M A RY L A N D
Physician YOUR PRACTICE. YOUR LIFE.
ORTHOPAEDIC UPDATE HELP YOUR PATIENTS GET A BETTER NIGHT’S SLEEP BEYOND CPOE: CLINICAL ANALYTICS IS KEY KEEPING PATIENTS SAFE
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VOLUME 3: ISSUE 4 JULY/AUGUST 2013
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Contents 16
VOLUME 3: ISSUE 4 JULY/AUGUST 2013
12 F E AT U R E S
12 Orthopaedic Update: Carpal Tunnel, Complex ACL Tears, Cartilage Repair and MSK Ultrasound
16 Help Your Patients Get a Better Night’s Sleep D E PA R T M E N T S
Cases
| 7 | Advanced Digital Replantation
Compliance
| 9 | How to Avoid Ten Common Mistakes
Medical Beat
| 10 | Maryland Physician and Healthcare Leader News and Awards
Healthcare IT Policy
| 24 | Keeping Patients Safe
Good Deeds Solutions Living
| 20 | Beyond CPOE: Clinical Analytics is Key
| 26 | Special Camps for Kids with Special Medical Needs
| 29 | Engaging a Commercial Real Estate Advisor/Broker is Good Medicine
| 30 | A Little Piece of Paradise Along Smith Mountain Lake
On the Cover: James York, M.D., orthopaedic surgeon at Chesapeake Orthopaedic & Sports Medicine Center
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JACQUIE COHEN ROTH PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com MANAGER OF DIGITAL CONTENT AND SOCIAL MEDIA Jackie Kinsella jkinsella@mojomedia.biz CONTRIBUTING WRITER Tracy Fitzgerald PROOFREADER Ellen Kinsella
“Innovation”
is ever present in today’s lexicon. Innovation in medicine is built upon existing knowledge and discoveries, driving more accurate diagnoses with better treatment and outcomes. In every issue of Maryland Physician, we strive to bring you the latest medical innovations delivered by your Maryland peers and colleagues, as well as innovations that facilitate more efficient patient care and practice management solutions. Sometimes innovation is simply raising awareness of treatments that have been available for years, such as using a patient’s own cartilage to heal joint injury, or using low imaging devices such as ultrasound in new ways. This issue’s cover story is our annual update on orthopaedic treatments – spotlighting innovations in existing knowledge, discoveries of new uses for existing equipment, and advances in training – all with a focus on improving disease prevention, treatment and outcomes. Innovation in technology also drives how and where you’re reading Maryland Physician. Our online readership is poised to exceed our print audience in the coming issues - maybe even this one, while you’re reading it on your summer vacation. For most of us, catching up on sleep is top of the vacation’s “to-do” list. Sleep is a third of our life – time that can’t really be recaptured - but, as our feature on sleep underscores, that has a direct correlation with both mental and physical health. Our experts advise making questions about patient’s sleep habits part of your H & P, and provide some tips for better treatment of the most common sleep issues. Everyone who is part of a healthcare delivery system is well aware that technology innovations are looming to make a major shift in reimbursement models and the economic realities of delivering integrated and coordinated care. In our HIT feature, we’ve explored the value of computerized order entry (CPOE), which provides workflow efficiencies and clinical analytics with a keen eye on the bottom line. Implementation of CPOE often comes with a resistance to change, but without change, where are progress and innovation? Enjoy your summer – whether you’re able to sneak away for a long weekend to explore not too distant waterways like Smith Mountain Lake; enable a special needs child to discover what summer camp is all about while learning how to manage a chronic illness; or just enjoy the light and flight of a firefly. To life!
Jacquie Cohen Roth Publisher/Executive Editor jroth@mdphysicianmag.com @mdphysicianmag
PHOTOGRAPHY Tracey Brown, Papercamera Photography Melissa Grimes-Guy, Location Photography, Inc. Kevin J. Parks, Mercy Medical Center Randy Sager, Randy Sager Photography, Inc. BUSINESS DEVELOPMENT Eileen Nonemaker enonemaker@mdphysicianmag.com Maryland Physician Magazine – Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC. a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 949 Annapolis, MD 21404 443-837-6948 www.mojomedia.biz Subscription information: Maryland Physician Magazine is mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52.00. To be added to the circulation list, call 443-837-6948. Reprints: Reproduction of any content is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443-837-6948 or email jroth@ mdphysicianmag.com. Maryland Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Maryland Physician. Advisory board members include: PATRICIA CZAPP, M.D. Anne Arundel Medical Center HOLLY DAHLMAN, M.D. Greenspring Valley Internal Medicine, LLC PAUL W. DAVIES, M.D., FACS KURE Pain Management MICHAEL EPSTEIN, M.D. Digestive Disorders Associates STACY D. FISHER, M.D. University of Maryland Medical Center REGINA HAMPTON, M.D. FACS Signature Breast Care DANILO ESPINOLA, M.D. Advanced Radiology GENE RANSOM, J.D., CEO MedChi CHRISTOPHER L. RUNZ, D.O. Shore Health Comprehensive Urology JAMES YORK, M.D. Chesapeake Orthopaedic & Sports Medicine Center Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources. Printed on FSC certified, 100% PCW, chlorine free paper
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Cases
Advanced Digital Replantation By Ryan Katz, M.D.
CASE: In July 2011, MP sustained a near-complete amputation of his left thumb while using a power saw. The saw had passed through all the important anatomic structures, including the nerves, arteries, tendon, and bone. The digit, attached to the hand by only a small skin bridge, was nonviable. He was transferred emergently to Curtis National Hand Center in Baltimore, where a trauma survey revealed his injuries to be isolated to the hand. In the OR, the part was found suitable for replant. After a thorough washout and debridement, the bone was stabilized with percutaneous pins. The flexor and extensor tendons were then repaired. The nerves, artery, and veins were repaired using the operative microscope for optimal visualization. The patient was admitted to the hospital for five days postop, where he received serial clinical exams, subcutaneous heparin injections for DVT prophylaxis, and aspirin to prevent platelet aggregation. He was discharged with a viable thumb and an uneventful postoperative course.
DISCUSSION Replantation of an amputated part is not a novel idea. The surgical techniques have existed for at least 50 years1 and those required to replant digital level amputations have existed for nearly 40.2,3 The replantation principles of “form and function” have not changed, but surgeons can now suture blood vessels only millimeters in diameter – once believed impossible. This is a direct consequence of the development of hand surgery training programs and specialty “centers of excellence”. Digit replantation should only be considered once a trauma survey has been completed and life-threatening injuries have been ruled out. Too easily, the physician can be distracted by a mangled limb and miss a potentially serious hidden injury such as tension pneumothorax. In isolated extremity injuries, bleeding can usually be controlled with elevation and a lightly compressive dressing or direct pressure. A tourniquet is rarely needed and can even, by elevating venous pressure, exacerbate bleeding and cause the patient undue pain. Attempting to ligate “bleeders” in the hand is strongly discouraged. Doing so in an uncontrolled setting may inadvertently injure potential usable nerves, arteries, and veins. The digit should be placed in a sealable container within a separate container of ice water to slow cellular metabolism without injuring the cells. The indications for digit replantation include amputation of the thumb, multiple digits, any digit in a child, or a part necessary for a vocation or avocation. Contraindications include a grossly contaminated part, an unsuitable recipient bed, the presence of a life threatening injury, or a psychiatric condition that could limit the patient’s ability to participate in the requisite postoperative therapy. An isolated non-thumb digit is often considered a relative contraindication to
replantation because it is often bypassed, and may impair hand use. Surprisingly, advanced age, smoking, and diabetes are not strict contraindications.4,5 Digits amputated via a sharp mechanism often survive and function better than those amputated through a blunt or avulsive mechanism.5 The surgeon typically completes all macroscopic work (bone and tendon) prior to performing the microscopic nerve and vessel work. Most digits require repair of just one of the two digital arteries. To prevent venous congestion and resultant thrombosis, the surgeon aims to repair as many digital veins as possible. If detected early, venous congestion often can be corrected with either surgical revision of the venous anastomosis or therapeutic leeching. If a replant fails, a prosthetic can camouflage the resultant deformity, but is insensate and typically does not add function. For the failed thumb replant, a toe-to-thumb transfer remains an excellent reconstructive option. This surgery can accomplish all of the same goals of replantation surgery – restoration of function, preservation of sensibility, and maintenance of aesthetic balance. Ryan Katz, M.D. is trained in plastic and reconstructive surgery at the Johns Hopkins Hospital and fellowship trained in hand surgery at The Curtis National Hand Center in Baltimore’s Union Memorial Hospital. www.unionmemorial.org
1) Malt RA, Remensnyder JP, Harris WH. 1972. “Longterm utility of replanted arms.” Ann Surg 176 (3): 334–42. 2) Buncke H, Buncke C, Schulz W 1966. “Immediate Nicoladoni procedure in the Rhesus monkey, or hallux-tohand transplantation, utilising microminiature vascular anastomoses.” Br J Plast Surg 19 (4): 332–7. 3) Komatsu S, Tamai S. 1968. “Successful replantation of a completely cut-off thumb: case report.” Plast Reconstr Surg 1968;42:374–7. 4) Sanmartin, Marcos, Francisco Fernandes, A Scott Lajoie, and Amit Gupta. 2004. “Analysis of Prognostic Factors in Ring Avulsion Injuries.” The Journal of Hand Surgery 29 (6) (November): 1028–1037. 5) Dec, Wojciech. 2006. “A Meta-Analysis of Success Rates for Digit Replantation.” Techniques in Hand & Upper Extremity Surgery 10 (3) (September): 124–129.
JULY/AUGUST 2013
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Compliance
How to Avoid Ten Common Mistakes Responding to the Maryland Medical Licensing Boards
Y
By Neal M. Brown and Nicole A. McCarus
OUR MEDICAL LICENSE IS your livelihood and every inquiry from a licensing board is a “big deal”. Licensing boards have almost unfettered authority to investigate, prosecute and impact your ability to practice medicine in Maryland. How you respond to a board inquiry, no matter how innocuous, may have substantial and long-term ramifications. Licensing boards may initiate an investigation based on a specific complaint or other information. Investigations usually begin with a request for the factual circumstances surrounding the complaint, a subpoena for records, or access to patient records. The board may seek an interview (informal or under oath) or refer the matter for formal charges. Failure to answer board inquiries may lead to disciplinary action or formal charges. Maryland boards are empowered to revoke or suspend medical licenses, as well as to reprimand or place a licensee on probation. Boards are required to report disciplinary actions to the National Practitioner Data Bank, which hospitals consult regarding staff privileges, and which insurance carriers check for provider eligibility. The provider who mishandles a board complaint risks adverse financial and professional consequences. The importance of responding appropriately to a board complaint or request cannot be overstated. Based on our experience, we have summarized common mistakes healthcare professionals make following receipt of a board complaint or inquiry. We also offer these recommendations to help avoid adverse outcomes. Neal M. Brown is founding partner of and Nicole A. McCarus is a partner at Waranch & Brown, LLC: nbrown@waranch-brown.com and nmccarus@waranch-brown.com.
Common Mistakes
Recommended Actions
1. “It’s no big deal.”
Do not dismiss the allegations as frivolous, meritless or an outright fabrication by the patient. Treat correspondence from the board seriously, requiring your immediate and thoughtful response.
2. “I don’t need to involve my insurance carrier in this matter.”
Review your professional insurance policy and contact your agent to evaluate the situation.
3. “I don’t need an attorney to respond to this complaint.”
Do not contact the board to discuss the complaint without first contacting legal counsel. Promptly provide your attorney with all pertinent information, and do not omit significant details with the hope they will not surface later.
4. “I’ll get to it when I can – there’s no rush.”
Highlight the due date for the response immediately on the calendar, and request an extension if necessary.
5. “I’m sure I can work it out with the patient.”
Consult counsel before discussing the matter with anyone; if approached for comment, politely decline. This ensures that your lawyer is able to protect your legal rights whenever possible.
6. “I can just correct the patient’s chart.”
Do not alter, modify, destroy or dispose of records. If errors or omissions in the original record exist, you may supplement, but only in accordance with previously established recordkeeping guidelines. Clearly note the date and reasons for any supplement, amendment or addendum, and produce the original record.
7. “The patient was not harmed, so the board cannot find against me.”
Do not make assumptions based upon the patient’s outcome. Discuss with your attorney whether there is a valid defense to the allegations.
8. “I messed up. I should just admit it and get this over with.”
It may be appropriate to express concern for the patient. However, consult with your attorney to discuss defending or mitigating your care. Even where an admission of fault is the only option available, the best possible terms should be sought before a concession.
9. “The board is full of health professionals so I don’t need to explain the medicine.”
In your response, inform board members of any unique aspects of the case involving your practice or specialty. It may also be helpful to include citations to medical references or support from consulting physicians or experts.
10. “I’m so angry, I can’t see straight!”
Take time to think through your response. Be factual, precise, respectful and cooperative.
This article is not intended to constitute legal advice or create an attorney-client relationship, but is intended for general information only. An attorney or other resource should be consulted regarding individual cases.
JULY/AUGUST 2013
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Medical Beat
New National Institute of Robotic Surgery at Mercy Dwight Im, M.D., director of Mercy’s Center for Gynecologic Oncology at Mercy Medical Center, has formed the National Institute of Robotic Surgery at Mercy. Dr. Im was one of the first six surgeons in the United States--and the first in the state of Maryland--to perform a robotic Single Site Hysterectomy, utilizing one small incision through a woman’s navel. Some of the benefits of robotic surgery include pinpoint accuracy, the potential for faster healing, less blood loss and scarring, and reduced need for wound management after the surgery. With recent media attention given to robotic
AAMC Center Opens Patient-Centered Geriatric Unit AAMC recently opened its 30-bed Acute Care of the Elderly (ACE) unit. The ACE unit offers a specialized model of care for older, hospitalized patients with acute illness. AAMC was awarded the Nurses Improving Care for Healthsystem Elders (NICHE) facility designation in December 2012 as they prepared for the ACE unit opening. NICHE is a national organization striving to improve the quality of care for hospitalized older adults, provides evidence-based geriatric protocols and geriatric education for hospital staff members so they are better equipped to care for older adults. NICHE is the largest geriatric nursing program available in the United States. “Geriatric patients face a variety of health risks. This model of care has proven that focusing on the unique needs of the elderly enhances clinical outcomes during and following hospital admission,” says Sherry Perkins, PhD, R.N., AAMC’s chief operating officer and chief nursing officer.
surgery, patients are seeking physicians and centers with the most experience and highest rates of positive patient outcomes. Mercy’s National Institute of Robotic Surgery offers surgical procedures performed by physician experts in multiple specialties and sub-specialties, including Urology, General Surgery, Surgical Oncology, Gynecology and Gynecologic Oncology at Mercy Medical Center. Dr. Im received his medical degree from UMDNJ-Robert Wood Johnson and completed both his residency and fellowship training at The Johns Hopkins Hospital.
Northwest Hospital Names Women’s Wellness Center Medical Director Northwest Hospital has appointed Katharine H. Taber, M.D., FACOG, as the new medical director of its Women’s Wellness Center. Dr. Taber is a board-certified gynecologist and a fellow of the American College of Obstetrics and Gynecology. “Under Dr. Taber’s leadership, I’m confident that our Women’s Wellness Center will become an even more robust resource for women seeking gynecologic care,” says Brian White, president of Northwest Hospital and senior vice president of LifeBridge Health. The Women’s Wellness Center’s comprehensive philosophy emphasizes highquality care across a broad spectrum of women’s health needs, from routine exams to leading-edge gynecologic surgery to ensuring patients are up-to-date on their health screenings. Dr. Taber received her medical degree from the University of Virginia School of Medicine and completed her residency in OB/GYN at Duke University Medical Center. Prior to joining the Women’s Wellness Center at Northwest Hospital, she practiced at Women’s Health Associates in Towson.
Hospice of the Chesapeake Welcomes New Board Chairman Hospice of the Chesapeake announced the appointment of Richard M. Lerner, market chairman for the Maryland Region of First National Bank, as chairman of the board at the nonprofit headquartered in Annapolis. Lerner is formerly Chairman and CEO of Annapolis Bancorp, Inc. and its principal subsidiary, BankAnnapolis. He assumed his new role with First National Bank following the company’s merger with BankAnnapolis in April. Lerner’s involvement with Hospice of the Chesapeake dates back to 2005 when he first joined the nonprofit Foundation’s board of directors. In keeping with First National Bank’s commitment to community leadership, the bank established a corporate partnership with Hospice of the Chesapeake in January that included a diamond sponsorship of the 2013 Hospice gala held in March, and an event which raised $350,000 for the nonprofit.
AAMC Nurses Select Outstanding Physician of the Year Obstetrician hospitalist Bruce Bolten, M.D., was recently chosen as Outstanding Physician of the Year at AAMC — an honor bestowed by the hospital’s nurses. Dr. Bolten was the top vote-getter out of 1,000 cast by the center’s nurses, who were asked to nominate a doctor considered a role model and who “collaborates and communicates for care.” Dr. Bolten received his medical degree from Howard University and completed both his internship and residency at Sinai Hospital of Baltimore.
Kohl’s & University of Maryland Children’s Hospital Unveil New Breathmobile University of Maryland Children’s Hospital will unveil a new and enhanced Breathmobile, courtesy of Kohl’s Cares “Keeping Asthma on the Move” program. Each year this mobile asthma clinic serves more than 500 children by visiting 19 Baltimore city schools. Clinicians from the University of Maryland Children’s Hospital staff the Breathmobile to bring diagnostics and
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treatments directly to kids at their schools. Asthma causes 640,000 missed school days each year in Maryland and is the No. 1 cause of pediatric emergency room visits. Hospitalization rates among asthmatic children in Baltimore are three times higher than the rest of the country. And about half of Baltimore children with asthma have had an emergency
department visit in the prior six months. Kohl’s will present a check for $215,088 to continue to support the Breathmobile outreach program. Since 2008, Kohl’s has donated more than $780,000 to support children’s health and wellness programs at University of Maryland Children’s Hospital through Kohl’s Cares.
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ORTHOPAEDIC UPDATE LINDA HAR DE R • P HOTOGRAPHY BY TRACEY BROWN
CARPAL TUNNEL, COMPLEX ACL TEARS, CARTILAGE REPAIR AND MSK ULTRASOUND Is It Really Carpal Tunnel Syndrome?
Carpal tunnel syndrome (CTS) is prevalent in the U.S., affecting about 5% of the population. Still, its prevalence sometimes clouds the ability of physicians to accurately diagnose pain or numbness in the hand. “The issue with CTS is that the public and physicians perceive it to be so common that almost any hand pain is assumed to be carpal tunnel,” says Mark Deitch, M.D., hand and upper extremity orthopaedic surgeon, OrthoMaryland. “There are many different causes of hand pain.” Etiology
CTS occurs when the median nerve is compressed within the carpal tunnel. The narrow tunnel also contains nine tendons, making it an area prone to nerve entrapment. The usual symptoms of CTS are numbness, paresthesias and pain in the thumb, index and middle fingers. Patients often complain of numbness at nighttime, or when holding a phone, driving, or writing. “Gripping activities probably increase the crowding of the median nerve,” explains Dr. Deitch. “Most people curl up their wrists when sleeping. Bending the wrist for long periods of time increases pressure on the median nerve, 12 | WWW.MDPHYSICIANMAG.COM
which is the reason we prescribe braces for nighttime wear.” The exact etiology of CTS has not been determined, but the syndrome is believed to be related to a combination of genetic, demographic and avocational or vocational factors. Women, whites, those aged 45 to 60, diabetics, arthritics and those with fluid changes (e.g., pregnancy or weight-related) are at higher risk. While some believe keyboarding is a trigger, there is no casecontrolled study that shows it causes CTS. “It causes symptoms,” Dr. Deitch explains, “but there is no data to show that it causes the syndrome. I believe it exacerbates the condition, rather than causes it.” He explains, “Most CTS is idiopathic. Often, I can diagnose the syndrome when the patient walks in. It’s a threshold phenomenon. Patients tell me they’ve been doing the same thing for 20 years, but it only started bothering them recently. I tell them it’s because their threshold – their tolerance – has decreased as they age.” Differential Diagnosis
Repetitive Strain Injury (RSI) is not CTS, notes Dr. Deitch. “Patients get RSI from repetitive tasks such as working on a conveyor belt. The inflammation of the tendon lining presses on the
nerve. Flexor tendonitis can give you carpal tunnel symptoms over time if swollen tendons crowd the nerve in the carpal tunnel.” He adds, “If there is no numbness in the fingers, it’s usually not CTS. Arthritis in the base of the thumb is common, especially in women over age 50, but that causes pain without numbness. A less common possibility is that it’s a slipped disc or pinched nerve in the neck, which can mimic the symptoms of CTS.” In addition to the history and physical exam, “EMG and nerve conduction velocity studies are often useful in making the diagnosis,” Dr. Deitch comments. “They measure the speed of the nerve impulses, and slowing at the level of the wrist usually indicates carpal tunnel syndrome. Many insurers require this test before they will pay for surgery. “If a primary care physician suspects CTS, he or she can prescribe a wrist brace at night for several weeks,” he continues. “Then, refer them to a hand specialist if symptoms don’t subside. If the patient has increasing pain, grip weakness or constant numbness, they need a faster referral to decrease the risk of permanent nerve damage.” Dr. Deitch stresses that wrist braces generally should not be worn during the day for CTS, as they can create other problems such as soreness in the upper arm or shoulder. Treatment
Treatment is initiated with conservative measures that, in addition to a night brace, may include avoidance of activities that cause symptoms, and when needed, injection of cortisone in the carpal tunnel area. “Injections can serve as both a diagnostic measure and treatment,” he notes. “Patients can have a pinched nerve in their neck as well as carpal tunnel – if the cortisone injection eradicates the symptoms, it’s more likely the hand numbness is due to CTS. I also stress the importance of proper body positioning rather than special devices – the hips and elbows should be at 90 degrees and the elbow to hands should be neutral. Ideally, the forearm is supported by the chair armrest. And laptops go on your lap, not the table top!” Surgery may be appropriate when: z Persistent symptoms are not relieved by injection or bracing z Symptoms worsen z Constant numbness is present z Thenar muscle atrophy is present
Mark Deitch, M.D., hand and upper extremity orthopaedic surgeon, OrthoMaryland.
Both open and endoscopic surgeries offer patients similar long-term results, though Dr. Deitch has performed primarily endoscopic surgeries for the last 10 years. “It provides patients a faster return to work by several weeks. After a 30-minute outpatient procedure, patients return home with a soft dressing. They can resume most daily light activities within a week.”
Managing Complex ACL Tears Anterior cruciate ligament (ACL) tears are common injuries in young athletes, especially females, affecting about
100,000 to 150,000 Americans each year. A patient with a torn ACL and significant functional instability has a high risk of developing further knee damage, and should therefore consider ACL reconstruction. A surprisingly high percentage of ACL injuries also involve damage to other knee structures, including the meniscus cartilages (50%), articular (joint surface) cartilage (30%), collateral ligaments (30%), joint capsule, or a combination of the above. James York, M.D., orthopaedic surgeon at Chesapeake Orthopaedic & Sports Medicine Center, JULY/AUGUST 2013
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says, “An ‘unhappy triad,’ which is frequently seen in football players and skiers, consists of injuries to the ACL, the medial collateral ligament (MCL) and the meniscus. In combined injuries, surgical treatment is indicated and generally produces better outcomes. As many as 50% of meniscus tears that occur in association with ACL tears are repairable, and heal better if the repair is performed in combination with the ACL reconstruction.” Therapy and Surgery
Dr. York states, “I order physical therapy (PT) prior to surgery; patients who have a stiff, swollen knee lacking full range of motion at the time of ACL surgery are less likely to regain motion after surgery. It usually takes three or more weeks from the time of injury to achieve full range of motion. Ligament injuries that occur along with the ACL injury are treated with a knee brace in addition to having the ACL surgery.” PT is particularly critical post-surgery. Dr. York says, “Much of the success of ACL reconstructive surgery depends on the patient's dedication to rigorous PT. With new surgical techniques and stronger graft fixation, current physical therapy uses an accelerated course of rehabilitation with more rapid return to play or to your job than in prior years.” Repairing Articular (Joint Surface) Cartilage Injuries
Diagnosing articular cartilage damage can be challenging. Dr. York observes, “The X-ray looks normal, and if very small, even an MRI may not detect damage.” Articular cartilage in the knee is a “tread” about 3/16” thick and has the consistency of slippery vinyl. When injured, a painful divot or crater can occur in this surface. Dr. York says, “If the surrounding cartilage is in good condition, then tiny defects – the size of a dime or smaller – can be repaired using an arthroscopic microfracture technique, where tiny holes are punched into the affected area and debrided to promote cartilage healing. Patients are on crutches for about six weeks post op.” When articular cartilage damage is the size of a nickel or larger, other more advanced approaches are required. “Some procedures use small cartilage ‘plugs’ taken from the periphery of the knee to fill the cartilage defect, but that’s 14 | WWW.MDPHYSICIANMAG.COM
James York, M.D., orthopaedic surgeon at Chesapeake Orthopaedic & Sports Medicine Center
Carticel Autologous Cartilage Implantation can offer the opportunity to return to work and a normal lifestyle. —James York, M.D. like robbing Peter to pay Paul,” notes Dr. York. For older patients with large defects, he prefers to use osteochondral allografts (tissue bank cartilage). “If trauma is the cause of a larger cartilage lesion in an older patient, they may be a candidate for partial or total knee replacement.” Growing Your Own Cartilage to Heal Joint Injury
In patients under age 40 with overall good cartilage health and no arthritis, Dr. York has successfully used the Carticel Autologous Cartilage
Implantation (ACI) for larger defects (www.Carticel.com). This procedure has been in use in this country since 1995, but is not well known by the public or specialties outside of orthopaedics. The first of the two-staged procedure is performed micro-surgically with an arthroscope. A tiny piece of the joint cartilage is harvested and sent to a special laboratory to be cultured and grown to about 16 million “baby” cartilage cells. These cartilage cells are then implanted back into the knee joint through a second open surgical procedure about two months later.
The damaged cartilage is cleaned out of the crater-like defect in the knee joint surface. A small piece of membrane is then surgically sewn over the defect, using suture that is as fine as human hair. Next, the cartilage cells are injected into a temporary hole under the membrane that is then sealed over. These new cells adhere to the base of the defect within six hours and begin to grow. Complete healing takes several months, but the joint is returned to almost pre-injury status. Dr. York observes, “ACI can offer the opportunity to return to work and a normal lifestyle. The best candidates for cartilage transplant are patients in their 20s, 30s and early 40s who do NOT have arthritis.”
MSK Ultrasound Ultrasound (US) is a low-tech imaging device that has been available for decades, yet only recently has it been used for musculoskeletal (MS) diagnosis and treatment. Ashley Beall, M.D., FACR, physician director of infusion services at Arthritis and Rheumatism Associates, P.C., explains, “Focus on uses of ultrasound began in the early 2000s, but interest has exploded in recent years. The American College of Rheumatology (ACR) holds annual conferences on MSUS and I speak locally on this topic.” A 2012 ACR report noted it is reasonable to use MSUS for
Ashley Beall, M.D., FACR, physician director of infusion services at Arthritis and Rheumatism Associates, P.C.
patients with “articular pain, swelling, or mechanical symptoms without definitive diagnosis on clinical examination” in various joints that include the shoulder, elbow, wrist, hip, knee and ankle. Ultrasound provides the ability to observe the tissue in motion, so it can create a dynamic image in real time of anatomic structures and of blood flow or inflammation. No radiation is involved, and it can be performed in the office immediately after evaluation. Dr. Beall exclaims, “Patients love to see what’s happening. It facilitates a conversation with them and is an educational tool.” She continues, “Changes of early rheumatoid arthritis and gout can be evaluated with US. On a plain X-ray, you may not see bony damage for years, while US can visualize erosions much sooner. You can see the crystals depositing on cartilage to help diagnose gout, and you can measure indirectly the amount of inflammation in a joint.” Power Doppler, a special type of color doppler, detects small blood vessels that occur when there is inflammation in the synovium or the tendon insertion into the bone. “You can see roughly how much inflammation is present in the area,” Dr. Beall notes. Rotator cuff tears may be diagnosed with ultrasound. According to Dr. Beall, “In the right hands, partial or total
rotator cuff tears can be visualized at the bedside using ultrasound. If a new patient has shoulder pain and we suspect rotator cuff injury, we can perform an X-ray to evaluate the bones, then use ultrasound to evaluate soft tissue. MRI remains the gold standard, but patients love that ultrasound is quick, and we know whether the next step should be orthopaedic surgery or physical therapy.” Aspirations and Pain Injections
Dr. Beall now uses real-time US guidance to withdraw fluid from knees or hips with osteoarthritis or other conditions at the bedside, instead of sending patients to the hospital for interventional radiology. “Now, after evaluating them, we can inject them at the bedside, using a 1.5” needle while the patient is supine. We can literally watch the needle go into the joint capsule. Patients experience less pain and often enjoy better outcomes. Once you’re experienced and set up, you can perform an injection under US guidance almost as quickly as one without it.” Dr. Beall also has found US guidance useful in carpal tunnel injections. “You can see the nerves in real time and know precisely where they are. If the physical exam is suggestive of carpal tunnel, we can perform an ultrasound. If the nerve is enlarged, we can perform an injection the same day.”
Mark Deitch, M.D., OrthoMaryland, and clinical assistant professor, Orthopaedic Surgery, Johns Hopkins University School of Medicine. James York, M.D., Chesapeake Orthopaedic & Sports Medicine Center, and clinical instructor in Orthopaedics, University of Maryland. Ashley Beall, M.D., FACR, physician director of infusion services, Arthritis and Rheumatism Associates, P.C.
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Help Your Patients Get a Better Night’s SLEEP BY L IN D A HA RDER PH OTOGRA PH Y BY TRACEY BROW N
SLEEP.
It’s a third of our life, and many of us will spend 25 to 30 ‘years’ of it sleeping. Not getting quality sleep or sufficient sleep is correlated with unhealthy habits and even disease. Yet until recently, sleep did not get the respect and attention that diet and exercise have had as a cornerstone of health. Ira Weinstein, M.D., medical director of Anne Arundel Medical Center’s Sleep Disorders Center, says, “There has to be a reason we sleep a third of our lives. Without sleep, many of our systems don’t work and muscles can’t repair themselves. It’s common for sleep to be interrupted
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before you get sick, and studies increasingly find a correlation between sleep issues and diseases such as prostate and breast cancer, or dementias. It’s logical that sleep would be a marker of disease because sleep deprivation affects memory and other brain functions.” He adds, “I think of sleep as equally important to health as diet and exercise. My advice to referring physicians is to ask about the patient’s sleep habits during the history and physical. Many sleep disorders start when the patient experiences a personal issue such as divorce or job loss, but become habitual.
Psychological issues, including stress, are significant causes.”
Sleep Apnea Of all the causes that bring patients to a sleep specialist or center, the most prevalent is obstructive sleep apnea – even as some 70 to 80% of those with this disorder go undiagnosed. The disorder is characterized by repetitive cessation of breathing or shallow breathing during sleep that lasts 10 seconds or more. Entailing repeated arousals from sleep and a fall in blood oxygen levels, it can result from large tonsils or tongue, excess fat in the upper
improving and weight loss is crucial,” Dr. Marx remarks. “If a patient declines CPAP or cannot tolerate CPAP and wishes to try an oral appliance, make sure the patient is referred to a dentist who specializes in these appliances. A newer option is nasal resistance plugs, but I think the jury is still out on their effectiveness. Also, insurance coverage for some of these alternative treatments could be an issue.”
Document Co-morbid Conditions
Jason Marx, M.D., chief of Pulmonary, Critical Care, and Sleep Medicine at University of Maryland St. Joseph Medical Center
airway, blocked nasal passages or anatomical issues in the jaw or airway. Jason Marx, M.D., chief of Pulmonary, Critical Care, and Sleep Medicine at University of Maryland St. Joseph Medical Center, says, “About half of those who snore have sleep apnea; the only way to diagnose it is through a polysomnogram (sleep study). If the patient snores and has one other risk factor, or has daytime sleepiness, he or she is a candidate for a polysomnogram.” Insurers are driving more patients to unattended home sleep studies, rather than being evaluated overnight in a sleep
sleep study? Anita Naik, D.O., medical director of the Sleep Disorders Center, Harford Memorial Hospital and Northern Maryland Sleep Center, answers, “Those with significant comorbid conditions such as severe CVA, CHF, or lung disease, or those with suspected parasomnias. By contrast, a home study can be adequate for those with a high pre-test probability of sleep apnea, such as those with significant obesity, snoring or witnessed apneas.” Home sleep studies that are diagnostic for obstructive sleep apnea can be followed by a formal lab-based CPAP titration or the patient maybe set up
If the patient snores and has one other risk factor, or has daytime sleepiness, he or she is a candidate for a polysomnogram. —Jason Marx, M.D. center. Our sleep specialists note that home studies are appropriate for some patients, but not those with comorbid conditions or other disorders. Dr. Marx notes, “The big story is the transition from inpatient labs to home sleep studies, and some sleep labs are closing as a result. It’s not necessarily bad medicine, but it’s a new paradigm.” Who is not appropriate for a home
with an automatic CPAP device. These devices are about 80 to 90% effective. They are not effective at detecting and treating central sleep apnea, and are not indicated for patients with co-morbid diseases that could require additional therapies such as bi-level therapy or supplemental oxygen. “CPAP remains the gold standard for treatment, but oral appliances are
When ordering a lab-based sleep study, it is important for primary care physicians to document co-morbid diseases or a suspicion of other sleep disorders. A board-certified sleep doctor should always interpret the test to assure accuracy. Dr. Marx notes, “Sleep specialists can be called on to interpret the sleep study and, if appropriate, consult as well. It’s the primary care physician’s discretion whether they or we manage the patient. If you’re having trouble getting what you think the patient needs, contact a sleep specialist. We can work with the patient and insurer to select the appropriate diagnostic approach and treatment.”
Increased Anesthesia Risk Physicians should also be aware that anesthetics, including conscious sedation used in procedures such as a colonoscopy, make sleep apnea worse. “It’s like a stress test for sleep apnea,” Dr. Marx cautions. “Post-op patients are at higher risk for several days after their procedure. It’s important to indicate on your pre-op notes if a patient has or is at risk for sleep apnea.”
Insomnia Insomnia can be challenging to treat and typically requires both a medical and a psychological/behavioral approach. Dr. Naik recommends that the latter approach be tried first. “Good sleep hygiene is the first step.” Dr. Weinstein says, “Many cases of insomnia start with a personal problem like a divorce, but then become habitual. Physicians should ask about sleep as part of the history and physical. Review their medications to make sure they aren’t causing problems, and ask about alcohol
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and family issues.” When good sleep hygiene alone does not impact insomnia, Dr. Naik is a proponent of cognitive behavioral therapy, with or without medications. “I try to empower the patient,” she says. “They can use tapes or CDs, progressive relaxation techniques, and so on. If a single approach doesn’t work, try a combination. We often refer patients to specialists in sleep cognitive behavioral therapy. If anxiety or depression is suspected, seeing a psychiatrist or psychologist may be helpful.” Studies have not demonstrated a consistent benefit from melatonin supplements for insomnia but it may help jet lag or circadian rhythm disturbances. Valerian root and acupuncture have shown some promise in very small, early studies, but more research is needed. Medications can be very effective, including extended-release versions such as Ambien CR (zolpidem). Dr. Naik notes, “Melatonin agonists such as Rozerem (ramelteon) are useful for many patients and have limited side effects. Sedative-hypnotics such as Lunesta (eszopiclone) and Sonata (zaleplon) can be effective but should be approached with caution because they still have habit-forming tendencies.”
Restless Leg Syndrome and PLM
Ira Weinstein, M.D., medical director of Anne Arundel Medical Center’s Sleep Disorders Center
Physicians should ask about sleep as part of the history and physical. Review their medications to make sure they aren’t causing problems, and ask about alcohol and family issues. —Ira Weinstein, M.D.
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Another common sleep disorder is restless leg syndrome (RLS), accompanied in about 80% of patients by periodic limb movement disorder (PLM). RLS affects from 1% to 7% of the population and is more prevalent in those 50 and older. RLS is characterized by painful dysesthesias such as crawling, creeping and/or burning sensations in the legs. “It usually happens in the evening and when sedentary,” says Pavel Klein, M.D., director, Mid-Atlantic Epilepsy & Sleep Center, LLC. “The sensations are relieved by movement but it often keeps patients from falling asleep. PLM typically occurs once asleep in the first third of the night. A sleep study can evaluate for PLM and help determine the cause. “The primary cause in younger patients is a family history,” he explains. “Iron deficiencies, renal impairment, peripheral neuropathy or Parkinson’s are
Dr. Naik’s Recommendations for Good Sleep Hygiene Include: z z z z z z z z
Avoid caffeine (including energy drinks) and alcohol after 3 pm. As a depressant, alcohol helps people fall asleep but then disrupts sleep Avoid smoking, as nicotine is a stimulant Exercise regularly but not close to bedtime Don’t go to bed stuffed or starving – instead, have a light snack Avoid napping Don’t spend more than 20 minutes wide-awake in bed 20 minutes before sleep, avoid light exposure from smart phones or any backlit device Don’t fall asleep to the television
Anita Naik, D.O., medical director of the Sleep Disorders Center, Harford Memorial Hospital and Northern Maryland Sleep Center
other possible causes in the older patient population, e.g. in those over the age of 50. If there is no identifiable cause, treat symptomatically. The most common medications are the dopamine agonists like Mirapex and Requip, which increase dopamine transmission between the neurons.” For patients who do require treatment, the next step may involve anti-seizure medications such as Gabapentin (neurontin) or Lyrica (pregabalin), and for those who don’t respond to this therapy, narcotics may be a last resort. Dr. Naik notes, “Recent data suggests that those with PLM alone should not usually be put on benzodiazepines unless they are injuring their partner or significantly disrupting their sleep continuity.”
Circadian Rhythm Disturbances Night owls, or those with circadian rhythm disturbances, have sleep schedules out of synch with societal norms. Dr. Klein comments, “Delayed Sleep Phase Syndrome, where the person falls asleep at 2 or 3 am, is more common than Advanced Sleep, where
they fall asleep too early in the evening. It commonly starts in adolescents and manifests itself in poor academic performance or being habitually late for school or work in the morning. Primary care physicians should be attuned to this problem because, while common, it’s often overlooked. Symptoms include having difficulty falling asleep at 10 or 11 pm, feeling most awake in the late evening, and feeling extremely sleepy or groggy, especially in the morning. It’s common for patients to sleep through their alarm five to six times.” The treatment is not highly technical, but may be hard to implement except during a long vacation period. “We train the brain through regular exposures to bright light,” notes Dr. Klein. “When the patient naturally wakes up, say at 1 pm, they sit in front of a light box with 10,000 LUX for 30 minutes for three to four days. Then we continue the light box therapy while having them get up a half hour earlier every three to four days until they return to a more normal waking time. If done correctly, the treatment is about 80% effective.” Sleep is so critical to well being that sleep disruption, not incontinence or
memory issues, is the reason many caregivers finally refer loved ones with dementia to a residential facility. Dr. Weinstein concludes, “The deal breaker is often when the person with dementia gets up at night and has their sense of day and night disrupted. It becomes intolerable for the caretaker to get up at night/worry about them.”
Jason Marx, M.D., chief of Pulmonary, Critical Care, and Sleep Medicine, University of Maryland St. Joseph Medical Center Ira Weinstein, M.D., FCCP, Annapolis Asthma, Pulmonary and Sleep Specialists and medical director of Anne Arundel Medical Center’s Sleep Disorders Center Pavel Klein, M.D., director, MidAtlantic Epilepsy & Sleep Center, LLC Anita Naik, D.O., medical director, Sleep Disorders Center, Harford Memorial Hospital and Northern Maryland Sleep Center
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Healthcare IT
B E Y O N D
CPOE C L I N I C A L A N A LY T I C S I S K E Y
Maryland Physician explores the value of computerized physician order entry (CPOE) and clinical analytics in both a Maryland hospital system and a sole community hospital. By Linda Harder
A
fter decades of talk, the healthcare industry is finally poised to make major shifts in care reimbursement, moving from fee-for-service to global payments, and providing new incentives to better monitor and coordinate care. An essential component of the new paradigm is CPOE, a system that allows providers to enter medical orders and instructions that are communicated through a computer network. The potential benefits of CPOE include faster order completion; reduction of handwriting, transcription or dosage errors; and informatics that provide far more comprehensive data that can ultimately transform care delivery. Most hospitals are coupling CPOE with clinical analytics to get the optimum benefit and to survive in the new reimbursement climate.
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CPOE in a Healthcare System
Some larger health systems have only recently implemented CPOE, while others are on their second vendor. Many of these health systems are migrating to Epic – a software company aimed at mid-size and large medical groups, hospitals and integrated healthcare organizations – for their CPOE. In all, more than 100 million people, 100,000 physicians and 1,000 hospitals use this software. Howard County General Hospital, part of the The Johns Hopkins Health System, is one of those. “The way we practice medicine is changing because of economic realities and the Affordable Care Act,” says Eric Aldrich, M.D., Ph.D, vice president of medical affairs at Howard County General Hospital (HCGH). “We’re switching from fee-for-service to an
“When we first converted to Meditech years ago, we got a 30-minute tutorial,” Dr. Aldrich recalls. “Epic requires 12 hours of training because it’s complex. Physicians undergo online training before they take two six-hour classes, followed by trying it in a practice environment.” Physicians that don’t come into the hospital, as well as their staff, can
CPOE forces you to clean up your process and be more coordinated because everything is documented and scrutinized. – Eric Aldrich, M.D., Ph.D problems, but create new ones. “It requires you to clean up your practice,” Dr. Aldrich notes. “In a paper world, you might pre-document. In an electronic world, you can cut and paste, so every note is dated, timed and legible, but the content of the notes is also more similar. Physicians can also more readily leave a draft note without signing it for several days, which you couldn’t do with paper.” When CPOE was first implemented, the number of ‘errors’ actually increased. Dr. Aldrich explains, “Medication ‘errors’ appeared to increase at first, because we were now tracking when they were given a few minutes early or late. However, giving Tylenol 15 minutes late is not a patient safety issue. The University of Pittsburgh, an early adopter, published a paper on this topic. CPOE forces you to clean up your process and be more coordinated because everything is documented and scrutinized. Good comes from it, but it can also be painful.” He adds, “Our Epic system is more than orders and documentation. It’s about workflow – how to create an after-visit summary and who does the medication reconciliation. To meet Meaningful Use Stage 2, you have to provide an after-visit summary and the means to communicate it electronically to the patient. A patient portal module, My Chart, allows you to connect easily with patients.” Transferring to the new system requires significant change management and a heavy investment of training.
participate in the system through a readonly version called Epic CareLink. The system alerts them when their patients are admitted or discharged. They no longer will have to fax a history and physical to the hospital, but can send it electronically. Physicians can get CME credits for their training time, but Stark law prohibits reimbursement from the hospital. The Johns Hopkins outpatient and surgery centers were the first to roll out the new Epic system in January 2013, followed by HCGH and Sibley in June 2013. Beginning Fall 2013, Hopkins’ employed physicians will begin using it, and eventually physicians in private practice will be incorporated. “We can also use CRISP*,” notes Dr. Aldrich, “but this system keeps all the communication in the family. It lets us coordinate cost-effective care, not deny care.”
hospital, comments, “The average admission involves a surprisingly high number of orders – 30 to 50 on average. To help our physicians, we created special order sets called i-forms. I-forms allowed us to program complex decision support with a simple graphic interface (similar to a web page). Order sets are used to guide the physician’s treatment. The system can handle any order, from medications to labs, to stockings to diet. Many orders are pre-selected, such as the order for prophylaxis for deep vein thrombosis, which helped our compliance rates jump from about 20% to 99%. You can opt out of the pre-selected orders, but you have to explain why.” He continues, “The hospital is about to undergo a new upgrade, this time to a single integrated database that incorporates billing, clinical, demographic and materials data. In our old system, an allergy could appear in four places within the system; with the new Paragon Hospital Information Jed Rosen, M.D., chief medical information officer, Carroll Hospital Center
CPOE in the Stand-alone Community Hospital
In 2009, after using a clinical system for nearly 10 years that was more oriented to the needs of nurses, Carroll Hospital Center began switching to a CPOE system to standardize orders and eliminate errors caused by poor handwriting. After selecting McKesson’s Horizon Suite, they completed implementation in 2010 and immediately noticed an improvement in processing more than 400,000 orders generated each month. Jed Rosen, M.D., chief of surgery and chief medical information officer at the
TRACEY BROWN - PAPER CAMERA
integrated health system and the foundation is the electronic medical record (EMR). We need clinical analytics to determine how to coordinate costeffective care. To do that, we have to switch from paper orders and notes to a system that’s more comprehensive.” Ironically, electronic clinical documentation may solve existing
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Healthcare IT System (McKesson), which goes live midSeptember 2013, providers will only have to enter it in one place. It’s like going from a Chevy to a Cadillac.” Dr. Rosen notes that the new system will make programming simpler. “We can mine the data and send it to CRISP, and to the primary care physician through CRISP. With the new Paragon system, within 24 hours of admission, the primary care physician is informed and can access information, such as an H & P. We can tailor the information to what the referring physician wants. The new system will also accommodate mobile devices and apps.” These transitions don’t come without a significant investment of human and monetary capital – and a bit of armtwisting. In addition to requiring the time of six nursing analysts in the clinical informatics department, a significant time investment is required by more than 35 employees of the IT department. “It’s exhausting. Our team works 60- 70-hour weeks,” Dr. Rosen remarks. From a financial perspective, the cost
of the new system is roughly half that of the original CPOE system. Dr. Rosen notes, “It does increase our total cost, but the rate at which it’s growing is changing from an exponential rate to a linear curve.” A key barrier to implementing CPOE is provider reluctance to change. “An EMR takes 120% of the time a paperbased approach does because we’re documenting more information,” Dr. Rosen reflects. “Yet, after working with an EMR for 18 months, more than 75% of doctors wouldn’t go back to paper, because they get better documentation and outcomes. They’re not missing things they used to miss. In fact, the physicians who fought me the most three years ago are now glad they’re doing it.” The hospital discovered a voluntary approach didn’t work. Dr. Rosen explains, “After finding that CPOE didn’t work unless we mandated it, we now have 98% compliance. We developed an extensive education program, using nurses as the backbone. They’re the super-users because they use
order-entry more than anyone else. They ‘adopted a doc’ for physicians who needed the extra support.” With CPOE and EMR, Carroll Hospital Center was prepared for the advent of Total Patient Revenue (TPR) in 2011, a pilot Maryland reimbursement model that pays sole community hospitals a global fee for all inpatient and outpatient care. Dr. Rosen concludes, “We can now closely monitor length of stay and provide case management and good patient throughput. And we were one of the first in Maryland to attest to Meaningful Use.” *Chesapeake Regional Information System for our Patients (CRISP) is Maryland’s statewide health information exchange entity.
Eric Aldrich, M.D., Ph.D, vice president of medical affairs, Howard County General Hospital Jed Rosen, M.D., chief of surgery and chief medical information officer, Carroll Hospital Center
Clinical Feature Maryland Physician spotlights the latest innovations in clinical care and treatment delivered by your Maryland peers and colleagues as well as advances in medical training which facilitate achieving the highest standards of quality patient care and practice management solutions.
Healthcare IT In every issue, Maryland Physician explores a different facet of the race to implement EHRs to meet Meaningful Use and other e-health government incentives. Don’t be left behind – read what Maryland physicians and healthcare IT experts have to say that eases the pain of transition to an electronic world.
In Every Issue and Online
Cases x Solutions x Compliance x Medical Beat x Policy Jacquie Cohen Roth x Publisher/Executive Editor 410.837.6948 x jroth@mdphysicianmag.com www.mdphysicianmag.com
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Policy
Keeping Patients Safe By Linda Harder
is spring, Maryland Physician attended the Maryland Patient Safety Center conference, which addressed the challenges healthcare providers face in keeping patients safe, as well as state and national initiatives to improve safety.
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L
ET’S BE HONEST. Healthcare still has a pretty weak track record when it comes to patient safety. While strides have certainly been made in the past decades, the industry lags behind other industries where safety is critical, such as amusement rides and airlines. Fortunately, a host of new organizations and initiatives at both the state and federal level are seeking to address safety with renewed zeal. Patient Safety in Maryland
To better tackle patient safety issues in the state, the Maryland Legislature established the Maryland Patient Safety Center in 2003. The center received designation by the Maryland Health Care Commission in 2004 and was incorporated in 2007. The not-forprofit organization was among the first organizations in the nation to be listed as a Patient Safety Organization (PSO) by the federal Agency for Healthcare Research and Quality (AHRQ) under provisions of the Patient Safety and Quality Improvement Act of 2005.
The center seeks to bring providers together to accelerate their understanding of the factors that harm patients and implement evidence-based solutions. Beyond convening an annual conference and other educational programs, their initiatives include: z Safe from Falls – this initiative seeks to lower the current rate of falls in this state (currently 3.0 per 1000 patient days vs. 4.6 nationally) z Hand Hygiene – 44 out of 46 hospitals are participating in this effort, with a goal of 90% participation in proper hand hygiene z Get Centered – an initiative launched July 2013 to provide tangible reminders of the importance of patient safety to hospitals and their staff Provider and Patient Engagement
To move toward safer patient care, Robert Imhoff, president and CEO of the center, believes, “Patients and their loved ones need to take an active role –
individuals in other states,” says Imhoff, “but certifying the entire institution would be unique to Maryland.” Imhoff also notes, “The center’s focus is primarily on hospitals now, but in the near future, we’ll expand our reach to other providers, including primary care physicians.”
TRACEY BROWN
they should ask questions and explore their options. Problems arise when people aren’t informed – there should be open lines of communication between caregivers and patients/families. Caregivers can do their part by explaining the procedure they’re doing, being open to questions and inviting follow-up questions after the patient has returned home and had time to process the information.” However, according to Linda Kenney, executive director of MITSS (Medically Induced Trauma Support Services, Inc.), the problem is not so much that patients are unengaged, but that providers often aren’t very engaging. Speaking at the conference, she noted that a common theme from patients who have been harmed while receiving healthcare is, “I kept telling them something was wrong, but no one listened.” Another speaker at the conference – Jean Rexford, executive director of Connecticut Center for Patient Safety – noted that small changes are critical. Her organization found that asking the patient how they’ve been since their last visit, rather than weighing them and taking their blood pressure first, was surprisingly powerful.
National Patient Safety: The Joint Commission
Keynote Speaker Mark Chassin, M.D., FACP, MPP, MPH, president of The Joint Commission, described the barriers to what he calls ‘high reliability’ in healthcare. At the conference, he noted that, despite decades of efforts, routine safety processes are still failing routinely – from hand hygiene to medication errors. He cited James Reason’s ‘Swiss Cheese’ model that explains the occurrence of system failures. In this oft-cited model, health facilities construct numerous defenses, but each defense has one or more weaknesses or ‘holes’ in it – similar to the holes in Swiss cheese. Dr. Chassin also observed that other industries, such as the airlines, have created effective process improvement tools without the Swiss cheese by
The [Maryland Patient Safety] center’s focus is primarily on hospitals now, but in the near future, we’ll expand our reach to other providers, including primary care physicians. – Robert Imhoff
Patient Safety Certification
An upcoming initiative from the Maryland Patient Safety Center is a safety certification program for healthcare providers. First, the safety officers at each hospital would be encouraged to participate in an assessment of their training, identify patient safety issues, and receive coaching. After the officer receives individual certification, the next step would be to certify departments within the hospital, and eventually the entire institution. “There are certifications for
identifying problems when smaller and easier to fix. He commented that the impact of the U.S. airline safety processes was a drop from 13.9 deaths/million flights in the 1990s to only 1.6 deaths/million flights from 2002 to 2011. Dr. Chassin concluded the hospital industry is roughly 1000 times less safe than the airline industry, with the number of annual deaths due to error estimated at 44,000 to 98,000. According to Dr. Chassin, health systems must embrace three changes to significantly improve their safety record:
- A leadership commitment to zero patient harm - Adoption of a safety culture - A robust process improvement system/approach He also cited three components that the Commission’s Center for Transforming Healthcare has found necessary to get to a nearly zero error rate: - Recognize that there are multiple causes – perhaps as many as 30 to 50 – of each problem. Most hospitals deal with the top three to five causes, but fail to address the others. - Understand that each cause requires a different strategy. - Realize that the key causes differ from place to place, so each place needs a customized strategy. Dr. Chassin noted that there are many factors that may underlie staff’s failure to follow proper hygiene, such as having their hands full, lack of accountability, ineffective education, poor sink location, distraction, and a belief that wearing gloves eliminates the need for hand washing. When the many causes are named specifically and then targeted systematically, according to Dr. Chassin, hospitals can achieve improvements of 40 to 60%. Targeted Solutions Tool
The Commission also has created a webbased Targeted Solutions Tool (TST) to help health providers enhance safety. The application guides healthcare organizations through a step-by-step process to accurately measure their organization’s actual performance, identify their barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers. Currently, hospitals using three modules – hand hygiene, hand-off communications (from one shift to the next) and wrong site surgeries – have decreased the readmission rate by 50%. With 1.7 million hospital-acquired infections per year causing 99,000 deaths, using TST is estimated to save 25,000 lives. The next time you fail to wash your hands between patients, remember that you’re contributing to the industry’s poor safety record, and potentially harming your patient. JULY/AUGUST 2013
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Good Deeds
Special Camps for Kids with Special Medical Needs By Tracy M. Fitzgerald
F
OR MOST YOUNGSTERS, ALONG with the summertime break from school comes the opportunity to have some fun. There is no shortage of options to consider when it comes to finding a summer camp for the kid that has a love for sports, a desire to explore the great outdoors or a passion for art. But what about the child who has a challenging health condition, preventing them from fully participating in most of the ordinary summer camps out there? A few local organizations have created programs especially for those with special medical needs, providing a valuable community service while giving every child who wants to go to summer camp a chance to do so.
Camp Airways director. “We talk a lot about the importance of staying active, and show the kids how to proactively plan and medicate themselves before physical activity.” Camp Airways, held in Severna Park, is staffed by therapists, nurses and junior counselors who are often asthma patients and previous campers themselves. “Parents can feel safe sending their kids here because we know how to manage asthma and can teach campers how to take care of themselves, while also making sure they have a good time,” said Thomas.
Breathing Easier at Camp Airways
Each summer, pediatric endocrinologist Rachel Gafni, M.D. volunteers her time to serve as medical director of Camp Possibilities, a special program for kids with diabetes. Held in Harford County in late July, the camp invites children ages eight to 15 for an overnight
Every August, Baltimore Washington Medical Center (BWMC) gives kids who suffer from asthma a chance to breathe a bit easier while still enjoying a wide range of traditional summer camp activities, from swimming and arts and crafts to yoga and yard games. Camp Airways teaches kids to live with and manage their asthmatic conditions, including how to recognize triggers, how to monitor and maintain peak flow levels, and how to respond in emergency situations. Campers also learn about the impact of nutritional choices on their asthma, the importance of proper hand washing, and the benefits of incorporating daily exercise and physical activity into their schedules. “Many asthma attacks are exercise induced, and a lot of kids will tell us they don’t exercise because they can’t breathe,” said Sandy Thomas, director of Respiratory Care and Neurology Services at BWMC, who also serves as 26 | WWW.MDPHYSICIANMAG.COM
Keeping Blood Sugar In Check at Camp Possibilities
through the same thing. Tremendous friendships are formed as the campers learn and have fun.” The daily itinerary for Camp Possibilities is packed with all of the normal activities you would expect to see at any other summer camp, from swimming and sports to talent shows and songs around the campfire. Upon arrival, campers are asked to establish goals to identify what they hope to get out of their experience and what they hope to learn over the course of the week. “Juvenile diabetes is complicated,” said Gafni. “We want to help these kids understand their disease and learn how they can best manage their blood sugar levels in an environment that is safe, fun and understanding.” Grief Camps Get Kids Smiling Again
The loss of a loved one is tough for any person to handle, especially a child. Camp Nabi, available to kids ages six to 12, and Camp Phoenix Rising, for those
“Juvenile diabetes is complicated. Our goal is to help these kids understand their disease and how they can best manage their blood sugar levels, in an environment that is safe, fun and understanding.”—Rachel Gafni, Medical Director, Camp Possibilities experience that some have referred to as “the best week of their lives.” “Some kids with diabetes don’t know any other kids who have diabetes,” Gafni said. “Then they come to Camp Possibilities and they meet all of these people who understand – who are going
12 to 18, are both sponsored by Hospice of the Chesapeake and are designed especially for kids who are grieving due to a loss they’ve recently experienced. Individual and group-based therapeutic activities, outdoor adventures and healing arts are emphasized at both
Kids with special medical needs can tap into the wide range of specialty summer camps that are made available by local hospitals and healthcare organizations, giving them an opportunity to learn and laugh with others who face similar medical challenges.
camps. Each camper is paired up with a “buddy” whose role is to offer support and to provide a relationship that can be counted on throughout the camp week. “In many cases camp is the first time the child has been away from his or her family since the loss happened,” said Sandra Dillon Anderson, director of communication for Hospice of the Chesapeake. “We strive to help these kids learn to trust again.” Similarly, Camp New Dawn is an overnight grief camp for kids ages seven to 17, offered by Hospice of Queen Anne’s County. According to Camp Director Rhonda Knotts, kids who have experienced loss can benefit tremendously simply by being around others who are dealing with the same issues. “We give the campers a chance to write a letter to their loved one and then share it if they wish,” explained Knotts. “It’s a very special time of reflection and remembrance that helps the kids realize they are not alone. They also participate in a series of five support-group sessions at Camp New Dawn that address their issues as they adjust to the changes happening in their lives.”
FOR MORE INFORMATION Camp Airways www.mybwmc.org/camp-airways-0 Camp Possibilities www.camppossibilities.org Camp Nabi and Camp Phoenix Rising www.chesapeakelifecenter.org/ camp-nabi Camp New Dawn www.hospiceofqueenannes.com/grieving
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28 | WWW.MDPHYSICIANMAG.COM
Solutions
Engaging a Commercial Real Estate Advisor/Broker is Good Medicine By Gary D. Applestein, SIOR
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ITH REAL ESTATE occupancy costs among the largest overhead expenses in any practice, physicians should recognize that their lease is actually a desirable asset to any prospective landlord. Building owners like having physicians as tenants because medical leases are typically longer and have higher rental rates. Many physician practices are merging into super groups or joining health systems, providing better credit for building owners. As a result, owners get higher returns if they sell or refinance their building. Knowing that their lease is desirable, physicians should engage a commercial real estate advisor/broker who is experienced at negotiating medical office leases. All buildings are leased directly by the owner or are listed with a broker whose interests are solely aligned with the building owner. Therefore, it makes sense to hire a broker who only represents your interest. A tenant advisor creates an atmosphere of competition and provides advice. Since the broker fees are typically paid by the building owner, there is no direct cost to the tenant, and the fees generated are shared with the building owner or listing agent. A good broker does more than simply find space. Your real estate advisor is the quarterback of the team, and should remember there are many other players that will join in the effort. The advisor should have relationships with other service providers who are also experts in medical office transactions; for example, space planners, architects, engineers, contractors, attorneys, IT specialists and furniture dealers. Having a good commercial broker offers a practical and detailed lease negotiation process that includes:
z Identifying and Selecting Alternatives When selecting a building, consider the property location, rental rate, ADA access, building age and ownership. z Space Planning Medical practices have unique build-out requirements. A space planner who knows how to design a medical space plan is essential in order to avoid having a poorly designed space that you will live with for many years. z The Initial Request for Proposal (RFP) Once the preferred list of potential buildings is developed, your broker should solicit proposals by sending an RFP to each building owner. A good broker understands that the RFP lays the foundation for subsequent negotiations on both the business and legal terms. z Analyzing Proposals and Counter Offers The advisor should analyze each response and prepare a counter offer that frames the position and provides the basis for further negotiations. Your advisor should prepare a detailed financial analysis, comparing all economic variables, such as rent, tenant improvements and annual increases. The counter offer should include items that are pre-negotiated, such as assignment and subletting, exclusivity, tenant guaranties, options to renew and expansion rights. z Letter of Intent (LOI) Once the preferred property is selected, it is recommended that an LOI be drafted between the parties. The LOI will summarize the agreed-upon business terms and address certain legal issues before the attorney becomes involved.
z Negotiating the Lease Most leases reflect forms previously drafted by the landlord and approved by the landlord’s lender. These forms are written to benefit the landlord more than the tenant. Your real estate advisor and lawyer should review and comment on the lease. z Designing the Medical Office The space planner will prepare or coordinate architectural and mechanical working drawings so the general contractor can estimate the costs and obtain the permits. Special consideration must be given to items often used in medical construction, such as seamless floors, special electric, special HVAC and extensive plumbing and cabinetry. z Construction Process and Move-In During construction, your advisor should meet regularly with the building’s agent and contractor to make certain the original schedule is met. The tenant will need to coordinate the installation of the phone and data-line infrastructure, and also contact movers and furniture dealers. This also may be the best time to implement or complete the conversion to Electronic Medical Records. Hiring a seasoned commercial real estate advisor makes sense for most medical practices. By managing the process and creating an atmosphere of competition between property owners, you can reduce occupancy costs. Moving occurs so infrequently that hiring a real estate advisor with the wisdom gained from experience is good medicine. Gary D. Applestein, SIOR, is managing director/principal of Baltimore Colliers International. He can be reached at gary.appelstein@colliers.com.
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Living
A Little Piece of Paradise Along Smith Mountain Lake
HEY SAY VIRGINIA IS FOR Lovers. And nestled in the central part of the state, with a skyline adorned by the picturesque Blue Ridge Mountains, is a place that can easily be fallen in love with – Smith Mountain Lake. Stretching 40 miles in length, and situated along 500 miles of shoreline bordering Franklin, Bedford and Pittsylvania Counties, the man-made Smith Mountain Lake was formed in the 1960s, with a vision to create year-round recreational opportunities for locals and tourists. During the area’s prime season (Memorial Day to Labor Day), there is no shortage of folks out on the water for a day of motor boating, wakeboarding, canoeing, kayaking or sailing, with access to the water made easy through a string of full-service marinas and boat rental companies that line the lake. Fishermen come from near and far to take advantage of Smith Mountain Lake’s bountiful largemouth and smallmouth bass, walleye and muskie populations. The opportunities to catch are so abundant, in fact, that ESPN Sports holds an annual competitive fishing tournament every April in the area, the Blue Ridge Big Bass Classic. “When you come here, you can experience the best of many worlds,” said Annette Stamus, marketing and communications manager for the Smith Mountain Lake Regional Chamber of Commerce and Visitor’s Center. “We make it easy for our visitors to enjoy the lake and all of the activities it offers. You can explore the state parks and historical areas that are just a short distance away, or you can dine, shop and relax. There is truly something for everyone here.” The U.S. D-Day Memorial and the Booker T. Washington National Monument are located within a short 30 | WWW.MDPHYSICIANMAG.COM
Watersport enthusiasts appreciate the wide range of activities available in the Smith Mountain Lake area. The scenic Blue Ridge Mountains add a touch of beauty.
drive of the lake, and those looking for a more interactive historical experience can dress in a periodic costume and participate in a Civil War re-enactment, or simply spectate as the commemoration of history unfolds. Visitors looking for a different kind of “playing field” can take to the greens on one of the Smith Mountain Lake area’s five 18-hole golf courses or three miniature golf courses, designed for family fun. As the sun goes down, make it a point to venture into downtown Moneta, the newest retail area to be developed along the lake, offering an antique mall, shops and art galleries, a variety of authentic, locally owned restaurants and even a drive-in movie theater, complete with a retro diner. “Smith Mountain Lake is a little piece of paradise,” said Stamus. “It may take a few hours to get here, but once you arrive, you will see that it was worth it. A lot of vacationers end up retiring here
because there is so much to see, do and enjoy, or they are drawn to the scenic beauty of the rolling mountains along the lake.” The Smith Mountain Lake Regional Chamber of Commerce recently launched a mobile app to make it easier to travel to the area and explore it. Get instant access to maps, local websites, images and videos by downloading the app at www.MyChamberApp.com.
Mark your calendar for the 25th Annual Smith Mountain Lake Wine Festival! This two-day event will be held September 28-29 and is the area’s biggest event of the year, with 27 participating wineries and food and crafts available from 85 vendors! Enjoy continuous live music as you wine, dine and relax with friends along the lake.
COURTESY OF THE SMITH MOUNTAIN LAKE REGIONAL CHAMBER OF COMMERCE AND VISITOR’S CENTER
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By Tracy M. Fitzgerald
Good intentions or bad judgment?
There are times we do crazy, misguided things; feats that shouldn’t be possible, and sometimes aren’t. So when you push yourself past your limits, it’s nice to know there’s a place like the Rubin Institute for Advanced Orthopedics – where doctors perform more total hip and knee replacements and progressive procedures like hip resurfacing – all combined with the latest rehabilitation services. Nice work knees and hips – the dynamic duo – when we ask too much of you! www.lifebridgehealth.org