ja n ua ry 2 012
New Piedmont Outpatient Surgery Center The First of Its Kind in North Carolina
Also in This Issue Diabetes Management Legal Matters
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2012 Editorial Calendar January Diabetes Banking February Heart Disease in Women Accounting for Medical Practices
June Neurology Sleep Apnea July New Imaging Technologies Electronic Medical Records August Digestive Disease Computer Technologies September Sports Medicine Physical Therapy October Breast Cancer Reconstructive Surgery November Urology Robotic Surgery December Pain Management
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Stokes
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Caswell
Rockingham
Guilford
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Boone, Wilkesboro, Mount Airy, Lexington, Thomasville, Kernersville, Asheboro, Eden, and Statesville
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April Women’s Health Marketing Your Services
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March Men’s Health Vision New Medical Devices
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January 2012
1
Editor’s Note
Healthy Competition Bravo, Piedmont Ear, Nose & Throat Associates! The focus of this month’s The Triad Physician cover story, PENTA has opened North Carolina’s first ambulatory surgery center dedicated to ear, nose and throat services and owned by otolaryngology specialists. The ASC is an extension of PENTA’s participation in a five-year demonstration project to improve health care safety, quality, access and value. It could lead to more single-specialty, physician-owned ASCs across the state, and many believe this would make way for healthy competition and overall improvements in North Carolina health care. This inaugural issue also features four contributors, who have answered the call for timely news and insight. We will continue to invite guest editorials of interest to the Triad medical community. Endocrinologist Michael Brennan, who has specialized training as a diabetologist, details the public health concern of diabetes. Endocrinologist Preston Clark presents a concise overview of diabetes management guided by risk-factor monitoring. Dr. Kerr argues that diabetes measurement of hemoglobin A1c levels is a valuable tool in glycemic control, but only if it is accompanied by proper patient education and understanding of the measured values. Also in this issue, attorney Karen McKeithen Schaede explores the options for opening a medical practice. Ms. Schaede offers unique perspective, having worked as a registered nurse for 10 years. Finally, a note about how The Triad Physician contributes to healthy competition, through competitive advertising rates that make marketing sense, especially if your target market is the Triad medical community. Consider that every month, the magazine reaches approximately 6,000 physicians, physician assistants, nurse practitioners, administrators and hospitals throughout the greater Triad area.
Editor Heidi Ketler, APR Contributing Editors Michael S. Kerzner, D.P.M. Michael J. Brennan, M.D., C.D.E. Preston S. Clark, M.D. Jeffrey S. Kerr, M.D. Karen McKeithen Schaede, J.D., B.S.N Elie Aziz, MBA Photography Anna Paschal Photography Creative Director Joseph Dally Contact Information for Marketing, Media & News: Angie Griffin angie@triadphysician.com 336-509-2209 News and Columns Please send to info@triadphysician.com Subscription Rates: $48.00 per year/$6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401 Every precaution is taken to insure the accuracy of the articles published. The Triad Physician can not be held responsible for the opinions expressed or facts supplied by its authors.
That said, a heartfelt thank you to all who contributed to the January 2012 Triad Physician. We are encouraged by the great start in our mission to serve your medical profession as a trusted information source. We are honored to serve.
Opinion expressed or facts supplied by its authors are not the responsibility of The Tirad Physician. However, The Triad Physician makes no warrant to the accuracy or reliability of this information.
With sincere gratitude for all you do and best wishes for continued success in the new year,
All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser.
Heidi Ketler Editor
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The Triad Physician
No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triad Physician.
Category
Contents
COVER STORY
6
New Piedmont Outpatient Surgery Center Is the First of Its Kind in North Carolina
January 2012
FEATURES
5
Endocrinology
Vol. 1, Issue 1
4
DEPARTMENTS 10 Endocrinology Diabetes Mellitus: The Battle Against a Growing Health Care Problem
Wound Management
12 Legal
Early, Aggressive Treatment of Diabetic Ulcers Can Save Foot
Opening a Practice? Which Professional
Dr. Jeffrey Kerr discusses the importance
Dr. Michael Kerzner offers clinical findings
of patient education about hemoglobin
that underscore the need for immediate
13 News
A1c in proper diabetes management.
and specialized treatment of foot ulcers.
Proper Guidance Helps Patients Understand Hemoglobin A1c Levels
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14 Endocrinology Risk-Factor Monitoring Should Guide Goals for Optimal Glycemic Control
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15 News New Epilepsy Monitoring Unit Equipped for Precise Diagnosis
16 Cone Health News Report Quantifies Impact of Health Care on Economy
January 2012
3
Wound Management
Early, Aggressive Treatment of
Diabetic Ulcers Can Save Foot By Michael S. Kerzner, D.P.M.
Nearly 24,000,000 Americans have diabetes,
continued damage to the involved area;
with 15 percent developing foot ulcers each
treatment of any infection; good blood sugar
year. This results in 60,000 amputations
control; proper nutrition; and evaluation for
annually. Durham County, North Carolina,
possible peripheral arterial disease or other
has the third highest amputation rate in
diseases or illnesses.
the diabetic population based on statistics published through Medicare.
Delaying treatment can be a serious error, and diabetics need to be careful when trying
Part of the problem is diabetics have
to treat the wound themselves. Cleansing
decreased feeling in their feet and often do
wounds with some products can be too harsh
not realize they have an ulcer or wound. In
and can damage tissue. Allowing wounds to
addition, patients and families often do not
get too dry or too wet can slow healing and
know how quickly diabetic foot ulcers can
cause other complications. Patient’s should
break down, become infected and spread
always be encouraged to check with their
into deep tissue.
doctor on any home treatment.
Michael S. Kerzner, DPM, is the attending podiatrist at the Wound Management Institute at Duke University Medical Center. He is a board-certified podiatric physician with many years of experience in limb salvage and reconstruction. Dr. Kerzner earned his doctor of podiatric medicine from Temple University School of Podiatric Medicine in Pennsylvania.
improvement within the first four weeks healed greater than 63 percent of the time
In cases that are slow to heal or getting worse, it
within the following three months.
is important to seek advanced treatment from a
Advanced
comprehensive wound care center.
regular
treatment
options
include:
specialized dressings to promote healing; and
aggressive
debridement;
application of a total contact cast; and use of negative pressure wound treatment devices,
It has been shown that early recognition
While standard treatment is important, it
bioengineered skin substitute and hyperbaric
of foot ulcers is a very important factor in
doesn’t always work. Studies show only 25
oxygen treatment for selected wounds.
preventing amputation and loss of limbs.
percent of diabetic ulcers will heal within
For this reason, it is recommended that
three months, despite the best of care. In
The goal of treatment is always
diabetics have their feet checked every visit
cases that are slow to heal or getting worse, it
the prevention of amputation,
to the primary care doctor, endocrinologist
is important to seek advanced treatment from
preservation of function
or podiatrist.
a comprehensive wound care center.
and maintaining
If an ulcer is found, there is standard
Recent data suggests that if a diabetic foot
treatment available that’s best provided by
ulcer does not show greater than 50 percent
a wound care physician. The treatment may
improvement after the first four weeks of
include debridement (removing unhealthy
appropriate management, then less than 9
tissue); application of dressings to keep the
percent will heal within the following three
wound moist and encourage the body’s own
months. The same study revealed that those
healing process (autolytic debridement);
wounds treated with advanced treatment
use of special shoes and boots to prevent
modalities showing greater than 50 percent
quality of life.
4
The Triad Physician
Endocrinology
Proper Guidance Helps Patients Understand
Hemoglobin A1c Levels By Jeffrey S. Kerr, M.D.
During my endocrinology fellowship, I gath-
milligrams per deciliter to millimoles per liter
ered several journal articles published from
helped his relatives in Europe understand his
1958 to 1976, documenting the discovery and
glycemic control.
characterization of hemoglobin A1c. The recognition of hemoglobin A1c in increased
Most reference laboratories now report
amounts in diabetic subjects eventually led
the estimated average glucose with the
to its use in clinical laboratories.. These initial
hemoglobin A1c. An online calculator,
insights provided a reliable measure of glyce-
smart phone apps, spreadsheets and a free
mic control.
conversion wheel are also available for use in your practice. For additional information,
After hearing his hemoglobin A1c result,
please contact me or visit: diabetes.org/
a patient asked me, “So what does that
professional/eAG.
mean?� Many other patients have asked
With our current efforts to improve measures of health
Dr. Jeffrey Kerr completed his residency training at the Moses H. Cone Memorial Hospital Internal Medicine Program, where he also served as the chief resident. He completed his endocrinology fellowship at Southern Illinois University School of Medicine. Now, Dr. Kerr provides endocrinology care at Eagle Physicians & Associates in Greensboro.
insufficiency, chronic liver disease, anemia, blood loss, transfusions, or erythropoietin
care, hemoglobin A1c levels certainly will remain a focus.
therapy. To learn more about factors that
Yet, we must recognize the limitations of this test. We also
org/factors.asp
must communicate the results effectively with our patients.
Other markers for glycemic control include
interfere with this lab test, visit www.ngsp.
total glycohemoglobin, fructosamine and a similar question. People with diabetes
I now share the estimated average glucose
1,5-anhydroglucitol (GlycoMark). On occa-
mellitus are often familiar with blood
with each patient. The estimate usually
sion, I have ordered fructosamine or 1,5-anhy-
glucose
milligrams
matches the median glucose on home
droglucitol when unable to rely on the hemo-
hemoglobin
monitoring. Discordant results may reflect
globin A1c. Of course, blood glucose meters
A1c is expressed as the percentage of
insufficient home monitoring to establish
and continuous glucose monitors provide
hemoglobin that is glycated.
glycemic patterns, fabricated entries into a
considerable information as well.
per
measurements
deciliter.
in
However,
logbook or a recent substantial change in The A1c-Derived Average Glucose study
With our current efforts to improve measures
glycemic control.
of health care, hemoglobin A1c levels
helped establish the relationship between hemoglobin A1c and average blood glucose
However, the hemoglobin A1c itself may
certainly will remain a focus. Yet, we must
levels. The formula: 28.7 x A1c - 46.7 provides
be misleading in certain situations. Some
recognize the limitations of this test. We also
the estimated average glucose.
conditions and treatments may interfere
must communicate the results effectively
with the measurement of hemoglobin
with our patients.
Translating the hemoglobin A1c percentage
A1c, such as hemoglobinopathies. Other
into the estimated average glucose helped
conditions and treatments change the
For more information visit the website at
my patient appreciate his success in glycemic
relationship between hemoglobin A1c and
www.eaglemds.com.
control. Converting his blood glucose from
average glucose. This includes chronic renal
January 2012
5
Category On the Cover
New Piedmont Outpatient Surgery Center Is the First of Its Kind in North Carolina “The demonstration project is to determine whether single-specialty ambulatory surgery centers are a good way to address the rising cost of medical care. In my opinion, this is a pretty big segment.” – Ronald B Shealy, M.D., F.A.C.S. The new Piedmont Outpatient Surgery Cen-
Human Services, Division of Health Ser-
ter L.L.C. in Winston-Salem will be opening
vice Regulation, State Health Coordinating
this month with great expectation.
Council. The project is designed to improve health care safety, quality, access and value.
It is North Carolina’s first ambulatory surgery center wholly dedicated to ear, nose
The expectation is that the Single Specialty
and throat services and owned by oto-
Ambulatory Surgery Demonstration Project
laryngology specialists. The $2.1 million,
– the first of its kind in North Carolina – will
9,489-square-foot facility is owned by the
exceed the clinical criteria for cost efficien-
physicians of Piedmont Ear, Nose & Throat
cies, while ensuring quality care. It could
Associates (PENTA).
potentially lead to changes that will pave the way for more single-specialty, physician-
It also is one of three separately licensed
owned ASCs to open across the state.
single-specialty ambulatory surgical facilities in the state opening as part of a five-year
“The cost of health care is an important
demonstration project launched by the
national issue, and the ambulatory surgery
North Carolina Department of Health and
center is one of the ways that costs can
be lowered,” says Ronald B. Shealy, M.D., F.A.C.S, the Piedmont Outpatient Surgery Center’s medical director. “We can offer the exact same services as a hospital, and we can do it more efficiently and at a lower cost.”
All Sights Are Set on Demonstration Project PENTA was selected to participate in the demonstration project for the Triad region. Two orthopedic practices were selected for the Charlotte and Triangle regions. “We were the David and Goliath story,” says Cheryl Fatzinger, Piedmont Ear, Nose & Throat Associates practice administrator. “We were in competition with two orthopedic practices, one backed by Baptist and one by Novant. We weren’t backed by anything but our own gumption.” The North Carolina Department of Health and Human Services selection process gave priority to facilities owned wholly or in part by physicians. “Giving priority to demonstration project facilities owned wholly or in part by physicians is an innovative idea with the potential to improve safety, quality, access and value. Implementing this innovation through a demonstration project enables the State Health Coordinating Council to monitor and evaluate the innovation’s impact.” “Doing a single-specialty project gives you an apples-to-apples comparison,” says Dr. Shealy. “If I am doing the full range of procedures within a specialty area, I can be more selective in the types of supplies, in-
Each member of the Piedmont Outpatient Surgery Center team has extensive ENT training and expertise, and a customer-service focus.
6
The Triad Physician
struments and specialized staff I utilize, and I will require fewer of them.”
“The fact is, we will be able to monitor patient progress from the time they call to make an appointment to the time they are discharged from our practice, and that will include the surgical experience,” says Ms. Fatzinger. “We will now be able to evaluate every single aspect of each patient’s care.” According to Dr. Shealy, there has been considerable regional interest in the demonstration project since selection of participants in 2009. “I don’t think there is any question that our other specialty colleagues support us. Almost every day at the hospital somebody asks us, ‘How’s it going? How far along are you?’” says Dr. Shealy.
State-of-the-art ENT surgery suites are specially designed for improved outcomes and efficiencies.
“Certain specialties lend themselves to
of ear, nose and throat services at its main
constantly evaluate and implement new
ASCs, not only otolaryngologists and or-
office in Winston-Salem and satellite offices
ways to increase customer satisfaction. Our
thopedists, but ophthalmologists and oral
in Kernersville and Mount Airy.
quality assurance program also includes
surgeons,” says Ms. Fatzinger. “I’m sure
a patient advocate on the staff, and I don’t
they’re going to be watching this with keen
Subspecialties include neuro-otology; pedi-
know of many practices that actually pro-
interest.”
atric ear, nose and throat (ENT); and facial
vide this service.”
plastic and reconstructive surgery. On-site
PENTA Is a Leader in Quality ENT Care Piedmont Ear, Nose & Throat Associates was formed in 1999, with the merger of two practices and five physicians. Today, PENTA is comprised of nine otolaryngologists, one physician assistant and a team of audiologists. They provide the full complement
“We can save hundreds, if not thousands, on just one case. So this is a huge opportunity to lower the cost of health care for everyone in North Carolina.” – Cheryl Fatzinger, Piedmont Ear, Nose, Throat & Associates practice administrator testing and treatment, and hearing aid sales
Medical Community Is Quick to Support Cause
and service are among the practice’s ancil-
PENTA is opening Piedmont Outpatient
lary services. For the past five years, the
Surgery Center (POSC) for patients who re-
hearing aid service has won the Winston-
quire ENT surgical services but not a hospi-
Salem Journal’s Readers Choice Award for
tal stay. That is often the case for tympanos-
Best Hearing Care.
tomies (tube insertions), tonsillectomies,
computed tomography scanning, allergy
adenoidectomies, sinus surgeries, middle “We are the best in the area, without ques-
ear surgeries, septal deviation repairs, nasal
tion and we are the biggest ENT practice
reconstructions and skin lesion removals.
in the region,” says Dr. Shealy. “We offer
Approximately 90 percent of all surgical
as many ENT services as possible. The sur-
ENT procedures are outpatient, according
gery center is just another way of serving
to Ms. Fatzinger.
the community at a much lower cost.” POSC is specially outfitted for ENT proce-
Post Anesthesia Care Unit
“Exceeding expectations is the overriding
dures. All 14 new staff members were care-
goal of our practice, and the ASC will be an
fully screened and selected for their ENT
extension of that,” says Ms. Fatzinger. “We
surgery experience, a reported average
January 2012
7
of 12 years. Each also has pediatric experience, in addition to adult care, which is important for a practice in which 51 percent of the patients are children. “Even the anesthesiologists we will be using on a routine basis are highly trained and experienced in pediatric anesthesiology,” says Brandi Cunningham, Piedmont Outpatient Surgery Center administrator. “Even though we are being cost effective on the choices we make, we are by no means taking any short cuts with our standards of
Improved health care outcomes and efficiencies, in addition to patient satisfaction, are central to Piedmont Outpatient Surgery Center.
care. We offer the same standards of care, if not better, than patients receive at a hospital,” says Ms. Cunningham.
Insurance Companies Slow to Join Initiative
That’s why it is so amazing to all of us, that
According to federal data, Medicare pa-
down our door.”
insurance companies are not knocking
The new staff members previously worked
tients who have a procedure at an ASC pay
in area hospital surgical services areas, as
an average of 41 percent less out-of-pocket
Opening a medical facility, such as an
well as with PENTA physicians. “So they
expense. Out-of-pocket expenses for other
ASC or radiology center, requires a cer-
know our physicians, they know our staff
insurances depend on a patient’s insurance
tificate of need (CON), and each state has
and they are aware of our patient popula-
plan.
its own laws governing them. According
tion,” Ms. Cunningham says.
to Dr. Shealy, North Carolina’s are among “We can save hundreds, if not thousands,
the toughest in the country. “That’s why
The strategic hiring approach is to ensure
on just one case. So this is a huge oppor-
you don’t see an XYZ outpatient medical
the new POSC health care team functions at
tunity to lower the cost of health care for
facility without having ‘Novant’ or ‘Baptist’
a higher level than is possible within a hos-
everyone in North Carolina,” says Ms. Fatz-
attached to it. It’s too expensive, cumber-
pital, Ms. Cunningham says. “It all makes us
inger. “Hopefully, we can get insurance
some and difficult. All Novant or Baptist has
more efficient, because everyone knows
companies on board and negotiate fair re-
to do is oppose (the CON).”
what to expect and what is expected.”
imbursement rates, but right now, that’s not happening. We will still be able to achieve
By contrast, South Carolina’s CON regula-
Ms. Cunningham notes that POSC was able
cost savings for the patient by filing ASC in-
tions are less cumbersome or expensive,
to fill all ASC positions without having to
surance claims on an out-of-network basis.”
he says. As a result, the state has more pri-
advertise. “Licensed professionals, such as
vately owned centers. “The state of North
registered nurses, who are specialized in a
“The demonstration project is to determine
Carolina has woken up to the fact that com-
field such as surgical services, are notori-
whether single-specialty ambulatory sur-
petition for patients is keener in other states.
ously in short supply, and we had no prob-
gery centers are a good way to address the
It has a lot of employees on its Blue Cross
lem filling any of our positions. I think it’s
rising cost of medical care. In my opinion,
Blue Shield health plan. It’s interested in
because our surgeons have such a good
this is a pretty big segment. The surgical
looking at ways to lower insurance premi-
reputation throughout the hospital system
costs and expenses to the medical system
um money. I hope that’s what the demon-
for patient care. We, literally, have had peo-
are pretty significant. Even nowadays, costs
stration project will prove,” says Dr. Shealy.
ple calling us from the day they heard about
on an outpatient basis are still fairly expen-
the new ASC.”
sive. There should be a break in there for
“It’s been a really incredible experience,
procedures that can be done routinely,
getting the CON through all the planning,
safely, easily,” says Dr. Shealy.
design and construction. We’ve learned a
Even other surgeons have been inquiring. “Any board-certified ENT surgeon is wel-
lot from this. It’s not inconceivable for other
come (to apply for open-access privileges).
“Often the benefit of cost savings goes back
physicians to do it, as well. I hope you’ll
It’s one of the demonstration project crite-
to the patient, because if insurers were to
see more of this type of initiative going on,
ria, and we would welcome them,” Ms. Cun-
save money, theoretically, the premiums
for all of the good things that it does,” Dr.
ningham says.
would be less and would then support a
Shealy says.
downward trend (in health care costs).
8
The Triad Physician
January 2012
9
Endocrinology
Diabetes Mellitus
The Battle Against a Growing Public Health Problem By Michael J. Brennan, M.D., C.D.E.
Today, we face an ever-expanding epidemic
producing insulin, increase by some
of DM usually associated with obesity,
of diabetes mellitus in both children and
3-5percent per year. These are the highest
increased by at least the same amount, if
adolescents.
increases in incidence rates for T1DM ever
not more. Since T2DM accounts for about
seen in our nation.
95 percent of all cases of DM in adults, the
Since 2000 we’ve seen the incidence rates
massive increases of T2DM in kids and
of Type 1 Diabetes Mellitus (T1DM), the
At the same time, the incidence rates of
teens will result in ever greater numbers of
form of DM in which our patients stop
Type 2 Diabetes Mellitus (T2DM), the form
adults having T2DM. If our current estimates of DM prevalence are correct, some 10-15 percent of Americans have DM now. In comparison, it is estimated by 2040, perhaps 35-45 percent of Americans will have DM. The numbers speak for themselves. We face a doubling or even a tripling of patients with DM in the next 30 years. This will be a public health burden that will be unprecedented in history. We will also face a future in which our children and grandchildren may be less healthy as they age than their parents and grandparents have been. Today, we know that most cases of T1DM are due to autoimmune destruction of the pancreatic beta cells that produce insulin, often in patients with a genetic predisposition to autoimmune diseases. Unfortunately, we don’t know how to prevent T1DM, so we are forced to do the next best thing, to control blood glucose values and try to prevent the long-term complications of poorly controlled DM: the microvascular diseases of the eyes, kidneys
10
The Triad Physician
Dr. Michael J. Brennan is an endocrinologist and diabetologist for adults and children. After graduating from the United States Military Academy at West Point, N.Y., in 1968, he served as an infantry officer for six years, then attended the University of Massachusetts Medical School, graduating in 1978. Dr. Brennan subsequently completed an internship, a combined internal medicine-pediatrics residency, and a combined adult and pediatric endocrinology fellowship at the Walter Reed Army Medical Center in Washington, D.C. During his career, he served as a combat infantry officer in Vietnam, as a staff officer at several levels, and as a commander of both infantry and medical units, to include the Letterman U.S. Army Hospital in San Francisco, Calif., and the Womack Army Medical Center at Fort Bragg, N.C. After retiring from the U.S. Army in 1999, Dr. Brennan worked in Goldsboro, N.C., until 2005, when he and his wife, Beverley Brennan, R.N., B.S.N., moved to Greensboro. The Brennans work together in the Pediatric Sub-Specialists of Greensboro practice. Dr. Brennan is chairman of the Moses Cone Pediatric Diabetes Council, medical director for the Moses Cone Nutrition and Diabetes Management Center, co-medical director for the Moses Cone Diabetes Treatment Program and coordinator for the Guilford Endocrine Club, an association of endocrinologists in Guilford County and the surrounding area. He is board certified in internal medicine, pediatrics, pediatric endocrinology and (adult) endocrinology and metabolism. Dr. Brennan is a fellow of both the American College of Endocrinology and the American Academy of Pediatrics.
and nerves and the macrovascular diseases of the brain, heart and peripheral arteries.
We face a doubling or even a tripling of patients with DM in the next 30 years. This will be a public health burden that will be unprecedented in history While we can’t prevent T1DM, we as health care professionals can do more to help prevent obesity and T2DM. At every contact with kids and teens, we need to screen for, and to address the issue of, obesity. Yes, I know that it is difficult and that most parents of obese kids are themselves obese. Yes, I know that it is difficult to exercise, to eat right and to lose weight. And, yes, I know that some obese parents resent having the issue of their kids’ obesity and their obesity discussed by their health care providers. Yet we must. Today, we are losing the battle of obesity and T2DM. If we are to ever win this battle, all of us in health care need to re-dedicate ourselves to take action – to identify kids and teens who are overweight or obese, to assist them and their families to obtain the nutrition education they need to help themselves. We need to continuously work with these families and support them, with the goal of losing weight and preventing T2DM, or treating T2DM very early in the course of T2DM. If we do not win this battle, it will be our children and our grandchildren who will suffer. We must not allow that to happen.
Legal Expertise, Health Care Knowledge Principal Karen McKeithen Schaede, a registered nurse for 10 years, brings in-depth understanding of health care to the practice of law.
We also know that most cases of T2DM are caused by a
Our staff can assist you with: • Medical Practice Formation • Physician Employment • Medical Practice Sale, Acquisition or Consolidation • Medical Joint Ventures • Medical Staff Disputes • HIPAA Issues • Corporate Compliance • Contract Disputes • Employment and Labor Law
combination of resistance to insulin and a gradual decline in insulin production over time. The insulin resistance is caused mainly by the production of cytokines in overly fat adipose cells in patients with a genetic predisposition to obesity and T2DM. Unlike T1DM, however, T2DM can be significantly prevented, if children, teens, and adults never become overweight or obese or if they get their weight under control early in the course of their obesity. Today, some 20-25 percent of children and adolescents are overweight or obese. Population studies and our family photo
1175 Revolution Mill Drive Studio 7A Greensboro, NC 27405 Fax: (888) 392-2707 karen@shadylaw.net www.shadylaw.net
albums show us that our kids and teens tend to be 25-100 pounds heavier than their parents and grandparents were at the same ages. If you want additional proof, just skim through a high school yearbook from 2010 or 2011, then through a yearbook
336-288-4055
from 20-30 years earlier. It’s frightening.
January 2012
11
Legal
Opening a Practice
Which Professional Entity Legal Expertise Health Care Kn Should You Choose?
Principal Karen McKeithen Scha nurse for 10 years, brings in-dep health care to the practice of law
By Karen McKeithen Schaede, Attorney at Law
If you are planning to start your own
after consultation with accounting and/or
practice,
legal professionals.
you
have
some
important
decisions to make. The first is which
Karen McKeithen Schaede is the principal of
type of professional entity you will form.
In general, though, professional limited
This decision will affect many aspects
liability companies are a more flexible
of the resulting practice, such as taxes,
form of doing business, with fewer record-
at Law, PLLC. The
transferability of ownership interests and
keeping requirements than professional
boutique law firm
liability that may be attributed to owners.
corporations. For example, professional
in Greensboro,
corporations are required to hold an an-
N.C., specializes in health law, business/
nual meeting and record minutes. There
corporate law and employment law.
options, with the most common choices
also may be tax advantages to creating a
Before earning her juris doctor from
being either a professional corporation
professional limited liability company, with
Mississippi College School of Law, Ms.
(PC) or a professional limited liability
opportunities for deductions not available
Schaede earned a bachelor of science
company (PLLC). Each has advantages.
to professional corporations.
Both are organizations formed with state
The first step in forming either a
government approval by owners from one
professional corporation or a professional
discipline (e.g., medicine) to provide a
limited liability company in North Carolina
professional licensed service to the public.
is to inform the governing board for your
A health care professional has several entity
Karen McKeithen Schaede Attorney
degree in nursing from the University of North Florida and worked for 10
1175 Studi Gree Fax: ( karen www.
336-288-40
years as a registered nurse. Her clinical background puts Ms. Schaede in a unique position to offer legal expertise to health care clients.
profession of your desire to do so. Each Major differences between professional
governing board has its own set of rules
The issues touched on in this story are
corporations and professional limited
and regulations that must be followed
preliminary
liability companies include:
in the formation process, all of which
prudent health care provider should
involve granting certification that the
weigh when contemplating the formation
governed by bylaws, while profes-
organizer of the professional entity is,
of a professional entity. I will discuss key
sional limited liability companies are
in fact, credentialed by that governing
additional matters to be considered in
governed by operating agreements.
board and, therefore, eligible to organize a
future articles.
• Professional corporations are
• Professional corporations are owned
that
any
professional entity.
by shareholders, while professional
This article is for informational purposes
limited liability companies are owned
Once board certification is obtained, the
only and not for the purpose of providing
by members.
articles of incorporation for a professional
legal advice. Readers should contact their
corporation or the articles of organization
attorney to obtain advice with respect
managed by officers and directors,
for a professional limited liability company
to any particular issue or problem. The
while professional limited liability
are filed with the North Carolina secretary
information contained in this article does
companies are managed by
of state. Depending on the professional
not create an attorney-client relationship
managers or a member/manager.
governing board, you may have to provide
between Karen McKeithen Schaede
a copy of the articles once they have been
Attorney at Law, PLLC, and the reader.
• Professional corporations are
Which is a better option for a medical
accepted and file-stamped by the secretary
practice? That decision should be made
of state.
12
considerations
The Triad Physician
Our staff • Medical • Physicia • Medical Acquisit • Medical • Medical • HIPAA I • Corpora • Contrac • Employm
News
A Big Idea Becomes Reality
The Joint School of Nanoscience and Nanoengineering By Elie Azzi
The Joint School of Nanoscience and
JSNN is a $56.3 million, 105,000 square foot,
located on the second floor. Laboratories
Nanoengineering (JSNN) is a collaboration
state-of-the-art science and engineering
are also available for various aspects
between
building
of nanobioscience and nanomedicine
North
Carolina
A&T
State
with
nanoelectronics
and
applications.
University (NCA&T) and The University
nanobio cleanrooms, nanoengineering
of North Carolina at Greensboro (UNCG).
and
JSNN, located at The Gateway University
extensive
facilities.
JSNN collaborates with Guilford Technical
Research Park South Campus, officially
JSNN’s characterization capability includes
Community College and Forsyth Technical
opened on December 7, 2011, a holiday gift
a suite of microscopes from Carl Zeiss,
Community College on an internship
to Greensboro and the Triad.
including the only helium ion microscope
program that exposes students to the
in the southeast. Also, a visualization
advanced
center allows three-dimension imaging for
JSNN also is actively engaged with
modeling of nanotechnology problems.
kindergarten-12 outreach with Guilford
JSNN areas:
focuses
on
six
nanobiology,
nanometrology,
research
nanomaterials,
nanoscience materials
laboratories analysis
and
and
nanotechnology.
JSNN
computational offers
four
at
its
facility.
County Schools, in collaboration with the
nanoenergy,
nanobioelectronics
technology
A laboratory devoted to developing and
understanding
Gate City Kiwanis Club.
nanomaterials
degree programs, a master of science
manufacturing techniques, a nanobiology
JSNN is aspiring to achieve LEED Gold
in nanoengineering and a Ph.D. in
laboratory and a biophysics lab that
Certification for its building. The economic
nanoengineering awarded by NC A&T
will carry out electrical characterization
impact from the construction is significant:
and a professional master of science in
completes the first floor of JSNN.
nanoscience and a Ph.D. in nanoscience
genomics lab, including specialized labs
awarded by UNCG.
for RNA extraction and cell culture, is
A
• 1 ,966 people worked on the project and logged 382,450 working hours. •T he workers included 71 subcontractors, 97 percent of whom were located within an 80-mile radius. Some 800 vendors/ suppliers were within an 80-mile radius. • I n total, $45 million was expended within this geographic radius, 23.25 percent of which was directed to minority and women-owned business enterprises. •D uring the 2011-2012 fiscal year, Gateway University Research Park and JSNN have created over 40 jobs. As much as $500 million economic impact is expected during the next 10 years to be generated by JSNN
January 2012
13
Endocrinology
Risk-Factor Monitoring Should Guide Goals for Optimal Glycemic Control By Preston S. Clark, M.D.
Goals for glycemic control should be set for the individual patient based on the risks of co-morbidities, life expectancy and complications. Diabetes mellitus continues to be a major
reached and then every six months if the
challenge in the medical field. It requires
patient is stable.
proper health screening, patient education and medical care in an attempt to avoid acute
Goals for glycemic control should be set for
and chronic complications. In addition to
the individual patient based on the risks of
the traditional components of the standard
co-morbidities, life expectancy and compli-
medical
history,
physical
exam
Preston S. Clark, M.D., is a practicing endocrinologist in Greensboro, North Carolina. A graduate of New York University School of Medicine, he completed a residency at Columbia University/ Harlem Hospital Center and an endocrine fellowship at the University of North Carolina-Chapel Hill. Dr. Clark is an affiliated physician with Cone Health. He can be reached at (336) 373-0311.
and
cations. General guidelines suggest a goal of
laboratory evaluation, the standards of care
6.5 percent, a pre-prandial plasma glucose of
continue to change and expand.
90-150 mg/dl and a peak postprandial plas-
angiotensin
ma glucose of 180 mg/dl. It should be noted
continues to be the mainstay of therapy.
Optimum glycemic control has many ben-
that the capillary blood sugar level is 10-15
Of recent note is the reminder that treating
efits. These include a decreased incidence
percent lower than the plasma level. Some
below goal, in particular, the diastolic blood
of acute complications, such as diabetic
devices may automatically make the conver-
pressure, may be harmful. Studies have
ketoacidosis and non-ketotic hyperosmolar
sion for you.
shown that coronary events do increase with
receptor
blockers
(ARBs)
diastolic pressures below 70-80 (J curve).
coma. Others include prevention and slowing the progression of chronic microvascular
The increased risk of cardiovascular
complications of nephropathy, retinopathy
disease in association with diabetes is well
Another risk factor modification should
and neuropathy. Most important, glycemic
documented. The reduction depends upon
include dyslipidemias with goals of moving
control reduces the diabetes-related deaths
the comprehensive management of all the
LDL cholesterol to less than 100 mg/dl,
and all-cause mortality.
risk factors associated with diabetes. These
triglycerides to less than 150 mg/dl and HDL
include coexisting coronary artery disease,
levels to greater than 40 mg/dl.
The two primary ways to monitor glycemic
dyslipidemia and elevated blood pressure. Retinal disease is a microvascular
control are self-monitored blood glucose hemoglobin
The management of hypertension is crucial
complication that diabetes patients also
(HbA1c). Blood sugars are generally checked
in diabetes. Our current blood pressure
face. A serious threat to vision, it is the
before meals and at bedtime. The frequency
goal is below 130/80. Cardiovascular events
leading cause of blindness in middle-aged
varies depending on the intensity of the
and mortality are directly related to blood
Americans. To monitor and increase the
treatment and the risk of hypoglycemia. The
pressure, regardless of age, but there appears
chance for early treatment, yearly dilated
HbA1c reflects blood sugar levels over the
to be no added benefit to lowering it below
ophthalmologic evaluations are required.
previous two to three months, but in a few
115/80.
levels
and
glucosylated
Diabetic nephropathy is the leading
genetic variants may not be as consistent or reliable. The HbA1c should be monitored,
The use of angiotensin-converting enzyme
cause of end-stage kidney disease in the
in general, every three months until goal is
(ACE)
United States. The earliest sign of diabetic
14
The Triad Physician
inhibitors,
beta-blockers
and
nephropathy is microalbuminuria, and the
Monitoring for circulation and neurolog-
be treated aggressively and in a
microalbumin-to-creatanine ratio in a spot
ic complications should include annual foot
comprehensive manner, because of
urine collection with a range of 30-300 is
exams. The use of the 10 milligram monofila-
associated cardiovascular disease.
significant. The presence of microalbumin
ment and tuning fork, checking pedal pulses
•G oals for glycemic control must be
warrants the initiation of therapy with an
and deep tendon reflexes, along with visual
ACE inhibitor or ARB, even if the patient is
inspection, should be done at each visit. Any
• I t is important to screen for albuminuria
normotensive. Early referral to a nephrologist
questionable pathology should be referred
and treat with ACE inhibitors or ARBs.
is strongly recommended.
for more detailed evaluation by a podiatrist,
• S creen for and refer patients for annual
individualized.
dilated retinal exams.
neurologist or vascular surgeon. Nerve damage associated with diabetes
• I nspect the feet at each visit and provide
can be quite variable. A neurologic exam
The subject of diabetes mellitus care is
should be done at each office visit. In addi-
significant and treatment even more so. The
tion to eliciting a history of pain, numbness,
latter will be discussed in another setting, but
educators, dieticians, ophthalmologists,
paresthesiae, early satiety and erectile dys-
the important points from this discussion of
podiatrists and cardiologists in this team
function, a test of sensation and deep-tendon
the standards of care include:
approach to diabetes care.
reflexes should be performed. Strict control of blood sugars decreases the incidence and progression of neuropathy.
comprehensive exam yearly. •U se other specialists, including nurse
• Tight control of blood sugars reduces microvascular complications. • All atherosclerotic risk factors must
News
New Epilepsy Monitoring Unit Equipped for Precise Diagnosis The new epilepsy monitoring unit at Forsyth
“About one-third of people diagnosed with
clear, precise diagnosis of epilepsy so we
Medical Center is a dedicated four-bed unit
epilepsy don’t respond to medications,”
can devise a course of treatment specific to
where specially-trained staff can monitor
said Andrew Evans, M.D., medical director,
that person. If medication isn’t working, we
and evaluate patients with seizure disorders
epilepsy monitoring unit, Forsyth Medical
consider other treatment options, including
in a safe environment.
Center. “This unit will help us provide a
surgery or epilepsy devices.”
A specially-designed monitoring room is
Seizures have many different causes, includ-
equipped with state-of-the-art digital equip-
ing head trauma, infection, stroke, congeni-
ment, including EEG (electroencephalo-
tal brain problems and heredity, but in 60-70
gram) and video monitoring. The EEG re-
percent of seizures, the cause is not known.
cords brain waves and physical actions,
Epilepsy affects around 3 million people in
while the video camera records what
the United States, about one in 100 adults.
the seizures look like.
In North Carolina about 80,000 people have epilepsy.
Epilepsy is a neurological condition that causes recurrent seizures.
“There is a great need for epilepsy monitor-
Symptoms can range from a con-
ing in our area,” said Dr. Evans. “We expect
vulsion, in which the person loses
to see more than 100 patients a year, many
consciousness and shakes in the ex-
of them from surrounding counties and
tremities, to a brief staring spell, when
states. Epilepsy is a challenging condition
the person is not aware of what is hap-
because you need a thorough diagnosis in
pening. The part of the brain affected de-
order to treat it properly, and most commu-
termines how the symptoms of a seizure
nity hospitals aren’t equipped to offer this
will appear.
type of specialized testing.”
January 2012
15
Cone Health News
Report Quantifies Impact of Health Care on Economy Cone Health fostered more than $2.2 billion
the overall regional economy grew just 2.9
in additional revenue for local area busi-
percent.
last six years. Currently, $250 million in Cone Health con-
nesses and generated nearly 6 percent of A study of employment trends in the Greens-
struction is under way, including the $18 mil-
boro/High Point MSA estimates that the de-
lion cost of relocation and construction of
These and other economic stimuli are cited
mand for health care practitioners (doctors,
the new Wesley Long Hospital Emergency
in the recent University of North Carolina at
dentists, nurses, etc.) will increase by 27 per-
Department. Last renovated in 1996, the 22-
Greensboro report on “The Economic Im-
cent from 2009 through 2018. Demand for
bed facility reportedly treats a daily average
pact of Cone Health.” Developed by G. Don-
workers in health care support occupations
of 130 patients. It will be converted into a
ald Jud, Ph.D., Center for Business and Eco-
(nursing aides, medical assistants, etc.) will
surgical short stay center when construction
nomic Research at the UNCG Bryan School
grow by 35 percent.
is complete.
tails the value of the health care provider’s
Among other economic contributions,
The new 28,000-square-foot facility, with 49
commitment to the community in terms of
Cone Health is credited with:
treatment rooms, will offer improved privacy
the area’s total employment in 2010.
of Business and Economics, the report de-
jobs, construction and operational funding.
•C reation of 18,198 new jobs in the
for patients and families and more parking near emergency department. It will include
region in 2010. Health care has become an important
• I nvestment of more than $500 million
a clinical decision unit for patients needing
economic engine that powers commu-
in facilities, equipment and informa-
observation or waiting for test results and a
tion technology.
radiology area, with computed tomography,
nity growth, both on the national and local level. According to Cone Health, demand
•D elivery of more than $800 million
for health care in the region expanded 5.4
in uncompensated patient care since
percent annually from 2003 to 2009, while
2001, an amount that doubled in the
X-ray and other diagnostic tools. In addition, ambulance bays will face Elam Avenue.
Welcome to the Area
Physicians Salah Ahmed Abdelhai, MD Moses H Cone Hospital Greensboro
Vijaya Bhargavi Akula, MD Moses Cone Greensboro
Madhu SudhanReddy Badireddy, MD Wake Forest Baptist Medical Center Winston-Salem
David Barry, MD Gastroenterology, Internal Medicine Wake Forest Univ Baptist Medical Center Winston-Salem
Ebere Onyekachi Chukwu, MD PO Box 289 Advance
Christopher Dean Conley, MD Wake Forest Univ SOM Radiology Winston-Salem
16
The Triad Physician
Norman Hessen Garrett, MD
Ramses Vega, MD
Endocrinology, Internal Medicine 3932 Madison Avenue Greensboro
Internal Medicine Moses Cone Internal Medicine Greensboro
Marcum Glenn Gillis, MD
Christopher Alan Wallace, MD
Internal Medicine Wake Forest University Baptist Medical Center, Winston-Salem
Dermatopathology Anatomic and Clinical Pathology 706 Green Valley Rd, Ste 104 Greensboro
Michael Raymond Manogue, MD
Cameron E. West, MD
Internal Medicine Wake Forest University Baptist Medical Center, Winston-Salem
Wake Forest Univ School of Medicine Winston-Salem
Weston Wyatt Saunders, MD
Physician Assistants
Family Medicine Cone Health Family Medicine Greensboro
David Wilde Sillmon, MD 4707 Towne Ridge Dr Greensboro
Amber Bethany Strother, MD Family Medicine Moses Cone Family Medicine Greensboro
The Triad Physician 2012 Editorial Calendar February
Heart Disease in Women Accounting for Medical Practices
March
Men’s Health – Vision New Medical Devices
April
Women’s Health Marketing Your Services
May
Orthopedics – Medical Insurance
June
Neurology – Sleep Apnea
Katie Shaw Gardner, PA 1806 Benjamin Drive Salisbury
July
New Imaging Technologies Electronic Medical Records
August
Digestive Disease Computer Technologies
September
Sports Medicine – Physical Therapy
Brianna Lee Garrison, PA
October
Piedmont Triad Family Medicine Kernersville
Breast Cancer Reconstructive Surgery
Jason Michael Kaylor, PA
Urology – Robotic Surgery
Orthopaedic Specialists Winston-Salem
November December
Pain Management
· Coronary Interventions · Treatment of Peripheral Vascular Disease · DVT Evaluation and Treatment of Venus Reflux Disease (Including VNUS Ablation) · Implantable Cardiac Defibrillators (ICD) · Carotid Artery Stenting · Loop Recorder Implantation · Percutaneous Revascularization (PCI) · Bi-Ventricular Pacemakers · Percutaneous Transluminal Angioplasty (PTA) · Echocardiography (2D and Transesophogeal) · Lipid and Hypertension Management · Treatment of Obstructive Sleep Apnea
David W. Harding, MD, MS
K. Chad Hilty, MD
Board Certifications: Interventional Cardiology, Cardiovascular Disease, Internal Medicine Fellowships: Interventional Cardiology, Cardiology Residency: UNC School of Medicine Medical School: UNC School of Medicine
Jonathan J. Berry, MD, FACC Mihai Croitoru, MD, FACC David W. Harding, MD, MS
K. Chad Hilty, MD Thomas A. Kelly, MD, FACC Alfred B. Little, MD, FACC
Board Certification: Internal Medicine Fellowship: Cardiovascular Disease Residency: University of Rochester Medical School: University of Cincinnati College of Medicine
Hemant Solomon, MD, FACC Richard A. Weintraub, MD, FACC
CLEVELAND CLINIC
FORSYTH MEDICAL CENTER
Forsyth Medical Center is now affiliated with #1 ranked Cleveland Clinic. Forsyth Medical Center has been selected as the Triad region’s only affiliate heart hospital for the Cleveland Clinic — ranked #1 in the nation by U.S. News & World Report, 17 years in a row. This transforms our healthcare landscape forever. With Forsyth Medical Center and Cleveland Clinic working together, you have the best of the best on your side, with access to the most advanced research, programs, technologies and techniques in the world of cardiovascular medicine and surgery. Now there’s no need for you or your loved ones to travel for most cardiac care. Or to compromise. The #1 choice in cardiovascular care is right here for you.
www.forsythmedicalcenter.org/heart www.clevelandclinic.org/heart