A combined publication of the Arizona Medical Association, Maricopa County Medical Society, and Pima County Medical Society

January 2017

Medical Technology: Master or Slave?

Read what our physicians think about technologyâ€™s role in medicine, pg. 28

Bernard Bendok, MD Profiling Mayoâ€™s chief of neurosurgery and how he integrates technology, pg. 23

INAUGURAL

EDITION

ARIZONA PHYSICIAN | January 2017

January 2017 | arizonaphysician.com

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Visit ce.atsu.edu for more information

ARIZONA PHYSICIAN | January 2017

VOLUME 1, ISSUE 1 EDITOR-IN-CHIEF JAY CONYERS, PhD

jconyers@arizonaphysician.com

Contents

MANAGING EDITOR SHARLA HOOPER

Physician Profile

Medical technology as a tool to affect outcomes and improve humanity: a sit-down with Mayo’s Bernard R. Bendok, MD.

shooper@arizonaphysician.com

ASSOCIATE MANAGING EDITOR DOMINIQUE PERKINS dperkins@arizonaphysician.com

PHOTOGRAPHY DENNY COLLINS

www.dennycollins.com

LAYOUT & PRINTING PRISMA

www.prismagraphic.com

ADVERTISING MANAGER BARB SPITZOCK

bspitzock@arizonaphysician.com

EDITORIAL BOARD GRETCHEN ALEXANDER, MD MICHAEL BUGOLA, MD JOHN COUVARAS, MD MICHAEL DEAN, MD TIMOTHY FAGAN, MD TABITHA MOE, MD ROBERT ORFORD, MD WILLIAM THOMPSON, MD JAREN TROST, MD

arizonaphysician.com twitter.com: /AZPhysician facebook: /ArizonaPhysician instagram.com: /azphysician

Features 15 28

How to use technology to boost the physicianpatient relationship How do physicians feel about technology in medicine?

31 37

Achieving healthcare without walls

Time for payment models to stop discriminating against in-home care

In This Issue 19

Community: Mission of Mercy

Congressional Corner with Governor Doug Ducey

Legal: Protect your Ideas

Precision Medicine

Policy Corner

Public Health: Zika Virus

Wearable Devices & Healthcare

What’s Inside

President’s Page

January 2017 | arizonaphysician.com

What’s Inside “The way to get started is to quit talking and start doing.”

Jay Conyers, PhD

– WALT DISNEY

fter nearly a year of discussing the value of a unified voice for the nearly 18,000 physicians of Arizona, our three organizations – Arizona Medical Association (ArMA), Maricopa County Medical Society (MCMS), Pima County Medical Society (PCMS) – are finally doing what we set out to do. This inaugural issue of Arizona Physician is the beginning of us establishing that voice.

So what’s inside?

For our first issue, we chose a topic familiar to most physicians. Technology has seemingly become as much of a hindrance in medicine as it has contributed to it. Sure, it’s led to some remarkable breakthroughs in medicine, from futuristic devices to innovative techniques to cutting-edge therapies. Nearly every physician can point to numerous improvements in how he or she delivers care as a result of technology and innovation. But it’s also become the bane of many, especially those who routinely utilize electronic health records (EHRs) in their practice. Technology, as the saying goes, has become both master and slave in medicine. When speaking with physicians about the good and bad aspects of technology in medicine, the elephant in the room is almost always EHRs. Collectively, there is a considerable dissatisfaction with their impact. Many point to the amount of time it takes to input data, how it limits face-to-face time with patients, or how the EHR was not designed to incorporate a typical physician routine into the workflow. Sure, they were designed to make physicians’ lives easier, but in reality, EHRs have done exactly the opposite. It’s hard not to argue that EHRs serve administrators way more than they do physicians. For the hundreds of EHRs available on the market, nearly all converge on optimization of the financial components of medicine. Proper coding, enhanced claims submission, speedier payments. While many EHRs are shrouded in claims that they were designed to enhance the doctor-patient relationship and better organize a patient’s health information, most fail to do so. While many will argue that technological advances account for the lion’s share of increasing healthcare costs, most agree that the benefits, such as improved outcomes 4

ARIZONA PHYSICIAN | January 2017

and quality of life, far outweigh the financial concerns. For example, a child born in 1990 has a life expectancy seven years longer than one born four decades earlier, thanks largely to technology. Not only has technology reduced the incidence of heart attacks over the past three decades, but it has also improved outcomes for those who suffer a non-fatal event. In 1984, roughly 10% of heart attack patients received surgical treatment, but by 1998, that number ballooned (pun intended) to more than 50% – thanks largely to angioplasty with stents. What about other examples? Thanks to the development of selective serotonin reuptake inhibitors (SSRIs) in the 1990s, depression is now more readily diagnosed and treated, providing millions of people with hope and the ability to lead normal lives. The popularity of cataracts surgery has exploded since the 1960s, when a procedure was complicated and required several nights of recovery in the hospital. Today, most procedures are done in outpatient settings in under an hour, at a fraction of the inflation-adjusted cost of what it was decades before. Perhaps in the future, the bad parts of technology in medicine will become a thing of the past. EHRs might actually improve your clinical productivity and accuracy. Patients might responsibly utilize their mobile devices and web resources to track their health and make positive lifestyle changes, based on the advice of their physicians. All EHRs become seamlessly interoperable, such that all patient data across multiple EHRs can be integrated into a virtual record for each patient. Patients begin to properly use home medical devices that transmit reliable data to their physicians. And the benefits of each technological advancement in medicine far outweighs the costs of the technology. Until then, we have no choice but to take the good with the bad. So what do we have in store for this first issue of Arizona Physician? For starters, we profile Bernard Bendok, MD, chairman of neurosurgery at the Mayo Clinic. He shares with us his views on technology and how it impacts the way he treats neurovascular conditions and skull-based diseases. We hope you enjoy his story.

In this issue, we have a number of technology-centric articles that we hope you find informative and impactful. One looks at ten ways wearable devices are having a positive impact on medicine, whereas another touches on the President’s Precision Medicine Initiative (PMI) and plans to launch the program here in Arizona through a landmark NIH grant. We also have an interesting article about how a local practice, MD24 House Call, is utilizing telemedicine to treat Medicare patients from their own homes. Lastly, we include in this issue a thought-provoking write-up of how technology can actually improve the doctor-patient relationship. This issue also has the results of our recent physician survey, where we asked our members how they perceive the impact of technology on the way they deliver care. In our congressional corner, Governor Ducey shares with us his Administration’s plans for improving healthcare in our state, and the role that physicians can and should play. We also have a policy corner, which looks ahead to the upcoming legislative session and shares with us some ways that physicians can get involved. Each issue of Arizona Physician will also have sections for legal, public health, and community partners. For the legal corner this month, we have a great piece providing a ‘how-to’ guide for physicians unsure of how to protect their ideas and intellectual property. This month’s community corner highlights the work being done by Mission of Mercy, a Phoenix non-profit with numerous community clinics providing care for those less fortunate. Our public health corner looks

at where we now stand with Zika virus and offers some recommendations for physicians who may encounter a patient who has potentially been exposed. That’s a lot of information packed into this one issue, so we hope you enjoy reading it all! What about next month? Our February issue of Arizona Physician looks at government’s role in healthcare, at both the state and federal levels. We’ll have another robust issue for you, and hope to see you at one of our organization’s events soon. Be on the lookout for event announcements, such as ArMA’s physician leadership conference scheduled for March 25th, MCMS’s health policy forum on January 26th, and MCMS’s physician lecture by Richard Gunderman, MD, scheduled for February 17th. On behalf of our three organizations, we’d love to see you at any of these events. Until then, enjoy this first issue of Arizona Physician and provide us any feedback you might have. We look forward to hearing from you! The cost-benefit examples highlighted above were taken from a recent article published by Dr. David Cutler, a Harvard professor of economics, and Dr. Mark McClellan, a Stanford associate professor of economics and board certified internist. (Health Affairs, vol. 35, no. 12, Dec 2016) Jay Conyers, PhD, is the Editor-in-Chief for Arizona Physician and serves as Executive Director of the Maricopa County Medical Society.

January 2017 | arizonaphysician.com

President’s Page T E C H N O LO G Y : M A S T E R O R SL AV E ?

reetings! And welcome to a new year and to the inaugural edition of Arizona Physician, a joint venture of the Arizona Medical Association (ArMA), the Maricopa County Medical Society (MCMS), and the Pima County Medical Society (PCMS). It is the hope of our organizations that this publication, which will be distributed free of charge every month to all Arizona physicians, will provide a catalyst for unity, communication, and engagement among all of us who care about the practice of medicine in Arizona. Each issue will be planned to highlight a specific topic of interest to the medical community. As the current president of the Arizona Medical Association, it is my privilege to introduce our first issue – “Technology in Medicine: Master or Slave?” This question is a pertinent one for a profession whose current members are largely “digital immigrants,” i.e., individuals born before 1980 and therefore not exposed from childhood to widespread digital technology. Data from the Federation of State Medical Boards shows that only 21% of allopathic and osteopathic physicians in 2014 were aged 39 or younger, making the remaining 79% of us, by accident of birth, late to the technology game.1 One could speculate that physicians older than 40 might tend to perceive technology as an exacting “master,” while younger physicians could welcome technology as a “slave” ideally suited for improving workflow and efficiency. Interestingly, however, the Physicians Foundation Biennial Physician Survey found in 2014 that among physicians aged 45 or younger who had adopted electronic medical record technology (EMR), 38% felt that EMR detracted from their efficiency, while only 30% of the same group felt that efficiency was improved. And, a remarkable 43% of younger physicians reported that EMR detracted from patient interaction compared to 6% who felt that patient interactions were improved by technology.2

Patient safety

Given that generational differences do not appear to entirely account for negative physician perceptions of technology’s impact on physician efficiency and patient

ARIZONA PHYSICIAN | January 2017

Gretchen Alexander, MD

interaction, what is known about another proposed benefit of technology in medicine: patient safety? Here, although younger physicians’ attitudes are more generally favorable, the evidence itself is mixed. In a review of the literature completed last year as part of a study evaluating how EMR adoption affected reported medication errors in my workplace, the following background emerged. Concerns regarding patient safety have intensified since 1999 when the Institute of Medicine report, To Err is Human: Building a Safer Health System, estimated that medical errors contributed to as many as 98,000 deaths annually in the United States.3 It has been generally recognized that medication errors are the most common type of medical error.4 As a result, business organizations such as the Leapfrog Group have called for healthcare system improvements including universal adoption of computerized physician order entry (CPOE). In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) act provided financial incentives for hospitals to meet stage 1 meaningful use criteria through the implementation of electronic health records including CPOE.5 As of 2014, 59% of hospitals met a standard of 75% of inpatient medication orders entered using CPOE.6 Historically, studies have demonstrated an association between CPOE adoption and decreased medication errors,7 with some evidence suggesting that internally developed (“homegrown”) CPOE systems may provide greater benefit than commercially developed systems.8 Interestingly, however, many of these positive studies included prescribing events that would not be generally considered medical errors by physicians, such as incomplete orders requiring verbal clarification by the pharmacist. These were events with no potential to result in patient harm, yet were included in the category of “medication errors.” Also, improvements with respect to patient mortality and morbidity have not been as clearly associated with CPOE adoption. Variable outcomes including increased, decreased or unchanged mortality9-11 have all been demonstrated. Other work has shown unexpected consequences of CPOE including increases in physician

Error Source

2011

Percent

2012-post

2013

Post Totals

Percent

Administering

465

557

43.01

311

329

640

47.44

Dispensing

279

330

25.48

117

120

2237

17.57

<0.001

Documenting

212

245

18.92

150

11.12

<0.001

Monitoring

6.67

6.89

0.796

Prescribing

5.32

109

204

15.12

<0.001

(non listed)

0.62

1.85

0.004

Total Errors Per Period

2012-pre Pre-Totals

1295

P value

0.022*

1349

*Chi-squared P-value compaing the Pre vs. Post periods across “Administration” vs “All the rest” of sources combined.

cognitive workload12 as well as increases in new types of medication errors.13 As for the results of our own study, although the overall number of medication errors declined, a significant increase in both numbers and rates of prescriber errors was reported in the 22 months following center-wide adoption of a commercial electronic health record system (See table).14 In conclusion, the evidence suggests that EMR technology, especially when designed by and for the ultimate users, has significant potential to enhance patient safety during the course of clinical care. However, unanticipated consequences in the form of negative impacts on patient engagement, practitioner efficiency and in some circumstances, patient safety have also been described. These negative impacts must be acknowledged and dealt with, if we are to be truly able to develop better systems of care for the future. Nobel Laureate Christian Louis Lange commented in 1921 that “Technology is a useful servant but a dangerous References 1. Aaron Young, PhD; Humayun J. Chaudhry, DO, MS; et. al. A Census of Actively Licensed Physicians in the United States, 2014. Journal of Medical Regulation. Vol 101, No 2. 2. http://www.physiciansfoundation.org/uploads/default/2014_ Physicians_Foundation_Biennial_Physician_Survey_Report.pdf 1. Kohn LT, Corrigan JM, Dondalson MS, eds. 3. To Err is Human: Building a Safer Health System. Institute of Medicine (U.S.) Committee on Quality of Health Care in American. Washington, DC: National Academy Press; 1999 4. Leape LL. Error in medicine. JAMA 1994; 272:1851-1857 5. Blumenthal D. Wiring the health system-origins and provisions of a new federal program. N. England J. Med. 2011; 365(24):2323-2329 6. http://www.leapfroggroup.org/media/file/2014LeapfrogReport_ CPOE_FINAL.pdf 7. Nuckols TK, Smith-Spangler C, Morton SC, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Syst Rev. 2014; 3:56. 8. Leung AA, Schiff G, Keohane C, et al. Impact of vendor computerized physician order entry on patients with renal impairment in community hospitals. Journal of Hospital Medicine. 2013;8:545-552.

master.” Although the technology of Lange’s day was different from our own, his observation is as pertinent now as it was in the early 20th century. We must take care as we develop and apply technological advances in medicine to do so in a thoughtful manner, in order to ensure that technology continues to be a useful servant to us in the care of our patients. It is critical that we continue to insist on direct engagement in the processes of developing, implementing and refining technology applications as they are incorporated into our working lives, and the lives of our patients. Gretchen Alexander, MD, is the 125th president of ArMA. Dr. Alexander is Clinical Associate Professor of Psychiatry at the University of Arizona College of Medicine – Phoenix and Associate Program Director of Maricopa Integrated Health System (MIHS) Psychiatry Residency Program. She is Unit Attending Psychiatrist for MIHS/District Medical Group at Maricopa Medical Center Behavioral Health Annex.

9. Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005; 116(6):1506-1512 10. Del Beccaro MA, Jeffries HE, Eisenberg MA, et al. Computerized provider order entry implementation; no association with increased mortality rates in an intensive care unit. Pediatrics. 2006; 118(1):290-295 11. Longhurst CA, Parast L, Sandborg CI, et al. Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2010; 126(1):14-21 12. Ash JS, Sittig DF, Poon EG, et al. The extent and importance of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2007; 14:415-423 13. Leung AA, Keohane C, Amato M, et al. Impact of vendor computerized physician order entry in community hospitals. J Gen Intern Med. Jul 2012; 27(7): 801-807. 14. Alexander G, Ramos G. Increase in prescriber error rates following implementation of computerized physician order entry. Proceedings: AMIA Annual Symposium Poster Session. Nov 2015.

January 2017 | arizonaphysician.com

Congressional Corner G O V E R N O R

D O U G

D U C E Y

am honored to be able to address over 18,000 Arizona physicians in the inaugural edition of Arizona Physician. As we celebrate this inaugural edition, another inaugural is occurring in Washington, DC – the inauguration of a new President. While a new President has the opportunity to affect many policy areas, there is no area likely to be more greatly impacted than healthcare. It is no secret that I have long been a critic of Obamacare. When Obamacare was first passed, the American people were told they would “find more choices, more competition, and in many cases, lower prices.” Unfortunately, these promises have proven false. I have long said that Obamacare is a rolling disaster and the volatility in the Arizona insurance market has only strengthened that belief. In 2017, Arizonans shopping for coverage on the federal marketplace in Arizona will have a single choice for coverage and will see an average premium increase of 49%. Additionally, insurers, seeking to protect themselves from further losses, have engaged one of the few options left open to them: narrowing their networks. As you well know, narrow networks limit the ability of consumers to visit the doctor of their choice no matter how sick they may be. But even as we point out the very real flaws of Obamacare, it is important to note that there were flaws in the system we had before. We have all heard the stories of individuals who were unable to find coverage due to a pre-existing condition. These individuals need access to health insurance, and for them, the thought of repeal and returning to a time when they could not buy coverage at all is very scary. This is why any discussion of “repeal” must also include discussion of what “replace” will look like. It is my hope that Congress and the President will put together a replace plan that truly brings choice and competition back to the healthcare market while putting in place protections to ensure that all individuals have the ability to obtain coverage. I will continue to work with our Congressional delegation to provide them all necessary information on the impact of proposed replace plans on Arizona.

ARIZONA PHYSICIAN | January 2017

But while we wait for action from Washington on Obamacare, we are taking action of our own here in Arizona. One of the most common complaints that I have heard from the healthcare community relates to the length of time it takes to license a doctor. We have taken two important steps to address that. First, we have provided the Arizona Medical Board with assistance from our lean government team to assist in improving their overall process and shorten the time frame from application to licensure. Second, I signed legislation in May allowing Arizona to join the Interstate Medical Licensure Compact. This compact, which includes 18 states, will provide qualified physicians in good standing in another compact state with a new and faster path to licensure in Arizona.

Each and every one of the physicians in Arizona plays an extremely important role in our state. You keep us healthy and treat us when we are ill. We have also made strides in other areas, including expanding our physician loan repayment program, re-opening the KidsCare program to ensure that children in low-income families have access to affordable healthcare, increased funding for graduate medical education, and averting Medicaid provider cuts that would have placed additional pressures on the physician community. My administration has also been focused on fighting the scourge of opiate abuse. Last year, Arizona was ranked as the 9th highest state for drug overdose deaths. That is a top 10 list

we don’t want to be on, and my administration is committed to doing everything we can to address the issue. So far we have made Naloxone more widely available to help save the lives of those already suffering from addiction, removed pre-authorization requirements at AHCCCS for new forms of medication-assisted treatment including Vivitrol, and requiring a check of the CSPMP before prescribing opiates in most circumstances. As we move to implement the new CSPMP requirement, we are committed to ensuring that the system is as user-friendly as possible for doctors and we are currently in the process of implementing several upgrades. Additionally, we secured a waiver from the federal government to modernize our Medicaid program. This new AHCCCS waiver is focused on able-bodied adults and is designed to help them prepare to re-enter the commercial market by rewarding healthy behaviors, engaging them in work search activities, and helping them build a personal safety-net which will be there for them to help cover co-pays and premiums after they have left the Medicaid program. Each and every one of the physicians in Arizona plays an extremely important role in our state. You keep us healthy and treat us when we are ill. I am extremely proud to have world class medical facilities such as Mayo Clinic, Barrow Neurological, Banner University Medical Center, Phoenix Children’s Hospital, and many others right here in Arizona. None of those facilities could operate without world-class physicians. We value your work and look forward to working with your professional associations as we move forward to ensure that Arizona is a welcoming place for our growing medical community.

The Great Plains Laboratory, Inc. is pleased to bring you GPL University, a series of workshops designed to help practitioners learn how to integrate our comprehensive testing into their practices. When you attend a GPL University workshop, you will ﬁnd out why our tests may be incredibly valuable to your practice and what particular markers may be the most meaningful to speciﬁc patients. Attend both of the following workshops and you’ll learn how to use these tests in tandem to provide your patients with the most comprehensive and personalized treatment plans possible! DAY 1 | ORGANIC ACIDS TESTING DAY 2 | GENETIC TESTING & TOXIC CHEMICAL TESTING

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January 2017 | arizonaphysician.com

Policy Corner 2 0 1 7 L E G I S L AT U R E L A U N C H E S

pening Day for the 2017 Legislative session is on Monday, January 9th and we are excited to share information and resources with Arizona physicians in this new publication! Look for us to provide updates and insights each month during the legislative session. In this edition, we will be sharing our insights on the issues we expect to face this session, identifying key legislative members for health issues, and providing an overview of opportunities for you to engage in the process. Scope of practice for health professions is determined at the state level. Since 1985 Arizona has had an established process, called the sunrise process, to provide a mechanism for both health and non-health professionals to request regulation and expansion of scope of practice. The sunrise process begins by a group filing an application which should demonstrate the need for regulation or increased scope of practice. For health professionals, the applications are heard by the Health Committees of Reference (“COR”) consisting of members from both the Senate and House Health Committees. The COR meets outside of the regular legislative session in order to give increased focus and attention to these complicated matters. We have seen the first set of issues crop up during the sunrise process which evaluates regulation and scope of practice issues for health professionals. Scope of practice issues are one of the most persistent and challenging issues facing physicians today; we have seen a growing demand by a broad array of non-physician providers to expand the scope of their practices into new areas of patient care. These issues have great implications for health care and patients. The changes in our healthcare system and delivery, changes in physician practices, increased healthcare demands and evolving physician-led care tend to make these issues extremely complicated. Thus, they must be reviewed and evaluated from a multitude of perspectives, including: patient safety, quality of care, coordination of care, training and education, access to care, cost effectiveness of care, political forces, and changing federal policies. This year, nine sunrise applications have been filed. They are summarized below.

ARIZONA PHYSICIAN | January 2017

Pele Fischer, JD

Requests for expansion of scope of practice: 1.

Arizona Association of Nurse Anesthetists – a renewed effort to address the “direction” and “presence” requirements in their law, and address the DEA number issue.

Arizona Naturopathic Medical Association (two applications) – requests for authority to sign medical exemptions for required immunizations, and to permit the use of IV antibiotics.

Arizona Pharmacy Association – multiple requests: to allow pharmacists to administer oral fluoride varnish; to administer and interpret TB tests; to prescribe both OTC and prescription tobacco cessation products; to prescribe medications to patients testing positive for influenza or strep throat; to administer and interpret strep throat and influenza tests; and to extend a routine, non-controlled, chronic medication for an additional 30-60 days.

The CORE Institute (regarding Podiatrists) – request to perform toe amputations.

Requests for regulation: 1.

Arizona Art Therapy Association – request to create a new professional regulatory framework for art therapists.

Arizona Community Health Worker Association – request to create a voluntary professional certification framework for community health workers.

Dental Care for AZ (regarding Dental Therapists) – request to create a new midlevel dental provider category (dental therapist).

Lauren Moore (regarding Phlebotomists) – request to create a new professional regulatory framework for phlebotomists.

Beyond the sunrise applications, there are numerous other health-related issues that the Arizona Medical Association (ArMA) is currently engaged in and which will likely be addressed in some capacity during the 2017 legislative session. These include: surprise billings, healthrelated board reforms, the opioid epidemic, and the future of health care reform (“repeal and replace” of the Affordable Care Act and the future of Medicaid/AHCCCS expansion). As the legislative session begins and bills are introduced, we will know the additional areas of healthcare legislation that legislators and interest groups are pursuing. ArMA fights and advocates for YOU, Arizona physicians, and your patients. Our lobbying team tracks hundreds of bills throughout the legislative session and is a strong and powerful advocate for solutions based on the best interests of physicians and patients. Please make sure to check back for future updates regarding the 2017 legislative session. As we work to educate legislators on healthcare issues, it is important to know who the key leaders are on these issues. This starts with the Health committees in the Arizona House and Senate. This year’s Committees include the following members. Are you a constituent of any of these legislators?

Members of the House Health Committee Chair – Heather Carter, R-LD15 Vice Chair – Regina Cobb, R-LD5 Jay Lawrence, R-LD23 Tony Rivero, R-LD21 Maria Syms, R-LD28 Michelle Udall, R-LD25 Kelli Butler, D-LD28 Oteniel Navarrete, D-LD30 Pamela Powers Hannley, D-LD9

Members of the Senate Health and Human Services Committee Chair – Nancy Barto, R-LD15 Vice Chair – Kate Brophy McGee, R-LD28 Debbie Lesko – R-LD21

Steve Montenegro, R-LD13 Kimberly Yee, R-LD20 David Bradley, D-LD10 Katie Hobbs, D-LD24 Not sure of your legislative district? Find it using the Arizona District Locator: http://azredistricting.org/ districtlocator/. • •

• •

You can reach out to your legislators in several ways: Review the updated azleg.gov website to locate contact information for your legislators. Sign up for the Arizona Legislative Information System (ALIS) and its “Request to Speak” function to provide public input on specific bills. Engage with your legislators on social media. Follow them on Twitter and Facebook. Interested in an issue and want to serve as a resource for our advocacy and education efforts? Contact me directly at pele@azmed.org.

The ArMA flagship “Doctor of the Day Program” offers a wonderful opportunity to enhance the visibility of the medical profession, and to create collaboration between doctors and elected officials whose decisions impact the way medicine is practiced in Arizona. The Doctor of the Day Program runs from January through April, Monday – Thursday, 9 a.m. – 2 p.m. The Doctor of the Day provides invaluable medical assistance should any emergency arise at the Capitol complex. The doctors attend committee meetings, watch sessions of the House and Senate and meet with their district legislators to offer their views on issues which affect their patients’ access to quality health care and their ability to provide it. To learn more about the program, contact Ingrid Garvey, ArMA’s AVP of Policy & Political Affairs at (602) 347-6905 or igarvey@azmed.org. Pele Fischer, JD, is the Vice President of Policy & Political Affairs for the Arizona Medical Association.

January 2017 | arizonaphysician.com

WHERE ARE WE NOW? BOB ENGL A ND, MD, MPH DIRECTOR, MARICOPA COUNTY DEPARTMENT OF PUBLIC HEALTH

ARIZONA PHYSICIAN | January 2017

hat we know about Zika will change by the time you read this. That’s a key to dealing with this – don’t print out guidelines. They’ll be out-of-date by the time you need them. Look them up online instead. In November, the World Health Organization declared the end of the “Public Health Emergency of International Concern” for Zika virus. I heard it on the radio myself… “WHO says Zika emergency is over.” So we can all stop worrying, right? Wrong. All that WHO was doing was making a technical change – switching the status from emergency to ongoing “significant enduring public health challenge.” What they were saying is that it’s here to stay. But this is emblematic of communication problems with Zika virus – we’ve really messed up the messaging… with heartbreaking consequences. This is a much bigger problem than many people realize, and much worse than even I originally thought it would be. Initially, I thought, “OK, some fraction of infants born to moms infected during pregnancy will be microcephalic –we’ll have to see what that fraction is.” But it has become much more than that. All sorts of neurologic deficits that present later are coming to light. Infections that occurred late in pregnancy have been shown to result in normal head size at birth, yet “late stage microcephaly” occurs as the brain does not continue to grow normally as the child ages. The latest report from the CDC that I’ve seen reported on 13 infants born with congenital Zika infection but without microcephaly. All 13 showed malformations of cortical development and developed microcephaly after birth. Dysphagia, seizure disorders, visual disorders, hearing loss… all have been found so far, and no doubt other developmental and neurologic disorders are yet to be found as these children age. Given the number of pregnancies in Zika endemic areas, and the developing economies involved with a limited capacity to afford extensive care for these children, the effect of this disaster will be felt for generations. And we are not immune to this here.

What you need to know right now Pregnant women, women who may become pregnant, or their sexual partners should NOT travel to areas with Zika virus transmission. Do you know where these are? (Here’s the website to find out: https://www. cdc.gov/zika/geo/active-countries.html). They include our closest neighbor – right on our doorstep. There have been not one, but two clusters of local transmission of Zika in the state of Sonora, Mexico. So Mexico, our neighbor immediately to the south, including border towns and areas, are considered to be areas with Zika virus transmission.

January 2017 | arizonaphysician.com

Tens of thousands of our residents cross our border to the south daily. Thousands are women who may become pregnant. Hundreds are pregnant at the time. Every single one of them is now considered at risk for Zika. All of them would qualify as priorities for testing for Zika infection. Yet none of them should be in that position. Tell your female patients who are or may become pregnant not to travel to Mexico. Even to Nogales, Sonora, or other points south. When spring break comes, tell all those young people not to go to Rocky Point. This is a big deal. Children will be born who will require care for a lifetime. These are the current recommendations, as of the time of this writing:

1. Zika primarily spreads through:

a. infected mosquitos, b. having sex, (even if the person does not have symptoms) for up to 6 months after infection/exposure.

2. Zika’s best prevention strategies include:

a. Avoid unnecessary travel to areas with Zika virus transmission; refer to CDC’s map of affected countries with local spread of Zika at: https://www.cdc.gov/zika/geo/active-countries.html. b. Avoid mosquito bites by using DEET-containing insect repellent, staying inside with closed screened doors and windows, wearing long shirts and/or pants, and c. Avoid unprotected sex within 6 months of travel to an

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area with Zika virus transmission and for the duration of the pregnancy if pregnant. The Zika virus has been found to persist in semen up to 188 days after symptom onset.

3. If a patient has returned from travel to area(s) with Zika virus transmission and is of child bearing age or has symptoms:

a. Obtain a thorough travel history including specific location(s) and date(s). b. Determine if the patient was exposed to Zika using website above or calling public health (602-506-6767, Mon – Fri, 8AM-5PM; after-hours at 602-747-7111). c. Educate regarding Zika symptoms including: 80% are asymptomatic; 20% have mild symptoms: rash, fever, joint/muscle pain, red eyes, and/or headache for < 1 week. d. Everyone who has travelled to an area with Zika virus transmission should avoid mosquitoes for a minimum of 1-2 weeks after return from travel. e. All pregnant women and symptomatic men/ non-pregnant women returning from an area with Zika virus transmission are eligible for testing at the Arizona State Public Health Lab. Maricopa County Department of Public Health (MCDPH) will assist with risk assessment, testing coordination, and counseling for interpretation of results. Contact MCDPH Epidemiology at 602-506-6767, Mon – Fri, 8 a.m. – 5 p.m.; after-hours at 602-747-7111 for assistance. Testing guidelines include: i. Zika specimen testing is specific to timing of exposure after symptom onset and pregnancy status. For assistance with which test to order and which specimens to collect, call MCDPH or visit: http://www.azdhs.gov/documents/preparedness/ epidemiology-disease-control/mosquito-borne/zika/ zika-healthcare-provider-algorithms.pdf. ii. Specimen testing will be prioritized by the following: 1. Pregnant women with travel to an area with Zika virus transmission; 2. Symptomatic men and non-pregnant women with travel to an area with Zika virus transmission; 3. Individuals with travel to an area with Zika virus transmission and public health reason to test will be assessed on a case by case basis. iii. Of note, those strongly suspected by clinician to have locally transmitted Zika infection with generalized rash plus two other symptoms (fever, joint pain and/or conjunctivitis) will also be prioritized for testing by public health.

4. Guidance for management of pregnant women who have been exposed to Zika virus can be found at: https://www.cdc.gov/zika/ pregnancy/index.html. MCDPH offers updated Zika factsheets in English & Spanish to help with Zika awareness at: http://www. maricopa.gov/publichealth/Diseases/mosquito/.

How to use technology to boost the physician-patient relationship BY MARY K . PR AT T

January 2017 | arizonaphysician.com

Twine’s platform is one of a growing number of technologies that enables greater connections between doctors and their patients. These technologies allow clinicians to collect and monitor patient biometrics without the patients having to visit the doctor’s office. The technologies also analyze that data using algorithms to identify which patients are doing well and which ones aren’t. Furthermore, these technologies allow clinicians to engage with patients based on their individual results by sending out educational information and motivational material as well as supporting texts, chats and personal messages alerting patients on what they need to do next. Proponents say these technologies have shown they can deliver better patient outcomes at lower costs than traditional healthcare processes. But others caution that getting these technologies into doctors’ offices won’t be easy because multiple obstacles prevent their widespread adoption. So even though early use cases show strong results using these technologies, very few doctors have implemented them in their practices. “A lot of physicians are quite resistant to this kind of thing. Their days are already full with a lot of hard work,” says Joseph C. Kvedar, MD, vice president of Partners HealthCare Connected Health, a Boston-based organization studying technology-enabled care delivery and connected health programs. “But [these technologies] are an inevitability. We just have to get to the point where both economically and from a care workflow we have the right balance.”

Promising results

uring his residency, John Moore, MD, PhD, saw a persistent problem: Many patients diagnosed with blinding eye diseases would stop using the highly effective prescriptive eye drops that could prevent them from losing their sight. Moore knew that other doctors also had patients struggling to comply with medicine regimens and other prescribed treatments. And he says he wasn’t surprised, considering that patients typically don’t retain most of the information they get when visiting their doctors. Part of the blame, Moore says, lies with the medical system. It’s designed to offer episodic care to treat acute problems, even though today most of the country’s medical spending now goes toward treating chronic conditions. So he set out to change that. In 2007, while still a resident, Moore started writing software that enabled him to collaborate with patients on treatment plans they could print out and take home. He went on to become co-founder and CEO of Twine Health, a Cambridge, Massachusetts-based maker of a software-as-a-service platform that aims to help healthcare providers work with patients on a more collaborative and consistent basis.

ARIZONA PHYSICIAN | January 2017

Gregory R. Weidner, MD, medical director for primary care innovation and proactive health at Carolinas HealthCare System, and an internist at a Charlotte, North Carolina, medical practice, says he’s seeing positive results using such technologies. A team of clinicians – medical assistants, RNs, health coaches and others – launched a pilot program at Carolinas using the Twine platform for about 250 patients with uncontrolled hypertension. The team worked with each patient to develop a personalized plan of action; those plans generally include taking prescription medicine, getting more physical activity, and changing their diets, Weidner says. The Twine platform delivers reminders and tips to patients; collects patient data (such as blood pressure readings) that are analyzed and presented to clinicians; and allows patients and clinicians to interact through text messages and other social channels, Weidner explains. The platform lets clinicians easily see and encourage those sticking with their plans, and to track and reach out to those who aren’t. That functionality, Weidner says, “allows us to make care more continuous and collaborative. By leveraging the technology, we can actually be with them and communicate with them and see how they’re tracking against their plans.” According to Weidner, 82% of the 254 patients in the pilot had their hypertension under control within 90 days without follow-up doctor visits. Moreover, 93% of the patients reported high satisfaction with the program.

In comparison, hypertension control rates range from 30% to 55%, according to published studies, and the Centers for Disease Control and Prevention cites overall rate of 52%. Additionally, under traditional care models, a patient would usually have two to four visits over a six- to 12-month period to manage uncontrolled hypertension. Despite such results, adoption of collaborative care technologies is low, Kvedar says. “We’re in the land of early adopters for sure,” he says, noting that most adopters so far are clinicians focused in specialized areas of care, such as hypertension, diabetes, chronic pain, and mental health. Some innovative physicians are fitting Type 2 diabetes patients with activity trackers, organizing them in support groups, and starting friendly competitions to boost activity levels, he says. The trackers can transmit data back to the physicians, helping them monitor the patients’ progress. Kvedar says there are a variety of products on the market, with some coming from vendors and some being developed by healthcare systems. Carolinas, for example, developed MyCarolinas Tracker, a mobile app that allows patients to track and view their health status. It enables patients to compile health information from different locations, and it syncs information from select exercise trackers, blood pressure cuffs, glucometers, scales, heart rate monitors, pulse oximeters, and thermometers. In addition, it allows patients to add information manually, such as laboratory data. Kvedar says the available platforms often include smartphone and tablet apps and web portals. Many products can collect data seamlessly from patients’ health-related

devices, like smart blood pressure cuffs and glucometers, as well as Wi-Fi-enabled scales and activity trackers such as Fitbit. Rasu Shrestha, MD, MBA, chief innovation officer at the University of Pittsburgh Medical Center and executive vice president of UPMC Enterprises, says these technologies could restore a lot of the doctor-patient communication that was lost during the past decade as healthcare went digital. The technology, he points out, allows clinicians to be present not just for 20-minute checkups but throughout the patient’s daily life. In addition, he believes these technologies can deliver the patient empowerment needed for doctors to move away from focusing on treating the sick toward helping patients stay well. Shrestha cites a couple of examples to illustrate his point. In one case UPMC is using a mobile app from Lantern, a provider of online mental health wellness services, to deliver services such as personalized coaching to patients. In the second case, patients with congestive heart failure use a Vivify Health app to access individualized instructions after they’re discharged from the hospital. The app also collects and analyzes data, such as blood pressure readings, to provide clinicians insights on how the patients are doing. “With Vivify, we’re able to engage the patient in a much more meaningful way. Before Vivify we’d discharge a patient with congestive heart failure with instructions and there would be silence in our interaction with the patient unless the patient came back. We wouldn’t know what was going on for a given period of time,” Shrestha says.

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January 2017 | arizonaphysician.com

Challenges to overcome Despite such enthusiasm, Shrestha and other users acknowledge there are significant obstacles to widespread adoption of these technologies – particularly for medical practices that rely on a fee-for-service payment model. That’s because engagement technologies are designed to keep patients healthier and to connect patients with their doctors outside the exam room. And at this point, under traditional reimbursement models, doctors don’t get paid for that work. Richard Ricciardi, PhD, NP, director of the Agency for Healthcare Research and Quality (AHRQ) division of practice improvement, and AHRQ’s senior nursing advisor, says few providers are wholeheartedly embracing these technologies, “because they’re not integrated with electronic health records, payment models, [and] reimbursements.” But Kvedar points out that payment models are changing, and as more doctors get paid under models other than fee-for-service, they’ll see that using technologies to remotely monitor and analyze their patients’ health and encourage healthy habits will save time and money by producing better patient outcomes. “That way I’m using my brick-and-mortar resources to take care of the patients who need it the most,” he explains. Clinician concerns about adding to their already busy workload is another obstacle, say Kvedar and others. They’ll need to figure out how to incorporate these platforms into their workflows to create efficiencies rather than redundancies. Kvedar says he’s confident that will happen. He compares these technologies to email; many clinicians once viewed email as burdensome extra work, but now it has nearly replaced voicemail and added efficiencies to boot.

Making technology fit Doctors likely will find that connected care technologies fit best into practices where the workflow process includes physician extenders – coaches, patient advocates, nutritionists, and other support staff – who can take the lead in using the technologies to teach, motivate and interact with patients as well as track patient data, allowing doctors to focus their time on delivering the highly-skilled care they’ve been trained to provide. “If it’s just the doctor that’s trying to manage this continuous care delivery, then that’s a lot and it’s not leveraging their skills,” says Moore. “There’s a lot of evidence that the most cost-effective model of care would be a combination of these practice extenders so each one can [work] at the top of their practice.” David C. Rhew, MD, chief medical officer and head of healthcare and fitness for Samsung Electronics America, which offers technologies in this market, says doctors will have to adjust their mindset. “Physicians have been traditionally focused on what happened in their office,” he says, with doctors assuming that patients follow their instructions once they were sent home. But as any doctor knows, “that doesn’t always occur.”

ARIZONA PHYSICIAN | January 2017

That could explain why studies show that physicians who follow up after office visits produce better patient outcomes than those who don’t, Rhew says. In the past, such follow-up was time-consuming and costly. But these connected care technologies are designed to make follow-ups easier and enable more collaborations and communication with patients in timely cost-effective ways. “The more contact you have, the more ability to course correct or reinforce one’s behavior to help them better understand risks, the more you allow patients to become empowered, the better results you’ll get,” he says. Ricciardi, though, cautions against expecting too much from these technologies. He says they may indeed help patients stay motivated and encourage them to adopt or keep healthy habits, but the patients still must be willing to do whatever work their doctors prescribe, whether it’s adherence to their medication schedule or a nutrition plan. “I see them as a lever for management, but not a panacea,” says Ricciardi, who in his practice at a Department of Defense facility uses activity trackers as a way to help patients stay motivated and record their physical exercise. “If you want to help facilitate someone to lose weight and get some physiological data on their activity levels, yes, you could use apps that could track that information and provide a feedback loop,” he says. “But in my opinion they’re primarily there to help the patient with self-management.” Ricciardi adds: “Is this the first thing they think of in terms of self-management? No. Is it part of the tool kit? Yes.” Copyrighted 2016. Advanstar. 124845:1216DS

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Big-Hearted Doctors Provide Care Without Barriers Mission of Mercy offers medical care to Maricopa County’s uninsured BY KAREN WERNER

aria Clark suffers from a blood disorder that requires expensive care. “She has a condition called thrombocytosis, which means she has too many platelets in her blood and it makes her at risk for having a stroke,” says Charles Levison, MD. Although Clark works full-time, her job doesn’t provide health benefits. Without such coverage, the cost of the physicians, prescriptions, and labs needed to manage her condition was too expensive for her to manage on her own. “If you can’t get the medication at a reasonable price, people go without it. I had to go without it,” she says. A coworker told Clark about Mission of Mercy, a nonprofit organization that operates free primary health clinics across Maricopa County. Out of options, Clark gave it a try. “The doctor requested all kinds of labwork. I didn’t know what the charge was going to be,” she says. “I came to realize there was no cost to me.” Founded in 1991 by clinical pharmacist Gianna Talone Sullivan, PharmD., Mission of Mercy now operates six clinics in Maricopa County, with plans to open three more clinics in the East Valley over the next three to five years. An independent, faith-based organization, Mission of Mercy offers a range of services for patients, from physician services to diagnostics and prescriptions – all free of charge. The organization’s mobile clinics operate five days a week, rotating between four churches, schools, and a community center. In 2016, Mission of Mercy will provide more than 16,000 free doctor visits and dispense over 20,000 no-cost prescriptions to hardworking individuals and families. “The people we see are not lazy. The people we see are in trouble,” says Ira Ehrlich, MD, a retired cardiologist who

volunteers with the organization. “They’re trying their best in a tough situation and we’re trying our best to help them.” In Maricopa County, roughly 20 percent of the population is uninsured, so the need for Mission of Mercy is great. So much so that patients carpool, bike, and take buses to the clinics. One patient even got up at 5:30 a.m. recently to walk from Tempe to the clinic in Mesa, along with her 5-year-old granddaughter. When patients arrive at Mission of Mercy, they receive holistic, compassionate care. The organization’s mission is to restore dignity and “healing through love” by bringing volunteer doctors, nurses, and bilingual interpreters to the people, providing a medical home for thousands of patients who would otherwise have nowhere to go. Roselynde Bryant, NMD, assistant medical director of Mission of Mercy, recalls visiting the Mesa clinic for the first time as a medical student. “When I walked into the clinic, there was a buzz about it. From the front desk workers checking people in, to the interpreters, to the volunteer doctors, everyone had smiles on their faces – even the patients had smiles on their faces,” she says. “I thought whatever I can do to help Mission of Mercy, I will be willing to do.” Mission of Mercy is privately funded and provides healthcare without pre-qualifications. Patients don’t have to prove poverty, residency, and there are no other embarrassing inquiries, sliding-scale payment expectations, or out-of-pocket costs. In short, there’s no red tape, something the volunteer doctors also appreciate. “I’m no longer told by an insurance company what I can do for a patient,” Dr. Ehrlich says. “At Mission of Mercy, I can take all the time that I want. I think the patient leaves January 2017 | arizonaphysician.com

TOP: Assistant medical director Dr. Roselynde Bryant chats with a patient. MIDDLE: Mission of Mercy volunteer physician Dr. Charles Levison works with a patient and her child, while a volunteer interpreter explains the medication to her. BOTTOM: A volunteer nurse takes a patient’s blood pressure, with a view of a busy clinic in the background. The model is successful because there are no walls or rooms; triage is done at tables in church halls, community centers, and school buildings. 20

ARIZONA PHYSICIAN | January 2017

with the feeling that they’ve actually seen a doctor and have been listened to.” Patients who visit the clinics come in with the same types of conditions typically seen in a primary care physician’s office. “High blood pressure, thyroid disorders, diabetes, colds, flus, sometimes mental and emotional cases,” Dr. Bryant says. About half suffer from chronic conditions that require ongoing treatment. One such patient is Bertha Morales, a native of Guatemala. Morales is a housekeeper who doesn’t make much money, so Mission of Mercy was the only place she could turn for medical help. “I was looking for help because I wasn’t feeling healthy,” she says. Initially nervous about coming to the clinic, she found the doctors very friendly. They diagnosed her with scleroderma and treated her condition while caring for her as a person as well. “I am very thankful because they care about me, and they take their time with me. I thank God for the work they are doing and for the help I have received.” Although Mission of Mercy is a faith-based organization, it does not proselytize and the doctors and other volunteers are themselves of many faiths. “Our mission statement is restoring dignity to the poor and healing through love. We don’t take that lightly,” says Brad Smith, NMD, Mission of Mercy’s medical director. One example of this love took place on a recent morning. A volunteer doctor did an EKG on a patient and discovered he had a low pulse rate. “He had ridden a bike from about four miles away and the doctor asked if there was a way to get him home,” Dr. Smith says. “We could have called a taxi, but I have a truck. So I threw his bike in the back of my truck and took him home because I think that’s a way of showing love.” Incidents like this happen every day a Mission of Mercy clinic is open. That’s why Valley churches happily offer space so the clinics can serve the uninsured. “For our church, working with Mission of Mercy is a very natural partnership,” says Pastor Jack Marslender of First Southern Baptist Church in Avondale. “This is not just a clinic. These are their doctors. They are people they know. It’s where they turn when they have a need.” This is all thanks to the doctors, nurses, and other volunteers who provided more than 17,000 pro bono hours to Mission of Mercy last year. “We bring a lot of years of experience and good, sound clinical judgment,” says volunteer physician Paul Petelin, MD. “In return for that, we get the gratification and the satisfaction of treating patients.” Doctors are able to check patients’ blood sugar, do urinalyses, and offer pregnancy tests at Mission of Mercy clinics. They can also perform EKGs on the 43-foot van, which is also equipped with patient beds and a small pharmacy. Sonora Quest donates all labwork, so doctors can properly manage disorders and illnesses and also use those results as a teaching point so patients can become active participants in their own care. “Mission of Mercy is a magical place where miracles happen,” says Lisa Glow, Mission of Mercy Vice President and Director of Development. This is true for both the volunteers and the patients.

Mission of Mercy currently has two mobile units that drive out to six clinic sites in the Valley. Each unit houses an EKG machine, private exam rooms, and more than 200 generic prescription medications.

Dr. Ehrlich finds that volunteering at Mission of Mercy offers him a connection to the field he practiced for 42 years. “When I retired, it was apparent to me that I was not done practicing medicine,” he says. “I receive zero monetary compensation at Mission of Mercy, but I receive a great deal of compensation in terms of the good feeling I get being there.” As for the patients, there are countless stories of lives forever changed, whether it be a woman who was diagnosed with stomach cancer and received free surgery, or the young girl who was treated for hypothyroidism while waiting for her father’s insurance to start at his new job, or Maria Clark, whose thrombocytosis is now under control. “It’s been a blessing all the way around,” she says. “I’m so grateful to Mission of Mercy.”

How you can help Mission of Mercy is always looking for dedicated volunteer healthcare professionals as well as volunteer greeters, interpreters, and registration staff. For information about volunteer opportunities, call 602-861-2233 or write Paula Carvalho at pcarvalho@amissionofmercy.org.

Donate to Mission of Mercy at no cost to you through the Arizona Charitable Tax Credit – and Legacy Connection will double your donation! Mission of Mercy is headquartered at Legacy Place, a unique center in downtown Phoenix that houses nonprofits dedicated to improving the quality of life in our community. Legacy Place is owned and operated by BHHS Legacy Foundation, a nonprofit that helps other community organizations improve the health and quality of life of citizens in need.

BHHS Legacy Foundation and Legacy Connection are affiliated 501(c)(3) nonprofit public charities. The two organizations have teamed up to double the donations going to select programs – including Mission of Mercy – so public donations can go twice as far to help Arizona families. Plus, when you give to Legacy Connection, you can take advantage of the Arizona Charitable Tax Credit. A $400 contribution to Legacy Connection if single or $800 if filing a joint return means decreasing your Arizona tax bill – or increasing your refund – by $400 or $800. Your gift ends up costing you nothing! And your donation – plus BHHS Legacy Foundation’s matching funds – will benefit the programs Legacy serves. To donate to Mission of Mercy, go to bhhslegacy.org/ donate-now, choose ‘Other Health-Related Agencies,’ and select “Mission of Mercy” from the drop-down. You can also write a check to “Mission of Mercy Legacy Connection” and mail it to: Legacy Connection, 360 E. Coronado Road, Ste. 100, Phoenix, AZ 85004. BHHS Legacy Foundation will then match your donation dollar for dollar, and all of the money will go directly to providing care to some of Arizona’s most vulnerable people. Have a question? Call BHHS Legacy Foundation at 602-778-1200. Karen Werner is a writer, editor, and media consultant. She has interned at The New Yorker, worked at Parents Magazine, founded several local magazines, and edited three books for the Musical Instrument Museum. She has written for local and national publications including Sunset, Mental Floss, and the Saturday Evening Post.

January 2017 | arizonaphysician.com

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ARIZONA PHYSICIAN | January 2017

Improving Outcomes: A N IN T ER V IE W WI T H

Bernard R. Bendok, MD BY DOMINIQUE PERKINS

echnology has become so fully entrenched in our lives that one might wonder why we are still talking about its presence as if it is a debate. Some argue that it is here, it is here to stay, and the only choices we have are to keep up or be left behind. But, while it is certainly true that technology as a whole is here to stay, we still have a responsibility to ensure that we are using it in the best way possible. After all, what is the advantage of living in an era of such incredible technological advances and discoveries if we donâ€™t use them to make our lives more efficient, productive, and enjoyable? And, rise of-the-machine jokes aside, it is sometimes difficult to tell whether we are putting technology to work for us, or the other way around. Dr. Bernard Bendok uses some of the most interesting medical technologies in the field, things that seem to come

straight from a futuristic space series. And he is no stranger to the struggle of preventing new tech from becoming a distraction rather than a tool.

Beginnings When Bendok was in high school, he attended a lecture on the pituitary gland that left him incredulous, and fascinated with human physiology. However, while it was this experience that led him to medical science, Bendok said the true seeds of his motivation were planted even earlier. â€œThe foundations of seeking a career in healthcare were planted in me by two loving parents who cherished books above shiny possessions and espoused empathy towards others above self-interest,â€? he said. While attending Wayne State University for his undergraduate degree, Bendok worked in a cutting-edge January 2017 | arizonaphysician.com

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cancer genetics laboratory and did volunteer work with pediatric cancer patients. “These experiences cemented in me the passion to combine science and helping people with daunting problems,” he said. After graduating, he went to Medical School at Northwestern University in Chicago, and chose to specialize in neurological surgery. He completed his internship and residency at the McGaw Medical Center of Northwestern University, and a fellowship at the State University of Buffalo in New York. “I decided that I wanted to be a small part of a great ongoing revolution in therapeutics and technology that would move brain care from nihilism to giving people new birthdays, and new opportunities for improved quality of life,” he said. Bendok met many mentors along the way who influenced his choice of specialty, and the rest of his career. Bendok said he was fortunate in working with Dr. David McLone, an internationally recognized pioneer in Spina Bifida and other congenital disorders, with Dr. Hunt Batjer, an internationally acclaimed vascular and skull base neurosurgeon, and Dr. Nick Hopkins, a pioneer in the endovascular treatment of neurosurgical issues. These mentors also helped shape his views on the role of technology in healthcare. Bendok said of Batjer, “He was skeptical of technologies that did not add meaningful benefit to patient care but he also embraced innovations that made a difference. He had an uncanny ability to understand the implications of technology.”

Science fiction In 2014, Bendok was recruited to chair the Department of Neurosurgery for Mayo Clinic in Arizona. His practice focuses on the microsurgical, endovascular, endoscopic, and radiosurgical treatment of neurovascular and skull base diseases as well as brain tumors. In his journey with Mayo, Bendok has had the opportunity to see some incredible technological introductions. They’ve opened the Precision Neurotherapeutics Laboratory, which uses simulation science to make neurosurgical treatments safer, less invasive and more effective. Bendok said he has a strong interest in integrating new technologies with minimally invasive approaches. “Our goal in the Precision Neurotherapeutics is to ‘do the operation before the operation,’” he said. Using simulation science, 3D printing, mathematical modeling, augmented reality and holography, they are able to map out the surgery in advance and find the best strategies. “We are seeing amazing breakthroughs in our ability to deliver new life for patients who would have otherwise died or been severely disabled only several years ago,” he said of the many new techniques and devices in use today. Indeed, Bendok describes augmented reality used in current surgical suites as something that would have been considered complete science fiction just a decade ago. And the possibilities are just growing more and more fantastic.

“Endoscopic and endovascular devices have raised the bar for what can be done through minimally invasive approaches,” he said. “Brain computer interfaces are on the horizon and will transform rehabilitation and offer exceptional function to those who have been disabled and likely enhance function for those who need it. Tissue engineering is also on the horizon and will likely usher in a renaissance in the treatment of stroke and neuro degenerative diseases.”

The social factor As we see a dramatic increase in the popularity of wearable devices moving forward, the implications in the accessibility of patient information and delivery of care are certainly interesting. Bendok said the general concept of physicians reaching judgements in the traditional way – through the typical history and physical and short interactions in the office – has become inadequate to manage complex neurosurgical diseases. “In the area of back pain, for example, physical activity and the nature of that activity is very important in determining surgical thresholds and meaningful quality of life outcomes,” he said. The opportunity for physicians to monitor various aspects of the nervous system to help guide and individualize treatments is very interesting, and something Bendok said they are actively pursuing at Mayo. Social media is another popular life tool that has many implications for healthcare use. And, since it certainly doesn’t appear to be going anywhere any time soon, Bendok said he feels physicians should look for healthy ways to engage on social media by partnering with their healthcare organizations.

“The educational potential of this medium is staggering,” he said. “No other medium could reach those with rare diseases in such an effective way.”

A tool, and an obstacle Bendok describes technology as a tool, much like an artist’s brush. And, while it has the potential to improve outcomes when used strategically, it does not replace the innovation, attention, and care that a physician holds. “Technology does not guarantee better patient care any more than a paint brush can guarantee a work of art,” he said. Despite the great advantages it poses, Bendok also said technology poses some threats to healthcare; two major ones in his opinion. First, the dehumanizing of the doctor-patient relationship, and also the relationship between doctors and their healthcare team. This threat comes largely from electronic medical records (EMR). “In my opinion the screen is part of the problem,” Bendok said. “Humans are not wired to socialize via screens. We are wired to gather around a camp fire and share stories.” This is not to say there is no benefit to an EMR. Bendok agrees that a safe, integrated medical record crossing the medical “borders” has the potential to save a great deal of time and effort. “Patients should not have to reinvent the wheel every time they see a new doctor,” he said, adding that patients suffer from this sort of fragmented care. While the current use of EMRs may have made healthcare less personal, Bendok believes this is a detour that can be corrected given the right changes and advancements. Holography, in particular, he feels has the power to change

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the way we interact with EMRs, making the patient a dynamic partner in the process, and allowing doctor and patient to work together more seamlessly. “In my opinion the screens have to go unless they become shared screens or, ideally, holograms,” he said. “I always wished Steve Jobs had designed an [EMR] before he died.” The second threat Bendok sees is the ease of access to medical information, which he said may sound a bit counterintuitive at first. However, with so much information available it can be easy to get overwhelmed with surfacelevel data – and the discipline required to search for a deeper understanding could be abandoned. “Why pull source materials when “Wikipedia” has the bare bones of what you need to know?” Bendok said.

“The key in my opinion is for us as physicians and surgeons to hold on to the fundamental values and principles of healthcare,” he said. As far as technology can take us, the expertise, judgement, and discernment of the physician still reigns. A Star Wars future where robots rule healthcare delivery will remain science fiction, as no technology can replace the passion and caring that drives our physicians, or the trusted relationship that should exist between doctor and patient. “It is critical that we insist that our technologies be used in ways that enhance our humanity and not diminish it,” Bendok said. “If a technology makes us less compassionate it should be altered or discarded.” “Patients will know the difference!”

The artist’s brush Some have argued that technology takes some of the skill out of the physician’s hands, and, as robotics and other innovations take a stronger hold, it’s easy to see how that could be so. Bendok drew the parallel once again to an artist’s brush. As computers have advanced, in many cases the artist’s brush has now become the artist’s computer algorithm. And while it has been argued that computer animation and other tools like it have made classical painting less relevant, Bendok points out that new generations of artists are finding ways to integrate computing with classical art forms to form something entirely new, current, and undeniably beautiful.

Dr. Bendock’s family LEFT TO RIGHT: wife Karen, family dog Coco, daughter Sarah, and son Michael.

ARIZONA PHYSICIAN | January 2017

DOMINIQUE PERKINS Dominique is the Associate Managing Editor for Arizona Physician and serves as the Communications Coordinator for the Maricopa County Medical Society.

On the personal side.. 1. Describe yourself in one word.

Love (love of life, my family, my patients and people).

2. What is your favorite food, and favorite restaurant in the Valley?

Italian. Favorite restaurant is Casa Mia. It’s a family owned Italian restaurant where you feel generations of grandma’s love, heritage and artistry passed down.

3. What career would you be doing if you weren’t a physician?

A chef. Being a chef requires technical skill but it has to be combined with artistic and cultural dimensions with a focus on giving people meaning and happiness (just like a surgeon!).

4. What’s a hidden talent that you have that most wouldn’t know about you?

I can make pasta from scratch! (Ok, it’s not the best pasta but with the right sauce and wine I think it would make most people happy).

5. Best movie you’ve seen in the last ten years? Gladiator.

6. Favorite Arizona sports team (college or pro)? The Cardinals.

7. Favorite activity outside of medicine?

Traveling with my family, exploring new cities and biking.

8. Family?

I am blessed by a remarkable wife Karen and my two amazing children: Michael, 13, and Sarah, 8. They give me the joy and emotional energy to keep helping my patients. January 2017 | arizonaphysician.com

ARIZONA PHYSICIAN | January 2017

“[The] humanistic element of doctor/patient relationship has failed to keep up with technological advances in all aspects of medicine.” James H. Reifschneider, MD

BY SHARLA HOOPER

9.7%

arlier this month, our organizations surveyed members on the topic of technology in medicine. Technology has permeated our modern lives completely, and is seen as both an innovative asset and an encroachment in medicine. The survey allowed us to look at opinions on a broad range of technology aspects in medicine. Several respondents specifically cited the burdensome cost of electronic medical records (EMR), as well as concerns about how EMR has impacted the doctor-patient relationship. The alphabet soup of federal requirements and measures have generated concern about the impact on patient care as well as individual physician burnout. According to Dr. Mark Friedman, “EHR and CMS have horribly abused and misused the potential role of technology in the delivery and documentation of health care. We now spend most of our time complying with statistical nonsense, whether on paper or on screen.” Another physician pointed out the inefficiencies in time spent on EMR charting: “I feel that “inputting” data into the EMR has increased time spent with data entry. Surely there’s a better way.” A recent analysis of physician time found that for every one hour of patient care, physicians spend almost two hours with EMR documentation and other desk work. The respondents’ comments reflect the frustration with this status quo. “I think it is ridiculous that for every hour spent with a patient, two hours are spent in the EHR. Physicans need to be liberated from the mountain of documentation demands/clicks so we can care for patients,” stated Dr. Kevin Moynahan. Of our respondents, 43.1% feel that using an EMR has eroded their relationships with patients; 13.7 % feel it has enhanced their relationships. Asked to identify whether EMR has an impact on the care physicians deliver, 33.3% feel it has impaired care, while 31.3% feel it has improved care. Dr. John Boyer shared that “electronic record keeping… during interviews with patients has cooled what once was the best part of the Doctor-patient relationship.” And patients share their frustrations as well, as Dr. Dennis Cooper describes: “Patients complain the physician is so busy keeping the computer happy that they don’t make eye contact. They also state physicians are so over extended that they hardly ever see the physicians and are relegated to mid-level staff instead.” Asking about the impact of technology on patient ‘self-diagnosis’ (i.e. checking WebMD) revealed aspects of how different physicians manage this issue in their practice. While 25.7% of respondents found that patients’ online research “has improved my ability to practice, as my patients are more informed of their condition and treatment options,” another 28.7% of respondents found it more difficult. Self-diagnosis can lead to unnecessary testing, and direct to consumer advertising was cited as pervasive and problematic. Dr. William Nevin: “Patients have sought advice from incorrect web sites leading to requests for inappropriate investigations. Adverse outcomes have been avoided via counseling and redirection. The direct to [consumer] advertising of drugs has led to inappropriately increased

Significantly positive

35.9% 9.7% 14.6%

Slightly positive None at all

Significantly positive

30.1% Significantly negative

24.5%

Don’t use EMR

4.9% Not sure

13.7% Enhanced

13.7%

43.1%

No impact

Eroded

How has using an EMR impacted the care you deliver?

31.3% 33.3% 20.2% 15.2%

Improved the care I deliver Impaired the care I deliver No impact Not sure

January 2017 | arizonaphysician.com

25.7%

28.7%

Improved my ability to practice

More difficult to practice

32.7%

12.9%

No impact

Not sure

31.7%

Patients more enthusiastic about technology’s role

15.8%

Patients less enthusiastic about technology’s role

40.6%

11.9% Not sure

We have an equal view of technology’s role

Yes

costs with no improvement in outcome. The drug manufacturers are more skilled at advising patients through TV than I am at suggesting that the new stuff is definitely more expensive but probably not more dangerous…” Dr. Julie Wendt: “In medical school, before training, physicians actually saw real patients and developed a sense of normal v. abnormal; there was a phenomenon in which many students, after reading accounts of various disease states, thought they had them. That is, until they saw what abnormal really looked like. I see the same situation occurring with patients, they read or are told about an issue and feel they have it. If I didn’t test… it would erode our relationship. When I do, it makes medicine more costly. For these and other reasons, I truly feel direct to consumer advertising should be abolished.” Patient research can lead to helpful discussions in some cases. Dr. Robert Brown: “The use of online forums, especially for specific diseases, has allowed greater understanding of management by the patient but has also caused confusion as to why treatment differs from patient to patient. Addressing the use of these forums and creating better education for the patients will be necessary in this world of increased online resources.” Dr. Rex Ragsdale: “I welcome patients investigating health information on the web. Ironically, because much of it is incorrect, it gives me an opportunity to address the issues they raise and improve the increased impact of the discussion.” The survey reflects both insights and the limitations of gathering opinions on the multivalent impact of technology in the practice of medicine. As one respondent pointed out, to “pretty much every question in this survey… the real answer is almost always ‘it depends.’” Physicians overwhelming responded that increased technology should NOT be made available directly to patients without physician determination or referral. One physician clarified this position; “if they order tests and they are abnormal I cannot be responsible for monitoring. I hope that is clear in the law. I do not see this as a technology issue – but a patient being able to get lab work done issue.” The law referred to specifically is HB2645, and one of the features of the law that organized medicine was able to secure was removing liability burden from the physician, who would have no way to know of a patient’s self-referred lab test.

11.9%

66.3% Not Sure

19.8%

ARIZONA PHYSICIAN | January 2017

SHARLA HOOPER Sharla is the Managing Editor for Arizona Physician and serves as Associate Vice President of Communications and Accreditation for the Arizona Medical Association.

Achieving Healthcare Without Walls

o date, telemedicine has been a strong and popular force in the improvement of health care services across multiple settings. According to the U. S. Census Bureau, currently in the state of Arizona the elderly population is approximately 1.5 million. For many years, Medicare-funded telehealth has been exclusively for patients living in rural areas in Health Provider Shortage Areas. However, the majority of the Medicare population lives in urban areas, which leaves many beneficiaries unable to take full, advantage of the telehealth benefit. As an innovative healthcare company that appreciates the values of the telehealth technology reimbursable for Medicare patients in both rural and metro areas via next-generation Affordable

Care Organizationâ€™s (ACO) model, MD24 House Call has created a telemedicine application, DirectDocDial, which helps provide the service to high-risk homebound patients (HRHB) and all other Medicare patients throughout Arizona. This is the latest addition to their list of medical innovations â€“ the effective solution that bridges the gap between convenience and quality care for all Medicare patients and independent physicians. DirectDocDial is where medicine meets technology to connect patients with a network of primary care physicians and multiple medical specialists 24/7. This enables any small practice to become extremely scalable through the Healthcare Without Walls model.

January 2017 | arizonaphysician.com

The focus is to encourage physicians through the utilization of telemedicine to face the challenges of accomplishing their goals in the Healthcare Without Walls environment.

DirectDocDial is one of MD24 House Call’s ambitious innovations, which brings the enhanced medical experience to the HRHB and all Medicare patients through independent physicians, with available reimbursement in both rural and metro areas via Next Generation ACO. Running on both Android and iOS platforms, DirectDocDial offers high quality video interactions with providers for quick and satisfactory resolutions of patient health concerns. Additional assistance after completed calls is available with the 24/7 Medical Staff Call Center. All patient health information is synced with both the State Health Information Exchange and peripheral iHealth software for wireless vital signs (i.e. bluetooth blood pressure cuff, oxygen, etc.) to promote immediate access to secured patient health information with convenience to enable physicians to provide quality care. DirectDocDial technology offers all independent physicians better, faster telehealth solutions with no up-front costs for both reimbursable Medicare part B and cash paid solutions.

How DirectDocDial benefits physicians with quality, flexibility, and high reimbursement While MD24 House Call’s mission is Patients’ Values First,™ DirectDocDial wants to develop an effective network of quality independent physicians and healthcare engineers who will bring the highest quality of care and values to our patients via innovative approaches. With DirectDocDial and its unique features designed around the reimbursement from Next Generation ACO and State Bill SB1363, physicians can quickly identify and 32

ARIZONA PHYSICIAN | January 2017

see more patients beyond their traditional office practice hours. Physicians receive real-time access to healthcare information and online support, especially with the MD24 House Call’s extensive healthcare network, without any set-up fees and recurring monthly charges. This comes with lowered back office costs and expanded earning opportunities. Clinicians also receive education on two reimbursements: Next Generation ACO enabling the reimbursement for Medicare patients, 2017 and AZ State Bill SB1363 requiring reimbursement from all private payers throughout Arizona in 2018. Customizable technologies make it easier for networks of physicians to integrate a telemedicine approach with their existing patients. Different telemedicine applications are tailored according to physician requests and lets them put their own brands on the application with minimal fees for application design and IT support. The focus is to encourage physicians through the utilization of telemedicine to face the challenges of accomplishing their goals in the Healthcare Without Walls environment.

Potential application of DirectDocDial in chronic care management, transitional care management, and population health With DirectDocDial, MD24 House Call has moved the application to the next level of the Physician Clinical Decision Support System platform (patent-pending) for chronic diseases with focus on transitional care management and bundled payment for three models: post discharge, three days Skilled

Nursing Facility waivers, and telehealth throughout metro and rural areas. MD24 House Call offers fully equipped medical offices and outpatient surgical center spaces for any medical groups to unite with them via timeshares allowable by the Medicare Guideline, January 2016. With the available resources, the goal is to allow physicians to thoroughly address common chronic conditions in any setting, place, and time.

MD24 House Call’s vision of a physician-led population health model via healthcare information technologies owned by integrated independent physicians The idea of developing DirectDocDial came to MD24 House Call’s founder and CEO, Dr. Linh Nguyen, when he was a doctor in the US Air Force, treating Traumatic Brain Injury in soldiers injured by improvised explosive devices at Landstuhl Regional Medical Center, Germany. There he observed physician specialists providing consults to wounded soldiers via telemedicine. He had the vision for using telemedicine via Smart Phone, iWatch, Google Glass, and other wearable devices for healthcare. Dr. Nguyen realized the incredible value of telemedicine for High-Risk Home-Bound patients in reducing costs for unnecessary hospitalizations, readmissions, emergency room visits, and over-utilized tests. When friends and colleagues thought his vision was crazy, he did not give up, regardless of many obstacles during the journey.

To him, the journey to achieve Healthcare Without Walls is a worthy one, which can only be accomplished with the Patients’ Values First,™ through leveraging wearable technologies for telehealth and other innovative technologies, durable medical equipment and pharmacy deliveries by drones, labs anywhere via Uber-like app, and future genomic therapy. MD24 House Call has an open-door policy to share not only knowledge but also collaborative resources. Visit www. md24housecall.com, or www.directdocdial.com. Email contact@md24housecall.com for partnering information with MCMS, network referal code MCMSHC.

HEALING HANDS. BIG HEARTS.

Big Thanks.

Blue Cross Blue Shield of Arizona values the contributions and efforts of Arizona physicians in caring for our members.

January 2017 | arizonaphysician.com

Protect Your New Product Idea in the Early Stages BY DANIEL J. NOBLITT

ARIZONA PHYSICIAN | January 2017

any medical discoveries and inventions are not developed by big medical suppliers, but instead spring from the minds of doctors that don their white coats and see patients every day. Most of these advancements are not giant breakthroughs like insulin or x-rays. But useful tools and systems that improve medical treatments frequently succeed and bring tidy profits to their inventors. And every now and then, a doctor comes up with that idea that changes everything in the field. The early conception and development stages are crucial for a new product. How can the project develop while protecting the idea from those who would copy or just plain steal the idea? Research, common sense, and a little practical paranoia will help you get from concept to product.

Concept stage: keep it secret Your first line of protection is the simplest: keep the idea secret, especially in the early stages when researching the idea’s viability, market, and competition. Silence simply and reliably protects ideas. Bad guys can’t steal what they can’t find or even know about. This might seem obvious, but too often, inventors give away important information too early. The temptation to run the idea by friends and colleagues can easily lead to unintended consequences. Disclosing information means losing control, and the information can go unwelcome directions. At best, you can never be sure whether your medical company sales rep, colleague, neighbor, or brother-in-law has mentioned your idea to someone else. At worst, someone downstream may use or even claim credit for the idea. Reasonable exercise of pragmatic paranoia can avert obstacles down the road. Further, premature disclosure of the invention can destroy your ability to get a patent. United States law requires inventors to file a patent application within one year of either the first public use or first offer for sale of the invention. Failure to file within the one year results in absolute forfeiture of patent rights. Most foreign countries are even less forgiving, such that no patent application will issue unless a patent application is filed before public disclosure of the invention.

Check your employment relationship If you are an employee or otherwise contractually bound, check your contract for intellectual property provisions. Employment agreements often require inventors to hand over their inventions to the employer, or at least grant them a right of first refusal. This is especially common in larger institutions, such as academic environments and hospitals.

Use a good confidentiality agreement The time will come, of course, when you must disclose the invention to third parties, whether to potential customers, developers, consultants, or suppliers. The key is to do so intelligently. First, choose your partners wisely. If you don’t trust the potential partner, find a different partner.

Second, do not disclose more than is necessary. A potential component supplier doesn’t need to know why you want the component. Only disclose your idea on a “need to know” basis. And before you disclose any information, have the recipient sign a confidentiality agreement, also called a nondisclosure agreement or NDA. NDAs typically have several terms, but most importantly, they prohibit the recipient from disclosing or using the information without the disclosing party’s authorization. Any intellectual property or business attorney can set you up with an NDA. If you are in a hurry or just averse to lawyers, many NDAs are available on the Internet. Be careful, though. The wrong NDA can cause more harm than help. Some favor the disclosing party, while others favor the receiving party. Some may be too complex for your needs, others will be too simple. Some are just poorly written. When selecting an NDA, look for a broad, simple definition of the confidential information. For example, you might define “confidential information” as any disclosed information that is not generally known or available to the public. Avoid definitions that require you to mark information as “confidential,” follow up oral discussions with a written summary, or allow confidentiality to expire within a certain amount of time. These terms potentially allow valuable confidential information to slip away from coverage. Obviously, the NDA should have strong confidentiality provisions, including prohibiting any disclosure or use of the confidential information without your authorization, and requiring the recipient to restrict access to employees with a “need to know.” Further, the NDA should automatically transfer to you any technology derived from your confidential information. This deters claims that the recipient added new information and ideas to your concept and should therefore share in the rewards.

Get protection during development At some point you will want to enlist the help of a third party, such as an engineer, manufacturer, designer, software developer, or website designer. Use a development agreement to define the work to be done, the schedule, and the payment terms. Make sure the agreement also transfers ownership of any intellectual property developed by the third party to you. Otherwise, you may find that rights in your new product are owned by the person you hired. The general rule is that intellectual property is owned by the one who develops it, even if the developer is paid to do so. To avoid any confusion, the development agreement should specify that the hired party relinquishes to you all rights in any technology, inventions, software, copyrights, and any other information or intellectual property developed in conjunction with your project. In some cases, the hired party might object because the project will use pre-existing technology or technology acquired from another source. Consequently, the technology cannot be properly transferred. Avoid this issue by getting a full and perpetual license to use the relevant technology without further payment. January 2017 | arizonaphysician.com

Patent applications: file early, file often For many technologies, patents offer the only effective long-term protection. A patent attorney can help you determine whether to pursue patent protection and prepare the application. You can technically do this yourself, but the process is complex and unforgiving. Industry does not pay royalties for patents that can be easily avoided or invalidated; cutting corners on the patent process can ultimately cripple the whole project. Getting a patent requires filing a conventional patent application, but many inventors elect to begin with filing a provisional patent application. A provisional patent application cannot mature into a patent; it must be followed by a conventional nonprovisional patent application within one year to get any benefit. But provisional patent applications lend themselves to relatively fast and inexpensive preparation, so they are useful for early stage ideas that are not fully developed and ready for market. You might also want a professional patentability search. You should conduct preliminary searches online yourself, such as using conventional search engines and the Patent and Trademark Office resources at www.uspto.gov. But a professional search, while not required, can yield results similar to those of a patent examiner, and can therefore provide a clearer picture of the invention’s ultimate patentability. And perhaps most importantly, remember that you will lose your patent rights if you wait too long. As noted above, you forfeit your patent rights if you wait more than

one year from the first offer for sale or first public use of the invention (whichever occurs first) to file a patent application. Law books are filled with cases about whether an inventor waited too long after an alleged “offer for sale” or “public use.” You don’t want your name on one of those cases, so file patent applications as early as possible, and file updates when merited.

Be careful and prosper The early stages of a new product can be complicated, and you should exercise caution to maintain the idea’s value and keep control. But reasonable precautions, good contracts, and timely patent applications can guide you through the obstacles to your rightful place on the leader board with Pasteur, Edison, and Jobs.

DANIEL J. NOBLITT

Dan concentrates his practice in intellectual property law and technology-related issues. His practice involves acquiring and managing patents, trademarks, copyrights, and trade secrets, and advising clients and other lawyers about protecting rights in technology, ideas, and brands.

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ARIZONA PHYSICIAN | January 2017

Time for payment models to stop discriminating against in-home care

B Y S T E PH E N S C H I M PF F, M D

January 2017 | arizonaphysician.com

chance for errors and infections can go down, and the costs of care can decline substantially. The critical question, of course, is whether the clinical outcomes are just as good, or possibly even better. Enter an innovative and exceptionally transformational approach. Think of it perhaps as a virtual hospital that maximizes the capacity to use today’s digital technology. Embryonic at best in the United States, there are multiple examples worldwide as recently reviewed in the New England Journal of Medicine.1 The basic idea is to follow emergency room evaluation (or even doctor’s office evaluation) with the decision to admit to the hospital or to use hospital at home care. Not all patient conditions are appropriate for home care of course, but among those that are often appropriate: exacerbation of heart failure and chronic obstructive pulmonary disease, community-acquired pneumonia, asthmatic attacks, deep vein thrombosis, and possibly pulmonary embolus and deep-seated skin or soft tissue infections. One study compared 50 patients treated at home for a 34-day period to a similar group treated in the hospital after initial evaluation in the emergency room or observation unit. At the conclusion of the study period, the at-home patients had greater satisfaction with multiple query categories and met standard quality measures for their specific diagnoses. Those patients were less likely to need readmission over the ensuing ninety days.2

Keys to success

merican healthcare delivery is seriously dysfunctional. It takes patients about three weeks to get a doctor’s appointment, they sit in the waiting room for a long time, get 10 to 12 minutes with the doctor, and then have a hefty deductible and/or copay despite already paying handsomely for insurance. American medicine costs about three times per capita more than most other developed countries, yet outcomes are no better, patient satisfaction is low and burnout among physicians is high. Hospitalization is very expensive, the risk of a medical error is real, hospital-acquired infections are all too common and the patient frequently leaves feeling unsatisfied. But do all those individuals admitted necessarily need hospitalization? Today the answer is generally yes. But tomorrow, that could, and probably will change, for the better. What if many of the attributes of the hospital could be brought to the home? Attributes like nursing care, electronic monitoring of vital signs and intravenous therapy, to name just a few. There is really no reason why the home cannot serve this purpose for some selected patients today. When it does, the patient remains in familiar, comforting surroundings, the

ARIZONA PHYSICIAN | January 2017

Some keys to success include effective two-way digital communication systems that allow for virtual physician and nurse visits in a HIPAA secure setting along with remote virtual biometric monitoring. Proper patient selection is important, as those who might need more intensive diagnostics (e.g., MRI) or therapeutics (e.g., surgery) are inappropriate candidates. It is also important that the work traditionally done by hospital personnel not be offloaded to the family members; this will defeat the purpose and lead to ill-will. Maintaining contact virtually and with home visits for a prolonged period after the immediate acute episode will likely improve the care transition and lead to fewer readmissions. With positive results nationally and internationally, why hasn’t the hospital-at-home model become commonplace? I suspect it has multiple causes, not least of which is physician concern. Medical professionals are loath to make dramatic changes when the current system works, or at least works reasonably well for most episodes. Add in, of course, that the fee-for-service reimbursement model for physicians and hospitals discourages interest. Only when the physician can be paid for virtual/digital care approaches and the hospital benefits financially from fewer admissions will real interest develop. Innovative? Certainly. Transformative? Definitely. Makes sense from a quality of care perspective? Yes. Leads to greater patient satisfaction? Yes. Means fewer safety lapses and care associated infections? Perhaps. Reduces unplanned

remission rates? Probably. Costs less? Yes.

ACCURATE, ON-TIME RECORDS SINCE 2000

Time to make a start In sum, the time is right for implementation in those settings where payment models do not discriminate against in-home care models. Logical places to start would be Medicare Advantage plans, military or veterans’ plans and other entities that hold total fiscal and care risk. Home hospitalization could be one step in improving the American dysfunctional healthcare delivery system with improved care, greater satisfaction and reduced costs – the Triple Aim.

Medical Dictation to Electronic Medical Records

Stephen C. Schimpff, MD, is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, scientific advisor to Sanovas, senior advisor to Sage Growth Partners and is the author of Fixing the Primary Care Crisis: Reclaiming Relationship Medicine and Returning Healthcare Decisions To You And Your Doctor.

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Copyrighted 2016. Advanstar. 124844:1216DS References 1. Ticona, L and Schulman, K, Extreme Home makeover – the role of intensive home health care, NEJM, 2016; 375: 1707-1709 2. Summerfelt, w, etal, Scalable hospital at home with virtual physician visits: pilot study, Amer J Managed Care, 2015; 21: 675-684

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January 2017 | arizonaphysician.com

‘All of Us’ National Precision Medicine Research Program BY JEAN SPINELLI

ARIZONA PHYSICIAN | January 2017

recision medicine is an emerging approach for disease treatment and prevention that takes into account individual variability in environment, lifestyle and genes for each person. (source: https://www.nih.gov/ research-training/allofus-research-program) The Precision Medicine Initiative® (PMI), announced by President Obama in his January 2015 State of the Union address, is a new research effort to revolutionize improving health and treating disease. The PMI aims to leverage advances in genomics, emerging methods for managing and analyzing large data sets while protecting privacy, and health information technology to accelerate biomedical discoveries. In July, the University of Arizona Health Sciences and Banner Health were awarded a $4 million grant from the National Institutes of Health to participate in the PMI Cohort Program, the largest health and medical research program on precision medicine of its kind. The award, which totals $43.3 million over five years, is the largest NIH peer-reviewed grant in Arizona history. The landmark program – recently renamed the All of Us SM Research Program to better reflect the initiative’s inclusivity and openness – aims to enroll 1 million participants living in the United States to improve prevention and treatment of disease based on individual differences in lifestyle, environment and genetics. Health information contributed by participants will form the basis of a privacy-protected data set – accessible to researchers across the country – that will accelerate precision medicine discoveries. Participants also will have access to their information. UA/Banner’s two-year-old partnership, a 30-year academic affiliation agreement finalized in February 2015, facilitated the NIH grant to establish a regional enrollment center for the PMI. UA/Banner Health is one among a network of healthcare provider organizations (HPOs) that will engage their patients in the All of Us program, building research protocols and plans, enrolling interested individuals and collecting essential health data and biological specimens, with privacy and security safeguards. The initial set of HPOs includes eight regional medical centers and consortia nationwide, with others expected to be added. “Advancing precision medicine requires an effective collaborative organization such as ours, so that we can go away completely from the era of one size fits all and use medicine in a way that takes into account individual variation,” said UA Health Sciences Associate Vice President for Clinical Research Akinlolu (Lolu) Ojo, MD, MPH, PhD, principal investigator for the UA/Banner Health HPO. “The concept of precision medicine has been percolating for 20 years and now is coming to fruition because costs to analyze individual genomes have dropped considerably, electronic health records make large amounts of data available to researchers, and new technologies – such as wearable sensors that can measure heart health, blood pressure and glucose levels – are available.”

Courtesy of the National Institutes of Health

January 2017 | arizonaphysician.com

Initial plans call for an enrollment of 150,000 participants in the Southwest region, Alaska and Wyoming over five years. The inclusion of Hispanic/Latino participants will provide greater insights to disease prevention and treatment, making precision medicine advances available to traditionally underserved populations, regardless of race, ethnicity or geography, and reducing health disparities. Arizona physicians will play an important role in the success of the All of Us Research Program. “The program will depend greatly on the support and advocacy of clinicians across the region to endorse the program to potential participants and to meet goals of enrolling a truly diverse group of individuals,” said Co-Investigator Usha Menon, PhD, RN, FAAN, associate dean for research and global advances at the UA College of Nursing. Upon launch of the study’s enrollment period, physicians will be encouraged to refer individuals to join through enrollment sites that UA/Banner is now developing, or directly through the program’s website or call center. The initial enrollment sites in Arizona will include Banner – University Medical Center Tucson, Banner – UMC South, Banner – UMC Phoenix, Banner Desert Medical Center, and Banner Estrella Medical Center. Banner Boswell and Banner Thunderbird are expected to be online shortly following launch. To prepare to accept study participants, researchers are developing complex infrastructure – both physical and

electronic. As part of that effort, the HPO teams are testing data collection processes with the program’s biobank and Data and Research Center to ensure the secure transfer of biospecimens and electronic health record data. UA/Banner Health is supporting the production of program materials and surveys in Spanish, and local public awareness videos are in development with UA Health Sciences, Banner Health and community members. Coordinators, who will be deployed to enrollment sites and engaged in community outreach upon the launch of the All of Us program, are being recruited. Frequently asked questions about the All of Us Research Program can be found at https://www.nih.gov/allofusresearch-program/frequently-asked-questions. To contact the UA/Banner Health All of Us program team, please email precisionmedicine@email.arizona.edu. Jean Spinelli is Public Relations Manager of the University of Arizona Health Sciences Office of Public Affairs.

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ARIZONA PHYSICIAN | January 2017

10 Ways Wearables Are Impacting Healthcare T

hey started out as nifty little gadgets that could count how many steps you took or miles you ran or calories you burned. Wearables were great cocktail party conversation starters, but few took them seriously. Then suddenly, they were everywhere. Wearable technology has scaled faster than anyone could have imagined. It’s being used not just by consumers, but physicians, surgeons, and insurance companies, and it is changing the dynamics of the whole healthcare industry. Some 140 million devices will be sold worldwide this year, producing $30 billion in revenue. Among US consumers, the use of health wearables has doubled from 9% in 2014, to 21% in 2016, according to an Accenture survey. Seventy-seven percent of consumers and 85% of doctors agree that using wearables helps patients engage in their health.

Here are some of the ways wearable technology is changing the face of healthcare:

1. More power to patients. Many patients are sharing

data from their wearables with doctors, even when they don’t need to track their vitals for medical reasons. Devices track things like sleep patterns and exercise routines, which have an important effect on overall health, but aren’t a part of medical records – until patients share the information and doctors take notes. Parsing data from wearables and electronic health records, patients can monitor their own health and take the initiative to discuss. The relationship with physicians becomes consultative, instead of hierarchical.

2. Virtual doctor visits. Wearables enable doctors to

check on patients without an office visit, saving time January 2017 | arizonaphysician.com

and money. Children with an ear infection can be sent home wearing a device that conducts a “virtual ear exam” so that they don’t have to return for a follow-up. Wearables help seniors age in place with devices to monitor diabetes, macular degeneration, neuropathic pain and other conditions.

3. Help with disabilities. Wearables help disabled

people manage their daily lives without outside help. Special glasses enable the legally blind to see, and haptic shoes provide GPS technology for them to navigate. Smart glasses let people with cerebral palsy do internet research and take pictures. Other wearables help people manage heart disease, diabetes, and sleep apnea on their own.

4. Remote patient monitoring. Wearables have

dramatically improved in accuracy and reliability, in some cases meeting clinical standards. Blood pressure, heart rate, glucose levels, oxygenation, and more can be monitored remotely, and alerts sent to clinics.

The technology also scales. A nurse can oversee a hundred heart failure patients from a single computer dashboard, taking action when an emergency is signaled. Cedars Sinai in Los Angeles has connected the electronic health records of 80,000 patients to the Apple watch, which gathers data about heart activity. Continuous data enables cardiologists to review heart function over an entire 30-day period, rather than from one visit to the next.

5. Remote diagnosis. From a “smart bra” that provides

early detection of breast cancer to a contact lens that identifies which glaucoma patients are likely to get worse, scientists using wearables for diagnostics that are more convenient and less invasive for patients.

6. Remote treatment. Wearables can stop pain. Quell,

a wrapper that attaches to the upper calf, uses electrical stimulation to trigger a central nervous system response and block pain signals anywhere in the body. Other wearables have been developed to stop morning sickness and reduce anxiety.

In the future, wearables may treat or prevent more serious diseases. IBM is partnering with Pfizer to develop wearables to track the progress of Parkinson’s disease and alleviate symptoms by gathering rich data on motor function, dyskinesia, cognition, and sleep.

7. Promoting adherence. Getting patients to follow

their treatment is a perennial problem in medicine. But soon doctors will be able to receive information from a “smart pill” that is coated with material that reacts with stomach acid and sends an electrical signal to a skin patch. The data is then picked up by an app that tells the doctor whether the medicine has been taken. Developed by Proteus Digital Health, the pill has received FDA approval and is being used in pilot programs.

Less intelligent wearables provide patients with medication and regimen reminders, as well as information on healthy 44

ARIZONA PHYSICIAN | January 2017

lifestyles, which could also lead to better adherence.

8. Insurance coverage. Wearables are becoming a good fit

for insurers as they adopt the Affordable Care Act’s emphasis on prevention and evidence-based treatment. Some are covering costs for wearables that help with the management of chronic diseases such as diabetes. Others are going further.

UnitedHealth Group, the nation’s largest insurer, is rolling out a program that not only covers the cost of wearables, but pays up to nearly $1,500 a year to plan members who reach specified wellness goals. For example, enrollees can earn $1.25 a day for walking 10,000 steps. The company expects to reach 20 million members when the program is fully implemented. Humana also rewards members who use wearables to reach fitness goals, and a three-year study of the wellness plan that uses them showed a 44% decrease in employee sick days.

9. Clinical trials. Monitoring and compliance are frequent issues in clinical trials, and wearables offer a convenient solution. Nearly 300 clinical trials have already used wearables to monitor patients. Google has built a new wearable intended for use by clinical trial participants. It can measure the wearer’s pulse, heartbeat rhythm, skin temperature, and exposure to light and noise.

Eli Lilly recently sponsored an interactive and immersive clinical trial simulation at Stanford, and is working on a closed-loop system that triggers alerts for things like drug reactions, enabling real time intervention. The clinical trial of the future may take place in patients’ homes. A constant stream of data from wearables will give researchers a better of picture of results, and may also lead to broader participation.

10. Surgery. Google Glass has entered the OR. A handful

of surgeons have used the internet-connected glasses to preload CT scan and X-ray images, enabling them to focus on the patient without having to turn away. In a Stanford study, medical residents who operated on dummies performed “markedly better,” when wearing Google Glass, noticing indicators such as critical desaturation and hypotension several seconds faster than they did without them. In the future, medics may use the glasses or a similar technology to handle patients in an emergency while communicating with a hospital.

Lisa Majdi is the Director of Cox Business segment marketing, focused on the Mid-Market/Large Local customer segment. In her role, she leads the national marketing strategy for the Mid-Market/Large Local customer segment of Cox Business. Lisa has more than 17 years of experience in segment marketing, customer relationship management and marketing communications with Verizon Wireless, BellSouth and AT&T. In addition to marketing leadership roles, She holds a Master’s degree in Communications from Western Kentucky University and holds a Six Sigma Green Belt certification.

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