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Physician YOUR PRACTICE. YOUR LIFE.

SEPTEMBER/OCTOBER 2011 VOLUME 1: ISSUE 3

Cutting-Edge Treatments In Prostate, Breast and Blood Cancers Imaging Advances More Power, Less Radiation Healthcare IT Resources Are You Missing Out?

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Contents 12

SEPTEMBER/OCTOBER 2011 Volume1: Issue 3

16

20

F E AT U R E S

12 With or Without a Scalpel Cutting-Edge Treatments in Prostate, Breast and Blood Cancer

16 Imaging Advances: More Power, Less Radiation 3T MRI and Image Wisely Campaign Help Diagnose More with Less

D E PA R T M E N T S

Cases | 7 | Treatment Options in the Management of Prostate Cancer Solutions | 8 | Managing the Peaks and Valleys of a Practice’s Cash Flow Medical Beat | 10 | News and Notes in the Medical Field Healthcare IT | 20 | Local HIT Resources and Incentives: AreYou Missing Out? Policy | 25 | New Maryland Law Mandates Changes in Concussion Education and Management Compliance | 23 | E-Prescribing and EHR – The Stick is Coming Good Deeds Heritage

| 25 | METAvivor Offers a Network of Support for Metastatic Breast Cancer Patients

| 26 | Maryland’s Supportive Sailing Regattas

On the Cover: Maria R. Baer, M.D., is professor of Medicine and Molecular Medicine at the University of Maryland School of Medicine and director, Hematologic Malignancies.

SEPTEMBER/OCTOBER 2011

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JACQUIE ROTH, PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com

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CONTRIBUTING WRITERS

IKE TOO MANY OF YOU and your patients, cancer has been a part of my life. I lost my sister to breast cancer and my mother to a blood cancer. Through my professional and volunteer commitments and personal experience with The Leukemia and Lymphoma Society and Hospice of the Chesapeake, I’ve taken an adage to heart, “The greatest cure for grief is action.” This issue of Maryland Physician, is dedicated to the memories of my sister and mother and to friends who are fiercely battling cancer. For our cover story, “With or Without a Scalpel,” Editor Linda Harder spoke with leading cancer specialists to learn about the latest developments in the fight against prostate, breast and blood cancers. The three physicians from Washington Hospital Center, Johns Hopkins Medicine and University of Maryland Greenebaum Cancer Center shared their news on cuts in morbidity, better treatment outcomes and new discoveries for treating these diseases. Maryland Physician is committed to enabling Maryland physicians to deliver the highest standards of patient care and practice management. As such, we regularly turn to Maryland’s subject matter experts for their contributions. In this issue, our experts focus on new options to manage prostate cancer, handle your practice's cash flow and on new laws that impact treatment and healthcare education. Whether you like it or not, healthcare reform is focused on IT being a part of your practice. Both our Compliance and our Healthcare IT departments deliver news vital to your practice’s performance, no matter its size or specialty. Maryland Physician is full of resources to help you meet and receive incentives for Meaningful Use. Are you taking advantage of all that is offered to you? Our experts discuss both the carrot and the stick approach to get you there. There are two photos in this issue that are particular favorites of mine. The first is Dozer the Labradoodle proudly wearing a medal awarded to him for helping raise funds for cancer research (Medical Beat on page 110); the second shows a group of incredibly brave and strong women on page 29. Both underscore that if there’s a will, there’s a way. We will beat cancer.

To life!

Jacquie Roth Publisher/Executive Editor jroth@mdphysicianmag.com

Allison Eatough Tracy Fitzgerald CONTRIBUTING PHOTOGRAPHERS Tracey Brown, Papercamera Photography www.papercamera.com Mark Molesky, Molesky Photography www.moleskyphotography.com Keith Weller DIGITAL Andrei Palmer, Digital General Manager Aertight Systems andreip@aertight.com ADMINISTRATION Ginger Jenkins Maryland Physician Magazine™ is published bimonthly by Mojo Media, LLC. a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 1663 Millersville, MD 21108 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 $42.00. To be added to the circulation list, please email circulation@mdphysicianmag.com or call 443-837-6948 Reprints: 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: JOHN BARRY, M.D. Chesapeake Orthopaedic & Sports Medicine Center KAREN COUSINS-BROWN, D.O. Maryland General Hospital HOLLY DAHLMAN, M.D. Greenspring Valley Internal Medicine, LLC PAUL W. DAVIES, M.D. Advanced 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 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.

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DR. YESH NAVALGUND / OWNER DNA ADVANCED PAIN TREATMENT CENTER CHRONIC PAIN MANAGEMENT PITTSBURGH, PA SINCE 2006 21 EMPLOYEES

LEARNING THE BUSINESS OF MEDICINE CHALLENGE: When Dr. Navalgund came out of medical school, he had all the right medical training. But when he decided to open his own practice, he needed something new — an education in the business side of medicine. SOLUTION: Dr. Navalgund had the Cash Flow Conversation with his PNC Healthcare Business Banker, who put his industry knowledge to work. Together, they tailored a set of solutions to strengthen his cash flow: loans for real estate and equipment along with a line of credit to grow his practice, plus remote deposit to help speed up receivables. ACHIEVEMENT: DNA Advanced Pain Treatment Center now has four private practices and a growing list of patients. And Dr. Navalgund has a place to turn for all his banking needs, allowing him to focus on what he does best. WATCH DR. NAVALGUND’S FULL STORY at pnc.com/cfo and see how The PNC Advantage for Healthcare Professionals can help solve your practice’s challenges, too. Or call PNC Healthcare Business Banker Les Pasternack at 1-866-356-6916 to start your own Cash Flow Conversation today. ACCELERATE RECEIVABLES IMPROVE PAYMENT PRACTICES INVEST EXCESS CASH LEVERAGE ONLINE TECHNOLOGY ENSURE ACCESS TO CREDIT

YES, WE’VE REDESIGNED OUR BREAST CARE CENTER TO FEEL MORE LIKE A FOUR-STAR HOTEL. NO, YOUR IN-LAWS CAN’T STAY HERE WHEN THEY’RE IN TOWN. Call it transformation. A renovation. Or an extreme hospital makeover. But for those who haven’t experienced the hotel-like comfort of the newly redesigned Herman & Walter Samuelson Breast Care Center at Northwest Hospital, you will be pleasantly surprised. Led by Dr. Dawn Leonard, fellowship-trained breast surgeon, you’ll find a relaxing spa-like atmosphere, the latest in digital mammography and a staff of leading oncologists and surgeons. There is no finer setting in Baltimore for comprehensive breast care. To learn more, go to lifebridgehealth.org.

Northwest Hospital is located at the corner of Old Court and Liberty Roads.

Cases

Treatment Options in the Management of Prostate Cancer David J. Perry, M.D. Veronica Kim, RN, BSN

CASE: A 60- year old male, in good overall health, presented with a gradually rising PSA level over the course of two years. He works full time, had minimal urinary symptoms, and normal erectile function. With the PSA reaching 5.3 ng/ml, his urologist chose to perform a biopsy. The pathology report confirmed Gleason 6, prostate cancer. In considering treatment options for his early stage prostate cancer, he was concerned about missing time from work, and the possibility of urinary, bowel, and sexual side effects. DISCUSSION According to the American Cancer Society, approximately 240,890 new cases of prostate cancer are estimated to occur in 2011. Prostate cancer is the second leading cause of cancer deaths in men. One out of 36 men will die from the disease. Prostate

cancer typically affects men 50 years of age and older. While the cancer often grows very slowly, there are some occurrences where the disease is more aggressive and can spread to other parts of the body quickly. Once a diagnosis of prostate cancer is made, and the stage is determined (how aggressive, or advanced the disease is), a patient has several different treatment options. These include: z Watchful Waiting z Prostatectomy z Brachytherapy z Hormonal Therapy z External Beam Radiation z CyberKnife速 Radiosurgery CyberKnife radiosurgery is a more recently developed treatment modality for prostate cancer. A robot is used to deliver multiple highly focused radiation beams to the prostate. The improved accuracy of this method over IMRT allows for larger daily doses of radiation, shortening the course of treatment from two months, to five days. Treatment is entirely outpatient, requires no anesthesia, and takes about one hour per day. Five-year outcome data is now available for CyberKnife prostate cancer treatment which demonstrates excellent treatment efficacy and safety. With few exceptions, rates of disease-free, and overall, survival are similar between the different types of radiation treatment, and surgery. As side effect profiles, however, can differ significantly between methods of treatment, patients should have a full understanding of what each entails, and

the potential impact on their life. This is best accomplished with a multidisciplinary approach, where the patient meets with both a urologist and radiation oncologist do discuss his options. After carefully considering his options, our patient elected to proceed with CyberKnife radiosurgery. He received a total radiation dose of 3,625 cGy over 5 days. Our patient had no urinary or bowel side effects during his course of treatment. He experienced some mild urinary symptoms in the days immediately following treatment. His erectile function was unchanged. It has been over two years since the patient was treated, and he continues to do well. He notes only mild, occasional, urinary irritation. His PSA level continues to decline, most recently at 1.52 ng/ml, demonstrating a biochemical response to treatment. In conclusion, although prostate cancer is the second leading cause of cancer deaths among men, the good news is there are a variety of treatment options available to fight the disease. A multidisciplinary approach is essential to ensure that patients understand all of their options, and the potential effects each can have on their lives. After careful consideration, our patient chose CyberKnife radiosurgery, as it is a noninvasive, highly effective, outpatient treatment, which addressed his cancer with minimal impact on his daily life. David J. Perry, M.D. is a board certified radiation oncologist with a special interest in prostate cancer. Dr. Perry is Chief of Radiation Oncology and Director of CyberKnife at Franklin Square Hospital Center. He can be reached at David.James.Perry@medstar.net.

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Solutions

Managing the Peaks and Valleys of a Practice’s Cash Flow By Rose Zuknick

T

HE MOST INTENSE, ANXIOUS moments of your career as a practice owner typically won’t be about making a profit – they’ll be about being out of cash. You want to manage your practice to be profitable, but you have to operate it to maximize cash flow. To do that, you must be prepared for the cash peaks and valleys that all practices experience.

when payments will come in and go out, you can anticipate disruptions to your cash flow. Consider maintaining a line of credit to avoid fluctuations. Also, if you have significant payments that occur on a regular basis – such as tax or insurance payments – consider creating a reserve fund to neutralize the disruptions that these disbursements may cause.

Take Stock of Your Cash Management Tools

Revisit Your Receivables Strategy – The more efficiently you manage your receivables, the sooner you can put those funds to work for your practice. Enhancing your receivables management starts by giving patients multiple payment options at the point of sale. To help

The key to positive cash flow is to keep money coming into a practice faster than it’s going out. Regardless of whether you’re currently meeting that goal, it’s critical to analyze your cash flow cycle

Online bill pay services allow you to reduce the time and costs involved with paying business bills, while online payroll services enable you to better manage your payroll processing. and devise a plan to ensure that you have the operating funds you need to support the successful operation of your practice. To maximize your cash flow and make the most of your money, take stock of the cash management tools at your disposal. Here are a few things to consider: Develop a Liquidity Plan – Liquidity doesn’t just happen; you need a plan in place to manage your cash on hand. By creating a simple cash forecast to predict

motivate patients to pay their invoices in a timely manner, you can offer a discount for early payments and assess a penalty for late payments. Finally, take advantage of remote deposit services that allow you deposit incoming checks as soon as you receive them. Take Advantage of Payment Technologies – Various new technologies are available to help you improve cash flow by enhancing your payment processes. Online bill pay services allow you to reduce the time and costs involved with

paying business bills, while online payroll services enable you to better manage your payroll processing. Also, consider using check cards, credit cards or purchasing cards to help you track business spending more effectively. Re-Evaluate Inventory Practices – Assess your inventory needs carefully, evaluate your mix of suppliers and possibly renegotiate trade terms. Inventory represents a critical pressure point for cash flow, so constantly be on the lookout for opportunities to enhance your inventory practices. Protect Your Practice through Good Times and Bad

Poor cash flow is one of the leading causes of small practice failures, while optimizing cash flow is one of the most important things you can do to help achieve your practice goals. By revisiting your contingency plans, leveraging your receivables and payments strategies and addressing the factors that create cash flow pressure, you are better able to manage the cash peaks and valleys that all practices inevitably face. Rose Zuknick is a vice president in the Healthcare Banking division of PNC Bank. She can be reached at rose.zuknick@pnc.com

The article you read was prepared for general information purposes is not intended as legal, tax or accounting advice or as recommendations to engage in any specific transaction, including with respect to any securities of PNC, and do not purport to be comprehensive. Under no circumstances should any information contained in this article be used or considered as an offer or commitment, or a solicitation of an offer or commitment, to participate in any particular transaction or strategy. Any reliance upon any such information is solely and exclusively at your own risk. Please consult your own counsel, accountant or other advisor regarding your specific situation. Neither PNC Bank nor any other subsidiary of The PNC Financial Services Group, Inc. will be responsible for any consequences of reliance upon any opinion or statement contained here, or any omission. The opinions expressed in this article is not necessarily the opinions of PNC Bank or any of its affiliates, directors, officers or employees. PNC is a registered mark of The PNC Financial Services Group, Inc.(“PNC”) Banking and lending products and services, bank deposit products, and Treasury Management services for healthcare providers and payers are provided by PNC Bank, National Association, a wholly-owned subsidiary of PNC and Member FDIC. Lending and leasing products and services, including card services, trade finance and merchant services, as well as certain other banking products and services, may require credit approval.

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Medical Beat

UM School of Medicine Team Cracks Genomic Code of Bacterium Outbreak

Bromberg named Head of UM School of Medicine Transplantation

A team led by the University of Maryland School of Medicine’s Institute for Genome Sciences recently unraveled the genomic code of the E.coli bacterium that caused in May a deadly outbreak in Germany. More than 50 people have died as a result of the outbreak, which has sickened thousands in Germany, Sweden and the United States. Within a few days, the team of worldwide researchers analyzed the genomics of outbreak samples, as well as closely-related strains. Then, researchers combine the findings with the biology and evolution of the bacteria. The quick analysis helped physicians treating those who were infected, as well as epidemiologists trying to trace the pathogen’s source.

The University of Maryland School of Medicine has named Jonathan S. Bromberg, M.D., head of the Division of Transplantation within the Department of Surgery. Dr. Bromberg, a professor of surgery and of microbiology and immunology, received his medical degree from Harvard Medical School and a Ph.D. in immunology from the Harvard Graduate School of Arts and Sciences. He conducted postgraduate research at University College in London before becoming chief resident at the University of Washington Affiliated Hospitals in Seattle. He also completed a fellowship in the Division of Transplantation of the Department of Surgery at the University of Pennsylvania. Dr. Bromberg’s research focuses on cellular and molecular immunology in transplantation.

Franklin Square Achieves Pediatric Asthma Certification

Director of St. Joseph Medical Center’s Breast Center Recognized by Tigerlily Foundation Michael J. Schultz, MD, the medical director of the Breast Center at St. Joseph Medical Center’s Cancer Institute, was recently honored at the Tiger lily Foundation’s 3rd annual Gala – called the EmPower Ball – in Washington, D.C. as a recipient of the Inspire Award. The Tigerlily Foundation is a national organization based in Washington, D.C., that provides special support for young women under age 40 faced with breast cancer that is often in the advanced stages of disease. Maima Karmo, who founded the organization after her own triumph over Stage IV, triple negative breast cancer, identified the very special care provided at St. Joseph’s Breast Center, under the direction of Dr. Schultz, as the “ideal model of care” which should be available to all women. Ms. Karmo struggled for a year to be diagnosed. In contrast, St. Joseph’s Breast Center offers “No More Sleepless Nights” ™, which not only provides a prompt diagnosis but is accompanied by a seamless, integrated, and individualized approach for treating women faced with the journey through breast cancer. "No More Sleepless Nights" was developed by Dr. Schultz, who has been in practice in Baltimore for 40 years. It is based on his own personal approach to patient care. For more information, visit www.tigerlilyfoundation.org.

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The Joint Commission on Accreditation of Healthcare Organizations recently honored Franklin Square Hospital Center with a certificate of distinction for its pediatric asthma management program. Asthma is the most frequent cause of hospitalization for children at Franklin Square Hospital Center. To address the disorder, the hospital introduced its asthma program in December 2008 through its Pediatric Emergency Department and inpatient units. By using a team approach, the program works to raise the standard of care by consistently and efficiently managing pediatric asthma patients. Franklin Square is one of only seven hospitals and organizations in the country and one of two in Maryland to receive the certificate.

New Certificate For Physician Assistants The National Commission on Certification of Physician Assistants (NCCPA) has announced its new Certificate of Added Qualifications program for certified physician assistants practicing in cardiovascular and thoracic surgery, emergency medicine, nephrology, orthopedic surgery and psychiatry. Physician assistants can build on their NCCPA generalist certification by earning a CAQ. For more information, visit www.nccpa.net

Marc W. Hungerford, M.D., Director of Joint Replacement and Reconstruction at Mercy Medical Center, recently became the state’s first surgeon to perform MAKOplasty Partial Knee Resurfacing using the RIO Robotic Arm Interactive Orthopedic System. The MAKOplasty partial knee Marc W. Hungerford, M.D., director of Joint resurfacing is a less invasive option Replacement and Reconstruction at Mercy than total knee replacement for Medical Center. patients with early to mid-stage knee osteoarthritis. By using the robotic component of the system, surgeons have access to real-time visual, tactile and auditory feedback. This helps the surgeon place the implant more precisely. Benefits of the procedure can include a smaller incision, less scarring, reduced blood loss and minimal hospitalization.

KEVIN J PARKS/MERCY MEDICAL CENTER

Mercy Surgeon First in State to Perform MAKOplasty “Mini Knee” Replacement

Pathways Director Receives Certification in Addiction Psychiatry Rhonda L. Allen, M.D., medical director of the Pathways Alcohol & Drug Treatment Center in Annapolis, recently received board certification in addiction psychiatry. Dr. Allen, who is also board certified in psychiatry, has served as Pathways’ medical director since July 2010. As medical director, she is responsible for each client's physical well-being during treatment. Pathways is part of the Anne Arundel Health System.

Hopkins Launches Research to Study Genetics of Blood Clotting Disorders Johns Hopkins scientists recently began a first-of-its-kind research program to create human platelet cells from stem cells in order to study inherited blood clotting abnormalities, ranging from clots causing heart attacks to bleeding disorders. The five-year study, funded by a $9 million National Institutes of Health grant, is part of a nationwide effort to examine how genetic variations cause blood, heart and lung disorders.

Labradoodle Raising Research Funds for the Greenebaum Cancer Center end of the 13.1-mile race, crossing the finish line with other runners at 2 hours and 14 minutes. Dozer was awarded a finisher's medal and a Facebook fan page was created for him. As Maryland Physician went to print with this issue, Dozer has raised nearly $24,000 for research at the University of Maryland Marlene and Stewart Greenebaum Cancer. That's more than any of the human runners. The money he has raised will be used to fund a clinical trial to test a possible new treatment for an aggressive form of breast cancer (called triple-negative breast cancer) and other research involving health disparities in cancer. The video of Dozer crossing the finish has gone viral, with more than 293,000 views on YouTube. For more information, visit www.umm.edu/dozer and join his nearly 16,000 Facebook fans at www.facebook.com/ dozerthedogfanpage. Dozer, a civic minded Labradoodle, escaped from his yard in Howard County on May 15, 2011, as hundreds of runners from the Maryland Half Marathon passed his house. He followed the runners from mile 5 to the

Send news and announcements for publication consideration with high res photo (300 dpi) to news@mdphysicianmag.com

Clinical Features Maryland Physician is dedicated to enabling Maryland physicians to deliver the highest standards of patient care with one-on-one conversations with clinical and subject matter experts. Maryland Physician showcases cuttingedge treatments.

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 Print and Online Cases x­Solutions x­Compliance x­Medical Beat x­Policy Heritage x­Legacy x­Good Deeds Jacquie Roth x Publisher/Executive Editor 443-837-6948 x­­jroth@mdphysicianmag.com www.mdphysicianmag.com

SEPTEMBER/OCTOBER 2011

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With or Without A Scalpel BY LINDA HARDER

Cutting-Edge Treatments in Prostate, Breast and Blood Cancer

While the eradication of cancer is still a dream, new treatments – some that involve a scalpel but many that do not – provide hope for a longer life expectancy coupled with a higher quality of life. Maryland Physician Magazine spoke with three Maryland cancer experts – Jonathan J. Hwang, M.D., Theodore N. Tsangaris, M.D. and Maria R. Baer, M.D. – to learn about the latest developments in the fight against prostate, breast and blood cancers. 12 |

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Prostate Cancer: Good News on Multiple Fronts Dr. Hwang, M.D., director, Robotic Surgery Program, Washington Hospital Center, is clearly buoyed by the many exciting developments in prostate cancer treatment and the increasingly early detection of this second-most prevalent male cancer. “In the past five years, when the cancer is caught early, we’ve had a growing array of treatment options,” he exults. “Which are right for a given patient depends not only on PSA and Gleason scores, but also on life expectancy, the patient’s risk tolerance and other factors.” Prognostic Nomograms

Sophisticated software tools are helping permit more nuanced treatment decisions. A prognostic tool developed by Memorial SloanKettering Cancer Center analyzes

PSA values, biopsy pathology data, hormone and radiation information to predict the disease course, and the likelihood of indolent versus aggressive prostate cancer. Robotic Surgery Cuts Morbidity

Dr. Hwang observes, “A 2010 NEJM article concluded that, when patients have less than a 15-year life expectancy, we can use surveillance unless the cancer is aggressive. However, there’s an ongoing debate about the best treatment for younger men with aggressive disease but no significant co-morbidity. Most urologists believe that surgery offers the best chance of a cure.” Increasing expertise in roboticassisted prostatectomies is thankfully cutting the risk of life-altering side effects such as incontinence and impotence. Dr. Hwang notes, “The

KEITH WELLER

Jonathan J. Hwang, M.D., a national expert in robotic surgery, is the director of the new Robotic Surgery Program at Washington Hospital Center.

risk of severe incontinence is less than 1% at centers proficient in robotic procedures, compared to 10% with open procedures. Our center also has been able to reduce erectile dysfunction (ED) rates to about 15%, vs. 50% with an open procedure. It’s not the approach per se, but the doctor’s and the center’s experience. I believe robotic surgery will provide more consistent results.” More Targeted Radiotherapies

“…mastectomies are making a bit of a comeback. As long as the woman has thought about it carefully, I support her decision.” KEITH WELLER

– Theodore Tsangaris, M.D.

Radiotherapy has also witnessed tremendous advances. “Proton beam, IMRT and cyberknife all decrease the amount of radiation scatter and the effects on surrounding tissue, providing highly precise radiotargeting,” comments Dr. Hwang. “Brachytherapy is also effective for early stage cancer, with a low risk of incontinence but a 15 to 20% risk of ED. Also, we’re now trying focal cryotherapy, targeting only sections that demonstrated cancer on biopsy. Preliminary results show that this therapy is effective for patients with early stage cancer, but we don’t yet have long term data.” Pharmacotherapy Options Exploding

Pharmaceutical options to treat prostate cancer or its side effects have recently exploded, including; z

z

z

z z

Theodore N. Tsangaris, M.D., F.A.C.S., is an associate professor of Surgery and chief of Breast Surgery, Johns Hopkins Comprehensive Breast Center

Provenge, an autologous cellular immunotherapy, used when cancer spreads beyond the prostate and hormone therapy is ineffective. Jevtana, which treats patients with metastatic hormone-refractory prostate cancer (mHRPC) previously treated with docetaxel. Zytiga, which inhibits the CYP17 enzyme to decrease testosterone production and prevent bone damage. Xgeva, which delays the spread to bones and reduces fracture risk. Cabozantinib, an experimental drug that may eradicate bone metastases.

“We’re in an exciting phase where we have new options,” exclaims Dr. Hwang. “It appears that we can increase life expectancy by up to a year; however, the best sequence of medications has not yet been determined.” Not surprisingly, these therapies can cost up to $100k for a course of treatment.

Breast Cancer: More Complex Diagnosis and Treatment Options Theodore Tsangaris, M.D., chief of Breast Surgery and director of the Johns Hopkins Comprehensive Breast Center, also 14 |

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expresses optimism when discussing breast cancer diagnosis and treatment advances. Diagnostics More Complex

The key to early detection is still a screening mammogram,” he says. “All women aged 40 and older should still get them each year.” Dr. Tsangaris adds, “Breast MRI can lengthen the diagnosis period and make it more complex, but it provides better outcomes for women in appropriate situations. And the days of finding breast cancer through an excisional biopsy are over. A core biopsy done by a breast imager is the right thing to do. As a result, I now see most of my patients after they’ve been diagnosed. Faster is not always better.” Mastectomies Resurging

A lumpectomy repeatedly has been proven to be the right approach for most women with breast cancer. When combined with radiation therapy, it’s comparable to a mastectomy except in two situations – where the cancer is too large relative to the size of the breast and when multiple lesions exist. “Nonetheless, mastectomies are making a bit of a comeback,” Dr. Tsangaris observes. “As long as the woman has thought about it carefully, I support her decision. However, if she opts to have a mastectomy, I often encourage her to get reconstruction. A 50 year old woman likely will live at least another 25 years, and an artificial prosthesis impacts many activities, not just her sexuality.” Breast reconstruction techniques have improved dramatically. In addition to the traditional implants, new approaches include tissue taken from the midriff, back or inner thigh. Breast surgeons can now set up the plastic surgeon by doing a friendly mastectomy that can include skin sparing and even nipple sparing approaches. “Believe it or not, we can make the breast look as good, if not better, than before,” says Dr. Tsangaris. “However, we can’t preserve breast sensation, which is important to many women.” Dr. Tsangaris is a supporter of the sentinel lymph node procedure in women with early stage breast cancer. Even when the sentinel lymph nodes are positive, new data suggests that the remaining lymph nodes do not have to be removed. Adjuvant Therapies Undergoing Dramatic Change

The many new developments in

PAPERCAMERA PHOTOGRAPHY

Maria R. Baer, M.D., is professor of Medicine and Molecular Medicine at the University of Maryland School of Medicine and director, Hematologic Malignancies.

with treatment using new approaches, without a lengthy hospital stay, while others may benefit from chemotherapy and a reduced intensity transplant approach. We are also testing a vaccine against a protein expressed in most patients’ AML cells.” Myelodysplastic Syndromes (MDS)

Until the past decade, there were no treatments to prevent 25% of patients with MDS from progressing to AML. Since that time, several efficacious, FDA-approved treatments have become available, including the demethylating agents azacitidine and decitabine. They can significantly increase response rates, improve quality of life, reduce risk of leukemic transformation, and improve survival. Current clinical trials are testing several new drugs and drug combinations to further improve outcomes. Myeloproliferative Neoplasms (MPN)

chemotherapy and radiation therapy make this an exciting field. In radiation therapy, the standard regimen of six weeks of radiation to the whole breast, followed by radiation targeted to the cancer site, is changing. Doctors are exploring options that include: z z z

Radiation targeting only the lesion Cutting radiation to three weeks or even one week Avoiding external beam radiation

Dr. Tsangaris concludes, “The good news is that we’re having a more positive impact on the disease but less of a negative impact on patients’ lives. Nonetheless, selecting the right treatment option is more complex; we need to avoid rushing into a specific treatment plan until we’ve thoroughly assessed all of a patient’s options.”

Blood Cancers: Molecular Advances Stratify Treatment Major breakthroughs also abound in the treatment of leukemias and other blood cancers. Maria Baer, M.D., director of Hematologic Malignancies at the University of Maryland Greenebaum Cancer Center, describes the progress being made in Acute Lymphoblastic Leukemia (ALL), Acute Myeloid Leukemia (AML), Myelodysplastic Syndrome and Myeloproliferative Neoplasms (MPNs). “We are now using both chromosome and molecular analysis to stratify treatment and develop targeted therapies,” she notes.

ALL and AML– Inhibiting Metabolic Abnormalities Improves Outcomes

“Doctors have long known how to detect chromosome abnormalities, but with our newer ability to detect molecular abnormalities, we can better predict how patients will respond to chemotherapy and who will benefit from bone marrow transplants. We can also incorporate targeted therapies,” says Dr. Baer. “For example, adults with ALL typically have responded less well to treatment than children, but the addition of Bcr-Abl inhibitors such as Gleevec, originally developed for chronic myelogenous leukemia (CML), to chemotherapy regimens significantly improves outcomes for patients with Philadelphia chromosome-positive ALL. “ Likewise, there is new hope for the 30% of AML patients who have a mutation of the FLT3 gene. These patients have typically responded poorly to therapy, but an ongoing international clinical trial is testing a FLT3 inhibitor in conjunction with chemotherapy. “Some patients had normal chromosomes in their leukemia cells, but still didn’t respond well to treatment,” observes Dr. Baer. “Now, we can detect molecular abnormalities in these patients’ leukemia cells and use the information to better tailor our treatment. “ She continues, “Older patients typically don’t respond as well to treatment and don’t stay in remission as long as younger patients. Using chromosome and molecular data, we can better identify patients who will do better

These diseases include myelofibrosis (MF), polycythemia vera (PV) and essential thrombocythemia (ET). Doctors recently discovered that these patients’ cells often have a mutation of the JAK2 gene, causing the abnormal proliferation. Several different JAK2 inhibitors are in clinical trials. In MF, these have been effective in shrinking the spleen and improving patient well-being; newer JAK2 inhibitors may also improve anemia. Dr. Baer ends by noting, ‘There has been a quantum leap in treating these diseases. The tremendous discoveries with regard to their molecular pathogenesis are being translated into new treatments. CML used to be lethal unless a bone marrow transplant could be performed, but since the advent of Gleevec and other BCR-ABL inhibitors, it is now the model of success in modern oncology.”

Jonathan J. Hwang, M.D., a national expert in robotic surgery, is the director of the new Robotic Surgery Program at Washington Hospital Center. Theodore N. Tsangaris, M.D., F.A.C.S., is associate professor of Surgery, chief of Breast Surgery, Division of Surgical Oncology and director, Johns Hopkins Comprehensive Breast Center Maria R. Baer, M.D., is professor of Medicine and Molecular Medicine at the University of Maryland School of Medicine and director, Hematologic Malignancies.

SEPTEMBER/OCTOBER 2011

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IMAGING ADVANCES

More Power Less Radiation

Jeffrey Hirata, M.D., musculoskeletal radiologist with Community Radiology Associates.

BY LINDA HARDER PHOTOGRAPHY BY MARK MOLESKY

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3T MRI and Image Wisely Campaign Help Diagnose More with Less MARYLAND PHYSICIAN SPOKE TO two Maryland radiologists – Jeffrey Hirata, M.D., musculoskeletal radiologist, and Parham Farid, M.D., neuroradiologist, both with Community Radiology Associates – about how the higher magnetic strength of 3T MRI is helping physicians diagnose minute problems throughout the body. At the same time, CT radiation doses are being dramatically reduced. Mark Baganz, M.D., medical director, Chesapeake Medical Imaging, explains why CT radiation doses are much lower today and why CT colonography is a useful adjunct to the traditional invasive procedure.

However, it offers clear advantages in some key areas, especially:

Ideal for Musculoskeletal Imaging

JOINT

Ideal 3T MRI Referrals

Dr. Hirata observes, “3T MRI excels in imaging of the small joints, including the elbows, wrists, ankles, feet, fingers and toes. The significant improvement in spatial resolution and image detail with a 3T magnet allows for a more accurate evaluation of significant injuries, which are often difficult to diagnose. 3T MRI also excels in evaluating articular cartilage that can be difficult to evaluate with lower strength magnets. Very small, yet significant abnormalities of the cartilage and menisci of the knee can be visualized with great detail.” Generally speaking, 3T MRI should be considered for patients with damage or injury to the small joints or their surrounding tissue – the wrist, hand, ankle, foot or elbow. 3T also is useful for diagnosing problems of large joints such as the shoulder, knee and hip. It can identify minute tendon tears, gradation of cartilage and articular abnormalities, greatly affecting treatment plans and surgical decisions. This high field magnet also provides surgeons with more detailed information that shapes accurate post-op expectations.

Wrist

Triangular fibrocartilage tears and scapholunate ligament tears

Select Body Applications

Thumb

Pain in the base of the thumb after trauma, often caused by an ulnar collateral ligament sprain or tear

This magnet’s superior spatial resolution also provides advantages in the abdomen and pelvis that include:

Knee

For medial or lateral knee pain - superb images of articular cartilage Can differentiate degenerative changes from a meniscal tear

z z

Toes

Determine plantar plate injuries and sesamoid bone injuries

Shoulder/Hip

Detailed evaluation of labral tears when performed as an MRI arthrogram

3T MRI: The Magic is in the Details

Providing nearly twice the strength of 1.5T MRI, 3T MRI is increasingly available in inpatient and outpatient settings throughout Maryland. At this time, 3T MRI has not proven sufficiently superior to lower strength magnets to warrant its use in many studies.

z­small joints and select large joint studies z­minute neurological lesions and structures z­select breast/body studies Dr. Farid comments, “The magic is in the details. 3T MRI’s higher field strength provides a greater signal-to-noise ratio, which allows us to see smaller structures in better detail. Its crisp, sharp images can help an orthopedic surgeon make a more definitive diagnosis. In the spine, we can see clear images of tiny demyelinating plaques. In brain imaging, we can see the cranial nerves and the brain stem in more detail, and in MR angiography, we can better visualize smaller peripheral vessels. Smaller lesions can be picked up on breast MRI, which can lead to earlier diagnosis and better outcomes. The clarity of 3T MR results in greater confidence in the interpretation.”

3D acquisitions and isotropic voxels Greater sensitivity to contrast that improves lesion conspicuity z MRCP for visualization of intrahepatic bile ducts and pancreatic ducts z­ Improved MRA

SEPTEMBER/OCTOBER 2011

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Slashing Radiation Dosage

A consortium of organizations led by the American College of Radiology has initiated two campaigns to lower the amount of radiation that patients receive in their imaging procedures. Image Gently, the first campaign, was aimed at reducing dosage in procedures for children. It was followed by Image Wisely, a campaign that targets radiation dosage in adult procedures. These campaigns have helped to foster changes in imaging that dramatically reduce radiation exposure without compromising the quality of the studies. “While the risk of the radiation from a CT scan using modern equipment is so low that it is not really measurable and no reliable studies suggest that they cause cancer, we have undertaken a number of efforts to avoid or minimize radiation whenever possible, achieving doses that are far lower than in the past,” says Dr. Baganz. “He continues, “We follow a six part program that is standard in radiology practices. This program includes:

Mark Baganz, M.D., medical director, Chesapeake Medical Imaging

Especially given the many precautions now taken, we don’t want to overstate a small theoretical risk if it leads to the real problem of patients avoiding a procedure that allows the timely diagnosis and treatment of a serious medical condition.” — Mark Baganz, M.D.

z­ optimizing CT technique to prevent motion and the need to repeat studies; z­ increasing pitch, the speed of the table moving through the scanner, to decrease radiation by as much as a third; z­ decreasing the electric current to the scanner, which also cuts radiation as much as a third without increasing the ‘noise;’ z­ using alternative procedures that don’t involve radiation (such as MRI and ultrasound) and encouraging alternative techniques where appropriate, such as CT without contrast; z­ using the computerized dose reduction techniques built into the newer scanners that modulates radiation to the exact dose needed based on the patient’s weight and region of the body being scanned; z­ using shields to protect sensitive body parts, such as eyes, breast and thyroid, and/or angling the X-ray beam to remove them from the field of study.” Dr. Baganz adds, “Excessive concern about radiation can lead to a real diagnostic dilemma. Especially given the

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Parham Farid, M.D., neuroradiologist with Community Radiology Associates, reviews 3T MRI scans of the brain.

many precautions now taken, we don’t want to overstate a small theoretical risk if it leads to the real problem of patients avoiding a procedure that allows the timely diagnosis and treatment of a serious medical condition.” CT Colonography

“CT has made tremendous advances in the past decade, and can now be used to diagnose heart disease non-invasively or perform a virtual colonoscopy,” comments Dr. Baganz. “CT colonography has a similar sensitivity to invasive colonoscopy for finding polyps. Some 10 percent or less of patients need to undergo a follow-up traditional procedure to biopsy the polyps found on CT. The CT procedure is extremely useful for patients whose colonoscopies were incomplete as a result of tortuosity or other problems. That accounts for nearly two thirds of the patients we see, while many others are those who were avoiding this important procedure due to fear of its discomfort.” Parham Farid, M.D., is a neuroradiologist with Community Radiology Associates (CRA) Jeffrey Hirata, M.D., is a musculoskeletal radiologist with CRA. Mark Baganz, M.D., is the medical director of Chesapeake Medical Imaging.

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Healthcare IT

Local HIT Resources and Incentives

Are you missing out? BY LINDA HARDER PHOTOGRAPHY BY TRACEY BROWN

T

HE RACE TO MEET MEANINGFUL Use criteria is on. In addition to the widely known incentives from CMS, many local agencies and hospitals are offering free resources and financial incentives for physician practices. Are you taking advantage of all that apply to you? To learn whatâ&#x20AC;&#x2122;s out there, we talked with the following Maryland experts: Daniel Wilt, program director, REC, CRISP (Chesapeake Regional Information System for our Patients); Sarah Orth, chief of Health Information Technology, MHCC (Maryland HealthCare Commission); Craig Behm, executive director, MedChi Network Services; Tawanda Cevis, director, IT, Mercy Medical Center and Gaurov Dayal, M.D., Sr. VP/CMP, Adventist HealthCare. CRISP: Consults, Resource Library, MSOs and RECs

CRISP, which serves as both Marylandâ&#x20AC;&#x2122;s HIE 20 |

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(Health Information Exchange) and REC (Regional Extension Centers), has a number of resources for physicians, including some for specialists. It already has signed up over 1,000 primary care providers with its MSOs (Management Service Organizations). MSOs offer centralized administrative and hosted technology services, providing an alternative to EHR client-servers where the technology is maintained at the provider site. They can support multiple EHR products at reduced costs. Physicians participating in the CRISP MSOs receive subsidized services totaling up to $4,035 for reaching three milestones that involve: signing up, going live with EHR/ e-prescribe and achieving Meaningful Use Stage 1. These service incentives are in addition to federal Meaningful Use incentives. Eligible participants may receive subsidized assistance with workflow redesign and other technical services at a discount. The program is having its intended effect

to promote EHR (electronic health record) adoption and meet Meaningful Use criteria. “Some 70% of our subscribing physicians are adopting EHR for the first time. We’re on track with our mission to make sure that the smallest practices are getting the right support,” states Wilt. While specialists do not qualify for subsidized services, they can still take advantage of the CRISP MSOs and their services. Wilt says, “CRISP and its MSOs can help you decide whether to stay with or switch from your current EHR, or which EHR is right for you. Our MSOs cover nine of the top-10-rated EHR vendors, helping physicians avoid being overwhelmed by the more than 400 certified products out there.” Frederick Memorial, GBMC, AAMC and Adventist Healthcare participate with the CRISP REC program. CRISP offers free online resources at www.crisphealth.org that include webinars, a resource bank and links. Alternatively, providers can contact CRISP at rec@crisphealth.org or 877-95CRISP to schedule a free, unbiased consult and practice self-assessment.

MHCC – Free Resources and an EHR Incentive Program

The MHCC’s Center for Health Information Technology is tasked with promoting the widespread use of EHRs and HIE in the state, working in concert with CRISP to achieve this goal. Its website, http://mhcc.maryland.gov/, contains a wide range of information on health information technology, including information on state-designated MSOs. About 12 MSOs are in Candidacy Status and, to date, seven have achieved State Designation. Sarah Orth comments, “MSOs are more than just an EHR vendor – they are responsible for ensuring privacy and security of electronic health records and must achieve national accreditation. They also provide an ongoing relationship with the physicians, rather than leaving after installing an EHR system. Physicians can call the REC for help in selecting the best MSO for their practice.” Free resources on the MHCC website include: z An EHR initiative checklist; z The pros and cons of client server vs. web hosted (ASP) EHRs; z An EHR return on investment calculator; and z Lessons from small physician practices. Physicians should also be aware of a new state EHR incentive program. The MHCC adopted regulations that require the six largest carriers in the state to pay incentives for adopting and implementing an EHR: Carefirst, Aetna, Kaiser, United, Cigna and Coventry. Primary care practices can earn up to $15,000 in incentive payments. Orth remarks, “Maryland is the first state to build on the federal incentives.” The state incentive program works as follows, with applications now available. The timeframe for participating is October 2011 through December, 2014. Primary care practices are eligible to receive a base incentive up to $7,500 and an additional incentive up to $7,500 for a total of $15,000 per practice per payer. Primary care practices may request incentives in various forms that include cash, lump sum payments, gain-sharing arrangements or rewards for quality and efficiency.

Sarah Orth, chief, Health Information Technology, MHCC

ORGANIZATION

RESOURCES

EMAIL/URL

PHONE

CRISP

MSOs; free consult, assessment, articles/tools

www.crisphealth.org rec@crisphealth.org

877-95-CRISP

MHCC

Financial incentives, MSOs, other support

http://mhcc.maryland.gov

410-764-3460

MedChi

MSO, education

healthIT @medchi.org

800-874-6573

AMA

IT articles, tools

www.ama.org www.amagine.com

800-262-0411

SEPTEMBER/OCTOBER 2011

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Gaurov Dayal, M.D., Sr. VP/CMO, Adventist Healthcare

Practices can receive the additional incentive by meeting three additional criteria:

offers pre-negotiated pricing for software and hardware purchase, plus installation, technical advice and other support during selection and implementation. The health system is on target with its goal to launch 100 of these in the first year. “We tried to simplify the challenge of acquiring EHRs,” says Dr. Dayal, “by providing transparent pricing and creating easy template contracts as well as facilitating physician-vendor relationships. We assessed about a dozen products and selected the two we felt would work best, bargaining to get the price as low as possible. It’s been very successful.” “EHRs are the stethoscope of the future,” continues Dr. Dayal. “We’ve now hit the inflexion point, where more than half of physicians expect to adopt EHRs by the end of 2012. EHR implementation presents enormous challenges, but the doctors who have used them for a few months say that they end up saving time and becoming even better physicians.” At this time, Mercy is concentrating on helping the some 130 physicians in its owned practices meet Meaningful Use criteria. “We provide the tools they need to meet Meaningful Use criteria, and have partnered with Allscripts. We’re striving to increase patient safety while decreasing costs and time by automating many of the clinical tasks,” notes Cevis. National Resource: AMA

z z z

Adopt an EHR through an MSO; Participate in the payers’ quality initiative programs; and Attest to advanced use of the EHR (defined differently by each payer).

For more details, visit http://mhcc. maryland.gov/electronichealth/ stateincentive/stateehrincentive.html. MedChi: An MSO plus Education and Advocacy

Craig Behm heads up MedChi’s new subsidiary, MedChi Network Services, designed specifically to provide impartial, customized support for physicians, including its own MSO as well as education and resources. As this publication went to press, the new website was still under development, but interested physicians can learn more at healthIT@medchi.org or 800-874-6573. “Our MSO, which has about 600 providers signed up, has achieved MSO Candidacy Status and is fully approved by CRISP,” says Behm. “We’re vendor neutral and responsive to all physicians, not just those in our MSO. Our emphasis is on providing great advice and support, and connecting doctors with good partners.” MedChi’s website will include a series of toolkits that walk providers through readiness assessments and EHR selection. It also plans to represent physician interests as MHCC incentives are being developed. Behm notes, “We’ll play a very active role in shaping the regulations to advocate for doctors in the submission and monitoring of incentives through the payers.”

The AMA’s website, at www.ama.org, offers advice on implementing EHRs, information about Meaningful Use incentives, and key HIT technologies. Its site includes a series of recorded webinars on EHR implementation. Recently, an AMA subsidiary launched the AMAGINE™ Physician Portal to provide physicians with comprehensive health IT tools and solutions at www.amagine.com. Physicians can receive a free practice assessment related to HIT by calling 800-262-0411. The site also contains free articles and webinars on related topics. Other services, however, may entail costs. Meeting Meaningful Use is not easy. Take advantage of the many available resources out there to achieve the maximum return on your investment of time and money.

Maryland Hospitals: Incentives and Technical Assist

Many Maryland hospitals are providing some form of assistance to their affiliated physicians. If you haven’t already done so, contact hospitals where you have medical staff privileges to inquire about the types of technical or other support you can access. Launched in May 2010, Adventist offers a program called ACES to speed the acquisition and implementation of EMRs among affiliated physicians. They partnered with eClinicalWorks and AllScripts to provide three EHR options to physicians and a monthly subsidy of $200 for up to 24 months. The program also 22 |

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Craig Behm, executive director of MedChi Network Services and Gene Ransom, MedChi CEO.

SEPTEMBER/OCTOBER 2011

| 23

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Policy

New Maryland Law Mandates Changes in Concussion Education and Management

A

Kevin Crutchfield, M.D.

T THIS TIME OF THE year, hundreds of Maryland studentathletes are on football, field hockey and soccer fields at risk for serious brain injury. Governor Martin O’Malley recently signed into law a landmark concussion bill that affects Maryland’s student-athletes, their parents and their coaches. The law, introduced in the Senate by Senator Joan Carter Conway as Senate Bill (SB) 711and in the House by Delegate Sheila E. Hixson as House Bill (HB) 858 during Maryland’s 428th Legislative Session in February 2011, took effect on July 1. This legislation is modeled after the Zackery Lystedt Law enacted in the state of Washington. Lystedt was a student athlete who nearly died after sustaining a concussion while playing football. His experience and subsequent crusade to raise awareness about the serious effects of concussions led to the passage of this seminal legislation in Washington. Maryland is the 18th state to enact this legislation in the United States. The Maryland law mandates: z Concussion education must be provided for players and their parents, as well as for coaches. z Any athlete, 19 years old and younger who is suspected of having a concussion must be removed from the field (game or practice) for the remainder of the day. z Prior to return to play, the studentathlete must be cleared by a licensed healthcare professional who is trained and certified in the management of concussions. z Schools and noninterscholastic youth sport programs must adhere to accommodations for learning, as this

brain injury causes cognitive dysfunction. Did we really need a law to dictate actions that make common sense? Sadly, the answer is yes. Prior to the enactment of the concussion law, I regularly witnessed deviations from the practices mandated by it. Lack of understanding and misinformation regarding concussions have long been prevalent among the general public and those who are involved in training and caring for student-athletes. As a result, the concussion law was enacted to provide further protections for the student-athletes of Maryland. Concussions are complicated brain injuries that occur following the conversion of kinetic forces into chemical, physiologic or structural alterations of the central nervous system. Contrary to popular misconception, neither actual head contact nor loss of consciousness is necessary for a concussion to occur. Most occur as a result of the brain being shaken inside the skull. Given that few changes in helmet design can guard against the shaking of the brain, changes in sporting rules and practices are much more effective in limiting sportsrelated brain injuries. Although athletes can train to guard against some injuries, they cannot “train” their brains to better take the hits toward reducing concussions. Every concussion is different, even in the same athlete. Research has shown that repeated concussions can lead to more extensive or permanent injury of the nervous system, with younger athletes being more susceptible. Research also suggests that cumulative hits over time may accelerate brain dysfunction later in life, which leads to debilitating dementia at a younger age. The most concerning effect of

repeated concussions is the rare but fatal condition called “second-impact syndrome,” which rapidly produces uncontrollable brain swelling. Athletes under the age of 25 are particularly at risk for this syndrome, as their brains are still in development. As healthcare professionals, we are obligated to stay current with new information regarding the pathophysiology and management of this disease process. Resources abound for physicians to learn more about concussions. Continuingeducation courses are now available at national and regional meetings and even locally. As we move forward in concussionmanagement methods and in the process of establishing guidelines that will define certification, physicians who manage concussions are strongly encouraged to attend at least one concussion-related CME event per year. In Maryland, fellowship programs in sports neurology are in the planning stages, and sports medicine fellowships are increasing their levels of concussion training and patient contact. These issues are the foundations upon which the concussion law was based, and the law is a good first step that will result in a much safer environment for the student-athletes of Maryland. We are still early in our understanding of this complex disease process. More research is needed to expand our knowledge base and refine the legislation in the future. Kevin Crutchfield, M.D., is director of the Comprehensive Sports Concussion Program at The Sandra and Malcolm Berman Brain & Spine Institute of LifeBridge Health. Dr. Crutchfield can be reached at Kcrutchf@ lifebridgehealth.org. For more information, visit the Brain Injury Association of Maryland www.biamd.org/ and http://mlis.state.md. us/2011rs/bills/hb/hb0858e.pdf

SEPTEMBER/OCTOBER 2011

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Compliance

E-Prescribing and EHR – The Stick is Coming

T

By Sarah E. Swank

HE PHRASE “THE CARROT and the stick” is often used to describe the two electronic health record (EHR) incentive programs – Meaningful Use and e-prescribing (or eRx). Currently, physicians who take Medicare patients may receive incentive payments from one of the programs, but in the future could face penalties soon. Some of you might not find this carrot that appetizing. Others might not know that the stick is coming sooner than you think. The confusing and complex laws related to the two incentive programs contributed to slowing the widespread adoption of EHR technology among physicians. Below is a summary of the two incentive programs and what you need to know before penalties begin.

eRx vs. Meaningful Use

eRx. eRx allows physicians to transmit electronic prescriptions to a patient’s pharmacy without the need for paper prescriptions. Arguably, this technology cuts down on adverse events, drug interactions and patient allergic reactions. Incentive payments began in 2009 and Medicare payment adjustments begin as early as 2012 at 1% (2013 - 1.5% and 2014 - 2%). The eRx program provides for significant hardship exemptions for physicians and group practices that are unable to meet the definition of successful e-prescribers to avoid these penalties. Meaningful Use. The meaningful use program provides incentive payments to eligible professionals, hospitals, and critical access hospitals for the Meaningful Use of certified EHR technology, including e-prescribing. This program began in 2011 and concludes in 2016. Those physicians treating Medicare patients who do not participate by 2015 will see their payments adjusted. Physicians may see payment reduction starting at 1% and with increased penalties each year that Medicare eligible physician does not

demonstrate Meaningful Use, to a maximum of 5%. The program will roll out in multiple stages. Currently, we are in Stage 1, with Stage 2 and 3 likely to be out soon. Perhaps a Stage 4 will follow if the earlier stages set aggressive functionality goals for EHRs. The Meaningful Use program also includes Medicaid incentive. Each state’s Medicaid Meaningful Use programs follow its own scheduled launch dates. The Good News

CMS released proposed changes to its eRx program in response to a report out this winter from the from the General Office of Accounting (GAO), which stated that the duel incentive programs created inconsistencies and delays in technology development of electronic prescription systems. The technology requirements under the two programs are similar, but not identical. For example, similar to a qualified eRx system, a certified EHR system must be capable of checking for drug-to-drug interactions or whether a drug is on the formulary. Under the EHR incentive program, however, the certified EHR must be tested and certified by an authorized body approved by CMS, currently the Office of National Coordinator for Health Information Technology. In contrast, the eRx program does not rely on a third party’s certification of the system. Under the current eRx program, physicians often rely on information received from the EHR vendor to determine if the system meets the standards under that program. The new regulation proposes to add a new hardship category allowing those who have a certified EHR system to also meet the requirements of the eRx program to avoid the upcoming penalties.

hospitals and other providers likely trigger federal laws for physicians, who face civil and criminal penalties for violations. Although CMS solicited comments on its proposed regulation to align the two incentive programs, physicians subject to the eRx program still needed to meet the June 30, 2011 deadline for reporting or qualifying for an exemption. Providers who delayed adoption of an e-prescribing system based in favor of participating in the Meaningful Use program will likely need to apply for the proposed “case-by-case” hardship exemption under the eRx program once finalized. Now What?

The Bad News

EHRs are here to stay. They support the healthcare reform goals of providing high quality and low cost care to patients. Providers will have to wait until this fall, when the proposed regulation aligning the two programs is due. It is a game of wait and see regarding the proposed regulation aligning the two programs, which should be out this fall. It is uncertain how aggressive the new stages for the Meaningful Use program and the required functionality of EHR systems. The big question is – will the technology need to catch up with the law or will the law create a low bar for EHR to ensure widespread usage of the technology? Either way, watch out for that stick.

EHR technology is expensive and dual federal standards are not only costly, but impractical. Free technology from

Sarah Swank is a principal in Ober Kaler's Health Law Group. She can be reached at seswank@ober.com SEPTEMBER/OCTOBER 2011

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Good Deeds

METAvivor Offers a Network of Support for Metastatic Breast Cancer Patients PHOTOS COURTESY OF METAVIVOR

By Tracy M. Fitzgerald

I

N 2004, DIAN “CJ” CorneliussenJames was diagnosed with Stage 2 breast cancer. Despite undergoing surgery, chemotherapy and radiation, two years later she learned that the small lump originally felt under her arm had metastasized, resulting in a new diagnosis; this time, being Stage 4 breast cancer. As questions of “how long will I live” entered her mind, she immediately began searching for the one thing she knew she needed, but didn’t have available: a network of support from others who were going through the same thing. “When you are diagnosed with a terminal illness, it’s frightening,” Corneliussen-James said. “A lot of hospitals have support group programs for breast cancer patients, but those discussions are often irrelevant to someone who is battling metastatic breast cancer. I quickly realized that I needed to create my own system of support.” And from that realization, a small circle of people, all with the common diagnosis of metastatic breast cancer, formed a group called “Compass” to offer one other support and encouragement. In 2009, the group changed their name to METAvivor Research and Support. Today, the volunteer-based organization dedicates time and effort to supporting metastatic breast cancer patients, raising awareness about the disease, and generating funds to advance research efforts that will ultimately transition Stage 4 breast cancer from a terminal illness to a controlled chronic condition. “We believe that someday, this can be a disease that you will not die from, but instead one that allows you to live a decent quality of life with medication and support,” Corneliussen-James said. To date, research efforts to halt the

METAvivor members (left to right) Cecilia Curry, Jane Levitt, Dian “CJ” Corneliussen-James, Ellen Eckert and Catherine Weber joined a social event in Annapolis earlier this year.

progression of disease and improve survival rates for Stage 4 patients has been lacking. In fact, the National Cancer Institute’s web site currently lists only one active clinical trial for Stage 4 breast cancer in the U.S. One of METAvivor’s primary goals is to change this, and make dollars more readily available for metastatic breast cancer research. “Research will give doctors new information about how to treat Stage 4 breast cancer and improve survival rates,” said Arti Santhanam, and independent research consultant and the only member of the METAvivor board of directors who has not been diagnosed with cancer. “This will eventually help control pain for people diagnosed with this illness.” Avis Halberstadt was diagnosed with breast cancer in 1998 and nine years later, learned that the cancer had spread to her stomach. Active with METAvivor as a co-founder and treasurer of the board of directors, Halberstadt stresses the importance of outreach to area physicians, who can pass information along to patients, and perhaps even rally to establish support groups for metastatic

breast cancer patients at their respective hospitals. “We want the doctors to know about us and what we can offer to their patients,” Halberstadt said. “We bring people together who have similar needs, and give them support and opportunities to get involved.” Getting involved has been a saving grace for Halberstadt. “Being part of METAvivor gives me a goal to work toward every single day,” she said. “There is a lot of sadness involved because we have lost some people, but that makes me want to keep going and helping others. Every day that I feel well, I want to give back.” For further information, visit www.metavivor.com. To request a copy of the METAvivor brochure for electronic (PDF) distribution to patients, please send an email to cj77@comcast.net.

Maryland Physician would like to hear about your “Good Deeds.” Please send your ideas to gooddeeds@mdphysicianmag.com

SEPTEMBER/OCTOBER 2011

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Heritage

Maryland’s Supportive Sailing Regattas By Allison Eatough

N

O ONE IN CEDRIC LEWIS’S family has needed hospice care, but for the past 15 years hospice has touched his life. Each of those years, the lifelong sailor raced the annual Hospice Cup charity regatta to help raise awareness of hospice care. Last year, Lewis and racing partner Fredrik Salvesen won. “You can’t really go more than one person away and find someone who hasn’t used hospice care,” the Annapolis resident said. “It really is an amazing way for people to pass with dignity and without pain.”

The Hospice Cup

Billed as America’s largest racing regatta, Hospice Cup is one of several area races designed to raise money and awareness for medical and support care. With causes ranging from leukemia to the physically – and developmentally – challenged, the events have all found successful homes in Maryland. A hospice is a program or facility that provides care to those in the final stages of a terminal illness. Care focuses on comfort and quality of life. Bereavement support is also available after a loved one dies. Today, hospices can be found nationwide. But 30 years ago, when Hospice Cup began, hospice treatment was an “unknown entity,” said Karma O’Neill, executive director of Hospice Cup, Inc. In 1982, Virginia Holland Brown, a member of the Development Committee for Hospice of Northern Virginia, Inc., was searching for a unique way to raise money for the hospice. After talking with Josephine Knoerr Erkiletian, a St. Michaels property owner, and Al Van Metre, a local sailor and businessman, the charity sailing regatta was born. Other hospices throughout Virginia, Maryland and Washington D.C. quickly joined the effort. Since its inception, 30 |

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Annual fall events, charity sailing regattas are uniquely Annapolis flavored.

Hospice Cup has raised more than $8 million to support hospice programs. Most hospices use the event as a “springboard” for their individual fundraising, O’Neill said. Others, like Talbot Hospice Foundation in Easton, rely on the event to help fund their programs. At Talbot, Hospice Cup money goes toward programs like Pathways – a prehospice program providing non-medical support services to Talbot County residents with life-limiting illnesses. “It’s a wonderful event to be a part of because it spreads the word about hospice, which is a difficult subject for a lot of people,” said Kate Cox, associate director of the Talbot Hospice Foundation. “We’re happy to be a part of it.” In addition to Talbot, hospices benefiting from this year’s event are Capital Hospice, Chester River Home Care and Hospice, Hospice of the Chesapeake and Montgomery Hospice. Hospice Cup XXX kicks off September 24 at the mouth of the Severn River. The race is managed by Shearwater Sailing Club and assisted by Storm Trysail Club Chesapeake Station. It is sanctioned by the Chesapeake Bay Yacht Racing Association (CBYRA). A special Hospice Class is available for novice racers. Overall, organizers expect about 100 boats to participate.

The Leukemia Cup Regatta

The Leukemia Cup Regatta, held annually in Annapolis, raises money for The Leukemia & Lymphoma Society (LLS). While the first event took place in Alabama in 1988, the Eastport Yacht Club in Annapolis transformed the concept in 1993 by having individuals collect money for the LLS. The concept quickly spread nationwide with the help of Gary Jobson, sailing expert, ESPN commentator, lymphoma survivor and national chairman of the Leukemia Cup Regatta. “Sailors as a whole are willing to help out worthy causes,” Jobson said. With the sailing community’s help, the Maryland event has gone from raising $30,000 in 1993 to about $150,000 last year. Nationwide, Leukemia Cup regattas have raised a total of $3.5 million for the cause, Jobson said. And as the fundraising grows, so does awareness, said Beth Prensky, LLS campaign director. “The race is a lot of fun for everyone involved, and it helps to highlight the mission of LLS, to cure blood cancers, in a very real and visible way,” she said. For more information, visit www.hospicecup.org and www.leukemiacup.org.

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Maryland Physician Magazine, Sept/Oct 2011