WNYP Roch vol 1 2018

Western New York

rochester and the finger lakes

PHYSICIAN the local voice of practice management and the business of medicine

VOLUME 1 / 2018

Leading-Edge Cancer Research at Wilmot Brings New Hope to Patients

Minimizing Legal Liability for the “Curbside� Consult

Radiologist-Referring Physician Collaboration Yields Impacts

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Contents WESTERN NEW YORK PHYSICIAN I VOLUME 1 I 2018

rochester and the finger lakes

Risk Management

03

Minimizing Legal Liability for the

“Curbside” Consult

14

Promoting Communication Between Referring and Consulting

Physicians

COVER STORY

05 Leading-Edge Cancer Research at Wilmot Brings New Hope to Patients With today’s expanded understanding of the complex immune system, scientists and physicians at the Wilmot Cancer Institute dedicated to cancer research work together to discover ways to harness the bodies native strengths to fight and heal and streamline speed of access to bring targeted new treatments to the bedside.

12

Medical Research

Low Levels of Alcohol Good for

the Brain

13

Physical Inactivity Linked to Higher

Risk of Lung, Head/Neck Cancers

12

Pancreatic Tumors May Require a

One-Two-Three Punch

In Wine, There’s Health:

Clinical Features

Perspective

Prior Authorizations 20

21 UR Medicine Boosts Women’s Heart Health with New, Larger Team

15 Reconstructive Surgery Restores Function after Head and Neck

Delay Treatment for Painful

Arthritic Conditions

Cancers

17 Innovative Models of Caring for Seniors in Upstate New York

23 The First Wave of the Future of Medicine is Already Here

14 17

Practice Management

10

Radiologist-Referring Physician

Collaboration Yields Impacts

The Doctor-Patient Relationship: 27

Satisfaction and Communication

Preferences by Generation

25

What’s New in Area Healthcare

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 1

from the publisher

Western New York

Visit us Online www.WNYPhysician.com

PHYSICIAN the local voice of

practice management and the business of medicine

publisher

Welcome to the latest issue of Western New York Physician – Rochester and the Finger Lakes where you will find informative stories and articles about and for physicians in western NY. Welcome Readers— In this issue, we meet leaders at the Wilmot Cancer Institute to hear about the latest advancing successes in immunotherapy and how the Institute’s active participation in clinical trials is speeding up access to new treatments as they develop.

The launch of sister publication Western NY Physician Magazine - Buffalo and the Great Lakes has created expanded opportunities to share expertise with a regional reach of more than 6,500 physicians and healthcare stakeholders across western NY. As healthcare systems and practices establish care centers in the outlying regions, Western NY Physician Magazine stands out as a single source to reach all physicians in the region.

Upcoming regional discussions on: • Robotics • Genetic Testing • Urological issues in Men and Women • Expanding Role of Telemedicine • Eye Disease Take Part in the Conversation Share your expertise in a relevant way with your medical colleagues when you contribute an article, take part in a Q&A or offer your expertise in an interview. Please email or call me directly to discuss suggestions, focus, timing and submission criteria. In the meantime, please enjoy the numerous other articles within the issue.

As always, we thank each of our supporting advertisers -- your continued partnership ensures that all physicians in the region benefit from this collaborative sharing of information and provides the WNYP editorial staff with a deep pool of expert resources for future interviews and articles.

Thank you for reading.

Andrea WNYPhysician@gmail.com (585)721-5238

2 I VOLUME 1 I 2018 WNYPHYSICIAN.COM

Andrea Sperry creative director

Lisa Mauro writer

Randi Minetor marketing director

Aileen Semler medical advisory board

Joseph L. Carbone, DPM John Garneau, MD Johann Piquion, MD, MPH, FACOG Catherine C. Tan, MD Chuck Lannon John R. Valvo, MD, FACS contributors

Randi Minetor Julie Nusbaum Annie Deck-Miller Peter Ronchetti, MD Al Kinel, MBA Marla Cybul, RN, MBA Roswell Press URMC Press Jacobs Institute Press Colleen K. Mattrey, Esq Rebecca Schallek, MD contact us

For information on being highlighted in a cover story or special feature, article submission, or advertising in Western New York Physician WNYPhysician@gmail.com Phone: 585.721.5238 reprints

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Although every precaution is taken to ensure the accuracy of published materials, Western New York Physician cannot be held responsible for opinions expressed or facts supplied by its authors. Western New York Physician is published bi-monthly by Insight Media Partners.

risk management

Minimizing Legal Liability for the “Curbside” Consult By: Colleen K. Mattrey, Esq., Smith Sovik, Kendrick & Sugnet, PC (Buffalo Office)

“Curbside” consults are common place in medical practice The next level of “curbside” consult is often utilized in surand can take on several different forms depending on the pargical practices, and is what I like to call the group consensus ticular circumstances and players involved. No matter the spemodel. Often, surgical practices will have weekly or biweekly cialty, physicians, much like any other profession, often engage meetings to discuss complex surgical cases coming up, review in conversations with their colleagues about how to manage radiological studies, and discuss the best course of treatment or treat a patient in effort to find the best possible approach for the patient. Arguably, this could be deemed as proactive for the best possible outcome--a “fresh pair of eyes” if you will. quality assurance, however, depending on how and if the meet“Curbside” consults can be as simple as two (2) colleagues runing is managed and documented, it is unlikely to be protected ning into each other in the cafeteria and discussing a patient, or from disclosure in litigation; hence, opening up its participants as complex as a colleague calling in another to assist in the opto liability as a member of the same surgical practice who is erating room. Both scenarios have differing levels of legal risk. impacting medical decision making for the patient, or at a Let’s start with the most benign of the “curbside” consult, minimum, buying them a trip to a deposition. It is extremely which I will call the unidentified patient. A colleague finds important for physicians who engage in this practice to ensure you at the nurse’s station and runs an that the appropriate safeguards are put anonymous scenario by you about a into place before this level of consult “Curbside” consults can be as patient that is having a difficult posteven occurs, including but not limited simple as two (2) colleagues operative course that they cannot figto redaction of all identifying patient ure out a reason for. They ask if you information, and not documenting the running into each other in the have ever encountered this situation discussion in notes or patient records. and what testing you may have or- cafeteria and discussing a patient Finally, there is the SOS “curbside” dered in effort to properly deal with consult. You are called by a colleague the situation. You are never told the who is in the operating room and enpatient’s name or any other identifying information. You never counters a problem. They ask you to come in and “take a look”. see the patient or talk to their family. You offer your colleague The minute you step foot in that operating room, your involvesome suggestions and move on with your day. ment in this patient’s direct care has just moved up to the next From a true legal perspective, it would be very unlikely that level. While this patient is unaware you are there and parthe patient being discussed would have any legal recourse ticipating in their care, you now know this patient’s identity. against you. Medical liability is predicated a doctor-patient You are laying eyes on them. More than likely, you will become relationship, which requires there to be an understanding bedirectly involved in the decisions made from this point forward tween the individual physician and the patient that a relationand/or may perform surgery on this patient. You have now asship is being formed, and, the physician takes on a duty to sumed a relationship, a duty, and possibly, a liability. engage in direct involvement and participation in that patient’s A prime example of this scenario realized into a four (4) year care. A prime example of an exception to this rule, is the indemedical malpractice case in Western New York. Physician A, pendent medical examination, where a physician is hired by an a gynecologist, was performing a hysterectomy on a 53 year attorney or insurance company to review records and examine old morbidly obese patient with a history of fibroids. The pathe patient to determine if there is a basis for diagnosis and tient was also a practicing Jehovah witness, and specifically detreatment for a particular condition. In those cases, the paclined the use of blood products. After exposing the surgical tient is told directly and in writing before the examination that area, Physician A encountered fibroids that were ten (10) times there is no doctor-patient relationship, that the physician will the normal and anticipated size, and which had adhered to the not be offering any direction or advice to the patient, and that patient’s bowel. He immediately called Physician B, a general the physician is not responsible for their treatment in any way surgeon, to come in and assist with separating the bowel from going forward. the pelvic structures so that the hysterectomy could be com WNYPHYSICIAN.COM VOLUME 1 I 2018 I 3

pleted. Physician B was able to separate the structures and before leaving the operating room, did a thorough examination of the bowel and surrounding structures to check for any excessive bleeding or perforations. Prior to Physician A resuming his completion of the hysterectomy, he asked the patient’s husband for consent to use blood products in light of significant blood loss caused by the additional procedure necessary to separate the bowel from the pelvic structures. The patient’s husband declined. Physician A returned to the OR and completed the hysterectomy. The patient went to the recovery room in stable condition, with close monitoring due to volume loss. She was transferred to the floor, and all of her post-operative care was ordered by Physician A. Approximately two (2) days later, the patient began to decline.

She was complaining of severe abdominal pain and shortness of breath over the course of twelve (12) hours. A CT failed to show any perforations in the surgical area. Blood work was negative for signs of infection or internal bleeding. A few hours later, she coded and was pronounced dead. On autopsy, it was revealed that this patient did in fact have a large perforation in the bowel, however, it was in an area that was not near the surgical site. It was further noted that the bowel tissue in the area of the perforation was friable and had evidence of long term breakdown. Physician A and B were sued, and physician B paid the lions share of a $575,000 settlement.

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In analyzing Physician B’s liability, especially in light of the autopsy findings that the perforation was no where near where Physician B had operated, Physician B failed to dictate his own operative note. He relied on Physician A to dictate a dual report. While Physician A’s report did include the basic information regarding what Physician B did during the surgery, it did not include information on how Physician B became involved in the case, critical information regarding what Physician B observed, what approach and instruments he used, and most importantly, it did not include statements regarding his inspection of the bowel before turning the remainder of the surgery over to Physician A. It also did not include statements regarding his medical judgment, or what his understanding was about management of the patient’s post-operative care. Three (3) different defense experts agreed that medically, the care by Physician B was appropriate, and the findings on autopsy showed a lack of causation attributable to Physician B. However, the lack of documentation by Physician B made the case impossible to defend to a lay jury.

So what is the takeaway? Avoid answering questions? Refuse to offer advice or become involved in a patient’s care? No, that just is not realistic nor would it do anything to advance patient care or fulfill your ethical obligation to the medical profession as a whole. The key is to understand what is being asked of you, to take it seriously, and to make sure that if you do cross the line and become directly involved with a patient’s treatment course, that you document appropriately.

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cover story

Leading-Edge Cancer Research at Wilmot Brings New Hope to Patients

Photo: Matt Wittmeyer

Randi Minetor

T

Photography courtesy of URMC

here’s been a seismic shift in the long-term prognosis for many cancer patients in recent years, and nowhere is this trajectory toward hope more prevalent than at UR Medicine’s Wilmot

Cancer Institute, a component of Strong Memorial Hospital in Rochester.

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 5

“People are living longer and better with their cancers,” said Jonathan W. Friedberg, MD, MMSc, Wilmot Cancer Institute director. “We are at a true renaissance time in cancer. Over the last ten years, scientific understanding of cancer has increased to a level where we are able to more rapidly move discoveries into treatment. Cure rates are going up, and many people are able to live much longer, normal lives with cancer.”

At Wilmot, teams of physicians and scientists are working together to develop more effective, less toxic therapies and to find ways to overcome cancer’s resistance to treatment. Through clinical trials, they bring promising therapies to patients from across upstate New York, and they are at the leading edge of national efforts to improve the lives of patients during and after treatment.

“Cancer is far more complex than we ever thought,” Friedberg noted. “It’s taken decades to figure out the complexities of the immune system, for example, and use it as a weapon against cancer. It’s like the computer chip, which seems to double in speed every year. We have so much more knowledge now that we can accelerate the pace of translating this information to the clinic. We’re at a real tipping point.”

Advancements in Immunotherapy Immunotherapies are helping to tip the balance against cancer. The concept of using the body’s own immune system to tackle tumors dates back to the 1890s, but only recently have

scientists been able to harness that power into effective treatments for a variety of cancers. Among the better known immunotherapies is the targeted drug Keytruda® (pembrolizumab), which gained national visibility three years ago when former President Jimmy Carter received it for his metastatic melanoma, resulting in remission.

CAR (chimeric antigen receptor) T-cell therapy is another immunotherapy that has garnered national attention. Last year, it became the first form of gene therapy ever approved by the U.S. Food and Drug Administration. In December, Wilmot became the first cancer center in New York State to become certified to offer it to patients with lymphoma.

CAR T-cell therapy involves removing a patient’s own fighter T-cells, reengineering them in a laboratory so that they can find and attack cancer in the body, and injecting these cells back into the patient. Although it can be accompanied by serious side effects, this treatment is considered a potentially transformative therapy for lymphoma patients who have relapsed and have aggressive disease.

“These cells act like a living drug,” says Friedberg, a lymphoma specialist. “You can still find these cells in the body months later, hunting for recurrence of cancer. We’ve seen here a subset of patients with highly refractory lymphomas who respond very well to treatment with this approach. We only have a few years of follow-up, but they seem to be cured. This has had a major impact for these patients.”

“People are living longer and better with their cancers”

Photography courtesy of URMC 6 I VOLUME 1 I 2018 WNYPHYSICIAN.COM

Wilmot’s commitment to clinical trials of innovative therapies made it a leading candidate for the CAR T-cell trial and its early use, Friedberg said. “We have been using this treatment in the last couple of years at our center, even though it was just approved a few months ago,” he said. “It was developed in several labs across the country, and we were a major contributor to the clinical trials which led to FDA approval.”

The challenge of pancreatic cancer The success of immunotherapy in treating some cancers has led to progress in finding a more effective way to treat pancreatic cancer, which often has a poor prognosis. David Linehan, MD, clinical director at Wilmot and a surgeon who also runs a research laboratory focusing on pancreatic cancer, partners with Marcus Noel, MD, and other Wilmot medical oncologists in translating Linehan’s bench science into a clinical trial of an experimental immunotherapy drug to help people with advanced pancreatic cancer.

Several new drugs target non-cancer cells in the tumor that support tumor growth. In pancreas cancer, these cells are immunosuppressive, shielding the cancer from attack by the immune system and effectively blocking the anti-tumor immune response. Combined with chemotherapy, drugs that block these cells can allow an immune response to take place so the patient’s own immune system can be harnessed to attack the cancer cells. “We’re seeing this type of immunotherapy work,” said Linehan. “We understand the biology, and why it works in some cancers and not in others. Targeting these pathways and supercharging the immune system to destroy cancer cells is working. It gives us a whole other way of thinking about therapy.”

“We’re seeing this type of immunotherapy work”

Wilmot built part of its reputation for success with immunotherapy on its history of bone marrow transplantation, one of the first therapies to harness the power of the immune system to fight blood cancers. Cancers including leukemia, Hodgkin and non-Hodgkin lymphoma, multiple myeloma and others are often treated with bone marrow transplant.

“The main way these transplants work is that you’re giving the patient a new, healthy immune system,” said Friedberg. “We’re the only bone marrow transplant center in the region—last year, we did 177 bone marrow transplants.”

Bone marrow transplants require a matching donor, who may be more difficult to find than patients realize. “You have a twenty-five percent chance of a brother or sister being a match,” said Friedberg. “With smaller families more common, finding a match is hard for many patients.”

Research oncologist Omar Aljitawi, M.B.B.S., at Wilmot is exploring two ways to overcome this obstacle to transplant.

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 7

Photography courtesy of URMC

Discoveries in bone marrow transplants

The first is using umbilical cord blood, which does not need to be as close as the match required for traditional bone marrow transplants. Second, patients may benefit from a haploidentical transplant—one in which the donor’s human leukocyte antigen (HLA) is a half match to the recipient’s HLA. This option opens the pool of potential donors to more parents and children, who are more likely to be a half-match.

Wilmot is exploring which of these strategies is more effective.

“We are participating in a randomized trial comparing umbilical cord blood to the haploidentical blood,” said Friedberg. “We can do both procedures at our center, and hope to definitively answer the question.”

Research beyond immunotherapy In addition to the search for cures and treatments that make cancer a livable disease, Wilmot conducts research that falls into two other programs it calls Hallmarks of Cancer and Cancer Control and Survivorship.

“In the Hallmarks of Cancer program, we’re looking at genetics and epigenetics, cases in which gene signaling has gone awry,” said Linehan. “Cancer is the unrestrained growth of cells, so we’re looking at gene signals that support the unregulated growth of cancer cells.”

The more researchers discover about this gene signaling, the better they can target their research toward determining the causes of specific cancers—which can lead to screening tests to find patients at high risk for disease, as well as therapies that can target the cancer at its earliest stage.

The Cancer Control and Survivorship program, led by Gary Morrow, Ph.D., and Karen Mustian, Ph.D., MPH, is devoted to addressing treatment toxicity and side effects, the late effects of cancer, and ways to help those battling cancer and long-term survivors live better.

“Gary’s motto is, ‘We take care of good people going through bad times,’” said Linehan. “Through a national network that executes important clinical trials, this group has made many highimpact advances in the effort to minimize side effects associated with cancer treatment, so that quality of life is improved for cancer patients.”

One example of the issues Morrow’s team studies is known colloquially as “chemo-brain,” the cognitive impairment and memory issues that arise during and after some kinds of chemotherapy. Research conducted at Wilmot by Michelle Janelsins, PhD, MPH, validated chemo-brain, which had been disputed as an effect of treatment by doctors since chemotherapy became widespread. Janelsins’s laboratory now works to find ways to prevent this side effect of some cancer treatments.

“When people think of chemo brain, they think it’s something patients have during chemo,” said Linehan. “It lasts longer than 8 I VOLUME 1 I 2018 WNYPHYSICIAN.COM

that—it can be a permanent impairment. So preventing it makes sense. Dr. Janelsins’s scientific groundbreaking studies that help us understand the biological mechanisms that cause chemo-brain will have great impact on improving the quality of life of cancer survivors.”

A unique focus on older patients Cancer is a more frequent diagnosis in older people—in fact, more than sixty percent of cancer patients are over the age of 65, in part because people are living longer than ever before in human history. Despite this prevalence, however, older patients are underrepresented in clinical trials, leaving a knowledge gap about the treatments that are safest and most effective for aging patients.

Wilmot has risen to meet this challenge by developing one of the largest geriatric oncology programs in the country. Led

by Supriya Mohile, MD, MS, the Specialized Oncology Care and Research in the Elderly (SOCARE) team runs a clinical service at Highland Hospital where physicians evaluate older patients and tailor their treatment. Mohile’s team looks beyond their patients’ chronological age to their physical fitness, the presence of other health conditions and other factors to identify a treatment approach that will be better tolerated and avoid unnecessary hospitalization.

“Let’s say you have colon cancer, and you have surgery, and they test your lymph nodes,” Friedberg said. “If they are positive, studies suggest chemo helps prevent the cancer from occurring. But the trials were done with patients in their forties.

Now what happens in the common situation where you’re seventy-five or eighty, and you have this problem? Oncologists may decide the patient is too old to treat, or the patient may turn down chemo, or they treat and it’s too rigorous for the patient. We need to do better than just looking at age for treatment decisions.”

What’s next Clinical trials are the key to getting new, promising therapies to the people who need them, said Linehan, and Wilmot Cancer Institute has an unwavering commitment to connecting patients with the opportunity to have access to therapies still in development. “My pancreas cancer patients don’t have ten years for me to figure things out in mouse models,” he said.

“We are committed to rapid translation. We work with drug companies and patient advocacy groups to rapidly translate scientific discovery into clinical trials. They should be open and available to every patient.”

The Wilmot Cancer Institute has also dedicated significant resources to the development of a “tumor bank,” a way to collect and store surgical specimens so that important research can be done on human tissue. By collecting and storing these

Photography courtesy of URMC

specimens, researchers can study them to understand why some patients have good responses and others do not, with the ultimate goal of personalized medicine, or delivering to an individual patient a therapy that is highly likely to work for their specific tumor.

Wilmot participates in many clinical trials involving a wide variety of therapies, but not all of these involve the development of new drugs. For example, Friedberg’s own research may result in the repurposing of a common nutrient to improve the effectiveness of an existing treatment for lymphoma. He has designed a randomized clinical trial that will compare the outcomes of people who receive standard rituximab therapy alone (plus a placebo pill) to a combination of rituximab and 2000 I.U. oral vitamin D daily for three years. They also will conduct genomics tests on tissue samples to determine subsets of patients who might particularly benefit from vitamin D therapy.

Low levels of vitamin D appear to be a factor in the outcomes for patients with follicular lymphoma, the most prevalent form of non-Hodgkin lymphoma in the United States. “One of our findings suggested that if you have follicular lymphoma and a low vitamin D level, your prognosis is worse,” Friedberg said.

“Vitamin D appears to help the immune system fight lymphoma when it’s treated with drugs. If we give vitamin D to patients, it helps them get better.”

The clinical trial for vitamin D therapy is currently running at Wilmot as well as at the Mayo Clinic, MD Anderson Cancer Center in Houston, Texas, the Winship Cancer Institute at Emory University, and other major cancer institutes. “Today,

if you come to a doctor with lymphoma, they don’t check your vitamin D level,” said Friedberg. “In the future, this may become a standard part of treatment.”

The findings of this trial could have implications not only for the treatment of this disease, but they could also have an impact on the cost of treatment. Today one treatment option for follicular lymphoma is Revlimid® (lenalidomide), a drug that can cost upwards of $15,000 per month. If the vitamin D trial shows benefit, the price difference would be significant. “These patients may be able to take vitamin D for 3 years—an over-the-counter vitamin at a markedly decreased cost,” said Friedberg.

The Rochester advantage Wilmot’s size provides advantages that lead to important discoveries, Friedberg said. “It’s easier to collaborate, less intimidating and bureaucratic, yet large enough to have the critical mass of patients and investigators,” he said. “You can be too big or too small, but the size of Rochester lends itself to advancements that are perfectly done in a place of our size. There are lots of areas that we can focus on and excel.”

Even with many developments approaching practical use and the pace of medical discoveries moving more briskly than ever before, this is a time when government funding has slackened and fewer dollars are available to take research to the clinical trial phase. “Cancer research is so important, so how does the average person advocate for it?” Linehan posed the question.

“Be engaged in understanding the importance of research. If you’re a patient or a loved one, be open to exploring clinical trials and talk to you doctors about it. Are there any investigational trials available for your type of cancer? There’s a lot of nihilism in pancreatic cancer—both doctors and patients saying there’s nothing we can do. If patients do not enroll in clinical trials, we are unable to progress and discover more effective treatments for cancer.”

Randi Minetor is a medical journalist and freelance author in Rochester, NY.

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 9

practice management

Radiologist-Referring Physician Collaboration Yields Impacts Transformation Based on Collaboration with Referring Physicians and Image Exchange Lowers Cost, Improves Care, and Enhances Provider/Patient Sat Al Kinel, MBA • Marla Cybul, RN, MBA

S

pecialists such as radiologists, surgeons,

and oncologists often identify ways to im-

prove care and operations through workflow redesign, but collaborate with each other to redesign processes to make a difference much less frequently. Also, many Buffalo and Rochester area practices leverage Regional Health Information Organization (RHIO) services to access clinical content and diagnostic images, but there are others that either do not yet use it, or do not leverage the full potential. A unique feature of the RHIOs in New York include an Image Exchange that provides access to diagnostic images to authorized clinicians. Several practices have found that combining cross-practice collaboration, use of RHIO and Image Exchange, with process re-design can be very impactful.

10 I VOLUME 1 I 2018 WNYPHYSICIAN.COM

Strategic Interests (SI), a Rochester-based health tech consulting firm, has worked with University Medical Imaging (UMI), as part of a program offered by CMS, called Transform Clinical Practice Initiative (TCPi). The program, managed by New York eHealth Collaborative (NYeC) helps PCPs and specialists gain strategic, business, operational and technical capabilities for the future. SI is one of the transformation agents delivering this program in the Rochester and Buffalo regions as part of the NY Practice Transformation Network (PTN).

SI works with practices to assess many aspects of their operations to uncover ways they can improve outcomes, reduce unnecessary hospitalizations, tests and procedures, and identify and manage patients most at risk. As a result of this program, the total cost of care will be reduced and the health of our population will be improved.

When SI assessed UMI it was immediately apparent that this practice was efficient, effective, and performing at a high-level. However, they openly embraced the TCPi process to identify ways they can become even stronger.

When challenged to find ways to lower the total cost of radiology services and improve patient care, they turned to working with referring physicians, specifically urologists, and orthopedic surgeons specializing in sports medicine.

They also are working with Excellus to ensure that the most cost-effective protocols are in place and approved for reimbursement.

The American College of Radiology (ACR) has a program designed to accomplish this called R-SCAN (Radiology Support Communication & Alignment). R-SCAN is a structured approach to develop a joint action plan bringing radiologists and referring clinicians together to improve

imaging appropriateness and streamline image ordering. They also incorporate novel use of a clinical decision support tool called Care Select to reinforce ordering imaging exams of high value for patient care.

SI facilitated conversations with UMI and ACR, and UMI deployed R-SCAN with several practices of referring physicians to decrease unnecessary imaging, enhance the appropriateness of tests ordered, and reduce unnecessary exposure to radiation. They jointly established a protocol with their referring base and promoted the use of the RHIO to search for prior exams that may eliminate the need for additional tests. When available, the IMAGE EXCHANGE is used to access the images and immediately proceed with diagnosis and care treatment.

Eric Weinberg, MD, Medical Director of University Medical Imaging described the process of working with Strategic Interests on transformation within TCPi “Preparing for the emerging models of payment for our practice including MIPS and MACRA seemed at first glance to be an insurmountable challenge for a busy outpatient Eric Weinberg, MD radiology practice.

Partnering with Strategic Interests was critical to our success in this process. SI was with our team to teach us what we needed to know so that we could be successful. SI also helped facilitate contact with the appropriate ACR leaders to help us understand the value of the new R-SCAN program. We chose to do a custom R-SCAN project on proper ordering of MRI hip arthrograms. Through the R-SCAN process, in close cooperation with the relevant referring sports medicine physicians, we achieved a success in reducing the number of incorrectly ordered MRI hip arthrograms. SI has also played an important role in advising our practice in how to approach our largest 3rd party payer, Excellus, to evaluate and negotiate adjustments to medical policy, protocol, and reimbursement.”

Nancy Fredericks, R-SCAN Director at the American College of Radiology commented on the work done

by UMI, “It was exciting to see the results achieved by UMI through their collaboration with urology and sports medicine colleagues. R-SCAN is truly a mechanism to

bring radiologists and referring physicians together to encourage the ordering of valueadded imaging exams and to facilitate communication.

Congratulations to the team!”

R-SCAN can be expanded to many other types of referring physicians and can have a dramatic impact when Nancy Fredericks, R-SCAN Director at the American College of Radiology. established communitywide. While radiologists are not yet actively participating in payment reform initiatives or Accountable Care Organizations, the industry is considering how the critical discipline can participate. Driving initiatives like this prepare radiology practices to participate and make significant, positive impacts on the financial and clinical outcomes we need to repair our health system. We feel that radiologists can succeed if the work with referring physicians to combine:

• education and communication such as R-SCAN • effective rollout of industry-standard ordering tools like Care-Select • adoption of services available from organizations like the Rochester RHIO to access imaging history, reports and studies Radiologists driving initiatives like this can be viewed as leaders in the industry. Payers are constantly looking for ways to reduce reimbursement. Radiologists can shift from a defensive position of justifying rates and prior-authorizations, to an offensive position collaborating with the payers, health systems, and specialists to improve overall care while simultaneously reducing cost. Of course, payers, including CMS, will need to recognize the role of the radiologists in this shift, and should be willing to share some of the financial savings generated.

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 11

medical research

In Wine, There’s Health: Low Levels of Alcohol Good for the Brain While a couple of glasses of wine can help clear the mind after a busy day, new research shows that it may actually help clean the mind as well.

The new study, which appears in the journal Scientific Reports, shows that low levels of alcohol consumption tamp down inflammation and helps the brain clear away toxins, including those associated with Alzheimer’s disease.

“Prolonged intake of excessive amounts of ethanol is known to have adverse effects on the central nervous system,” said Maiken Nedergaard, MD, DMSc, co-director of the Center for Translational Neuromedicine at the University of Rochester Medical Center (URMC) and lead author of the study.

“However, in this study we have shown for the first time that low doses of alcohol are potentially beneficial to brain health, namely it improves the brain’s ability to remove waste.”

The finding adds to a growing body of research that point to the health benefits of low doses of alcohol. While excessive consumption of alcohol is a well-documented health hazard, many studies have linked lower levels of drinking with a reduced risk of cardiovascular diseases as well as a number of cancers.

Nedergaard’s research focuses on the glymphatic system, the brain’s unique cleaning process that was first described by Nedergaard and her colleagues in 2012. They showed how cerebral spinal fluid (CSF) is pumped into brain tissue and flushes away waste, including the proteins beta amyloid and tau that are associated with Alzheimer’s disease and other forms of dementia. Subsequent research has shown that the glymphatic system is more active while we sleep, can be damaged by stroke and trauma, and improves with exercise.

The new study, which was conducted in mice, looked at the impact of both acute and chronic alcohol exposure. When they studied the brains of animals exposed to high levels of alcohol over a long period of time, the researchers observed high levels of a molecular marker for inflammation, particularly in cells called astrocytes which are key regulators of the glymphatic system. They also noted impairment of the animal’s cognitive abilities and motor skills.

Animals that were exposed to low levels of alcohol consumption, analogous to approximately 2 ½ drinks per day, actually showed less inflammation in the brain and their glymphatic system was more efficient in moving CSF through the brain and removing waste, compared to control mice who were not 12 I VOLUME 1 I 2018 WNYPHYSICIAN.COM

exposed to alcohol. The low dose animals’ performance in the cognitive and motor tests was identical to the controls.

“The data on the effects of alcohol on the glymphatic system seemingly matches the J-shaped model relating to the dose effects of alcohol on general health and mortality, whereby low doses of alcohol are beneficial, while excessive consumption is detrimental to overall health” said Nedergaard. “Studies have shown that low-to-moderate alcohol intake is associated with a lesser risk of dementia, while heavy drinking for many years confers an increased risk of cognitive decline. This study may help explain why this occurs. Specifically, low doses of alcohol appear to improve overall brain health.”

Additional co-authors include Iben Lundgaard, Wei Wang, Allison Eberhardt, Hanna Vinitsky, Benjamin Reeves, Sisi Peng, Nanhong Lou, and Rashid Hussein with URMC. Nedergaard maintains research labs at both URMC and the University of Copenhagen in Denmark. The study was funding with support from the Department of Navy’s Office of Naval Research, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.

Pancreatic Tumors May Require a One-Two-Three Punch One of the many difficult things about pancreatic cancer is that tumors are resistant to most treatments because of their unique density and cell composition. However, in a new Wilmot Cancer Institute study, scientists discovered that a three-drug combination can simultaneously target the cancer cells as well as the other harmful, inflammatory cells within the tumor, to improve survival.

The research builds on previous scientific data from the lab of David C. Linehan, MD, and may define a more personalized approach to treating pancreatic cancer. Ultimately, physicians will use information from the pancreas tumor biopsy about volume and predominance of cancer cells and non-cancerous inflammatory cells that impact the immune system, and then plan the best treatment.

“People with pancreatic cancer don’t have 10 years to wait for the next new drug,” said Linehan, a surgical oncologist, director of clinical operations at Wilmot, and the Seymour I. Schwartz Professor and Chair of the Department of Surgery at the University of Rochester Medical Center.

“Our approach is based on evidence that this disease has particular characteristics involving both the tumor and the immune response,” he said, “and we believe that treatment must address all sides of the problem.”

In fact, more than 80 percent of a pancreatic tumor is comprised of cells that are not malignant cancer cells. But many of these non-cancer cells, called tumor-associated macrophages (or TAMs) still play a vital role in promoting cancer by preventing the immune system from attacking the cancer. In addition to TAMs, pancreatic tumors are also comprised of and surrounded by tumor-associated neutrophils (TANs) that further block the immune system when pancreas cancer is present.

(The cancer recruits these detrimental “helper” cells, TAMs and TANs, from the bone marrow.)

Patients who have a high number of TAMs and TANs in their biopsy samples have a poorer prognosis. In general, survival odds for pancreatic cancer are dismal and the incidence is rising, fueling an urgent need for improvements in treatment through research.

The objective of the study, which was published in the British medical journal Gut, was to target TAM and TAN with a combination of experimental drugs that would reduce their numbers and allow the body’s own immune defenses to act appropriately and fight the cancer, and to boost the effectiveness of standard chemotherapy. The study was conducted in mice but researchers also performed correlative analyses on human pancreatic tumor samples.

Results showed that targeting TAM and TAN—as well as the cancer cells—improved antitumor immunity and chemotherapy response better than using any single therapy.

The Gut journal also published an accompanying editorial by a German physician and research leader in pancreatic cancer, who said the Wilmot study provides a strong rationale for using combinations of drugs to overcome immune evasion in pancreatic cancer and other solid tumors.

Linehan began this investigation at Washington University, where he was lauded for bringing novel and innovative therapies to patients with hard-to-treat cancers. Since joining the URMC and Wilmot in 2014, he’s continued to carry out pancreatic cancer studies in partnership with Washington University and other scientists. In 2016 the national Pancreatic Cancer Action Network awarded Linehan $2 million to continue clinical studies of immunotherapy treatment for patients whose disease has spread beyond the pancreas.

Physical Inactivity Linked to Higher Risk of Lung, Head/Neck Cancers New studies suggest sedentary lifestyle, like smoking, poses significant cancer risk

By Annie Deck-Miller An increasing body of evidence suggests that a lack of exercise can cause a wide variety of diseases, but physical inactivity is not currently recognized as a risk factor for cancer. Two research teams led by Kirsten Moysich, PhD, MS, Distinguished

Professor of Oncology in the Department of Cancer Prevention and Control at Roswell Park Comprehensive Cancer Center, have identified a direct association between physical inactivity and two different types of cancer: lung cancer and head and neck squamous cell carcinoma (HNSCC) — adding to a growing list of cancers linked to sedentary lifestyles.

The researchers used a large database of Roswell Park patients who had completed a questionnaire assessing their level of physical activity throughout adulthood. They compared those diagnosed with lung cancer or head/neck cancer with individuals who had come to Roswell Park with a suspicion of cancer but were determined to be cancer-free. Both studies found that those who reported no history of regular, weekly, recreational physical activity had a higher risk of cancer than those with a habit of at least one regular weekly session of physical activity.

“What is significant is that this increased risk was found even in people who had never smoked and were not overweight,” says Rikki Cannioto, PhD, EdD, MS, Assistant Professor of Oncology in the Department of Cancer Prevention and Control at Roswell Park and co-first author on both studies. “This adds to the growing body of evidence that, much like smoking or obesity, physical inactivity is an independent but modifiable risk factor for cancer.”

Although many studies have reported an association between physical inactivity and cancer, this is the first to systematically examine lifetime physical inactivity as an independent risk factor. “This different approach allowed us to identify the most sedentary segment of the population that is most at risk,” adds Iris Danziger, MD, Clinical Assistant Professor in the Department Otolaryngology at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, co-author of the study in head/neck cancer.

Considering that current reports suggest that the majority of Americans are not sufficiently active, these findings have broad and significant implications.

“The link between physical inactivity and cancer was consistently found in both men and women, normal-weight and overweight individuals, and among both smokers and nonsmokers,” adds Dr. Moysich. “Our findings strongly suggest that physical activity should be actively encouraged as part of a multidisciplinary cancer care, survivorship and prevention program.”

The research was supported by the Roswell Park Alliance Foundation and by grants from the New York State Department of Health (project no. C019286) and National Cancer Institute (project nos. P30CA16056 and T32CA108456).

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 13

risk management

Promoting Communication Between Referring and Consulting Physicians The Risk: Lack of communication between providers may result in poor coordination of care. This may include a delay in diagnosis or treatment, the failure to order diagnostic testing or act upon abnormal test results, or the failure to prescribe appropriate medications. Clearly defining the roles and responsibilities of the referring and consulting physicians will promote safe and effective patient care.

Recommendations: 1. A tracking system should be in place to determine if the patient obtained the recommended consultation.

2. Referring physicians should develop a process for determining whether a report hasbeen received from the consulting physician.

3. All consultation reports must be reviewed by the referring physician prior to being placed in the patient’s medical record.

4. If a patient has been non-compliant in obtaining the recommended consultation, follow-up is necessary. Document all attempts to contact the patient and any

discussions with the patient, including reinforcement of the necessity and reason for the consultation.

5. If a report is not received in a timely manner, contact the consultant to determine if the patient has been seen and whether a report has been generated.

6. Consultants should routinely send reports to referring physicians in a timely manner.

These reports should include the: • findings • recommendations including interventions • delineation of provider responsibility for treatment and follow-up of test results Reprinted with permission from Dateline, published by MLMIC, 2 Park Avenue, Room 2500, New York, NY 10016. All Rights Reserved. No part may be reproduced or transmitted in any form or by any means, electronic, photocopying, or otherwise, without the written permission of MLMIC.

Helping providers, payers, and vendors, prepare for payment reform and to collaborate and utilize technology to improve care and lower costs: • Selection, adoption and integration of EMRs and other IT solutions • Population Health and Disease Management • Patient Centered Medical Home (PCMH) and Meaningful Use (MU) • MACRA/MIPS or Participation in an ACO • Enhancing Transitions of Care

Expertise with: • Health Systems, Hospitals, IPAs and ACOs • Primary Care, Pediatrics, OB, Geriatrics • Behavioral Health • Radiology • Ophthalmology • Oral Health/Dental • Post-Acute/Long-Term Care • Surgery Centers

Strategic Interests is engaged by the NYS Department of Health through NYeC to help providers in Upstate NY with this transformation through a series of no-cost programs. Please contact us to see if you are eligible, or to discuss other ways in which we can assist you.

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585-797-2360

clinical

Reconstructive Surgery Restores Function after Head and Neck Cancers

by Randi Minetor

Head and neck tumors often require surgical removal, leaving the patient with unsightly scars and a loss of function of some portion of the throat, mouth, or jaw. This can lead to nutritional deficits and devastating psychological and social effects. When this happens, reconstructive surgeons can play a critical role in restoring the ability to swallow, eat, or speak normally.

“With the increasing tumor burden that head and neck surgeons are encountering, reconstructive surgeons are meeting the challenge,” said Heather Lee, MD, facial plastic and reconstructive surgeon at the Quatela Center for Plastic Surgery in Rochester. “We have to keep in mind that it’s not just a hole— we have to reconstitute the function of the head and neck. We want to be able to put people back together and improve quality of life.”

Generally, people take the function of their head and neck for granted, Lee noted, but eating, talking, and swallowing are all functions that can be lost to cancer.

Free-flap reconstruction is the gold standard for many complex reconstructions, a procedure that involves taking tissue— including bone, muscle, nerves, and veins and arteries— from other parts of the body and reimplanting it where the tumor was removed from the head or neck. The “flap” contains the blood vessels that keep this section of tissue alive, and the surgeon attaches these vessels to healthy ones in the head and neck, re-establishing blood flow through the flap. This procedure is particularly effective in reconstructing large areas in the head and neck. Reconstructive surgeons can also connect nerves from the harvested tissue to the recipient site to restore sensation to the affected area.

“There is an armamentarium of tools to help with reconstruction, including near infrared angiography,” said Lee. “While performing the tissue harvest in the thigh area, for example, a dye is introduced through an IV, and using a special imaging system in the operating room, we can visualize the vasculature in the tissue, aiding the flap harvest. This technology is now being investigated as a means to evaluate native tissue perfusion, so we can predict which patients will have wound healing complications, and work to avoid them.”

Reconstructive surgeons repair everything from small cancers on the face to large, complex tumors that affect multiple functions. “When we consider our reconstructive plan, we identify the tissues affected. The defect may only involve skin, but often with larger tumors, it may also involve soft tissue, muscle, mucosa and bone,” she said.

Rehabilitation often involves a multispecialty approach, including a nutritionist, physical therapist, speech therapist, oral surgeons, and dental oncologists, who install dental implants and fit patients with dental prostheses. “Many head and neck patients require a gastric feeding tube during treatment,” said Lee. “The goal is to rehabilitate quickly so that patients can begin using their oral cavity for eating and drinking.”

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 15

The Quatela Center is one of many medical centers using 3D printing to plan and individualize surgical reconstruction. “We have utilized 3D printing to assist us in ear reconstruction as a result of genetic abnormalities, trauma, or cancer,” Lee said.

“It can also be used for trauma reconstruction, and in head and neck reconstruction of the mandible and oral cavity.”

The medical team takes a CT scan and creates a 3D model of the patient and the tumor, Lee explained. “You can then have plates and cutting guides individually customized for the patient. Titanium plates can be pre-bent to fit the shape of a patient’s bony structure, and 3D printing can help with the operative procedure. For example, it can be used to guide where to cut the fibula, a common donor site. The technology helps increase precision, and expand the extent of our preoperative planning. This can increase the cost of the procedure, but also minimizes time in the operating room so patients have less time under anesthesia, which can decrease complications. We are trying to optimize all of these factors to improve patient outcomes.”

Down the road, Lee said, there may be advances that will make it possible for doctors to regenerate lost tissue instead of reconstructing it by borrowing from other areas of the body. “If you have surgery on your tongue, maybe one day we will be able to regenerate part of that tissue, so the patient can have a fully functioning tongue again,” she said. “There is a lot of potential that we have yet to realize and implement into day-to-day medical care for these patients.”

The opportunity to restore function attracted Lee to facial plastic surgery early in her career. She graduated from the UniAmerican HIFU

D VVEER R T I TS IE S R SE R S AA D

versity of Pennsylvania in Philadelphia with her undergraduate and master’s degree in biotechnology, and earned her medical degree at the University of Louisville School of Medicine in Kentucky, where she received an award for Outstanding Performance and Excellence in Otolaryngology. After a five-year residency in Louisville in Otolaryngology-Head and Neck surgery, Lee came to the Quatela Center to complete a fellowship in facial plastic surgery with a focus on both aesthetics and function.

“I loved head and neck surgery,” she said, “and I had a wonderful mentor who was a head and neck surgeon. But I became more intrigued with how we can help make patients whole again.”

In addition to cosmetic facial plastic surgery, Lee’s specialty is in Mohs reconstruction and auricular reconstruction. She has traveled around the world to provide surgery to people in medically underserved countries, most recently with the HUGS Foundation which was started in Rochester, NY, by Dr. Vito Quatela. “Most patients in the US are treated for congenital abnormalities, but in some countries, children are literally thrown into the garbage because of it,” she said. “The parents feel like God is punishing them. Many countries don’t have the medical support for this very difficult and complex surgery. It’s challenging and fascinating from a surgical standpoint, but it’s also the social implications that are compelling. I am grateful I can try to help.”

Randi Minetor is a medical journalist and freelance author based in upstate New York.

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clinical

Innovative Models of Caring for Seniors in Upstate New York

By Julie Nusbaum

Dr. Diane Kane, president and founding physician of Pillar Medical Associates seen here with colleague Dr. Brian Heppard.

As upstate New York’s senior population continues to rapidly grow, several models of innovative care have emerged to meet the needs and interests of its aging community. Many of the trends address the individual’s interest to retain autonomy, and remain in the least restrictive environment for as long as is possible and feasible.

Often, the least restrictive environment is initially homebased care, and for the past thirteen years, Dr. Diane Kane, who is president and founding physician of Pillar Medical Associates, PC, has pioneered a model of care that brings medical services to seniors in their place of residence, wherever that may be. “Our patient is the center of this model, and our care is patient-centered care,” she says. “Our model is predicated on the belief that the more we can keep our patients out of emergency rooms and hospitals, the better off they will be.”

Pillar Medical Associates seeks to treat the patient holistically along the entire continuum of care, and according to Dr. Kane, “our team will follow the individual throughout their journey.” Such a journey might begin in an independent setting, and if a patient becomes more frail or has memory issues, continue into to assisted living, assisted living memory care, and finally to skilled nursing home care if needed. The advantage of

this model of care is that, in addition to expertise in traditional internal medicine, “we bring to the table geriatric expertise and a palliative skill set which is unique,” adds Dr. Kane, who is Board-certified in Internal Medicine, Geriatrics, and Hospice and Palliative Care. In addition to her responsibilities with Pillar Medical, Dr. Kane is Chief Medical Officer of St. Ann’s Community in Rochester.

Dr. Kane explains that the premise of this model is that “the individual can live independently with the assistance of a team and an engaged family” and that “we can bring medical services to the individual to keep them out of a nursing home for as long as possible.” Perhaps, she says, “with hospice, individuals can even die in their homes in an independent setting.”

The Pillar Medical Associates team includes Dr. Kane and Dr. Brian Heppard as well as a Registered Nurse and a Nurse Practitioner. The practice serves about 200 patients, with expansion plans that include “identifying established senior communities and bringing medical services to them,” explains Dr. Kane.

One of their first ventures is at Valley Manor High Rise Senior Community, Episcopal Senior Life, where every week, “we go floor to floor to bring medical care to our clients there,” she continues. “We have applied this model successfully within our four walls at St. Ann’s, and now we will be bringing it out into the community.”

Central to Pillar Medical Associates’ care is a MOLST plan, or Medical Orders for Life Sustaining Treatment. On the very first patient visit, the patient fills out the MOLST form and reveals their goals of care in such areas as code status, lung failure, hydration wishes, and hospital or treatment in place plans.

“Once those goals are stated, everyone has to honor the goals,” emphasizes Dr. Kane. “We take it very seriously.” Additionally, whenever a patient has a change in their health status, the MOLST form and goals of care are reviewed and adapted accordingly.

To complement its practice, Pillar Medical has developed partnerships with mobile services to bring needed diagnostic services directly to their patients, including X-Rays, phlebotomy testing, or chest, bone, heart and belly ultrasounds. Fully electronic health records can be accessed during home visits, and are especially helpful in reconciling medications to identify

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 17

The newly opened Green House Cottages on the Jewish Senior Life campus in Brighton, NY consists of three, three-story buildings containing nine long-term care homes. side effects and potential drug interactions. After each patient visit, Pillar Medical Associates provides the patient with a list of their current medications and what each medicine is for.

“We help older adults navigate the complex network of health care services and advocate for our patients with compassion, understanding and expertise,” asserts Dr. Kane. “For those of us who do this, it is a passion and a privilege, and it is the right thing to do,” she adds.

Jewish Senior Life ( JSL) in Rochester recently debuted another exciting and dynamic model of care for aging seniors, its newly completed Green House Cottages. Three new three-story buildings contain nine long-term care homes on the Jewish Senior Life campus and serve 108 residents who moved there from the Jewish Home Farash Tower. Each floor contains a home for 12 residents, complete with kitchen, common area, and private rooms and bathrooms. Every new home has its own staff and self-managed care team. According to Michele Schirano, RN and senior vice president/administrator of the Jewish Home of Rochester, “the Green House Project® is a new model of care about creating a home environment for our residents.”

Research has shown that a homelike environment offers a more natural way of living; it enriches seniors’ lives qualitatively and is cognitively, emotionally and physically beneficial.

Residents of the Green House Cottages have more autonomy and independence in every aspect of their daily routine. This autonomy might include deciding when to wake up, when and what they will eat, and even offering input about the menu.

“The staff members, who are specially trained certified nursing 18 I VOLUME 1 I 2018 WNYPHYSICIAN.COM

assistants (CNAs), are empowered to help residents make decisions and set their rhythm every day,” states Schirano. Staff members, called adireens, provide housekeeping, cooking and personal care, and work to make the cottages feel like home for the residents.

Whether sharing in meals or attending cultural activities, family members are actively involved in many aspects of the Jewish Senior Life experience, and feedback has been enormously positive both from the residents and from their families.

In the short time since their relatives moved into the cottages, families report that their loved ones are more social, more relaxed and more attuned to their natural schedules. Residents are more engaged in their surroundings and empowered by their ability to make choices day to day.

The Green House Cottages are part of a larger transformation project for the Jewish Home of Rochester, which is also renovating the floors of its Farash Tower to incorporate the home model, featuring private rooms and bathrooms, and more common areas for socializing and gathering. Jewish Senior Life’s Green House Cottages were built in conjunction with the nationally-accredited Green House Project® and Schirano reports that outcomes such as “decreases in anxiety, changes in appetite and mood, and increases in family, resident and staff satisfaction” were key factors in bringing Green Houses to Jewish Senior Life’s campus. This ambitious project makes Jewish Senior Life the third largest Green House community in the country and Rochester’s only Green House model all on one campus.

“Green House Cottage residents are coming and the family, Happier at Home develops out of their rooms, making friends, eating beta care plan which details day-to-day activiter, making decisions, adjusting to their new ties and hours per week. In addition, “lines way of living, and in effect, coming to life,” of communication are always open with our observes Schirano. “Living in this environfamilies,” Voelkl remarks. “I talk to most of ment improves physical and emotional health my clients’ families weekly, and provide upand well-being, and improves the overall dates on their progress as well as address any health of our residents.” issues that arise.” Often, companion care serHappier at Home, a non-medical comvices are a 6-9 month transitional measure panion care company based in Buffalo, New to keep a family member in their own home York, offers yet another model with the aim until that is no longer possible. of keeping seniors in their homes as long as All of the caregivers are employed directly possible. By employing caregivers who assist

by Happier at Home and bonded and inclients with activities that are challenging sured. Screening is extensive, and includes a Trent Voelkl, President at Happier at Home, for them, such as errands, cooking, laundry, check of personal references, a state and fedBuffalo, NY. housekeeping and even doctor’s visits, Haperal background check and a 12-panel drug pier at Home helps seniors maintain their screen. In addition, Happier at Home emquality of life in their home environment. With 32 caregivers ployees are registered in the New York State LENS program, who “help to provide companionship and mental stimulation which notifies employers of personal and criminal infractions. to our clients,” Happier at Home offers “comfort and palliative “Our goal is to do what we can to help our clients fulfill their services to fulfill clients’ wishes to remain in their own homes wish of staying in their own home,” says Voelkl. “We want to as long as it is safe and feasible,” says President Trent Voelkl. provide continuity of care, and encourage as much indepenThe caregiving business was not a far stretch for Voelkl, dence as possible, to maintain peace of mind for clients and whose family has owned Buffalo Pharmacies for over 50 years. their families.”

“Over the years, we offered free home delivery for medicine and Whether providing companion care or in-home medical equipment,” Voelkl notes. “Providing good service for our cliservices throughout the health care continuum, or creating a ents is our main goal, and gave us the impetus to branch out nurturing home setting for seniors, Happier at Home, Pillar into the companion care business,” he adds.

Medical Associates and Jewish Senior Life are working on beFamily involvement is key to Happier at Home’s success. half of upstate New York’s older adults to ensure that they age Typically, family members are the initial point of contact for gracefully and independently while aiming to keep them in Voelkl, and often he interacts with the family as much if not their home environments as long as possible. more than the individual client. Together with the individual WNYPHYSICIAN.COM VOLUME 1 I 2018 I 19

perspectives

Prior Authorizations Delay Treatment for Painful Arthritic Conditions Patient-centered care has emerged as a major common goal across the health care industry. By empowering patients to play an active role in their care and assume a pivotal role with their physician in developing an individualized treatment plan to meet their health care needs, this care model can increase patients’ satisfaction with provided services and ultimately improve treatment quality and outcomes, while reducing or eliminating unnecessary costs.

Yet despite these clear advantages to adopting patientcentered care, physicians and their patients often face significant obstacles in putting this concept into practice.

Health insurance company utilization management programs (such as prior authorization and step therapy), can create significant barriers for patients by delaying the start or continuation of necessary treatment and possibly negatively affecting their outcomes. The highly manual, timeconsuming processes used in these programs burden all providers (physicians, pharmacies and hospitals) and divert valuable resources away from direct patient care. Health plans and benefit managers, however, contend that utilization management programs are employed to control costs and ensure appropriate treatment.

The question is, “Who knows best?” Is it a non-physician practitioner at the end of a phone line asking multiple questions? Is it an insurance company whose share price goes up as they make more profit from your premiums?

The answer is simple. Physicians know best. We were trained to look out for our patients’ best interests and take care of them. If a patient has disabling arthritis, which is a mechanical problem with loss of cartilage, who is best equipped to determine the most appropriate treatment? If a physician believes that cortisone injections or physical therapy will improve a patient’s condition to the point they don’t 20 I VOLUME 1 I 2018 WNYPHYSICIAN.COM

Peter Ronchetti, MD President Monroe County Medical Society

need surgery, then they will order it. You, the patient, do not benefit from the insurance company telling us to put you through painful therapy and/or injections if it will not change the course of the disease.

The concept of prior authorizations should be discussed with the parties involved and not dictated by how much money the insurance company allocates for a given condition, or their idea that a procedure is over utilized. In fact, this only delays care and costs both the patient and the insurance company more money in the long run.

Patients come to physicians for guidance and put their trust in us to look out for their best interests so why is it that insurance companies do not believe we are doing this?

Unfortunately, these bureaucratic bottlenecks do not serve patients and cause wasteful spending in our healthcare system.

Physician leaders in this community should be consulted before broad prior authorization programs are implemented. The Monroe County Medical Society (MCMS) welcomes the payers to share their concerns with the MCMS Quality Collaborative. Sitting at this table are physician leaders of the key healthcare stakeholders in our community. This high-quality level of community collaboration serves as a model for other parts of the country and has the ability to translate world-class knowledge into world-class outcomes.

What you don’t need are more barriers to accessing the treatment that your trusted physician recommends. When you see your doctor for your next appointment, ask him or her if the treatment you are getting is based on clinical judgment or your insurance company’s protocol. If it’s the latter, call your insurance company and let them know “Who knows best”.

clinical

UR Medicine Boosts Women’s Heart Health with New, Larger Team

Photo credit: Courtesy of URMC

It is the only program of its kind in Upstate New York

Kathleen Raman, MD, MPH, Vascular Surgeon, Co-Director

Hanna Mieszczanska, MD, Cardiologist

Rebecca Schallek, MD, PhD, Cardiologist, Co-Director

Renee Muchnik, MD, Cardiologist

Jennifer Ellis, MD, Vascular Surgeon

Mary Pudusseri, MBBS, Cardiologist

Lauren Kane, MD, Cardiac Surgeon

Himabindu Vidula, MD, Heart Failure Cardiologist

UR Medicine is tackling the growing, life-threatening problem of heart disease in women with Upstate New York’s largest team of female cardiovascular experts dedicated to the unique health challenges women experience.

The Women’s Heart Program features eight dynamic physicians dedicated to providing multidisciplinary cardiovascular care for women of all ages. The program includes co-directors Rebecca Schallek, MD, PhD, and Kathleen Raman, MD, along with vascular surgeon Jennifer Ellis, M.D., cardiac surgeon Lauren Kane, MD, and cardiologists Hanna Mieszczanska, MD, Renee Dallasen Muchnik, MD, Mary Pudusseri, MBBS, and Himabindu Vidula, MD.

They are supported by more than 70 specialists within UR Medicine Heart and Vascular, providing care at sites across the Finger Lakes Region.

It is the only program dedicated to supporting women’s heart health in Upstate New York.

“This new team meets a vital need for women across our region and Upstate,” said Schallek, a cardiologist. “Women have different needs for heart and vascular care and we are offering a focused, personalized approach to their care.”

The Women's Heart Program provides risk assessment, specialized diagnostic evaluation and testing, and evidencebased, comprehensive treatment.

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 21

“Studies show that 90 percent of women have one or more risk factors for developing cardiovascular disease. It’s important to identify them and work together to minimize them,” said vascular surgeon Raman. “Our mission is to increase awareness and reduce the burden of cardiovascular disease in women by offering personalized care and education.”

Women can receive comprehensive care for a broad range of cardiovascular diseases, including hypertension, diabetes, peripheral vascular disease, hypercholesterolemia and heart failure, as well as those recovering from a heart attack or stroke or who have been diagnosed with sleep disorders and heart disease. They will also partner with UR Medicine’s Maternal Fetal Medicine team to reduce risk of heart disease or events in women during high-risk pregnancies.

Statistics about heart disease and women are staggering: • Cardiovascular disease affects 43 million women in the U.S. • It is the leading cause of death among women, killing one in three.

• Women have a higher lifetime risk of stroke than men.

• As many as 80 percent of heart disease and stroke events may be prevented by lifestyle changes and education.

• The symptoms of heart attack can be different in women versus men, and are often misunderstood – even by some physicians.

• Fewer women than men survive their first heart attack.

Studies show that women, who tend to be the primary caregivers, often ignore their own health needs and focus on responsibilities to their family, workplace, school and aging parents. As a result, they receive a heart disease diagnosis after a life-threatening event or hospitalization.

Some of the warning signs of heart disease are: • • • •

Decreased exercise tolerance; Breathlessness with exertion; Increasing fatigue; Decreased stamina for no clear reason.

Signs of Heart Attack

By Rebecca Schallek, MD

When it comes to the warning signs of a heart attack, men and women are not created equal. As a result, women often ignore their symptoms or discount them as nothing serious—until they are rushed to an emergency department and told they’ve suffered a heart attack. It’s only then that they realize that nausea or achiness they felt earlier may have been an omen.

Women and men can experience heart attacks very differently, and it’s important to know the range of symptoms.

In general, men feel pressure or a squeezing pain in the center of their chest, which may spread to the neck, shoulder or jaw.

This may be accompanied by lightheadedness, fainting, sweating, nausea or shortness of breath.

Some women experience those symptoms, too. However, many do not feel the “hallmark symptom” of chest pain or intense pressure. Instead they feel arm, shoulder or neck pain, fatigue and nausea, which can easily be mistaken as a stomach bug or another minor ailment.

Heeding these warning signs can be a life-saver. Of the 43 million women living with some form of heart disease, one in three will die from it—making it the leading cause of death among women in the U.S. While heart disease can be hereditary, preventive steps can make a difference for many. These lifestyle choices can help reduce your risk: • Don’t smoke. Tobacco use increases the risk of death from heart disease by 2 to 3 times.

• Get plenty of exercise to strengthen your heart.

• Eat a plant-based diet to ensure quality nutrition.

• Monitor your blood pressure and cholesterol levels.

• Minimize chronic stress.

If you are concerned about your family history or personal risk factors, talk with your physician.

Rebecca Schallek, MD, is co-director of the Women’s Heart Program, a part of UR Medicine Heart and Vascular. To make an appointment with the Women’s Heart Program, call 585-275-2877.

22 I VOLUME 1 I 2018 WNYPHYSICIAN.COM

clinical

The First Wave of the Future of Medicine Is Already Here A

medical device innovation center located in the heart of the Buffalo Niagara Medical Campus in Buffalo, NY, known as the Jacobs Institute (JI), tackled a challenging topic in its recently published book The Future of Medicine.

The center’s chairman of the board is business leader and philanthropist Jeremy M. Jacobs, chairman of Delaware North a family-owned hospitality company. He and the JI released the book, which was written by a group of futurists and covers a wide array of topics—from previvors to artificial intelligence (AI) and robotic surgery to a physician morale crisis. Future is about the possibilities that lay before us, if physicians and health care systems work together to push for change that ultimately benefits patients. The JI is already using some of the futuristic technology featured in the report and developing partnerships with other companies.

Robotics Surgical guidance and robots aren’t a new proposition. In fact, if you are an ENT, urologist, gynecologist, orthopedic surgeon, general surgeon, or neurosurgeon, you may

already use a surgical robot. Companies such as Corindus, Mazor Robotics, Stryker, and Synaptive Medical, have robots on the market that are used to treat patients at Kaleida Health’s Gates Vascular Institute (GVI)—just one floor below the JI. Corindus offers a paired system with a surgical robot that inserts devices for percutaneous coronary interventions and a remote lead-lined cockpit with controls so the surgeon can stay safe from radiation. Mazor X and Stryker’s Mako offer robotic arms that are predominantly used for spine surgeries at the GVI. Synaptive Medical’s BrightMatter has a surgical guidance and robotic surgical arm, which work together, for invasive neurosurgical procedures such as tumor removal.

Surgical systems can be pricey, with a da Vinci laparoscopic robot system running about $1.5-$2 million, not including annual service contracts and the cost of single use tools and supplies. Orthopedic robots can cost approximately $1 million. At current prices, there is a case minimum required in order for a hospital to see a return on its investment. With improved cost containment models and improved outcomes, the economics will ultimately prevail,

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 23

with more hospitals adapting this tech wave. Creative payment models, such as pay-per-procedure, will also make robotic surgical systems more attainable, even for small town hospitals.

Robotic technology is improving at a rapid pace. Promises of smaller robots with better access into difficult sites and greater flexibility for use across specialties, make them even more appealing. Additionally, the incorporation of AI into instrumentation and visualization will be a game changer. The end game is robots that perform surgeries autonomously, allowing a single surgeon to oversee multiple operations concurrently. This translates into a cost saving for hospitals and patients alike.

3D Printing/BioMimics The traditional approach to medical education will see a disruption, Future notes, with a focus on adaptive learning.

This shift to self-directed medical coursework is already underway at Stanford and through Khan Academy. The push to provide students with greater hands-on experience in simulated environments will grow exponentially.

Medical simulators have existed for a long time, but the latest computing advances offer a more interactive, realistic experience. The JI houses a Mentice vascular simulator, which allows hands-on experience in selecting and inserting the appropriate devices for endovascular procedures. There is also an explosion of virtual reality (VR) products on the market for medical simulation.

Additive manufacturing—also known as 3D printing—is making a significant splash in the medical realm, with 24 I VOLUME 1 I 2018 WNYPHYSICIAN.COM

education being only one of its facets.

3D printer manufacturers are doing due diligence by partnering with hospitals, researchers, and surgeons to determine how to leverage their technology to provide value. At the end of 2017, Stratasys announced BioMimics, a fee-for-service model for hospitals and surgeons to order custom-made, realistic models for orthopedic and cardiac surgery delivered to their facility for research, surgery, or device testing.

This technology offers a level of sophistication and customization previously unimaginable.

The JI’s biomedical engineers have long collaborated with University at Buffalo (UB) and Stratasys, to develop our signature 3D vascular flow models. Since the JI is located below UB’s Clinical and Translational Research Center and above the GVI, it is well-positioned—literally—to put the 3D models to use for training, testing, and planning.

Through a grant from the James H. Cummings Foundation and a partnership with Stratasys, the JI was able to procure an Objet 500 Connex 3, which is a multi-color, multimaterial 3D printer. Such cutting-edge technology allows for more realistic anatomical designs for endovascular procedure planning, medical training, and endovascular device testing. We offer these upgraded models to everyone coming to the JI. UB neurosurgical residents and medical students visit for training sessions, thrilled by the chance to try their hand at retrieving a clot from the same 3D models that Dr. Adnan Siddiqui, our chief medical officer, uses to plan for complex endovascular surgeries.

These models provide precisely the high-quality, hands-on training that medical students need for the most realistic educational environment.

The scenarios laid out in The Future of Medicine can become reality if physicians and health care systems open our minds to the possibilities. Some forward-looking technology is already in use or well within reach. There is much at stake and much in store for WNY in the coming years, with the ever-changing healthcare landscape.

For the complete book, please visit: http://www.futureof.org/medicine-1-0

new product news

WHAT’S NEW

in

Area Healthcare

HIGHLAND HOSPITAL Highland Hospital becomes first in the area to offer customized weight loss app for patients Highland Hospital is teaming up with “Baritastic,” a weight loss app, to offer a customized experience for patients in the Highland Bariatric Program. By connecting to Highland’s Bariatric Program through the “Baritastic” app, users will be able to more easily share information with their dietitians, access the program’s meal plans, and receive notifications of upcoming support events. Highland is the first hospital in Monroe County to offer this kind of tool for weight loss patients.

The app provides an outline for potential patients to learn more about what to expect on their weight loss journey, both before and after bariatric surgery. It also allows current patients to track their daily food intake and exercise routines. Patients will be able to set reminders for vitamins and supplements, store before and after photos, and set reminders for upcoming support group meetings. The app also has the capability to link to most steptracking devices. The goal is for patients to have more information at their fingertips and to help them stay better connected to the Highland Hospital Bariatric Surgery Center throughout their weight loss journey.

Patients looking to download the app can find “Baritastic” in either the Apple or Google app stores and connect to Highland Bariatric Center using code 410366.

Medical Students Host Anti-Human Trafficking Conference An estimated 17,500 people are trafficked into or around the US each year, and the industry’s proceeds measure in the billions globally, however it remains a largely hidden crime.

Students from the School of Medicine and Dentistry are recently hosted a day-long conference to bring attention to the global epidemic of human trafficking, and educate health

care providers and members of the community about the role they can play in identifying and helping victims.

The event aims to promote advocacy and collaboration between URMC health care providers and local and regional agencies working to battle the problem.

Sponsored by several URMC departments, the Office for Inclusion and Cultural Development, UR’s Susan B. Anthony Center, student groups and community donors, the event includes a keynote speech by internationallyknown human trafficking researcher Parveen Parmar, MD, MPH, associate professor of Clinical Emergency Medicine and chief of the Division of International Medicine at the University of Southern California.

Parmar’s research focuses on health and human rights violations in refugee and internally- displaced populations.

Other speakers include representatives from the Center for Youth, the Rochester Regional Coalition Against Anti-Human Trafficking, the National Center for Missing and Exploited Children (regional chapter), the Angels of Mercy, and the Worker Justice Center.

The issue of human trafficking strikes particularly close to home in Rochester, as our relatively small city

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 25

has staggering numbers of trafficked individuals due to its high poverty rate.

“The issue of human trafficking strikes particularly close to home in Rochester, as our relatively small city has staggering numbers of trafficked individuals due to its high poverty rate,” says second-year medical student Anna Bowen, one of the event coordinators.

“We are hoping our conference raises awareness of an issue that is often forgotten, and engages more health care professionals in anti-human trafficking efforts.”

An estimated 17,500 people are trafficked into or around the U.S. each year, and the industry’s proceeds measure in the billions globally, however it remains a largely hidden crime. Many victims are first exploited as children and teens, and individuals living in poverty or from refugee families are particularly vulnerable.

Exploitation often continues for years, as victims fear for their safety and survival if they try to escape their trafficker.

Physicians, nurses, social workers and other providers have a large opportunity to identify victims when they come in contact with the health care system for such incidents as physical abuse injuries, sexuallytransmitted infections, pregnancy, drug or alcohol abuse, or other issues requiring emergent care. The event will help providers and other members of the community spot the tell-tale signs of trafficking, teach them the steps they can take, and who to contact to connect victims with the help they need.

Deputy Mayor, Dr. Cedric Alexander spoke during lunch on human trafficking being a worldwide, national and local human rights issue. He shared some of his experiences in law enforcement with human trafficking victims. His stories were powerful and gave us a unique insight on how tragically widespread trafficking is in the United States.

The people in the "student organizers" photo are as follows (MS2 denotes second year medical student): Raiaan Ullah, MS2; Susan Greenman, MS2; Marina Seminatore, MS2; Dr. Parveen Parmar; Dr. Adrienne Morgan; Anna Bowen, MS2; Shea Allison Nagle, MS2

Dr. Celia McIntosh, DNP, of the Rochester Regional Coalition Against Human Trafficking and Nichole Thomson, Safe Harbor Coordinator at The Center for Youth educated attendees on the signs to look for with a patient who is being trafficked and the importance of traumainformed care. They emphasized re-framing our perspective on patients to understand their trauma and treat them appropriately.

26 I VOLUME 1 I 2018 WNYPHYSICIAN.COM

practice management

The Doctor-Patient Relationship: Satisfaction and Communication Preferences by Generation

To help healthcare marketers better target their messaging, here are some of the key findings from the research for each age group:

B

rands and marketers alike have many things to consider in today’s ever-changing healthcare landscape. Are patients happy with their relationships with their healthcare providers?

How likely are they to switch doctors? What could be improved with the doctor-patient experience? How do people want to be communicated with by their providers’ offices?

To find out, Solutionreach recently conducted an in-depth study involving interviews with 2,100 consumers in the United States. All respondents have health insurance, make health decisions for themselves or their families, and have visited a doctor in the past year.

Overall, consumers cite three key things that could improve the doctor-patient relationship: greater connectivity, better convenience via text and online tools, and more time with the doctor.

While these improvements would be welcomed by all respondents, the researchers found major differences in how important each is with Millennials (age 21–34), Gen Xers (35–51), and Baby Boomers (52–70).

Moreover, each age group showed distinct preferences across a host of other healthcare provider–related areas, including satisfaction with service, preferred channels for interaction, and likelihood to switch providers.

Millennials Among the three generations, Millennials are the least satisfied with their doctors and are most likely to switch practices.

Not surprisingly, the researchers found that they are also the generation that is most likely to want to receive email and text communication from offices.

• Only 19% of Millennials are satisfied with their primary care physician, just 37% are satisfied with their eye doctor, 28% with their dermatologist, and 36% with their dentist.

• Some 42% of Millennials say they are likely to switch their primary care provider in the next few years and 54% have already switched practices in the past two or three years.

• Millennials are open to communication across all channels, with more than 70% saying it is appealing to get appointment reminders, appointment alerts, and follow-up reminders via phone, email, and text.

Generation X Many Generation Xers control healthcare decisions across multiple generations, and their preferences and satisfaction levels both fall somewhere between younger and older consumers.

Overall, the researchers found that they are fairly similar to Millennials, with an openness to digital communication and to switching providers.

• Some 32% of Gen Xers are satisfied with their primary care physician, 31% are satisfied with their eye doctor, 30% with their dermatologist, and 40% with their dentist.

• Gen Xers are the most likely generation to say they may switch their primary care provider in the next few years: 44% are likely to do so.

• Phone remains the preferred communication channel for Gen Xers to receive appointment reminders, appointment alerts, and follow-up reminders. However more than 60% say it is also appealing to get alerts via email and text.

WNYPHYSICIAN.COM VOLUME 1 I 2018 I 27

Baby Boomers Baby Boomers, the biggest consumers of healthcare services, are the least likely to switch doctors. However, that doesn’t necessarily mean they’re happy: less than half are satisfied with their current providers. Boomers are also the generation least interested in receiving communications from doctors’ offices digitally.

• Some 42% of Baby Boomers are satisfied with their primary care physician, 47% are satisfied with their eye doctor, 39% with their dermatologist, and 43% with their dentist.

• Only 20% of Baby Boomers say they are likely to switch their primary care provider in the next few years, 14% are likely to switch their eye doctor, 21% their dermatologist, and 23% their dentist.

• Phone is overwhelmingly the preferred communication channel for Baby Boomers to receive appointment reminders, appointment alerts, and follow-up reminders. Around half or fewer of Boomers say the idea of receiving alerts via email and text is appealing.

What should healthcare providers and marketers make of all this?

The first big takeaway from the report is that there’s a lot of room for improvement.

Fewer than half of patients across all generations are satisfied with their current doctors, and the share of dissatisfied consumers is especially high with Millennials and Gen Xers.

Moreover, unhappiness is paired with an openness to switching providers—again, especially with younger patients.

This combination of dissatisfaction and willingness to change should give every healthcare provider pause; it should not be taken for granted by any means that patients will stay with your practice simply out of loyalty.

So, what can you do to improve the relationship? Beyond the eternal request—that doctors spend more time with their patients—the research shows that consumers want better doctor-office staff communication and that they want interactions/ management/scheduling to be more convenient.

What’s important to understand from the report is that convenience can come in different forms for different generations.

For older consumers it may mean a friendly staff member calling by phone to personally deliver reminders. For younger consumers, it may mean supplementing phone calls with email and text alerts.

What emerges from the research is that there is no onesize-fits-all approach to patient communications or healthcare marketing that will satisfy every patient. Each age group, and each individual, has a unique set of preferences. Ultimately, the key to improving the doctor-patient relationship isn’t shifting to one particular communication or marketing approach, but rather embracing a wide mix so that the full spectrum of consumers is served well.

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WE HAVE ANSWERS 28 I VOLUME 1 I 2018 WNYPHYSICIAN.COM

Tony Duffy, CPA, ABV, CVA Director, ValuQuest, LLC aduffy@bonadio.com | 518.250.7715

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Joinus usfor forthe the Join

2018HOD HOD 2018 RiskManagement Management Risk Conference Conference Take a look at the latest issues in risk management at MLMIC’s 2018 HOD Risk Management Conference, to be held the morning of the 2018 MSSNY House of Delegates on March 22nd.

Earn up to 3 CME Credits exploring a range of important issues in risk management, including: • Effective Coordination of Care: The Role of the Hospitalist

2018 HOD Risk Management Conference Thursday, March 22, 2018 Adams Mark Hotel Buffalo, NY

• The Physician-Patient Relationship: A Closer Look • 2018 Healthcare Law Review There is no charge to attend this event, but space is limited so reserve your seat today!

Register now at MLMIC.com/2018Risk

Endorsed by MSSNY

This Risk Management Conference is designed for physicians in all specialties.

MLMIC is accredited by the Medical Society of the State of New York to provide continuing medical education for physicians.

MLMIC designates this live activity for a maximum of 3.0 AMA PRA Category 1 CME Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the program.