:

Dr Loehr:

Then, we transition them to oral medications.

What is the communication with referring

Yes. Most large and many local regional

Patients are then discharged with appropriate

physicians?

insurance companies approve UFE in

instructions and prescriptions. As an aside,

Dr Loehr:

appropriate cases. We have over a decade of

many patients tell me that heating pads work

I believe in an open network of communication

successful experience with UFE; and UFE is

wonderfully in mitigating UFE cramping and

between the patients, referring physicians

recognized by many professional organizations

we use these for all our patients.

and the treating physician. In my experience,

including SIR (Society of Interventional

Triangle Physician:

this approach as improved patient care and

Radiology) and American college of OB/GYN).

If patients experience any complications

Some insurance companies do require

after they return home, do they contact their

patients to have services performed by

referring physician or call you? What if it is

For further information, please visit our

specific (in-service) providers or at designated

the weekend?

website at triangleinterventional.com.

facilitates for in-service benefits. We do

Dr Loehr:

Questions in February and March will be

discuss and review any insurance require-

All patients we treat are under our care and we

focused on Varicose and Spider Veins followed

ments or limitations with patients at their

call everyone 24 hours after the procedures

by Pain Management. Please submit your

initial office consultation.

and schedule a 1 month follow-up visit. We

questions to lpritchett@aac-llc.com.

The Triangle Physician | JANUARY 2010

understanding between specialists.

Events and Opportunities to Connect

Joined Regional Vascular Associates and Triangle Interventional Services in 2009 Medical School | University of Tennessee, Knoxville, TN Internship | Transitional Internship, Methodist Hospital, Memphis TN Residency | Diagnostic Radiology, Memorial Medical Center, Savannah, GA Fellowship | Vascular and Interventional Radiology, Medical University of South Carolina, Charleston, SC Board Certification | American Board of Radiology with Certificate of Added Qualification in Vascular and Interventional Radiology

T. SCOTT DZIEDZIC, MS, MD Emergency Department Radiologist Joined Wake Radiology in 2009 Medical School | New York Medical College, Valhalla, NY Residency | Diagnostic Radiology, Duke University Medical Center, Durham Fellowship | Musculoskeletal Radiology, Duke University Medical Center Certification | American Board of Radiology—Diagnostic Radiology

MATTHEW S. FORCINA MD Clinical Cardiac Electrophysiology Joined Wake Heart and Vascular 2009 Medical School | M.D. Temple University, Philadelphia, PA; B.S. Yale University, New Haven, CT Fellowship | Clinical Cardiac Electrophysiology Fellowship, Medical University of South Carolina, Charleston, South Carolina; Cardiology Fellowship, William Beaumont Hospital, Royal Oak, Michigan; Internal Medicine Internship and Residency, Duke University Medical Center, Durham, North Carolina Certification | North Carolina, Training 2001-2004, Permanent 2009-present; South Carolina, Educational, 2007-2009; Michigan, Educational 2004-2006, Permanent 2006-2007

Joined Wake Radiology in 2009 Medical School | Columbia University College of Physicians and Surgeons, New York Residency | Diagnostic Radiology— Chief Resident, Duke University Medical Center, Durham Fellowship | Pediatric Radiology, Duke University Medical Center Certification | American Board of Radiology—Diagnostic Radiology

DAN MCRACKAN, MD Adult Urology with an emphasis on Advanced Laparoscopic and Robotic-assisted Surgery Joined Landmark Urology and Complementary Medicine 2009 Medical School | Medical University of South Carolina College of Medicine, Charleston, SC Medical School Residency | Medical University of South Carolina College of Medicine, Charleston, SC Fellowship | University of North Carolina, Chapel Hill

LAURA T. MEYER, MD Pediatric Radiologist Joined Wake Radiology in 2009 Medical School | Duke University School of Medicine, Durham Residency | Diagnostic Radiology, Duke University Medical Center Fellowship | Pediatric Radiology with special emphasis in cardiovascular imaging, Duke University Medical Center Certification | American Board of Radiology—Diagnostic Radiology

DAVID I. SCHULZ, MD Body Imaging Radiologist Joined Wake Radiology in 2009 Medical School | College of Human Medicine, Michigan State University, East Lansing, MI Residency | Diagnostic Radiology, Duke University Medical Center, Durham Fellowship | Abdominal Imaging, Duke University Medical Center Certification | American Board of Radiology—Diagnostic Radiology

BRENT A. TOWNSEND, MD Pediatric Radiologist Joined Wake Radiology in 2009 Medical School | Duke University School of Medicine, Durham Residency | Diagnostic Radiology, Brigham and Women’s Hospital, Boston, MA Fellowship | Pediatric Radiology, Children’s Hospital Boston Certification | American Board of Radiology—Diagnostic Radiology

Feb. 13, 2010

25TH ANNIVERSARY TRIANGLE HEART BALL Raleigh Convention Center, Downtown Raleigh 463-8353 www.triangleheartball.org 25th Anniversary event raises funds to support American Heart Association research and education for heart disease and stroke, the #1 and #3 leading causes of death in America. Feb. 13, 2010 from 6 p.m.– 11 p.m.

Feb. 13, 2010

BLUE JEAN BALL The third annual Blue Jean Ball, a women’s health benefit , will be held at the Sheraton Imperial, on Page Road, Durham, NC. The event date is Saturday, February 13, 2010. Join the “dress down,sparkle up” event where Blue Jeans are the expected attire. A silent auction, dinner and live band are a part of what you will enjoy during an evening dedicated to raising awareness and funds to provide surgical and medical care to women in East Africa. For ticket or program information, please visit http:// bluejeanball.mc.duke.edu or call (919) 660-2378.

April 7, 2010

NATIONAL START! WALKING DAY Lace up your sneakers and take a walk to celebrate National Start! Walking Day. Walking has been proven to lower heart disease risk and improve wellness. For free walking resources visit StartWalkingNow.org or contact the AHA at 919-4638353.

May 7, 2010

TRIANGLE GOES RED FOR WOMEN LUNCHEON Crabtree Marriott, Raleigh 919-463-8307 www.trianglegoesred.org Celebrate the power of women to join together in the fight against their No.1 killer – heart disease. Enjoy heart health seminars, networking, a healthy lunch and powerful keynote address.

New and Relocated Practices SMITHFIELD HEART AND VASCULAR ASSOCIATES 910 Berkshire Road Smithfield, NC 27577 WAKE HEART AND VASCULAR ASSOCIATES 2076 NC Hwy 42 West, Suite 100 Clayton, NC 27520 DR ERIC DUBBERMAN, WESTERN WAKE SURGICAL 155 Parkway Office Ct, Suite 101 Cary, NC 27518

JANUARY 2010 | The Triangle Physician

Practice Management

Revenue Cycle Management in Physician Practices:

What it Takes to Get The physician revenue cycle is so complex that getting reimbursed per your contract is virtually impossible with traditional methods. In order to collect 100% of your contracted rate, a practice must implement a revenue cycle management solution that effectively incorporates people, processes and technology.

John Reidelbach John J. Reidelbach, founder of Physician Advocates, Inc. (PAI), has degrees in Engineering, Education, an MBA and more than twenty years experience in healthcare. Mr. Reidelbach has developed several healthcare management entities to include IPAs, PPMCs, MSOs and group practices. He is experienced in providing assistance to healthcare entities in all aspects of practice management, operation and strategic development and implementation, education, contact negotiations, data analysis and capital funding.

The physician revenue cycle is so complex

Improvement of the internal

that getting reimbursed per your contract is

revenue cycle which is controlled

virtually impossible with traditional methods.

by the practice will typically result

In order to collect 100% of your contracted

in a 5-15% increase in net

rate, a practice must implement a revenue

collections! This can be achieved

assure the physician-owners of the practice

The majority of practices place a very high

cycle management solution that effectively

in ten (10) steps with an effective

that the activities performed follow formally

priority and value on the coding process.

incorporates people, processes and technology.

implementation process:

set guidelines. Among better performing

Many hire certified coders. Practices can

practices, formal policies & procedures

maximize reimbursement by properly

Human resources.

include: posting charges & electronic

coding for services rendered and by

Good hiring processes, well-

transmission of claims within 24 hours of the

understanding that coding is one of the top

defined job descriptions/duties,

date of service and posting payments within

compliance concerns for most practices. You

clearly communicated expectations

48 hours of receipt by the practice. Posting

must take the appropriate steps necessary to

with standard operating procedures (SOPs)

should have a complete balancing process

ensure that your coding is accurate.

statements, data entry, submitting claims,

articulated in writing for each step in the

tying the transactions posted to the practice

payment posting and then aggressively

billing process. Accountability and respon-

management system to the actual deposit in

managing the Accounts Receivables (A/R).

sibility are critical.

the bank. Working denials within a 48-hour

Previously referred to as billing and collections, today, the process of maximizing patient care revenues is known as â&#x20AC;&#x153;revenue cycle managementâ&#x20AC;? or RCM. This process includes everything from checking eligibility and collecting co-pays to charge coding,

Processes. Written policies and procedures provide guidance for staff to perform their duties. They also

Coding. Coding is the source of compliance concerns as well as denials for most practices.

Internal monitoring of

management includes a regular process of

systems.

analyzing and understanding claims that were

exist. Steps can then be taken to proactively

Better performers monitor their

denied, provides corrective measures, and

eliminate/ greatly reduce denials. Better

the revenue cycle. In an effort to

ultimately ensures payment for the services

performing practices have lower denial

must have access to reports from a Practice

measure and understand how their practices

provided. This should include clearinghouse

rates, and the few they do have are quickly

Management (PM) system that is up-to-date

are performing, these practices continually

denials as well as denials received on the

turned around and resubmitted to the

and sophisticated. Currently, approximately

compare their current as well as their

Explanation of Benefits (EOBs). Statements

payers. Provide regular feedback to your

80+% of medical practices handle their

historical data to similarly situated practices.

should be sent on a weekly basis with balances

staff in an effort to eliminate future denials.

RCM internally and most consultants agree

These same practices also consistently analyze

that have been transferred to patient accounts.

Correct root issues by tracking denials from

that is the way to go, even if a practice has

the data culled from their PM system along

The patient should receive a statement

several points in the practice. Whether you

been poorly run. Why, you might ask?

with information they obtain from their

within 7-10 days of when the balance was

utilize your PM system, your clearinghouse

Control (it is easier to manage that which

clearinghouse. Many practices find tools

moved to patient responsibility, aligning the

reporting, or by implementing a manual

you can control)! Cost (outsourced billing

such as a performance scorecard useful in

statement as closely to the receipt of EOB as

process will depend on the systems you

runs anywhere from 5-8+% of revenues

educating their staff, sharing expectations,

possible. After the initial new patient statement,

have place in your practice. Successful

collected) and you can manage it in-house at

and working toward organizational goals

patients should receive statements and

practices focus on tracking denials from

substantially lower costs.

and objectives.

collection follow-up every thirty days.

the clearinghouse, payment posting, and

To do this correctly, you must possess a thorough knowledge of payer rules and procedures. Additionally, you must continually improve your billing & collections processes. And, to do that, you

The Triangle Physician | JANUARY 2010

turn-around time should be your goal. Denial

Third-party A/R and denial management. Monitoring your denials helps you understand where problems

JANUARY 2010 | The Triangle Physician

Insurance

Evaluating the Lease on Your Business Life

Collections.

stand in relation to industry best practices.

Patient account balances are

Additionally, the practice should benchmark

fee schedule amount for each service (CPT)

growing nationally due to

their own A/R numbers, look at aging,

you provide and ensuring that it is set high

the economy, loss of jobs and

days in A/R, net and/or gross collections

enough to capture all applicable insurance

associated insurance benefits, higher

percentages, average charges, payments and

company reimbursement. Most practices

deductibles, co-pays and co-insurance

adjustments on a monthly basis to monitor

utilize Medicare RVU factors or a percentage

amounts. This trend has prompted practices

for unusual changes or trends.

of the Medicare allowable. Crucial, yet often

to devote more resources to collecting

The following reports should be run on a

overlooked by practices is loading the

I don’t know about you, but I hate getting a laundry list of items from

patient balances. These practices also accept

regular basis:

reimbursement schedules by payer on the

a supplier when I need something for my business. It seems to me

My first lesson to you today is an easy, yet imperative, one: have

credit cards, offer self-pay discounts, and

• Accounts receivable aging – total

PM system. This allows you to report on

whether I’m adding a new insurance carrier, applying for a loan or

your lease reviewed! There are many exposures within a lease that are

set up payment plans for patients. This

• Accounts receivable aging – patient

incidents where the payer has paid less than

hiring a new employee, the list of items needed tends to be long and

sometimes are overlooked by realtors, insurance agents and attorneys.

the negotiated rate. This serious omission is

tenuous.

For most of us, it’s been many years since we looked at what our

insurance companies. Overlapping problems

custom reports. They run reports frequently

should be addressed first.

and review them in a timely manner. This

allows them to determine where they

trend has also created an environment where practices must take a more proactive role in handling patient account balances. Educating patients about their financial responsibility to the practice should also be undertaken by providing well-defined and updated financial policies for patients. These policies should address self-pay discounts, payment plans, interest charged, if any, and collection agency fees. Successful practices invest time before the patient’s visit to determine if the patient has an existing balance. These practices then contact the patient to instruct them to bring the payment with them. Evolving technology including on-line eligibility

balance • Accounts receivable aging – insurance by payer, summary • Credit report – line item and account total • Unallocated/undistributed payments summary

and fee schedule review. Key to managing the revenue cycle is determining the current

by Mike Riddick

Mike Riddick is the president of Riddick Insurance Group Inc, an independent insurance agency in Raleigh, NC. For 10 years, Mike has been helping professionals protect their assets through insurance and financial planning. The motto of Riddick Insurance Group is to help clients protect their standard of living by being better protected today and better prepared for tomorrow. Riddick Insurance Group specializes in helping small business owners with property, casualty, liability, and life insurance planning.

and operator • Financial summaries with payments, charges, and adjustments Information technology. Most practices today utilize some type of PM system. However, better performers fully

one of the most frequent problems we find Recently I had a personal-lines customer call me about a new dental

you from an insurance perspective. You might be surprised at the

practice he was opening with a partner. Of course I gave him a nice

exposures he can protect you from.

practices that do not review their fee

list of items we needed in order to give him an accurate quote. He also

schedules and update them on a yearly basis

called his business partner’s agent for a second quote.

and they don’t give you a laundry list of items and questions so they I was excited about the opportunity, and when we met at his new

can learn about your business, call someone else! If they don’t ask a

recoupment of overpayments. Further, practices

office, we had a great conversation about the new business. It appeared

lot of questions, they can’t know and understand your practice!

must maintain active dialogue with their

to be your typical new medical/dental practice. He had lots of new

payer representatives to make certain they

equipment, a beautiful new office space and a great location with

are keeping abreast of market conditions.

lots of good road frontage. All in all, our client had about $400,000 in

new equipment and lease improvements. He had signed a long-term Communication.

lease, so this will be his location for many years.

Your management team must

communicate

Feeling great about our conversation, I was very surprised when he

denials and create efficiencies by reducing

themselves and other employees as well as

that the other agent was able to produce a quote for him in less than

manual processes.

the physician leadership in the practice.

three hours with an outstanding rate. But I did wonder, “How did the

through most payer’s web sites allow

Technology also reduces the time spent on

Regular meetings should be held, with

other agent understand my client and his practice without spending

practices to use automated systems to

the following:

agendas set in advance to maximize

any time getting to know how the practice was set up?”

check patient’s eligibility and benefits. Better

• Insurance eligibility/benefits

productivity. Data should be provided for

performing practices perform these checks

• Daily electronic claims submission

review and discussion.

before the patients arrive for their visit,

• Electronic patient statements— week-

Better performing practices understand the key indicators

received from payers • Electronic fund transfers (EFTs) received from payers

regularly

amongst

pulled out a quote from that competing agent. I was also surprised

I took the competitor’s quote with me and headed back to my office to begin my task of evaluating what the dentist needed for his insurance

In summary, every practice must strive

coverage. One of the key pieces I had asked him for was a copy of his

to gain faster access to revenue, better

lease. As I worked through my notes, I noticed a critical item in the

realization in gross revenue, and less cost

lease—a clause stating that the dentist is responsible for insurance for

associated with the collection of revenue, i.e.,

the entire building, even though he is only a tenant.

decreased overhead. If you are successful, the

of the revenue cycle and make

• Daily review/correction of electronic

results will yield higher physician income,

I was surprised the dentist was unaware that this common clause

the most of their PM system’s reporting

data interchange (EDI) denial reports

greater job satisfaction for stakeholders,

was a part of his lease. I then understood why the competing agent’s

and improved patient satisfaction levels.

rate was so low—he hadn’t taken the time to evaluate the conditions

capabilities, even if it requires building

My second lesson: next time you work with an insurance agent

provisions such as silent PPOs or extensive

owed by patients. On-line capabilities

• Electronic remittance advice (ERA)

this amount in the event of a total loss, in addition to the $400,000 in

Other problems we frequently find includes

adjudication helps practices collect monies

Reporting and measuring.

of the building is almost $500,000, and he would be responsible for

when consulting with medical practices.

utilize this technology to decrease errors and

ly billing cycle

we were able to uncover a huge potential exposure for him. The value

lease calls for. Call your insurance agent and ask him to review it for

and benefits as well as real-time claim

thereby reducing denials.

By taking the time and effort to evaluate our client’s entire situation,

contents.

and managing each payer contract for

• Adjustment report –by adjustment type

Managed care contracting

of the lease. 22

The Triangle Physician | JANUARY 2010

JANUARY 2010 | The Triangle Physician

Good Business

Medic@l Communication

potential for security breach. There is some significant controversy as

by Mark Wiener BizCom.net

to where in the message the notice needs to occur. Many attorneys have suggested moving the disclosure notice to the beginning of the

Mark Wiener, President of BizCom Web Services has more than twenty years experience working with medical practices, large and small, to aid them in curing their technical, regulatory, management and communication practice ailments. He currently, works with practices to help them manage and minimize their overall IT budgets by providing enterprise-class solutions to small and midsized practices all the while increasing security and improving practice performance, communications and efficiencies.

communication as, by the time the notice is read, the “cat is out of the bag”. Below is a sample message that can be used/edited for email. The information contained in this message may be privileged and confidential. If you are NOT the intended

“Please wait a second…let me just finish this quick email.”

recipient, please notify the sender immediately and

Email Encryption Services

destroy this message.

There is too much risk in sending PHI in a fashion that does not encrypt the email message from when it is written until i’s read with an

Please be aware that it is possible for email

unbreakable encryption methodology. There are systems that meet

communication to be intercepted in transmission or

this standard for secure electronic me sages which require logins to

misdirected. Your use of email to communicate

secure access, provide information about when the information was

It has become very easy to send information around the world at the push of the

protected health information (PHI) to us indicates that

picked up, and allow for the message to expire after a set period of

send button. Medicine is under a strict set of rules (HIPAA) where it is paramount

you acknowledge and accept the possible risks

time. This adds a new layer of security into the mix and would allow

that we think about how and when that communication occurs. I speak with

associated with such communication. Please consider

for a freer discourse.

physicians every day where they disregard the dangers of communicating

communicating any sensitive information by telephone

with a patient or a colleague regarding a patient by email. The electronic

or an office visit. If you do not wish to have your

Getting Paid

communication of PHI (personal health information) between a

information sent by email, please contact the sender

There are a few Insurance companies that are paying for email or

medical provider (staff included) and patients should only be done

immediately.

web visits via pilot programs. Don’t expect most payers to reimburse claims anytime soon. There are providers that are charging email-

using secure electronic messaging. You should not under any circumstances be using public email (AOL, Gmail,

Consent

Yahoo, POL…) as this not confidential in nature.

It is important to get consent from the patient (even if they initiate

Your normal corporate email (POP, IMAP,

the discourse), as it is possible that PHI is can be intercepted in

Exchange) may

transmission or misdirected.

based visits and letting patients know they are non-covered services. riddick insurance group ad.pdf 12/26/2009 9:02:32 PM

not, in itself be any more secure

Here is a sample of informed consent for electronic communications

than the public email services if it

I will be happy to respond to your request, however

was not configured

to do so via email you first must provide your consent,

properly. It is

recognizing that email is not a secure form of

important that

communication. There is some risk that any protected

the transmission from

health information that may be contained in such email

beginning to end is

may be disclosed to, or intercepted by, unauthorized

encrypted. There are ways

third parties. I will use the minimum necessary amount

to improve the security within the system by ensuring

of protected health information to respond. If you wish

that SSL/TLS encryption (a setting that your service provider or

to conduct this discussion via email, please indicate

local IT department can help you with) is enabled when transmitting

your acceptance of this risk with your email reply.

Alternatively, please call my office to arrange a phone

Any PHI transmitted by email should be limited to the minimum

conversation or office visit.

necessary to meet the recipient’s needs. (i.e. if SS#, last appointment

The Provider needs to make sure they are confident of the

date, prescriptions the patient used to take is not needed don’t send it.)

correspondent’s identity. If there is any doubt as to the identity of the sender or that the communication may be compromised, even when

Email Notice

requested by a patient, the provider should decline to use email and

It is highly recommended that you place a notice on your email

redirect to the phone or an office visit.

regarding the confidential nature of the communication and the

The Triangle Physician | JANUARY 2010

CMY

Keep Disclosures to a Minimum

The Right Person

and receiving from the email server.

Documentation Remember the email conversation holds the same correspondence weight as phone conversations, fax or mail exchanges. Make sure that the communication is documented, as appropriate, in the patient’s medical records. JANUARY 2010 | The Triangle Physician

Local Interest

THE RIGHT STUFF

The North Carolina Museum of Natural Sciences in downtown Raleigh houses the bones of two North Atlantic right whales (Eubalaena glacialis), one of the most endangered animals on the planet. Most visitors have seen the articulated skeleton of one of these whales hanging high over the Coastal North Carolina wing. This specimen, nicknamed Mayflower, was one of the first acquired by the Museum and has been on display since 1894—more than 100 years! Museum collections hold a more recent addition—specimen Eg1004 (whose skull is featured on the cover). According to Curator of Mammals Lisa Gatens, this individual (nicknamed “Stumpy” because of its abbreviated fluke, or tail fin) had been tracked by researchers since 1975 up until the time of her death and beaching on the south end of Bodie Island in February 2004. The specimen came to the Museum via multiple vehicles later that spring, and its bones have since become the subject of intense research by Woods Hole Oceanographic Institution guest investigator Regina Campbell-Malone. Ship strikes are a major source of mortality in the North Atlantic right whale population. Vessel-whale collisions often result in major trauma and skeletal fractures, particularly to the skull, jaw bones (mandibles), ribs and vertebrae. Campbell-Malone has been studying mandibles from Eg1004 with the idea that these bones may be the right whale’s Achilles’ heel—a relatively weak bone that bears the brunt of head-on collisions.

Rounds

Pick Out Flu-Fighting Foods

For two years, Campbell-Malone performed

This flu season, making three different food choices can boost your immunity naturally.

CT and 3D laser scans, as well as bone density and other mechanical tests, to determine the mandible’s physical and material properties. She then incorporated these properties into a computer model capable of predicting the bone’s response to applied

by Allen Mask, MD

stress and was able to determine that speed

“The foods you eat are really imperative to living a healthy life,” said WakeMed registered dietitian Emily Ford.

restrictions were a viable management strategy for reducing mortality and serious injury resulting from vessel-whale collisions. Her findings were recently used by the National Marine Fisheries Service to substantiate the use of speed restrictions for vessels 65 feet or larger traversing right whale critical habitat. This ended up being a win-win situation. Shipping companies were initially concerned that slower speeds would cost them time and hence, money. They soon discovered the resulting reduction in fuel costs actually saved them money overall.

The No. 1 place to start boosting

The second immunity booster:

The third immunity booster is

your immunity is the produce aisle.

Fill up a fourth of your plate with

grains, including whole grain bread,

foods rich in proteins.

brown rice and whole grain cereals.

“I always look for color in my fruits and my

“Proteins are actually the molecules that help

“With the whole grains, you can buy these

vegetables, and I want a variety both in color

defend the body,” Ford said.

in bulk quantity, which decreases the costs,”

and in just the type of food,” she said.

Ford said.

PHOTO BY STEVE EXUM

Ford recommended lean proteins, such as Fruits and vegetables are an afterthought

beans and skinless chicken, and occasionally

Studies have shown that a high-fiber diet

in many meals, but Ford said they should fill

a serving of red meat with very little white

can actually make white blood cells stronger

half your plate.

marbled fat.

and more effective disease fighters.

“Some of the nutrients and the vitamins that

“And in selecting fish, pretty much everything

are in fruits and vegetables have an antioxidant

is fair game,” she said.

effect,” she said. Additionally, tuna and salmon are great sources

MUSEUM HOURS:

PHOTO BY JAY MANGUM

Monday-Saturday, 9a-5p and Sunday 12-5p General admission is free. For more information visit naturalsciences.org<http://naturalsciences.org>

Antioxidants provide a layer of protection

of another immunity booster in vitamin D,

for the cells and tissues of the body, just as car

which is also found in dairy products.

wax protects a car’s finish from dirt.

SPECIAL EXHIBIT: “Megalodon: Largest Shark that Ever Lived” opens February 13 and runs through May 9, 2010. At 60 feet long, Carcharodon megalodon was the largest shark that ever lived and a dominant marine predator. While the Megalodon vanished 2 million years ago, its fascinating story inspires lessons for contemporary science and shark conservation. Tickets for the Megalodon exhibit: $7 for adults, $4 for children (5-11), free for members

As originally reported for WRAL News. JANUARY 2010 | The Triangle Physician

The Triangle Physician | JANUARY 2010