New Orlando Health Spine Center Elevates Patient Care With Collaborative Approach
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COVER STORY
Patients dealing with troublesome back and neck pain can now receive attention and care faster and more efficiently through the new Orlando Health Spine Center.
The Spine Center was launched in March, bringing together the expertise of Orlando Health Jewett Orthopedic Institute and Orlando Health Neuroscience Institute to completely rethink how patients receive care.
“Bringing those two specialties together to work in unison to create a center that’s focused on spine care really is the best of both worlds,” said Dr. Michael Jablonski, president of Orlando Health Jewett Orthopedic Institute and Orlando Health Neuroscience Institute. “The top spine programs in the country are combined programs of neurosurgery and orthopedics.”
Before the center was created, Orlando Health’s orthopedic surgeons and neurosurgeons didn’t always have reasons to collaborate. And general practitioners in the region weren’t always sure where they should send their referrals.
ON THE COVER: From left to right: Dr. Robert Hirschl, Dr. Shehzad Choudry, Dr. Sheyan Armaghani
Iam pleased to bring you another issue of Florida MD. Sometimes a patient may have the opportunity to participate in a clinical trial. Sometimes a patient may need specialized treatment that is not available in Central Florida. And sometimes there’s no money for that patient to get to those places. Fortunately there is Angel Flight Southeast to get those patients where they need to go. I asked them to tell us about their organization and how you, as physicians, can help. Please join me in supporting this truly wonderful organization.
Best regards,
Donald B. Rauhofer Publisher
ANGELS ON EARTH HELP PATIENTS GET TO LIFESAVING MEDICAL TREATMENT
Everyone knows angels have wings! But did you know in Florida and many parts of the nation they have engines and tails with dedicated volunteers who donate lifesaving services every day? Leesburg, Fla.-based Angel Flight Southeast is a network of approximately 650 pilots who volunteer their time, personal airplanes and fuel to help passengers get to far-from-home medical care. A member of the national Air Charity Network, Angel Flight Southeast has been flying passengers since 1993.
Almost all of its passengers are chronic-needs patients who require multiple, sometimes 25-50 treatments. Passengers may be participating in clinical trials, may require post-transplant medical attention or are getting specialized treatment that is not available near home. Each passenger is vetted to confirm medical and financial need and is often referred to Angel Flight Southeast by medical personnel and social workers.
Angel Flight Southeast “Care Traffic Controllers” arrange flights 24 hours a day, 365 days a year. In the event of a transplant procedure, the Care Traffic Controllers have precious minutes to reach out to its list of volunteer pilots who have agreed to be prepared on a moment’s notice to fly a patient to receive his or her potentially lifesaving organ.
The organization is completely funded through donations by individuals and organizations. A typical Angel Flight Southeast pilot donates $400 to $500 in services-per-trip. In fact, Angel Flight Southeast has earned the Independent Charities of America Seal of Approval as a good steward of the funds it generates from the public. Each $1 donated generates more than $10 worth of contributed services by Angel Flight Southeast.
The charity always seeks prospective passengers, volunteer pilots and donations. For additional information, please visit https://www.angelflightse.org or call 1-888-744.8263.
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New Orlando Health Spine Center–Elevates Patient Care With Collaborative Approach
By Staff Writer
Patients dealing with troublesome back and neck pain can now receive attention and care faster and more efficiently through the new Orlando Health Spine Center.
The Spine Center was launched in March, bringing together the expertise of Orlando Health Jewett Orthopedic Institute and Orlando Health Neuroscience Institute to completely rethink how patients receive care.
“Bringing those two specialties together to work in unison to create a center that’s focused on spine care really is the best of both worlds,” said Dr. Michael Jablonski, president of Orlando Health Jewett Orthopedic Institute and Orlando Health Neuroscience Institute. “The top spine programs in the country are combined programs of neurosurgery and orthopedics.”
Before the center was created, Orlando Health’s orthopedic surgeons and neurosurgeons didn’t always have reasons to collaborate. And general practitioners in the region weren’t always sure where they should send their referrals.
“At Orlando Health, we had two separate programs. We just kind of ran in parallel, and it wasn’t very efficient,” said Dr. Robert Hirschl, physician president of the Orlando Health Neuroscience Institute.
Now, the programs share resources and exchange information through regular conferences that have them working as a cohesive unit. The Spine Center, which is the only fully integrated pro-
gram in Florida to bring together orthopedic and neurosurgical physicians who specialize in spine surgery, relies on the combined expertise of both programs to help patients find the best treatment path, as quickly as possible.
Consider the plight of a patient dealing with new back or neck pain. The sheer complexity of the spine – with all of its related bones, nerves and muscles – can make diagnosis and treatment a challenge. But for patients dealing with debilitating pain, the most important thing is quickly finding the right specialist or treatment to help them get better.
Unfortunately, this wasn’t always easy under the previous approach. A patient, for example, might be referred by their general practitioner to a surgeon for a condition that ends up not requiring surgery. Or they might find it impossible to get in front of a specialist without a lengthy delay.
“Patients would wait six to eight weeks to see somebody, just for that provider to come in and tell them: ‘Oh, you’re seeing the wrong person. You need to see this person,’” said Dr. Sheyan Armaghani, an orthopedic surgeon with Orlando Health Jewett Orthopedic Institute. “And then another six to eight weeks goes by. Meanwhile the patient is in pain for three or four months.”
The Spine Center’s new approach allows patients dealing with a variety of spine issues to receive an appointment within one or two days. It also helps patients avoid being placed in front of a surgeon or health careprofessional who may not be best for them. Specialized spine naviga-
The Orlando Health Neuroscience Institute’s pavilion in downtown Orlando houses neurology, neurosurgery specialists, interventional pain management, and more, under one roof.
Orlando Health Jewett Orthopedic Institute, Florida’s first orthopedic hospital, is dedicated to orthopedic and spine care and is where most of the spine surgeries are performed.
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tors help ensure they are sent to the appropriate specialist, whether it be pain management or physical therapy.
The Spine Center, which has 16 locations across Central Florida, makes the referral process for primary care physicians significantly more streamlined.
“It really makes their life easier. It takes all of the thought process out,” Dr. Hirschl said. “Right now you have to think: ‘Should I send them for an MRI? Should I send them for physical therapy? Should I send them to pain management?’”
Now, instead of figuring out the answers to those questions on their own, providers can simply refer patients with any kind of back problems to the Spine Center.
“And then they’re done,” Dr. Hirschl said. “They can take care of other patients that need their services and not worry about all of these decision trees.”
CREATING THE SPINE CENTER
Orlando Health began discussing the creation of a Spine Center two years ago as a response to shifting trends in the industry.
“Traditionally, spine care has been delivered independently by either orthopedic spine surgeons or neurosurgeons,” Dr. Armaghani
said. “Over the last 20 years or so, a lot of those lines between orthopedic spine surgeons and neurosurgeons have been blurred.”
Orlando Health also noticed that many of the nation’s top hospitals use a combined approach where both orthopedic surgeons and neurosurgeons work collaboratively with disciplines like pain management and physical therapy to provide the best care for patients.
“That was the initial reasoning for us to go ahead and start to combine forces so that we can deliver care to patients in a coordinated manner,” Dr. Armaghani said. “The ultimate goal of this is to get patients seen in an efficient manner and get them treated in the quickest way possible.”
With that goal in mind, Orlando Health Jewett Orthopedic Institute and the Orlando Health Neuroscience Institute began working to make the vision a reality.
The two units started sharing ideas and research to develop new protocols for patients, combining service lines and hiring new team members, including pain management specialists and navigators.
“Watching them work together to do this to make sure the patients have the best chance at the best outcome for a very complicated problem, it’s really exciting and it’s been fascinating to watch,” Dr. Jablonski said.
SPINE CENTER IMPROVES PATIENT EXPERIENCE, OUTCOMES
A key priority of the Orlando Health Spine Center has been to make sure that patients are getting in front of the right specialists and receiving care in an efficient manner.
Members of the Orlando Health Jewett Orthopedic Institute and Orlando Health Neuroscience Institute worked in tandem to come up with state-of the-art protocols for patients.
The new Orlando Health Spine Center brings together both orthopedic and neurosurgical physicians who specialize in spine surgery.
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With 16 locations across Central Florida, the Orlando Health Spine Center makes the referral process for primary care physicians significantly more streamlined.
“Coming together to say: ‘How are these patients treated the best?’ And bringing those two specialties develop standardized protocols will really be great for the outcomes and patient experience,” Dr. Jablonski said.
The new protocols were also set up to make surgery a last option for most patients, instead focusing on more conservative treatments first.
“Our design of how we do things is really to push for nonoperative management for patients,” Dr. Armaghani said. “We know from our data that 90 to 95 percent of patients who have a spine-related issue are going to get better without surgery.”
And for patients who do need surgery, the Spine Center is designed to promote the best possible outcomes. This is done through new postoperative protocols and a preoptimization process that lowers the risk of complications.
Another focus of the Orlando Health Spine Center is getting patients the appointments and care they need much faster.
“We wanted to eliminate that barrier and have patients be seen quickly,” Dr. Hirschl said. “When you’re in terrible pain, the last thing you want to do is wait six weeks to be seen.”
The new center uses its spine navigators – specialists who field referrals and work closely with patients and general practitioners to make sure patients are sent to the right provider. This has reduced wait times for patients to be seen from sometimes as long as two months to just two days or less.
“If you just have neck pain or back pain or any kind of spine pain, there’s one number that you call,” Dr. Jablonski said. “A navigator will answer the phone and we’re going to get you in within 24 to 48 hours to the right provider.”
This new strategy has also played a role in freeing up surgeons helping keep surgery as a last resort option and limiting the possibility of patients being referred to surgeons when their condition might better be handled with pain management or physical therapy.
“Patients don’t have to see a surgeon if they don’t need surgery,” Dr. Hirschl said. “And if they get better, wonderful. They don’t have to spend time with a surgeon. But if they’re not getting better, that’s when it’s more appropriate to see a surgeon and start escalating care from there.”
POSITIVE EFFECTS OF SPINE CENTER ALREADY SEEN
While the Orlando Health Spine Center is in its infancy, it hasn’t taken long for team members and patients to see the benefit of the new multidisciplinary approach to patient care and outcomes.
Among the most noticeable immediate impacts has been the speed with which new patients are making their way to a doctor, physical therapist or other specialist who can best serve their needs.
“We’ve already had patients that are extremely thankful that they’re getting into the appropriate provider within 24 to 48
hours,” Dr. Jablonski said. “In a very short period, we’ve had patients who have had tremendous responses say: ‘Thank you so much for getting me in so quickly and starting my care so I can get back to a more pain-free existence.’”
This accelerated timeline has been accomplished in part by laying out a new roadmap for patient care. Instead of starting with a surgeon, most patients with back pain begin their treatment journey with a course of physical therapy and anti-inflammatory medications.
This alleviates patient symptoms as often as 80 percent of the time. But, if the problems persist, then they can move onto imaging and continue to work their way down the treatment road.
“We have a process in which we’re able to get patients worked up and we have different exits along this highway in terms of their ultimate recovery.” Dr. Armaghani said.
An added benefit of this approach is that, by the time a patient reaches a surgeon – if needed – they’ve already received a wide range of imaging and therapies that can help make the surgeon’s job easier.
SPINE CENTER BRINGS NEW APPROACH TO STATE OF FLORIDA
When the idea of the Orlando Health Spine Center was first being discussed, members of the Orlando Health Jewett Orthopedic Institute and the Orlando Health Neuroscience Institute searched across Florida for examples of other health care organizations using a similar approach in terms of bringing together orthopedic and neurosurgical physicians who are spine surgery specialists.
“We tried to look and see if this was present anywhere else in the state,” Dr. Armaghani said. “We were really unable to see this approach being utilized in Florida, which was surprising to us as one of the most populous states in the country.”
Now, the Spine Center will fill that gap, offering access to this multidisciplinary approach to residents across Central Florida with 29 dedicated providers. Making this service readily available to the entire community was a key goal in the development of the new center.
Having more than a dozen locations around the region means easy access for the 3.5 million residents of greater Orlando. Surgeons, pain management doctors and immediate access providers are strategically placed across the region to ensure a wide net of care. A patient will not have to drive more than 15 minutes on average to get somewhere they can receive the expertise of the Spine Center.
“We’re very sensitive to patients not wanting to travel long distances to see us,” Dr. Armaghani said. “If you’re in pain when you sit down, you’re not going to spend 30 minutes on I-4 to go to one specific location to see a doctor or specialist.”
The Spine Center also plans to offer some of its options via telehealth, so patients can be evaluated and receive the care theyneed from the comfort of their homes.
ORLANDO HEALTH’S COMMITMENT TO THE COMMUNITY
Orlando Health is dedicated to providing world-class care to the residents of Central Florida, with a significant investment in the Orlando Health Spine Center representing the latest example of those efforts.
Patients can now receive care using a streamlined approach that hasn’t been available in the state before now.
“It takes a lot to invest in the infrastructure that’s required to do this,” Dr. Armaghani said. “I’ve worked at other places in the past and have floated this idea and been met with a door in my face every time because of the investment that’s needed.”
Orlando Health remains focused on dedication to quality and investigating new strategies and investments that can play a role in helping patients to have the best outcomes possible.
The Orlando Health Spine Center helps to do that through a more efficient and cohesive approach that makes patient care simpler and more effective for everyone involved.
“We want to make it easy for patients and easy for primary care providers so that all they have to do is call the number, send a referral in and we will take over,” Dr. Jablonski said.
To refer a patient or to learn more about us, visit OrlandoHealth.com/spinecenter or call 321.842.2225.
Orlando Health remains focused on dedication to quality and investigating new strategies that can help patients to have the best outcomes possible.
CONDITIONS WE TREAT
We care for a wide range of conditions and injuries affecting the spine, including:
• Herniated/ruptured discs
• Degenerative spinal conditions
• Spinal stenosis
• Compression fracture
• Myelopathy
• Radiculopathy
• Adult and adolescent scoliosis
• Spine fractures
• Neck pain
• Sciatica pain
• Spinal deformity
• Sacroiliac (SI) joint pain
• Disorders of the cervical, thoracic and lumbar spine
MINIMALLY INVASIVE AND COMPLEX SURGERY
Orlando Health Spine Center offers a comprehensive center dedicated solely to the care of disorders affecting the spinal column. From common conditions such as disc herniations to more complex issues, including spinal tumors, infections and fractures, we offer the most advanced diagnostic tools, technologies and therapies to treat a full range of conditions.
INTERVENTIONAL SPINE AND PAIN MANAGEMENT
We understand the challenges of living with chronic pain. Our goal is to deliver the best treatment for your underlying condition and its painful symptoms, so you can get back to living the life you love. Our team of award-winning pain specialists focus on the latest minimally invasive treatments for a broad range of chronic conditions. We will evaluate and diagnose the cause of your pain and work with you to create a unique care plan to relieve your symptoms.
PHYSICAL THERAPY
We deliver advanced care using a patient-centered approach. Our team of highly specialized clinicians works with both the patient and family to establish rehabilitation goals that promote the highest level of function and independence possible, while improving overall quality of life - physically, emotionally and socially.
The $8500 Tube of Cream
By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII, MD
Several years ago, a patient came back to my office for a return visit. She had been seen earlier that week for a small amount of intertrigo underneath her breasts. Intertrigo is a common inflammatory condition of the skin folds, and it is aggravated by heat, moisture, and friction. Occasionally a patient might get a minor secondary yeast infection in the area as well. The treatment is keeping the area dry and using a topical cream to clear the yeast and decrease the inflammation.
The patient said, “doctor, I am worse.” I asked how she was using the cream, and she responded that she had not filled her prescription. Now I have lived through this scenario before with other patients. I am always amazed when people seem surprised that their condition has not improved when they have either not filled their prescription or filled the prescription and never used the medicine.
Now, if they filled the prescription and didn’t use the medicine, I am flummoxed as I am not sure how to respond. So, I usually say “oh” and stop talking, leaving a long moment of uncomfortable silence that eventually forces the patient to speak. Then the response comes, “so you think I should use the medicine you prescribed?” I reply, “Well, yes, as we have tried not using the medicine, and that plan is not working so good.” Amazingly, the patient seems okay with this response and goes happily on his or her way. Yes, this very conversation has happened on more than one occasion.
Now, in this case, since this patient had not filled her prescription, I wanted to know why. In the past, the cream I prescribed called Alcortin sold for about $35 a tube, so I didn’t think the cost was a concern. She then told me that the pharmacist wanted to charge her $8500.00 for a tube of the cream. I laughed out loud because I knew there had been some gross misunderstanding regarding the cost, and I said there must have been a decimal put in the wrong place. I was confident she didn’t understand the pharmacist correctly.
and it wasn’t for a flatbed truck loaded with cream; it was for one lousy 60gram tube. At the time, that cream was selling for four times its weight in gold! The pharmacist had no explanation for why the medicine went up so much in price; all he knew was that was the price.
Since that bit of medical-cultural shock, other medicine prices have skyrocketed as well as everyone reading this knows. Nobody seems to know why, but I suspect this is due to our government meddling with the free market system. When the
Intertrigo - Would you spend $8500.00 on a tube of cream to treat this eruption?
last big round of Medicare laws changed the way Medicare buys drugs, and this had bipartisan support I might add, this is when the chaos started. Drug companies loved the clause that they could name their price without any negotiation on price, and we are all now living the outcome.
The patient was very adamant that she had spoken with the pharmacist in person, and there was no question that the price was $8500.00. I asked her for her pharmacy, and I contacted the pharmacist myself. I started by saying, “well, I am just clearing up a misunderstanding. There is a patient here that is trying to tell me that Alcortin is $8500.00 a tube. I am sure the decimal point has been put in the wrong place, or you mistakenly thought I ordered a tractor-trailer full of the cream. There was a long pause, and the pharmacist said, “no, $8500 is correct,”
Just recently, a study showed that worldwide, when several first world countries were compared for the average cost spent on nineteen different conventional medicines, the United States was paying 300% more than the average price paid by other countries. Iceland, for example, was paying approximately 50% the average cost, which means that we are spending six times as much as the Icelanders for the same medication. So why don’t we go to Iceland and buy all our medicines straight from Iceland? The answer is the drug companies have convinced the government that reimportation should be illegal. Therefore, it is unContinued on page 15
PHOTO: JOHN MEISENHEIMER, VII, MD
Is Your Online Reputation Costing You Patients?
By Sonda Eunus, MHA, CMPE
What does your online reputation say about your practice? If you have a negative online reputation, you are missing out on new patients every day. Most medical practices now get the majority of their new patients through Google and other search engine queries, such as “Pediatrician in Orlando”. If your practice appears in these searches, the most common next step for a potential new patient would be to check out your reviews – what are other patients saying about your practice? It has been reported that 90% of consumers read online reviews before visiting a business and that online reviews influence 67% of purchasing decisions (Bright Local). For this reason, it is incredibly important to pay attention to the rating and reviews that your practice has on search engines, social media platforms, and local online business directories.
However, despite the importance of cultivating a positive online reputation, only 33% of businesses report actively collecting and asking for reviews (1). One great process to set in place at your practice is asking for patient reviews after each patient visit. It can be as simple as training your front office staff to ask each patient how their visit went while checking them out, and if they receive favorable feedback then they can ask the patient to please leave a review on Google or Facebook about their experience. If they receive negative feedback, this feedback should be taken very seriously, and management should be notified as soon as possible so that the issue can be mitigated before the patient decides to post a negative review.
Setting up an automated text or email campaign that asks each patient for their feedback after their appointment is also a great way to improve your online reputation as well as to correct any issues that may be occurring at your practice. When you receive feedback from patients, you are then able to prompt them to leave a public review on Facebook, Google, Yelp, Healthgrades, or other applicable review platforms. However, you must be aware that legally, you are not allowed to only direct people with favorable feedback to leave reviews, which is known as review-gating – so if you are implementing an automated system like this, just make sure that you are aware of this limitation. There are online reputation management platforms which allow you to customize the messages that people see when they leave negative feedback as opposed to positive feedback, but both of those messages must still offer the option to leave a public review. However, if you create your message in such a way as to communicate to the patient who may leave negative feedback that you are working hard on resolving the issue and that someone will be in touch shortly, that may prevent them from leaving a public negative review.
When you receive a public review on Google, Facebook, or other review sites, make sure that you respond to it – either by thanking them for a good review or by asking them to contact you to discuss how you can improve their experience. Do not argue or try to defend yourself online – try to speak about it with them privately, fix the issue, and ask them to remove the review if possible. When you receive great reviews, make sure to cross-share them on your various social media platforms. You should also create a “Reviews” page on your website and add all great reviews to this page. This instantly adds credibility to your website.
Finally, make sure that when you look over the feedback and reviews that you receive, you are paying attention to what the negative reviews are saying – this is a great opportunity to identify current process challenges and improve your patients’ experience at your practice. Need help managing your practice’s online reputation? Visit www.lms-plus.com to see how Leading Marketing Solutions can help.
Sonda Eunus is the CEO of Leading Marketing Solutions, a Marketing Agency working with Medical Practices and other Businesses to help them identify the best marketing strategies for their business, create a strong online presence, and automate their marketing processes for a better return on their Marketing budget. Learn more about Leading Marketing Solutions at www.lms-plus.com.
Halotherapy
By Daniel T. Layish, MD, FACP, FCCP, FAASM
The word Halotherapy comes from the Greek word “halos” meaning salt. While the potential benefits and therapeutic nature of salt has been known for centuries, it was not until the early 1800’s that the underground salt mines throughout Eastern Europe were noted to benefit various respiratory conditions. As the workers were mining the salt in these climate-enriched chambers, dry salt particles would be inhaled into the respiratory system. The dry salt was discovered to be super absorbent, anti-bacterial and anti-inflammatory. Soon people with various conditions were spending time in these salt mines. In the mid-1900’s the Russians began working on a technology to replicate the dry salt particles in the air and developed the first halogenerator, a device that grinds pure sodium chloride into precise particles (several microns in diameter) and disperses the dry salt into a climate controlled room or chamber. This was the start of modern Halotherapy, which has been utilized for several decades throughout Eastern Europe and has begun to expand into many other countries including the United States and Canada. The small particle size is felt to be important to allow penetration deep into the lungs, since larger particles will simply be deposited in the nose, throat or large airways. The air in a halotherapy chamber is also filtered to remove contaminants and the temperature and humidity are well controlled.
As a pulmonologist, I initially became familiar with halotherapy through my care of individuals with Cystic Fibrosis. Cystic Fibrosis is a genetic disorder characterized by dehydration of the respiratory epithelial surface, resulting in impaired mucociliary clearance. In this disorder, thick tenacious secretions obstruct the lower airway and sinuses and provide an environment for chronic infection. Nebulized hypertonic saline has been shown (in well done randomized clinical trials) to improve pulmonary function and respiratory symptoms as well as reduce pulmonary exacerbation rate in individuals with cystic fibrosis. This may be referred to as “wet” salt therapy as opposed to halotherapy which is “dry” salt therapy. Nebulized hypertonic saline can sometimes cause bronchospasm, and not all patients can tolerate this therapy even when premedicated with a bronchodilator. In cystic fibrosis, halotherapy has some theoretical advantages over nebulized hypertonic saline. The prolonged duration of therapy (typically a 45-minute session) appears to be associated with a much lower incidence of bronchospasm then is seen in the setting of nebulized hypertonic saline. In addition, in the halotherapy mode of administration the salt particles are delivered to both the sinuses and the lower respiratory tract. After seeing anecdotal benefit in our patients with cystic fibrosis, we performed a clinical study, which confirmed that this therapy was well tolerated and the patients derived symptomatic benefit in terms of their sinus complaints. Other studies are planned to study this therapy further in individuals with cystic fibrosis.
The fundamental defect in cystic fibrosis is related to chloride transport and therefore there is a strong rationale for halotherapy in this particular disease. Anecdotally, I have seen patients with other respiratory diseases derive significant benefit from Halo-
therapy including bronchiectasis, chronic bronchitis, chronic sinusitis and allergic rhinitis. The hypothesis is that Halotherapy may help with respiratory illnesses by liquefaction of airway secretions thereby enhancing expectoration. There seems to be very little risk to this therapy other than the financial and time investment. There is certainly a theoretical basis for the possible benefit of halotherapy, given the known antiinflammatory and anti-infective properties of salt. Currently, halotherapy is not covered by medical insurance companies. However, it is hoped that this may change as research is planned to try to prove the benefits that many patients have reported. Many halotherapy institutions offer a monthly pass that can make therapy more affordable than purchasing individual sessions. There is also an effort to develop systems that can deliver halotherapy in the home setting, avoiding the need to travel to a salt room. This is important since many people do not live close to a halotherapy center. It is worth noting that many patients have also noticed benefits in non-respiratory conditions, particularly dermatalogic conditions such as acne and psoriasis and research is planned in this area as well.
References available upon request. I would like to thank Leo Tonkin and Ulle Pukk for reviewing this manuscript.
Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. Dr. Layish serves as the medical advisor for the Just Breathe Salt Therapy Wellness Spa and also sits on the board of the Salt Therapy Association. He may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com.
When a Screening Changes Everything
By Staff Writer
For most young athletes, a pre-participation heart screening is routine. For a small number, however, that screening becomes the moment a potentially lifethreatening heart condition is discovered.
That was the case for Josiah Gilyard.
An elite basketball player with Division I aspirations, Josiah underwent a screening electrocardiogram (ECG) that uncovered something unexpected: Wolff-ParkinsonWhite syndrome (WPW), a condition caused by an extra electrical pathway in the heart that can lead to dangerous heart rhythms.
Josiah was referred to Nemours Children’s Health for evaluation. An electrophysiology study confirmed the diagnosis, and a catheter ablation successfully eliminated the abnormal pathway.
Today, Josiah is back on the court doing what he loves.
Josiah’s story illustrates why early detection matters. For some student athletes, a routine ECG may identify a serious cardiac condition before symptoms ever appear.
A NEW ERA FOR CARDIAC SCREENING IN FLORIDA
For pediatricians and primary care providers, broader ECG screening also means more abnormal findings that require timely evaluation. Questions naturally follow: Who interprets the results? Which findings warrant urgent referral? How quickly can families be seen? And when is it safe for an athlete to return to play?
Nemours Children’s is helping providers across Florida navigate these questions. Through statewide education, streamlined referral pathways, and a comprehensive pediatric electrophysiology program, Nemours Children’s is helping ensure abnormal screenings lead to timely diagnosis and appropriate treatment.
The most common cause of sudden death in young athletes is hypertrophic cardiomyopathy. Florida’s Second Chance Act is designed to change that by expanding access to ECG screenings that can identify children who are at risk before symptoms occur.
SUPPORTING PROVIDERS IN FLORIDA
As ECG screening expands across Florida, helping providers interpret results and navigate referral pathways has become an important part of successful implementation. Over the past year, Nemours Children’s cardiologists, including Dr. Gul Dadlani and Dr. Vanessa Hormaza, have partnered with community physicians to discuss ECG interpretation, documentation requirements, and return-toplay considerations. Additional education programs for providers and school personnel are planned as screening becomes more widely adopted.
WHEN AN ECG RAISES QUESTIONS
An abnormal ECG doesn’t necessarily indicate serious heart disease. But it does require expert evaluation. For families waiting to learn whether their child can safely return to sports, timely
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answers matter. With pediatric cardiology locations throughout Central Florida, the East Coast, and Northwest Florida, Nemours Children’s makes specialty evaluation accessible for families throughout much of the state.
Once referred to Nemours Children’s, patients undergo evaluation tailored to the screening findings, which may include advanced imaging, exercise testing, rhythm monitoring, or electrophysiology consultation. Referring providers receive timely communication regarding diagnosis, treatment recommendations, and return-to-play guidance.
BEYOND THE SCREENING
Identifying an abnormal ECG is only the first step. The next is ensuring children have timely access to pediatric cardiology and electrophysiology expertise when further evaluation or treatment is needed.
The electrophysiology team at Nemours Children’s evaluates and treats the full spectrum of heart rhythm disorders in children, from common arrhythmias to rare inherited conditions associated with sudden cardiac arrest.
For most children with WPW, catheter ablation offers a permanent cure, with a return to normal life and physical activities within one week. Others benefit from advanced therapies including leadless pacemakers, next-generation implantable cardioverter-defibrillators (ICDs), and advanced 3D mapping technologies that support treatment planning for the most complex rhythm disorders.
This continuum of care — from screening and diagnosis to treatment and long-term follow-up — is what transforms a legislative mandate into a system that can save lives.
LOOKING AHEAD
Florida’s expanded ECG screening legislation has the potential to identify heart disease before tragedy occurs. Realizing that potential will require close collaboration among primary care providers, schools, athletic programs, and pediatric cardiology specialists.
When an ECG raises questions, timely evaluation and clear communication help families move forward with confidence, while giving young athletes the best chance to safely return to the sports they love.
MEET THE TEAM:
Nemours Children’s Orlando electrophysiology teams are experienced and focused on your child’s healthiest future.
Learn more by visiting www.nemours.org.
PHOTO:
BY
Svjetlana Tisma-dupanovic, MD
Ozlem Turan, MD
Lauren Day ARNP
Many Floridians Suffer From Arthrofibrotic Knees That Can Be Treated Successfully With Minimally Invasive Surgery
By Bruce Levy, MD
Since arriving at Orlando Health Jewett Orthopedic Institute, I have seen numerous patients referred to us who are dealing with a relatively uncommon condition: arthrofibrosis of the knee. This debilitating condition can be seen following knee ligament reconstruction, trauma fracture surgery and after knee replacements to name a few. This condition can cause significant functional limitations to a patient, resulting in extreme stiffness in the joint, decreased range of motion, and even chronic pain. Surgical treatment in the form of arthroscopic releases and removal of scar tissue can offer patients a minimally invasive approach with published successful patient reported outcomes.
The causes of arthrofibrosis vary and the susceptibility of some patients over others is not fully understood. Usually, it develops following a traumatic insult to the joint, an infection, or with surgery; for example, following anterior cruciate ligament (ACL) surgery. ACL reconstruction is one of the most common orthopedic surgeries in the United States; by some estimates there are more than 250,000 such procedures performed every year. Although complications following ACL surgery are rare, at this volume, even a small percentage can mean a significant number.
Once arthrofibrosis begins, it can initiate a cascade of proinflammatory mediators which then drives the proliferation of fibroblasts. These fibroblasts secrete Transforming Growth Factor Beta (TGF-β), a crucial cytokine, that begins a positive feedback loop that generates more fibroblasts, which then generates more TGF- β, and so on. This in turn forms an extra-cellular matrix, causing more adhesions to form inside the joint, which in turn causes bursa (the little pouches and fluid pockets in the knee) to contract. The results are pain, stiffness and decreased range of motion.
During my time at the Mayo Clinic, along with my colleagues Abhinav Lamba BS, Charles L. Holliday MD, Erick M. Marigi MD, Anna K. Reinholz MD, Ryan R. Wilbur MD, Bryant M. Song MD, Mario Hevesi MD, PhD, Aaron J. Krych MD, and Michael J. Stuart MD, we published “Arthroscopic Lysis of Adhesions for Arthrofibrosis After Anterior Cruciate Ligament Reconstruction” (https://journals.sagepub.com/doi/abs/10.1177 /03635465231195366).
We showed that with a minimally invasive arthroscopic approach combined with medications to inhibit TGF- β and physical therapy, people can have very successful outcomes with regards to pain relief, improvement to range of motion, and overall improvement of function. We had a mean follow-up of 10 years, so this was a long-term study. The protocols we developed were the result of a lot of dedicated work and study by medical students, research fellows, and lead by my orthopedic partners at Mayo Dr. Matthew Abdel and Dr. Mark Morrey. These protocols
have been shown to be effective in reducing the recurrence, at least, in people who are being treated for this disease.
The article was published in the American Journal of Sports Medicine (AJSM) and the AJSM editors followed it with an extensive podcast.
Because we saw a large number of referrals at Mayo and now at Orlando Health Jewett Orthopedic Institute, our techniques have continued to evolve. With these advancements we are now able to reach even the posterior aspects of the knee (back of the knee) joint and release the scar tissue trapped there.
Although we are encouraged by the results of these techniques, this surgery presents a number of significant risk factors, such as the potential for neurovascular injury in particular when in these posterior recesses of the knee joint. The joint spaces behind the knee in which we are making incisions to release the scar tissue tend to be very contracted and very narrow. The popliteal neurovascular structures are sometimes within millimeters of where we are operating.
To help mitigate these risks, in addition to the techniques we’ve developed, we need a team of other specialists. Earlier this spring, I took care of a young man from Pittsburgh who had already had several operations to help with his arthrofibrosis. Unfortunately, even after months of therapy he was unable to straighten his knee and walked with his knee bent the whole time. He was so scarred in the back of the knee that the popliteal artery (the main artery giving blood supply to the lower leg) was within millimeters from where we needed to work. After thoroughly discussing the risks with the patient and his family, we developed a plan that included having a vascular surgeon from Orlando Health on standby and all their necessary equipment ready to go in the operating room. It is imperative to be prepared for as many potential complications as possible.
And, of course, this is one of the advantages of having a dedicated orthopedic institute that is directly adjoined to a leading multi-disciplinary healthcare system like Orlando Health. Throughout the patient’s treatment, we are able to align a team of all of the specialists and care providers who are within steps of each other: orthopedic, vascular, neurological, anesthesia, radiology, physical therapy, and all of the support staff. Fortunately, we were able to remove all the scar tissue in his knee through our minimally invasive techniques and he is now able to fully straighten his knee and walk with a completely normal gait.
The most important thing for prospective patients to know is that there is help available. The decision to have surgery is certainly not one to be made lightly. You want to begin with all of the non-surgical modalities first. And then only consider surgery as a last resort. That said, we have clearly shown with data from several published studies that people with arthrofibrosis after knee surgery can be successfully helped with these minimally invasive techniques, and the results appear to be sustainable overtime.
Seven of our most recent published studies on arthrofibrosis are collected by the National Library of Medicine at this link: https:// pubmed.ncbi.nlm.nih.gov/?term=levy+ba+arthrofibrosis.
Our podcast on arthroscopic lysis of adhesions for arthrofibrosis is available at this link: https://sageorthopaedics.libsyn.com/ajsmoctober-podcast-arthroscopic-lysis-of-adhesions-for-arthrofibrosis-after-anterior-cruciate-ligament-reconstruction
Bruce Levy, MD, is a board-certified orthopedic and sports medicine surgeon with Orlando Health Jewett Orthopedic Institute. He also serves as the academic chief of sports medicine and the director of the Sports Medicine Surgical Fellowship program. Previously he was a professor of orthopedics and surgeon at the Mayo Clinic in Rochester, Minnesota. He is an editorial board member for numerous medical journals and has published more than 300 scientific papers.
DERMATOLOGY Continued from page 8
lawful to reimport medicines (a bill has been passed in Florida to allow reimportation, but it still faces an uphill battle for implementation). In other words, the United States is subsidizing the healthcare of the rest of the world by paying outrageous prices, allowing other countries to continue paying bargain-basement prices. Yet, we wonder why our healthcare costs so much here in America.
So how did I resolve the problem of the $8500 cream? Well, we sent the prescription to the local compounding pharmacy and had virtually the same medicine compounded up for $75. The patient did well and saved $8425 along the way. And what happened to the company that made Alcortin and raised the price thousands of dollars? Well, they went bankrupt. What goes around comes around.
Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. John Meisenheimer, VII is an MD practicing in Orlando.
A New Era in Severe Obstructive Sleep Apnea Treatment:
FDA Clears Innovative Oral Medical Devices
By Tara M. Griffin, DMD, DBDSM, DASBA
A New Era in Severe Obstructive Sleep Apnea Treatment: FDA Clears Innovative Oral Medical Devices
A New Era in Severe Obstructive Sleep Apnea Treatment: FDA Clears Innovative Oral Medical
Devices
By Tara M. Griffin, DMD, DBDSM, DASBA
By Tara M. Griffin, DMD, DBDSM, DASBA
At Sleep Solution Centers, we are here to provide safe, effective alternative treatment solutions to chronic sleep breathing disorders such as obstructive sleep apnea (OSA), and other related conditions. These options are ideal for patients who can’t tolerate traditional treatment methods such as a CPAP machine with low compliance and fear of having to endure a lifetime of wearing a mask while sleeping, or those not keen on invasive surgeries such as tonsil and adenoid removal or neurostimulation implant devices. Our goal is to bring a new dawn in treatment for such disorders that is safe, convenient, and non-invasive.
At Sleep Solution Centers, we are here to provide safe, effective alternative treatment solutions to chronic sleep breathing disorders such as obstructive sleep apnea (OSA), and other related conditions. These options are ideal for patients who can’t tolerate traditional treatment methods such as a CPAP machine with low compliance and fear of having to endure a lifetime of wearing a mask while sleeping, or those not keen on invasive surgeries such as tonsil and adenoid removal or neurostimulation implant devices. Our goal is to bring a new dawn in treatment for such disorders that is safe, convenient, and non-invasive.
At Sleep Solution Centers, we are here to provide safe, effective alternative treatment solutions to chronic sleep breathing disorders such as obstructive sleep apnea (OSA), and other related conditions. These options are ideal for patients who can’t tolerate traditional treatment methods such as a CPAP machine with low compliance and fear of having to endure a lifetime of wearing a mask while sleeping, or those not keen on invasive surgeries such as tonsil and adenoid removal or neurostimulation implant devices. Our goal is to bring a new dawn in treatment for such disorders that is safe, convenient, and non-invasive.
The recent FDA granting of the first-ever 510(k) clearance permitting the use of unique oral medical devices for the treatment of Severe OSA reflects an exceptional moment in the field of dentistry and medicine. It marks a grand stride towards a more integrative approach between the medical and dental communities, aiming to effectively and holistically treat OSA in patients across all severity levels.
an unprecedented breakthrough in OSA treatment! The resolution of OSA occurred when a sleep test was taken without any oral device in the patient’s mouth and the patient had an AHI < 5 with no diagnosis of OSA after treatment.
breakthrough in OSA treatment! The resolution of OSA occurred when a sleep test was taken without any oral device in the patient’s mouth and the patient had an AHI < 5 with no diagnosis of OSA after treatment.
an unprecedented breakthrough in OSA treatment! The resolution of OSA occurred when a sleep test was taken without any oral device in the patient’s mouth and the patient had an AHI < 5 with no diagnosis of OSA after treatment.
The recent FDA granting of the first-ever 510(k) clearance permitting the use of unique oral medical devices for the treatment of Severe OSA reflects an exceptional moment in the field of dentistry and medicine. It marks a grand stride towards a more integrative approach between the medical and dental communities, aiming to effectively and holistically treat OSA in patients across all severity levels.
The recent FDA granting of the first-ever 510(k) clearance permitting the use of unique oral medical devices for the treatment of Severe OSA reflects an exceptional moment in the field of dentistry and medicine. It marks a grand stride towards a more integrative approach between the medical and dental communities, aiming to effectively and holistically treat OSA in patients across all severity levels.
For over 40 years, professionals in both the medical and dental industries have eagerly envisaged this momentous development. The recent FDA clearance implies that advanced oral medical devices, such as Vivos CARE devices, can cater to OSA patients with ground-breaking success rates—a blend of innovation and convenience that perfectly aligns with our philosophy at Sleep Solution Centers.
As the medical community scales up its understanding of the complex nature of OSA, the structure and functionality of the oral vault have emerged as paramount factors to this condition. This realization helps establish why collaboration with Sleep Solution Centers and airway-centered dentistry approaches like Vivos, is evolving as a unique game-changer providing transformative therapeutic alternatives for this condition that transcends traditional CPAP treatment.
As the medical community scales up its understanding of the complex nature of OSA, the structure and functionality of the oral vault have emerged as paramount factors to this condition. This realization helps establish why collaboration with Sleep Solution Centers and airway-centered dentistry approaches like Vivos, is evolving as a unique game-changer providing transformative therapeutic alternatives for this condition that transcends traditional CPAP treatment.
As the medical community scales up its understanding of the complex nature of OSA, the structure and functionality of the oral vault have emerged as paramount factors to this condition. This realization helps establish why collaboration with Sleep Solution Centers and airway-centered dentistry approaches like Vivos, is evolving as a unique game-changer providing transformative therapeutic alternatives for this condition that transcends traditional CPAP treatment.
For over 40 years, professionals in both the medical and dental industries have eagerly envisaged this momentous development. The recent FDA clearance implies that advanced oral medical devices, such as Vivos CARE devices, can cater to OSA patients with ground-breaking success rates—a blend of innovation and convenience that perfectly aligns with our philosophy at Sleep Solution Centers.
For over 40 years, professionals in both the medical and dental industries have eagerly envisaged this momentous development. The recent FDA clearance implies that advanced oral medical devices, such as Vivos CARE devices, can cater to OSA patients with ground-breaking success rates—a blend of innovation and convenience that perfectly aligns with our philosophy at Sleep Solution Centers.
A study published in the esteemed Journal of Sleep Medicine substantiates the impressive efficacy of such oral medical devices. In the study, Vivos CARE demonstrated substantial reduction in apnea hypnopnea index (AHI) scores in a majority of OSA patients. Remarkably, 61% of the patients saw significant improvements in their OSA, with a full 26% experiencing complete resolution of their OSA symptoms and diagnosis–
A study published in the esteemed Journal of Sleep Medicine substantiates the impressive efficacy of such oral medical devices. In the study, Vivos CARE demonstrated substantial reduction in apnea hypnopnea index (AHI) scores in a majority of OSA patients. Remarkably, 61% of the patients saw significant improvements in their OSA, with a full 26% experiencing complete resolution of their OSA symptoms and diagnosis–an unprecedented
A study published in the esteemed Journal of Sleep Medicine substantiates the impressive efficacy of such oral medical devices. In the study, Vivos CARE demonstrated substantial reduction in apnea hypnopnea index (AHI) scores in a majority of OSA patients. Remarkably, 61% of the patients saw significant improvements in their OSA, with a full 26% experiencing complete resolution of their OSA symptoms and diagnosis–
The FDA’s decision to corroborate the application of oral medical devices for the treatment of mild to severe obstructive sleep apnea is surely a beacon of progress in the realm of patient care. Besides chronic OSA sufferers who have struggled to attain relief through traditional treatment methods, patients who prefer non-invasive treatments stand to benefit immensely from this development.
The FDA’s decision to corroborate the application of oral medical devices for the treatment of mild to severe obstructive sleep apnea is surely a beacon of progress in the realm of patient care. Besides chronic OSA sufferers who have struggled to attain relief through traditional treatment methods, patients who prefer non-invasive treatments stand to benefit immensely from this development.
The FDA’s decision to corroborate the application of oral medical devices for the treatment of mild to severe obstructive sleep apnea is surely a beacon of progress in the realm of patient care. Besides chronic OSA sufferers who have struggled to attain relief through traditional treatment methods, patients who prefer non-invasive treatments stand to benefit immensely from this development.
In light of this significant advancement, we urge physicians to consider these alternative treatment solutions to traditional CPAP, particularly for patients who are averse to a lifetime of continuous treatment or invasive surgeries. By referring them to specialized facilities such as Sleep Solution Centers, equipped with state-of-the-art advancements in oral appliance therapy as well as non-invasive adjunctive therapies, we can collectively contribute to a revolution in holistic and sustainable OSA management and/or resolution.
In light of this significant advancement, we urge physicians to consider these alternative treatment solutions to traditional CPAP, particularly for patients who are averse to a lifetime of continuous treatment or invasive surgeries. By referring them to specialized facilities such as Sleep Solution Centers, equipped with state-of-the-art advancements in oral appliance therapy as well as non-invasive adjunctive therapies, we can collectively contribute to a revolution in holistic and sustainable OSA management and/or resolution.
In light of this significant advancement, we urge physicians to consider these alternative treatment solutions to traditional CPAP, particularly for patients who are averse to a lifetime of continuous treatment or invasive surgeries. By referring them to specialized facilities such as Sleep Solution Centers, equipped with state-of-the-art advancements in oral appliance therapy as well as non-invasive adjunctive therapies, we can collectively contribute to a revolution in holistic and sustainable OSA management and/or resolution.
The FDA’s clearance of breakthrough oral medical devices for the treatment of mild to severe OSA marks the onset of a new
The FDA’s clearance of breakthrough oral medical devices for the treatment of mild to severe OSA marks the onset of a new
The FDA’s clearance of breakthrough oral medical devices for the treatment of mild to severe OSA marks the onset of a new
Continued on page 20
Continued on page 24
Continued on page 24
The Vivos mRNA appliance
Sleep Solution Centers
The Vivos mRNA appliance
Sleep Solution Centers
The Vivos mRNA appliance
Sleep Solution Centers
Social Media – Five Things Physicians Should Never Post
By Julie A. Tyk, JD
Last year, Alaska dentist, Seth Lookhart, made national headlines for filming a video of himself riding a hoverboard while extracting a patient’s tooth. Dr. Lookhart filmed the procedure on a sedated patient without authorization and forwarded the video to several people. A lawsuit was filed by the State of Alaska in 2017 charging Dr. Lookhart with “unlawful dental acts”, saying his patient care did not meet professional standards. The lawsuit goes on to further allege Dr. Lookhart joked that performing oral surgery on a hoverboard was a “new standard of care,” citing phone records that were obtained. Dr. Lookhart has also been charged with medical assistance fraud for billing Medicaid for procedures that were not justified, unnecessary, and theft of $25,000 or more by diverting funds from Alaska Dental Arts. On Friday, January 17, 2020, Dr. Lookhart was convicted on 46 counts of felony medical assistance fraud, scheming to defraud, misdemeanor counts of illegally practicing dentistry and reckless endangerment. Dr. Lookhart is expected to be sentenced on April 30, 2020. He faces the possibility of up to 10 years in prison.
A doctor in Rhode Island was fired from a hospital and reprimanded by the state medical board. The hospital took away her privileges to work in the emergency room for posting information online about a trauma patient. The doctor’s post did not include the patient’s name, but she wrote enough that others in the community could identify the patient, according to a board filing.
The popularity of social media has exploded in recent years. According to a recent PEW report, 70% of Americans use social media. Before jumping on the bandwagon, healthcare professionals are advised to be mindful of the possible ramifications of posting information on social media sites. There are numerous legal issues that can arise when healthcare providers use social media, including issues related to patient privacy, fraud and abuse, tax-exempt status, and physician licensing. The Federation of State Medical Boards has issued the Model Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice, which contains the “industry standards” for cyber security, online behavior, and patient privacy. Physicians should familiarize themselves with these guidelines.
Five things which physicians should never post to social media.
1. Inaccurate Medical Information: Medical professionals should avoid republishing, sharing, “liking,” or “retweeting” news stories about medical treatments unless they have completely read the story and have verified its accuracy. If a user finds inaccurate medical information through your social media channel, it can reflect very poorly upon you and your practice. Healthcare professionals also need to be careful about providing medical advice to patients using social media. If a patient receiving the medical advice from a doctor through social media is located in a state in which the doctor is not licensed, the doctor giving the advice risks liability under state licensing laws.
2. Do Not Post Anything that Violates Patient Confidentiality: Friending patients on social media sites may pose risks under Health Insurance Portability and Accountability Act (HIPAA) and state privacy laws. The fact that an individual is a patient of a healthcare provider falls within the types of health information that these laws
are designed to protect. As a rule, healthcare providers should not use social media to share any health information that could be linked to an individual patient, such as names, pictures, and physical descriptions, without the patient’s consent. The American College of Physicians recommends that doctors be especially aware of the implications for patient confidentiality when using social media. There have been cases of physicians losing their medical license after posting an image on social media that violated patient confidentiality. Always obtain permission from the patient in writing if you intend to use an image featuring any body part. Avoid talking about specific patients at all on social media unless you have permission to do so. Even if there is no chance that a patient could be identified by what you write on social media, it is considered unprofessional to discuss the specifics of their condition. Also be careful when taking photographs of yourself while in your practice. There have been cases where medical professionals have accidentally included the image of the patient behind them while taking a ‘selfie’. Make sure there are no patient health records on display when taking photos in the medical practice and no patients are included in photographs unless they want to be.
3. Your Personal Information: The American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB) recommend that doctors create separate social media accounts for their professional and personal lives. They also suggest that the professional profile be more visible than any personal one.
4. Opinions on Controversial Issues: Any controversial topic or “hot button” topic should be avoided as much as possible, including anything to do with religion, politics, racism, abortion, and gun control. Moreover, healthcare providers that are exempt from taxation under Section 501(c)(3) of the Internal Revenue Code are prohibited from intervening in political campaigns and from seeking to influence legislation as a substantial part of their activities. This restriction may extend to advertising on or sponsoring social media sites that support a political candidate or particular pieces of legislation.
5. Complaints or Rants: It is unprofessional to use social media platforms to complain or rant about your professional situation. Everything you write on social media may one day come back to haunt you. A patient might realize that you were complaining about them on social media.
A medical malpractice claim can have far reaching implications. The Health Care Practice Group at Pearson Doyle Mohre and Pastis, LLP, is committed to assisting Clients in navigating and defending medical malpractice claims. For more information and assistance, please contact David Doyle and Julie Tyk at Pearson Doyle Mohre & Pastis, LLP.
Julie A. Tyk, JD, is a Partner with Pearson Doyle Mohre & Pastis, LLP. Julie concentrates her practice in medical practice defense litigation, insurance defense litigation and health care law. She has represented physicians, hospitals, ambulatory surgical centers, nurses and other health care providers across the state of Florida, and may be contacted by calling (407) 951-8523; jtyk@pdmplaw.com.
Don’t Manage Your Own Medical Build-Out Why Physicians Need an Owner’s Development Representative
By Frank Ricci, Healthcare Realty & Development Services LLC
Signing a lease or purchasing a medical office is an exciting milestone. Many physicians assume the difficult part is behind them.
In reality, it’s just beginning.
Design, permitting, contractor selection, equipment coordination, construction, inspections, and opening day all have to come together at the right time. A delay in one area quickly affects everything else. Without experienced oversight, costs rise, schedules slip, and physicians find themselves spending evenings and weekends managing a construction project instead of caring for patients.
I’ve seen this happen more times than I can count.
A two-physician practice purchases a medical office condominium expecting a six-month build-out with a $400,000 budget. Then permitting takes longer than expected. Equipment specifications change after construction begins. Contractors wait on architects. Vendors miss delivery dates. Change orders begin to accumulate.
Instead of opening in six months, the practice opens nearly a year later after spending almost $600,000.
The additional construction cost is only part of the problem. Every month the practice remains closed is another month of lost revenue, delayed patient care, and unnecessary stress.
Most of these problems are preventable.
That is why I believe physicians should never manage their own healthcare development projects.
A BETTER APPROACH
Turnkey Project Management (TPM) is an integrated system that brings every phase of a healthcare real estate project under one coordinated process.
Rather than asking physicians to manage architects, engineers, contractors, equipment vendors, consultants, inspectors, landlords, and lenders independently, TPM provides a single point of accountability from site selection through opening day.
At the center of that process is the Owner’s Development Representative (ODR).
The ODR represents the physician throughout the project, protecting the owner’s interests while coordinating every consultant, contractor, and vendor involved. Instead of spending valu-
able clinical time solving construction problems, physicians have one experienced professional responsible for keeping the project on schedule, on budget, and moving toward a successful opening.
WHY COORDINATION MATTERS
Healthcare construction is different from almost every other type of commercial development.
Medical facilities must satisfy building codes, ADA requirements, life safety standards, specialty equipment needs, infection control requirements, and often complex permitting processes. Every decision affects another discipline, making communication essential.
Industry studies consistently show that projects without coordinated oversight experience significantly more cost overruns, longer schedules, and more communication failures between project participants.
The question isn’t whether problems will arise.
The question is who will solve them.
Without a single leader coordinating the process, physicians often become the default project manager. That usually means making decisions outside their area of expertise while balancing patient care and practice operations.
An experienced ODR changes that equation.
WHAT AN ODR ACTUALLY DOES
The ODR oversees the entire development process, beginning before the lease or purchase agreement is finalized and continuing through opening day.
Responsibilities typically include coordinating due diligence, assisting with real estate negotiations, managing the design and permitting process, overseeing contractor selection, monitoring construction, reviewing budgets and change orders, coordinating equipment installation, and helping ensure the practice is ready to open on schedule.
The physician remains informed and involved in major decisions without becoming responsible for managing dozens of independent participants.
The result is better communication, stronger accountability,
improved budget control, and a far more predictable development process.
CHOOSING THE RIGHT ODR
Not every project manager has the experience required for healthcare development.
Medical facilities involve specialized regulatory requirements, complex building systems, and operational considerations that differ substantially from traditional commercial construction.
When selecting an ODR, physicians should look for someone with healthcare development experience, a strong understanding of medical real estate, practical construction knowledge, and a proven history of successfully delivering healthcare projects.
Just as important, the ODR should serve as the physician’s advocate throughout the process, helping protect the owner’s interests from the first property tour through opening day.
FINAL THOUGHT
Physicians spend years mastering medicine.
They should not have to become experts in healthcare development.
Signing a lease or purchasing a building is only the first step. What happens afterward will determine whether the project opens on time, stays within budget, and supports the long-term success of the practice.
A Turnkey Project Management (TPM) system provides the structure. An Owner’s Development Representative (ODR) provides the leadership and accountability.
Together, they allow physicians to focus on what they do best: caring for patients while someone else manages the complexity of building the facility..
Frank Ricci is one of the few healthcare real estate brokers in Florida who is also a licensed building contractor - a combination that allows him to identify and price improvement risks before they become transaction problems. With more than 30 years specializing in medical and dental facilities, he serves as Managing Broker of Healthcare Realty & Development Services and VP of HR&D Construction. Physicians considering the sale, lease, or repositioning of a medical office building can reach Frank directly at 407-947-5074.
era in OSA therapy. Our obligation is to ensure patients enjoy access to these transformative treatments and advance a sustainable and cross-disciplinary treatment outcome that holistically caters to OSA. This innovative approach bridges science and patient comfort to offer relief to patients in their long-standing battle against obstructive sleep apnea. Together, we can write a new chapter in the narrative of OSA treatment.
Sleep Solution Centers located in the heart of Medical City, Lake Nona, was co-founded by Dr’s Rupal Thakkar DMD and Tara M. Griffin DMD in March, 2024. We are both dentists by trade that have focused on treating sleep breathing disorders for the past 14 years of practice. The recent grand opening of Sleep Solution Centers marks our flagship medical center that solely treats the root cause of sleep breathing disorders and TMJ disorders for children and adults. With direct collaboration with our medical community, we aim to help revolutionize healthcare through early detection, prevention and treatment ensuring good quality sleep for a lifetime!
If you are interested in learning more about our practice, contact us at 407-502-0110 www.sleepsolutioncenters.com or info@sscln. com. References available upon request.
Tara M. Griffin, DMD, DBDSM, DASBA, graduated from Nova Southeastern University in 2006, with a doctorate in Dental Medicine. She became passionate about helping her patients breathe and sleep better and completed her Diplomate with the American Academy of Dental Sleep Medicine in 2011. In 2015, she completed her Diplomate with American Sleep and Breathing Academy. In 2016, she became a Clinical Advisor with Vivos Therapeutics to help educate and mentor doctors interested in the treatment of OSA with oral medical devices. She owned a private practice focused on sleep, TMD and general dentistry in the panhandle of Florida for 17 years before becoming the co-founder of Sleep Solution Centers in Medical City, Orlando in 2024. She may be contacted at 407-502-0110 or by visiting www.sleepsolutioncenters.com
W h e t h e r y o u l e a s e , b u y , o r s e l l , t h e o u t c o m e i s d r i v e n b y e a r l y d e c i s i o n s - s i t
I f y o u p l a n t o b u y i n 2 0 2 6 , s e l e c t i n g t h e r i g h t s i t e i s c r i t i c a l f o r s u c c e s s
W e h e l p y o u :
I d e n t i f y a n d s e c u r e t h e r i g h t s i t e b a s e d o n d e m o g r a p h i c s , a c c e s s , c o m p e t i t i o n , a n d
l o n g - t e r m g r o w t h
E v a l u a t e w h e t h e r a p r o p e r t y t r u l y s u p p o r t s y o u r c l i n i c a l , o p e r a t i o n a l , a n d f i n a n c i a l
g o a l s
I d e n t i f y h i d d e n c o s t s , r i s k s , a n d c a p i t a l r e q u i r e m e n t s b e f o r e y o u c o m m i t
A v o i d o v e r p a y i n g t h r o u g h m a r k e t a n a l y s i s , p o s i t i o n i n g , a n d r e p l a c e m e n t c o s t
i n s i g h t
S t r u c t u r e a c q u i s i t i o n s a l i g n e d w i t h y o u r l o n g - t e r m s t r a t e g y a n d e x i t o p t i o n s
M a k e c o n f i d e n t d e c i s i o n s b a s e d o n d a t a n o t a s s u m p t i o n s
If you plan to lease new space in 2026 - how you structure your lease will impact your practice for years.
We help you navigate the exact issues outlined in this article:
Rental Rate Analysis – Know what you should actually be paying Incentives & TI Strategy – Structure allowances that truly cover your buildout Escalation Review – Avoid long-term cost creep
Expense Audit (CAM, Taxes, Fees) – Identify what you're really responsible for Lease Term Strategy – Align term, extensions, and exit options with your growth
Exclusivity & Expansion Rights – Protect your ability to grow Use Restrictions Review – Ensure your services are fully permitted
p r i c i n g
H i g h l i g h t s t r e n g t h s t h a t m a t t e r t o h e a l t h c a r e - s p e c i f i c b u y e r s a n d t e n a n t s
R e d u c e t i m e o n m a r k e t a n d i m p r o v e d e a l c e r t a i n t y
A l i g n t i m i n g a n d s t r a t e g y t o a c h i e v e t h e b e s t p o s s i b l e o u t c o m e
B e f o r e y o u l e a s e , b u y , o r s e l l - p l a n y o u r s t r a t e g y f i r s t
C a l l F r a n k R i c c i : 4 0 7 . 9 4 7 . 5 0 7 4
L i c e n s e d
Cardiac MRI: Use and Benefits in Cardiovascular Disease
By Jesus Mendiolaza, MD, MPH, FACC, FASE, FSCMRI, FASNC, FSVU
Cardiac MRI (CMR) is a non-invasive, radiation-free imaging tool that provides unparalleled, detailed views of the heart’s anatomy, blood flow, and tissue health. It is a gold standard for diagnosing heart failure, cardiomyopathies, and congenital heart defects, excelling at pinpointing exactly where scarring, inflammation, or restricted blood flow exists. [1, 2, 3, 4, 5, 6]
KEY USES AND BENEFITS
• Tissue Characterization: CMR can accurately identify the difference between ischemic and non-ischemic heart conditions, fibrosis, and tumors without invasive biopsies. [1, 2, 3]
• Heart Function & Flow: It provides highly reproducible measurements of ventricular volumes, ejection fraction, and valvular regurgitation. [1, 2]
• Viability Assessment: It determines the extent of heart muscle damage following a heart attack to see if blood flow restoration procedures (like stents) will help. [1, 2, 3]
• Radiation-Free: Unlike X-rays or CT scans, CMR uses magnetic fields, making it safe for repeat testing and sensitive patient populations. [1, 2]
• Contrast Safety: The contrast agents (like gadolinium) used have a lower likelihood of allergic reactions compared to traditional iodine-based dyes
Jesus Mendiolaza MD, MPH, FACC, FASE, FSCMRI FASNC, FSVU: Board Certified Internal Medicine, Nuclear Cardiology, Echocardiography, Cardiac MRI, Heart Failure and Cardiovascular Disease, Certified in Cardio-Oncology, Congenital Heart Disease and Vascular Imaging by the American College of Cardiology and the Society of Vascular Ultrasound. He can be contacted by phone: (239)777-7180 or by email at jmendiolaza@gmail.com.
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