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M A RY L A N D

Physician YOUR PRACTICE. YOUR LIFE.

Tackling Obesity and Diabetes Fighting for Physicians and Consumers Attorney General Douglas F. Gansler Be Ready for mHealth

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VOLUME 1: ISSUE 6 MARCH/APRIL 2012


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Contents 12

March/April 2012 Volume 1: Issue 6

20

28

F E AT U R E S

12 Tackling Obesity and Diabetes 20 Follow Your Gut Managing Pancreatic Cysts and Hemorrhoids

24 Be Ready For mHealth Why physicians should become familiar with mobile healthcare tools D E PA R T M E N T S

Cases

| 7 | Celiac Disease: An Ancient Disease Remains Under-Diagnosed in Modern Times

Solutions

| 8 | Five Ways to ProtectYourself andYour Practice for Under $1,000

Living

| 28 | Gearing Up For Spring

Policy

| 30 | Interview with Douglas F. Gansler, Attorney General

Compliance

| 33 | Common Sense Measures Ensure a HIPAA Compliant Practice

Good Deeds

| 34 | “Camp Oasis” Offers Inspiration toYoungsters with Inflammatory Bowel Disease

On the Cover: Richa Bhatnagar, M.D., is a family practitioner with MedStar Physician Partners at Olney Professional Park.

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JACQUIE ROTH, PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com CONTRIBUTING WRITERS Allison Eatough Tracy Fitzgerald Jackie Kinsella CONTRIBUTING PHOTOGRAPHY Tracey Brown, Papercamera Photography www.papercamera.com Mark Molesky, Moleskey Photography www.moleskyphotography.com

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’M WRITING THIS AS I SIT 37,000 FEET IN THE AIR ON THE WAY TO one of the country’s oldest and most well-attended HIT conferences – the Healthcare Information and Management Systems Society (HIMMS) conference. Even at this altitude, the obesity epidemic, which is this issue’s clinical focus, is clear as the seats get smaller and some of my fellow travelers get bigger. Americans are fatter than ever and healthcare technology (HIT) seemingly isn’t moving fast enough to allow physicians to help their patients lead healthier lives and reduce the chronic conditions associated with obesity. Where does HIT fit? In this issue, we examine the state of mobile health (mHealth). Get ready for it – more and more of your patients are using it and you want them to use it (HIT page 24). Every day, gadgets and apps are being launched to help people monitor their body metrics and chronic diseases. These new launches often promote goal setting and rewards for patients living healthy lifestyles, using clinically valid data. Unfortunately, due to a slow-moving FDA train and an onslaught of HIT developments, many physicians are challenged to weed through the many tools available and apply the most useful tools to patient care delivery. Over the next few days, Maryland Physician Managing Editor Linda Harder and I, along with 35,000 others, will be introduced to the future of HIT, which we’re eager to share with our readers. In the short term, I’m excited about our own step into the future with the launch of the Maryland Physician web-based smartphone app and QR code (page 19), which connects you to Maryland Physician online and more. Despite a rancorous political climate, the reformation of America’s healthcare system is gaining momentum via HIT developments and changes to care access. We recently had the opportunity to sit with Maryland’s Attorney General Doug Gansler, a leader in protecting consumer health and a physician champion. To learn about the impacts his office’s actions might have on your practice, see Policy (page 30). Without a doubt, exercise has a positive impact on your physical and emotional well-being. Our new department, Living (page 28), takes you out of your practice to Maryland’s roads and trails, gearing up for spring cycling. I’m personally inspired by our piece; over the next several months, I’m training for Maryland’s Seagull Century Ride. I hope you’ll let me know if you are similarly inspired!

ADMINISTRATION Ginger Jenkins EXECUTIVE ASSISTANT/WEBMASTER Jackie Kinsella Maryland Physician Magazine™ is published bimonthly by Mojo Media, LLC. a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 1663 Millersville, MD 21108 443-837-6948 www.mojomedia.biz Subscription information: Maryland Physician Magazine is mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52.00. To be added to the circulation list, call 443-837-6948. Reprints: Reproduction of any contact is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443-837-6948 or email jroth@ mdphysicianmag.com. Maryland Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Maryland Physician. Advisory board members include: KAREN COUSINS-BROWN, D.O. Maryland General Hospital PATRICIA CZAPP, M.D. Anne Arundel Medical Center HOLLY DAHLMAN, M.D. Greenspring Valley Internal Medicine, LLC PAUL W. DAVIES, M.D., FACS KURE Pain Management GAUROV DAYAL, M.D. Adventist HealthCare MICHAEL EPSTEIN, M.D. Digestive Disorders Associates STACY D. FISHER, M.D. University of Maryland Medical Center REGINA HAMPTON, M.D. FACS Signature Breast Care DANILO ESPINOLA, M.D. Advanced Radiology GENE RANSOM, J.D., CEO MedChi

To life! Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources.

Jacquie Roth Publisher/Executive Editor jroth@mdphysicianmag.com 4 |

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

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


Cases

Celiac Disease: An Ancient Disease Remains Under-Diagnosed in Modern Times Michael Epstein, M.D. CASE: A 32-year old female who emigrated from Bulgaria several years ago presents with a long history of crampy, sometimes severe abdominal pain and constipation, as well as two miscarriages. She has been to a number of physicians in her home country and to emergency departments in the U.S. on several occasions with no specific diagnosis. At one point she was diagnosed with IBS. Her physical examination was unremarkable except for small patches of papulovesicular eruptions distributed symmetrically on extensor surfaces with blister-like lesions. Lab results revealed a mild iron deficiency with slightly elevated SGOT and SGPT. A DEXA scan revealed evidence of osteopenia. DISCUSSION In 50 AD Arelaus the Cappadocian stated, “If the stomach be irretentive of food and it passed through undigested and crude, we call such persons celiacs.” It wasn't until the 1950’s that cereals were linked to celiac disease. The disease itself is a heightened responsiveness to gluten in wheat, barley, and rye leading to autoimmune enteropathy and systemic disease. There are over 100 different proteins in gluten found in the endosperm of the grains. The gluten itself is not directly toxic, but it must be deaminated by tissue

transglutaminase, forming a complex that is much more antigenic. Celiac disease is five times more prevalent than Type 1 diabetes, with estimates that 1% of Americans are affected. Yet 2.1 million patients remain undiagnosed. The vast majority of celiac patients have one of two types of HLA-DQ. This gene is part of the MHC class II antigenpresenting receptor (also called the human leukocyte antigen) system and distinguishes cells between self and non-self for the purposes of the immune system. The gene is located on the short arm of the sixth chromosome and has been labeled CELIAC1.The receptors formed by these genes bind to gliadin peptides more tightly than other forms of the antigenpresenting receptor and activate T cells. In 1997 the role of tTG (tissue Transglutamase) antibodies was found to be pivotal to the diagnosis and causation of the disease. The tTG binds to the gliadin and forms the antigenic complex. The tTG antibodies should also be measured with serum IgA. If the patient is IgAdeficient, a serum EMA (Endomysial) IgG should be measured. The diagnosis must be made with a positive tTG as well as a sufficient biopsy of the small intestine. The positive predictive value of the antibodies is not sufficient to make the diagnosis. Celiac disease may affect the brain, skin, lungs, liver, and blood vessels. Symptoms, often present for 10 years before diagnosis, include increased LFTs, constipation, apthous ulcers, nausea, vomiting, heartburn, pancreatitis, fatigue, arthralgias, myalgias, neurologic ataxia, alopecia, headaches, dental problems, fertility issues, and cognitive defects. The consequences of the disease include increased risk of infection, lymphoma, ataxia, malnutrition and skin rash.

The only treatment is a strict glutenfree diet that avoids all products containing wheat, rye, and barley. Only 50 mg of gluten – a single breadcrumb – will reintroduce the disease. As gluten is found in virtually every food and in fillers such as in lipstick and medications, a gluten-free diet can be difficult to follow. More than 75% of patients who present to a clinician following a glutenfree diet do not have celiac disease. They may have a wheat allergy, but it is more likely that this is a form of functional disease and IBS. The gold standard of treatment remains consultation with a skilled celiac dietitian. Studies reveal that three simple questions can help physicians monitor patients:  Am I able to follow a gluten-free diet outside my home?  How many times in the past four weeks have I been exposed to gluten?  How important are accidental gluten exposures to my health? Physicians need to be vigilant about the diagnosis of celiac disease, whether the patient has reproductive or fertility issues, general GI complaints or skin rash, anemia or general ill health. Diagnosis starts with a tTG and treatment is a lifelong process involving a physician and dietitian. Our patient was not diagnosed until she presented to a specialist who ordered the appropriate antibody testing and small bowel biopsy. She was referred for appropriate dietary counseling and, with careful attention to her diet, enjoyed a markedly improved quality of life. Within two years of starting treatment, she delivered a healthy child. Michael S. Epstein, M.D., F.A.C.G., AGAF, is the founder of Digestive Disorders Associates in Annapolis, michael.epstein@dda.net.

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Solutions

Five Ways to Protect Yourself and Your Practice for Under $1,000 Steve Sherman, J.D.

D

O YOU WANT TO PROTECT yourself and your practice without breaking the bank? The following five tips for critical yet affordable insurance coverages are ones that all physicians should consider carrying to maximize their protection within a budget. This is not meant to be an exhaustive list. Consulting with an insurance professional is your best way to ensure that your particular situation is adequately addressed. Personal Insurance

One of the most overlooked areas for physicians is their homeowners and automobile insurance. A growing number of physicians buy their coverage on-line or with little thought about the actual coverage provided. Know what coverage you have in place, and whether it needs to be adjusted. Take a few minutes now to make sure you are sufficiently protected. 1) Upgrade Your Home and Automobile Coverage

You should upgrade to the maximum insurance limits on your automobile policy, which should be at least $500,000 per person, $500,000 per accident, and $100,000 for property damage. A review of one physician’s policy found that he had minimum limits ($30,000) of insurance. In other words, if he had caused an automobile accident that injured others, he had only $30,000 to pay for their injuries! If their medical costs exceeded $30,000, the physician could be personally liable for the difference. On your homeowner’s policy make sure that you have at least $500,000 in liability protection. It is also a good and inexpensive idea to purchase 8 |

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identity theft protection. Making these upgrades to your home and automobile coverage should cost you less than $1,000 a year. 2) Add an Umbrella Policy

While contemplating the proper limit of personal insurance, another affordable way to increase your personal insurance coverage is purchasing an umbrella policy. An umbrella policy adds an additional $1 million of liability coverage to your existing home and automobile liability coverage. In other words, if you have a $1 million umbrella policy and a $500,000 liability limit on your automobile, then you would have $1.5 million worth of coverage. Umbrella policies are commonly available in million-dollar increments from $1 million to $10 million. However, umbrella policies do not give you an extra layer of property loss protection. The cost of a $1 million umbrella policy is only about $200 per year. If you employ a nanny or other domestic worker to whom you pay more than $1,000 per quarter, you are required by the State of Maryland to buy a domestic worker’s compensation policy. These policies normally cost less than $1000 a year. Insurance for the Practice 3) Buy Disciplinary Board Legal Coverage

Every physician in private practice should buy coverage to pay their defense costs if they are brought before the Board of Physicians. Maryland is contemplating changes to the Board, and an increased emphasis on investigating and disciplining physicians is anticipated.

Many medical malpractice insurers will non-renew you if you have a Board action, so it is important to hire an attorney to defend you. Attorneys’ fees can add up quickly. The premiums for these policies range from $400 - $700 per year. 4) Buy Employment Practices Liability Insurance

Every year, there are nearly 2,000 employment-related lawsuits brought against Maryland employers. Physicians are especially susceptible to these claims, which can be extremely expensive to defend. Most insurers who sell this coverage will provide free human resources and legal advice – a great value! For small practices, basic policies typically cost under $1,000. 5) Have a Partner? You Should Have a Buy-Sell Agreement

In simplest terms, a buy–sell agreement dictates what happens if one partner dies, retires or becomes disabled. In these situations, it can be difficult to buy a partner’s interest with out-of-pocket funds, and the partner’s spouse may demand to be paid immediately. Some practices use simple term life insurance policies to fund the buy-out. Depending on the age of the physicians, a simple 10 or 20-year term policy may cost less than $1,000 per year. Make sure to discuss this with a lawyer. These five simple and affordable steps are ones you can take immediately to better protect yourself against potentially major catastrophic events. Mr. Sherman specializes in medical malpractice and professional liability insurance with PSA Insurance and Financial Services. Contact him at ssherman@psafinancial.com.


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Maryland General’s New Wound Healing Center Advanced, Multidisciplinary Care for Baltimore Residents

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Kapil Gopal, M.D., MBA, medical director, Maryland Wound Healing Center and associate program director, Vascular Fellowship Program at the University of Maryland Medical Center and Maryland General with two of the center's hyberbaric chambers.

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N ESTIMATED $25 billion is spent annually on treating chronic wounds. This process often entails expensive, repeat hospital visits and fragmented specialty services. Having access to a comprehensive wound healing center not only helps reduce expenses, but affords patients with the latest, most effective and coordinated treatment options. That was the impetus behind Maryland General Hospital’s state-of-the-art Maryland Wound Healing Center, which opened in March 2012. “We have a high prevalence of diabetes and vascular problems in our community,” says Sylvia Smith Johnson, Maryland General Hospital’s president and CEO. “We recognized that there were limited options for comprehensive wound care with advanced treatment that includes hyperbaric oxygen therapy.” The Maryland Wound Healing Center is affiliated with National Healing Corporation (NHC), one of the leading providers of wound healing centers throughout the country. Kapil Gopal, M.D., MBA, medical director, Maryland Wound Healing Center and associate program director, Vascular Fellowship Program at the University of Maryland Medical Center


Our program is successful because we focus exclusively on wound care, using treatment algorithms and tested approaches, including HBOT. – Kapil Gopal, M.D. and Maryland General Hospital, says, “Our program is successful because we focus exclusively on wound care, using algorithms and scientific evidence-based protocols, including HBOT, to develop an individualized treatment plan.” William Anthony, M.D., chief of medicine and an infectious disease specialist, notes, “I’ve been treating wounds for more than 30 years. We make sure that any underlying medical issue, such as vasculitis or diabetes, is addressed with the patient’s physician, who then gives us direction and provides input into his or her care.” HBOT is a widely utilized adjunctive modality that is reimbursed by most, if not all, insurance providers. The data on its efficacy is especially strong in treating diabetic foot ulcers classified Wagner Grade 3 or higher. The Wound Healing Center Process

The center’s multi-disciplinary panel comprises experienced family practitioners, vascular and general surgeons, infectious disease specialists and podiatrists that develop a comprehensive care plan tailored to each patient. The team keeps referring physicians involved and informed, including providing weekly/monthly progress reports and photos. “Each patient works with a single physician and nurse case manager who help us build a close, trusting relationship. Patients tell us they look forward to coming,” says Colleen Miller, RN, program director. Miller explains the wound care process. “We check insurance authorization, schedule the patient’s first and subsequent appointments, and advise them what to expect. The first visit involves a full history, including psychosocial history, and a thorough

assessment of the wound and relevant medical conditions. The team develops a customized wound care plan that typically involves weekly treatments until the wound starts to heal. If HBOT is ordered (about 20% of patients will be transitioned over to HBOT), it involves about 30 consecutive ‘dives’ in our singleuse, private chamber, which includes a television above the chamber for patients undergoing treatments. We also involve other providers as needed, such as home health care or an orthotist.” The center reports its clinical outcomes into a nationwide database that can be reviewed against the NHC Clinical Pathway . TM

THE MARYLAND WOUND HEALING CENTER CENTER OFFERS:  Joint Commission certified program  Skilled, multi-disciplinary team Experienced medical and program directors oversee a team of physician specialists, nurses and technologists trained to use the latest assessment and therapeutic methods.

Proximity, Coordinated Care Improve Outcomes

Ms. Smith Johnson observes, “Without clinical pathways and multidisciplinary care, there’s a high cost of wound care for payers and society, a higher amputation rate and an emotional and physical toll on patients and their families. Our center provides coordinated care that better addresses the needs of all these groups and improves outcomes.” Dr. Gopal adds, “The key to this center is its location at Maryland General, where it’s in close proximity to a large population that needs this service. It will help many with diabetes and venous stasis, as well as those with osteomyelitis, pressure sores, burns, post-surgical wounds and other nonhealing wounds.”

 Personalized care management Each patient works with a single physician and nurse case manager.  Proven clinical pathways Uses protocols which rely on evidence-based medicine, experience, dedicated research and best practices.  Successful outcomes In 2010, 90% of wounds treated in NHC centers were healed, with an amputation rate of less than 2%.  Accessibility Community hospital convenience, with easy access to public transportation or the hospital’s transport team.

When to Refer

“If a wound isn’t healing after two weeks and the patient is not making progress, I encourage physicians to call us to schedule an appointment,” states Miller. “Patients can also self refer and most insurers provide coverage.”

To refer a patient to the Maryland Wound Healing Center or for more information, call 1-855-866-HEAL or 410-225-8600.

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(

Tackling

)

Obesity and Diabetes BY LINDA HARDER

PHOTOG RAPHY BY TRACEY BROWN

Not much is harder than losing weight, except, perhaps, keeping it off. Maryland Physician interviewed three physicians – Drs. Michael Schweitzer, Kristi Silver and Richa Bhatnagar – for their advice about managing obesity and a common co-morbid condition, type 2 diabetes.

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FOR SEVERELY OBESE PATIENTS, bariatric surgery may be their best hope for losing and keeping off sufficient weight to improve their health. Michael A. Schweitzer, M.D., FACS, a bariatric surgeon at the Johns Hopkins Center for Bariatric Surgery stresses, “Bariatric surgery should never be undertaken for cosmetic reasons.” The purpose of bariatric surgery is to improve the health of the patient by reducing or eliminating their obesity-related medical diseases. Criteria

In Maryland, patients are fortunate that state law requires insurers to cover bariatric surgery when performed for people who meet the following criteria:  BMI of 40 kg/m2 or greater, or 35-40 kg/m2 with co-morbid condition(s)  Tried and failed previous diet(s) “We have one of the best laws in the country,” says Dr. Schweitzer. “Recently the FDA approved the laparoscopic adjustable gastric band for patients with a BMI between 30 and 35 with diabetes. Unfortunately insurers do not cover this procedure for non-morbidly obese patients and therefore, patients will have to pay out of pocket for now. Patients who have active substance abuse issues, uncontrolled mental health disease or who cannot cooperate with post-op requirements are not considered candidates.” He comments, “We do see teenage patients 16 and older, but they have to go through an intense program that includes their parents. Some of the more successful results involve teens whose mother had the procedure first. There’s no definite cut-off among older adults, though most patients are 65 or younger. We have made exceptions and performed surgery on patients up to 75 years old.”

Michael A. Schweitzer, M.D., FACS, is a bariatric surgeon at the Johns Hopkins Center for Bariatric Surgery.

Types of Bariatric Procedures

Results

Bariatric surgeons in the U.S. currently use one of four approaches:  Roux-en-Y gastric bypass – the gold standard and most common. Patients typically lose 60 to 75% of excess weight within 18-24 months.  Laparoscopic adjustable gastric band (‘Lap Band’ & ‘Realize Band’) – patients typically lose 30-50% of excess weight.  Vertical sleeve gastrectomy – patients typically lose 40-60% of excess weight. This procedure is newer and growing in popularity.  Duodenal switch with bileopancreatic diversion – only used for about one percent of patients.

A retrospective cohort study published in the New England Journal of Medicine in 2007 determined that long-term mortality in the group undergoing gastric bypass decreased by 40% compared to the control group. The rate of dying from heart disease, type 2 diabetes and cancer was less in the gastric bypass group. However, the rate of death from accidents and suicide, while small, was higher in the surgery group. “Physicians should know that the procedure doesn’t cure mental illness,” Dr. Schweitzer notes. “Mental health counseling even after surgery is an important adjunct for some patients who are dealing with the psychological issues of losing weight.” MARCH/APRIL 2012

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insulin resistance usually improves and they can better control their diabetes.” Risk Factors for Obesity and Diabetes

Kristi D. Silver, M.D., is acting director of the University of Maryland Center for Diabetes and Endocrinology.

Mortality rates at bariatric surgery Centers of Excellence are lower than previously published death rates when centers did not exist. “Johns Hopkins Medicine is a tertiary referral center where we are referred high-risk patients; however, our group has a 0.3% mortality rate, compared with higher mortality rates seen nationally.” Pre and Post-Op Care

After a short hospital stay, patients typically return to work within two weeks. On a high-protein, pureed diet for about a month post-op, they start to return to a normal healthy diet. Follow-up with their primary care physicians and bariatric surgeons is an important part of the postoperative course. Support groups meet monthly and specialized nutritionists help monitor protein intake and supplemental vitamins. Dr. Schweitzer provides additional advice for referring physicians:  For patients with sleep apnea symptoms, get a sleep study before surgery and put on CPAP if the patient has moderate to severe obstructive sleep apnea.  Seek better glucose control in type 2 diabetics. Ensure that the patient’s thyroid medication dosing is adequate. Counsel the patient to stop smoking.  Patients with ulcer symptoms may need an EGD before surgery.  Consider a hematology work-up for patients with a personal/family history 14 |

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of blood clotting.  Consider referring for bariatric surgery prior to hip/knee replacement surgery or spine surgery.  Refer patients to a bariatric dietitian and mental health professional if needed post-op. Regaining Weight

While bariatric surgery is highly successful, patients may gain back some weight. Dr. Schweitzer says, “The main reason they regain it is because they eat ‘bad’ carbs, such as potato chips. If they eat a healthy diet slowly, they won’t regain the weight.” The purpose of surgery is to help the patient stay on a healthy diet that makes them feel full and desire less snacking in-between meals. Dr. Schweitzer notes that an even less invasive procedure is on the horizon. “Endoscopic intraluminal trans-oral surgery is in its infancy. If we can surmount the current issue of staples not holding, this approach is likely to take off.” CONTROLLING TYPE 2 DIABETES Kristi D. Silver, M.D., acting director of the University of Maryland Center for Diabetes and Endocrinology, divides her time between clinical research on diabetes and treating patients. “The vast majority of adults with type 2 diabetes are overweight or obese,” she says. “When people are overweight, insulin resistance develops so their pancreas makes more insulin but it’s used less efficiently. When they lose weight, their

The strongest predictors of developing type 2 diabetes are family history and high BMI. Those with metabolic syndrome are also at increased risk. Dr. Silver notes, “While no one gene accounts for the majority of genetic risk for diabetes and obesity, Transcription factor 7-like 2 (TCF7L2) for diabetes and fat mass and obesity associated (FTO) gene for obesity are two of the more important genes identified.” Adds Dr. Silver, “Lifestyle modifications are the most effective way to combat the development of type 2 diabetes.” In a study published in 2008 in the Archives of Internal Medicine by Soren Snitker, PhD, researchers found that physical activity can largely counteract the risk of obesity due to a genetic variant in the FTO gene.” Managing Diabetes

“It’s important for patients to see a nutritionist and a diabetes educator,” says Dr. Silver. “The multi-disciplinary approach has been shown to work. The nutritionist can take the time to do a diet history and then work with the patient to develop a meal plan. Meeting with the diabetes educator helps patients learn other self -management skills such as glucose monitoring, prevention of complications and proper treatment of hyperglycemia and hypoglycemia. Diabetes education classes allow patients to learn from their peers as well as from professionals.” Dr. Silver continues, “In making dietary recommendations to patients, instead of changing everything in an unhealthy diet all at once, I recommend that patients take small steps. After mastering one dietary change, they can add others. When patients try to change everything in their diet at one time, they may be successful for a few weeks, but often revert back to their previous eating habits.” New Medication Options

“There are many new medication options today, plus many drugs are in development or awaiting FDA approval, though most are the same class of drugs that are currently available. Many newer drugs target specific molecular pathways involved with insulin secretion or resistance,” Dr. Silver states. “Current


guidelines recommend that patients be started on metformin unless they have contraindications or can’t tolerate it. Pioglitazone is being used less often due to recent but not conclusive studies suggesting that long-term use may

may decrease if they lose weight. In part, that is due to the diminishing of the insulin producing cells of the pancreas over time, even after lifestyle changes.” Insulin pumps have become more

“Lifestyle modifications are the most effective way to combat the development of type 2 diabetes.” –Kristi Silver, M.D.

increase the risk of bladder cancer. Newer classes of drugs such as DPP4 inhibitors are effective, but can be expensive. Patients often need several diabetes medications to reach their target HbA1c.” Dr. Silver adds, “Today, we have good data supporting the use of a longacting insulin as a basal insulin, with a rapid acting insulin to cover meals and correct elevated blood sugars. While the regimen requires four injections a day, most patients can be convinced to follow it due to improved blood sugar control and increased flexibility in eating. Physicians are sometimes reluctant to start insulin, but it’s often what patients need. With proper training on how to give the shot, fearful patients usually get over their anxiety. ” After starting insulin, most patients with type 2 diabetes on high doses of insulin can’t get completely off it, though their dose

sophisticated. Current pumps can help patients calculate the mealtime and correction insulin needed. Newer monitors allow interstitial glucose measurements to be sent to a hand held receiver that reads the level every five minutes. Continuous glucose monitors are best used to observe trends in glucose levels. Additionally, alarms can be set to avoid hyper or hypoglycemia. “We can look at glucose patterns and adjust insulin doses accordingly,” comments Dr. Silver. SUCCESSFUL PRIMARY CARE INTERVENTIONS Richa Bhatnagar, M.D., a family practitioner with MedStar Physician Partners in Olney, says, “In primary care, prevention is key. When a patient comes to the office, in addition to checking their vital signs, I also assess their BMI. If it’s high, then, I counsel them about

making lifestyle changes. I believe that nutrition is a critical component of health. In fact, I took a nutrition class this past fall to gain some additional knowledge for my patients.” Dr. Bhatnagar incorporates these discussions into her office visits. “I just find time to do it,” she says. “Many of my patients have multiple medical problems, such as diabetes and hypertension. At their office visits I discuss simple lifestyle changes that will positively affect their health.” Like Dr. Silver, Dr. Bhatnagar recommends that patients make small changes over time. “I stress that it’s a lifelong process, and they should start by making simple changes, such as drinking skim milk instead of whole. If they eliminate basic food groups, it is not only unhealthy, but the majority of patients will eventually return to old eating habits. I often recommend the Mediterranean Diet and provide handouts that patients can stick on their refrigerators.” Dr. Bhatnagar has found it effective to have patients keep food journals for at least two to three days. “After they track everything they eat for several days, I review the logs and suggest changes they can live with.” Research Findings on Diet Plans

The gold standard of diet studies is still considered by many to be a February, 2009 study in the New England Journal of

ADVICE FOR REFERRING PHYSICIANS

Richa Bhatnagar, M.D., is a family practitioner with MedStar Physician Partners at Olney Professional Park.

> Multidisciplinary approach involving diabetic educator, nutritionist, proven effective > If one drug is not effective, combine 2 drugs rather than change drugs; if two are not effective, consider insulin > Don’t assume patients will resist insulin – most adapt quickly > Combine long acting and rapid acting insulin – provides more meal flexibility with better glucose control > Consider using metformin with insulin > Refer newly diagnosed patients and those not meeting goals after 6 months of intensive treatment to endocrinologist

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Medicine that compared participants’ ability to lose weight on diets that emphasized protein, fat, or carbohydrate consumption. The authors found that all of the reduced-calorie diets had similar effects on satiety, satisfaction and weight loss, and that all improved lipid-related risk factors and fasting insulin levels. They concluded that the macronutrient emphasis was not important to the ability to lose clinically meaningful weight, and that continued attendance at a group session was related to the ability to lose and keep off weight.

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“In primary care, prevention is key... I believe that nutrition is a critical component of health.”

–Richa Bhatnagar, M.D.

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Exercise: Simple Steps are Effective

“It’s surprising how many patients aren’t familiar with the 10,000 Steps concept, which encourages people to build more walking into their daily routine,” Dr. Bhatnagar remarks. “Studies have shown that this is effective.” The concept, which originated in Japan about 40 years ago, encourages people to walk about 5 miles during the course of each day, far more than the average American’s 1.5 miles. Comments Dr. Bhatnagar, “I encourage patients to aim for 30 to 45 minutes of cardiovascular exercise every day, with the hopes of getting them to exercise at least four to five days a week. They don’t need to spend hours at a gym; walking outdoors is a great way to achieve their fitness goals.”

Michael A. Schweitzer, M.D., FACS, associate professor, surgery at the Johns Hopkins Center for Bariatric Surgery. Kristi D. Silver, M.D., associate professor of medicine, acting director of the University of Maryland Center for Diabetes and Endocrinology. Richa Bhatnagar, M.D., family practitioner with MedStar Physician Partners at Olney Professional Park.

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Follow

YOUR GUT Managing Pancreatic Cysts and Hemorrhoids

Maryland Physician spoke with two Maryland gastroenterologists, Sanjay Jagannath, M.D., and Rudra Rai, M.D., to learn the latest approaches to treating pancreatic cysts and hemorrhoids. LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

MANAGEMENT OF PANCREATIC CYSTS

Sanjay Jagannath, M.D., FASGE, AGAF, director, Pancreas Center at Mercy’s Institute for Digestive Health and Liver Disease, is on a mission to do for pancreatic cysts what colonoscopy has done for colon polyps. The recent deaths of celebrities such as Patrick Swayze, Steve Jobs and WBAL radio host Ron Smith have raised public awareness about pancreatic cancer. Pancreatic ductal adenocarcinoma accounts for about 90% of these cancers (including Swayze and Smith), with nearly all occurring in the main or branch ducts of the pancreas, while neuroendocrine cancer accounts for the remaining 10% (including Jobs). “In the old days, we found 20 |

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these cysts, called intraductal papillary mucinous neoplasms (IPMNs), only when people were at the end stage of pancreatic cancer – when the cyst spread outside the pancreas and became lethal,” Dr. Jagannath notes. “Now, we’re finding them early. The explosion in CT and

MRI imaging has increased the number of incidental pancreatic cysts that are detected, which are present in 1 to 2% of the population, and higher in older adults.” Dr. Jagannath explains that incidental cysts are often found when patients present to the ER with abdominal

pain and get a CT scan. He cautions primary care physicians, “Pancreatic cysts are clinically relevant, in contrast to many liver and renal cysts, which are common and not clinically relevant. They shouldn’t be ignored.” These cysts typically don’t cause symptoms until

IMPN GUIDELINES Location

Size/Symptoms

Guidelines for Follow-up

Branch duct IMPNs

Under 1 cm; no symptoms

Yearly exam

1 to 2 cm; no symptoms

CT, MRCP or EUS every 3 – 6 months

3 cm or more, contain a mass, or associated with dilatation of main pancreatic duct

Resection

Main duct IMPN

Under 3 mm

Yearly exam

3 to 6 mm

Imaging every 3- 6 months; more aggressive treatment when symptoms present

Over 6 mm

Resection


patients should be resected. When main duct cysts are 3 mm to 6 mm, we follow them with repeat imaging studies. If a patient also has symptoms, we need to intervene more aggressively.” Dr. Jagannath continues, “Patients with incidental branch duct cysts can be treated less aggressively. Studies have shown that only 10 to 20% become cancerous over a 10-year period. They’re very curable if caught early and still contained within the pancreas; however, once they extend outside the pancreas, the 5-year survival rate is less than 5%.” He adds, “Branch duct cysts over 3 cm increase the risk of cancer and should be resected. Smaller cysts should be followed with repeat CTs or MRCPs (MR cholangiopancreatography). Older and/or sicker patients are treated less aggressively.” “My personal feeling is that every cyst should be biopsied once,” he adds. “The best method is endoscopic ultrasound with fine needle aspiration (EUSFNA), which provides a better view of the cyst. If the cyst changes, we may repeat the biopsy or go to surgery, depending on other factors. The guidelines aren’t perfect and involve lots of imaging. In the future, molecular analysis to identify certain DNA mutations in cells will better determine which cysts will turn cancerous.” Sanjay Jagannath, MD, FASGE, AGAF, is a gastroenterologist and director, Pancreas Center, at Mercy’s Institute for Digestive Health and Liver Disease.

they are so advanced that treatment options are limited. The dilemma for physicians is managing them to minimize the chance of progression to cancer without subjecting patients to unnecessary testing and treatment. Since 2006, gastroenterologists have relied on a

set of guidelines that classify pancreatic cysts by size and location. Cysts are divided into those found in the main duct and the branch ducts. “I tell patients that benign is benign and cancerous is cancerous, but with precancerous cysts, it’s hard to predict when or if they’ll

turn cancerous,” says Dr. Jagannath. “The size and location of the cyst matter. Cysts in the main duct are more aggressive and when they are greater than 6 mm in this area, studies have shown that two-thirds of these patients will develop carcinoma in situ. These

He advises primary care physicians to:  Ask for a family history of pancreatic cancer. Refer those with two or more first-degree relatives to a gastroenterologist for assessment and genetic counseling.  Patients with late onset diabetes (over age 65) may have pancreatic cancer and should be screened with endoscopic ultrasound. MARCH/APRIL 2012

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Finally, Dr. Jagannath cautions, “We don’t want to pay attention to the tree and ignore the forest. A Japanese study showed that patients with a pancreatic cyst had one and a half times the risk of developing a new cancerous cyst or mass elsewhere in the pancreas. We need to be vigilant for those as well.” NEW TREATMENT FOR AN OLD PROBLEM

Precision Endoscopic IRC for Hemorrhoids Rudra Rai, MD, MBA, FACG, Assistant Professor at Johns Hopkins University, and Director of the Gastro Center of Maryland, is helping innovate new technologies to treat common ailments such as hemorrhoids. Hemorrhoids are estimated to affect about 75% of adults at some point in their lives. “It’s one of those common maladies, especially for women after childbirth or those who don’t get enough exercise or fiber in their diet. It can also be related to irregular bowel habits, prolonged straining, genetics, obesity and those who do heavy lifting or sit for long periods,” notes Dr. Rai. “We always start with conservative therapies, such as increasing the amount of fiber in the patient’s diet, drinking more water, and using topical steroids,” he comments. “Patients can also use a variety of overthe-counter ointments, suppositories or pads. Straining makes the problem worse, so probiotics, stool softeners and avoiding sitting or standing for prolonged periods can help. When conservative measures don’t work, we may consider treatments such as band ligation, infrared coagulation or hemorrhoidectomy.” Dr. Rai advises referring physicians to rule out other potential causes of blood in the stool. “Patients don’t worry because think they only 22 |

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have hemorrhoids, but they can have an inflammatory or neoplastic process, which is serious and warrants investigation. Physicians should make sure they check for a family history and screen for cancer in patients with rectal bleeding. Before age 50, 10% of people will have polyps, increasing to about a third of the population after that age.” Older non-surgical therapies include:  Sclerotherapy, in which a chemical solution is injected into the hemorrhoid, does not cause pain but is less effective than other approaches for most patients and is generally limited to use in grade 1 hemorrhoids.  Band ligation, which has been used for grade 3 hemorrhoids, uses a tiny band to tie off internal hemorrhoids. However, the procedure causes significant bleeding and discomfort. Coagulation techniques have emerged in the past few years as an alternative to the other non-surgical approaches. Infrared Coagulation (IRC) is one such technique, using laser-like, focused heat to cut off the hemorrhoid’s blood supply. It also helps shrink external tissue. “The drawback of this approach includes a relatively crude anoscope with limited lighting and vision, and limited reach,” says Dr. Rai. It also has had a higher recurrence rate than some other approaches. Precision endoscopic IRC, a new approach to coagulation developed by Michael Epstein, M.D. and colleagues, allows gastroenterologists to advance the distal tip of the colonoscope to the cecum. It uses a colonoscope or sigmoidoscope with fiberoptic technology to provide an unobstructed 360° view. “The new device improves visibility and access to the

Rudra Rai, MD, MBA, FACG is an assistant professor at Johns Hopkins University, and director of the Gastro Center of Maryland. He is a staff gastroenterologist at Howard County General Hospital.

internal hemorrhoids, and allows precise application of the infrared energy,” explains Dr. Rai. “This makes the procedure more effective. More than one hemorrhoid can be treated during the procedure and it is sufficiently painless that some patients opt not to receive sedation.” He adds, “While IRC has typically been used in grade 1 and 2 hemorrhoids, we are also seeing great responses in early grade 3 hemorrhoids using precision endoscopic IRC. Thus, we can offer this to a wider range of patients with less discomfort. Another advantage is that gastroenterologists can perform a diagnostic colonoscopy or sigmoidoscopy, and take care of the hemorrhoids in the same procedure.”

The new IRC approach has received FDA approval and has been tested in more than 100 patients in multiple centers. The study is being submitted to surgical journals as Maryland Physician goes to press. Most insurers cover the procedure. Hemorrhoidectomy is the procedure of last resort. It should be reserved for patients who fail less aggressive therapies or those for whom endoscopy is contraindicated. Dr. Rai concludes, “It takes most patients up to a week to recover and they often experience significant pain and sometimes infection. The problem may also return in a few years and surgery is contraindicated in inflammatory conditions such as Crohn’s Colitis.”


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Healthcare IT

mHealth Be Ready for

Why physicians should become familiar with mobile healthcare tools / BY LIN DA HARDER

What is mHealth? What is mobile health, often

known as mHealth? While definitions vary, the term generally refers to using mobile devices, such as mobile phones, PDAs and tablets, to support health services or information. Mobile devices can be used for a variety of health-related tasks, including accessing medical information from the web and helping patients better monitor or assess a wide variety of health and fitness indicators. 24 |

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Current Physician Usage Primarily for Education

Patient Usage is Exploding, Moving Beyond Fitness

While most doctors are not using mHealth for patient care, mobile devices have become ubiquitous for practicing medicine. More than 75% of doctors now use smart phones, and tablet use within the hospital or medical practice is skyrocketing. Popular mobile apps for physicians include:

mHealth tools and applications for patients are exploding, and the reality is that many people are or soon will be using one or more mHealth technologies in their lives. One estimate puts the number of health-related mobile apps at more than 17,000. Most apps have been oriented to fitness and weight management, but that’s changing. Emerging applications include:

 Medscape Mobile – news, full-text journal articles, CME and reference materials  Sermo – doctor-to-doctor social network enables on-the-go discussions  MIM Mobile – FDA-approved remote diagnostic imaging tool  ICD-10 Premium 2011 – details of ICD-10 diagnostic codes  JEMS Video Consult – HIPAAcompliant viewing of live medical consults Hospitals, an important part of the mobile trend, are beginning to use tablets to create helpful tools such as customizable dashboards for physicians to quickly access key patient health data such as vital signs, lab results and medications. Physicians have been slow to adopt mHealth for patient health monitoring. Ed Bennett, director, Web & Communications Technology at University of Maryland Medical Center, says, “There’s a legitimate inertia among physicians to use e-devices. Few studies exist showing its efficacy and physicians are right to be cautious given the accompanying legal and privacy issues.” Suzanne Sysko Clough, M.D., a Maryland endocrinologist and founder/ CMO of WellDoc, Inc., one of a small number of Maryland physicians creating interactive mHealth tools, concurs. “mHealth adoption by physicians is exactly where it should be, given where we are in the life cycle of innovation. The diffusion of innovation takes some time, but there are early adopters out there who recognize the ability of some of these solutions to move the needle on health outcomes as well as increase revenue, both directly and indirectly, to the practice. It will also help as more mHealth applications receive FDA clearance.”

 Continuous glucose monitoring  Sleep monitoring  Checking blood pressure and other vital signs  Electrocardiograms  Using saliva and a smartphone to diagnose infectious disease  Monitoring glaucoma  Screening for genotypes before administering some medications The potential for mHealth to extend care beyond the medical office is vast. “The healthcare system really is built to best support subacute and acute care,” Dr. Clough says. “Chronic disease is all about behavior change and giving patients the skills and confidence to self-manage their disease for the long haul. mHealth can enable physicians to support and encourage behavior change ‘virtually’ during those 8,700 hours a patient is out on their own, living day to day with their disease.”

patients with type 2 diabetes who used WellDoc’s DiabetesManager for one year cut their ER visits and hospitalizations by more than half. To physicians who believe that patients won’t use this type of device because they currently don’t check their blood glucose levels, Dr. Clough says, “Of course patients aren’t checking them now – they’re just dumb numbers. We need to provide the data in context – tying a blood glucose value to a specific event and then helping the patient learn from the data. This is done via both clinical and behavioral algorithms, because people have a lot more going on in their lives than their disease.” She continues, “Some programs provide only one-way text messaging. That can be effective for certain health care issues. But complicated chronic diseases need more. We’re using analytic tools geared to the needs of both patients and providers. Effective solutions must employ advanced analytics, user segmentation, behavioral change and just-in-time feedback. Most importantly, solutions must be simple to use and encourage users to engage and stay engaged.” “Don’t assume patients won’t use mHealth solutions because they’re ‘non-compliant’ now,” Dr. Clough adds. “The biggest wake up call I’ve had is how much of patient non-compliance really stems from poor health literacy and/or feeling overwhelmed or frustrated by their disease. You would not believe how

“mHealth can enable physicians to support and encourage behavior change virtually...”– Suzanne J. Czinn, M.D. One of WellDoc’s products is DiabetesManager, an FDA-approved software-based medical device powered by a proprietary Automated Expert Analytics System™. It provides real-time patient coaching plus clinical decision support to their healthcare providers, extending care beyond traditional office visits. In a study published in the September, 2011 issue of Diabetes Care, patients using this mHealth device had an average decline in A1C of 1.9% compared to a 0.7% decline seen among patients not using the system. In a second study – a recent demonstration project called DC HealthConnect – Medicaid

powerful something as simple as a positive message about checking their BG can be. At home, patients get only a number on a meter that often is not even looked at by a physician. There will soon be a lot of mHealth options out there. Physicians should ask if it has FDA clearance and demonstrated outcomes, if it can be integrated into your practice work flow and determine the expectations of your involvement with the solution.” For now, physicians should be aware of what apps their patients are using and what mHealth options are available, so that they can use – and guide patient usage of – these tools as appropriate.

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Profile

SPONSORED CONTENT

A Near-Normal Childhood for Those with Digestive Diseases

T

The University of Maryland Children’s Hospital Is Child-Friendly in Every Respect

HE RAPID GROWTH AMONG the division of gastroenterology at the University of Maryland Children’s Hospital, which now treats nearly 5000 patients a year, is not surprising given that it combines child-friendly care with worldclass technology and expertise. Steven J. Czinn, M.D., professor and chair of pediatrics at the University of Maryland, says, “The staff have created an incredible experience for children with digestive disorders and their families. They’re highly responsive, getting patients in quickly and bringing cutting-edge technology to treat and diagnose virtually every stomach and intestinal disorder.”

providing child-friendly care. Nearly 100 children at the University of Maryland have had an accurate diagnosis in the distal colon, which cannot be reached by either a colonoscopy or an endoscopy. “This ‘black box’ as it’s called, has now been opened,” notes Dr. Safta. “We can tailor the treatment for the disorder, rather than treating the child blindly. We can see problems such as inflammatory changes and ulceration that lead to an accurate diagnosis and save years of improper treatment.” Dr. Safta explains the procedure. “After the child swallows the capsule,

“The staff have created an incredible experience for children with digestive disorders and their families." – Steven J. Czinn, M.D., professor and chair of pediatrics The pediatric GI specialists see children and teens downtown and across the state, in the patients’ own communities. “We have clinics in Bel Air and Glen Burnie, and we’re also at Mt. Washington Pediatric Hospital several days a week,” observes Anca Safta, M.D., director of endoscopy. “Our team has grown to five full time and several part time physicians, plus a nurse practitioner, six RNs, a dietitian and an infusion tech.” “Our staff includes Dr. Alessio Fasano, the world’s authority on celiac disease, who is both treating patients and conducting the research to help cure it,” adds Dr. Czinn, who is a recognized leader in H. pylori research, immunology and vaccination. Capsule Endoscopy Peers into the ‘Black Box’

The use of wireless capsule endoscopy (PillCam) is a major advancement in 26 |

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(s)he wears a belt with a special receptor for eight hours. Soon thereafter, we can download the images and give the family an answer in a day or two. Thanks to this technology, a teenage girl with severe pain was diagnosed with celiac disease after other tests indicated she was in remission. She is now doing well on a gluten-free diet and Remicade.”

Components of the Pediatric Digestive Disease Center      

Pediatric IBS Center Celiac Center Pediatric Infusion Center Eosinophilic Center Multi-disciplinary Care Outreach Clinics

Comfort Reigns at Infusion Center

Patients who need bimonthly infusions of biologic therapies such as Remicade, or IV iron and fluid repletion are treated as outpatients in the Pediatric GI Infusion Center, where skilled pediatric nurses administer care in a comfortable setting complete with flat screen televisions. “We can keep most children out of the hospital thanks to this infusion center,” says Dr. Czinn. Comprehensive Procedures

The University of Maryland Children’s Hospital provides everything to diagnose and treat pediatric GI disorders except for ERCPs and ultrasound endoscopy, including:             

Upper endoscopy Sigmoidoscopy Colonoscopy Feeding gastrostomy and gastro-jejunal tubes Gastrostomy closures Liver biopsies Breath testing to evaluate carbohydrate malabsorption and bacterial overgrowth Capsule endoscopy Impedance and pH probe testing Antroduodenal, anorectal, colonic manometry Variceal banding and/or sclerotherapy Polypectomy Suction rectal biopsy

Treatment of Virtually all GI Disorders

Virtually all stomach and intestinal disorders are treated, including:  IBD – Crohn’s disease and ulcerative colitis  Celiac disease  Liver disease, including pre/post transplant care, biliary atresia


 GERD  Eosinophilic esophagitis and gastroenteropathies  Hepatitis B and C  Organic and functional GI disorders, including IBS, chronic abdominal pain, functional constipation, dyspesias  Carbohydrate malabsorption  Failure to thrive and special needs  Metabolic disorders  Short bowel syndrome Medication regimens are tailored for each individual patient. Many children also benefit from working with the onstaff dietitian, who creates a tailored diet plan that ensures the child gets the nutrients needed for growth – with foods he or she likes and will eat. Surgery is a last resort. “The need for colectomy is decreasing, thanks to better medications,” explains Samra Blanchard, M.D., division head of pediatric gastroenterology. “However, when it’s necessary, our pediatric surgeons are experts at using the latest minimally invasive procedures to reduce trauma and recovery time.” When to Refer A Child

Consider referral when a child has:  Recurrent reflux, constipation, abdominal pain, or diarrhea  Rectal bleeding  Unexplained weight loss  Delayed growth and development

Anca Safta, M.D., director of endoscopy at The University of Maryland's Children Hospital.

"[Using capsule endoscopy], we can see problems such as inflammatory changes and ulceration that lead to an accurate diagnosis and save years of improper treatment." – Anca Safta, M.D.

“Our goal is to diagnose GI disorders before they cause delayed development or irreversible harm,” Dr. Blanchard says. “With timely diagnoses, children can reach their full potential and live a nearly normal childhood.”

For more information, physicians may contact all University of Maryland physicians and services at 1-800-373-4111 or Pediatric Gastroenterology directly at pedsGI@peds.umaryland.edu.

MARCH/APRIL 2012

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Living

T

Sponsored by Salisbury University, the Sea Gull Century Ride is a 100-mile bike ride with about 8,000 participants from around the globe.

HERE IS NO BETTER WAY TO see the country than from the seat of a bicycle, where not even a windshield stands between you and the miles of beautiful landscape. For many physicians like Robert Stroud, M.D., a radiologist who spends hours in dark rooms reviewing patient films and images, bicycling is the perfect escape from their busy schedules. “Biking is an ideal way to get outside and see 20, 30, 40 miles of gorgeous scenery,” Dr. Stroud said. “And it’s great exercise.” Whether pedaling down roads or trails, physicians across Maryland have embraced cycling as a stress relieving pastime. The state offers a variety of riding options, ranging from casual group rides through 28 |

COURTESY OF SEA GULL CENTURY

Gearing Up For Spring Allison Eatough and Jackie Kinsella

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the hills of Baltimore County, along the C & O Canal and the long-distance races along the Eastern Shore. “Whether you’re going riding with your kids, long distance biking, racing, mountain biking, or commuting to work, bicycling is a lifetime sport,” explained Marc Lefkowitz, vice president of Race Pace Bicycles. Not only does biking accommodate many different lifestyles, it also positively affects some of the world’s health and environment issues. “Bicycling is completely healthy, good for the environment, and takes care of so many of today’s problems, such as carbon footprint and obesity. Biking is all good,” Lefkowitz further offers.

It All Starts With The Fit

For the best and most comfortable ride, it all starts with the fit. Bike frames and components must be designed a specific way to fit women and men, and to accommodate different-sized people. In the shop, small adjustments can then be made to the seat height and handlebars, but to guarantee a perfect fit, a custom bike can be built to your exact measurements and preferences. Fitting a rider to a bike is an art; an experienced fitter will take into account exactly what the rider wants. Along with fitted measurements, custom bikes also offer uniqueness, flexibility in design, and practicality if your bodily proportions are far from typical.


Physicians On The Open Road

Garth Smith, M.D., an orthopedic surgeon in Annapolis, and Patrick Cooper, M.D., a military neurosurgeon at Walter Reed Military Medical Center in Bethesda, prefer early morning rides to relax and clear their minds before a long day of work. “The rare times that I am not obligated to pick kids up from school or Tae Kwon Do, I will ride into work,” Cooper commented. “Weekends when not on call are optimal, but on more than a few occasions, I’ve been paged to an emergency while in the middle of a great ride up at Schaeffer Farms (in Germantown).” “Finding fellow cyclists to ride with also helps,” said Smith, who rides with several other physicians on a regular basis. “It is a good way to get together.” Not only is riding with a group safer than riding alone, but it also adds a nice friendly competition to the ride and causes you to challenge yourself and your skill level against other riders. “Another option is riding with a bike-shop sponsored group,” Dr. Stroud contributed. Joining a bike-shop sponsored group is an excellent way to meet others that share your passion. Throughout the year, group and weekend rides are offered in shops all over Maryland. Race

Pace Bicycles, which has locations throughout Maryland, offers indoor training rides and mountain bike rides among other types. Getting Competitive

For physicians who want to push themselves even further, there are dozens of bike races throughout Maryland in spring, summer and fall. In preparation for races and long

rides, Dr. Smith recommends road riders start with an individual time trial in which cyclists’ race alone against the clock. “It’s basically the race of truth. There are no accidents with another cyclist.” “Roadies looking for more of an endurance challenge could tackle a 100-mile race like the Sea Gull Century in Salisbury,” Dr. Stroud said. “Just be prepared to log some training miles beforehand.”

If you long to feel the electricity at the starting line of a race, here are a few area events to get you moving: Church Creek Time Trial (road) Date: June 23, 2012 & August 18, 2012. The Church Creek Time Trial is a 40-kilometer smooth, fast and scenic course in Church Creek, just outside of Cambridge. Hosted by the Annapolis Bicycle Racing Team, the time trial is usually part of the Time Trial Series. Sea Gull Century (road) – Date: October 6, 2012. The Sea Gull Century is a 100-mile or 100-kilometer bike ride hosted by Salisbury University. The ride takes participants through Wicomico, Somerset and Worcester counties. www.seagullcentury.org. Bay Country Century (road) – Date: September 1, 2012. The Bay Country Century includes a 25-, 50-, 62- and 100-mile bike ride hosted by the Annapolis Bicycle Racing Team. The ride takes participants along the Chesapeake Bay’s western shore. www.abrtcycling.com. MoCoEpic (mountain) – Date: October 14, 2012. The MoCo Epic is a 25-, 35-, 50- and 62-mile ride hosted by Denis Chazelle that crosses up to 10 different Montgomery County parks. www.mocoepic.com. Greenbrier Challenge (mountain) – Date: April 29, 2012. The Greenbrier Challenge race course is 5.7 miles long, and the number of laps depends on the racing class. Hosted by Potomac Velo Club, the race is held in hilly and rocky Greenbrier State Park in Boonsboro. www.greenbrier.potomacvelo.com

COURTESY OF SEA GULL CENTURY

Fit is paramount, but once the measurements are right, choose the bike that most appeals to you. “Finding the right bike is essential,” advised Stephen Jack, co-owner of Bike Doctor in Annapolis. “First, determine the types of riding you want to do and to what degree. With road, mountain or cyclocross, the more miles a cyclist plans to ride in a month, the better the components need to be on the bike.” A solid riding bike can cost anywhere from $500 to $5,000. When deciding on the right bicycle budget to fit your lifestyle, it is important to remember that spending more buys a lighter bike with smoother shifting, braking, and more durability. When figuring out a budget, “Don’t forget the accessories, such as helmets, padded shorts, gloves and bright clothing so drivers notice you,” Jack added. For more competitive cyclists, a small bike computer is a great investment, measuring distance, speed and time.

The Sea Gull Century takes participants throughout the scenic roads of Wicomico, Somerset, and Worcester counties.

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Policy

Interview with Douglas F. Gansler, Attorney General LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

Maryland Physician Publisher/Executive Editor Jacquie Roth and Managing Editor Linda Harder recently sat down with Attorney General Douglas F. Gansler to discuss his efforts to support physicians and protect consumers. He also comments on speculations that he will run for governor in 2014.

Q:

You are the first Attorney General to work with physicians to pass the Assignment of Benefits Law, which dealt with assignment of benefits for non-preferred providers. Why did you take on that issue?

Everyone needs a doctor at some point. We want to make sure that doctors have an advocate in state government and that’s the role I took upon myself… doctors have to get more politically active. Planners fashion the debate and shape it as they want it to be. Doctors think they’re immune from it… They think, ‘I’m just here to take care of people.’ I think MedChi has grown in influence in more recent years… some doctors are getting more involved and realize that what happens in Annapolis does indeed affect them and consumers.

Q:

Why were you the lead in filing an amicus brief to the U.S. Supreme Court supporting the Affordable Care Act (ACA)? 30 |

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We were the lead state in the amicus brief that supported the Patient Protection and Affordable Care Act. Not because we agree with all of the provisions of the act – most of us, like most Americans, haven’t read all of it. Our role in that was to say yes, the federal government does have the authority to address the healthcare crisis and does have the ability to pass laws… The Department of Justice asked us to take the lead because of our role in some of the cases in the lower courts. We were able to speak from the perspective of states regarding issues of the federal government… The Supreme Court took on four issues… The biggest one was, ‘Does congress have the ability to pass this law?’…

Q:

What challenges will states face in implementing this law?

The states will have great challenges in implementation. One of the great things about the PPACA is that, from the 30,000foot level, it’s a federal solution to a


national problem, but they give states the ability to fashion the essential services as they choose. I’m on a commission that the governor set up to look at implementation in 2014... Josh Auerbach is our principal counsel at the Department of Mental Health and Hygiene (DHMH) working with Secretary [Joshua] Sharfstein on this issue. So, Maryland is in the forefront. If for some reason it does get overturned over by the Supreme Court, we will still be able to implement much of what is in the act.

Q:

What is the likelihood that the Supreme Court will uphold the law?

It should be a 9-0 decision. The federal government can make you pay Social Security and get a driver’s license, they can take your children to die in wars across the world…. clearly, they can have you buy health insurance. But the Republicans made this a political issue... The problem is that everyone needs to avail themselves of the healthcare system at some point… That said, this is perhaps the most political Supreme Court we’ve ever had… and these are difficult cases to defend based solely on jurisprudence. Most people think this will be a 5 to 4 decision, not withstanding the absurdity of the argument.

Q:

What are your greatest healthcare accomplishments?

Each legislative session, we try to support at least one MedChi-sponsored bill. Tanning and truth in advertising are two 2012 session issues that they’ve identified for us. The ‘truth in advertising’ bill is so that you know who you are seeing, what degrees they have, what they’re supposed to be practicing. The bill hasn’t been drafted yet, but the concept is one that we would embrace. We also support MedChi on not having children use tanning booths. Our Healthcare Education and Advocacy Unit (HEAU) is probably, on a day-to-day basis the thing that affects people the most... It’s the unit that mediates between patients and the insurance companies. The bread and butter of an AG’s office is protecting consumers, especially the small person against the big guy. When the insurance company denies you coverage, you have no recourse. To hire a lawyer to address your claim would cost more than what you’re entitled to recover. The insurance companies bank on that… What the

HEAU can do is, at no cost, is mediate; they will come in and ask the insurer why they didn’t cover the procedure… That’s the most important thing we’ve done. … Kathleen Sebelius [secretary, Department of Health and Human Services] came to our office and was touting our program as a national model. We have a large federal grant to educate patients and providers about the program. Many providers don’t know that they can do it on behalf of the patient. The outreach coordinator has been going to providers’ offices to educate them... I’m President-elect of the National Association of Attorneys General (NAAG), and one of the initiatives I put forward is the prescription drug take-back program… We’re working on the whole state of Maryland becoming a take-back state so that anyone who has expired prescription drugs in their home, can take them back to the pharmacy where they will dispose of them in an environmentally friendly way… We’re going to try to get all 1200 Maryland pharmacies to participate. The antitrust exemption for the insurance companies is outrageous. We (NAAG) sent a letter to Congress trying to get that removed in 2010. The other thing we do is that we’ve brought literally millions and millions of dollars back to Maryland for our cases against the drug companies for off-label marketing and other issues. One of the things MedChi brought to us early on was the issue of physician ‘tiering’ by insurance companies. Patients were using that ranking to determine where they were going to go for their care... The problem was that the insurers didn’t explain that cost factors were part of that rating. Patients thought that it meant that the doctor was rated the best. We brought that issue to the task force and… insurers were forced to disclose [their methodology] as a result.

Q:

What impact has the HEAU had on insurance complaints?

We received 1934 consumer complaints through November 30, 2011. Some of those are not legitimate or are referred to MIA because it doesn’t fall into our jurisdiction. If we can get it and we have jurisdiction over it, we have a great success rate. We mediated 919 of them, and 781 of those had positive results – that’s an 85% success rate. We recouped $961,000 through November 30th for Maryland

consumers… If we had more people, we could do more, and if more people knew to avail themselves of the unit, I imagine those numbers would go up.

Q:

Are you planning to run for governor in 2014? To what do you attribute your successful fundraising?

There’s no campaign going on right now… I have two events a year – one in Baltimore and one in Montgomery County – we’ve been doing that for about 14 years and we haven’t changed that component... I like to think that people in Maryland think we’re doing a good job protecting consumers, protecting and helping doctors is a piece of that. The great thing about our job is we’re against criminals and we help a lot of people in a lot of different ways… Right now, we’re looking at Google’s new privacy statement. All these things add up. I was the first state-wide advocate for same sex marriage and a lot of people think that’s the right thing to do. I don’t have a natural constituency… but we’ve been fortunate to have people support our efforts.

Q:

If you were to run for governor, what would your healthcare initiatives be?

I’m not running for governor so I don’t have a platform or whitepaper on that. We have been very involved in healthcare issues such as access. That said, it’s a moving target. We’re in a crossroads right now, from the old way medical services were delivered to having a new way by 2014. Lending a supportive role on the legal side is critical… My overriding message, whatever I run for, is that I am supportive of doctors. I have the utmost respect for them. I think they get into the profession not to make money but to help people… Doctors work really, really hard and for very little money while they learn their trade. I think we ought to make sure that our government supports our doctors. Note: HB 585, which regulates the use of physician rating systems by carriers, took effect in 2010. The bill prohibits carriers from using a physician rating system unless the system is approved by a ratings examiner. Note: The Health Education and Advocacy Unit offers a mediation service to consumers who have a billing dispute with their health care provider or a coverage dispute. File appeals online at www.oag.state.md. us/consumer/ HEAU.htm or call 410-528-1840.

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Papercamera...................................................................32 www.papercamera.com MEDENT EMR.................................................................32 www.medent.com University of Maryland ............................................35 www.umm.edu/diabetes Adventist Healthcare.................................................36 www.adventisthealthcare.com

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Jacquie Roth - Publisher/Executive Editor 443-837-6948 jroth@mdphysicianmag.com


Compliance

Common Sense Measures Ensure a HIPAA Compliant Practice By Sigrid C. Haines

A

RE YOU AND YOUR staff confused by the many evolving rules of HIPAA (Health Insurance Portability and Accountability Act of 1996) and overlapping state laws? Are you tired of attending mind-numbing seminars? If so, you have lots of company. As noncompliance can be costly, a few common sense tips to help your staff adhere to HIPAA rules follow. HIPAA has several aspects, including the “Privacy Rule” and the “Security Rule.” In 2009, the Security Rule was affected by the HITECH Act (Health Information Technology for Economic and Clinical Health). The Privacy Rule and Security Rule apply when “covered entities” (healthcare providers, health plans and clearinghouses) transmit or store information in electronic format. The only practices exempt from HIPAA are those very few that have entirely paper-based medical records and claims transmissions. HIPAA implementation has generated a series of complicated and unread legal forms, such as:  Notice of Privacy Practices (notifying patients as to how a covered entity uses their protected health information)  Business Associate Agreement (multipage contractual obligations required for businesses that assist the covered entity’s provision of healthcare services). Like many legal documents, these forms only become important to the affected parties after they are breached. Even the term “protected health information” (PHI), which has a precise legal meaning, should be thought of, in day-to-day practice, as medical records and health insurance information. The first obligation of HIPAA compliance is to use common sense to protect medical records. Providers must

follow the Security Rule’s specific standards that require administrative, physical, and technical safeguards for records. Administrative standards include office training and policies and procedures designed to protect the confidentiality of personal health information. Physical safeguards refer to the physical protection of records. Technical safeguards refer to transmission and other such data transfer issues. Many security issues cross several of these areas. HIPAA’s implementation is designed to be on a “sliding scale,” according to the size of the practice. Thus, a large teaching hospital will be held to a higher standard than a solo practice physician. However, failures in HIPAA security implementation often arise from a failure to think through what the HIPAA standards really mean: protecting the confidentiality of protected health information from reasonably anticipated threats. When evaluating its security measures, a practice must assess:    

Its size, complexity and capacity Its technical infrastructure The cost of security measures The probability of potential risks to electronic information

As a practical matter, this means that office staff should be trained to absorb the concept behind patient confidentiality. For example, in each covered entity’s office, staff should consider how breaches are likely to occur. The answers will vary from office to office and may include:  Re-designing office space (e.g., adding locked filing cabinets or a separate medical records room, or reconfiguring the reception area so that the

      

receptionist’s computer screen is not visible to visitors). Training staff (e.g., teaching staff not to hand patients a stack of referral slips to allow the patient to look for his own). Purchasing a paper shredder. Programming desktops to require a password to log in and to log the user off after a period of inactivity. Implementing a system to track the activity of computer users. Requiring the use of passwords on electronic portable devices that can be easily lost or stolen. Requiring staff to sign an annual confidentiality reminder. In a high-crime area, enhancing the physical security of the area where the records are stored.

Proper HIPAA implementation will always require that staff be trained not to search for medical records for which they do not have a bona fide, work-related need. Many HIPAA breaches are triggered by a simple desire to satisfy curiosity. Physicians must enforce a prohibition against removing records from the office (or, if those records are to be removed, such as to allow an employee to work from home, ensure that the records be encrypted). Sigrid C. Haines practices law at Lerch, Early and Brewer where she chairs the firm’s Elder Law and Healthcare groups. She can be reached at schaines@lerchearly.com

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Good Deeds

“Camp Oasis” Offers Inspiration to Youngsters with Inflammatory Bowel Disease

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environments. It gives them a chance to relate to others.” Campers get to participate in a variety of activities, ranging from archery and baseball to swimming, arts and crafts, games and other group-oriented events. In addition to interacting with Dr. Schwartz, they are supported by a camp nurse, a mental health specialist and a team Dr. Jeff Schwartz spent time answering questions and providing of camp counselors, advice to those who participated in Camp Oasis last summer. He will return to serve as medical director for the West Virginia camp many of whom have once again, in 2012. inflammatory bowel some participants call Camp Oasis a true disease themselves. home away from home. “The counselors are incredible role “Many of these kids have never met models. They have had similar anyone else with the disease,” McNeil experiences but have gone on to do great said. “Here, they can be themselves and things,” Dr. Schwartz said. “It is really build friendships with people who important for the younger kids to see understand what they are going through. that. It motivates them and makes them They get to do a lot of things that they realize that they can be successful too.” normally cannot do, and they feel good Since its launch in 1997, over 4,250 children have participated in Camp Oasis, about it.” McNeil encourages physicians who which has grown from a small program to encounter patients with inflammatory one that is positively impacting children, bowel disease to utilize the CCFA web and can ask questions or site, which features an Information Center to support those are not comfortable talking Resource diagnosed and their caregivers.

ORE THAN 1.4 million Americans have been diagnosed with inflammatory bowel disease. Of those, approximately 140,000, or 10%, are children. Recognizing the challenges faced by young people who suffer this condition, each year the Crohn’s and Colitis Foundation of America (CCFA) offers “Camp Oasis” in locations across the country, giving youngsters with the disease a chance to come together in a safe and under-standing environment to learn, interact and perhaps most importantly, just be kids for a week of summertime fun. In 2011, Jeff Schwartz, M.D., division director of Gastroenterology at Maryland General Hospital for the past three years, volunteered his time to serve as medical director for Camp Oasis in High View, West Virginia, which attracted 52 campers from surrounding states, ranging in age from seven to 18. While administering medication and tending to the general health and medical needs of the campers was Dr. Schwartz’s primary focus, another equally important role was to simply to be available to support and encourage a group of kids who face an abundance of challenges in day-to-day life.

“Kids come to camp tell stories that they about in other environments. It gives them a chance to relate to others.”–Dr. Jeff Schwartz “Kids with inflammatory bowel disease often have unpredictable lives,” said Dr. Schwartz, who will return to Camp Oasis to serve as medical director again in 2012. “They come to camp and can ask questions or tell stories that they are not comfortable talking about in other 34 |

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and their ability to cope with their disease, across America. In 2011, a total of 12 camp sessions were offered in 11 locations coast to coast. Caneka McNeil, Mid-Atlantic Regional Education and Support Manager for CCFA, who is a Crohn’s disease patient herself, says that

This resource, along with further information about Camp Oasis, is available by visiting www.ccfa.org or calling 1-888-694-8872.

Maryland Physician would like to hear about your “Good Deeds.” Please share your ideas with us at news@mdphysicianmag.com.

COURTESY OF THE CROHN’S AND COLITIS FOUNDATION OF AMERICA

By Tracy M. Fitzgerald


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Maryland Physician Magazine/March April 2012