M A RY L A N D
Physician YOUR PRACTICE. YOUR LIFE.
VOLUME 3: ISSUE 2 MAR/APR 2013
THE EVOLUTION OF EMERGENCY CARE THERE'S AN APP FOR THAT INTERVIEW WITH DELEGATE DAN MORHAIM, M.D. GERD AND HIATAL HERNIAS
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VOLUME 3: ISSUE 2 MAR/APR 2013
F E AT U R E S
12 The Evolution Of Emergency Room Care Beyond fast track
18 Preventing GERD and Hiatal Hernias from Turning Deadly Our GI experts discuss why upper GI/esophageal conditions may go unrecognized, how to detect them and when to take action. D E PA R T M E N T S
| 9 | Diagnosing and Managing Colon Cancer in the Young
| 11 | Top 10 New HIPAA Changes for Physicians
| 24 | Using mHealth for Patient Care
| 28 | Addressing the Social Antecedents of Health Problems and End-of-Life Issues
| 30 | St. Michaels, Maryland: Culture, History and Wine
| 33 | Understanding Meaningful Use Stage 2
| 34 | Putting New Technologies in Patientsâ€™ Hands
On the Cover: Drew White, M.D., emergency physician and chairman of Emergency Medicine at Washington Adventist Hospital
JACQUIE COHEN ROTH PUBLISHER/EXECUTIVE EDITOR firstname.lastname@example.org LINDA HARDER, MANAGING EDITOR email@example.com
I’m passionate about what I do professionally: connect cuttingedge treatments, physicians, healthcare stakeholders, practice management solutions and healthcare policy. My mission is to enable you to have the information to make the best decisions about treating your patients and inspire you to do more outside of the rigors of your daily practice regimen. More – whether it’s research focused; community focused or even just getting away and focus on yourself and your family. My team and I have created a multi-dimensional platform with the print magazine you’re holding in your hands, online and via social media to engage you. Often, my inspiration for content comes from the healthcare experiences of those close to me. One of these personal experiences led to our case this month on colon cancer in the young, which also ties to March as “Colorectal Awareness Month” (see “Cases” page 9). Colon cancer is the second leading cause of cancer deaths in America. Screening is not just for the 50+ set. I couldn’t do what I do without Maryland Physician Managing Editor Linda Harder. In this particular issue, she’s done an outstanding job of spotlighting true leading-edge treatments here in Maryland – both on the clinical side and via healthcare policy. Our cover story on the evolution of emergency departments underscores that there’s dramatic growth in emergency services. Linda spoke with a number of ED docs who are leading the way to make ED care more efficient and effective, while reducing unnecessary testing (page 12). While outlining last year’s March/April issue, Linda and I were intrigued by one of the newest innovations in healthcare, mHealth (mobile health). At that time, it was challenging for us to find Maryland docs using apps on their smart phones and the variety of mHealth apps was more limited. The world has changed! According to ABI Research, 26 billion apps are expected to be downloaded world-wide this year and 136 billion in 2017. Incredible numbers! In December 2012, Linda and I attended an mHealth conference with more than 5,000 attendees. The message was loud and clear: mHealth is the new economy in healthcare. It cuts across organizational boundaries, allowing patients to be actively engaged in managing their health and reducing care delivery costs (page 24). Perfectly aligning with our ED cover story, Linda and I sat down with Maryland House of Delegates Representative Dan Morhaim, M.D. – the only physician in the House of Delegates. “Dr. Dan” has over 30 years of front-line clinical experience treating patients in emergency and internal medicine. His clinical experience made him realize that many of his patients’ problems had social antecedents that could best be dealt with outside the ED. The way to fix that, he saw, was to become a politician and make a change through legislation (see page 28). I hope we’ve inspired you to make a change, even if it’s as minor as uploading an app for your own personal health. Let us know. To health!
ERIN JAMES, ASSOCIATE PUBLISHER firstname.lastname@example.org CONTRIBUTING WRITERS Tracy Fitzgerald Jackie Kinsella PHOTOGRAPHY Tracey Brown, Papercamera Photography www.papercamera.com BUSINESS DEVELOPMENT Eileen Nonemaker email@example.com EXECUTIVE ASSISTANT/WEBMASTER Jackie Kinsella firstname.lastname@example.org Maryland Physician Magazine – Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC. a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 949 Annapolis, MD 21404 443-837-6948 www.mojomedia.biz Subscription information: Maryland Physician Magazine is mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52.00. To be added to the circulation list, call 443-837-6948. Reprints: Reproduction of any 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 MICHAEL EPSTEIN, M.D. Digestive Disorders Associates STACY D. FISHER, M.D. University of Maryland Medical Center REGINA HAMPTON, M.D. FACS Signature Breast Care DANILO ESPINOLA, M.D. Advanced Radiology GENE RANSOM, J.D., CEO MedChi CHRISTOPHER L. RUNZ, D.O. Shore Health Comprehensive Urology Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources.
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Jacquie Cohen Roth Publisher/Executive Editor email@example.com @mdphysicianmag
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Diagnosing and Managing Colon Cancer in the Young By Jonathan Schreiber, M.D.
CASE: In 2003, a 38-year-old
African-American woman was seen in the emergency room with crampy lower abdominal pain and diarrhea. She was diagnosed with irritable bowel syndrome and referred to her primary care physician. An anti-spasmodic was prescribed; when her symptoms persisted, she was referred to a gastroenterologist. Evaluation and management of irritable bowel syndrome was discussed. The patient initially denied any rectal bleeding. With further questioning, she reported, “Sometimes my hemorrhoids bleed when I have diarrhea.” A sigmoidoscopy was recommended. The patient did not have that test and did not return until four months later. Her crampy abdominal pain and diarrhea continued, with occasional episodes of bleeding. A colonoscopy demonstrated a well-differentiated adenocarcinoma of the sigmoid colon, later staged as T3/N2. The patient underwent low interior resection and adjuvant chemotherapy. She is now 10 years post-operative and post-chemotherapy without signs of recurrence.
DISCUSSION The value of routine colon cancer screening is widely recognized both in the lay public and in the medical community. As a result of implementing routine colon cancer screening at age 50, the overall incidence of colon cancer has declined. On the other hand, colon cancer in younger populations continues to rise, according to the National Cancer Institute. The case above illustrates several issues that arise in diagnosing and managing younger patients. Colon cancer increases with age. Nonetheless, about 10% of all cases occur in those under age 50. Certain younger population groups such as AfricanAmericans are at high risk. There is ongoing discussion as to whether routine screening exams should begin at an earlier age in that group, perhaps at age 45. The onset of screening is not the issue for this patient; rather, she has symptoms that necessitate evaluation. Sometimes patients will say, “But I’m not 50; I’m too young for colonoscopy.” Physicians should explain that age dictates when asymptomatic patients should be evaluated, but not when those with symptoms should. The symptom of bleeding is an especially common and important one. Repeated episodes of bleeding require evaluation, almost without exception. Deciding whether to perform a sigmoidoscopy or a colonoscopy in a young patient may be difficult, and should in part be based on his or her age, degree and duration of associated symptoms, and other risk factors. A family history of colon cancer may tip the scales toward a more complete evaluation. The point is that some anatomic evaluation must be done. Many patients deny the significance of their symptoms. Patients often initially report that they have no bleeding, but when pushed, report bleeding that they
discounted as being due to hemorrhoids. It is important to question carefully for this symptom. The myth that ‘bright red blood is not serious’ may also need to be addressed. Unfortunately, a rectal cancer is as likely to produce bright red blood as is a hemorrhoid. Hemorrhoids are not inherently dangerous; however, falsely attributing dangerous symptoms to them may be. The long-standing presence of hemorrhoids does not preclude patients from developing other more serious pathology. Physicians should address all of these issues when discussing the need for a sigmoidoscopy or colonoscopy. Interestingly, at the same time that patients are outwardly denying the severity of their symptoms, they often are quite worried about the possibility of cancer. This should be addressed as well. Young patients should understand that rectal bleeding should be evaluated. While hemorrhoids are the most likely cause, if more serious pathology is found, it is more likely to be inflammatory rather than neoplastic in nature. The goal is to inform the patient and convince them of the importance of further workup without overly frightening them. This patient proved to have a rather advanced cancer, which is not unusual in a younger population. The reasons for this are unclear but may have to do with more aggressive tumors in the young, and/or diagnosis later in the disease course. Fortunately the outcome here was favorable. Most young patients with diarrhea and rectal bleeding will prove to have benign disease such as irritable bowel syndrome and hemorrhoids, or perhaps even inflammatory bowel disease. Nonetheless, a workup to exclude colon cancer is essential even in patients under age 50. Jonathan Schreiber, M.D., is a gastroenterologist at Mercy Medical Center.
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Top 10 New HIPAA Changes For Physicians
By Sarah E. Swank
HE LONG-AWAITED CHANGES to HIPAA were released on January 25, 2013, overhauling physicians’ current obligations. Practices should begin reevaluating their business associates, policies, training and notice of privacy practices to come into compliance by September 23, 2013. The top 10 HIPAA topics for physicians follow.
1. Business Associates For the first time, business associates and downstream subcontractors must enter into agreements with their subcontractors ensuring protected health information (PHI) is safeguarded. Conduits or those who have custody of PHI are now considered business associates.
2. Access of Individuals to Protected Health Information
Physicians must send record copies directly to another individual when requested in writing by the patient. This request must be signed by the patient and clearly identify the designated person and their address. Individuals will now be able to request electronic copies of their PHI that is maintained in an electronic health record (EHR) or other electronic designated record set. Covered entities must provide an electronic, “machine readable copy” accommodating individual requests for specific formats, if possible. Physicians may charge a reasonable fee that complies with state law.
3. Disclosures About a Decedent to Family Members and Others Involved in Care
Physicians may disclose a decedent’s information to family members and others who were involved in the care or payment for care of the decedent,
unless inconsistent with any prior expressed preference of the individual.
4. Disclosures of Student Immunization to Schools
Physicians may provide school immunization records with the assent of a parent, guardian, or person acting in loco parentis as long as this agreement is documented and complies with state law.
8. Research Conditional and unconditional authorizations for research are permitted, if they differentiate between the two activities and allow for an opt-in of unconditional research activities, such as data repositories and tissue. Future research studies may now be part of a properly executed authorization, except for psychotherapy notes, which may be combined only with another authorization for their use or disclosure.
5. Marketing Authorizations are required for treatment or other communications, if the physician receives financial remuneration from the third party of that product or service. Exceptions exist for subsidized refill reminders or communications about a currently prescribed drug or biological, as well as certain face-to-face communications or gifts of nominal value.
9. Right to Request a Restriction of Uses and Disclosures
Individuals may now restrict certain disclosures of PHI to a health plan where the individual, family member or other person pays out of pocket in full for the healthcare item or service, noting the restriction in the medical record. Physicians can submit restricted information for required Medicare and Medicaid audits.
6. Sale of PHI A physician must obtain an authorization before receiving direct or indirect remuneration in exchange for the sale of PHI, except for certain activities related to public health activities, research, treatment, the sale or other business consolidation or record copy fees.
7. Fundraising The Privacy Rule permitted physicians to use or disclose certain PHI to a business associate or related foundation for fundraising purposes without an individual’s authorization, as long as an opt-out was provided (e.g., a toll-free number or email address). Once the individual opts out, physicians cannot provide further fundraising communications described in the opt-out.
10. Modifications to the Breach Notification Rule
Physicians must report breaches of unsecured electronic PHI to individuals and HHS, along with the media, if more than 500 individuals are affected. Harm is no longer a consideration in defining a breach. If more than 10 notifications to individuals are returned as undeliverable, substitute notice must be provided “as soon as reasonably possible” within the required 60-day notification period. Reports are valid even if the media fails to publish the breach; however, posting a general press release on a website is insufficient. Sarah E. Swank, a principal in Ober Kaler’s Health Law Group, can be reached at firstname.lastname@example.org.
BY LINDA HARDER PHOTO GRAPHY BY TRACEY BROWN
THE EVOLUTION OF
EMERGENCY ROOM CARE >> BEYOND FAST TRACK
Maryland Physician interviewed four emergency physician leaders to learn how various area emergency departments (EDs) have found better ways to evaluate patients, coordinate between shifts, provide humane psychiatric care, and even detach ED care from the hospital.
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hese advances take place against a backdrop of dramatic growth in emergency services; nationally, ED visits doubled in less than a decade, with wait times increasing 25% from 2003 through 2009. Population growth and aging, physician shortages and healthcare reform all make it likely that this trend will continue. Innovative approaches such as the ones described here enhance patient safety and convenience in these fast-paced environments.
Rapid Medical Evaluation: Keeping Patients Vertical For decades, the traditional model of treating a patient in the emergency department (ED) involved ‘serial processing’ – having a triage nurse assess the patient and then having them wait until the physician or mid-level provider could treat them. Even the advent of Fast Track systems did not significantly change this serial approach. A program at
Drew White, M.D., emergency physician and chairman of Emergency Medicine at Washington Adventist Hospital.
Washington Adventist Hospital has altered that model by having a team consisting of a nurse, physician and patient care technician see each patient as they arrive. Drew White, M.D., emergency physician and chairman of Emergency Medicine at Washington Adventist Hospital, initiated a pilot Rapid Medical Evaluation (RME) program in 2009. He says, “Nationally, the door-to-doctor times have been increasing in the past 15 years, and a long wait time is a predictor of bad patient outcomes. Our model addresses that gap by having a care team triage the patient, perform an initial exam, provide initial treatment and assign the patient to the appropriate level of care. If a treatment room is available, we start that process right in the room.” Dr. White notes that, while Washington Adventist did not invent the model, they were one of the first to launch it in this region. “What makes it successful is the way we implemented it
and that we have been able to sustain our gains,” he explains. “We performed intensive staff training, conducted focus groups, solicited input from people on the front line, and provided lots of data and feedback. For the first few weeks, we had frequent huddles to discuss how to address issues that arose and altered the plan as needed.” The hospital found that the model was most useful during peak times, typically 11 am to 9 pm. The model employs an additional full-time physician or physician assistant during these hours and dedicates two rooms to the RME. However, the costs of more staff and significant coordination are more than offset by other savings and benefits. “Our LWBS (left without being seen) patients went from about 4% to about 0.5%, versus a national average of 1% to 2%,” Dr. White comments. Other RME advantages relate to reductions in unnecessary testing, faster
treatment, and improved patient satisfaction. “Studies have shown that up to one third of patients don’t need to be subjected to lots of testing,” notes Dr. White. “We can address their medical issues right from the start and give them what they need to get better. Lots of EDs have triage nurses that can issue standing orders, but by using physicians and midlevel providers, we can customize the orders and decrease unnecessary testing. We order the correct tests for the patient and start the optimal medical treatment earlier, including giving IV fluids and medication. When we finish the initial triage and exam, everyone, including the nurse, tech, and patient, know the plan of care and what to expect.” He concludes, “Other advantages of this approach are decreased testing denials and the ability to stay off diversion far more often, so more people can come here for care. Our patient satisfaction is now among the highest in
Medical Director Eric Weintraub, M.D.at the University of Maryland Medical Center
“Patients needing medical stabilization must be cleared medically in the main ED before they come to us.” – Eric Weintraub, M.D.
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the country and our ED has had a higher growth rate than the regional average.”
Safer Sign Out: Bedside Rounding Dr. White and the team also sought to address the highly variable and high-risk sign out process among ED physicians during change of shift. “An estimated 80% of serious medical errors involve miscommunication between caregivers when patients are transferred or handed off,” he explains, “with 24% of ED malpractice claims involving these faulty handoffs. The Joint Commission has identified this as a National Patient Safety Goal. In place of the typical process, which involves giving a quick verbal report to the incoming physician, we now have a standardized communication tool and process for bedside rounding on all patients at shift change. The incoming doctor meets the patient instead of merely reviewing a chart.” Dr. White continues, “We will be presenting this concept at the Maryland Patient Safety Conference in April. It seems like a common sense idea, but it is a revolutionary change in practice. The more times you round on a patient, the more likely you are to pick up something.
With this approach, the incoming doctor knows what tests the patient is waiting for and, during the rounding, the physician may pick up on changes in the patient’s condition since they last checked him or her. We piloted this program at Calvert Memorial Hospital, Washington Adventist Hospital, and some of the other hospitals where Emergency Medicine Associates practices, and then we expanded it to all of our hospitals.”
Dedicated Psychiatric Emergency Services In contrast to many EDs, where mental healthcare typically consists of psychiatric consultants and a small section of the main ED, the psychiatric emergency services (PES) department at the University of Maryland Medical Center (UMMC) focuses solely on psychiatric/ addiction evaluation and care for those in crisis. Medical Director Eric Weintraub, M.D., was recruited in 2010 to head up this new service, which sees patients from as far away as Frederick and the Eastern Shore. During his tenure, volumes have grown from about 2500 to 3500 patients/year. PES patients enter through a central
triage area shared with the main ED. Those deemed to require psychiatric intervention and who do not have an acute medical problem go directly to the PES department, located within the same building. “We have parameters for blood glucose, blood pressure and other clinical syndromes such as chest pain,” notes Dr. Weintraub. “Patients needing medical stabilization must be cleared medically in the main ED before they come to us.” A team of attending psychiatrists, psychiatric nurses, psychiatric residents and social workers staffs the PES. An attending psychiatrist is available from 8 am to 9 pm on weekdays and 8 am to 4 pm on weekends. The space includes both an unlocked and locked area and patients are triaged to either side according to the acuity of their symptoms. The locked side can accommodate about 15 patients on reclining chairs and that accounts for nearly 80% of the total patient volume. The unit also includes a shower, a small room for interviews, and two seclusion rooms that can be left open or closed. “The advantages of this model,” Dr. Weintraub enthuses, “are that we can identify the patient’s major mental health issue(s) and then better manage the crisis, including starting patients on medications, performing crisis interventions with a variety of therapies and when appropriate referring patients to other appropriate mental health resources. We can forge a therapeutic alliance with the patient, and prevent a lot of hospitalizations. It’s not uncommon for patients to spend the night here so that we can watch and evaluate them overnight. Many people come in intoxicated from alcohol, cocaine, or other drugs including synthetic marijuana; after a few hours, their behavior often changes and you can get a much better assessment than you could have upon arrival.” “To the best of my knowledge, our PES is unique in Maryland,” continues Dr. Weintraub. “We refer patients to other great mental health services such as Baltimore Mental Health Systems, Baltimore Crisis Response Inc. and Healthcare for the Homeless. Where we can refer them is dependent in large part on their insurance and where they live.” Dr. Weintraub encourages referring physicians to call the PES before they refer a patient. He advises, “We depend on family, friends and physicians for
collateral information. We like to know what medications the patient is on, what their issue is, and what might have caused a crisis. Patients often tell us, ‘My doctor just told me to come in.’ We’re happy to speak with doctors by phone to get the information we need to better care for their patients.”
Freestanding EDs Come of Age By the early 2000s, explosive population growth and traffic congestion in upper Montgomery County had conspired to make it challenging at best for ambulances and those needing emergency care to get to an ED. The closest EDs were at Shady Grove Adventist in Rockville, which was handling some 90,000 visits a year and Frederick Memorial Hospital. Ambulance service was hampered by long out-of-service times required to travel to and from the available EDs. The solution? After years of addressing legislative and regulatory concerns about a freestanding center, in 2006 Shady Grove Adventist was able to open the first freestanding ED in Maryland in Germantown. Brett Gamma, M.D., chief of emergency services at Shady Grove Adventist Emergency Center at Germantown, describes the results. “The goal was to increase emergency access for upper Montgomery County residents and we’ve accomplished that,” he notes. “We have 19 private beds in a 17,000 square foot facility that sees about 37,000 patients a year. We diagnose, treat and stabilize patients, then transfer them to the hospital if needed. Most patients are discharged back home. Today, some 8 to 10% of our patients are transferred, up from 2006 when people were less educated about our ability to handle true emergencies.” Dr. Gamma explains that the freestanding ED can treat all emergencies. Patients who require surgery, cardiac catheterization, or a labor and delivery suite are stabilized and transferred to the hospital. He comments, “We can stabilize heart patients and get them to the cath lab at the hospital, which is a Cycle III Chest Pain Center, in a comparable amount of time as patients who present to the hospital directly. For stroke patients, we can give TPA before transferring them for definitive care.” In fact, the transfer times for ST-Elevation Myocardial Infarct (STEMI) patients from the Emergency
Center at Germantown to the catheterization lab in the main hospital is in the top 15% of the nation. The Center prides itself on being part of a hospital system that received a Gold Achievement Award for cardiac care and is an accredited Chest Pain Center and Primary Stroke Center, with one of the best door-to-TPA times in the state. The freestanding center also scores well on other clinical outcome measures, such as providing appropriate use of blood cultures and antibiotics to patients with community acquired pneumonia. “Our goal is to provide these to 100% of all community-acquired pneumonia patients within specified time frames,” comments Dr. Gamma. The center has comparable technology to that at a hospital-based ED. “We have all the technology we need, including ultrasound, high resolution CT and a dedicated lab that has incredibly fast turnaround because we’re not sharing it with inpatients,” Dr. Gamma continues. A Picture Archiving Communication System (PACS) provides digital imaging to radiologists at the hospital.
Brett Gamma, M.D., chief of emergency services at Shady Grove Adventist Emergency Center
The hospital recognized that it would be critical for the freestanding ED providers to have the same training and experience as those at the hospital – in fact, the same board certified emergency physicians rotate between the two EDs. The majority of patients who are discharged to home are discharged in less than 150 minutes. “Patient satisfaction is high, but perhaps no one is happier than those involved with EMS. They can now return to service for the next patient much faster,” he adds. Starting 2010, legislation requires the state to set reimbursement rates for freestanding emergency facilities in Maryland, bringing them under the authority of the Health Services Cost Review Commission and making them available for Medicare and Medicaid fee-for-services reimbursement. The Germantown ED is no longer the only one in the state; in 2010, a similar freestanding ED, the Queen Anne’s Emergency Center, opened on the Eastern Shore. The growth in freestanding facilities in Maryland mirrors a national trend; as of 2009, there were more than 240 freestanding EDs in the country.
Point of Care Testing Expands Point of Care testing (POCT) has been available to some extent for more than a decade, but several newer tests that deliver results in minutes rather than hours or days are now in use. Since 2007, the market for cardiac, stroke and infectious disease (especially HIV) POCT has roughly doubled. POCT includes the measurement of blood glucose, blood gas and electrolytes, rapid coagulation, rapid cardiac markers, drugs of abuse, urine strips, pregnancy testing, fecal occult blood, food pathogens, hemoglobin, infectious disease and cholesterol. While POCT may not decrease overall ED time significantly, “It gives the best care in the most efficient time,” according to Dov Frankel, M.D., assistant director of the Emergency Department at Sinai Hospital of Baltimore. “We can get results in less than two minutes using two drops of blood.” Dr. Frankel states, “POCT involving cardiac enzymes has made a huge difference in getting patients to the cath lab on time, and is especially valuable in anyone with an equivocal story that may or may not be cathed depending on the troponin results. 16 |
Dov Frankel, M.D., assistant director of the Emergency Department at Sinai Hospital
Since time is muscle, these tests are important for speeding treatment.” The most commonly tested cardiac markers (enzymes or proteins that tend to be concentrated when a cardiac event is likely to or has occurred) are Total CPK (creatine phosphokinase), CK-MB (creatine kinase) and troponin I/T. Myoglobin levels may also be tested. Testing for these markers can reliably indicate when intervention is or isn’t necessary. Lab-based tests can take up to 1.5 hours, which has driven demand for the point-of-care products that can deliver “stat” results. For patients with suspected MI who are first seen by their own physician, Dr. Frankel advises referring physicians to run basic chemistries or check INR instead of sending people to lab or ED to check. The Sinai ED also has found that POCT has improved the ability to determine which patients can benefit from TPA. “Using POCT to test the International Normalized Ratio (INR) for patients with suspected strokes has allowed ED physicians to decrease the time to administer TPA so that more patients can receive it within the threehour window,” Dr. Frankel notes. POCT is also useful for patients suspected of having internal bleeding with signs of pallor, shortness of breath, etc. “They can get a hematocrit in minutes, compared to an average of one hour for a ‘stat’ lab test. That allows us to give that patient a blood transfusion far faster,” says Dr. Frankel. However, Dr. Frankel believes there are certain conditions that should be diagnosed and treated even before the
labs come back, such as heart failure and sepsis, which are based on the clinical presentation. He comments, “These labs are still useful but patients should be treated before the lab results are back.” Those using POCT need rigorous systems to ensure ongoing quality. At Sinai, providers scan their badge, the patient’s badge and then the cartridge used in the POCT. Quality Control staff checks the machines weekly and recalibrates them as necessary. Dr. Frankel says, “I tell residents to ensure that the test result matches up with the patient’s clinical presentation, or redo it.” While the Sinai ED doesn’t yet offer a POCT CBC test for white counts, platelets and infections, Dr. Frankel acknowledges that this test would be useful. Perhaps surprisingly, however, he finds another valuable POCT test is the blood quantitative pregnancy test. “One in eight patients in our waiting room is pregnant. They came in due to a problem such as vaginal bleeding, but they often don’t know they’re pregnant.”
Drew White, MD, MBA, FACEP, chairman of Emergency Medicine and president of the Medical Staff, Washington Adventist Hospital. Eric Weintraub, M.D, associate professor and division head, Psychiatry, University of Maryland Medical Center Dov Frankel, M.D., assistant director, Emergency Department, Sinai Hospital of Baltimore Brett Gamma, M.D., chief of Emergency Medicine, Shady Grove Adventist Hospital.
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BY LINDA HARDER
PREVENTING GERDANDHIATAL HERNIAS FROM TURNING DEADLY
OUR GI EXPERTS DISCUSS WHY UPPER GI/ESOPHAGEAL CONDITIONS MAY GO UNRECOGNIZED, HOW TO DETECT THEM AND WHEN TO TAKE ACTION. 18 | WWW.MDPHYSICIANMAG.COM
Colleen Christmas, M.D., geriatrician and associate professor of medicine at Johns Hopkins Bayview Medical Center,
Steven Fleisher, M.D., chief, Division of Gastroenterology; and director, Interventional Gastroenterology Program at MedStar Franklin Square Medical Center.
OME 25 MILLION Americans are believed to suffer on a daily basis from gastroesophageal reflux disease (GERD) – better known as heartburn – and as much as 40% of the adult U.S. population are estimated to experience it less frequently. Some of these patients also suffer from a hiatal hernia, which is typically asymptomatic. For most patients, these conditions are a serious nuisance, but not a serious health hazard. The challenge for physicians lies in determining how to treat these common disorders before they become dangerous, without subjecting patients to unnecessary treatment. The rise in GERD, believed related to the epidemic of obesity and other lifestyle factors, is associated with an
increase in esophageal adenocarcinoma. This cancer has grown six-fold in the past 30 years, while squamous cell carcinoma (often associated with smoking and alcohol use) has declined. Given its former obscurity, physicians trained several decades ago may be less likely to recognize the potential for chronic GERD to turn cancerous. To manage GERD, patients should avoid alcohol, greasy foods, sodas, mints, licorice, chocolate and smoking. They should eat smaller, more frequent meals and avoid a large meal within a few hours of bedtime. Losing weight is also helpful. “Modest weight loss and a prudent diet are often sufficient to manage symptoms,” notes A. Steven Fleisher, M.D., chief, Division of
A PATIENT RESOURCE: ECAN To educate the public about the link between heartburn and cancer, a new advocacy group called the Esophageal Cancer Action Network (ECAN) was formed here in Maryland. Mindy Mintz Mordecai founded ECAN in 2009 after her husband died from late-stage esophageal adenocarcinoma. Visit www.ecan.org.
“Our practice uses the Prague Criteria, which is becoming the accepted classification for endoscopically-suspected Barrett’s.” – Steven Fleisher, M.D.
Gastroenterology; and director, Interventional Gastroenterology Program at MedStar Franklin Square Medical Center. If chronic use of over-the-counter antacids is necessary, patients should consult their primary care physician. In turn, primary care doctors should refer patients to a gastroenterologist if reflux continues for several years. While GERD medications are generally safe and effective, chronic use not only may indicate the need for further evaluation, but also may lead to osteoporosis and an increased risk of infections such as clostridium-difficile (C. diff). “Make sure the patient’s vitamin D levels are adequate so they can absorb calcium,” Dr. Fleisher advises.
Barrett’s Esophagus Compounding the issue is the fact that patients’ heartburn symptoms may decline or disappear not only with medication but also as their disease progresses. Chronic reflux can cause the esophageal lining to be damaged so significantly that it resembles stomach lining and causes discomfort to abate at the same time that the risk of cancer increases. This condition, called Barrett’s esophagus, is a strong risk factor for esophageal adenocarcinoma. The normal progression is from the initial stage of metaplasia to low grade dysplasia, high grade dysplasia and cancer; however, a Danish study published in the October 13, 2011 issue of the New England Journal of Medicine found that the annual risk of this cancer was only 0.12%, lower than the previously assumed risk of 0.5%. In the December 2, 2012, issue of the Annals of Internal Medicine, the American College of Physicians published guidelines for using upper
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endoscopy in GERD patients, as well as guidelines for screening for Barett’s (see sidebar). Patients with GERD should receive endoscopy if they also experience dysphagia, bleeding, weight loss or recurrent vomiting, or if they have not responded to medication after several months. If Barrett’s is found, Dr. Fleisher advises endoscopy surveillance at least every three years for patients who have Barrett’s without dysplasia and as often as every six months for those with dysplasia.
Treatment: EMR and Ablation Gastroenterologists often perform endoscopy to evaluate the mucosa of the esophagus for strictures and the presence of Barrett’s. Until 2007, when the Prague C & M (circumference and maximal extent) criteria were developed, consistent assessment criteria were lacking. Dr. Fleisher says, “Our practice uses the Prague Criteria, which is becoming the accepted classification for endoscopically-suspected Barrett’s. In non-dysplastic Barrett’s, four quadrant biopsies should be obtained every two centimeters in the involved esophageal segment. Barrett’s is suspected endoscopically when the normal pearlpink mucosal lining is replaced with a salmon-pink appearing mucosa. We also often see associated hiatal hernias. The length of the Barrett’s segment correlates with more significant cancer risk. While it’s unusual, some patients have one third to one half of their esophagus affected.” “If any nodular components are present,” he continues, “we perform an endoscopic mucosal resection (EMR). EMR can be a cure for very early stage adenocarcinoma and it can be performed at the time of initial endoscopy, but often
isn’t. Endoscopic ultrasound is often performed to assess for depth of invasion, and local lymphadenopathy prior to resection of sub-centimeter lesions. If the pathology shows disease limited to the lamina propria or muscularis mucosae, in the absence of lymph node metastases, lymphovascular invasion, or poor differentiation EMR provides definitive therapy. Nevertheless, these patient need close short term endoscopic surveillance.” Dr. Fleisher adds, “EMR involves using an endoscope with tools to suction up the affected tissue. A band is deployed around the lesion, which is then removed with a snare and electrocautery. We may inject submucosal saline to lift the lesion away to facilitate banding. When the sub mucosa is involved, medically fit patients will need esophagectomy. More extensive disease may need chemotherapy and radiation before or after surgical resection.“ Following EMR, the remaining affected tissue is ablated, typically using radiofrequency (RF) ablation. A study published in the September 2012 issue of Gastroenterology found that initial RF ablation might not be cost effective for patients with Barrett’s in the absence of dysplasia, but may be appropriate for confirmed and stable low grade dysplasia, and is superior to endoscopic surveillance in high grade dysplasia. Dr. Fleisher notes, “RF ablation is recommended along with photodynamic therapy and EMR for eradication of
WHO SHOULD BE SCREENED FOR BARRETT’S? Males over age 50 with:
GERD symptoms for 5 years Smoking history High body mass index, esp. abdominal fat
Hiatal hernias Dysphagia, bleeding, weight loss or recurrent vomiting Source: American College of Physicians
Adrian E. Park, M.D., MIS/GI surgeon and department chair of Surgery at Anne Arundel Medical Center
Barrett’s esophagus according to a March 2011 position statement on the management of Barrett’s esophagus by the American Gastroenterological Association (AGA). In selected cases, we also perform cryoablation, a technique that is still investigational for the management of dysplasia in Barrett’s esophagus. Prospective studies that demonstrate its comparable effectiveness are not yet completed. Cryotherapy freezes the involved tissue using liquid CO2 or liquid nitrogen. We use the latter, applying it for about 20 seconds in two to three applications. Patients appear to tolerate the procedure well other than some chest discomfort.”
When to Treat Hiatal Hernias Surgically Hiatal hernia, the most common diaphragmatic hernia, is a broad term that covers a variety of conditions in which an anatomical structure pierces the membrane of the diaphragm. While
the cause is often unclear, these hernias occur more often in women, those who are overweight, and those over age 50. Because a hiatal hernia may not create symptoms until there is an emergent situation, it is often discovered incidentally. Hiatal hernias are classified as Type I through Type IV, with Type I denoting a sliding hiatal hernia (roughly 80% of hiatal hernias) where the gastroesophageal (GE) junction followed by the body of the stomach protrudes through the esophageal hiatus and above the diaphragm. In the less common paraesophageal hernias (Types II – IV), the fundus is displaced into the mediastinum above the GE junction. Type IV denotes a large defect in the phrenoesophageal membrane that allows other organs, including the colon or spleen, to slip up into the chest. Adrian E. Park, M.D., MIS/GI surgeon and department chair of Surgery at Anne Arundel Medical Center,
explains, “Most hiatal hernias develop over a long period of time. Patients may have had GERD 10 to 15 years ago but then their symptoms subsided. However, if they get full quickly when they eat and have shortness of breath, they may have a hiatal hernia. The danger is that the hernia can twist suddenly and strangle the stomach, requiring urgent surgical intervention.” “Only 1 to 2% of these hernias need surgery,” continues Dr. Park, “but it’s a challenge to determine when surgery is necessary. Data shows that if we plan surgery electively, the mortality and morbidity rate is 1/5th to 1/20th that of emergency surgery. As a result, we’ve learned to err on the side of being aggressive. The great judgment required is when to intervene with patients who are not highly symptomatic. The way I approach it is to talk with the family members about the patient’s eating habits, their activities of daily living and whether they’re losing weight.”
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Dr. Park notes that many patients have lost their exercise tolerance and can’t walk around the mall or grocery store. “It happens so insidiously and slowly that patients often are worked up first for cardiac and pulmonary issues,” he comments. “Once it is determined that they have a large or paraesophageal hiatal hernia, surgery often allows them to improve their pulmonary function and, as a result, their exercise tolerance.” Laparoscopic surgery has greatly improved surgical outcomes for hiatal hernia repair. Dr. Park declares, “If you can prevail laparoscopically, you should; patients get up much more quickly and that makes all the difference. While 98% of patients are elderly, they can go home within two days and usually spend less than two hours in the OR.” Though not a fan of GI robotic surgery, Dr. Park says, “The camera systems and instruments used in the laparoscopic procedure are continuously improving. The interest in a single incision approach has waned and four to five incisions of 5mm are more the norm.” Dr. Park advises, “When seeking a surgeon, referring physicians should look for a surgeon who does at least several procedures per month with good pre and peri-op education and a nurse and nutritionist on the team. Some of these procedures are extremely complex and should be concentrated in select centers. The mortality rate should be under 1% and the complication rate less than 6%.” Unless patients are willing to make long-term adjustments to their lifestyle, the surgery may not be worthwhile. Dr. Park comments, “I tell patients that if they can’t commit to lifestyle and dietary changes, which in fact constitute a healthier way to eat and live, such as eating smaller and more frequent meals daily and chewing their food well, deep breathing and core/aerobic exercises, then they shouldn’t undergo surgery and we’ll part as friends.”
A. Steven Fleisher, M.D., general and interventional gastroenterologist; chief, Division of Gastroenterology; and director, Interventional Gastroenterology Program at MedStar Franklin Square Medical Center. Adrian E. Park, M.D., general surgeon and department chair, Surgery, Anne Arundel Medical Center
THERE’S AN APP FOR THAT USING MOBILE HEALTH FOR PATIENT CARE BY LINDA HARDER
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While attending the 2012 mHealth Summit just outside D.C., Maryland Physician explored how providers can select among some 15,000 apps to connect meaningfully with their patients.
Last year, in our March/April 2012 issue, Maryland Physician reviewed the nascent state of mHealth (mobile health) and noted that physicians primarily used it for reference and clinical decision support. While that continues to be the primary use of mHealth today, patient monitoring and compliance tools have exploded, and more insurers, health systems, wireless carriers and entrepreneurs are taking the necessary first steps to use these tools to improve patient health. In the process, the doctor visit is becoming a smaller piece of the health delivery pie. Using an app, providers can generate automatic reminders to patients to take medications or administer injections, or monitor their cardiac health on a daily basis, rather than waiting for their next doctor’s visit. Even the FCC is optimistic that mHealth can facilitate less costly, more efficient and more frequent care interventions for patients. Nearly every organization involved in healthcare is looking at mHealth to improve an aspect of care, whether reducing readmission rates, preventing and monitoring chronic diseases, improving medication and therapy compliance, or allowing patients access to mental health care without stigmatization. The approaches range from simple text messages to sophisticated wireless devices that remotely monitor more complex conditions. The role of mobile devices is growing so rapidly that the FCC’s mHealth Task Force’s goal is to have mHealth technology become a routine medical best practice within five years. By 2020, 160 million Americans will be monitored and treated remotely for at least one chronic condition, according to Nerac, a Connecticut research firm. With app availability burgeoning, how can physicians determine which apps make sense for their practice and their patients? A partial list of sources physicians can use to find medically validated apps follows.
FDA CLEARED APPS (THOSE INVOLVING A “MEDICAL DEVICE”)
To ensure the soundness of apps that involve a medical device to monitor patient health, physicians can turn to the elite group of apps that have received FDA clearance. Such clearance is currently required for apps that entail the remote use of a medical device or that transform a mobile device into a medical device (e.g., electronic stethoscopes or glucose meters), unless they otherwise fall under the exempted Class I devices. Examples of products that have obtained FDA approval are WellDoc’s Diabetes Manager (discussed in our March/April 2012 issue), Airstrip OB and RPM (remote patient monitoring), Proteus Biomedical’s “Raisin” skin patch and “intelligent pill” sensor, and AliveCor’s and Corventis’ Nuvant wireless heart monitors. APP CERTIFICATION AND PRESCRIPTION PROGRAM
Happtique (www.happtique.com), a subsidiary of GNYHA Ventures, Inc., the business arm of the Greater New York Hospital Association, may be a useful tool for sorting among the thousands of app options. The company allows providers to prescribe health apps via its secure, developer-agnostic platform, and in early 2013, Happtique launched an App Certification Program (note: as of publication, their standards were still in a draft state.) This program can help providers and consumers determine which apps not requiring FDA clearance have reliable content and meet high operability, privacy, and security standards. APPS VALIDATED BY MAJOR HEALTH SYSTEM STUDIES
Major health systems such as Johns Hopkins and Geisinger are collaborating with mHealth entrepreneurs to design and test patient applications. Such partnerships can provide evidence-based data about the efficacy of various apps. MARCH/APRIL 2013
Healthcare IT Johns Hopkins University’s Wilmer Eye Institute worked with MEMOTEXT, a company that developed a proprietary methodology, algorithm and communications platform to improve medication compliance – a huge issue for providers and costly to payers. “The key to positively affecting the kind of behavior change required in patients who are noncompliant are personalized programs that
Physician Use of mHealth
93% said physicians used mobile technology in day-to-day activities. 80% percent said physicians use mobile technology to provide patient care. Pharmacy management currently is likely to be the area of care receiving the most benefit from mHealth.
Source: The 2nd annual HIMSS Mobile Technology Survey, 2012, that surveyed 180 HIT professionals with mHealth responsibilities.
address their individual issues or barriers to adherence,” says Amos Adler M.Sc., founder and president, MEMOTEXT. “We understand that for technology to work in the mHealth space, we have to ask patients what the best means to communicate with them is, and what is important to them about their condition.” For 60 to 90 days, patients were asked how they were feeling and their complaints were triaged to the appropriate provider. If patients experienced side effects, they were asked if they had reported them. The study found a 31% increase in adherence to daily therapy. Geisinger Medical Center tested a “medical home” initiative among Medicare patients that uses text messaging and other technology to increase patient adherence to treatment regimens. The program decreased hospital admissions by 8% and overall health costs by 4% in the first year.
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WATCH MAJOR INSURERS
Major insurers also have jumped into the mHealth market with both feet in an effort to improve communication and service to members, as well as to improve health. Take Aetna, which purchased iTriage to help its members initially diagnose their health symptoms and match them to an appropriate provider in their area. It recently launched Carepass, an mHealth technology platform that can connect a wide variety of apps and that encourages entrepreneurs to develop new apps. Carepass encourages subscribers to manage their health by providing easy access to insurance information, an ID card, doctor’s visits, nutritional and health and fitness programs, including over 20 health-related apps such as MapMyFitness or GoodRx. Kaiser Permanente views mHealth as a new, “fourth site of care” for healthcare delivery that supplements care delivered in hospitals, clinics and the patient’s home. Kaiser launched a mobileoptimized website and created apps for both Android and iPhone users to allow its nearly nine million members 24/7 access to their medical information anywhere in the world from a mobile device. Members can email their providers, check lab test results, order prescription refills, and manage appointments. A study published in Health Affairs in 2010 found that glycemic, cholesterol and blood pressure measures improved 2% to 6.5% in more than 35,000 Kaiser Permanente patients with diabetes, hypertension, or both by using secure messaging for two months. OTHER APPROACHES
The number of studies validating mHealth approaches is growing on all fronts. For example, a winning abstract at the mHealth Summit presented the results of a smartphone-based platform for preventing alcohol relapse. Some 349 patients participated in the randomized clinical study through June 2011; participants had significantly fewer risky drinking days than did the control group. An online publication for medical professionals, patients, and analysts called imedicalapps (www.imedicalapps.com) offers reviews of apps under the direction of a team of physician editors.
Apple has a list of 80 recommended apps for healthcare professionals that includes every type of app from reference and clinical decision support apps to patient education and personal care apps. However, the rationale for their selection process is not clear, and providers should use other sources to validate the efficacy of apps on this list. RECOGNIZE THAT PATIENTS WANT mHEALTH
Some physicians have not yet realized how ready patients are for mHealth solutions. A recent study found that about three quarters of respondents would like to receive email reminders for doctor’s visits, schedule a doctor’s visit online, and email directly with their doctor. Another global study, conducted for PwC Global Healthcare by the Economist Intelligence Unit (EIU), found: About half of consumers believe mHealth will improve healthcare convenience, quality and cost in the next three years. Nearly half expect mHealth to change the way they manage chronic conditions, medication use and overall health. 59% of consumers using mHealth services say it has replaced some visits to doctors or nurses. The top three reasons consumers want mHealth is to have more convenient access to their provider, reduce out-ofpocket healthcare costs and take greater control over their health. Even Medicare is contributing to the move to mHealth approaches, as its 30-day readmission rule is making remote monitoring technologies an attractive tool to help keep patients healthy and at home. The bottom line is that, while providers are right to tread cautiously when recommending, prescribing or using apps for their patients, they should start now to explore the potential for vetted apps to improve their medical practice. What are your favorite patient care apps or sources for learning about apps? Email firstname.lastname@example.org or leave your comment at www.mdphysicianmag.com.
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Addressing the Social Antecedents of Health Problems and End-of-Life Issues An Interview With Delegate Dan Morhaim, M.D. Maryland House of Delegates, Democrat, 11th District
What led you to become a politician? There were so many things
I saw as a career emergency physician – first as Chairman of Emergency Medicine at Franklin Square for 14 years while building a six-hospital group practice. When I got elected to the legislature in 1994, I moved over to Sinai Hospital, a level-2 trauma center. So many of the cases I was seeing had social antecedents – such as diabetes and preventable trauma. Emergency rooms admit about 70% of patients seen in the hospital, so it’s a focal point. I kept seeing patients with problems that could have been better dealt with beforehand. There are underlying causes for many of our health problems that should be managed before coming to a crisis. In the early 90s, I attending community meetings and asking why we 28 | WWW.MDPHYSICIANMAG.COM
didn’t have curbside recycling. The end result was that I was appointed to the city/county task force on recycling. We designed a system that would work, and now we have recycling in Baltimore County and City. It gave me a sense that governing is hard work and requires attention to details, but that it makes a difference. That experience – and wanting to raise my three children in a world that was healthy and safe – contributed to my decision to run for office.
How did being an ER doctor influence you? As an ER doctor, you get a
direct and immediate indication of what’s going on in the community, and you take care of every kind of person. That requires learning to deal with everyone from a rich person to a drug addict to a young child, as well as the other health providers involved in care delivery. I finally stopped doing emergency medicine about three or four years ago. I calculated that I had not slept at night for 30 days in a row from 1974 to 2007. Over the years, I’ve treated about 170,000 patients. The last three years I worked at Healthcare for the Homeless, and now I’m on their board. And 12 years ago, I joined the faculty of Hopkins Bloomberg School of Public Health, where I do teaching and research. One of the papers I wrote was the data substrate for my book, The Better End: Surviving (and Dying) on Your Own Terms in Today’s Modern Medical World (Hopkins Press, www.thebetterend.com).
What are the most significant end-of-life issues physicians should be aware of? What’s your message to them? We are not comfortable talking
As part of our ongoing interviews with key Maryland policy makers that spotlight initiatives impacting physicians, Maryland Physician recently sat down with the only physician in the 188-member General Assembly. His views on addressing common health problems and their social causes follow.
about end-of-life care, but the more we do, the more comfortable we’ll be. We have a strong cultural and medical taboo against talking about death and dying, but we’re the first generation that likely has a say in how, when, and where we die. The good news is that technology has helped us live longer, healthier lives. The challenge is that, if you have widespread metastatic cancer, do you really want to end up in an ICU in your last days? There are free legal documents – advance directives – that have been around about 20 years. We did a study at Hopkins and found that only about a third of Americans have advance directives.
Describe some of the legislation you’ve been involved with.A lot of my
political actions were informed by my emergency medicine experience. For example, the worst night of my life was seeing three children killed in a drunk driving accident, and so I’ve been involved with bills related to drunk driving. I’ve worked on expanding and improving addiction treatment programs and legislation on the issues of advance directives and end of life care. I’ve done a lot of health care bills, with a focus on helping patients and supporting providers. At this point in my legislative career, I often choose to work on others’ bills and don’t feel the need to be the lead legislator as often. I also work to streamline government operations, saving money through consolidation and efficiency. I’ve also worked on
numerous bills promoting the environment, education, jobs, and public safety.
A lot of emergency medicine has become geriatric. I found myself doing things to patients in the name of care that is not care. A 95 year old comes in from a nursing home in extremis, and the ER staff jumps to full CPR mode, and that person may survive a few hours or days. In a culture that values individual rights and freedom so much, patients can and should have a role in making these decisions. Completing an advance directive doesn’t mean a diminution of care. It’s care according to your wishes and values. But we collectively abdicate on this issue. It’s important to empower people because we can influence this process that we’re all going to confront. And our study showed the people want to discuss this with their physician. End-of-life care costs a lot of money. About 30% of Medicare expenses are for end-of-life care, and expenses are considerable for Medicaid and commercial insurance as well. Presumably if the rate of advance directives went up, more people would choose less intense care and less money would be spent. But we’d be spending less money the right way – through individual decisionmaking. Technology can serve us, but it can also separate us from the process of death and dying. This all starts with the individual filling out the forms. Only you can do the paperwork.
Tell us about your peer-review legislation. When I started years ago
there wasn’t any particular orientation to peer review. When I was in emergency care, I evolved with my colleagues to a reasonably good system, but it wasn’t as well structured or as valuable as it could have been. It’s an important part of healthcare. It’s not just pushing papers around. It actually has to have integrity and value in improving the quality of care. But even the simplest things in healthcare are complicated – treating a sore throat, for example: you have to at a glance evaluate the tonsils, look for exudate, dentition,
wins, and often doesn’t help the patient. The solutions can include mediation, no-fault, open discussions when things don’t go well, and aggressively addressing systemic problems. The tort system we’re currently using is cumbersome, expensive, and rarely fair or helpful.
Gun control – do you think it will pass and what is your position? I think
it will pass, and I’m pretty sure I’ll support it. However, what you really want to do is prevent murders before they happen. The bulk of murders can be traced back to several things. Most shootings are related to drugs. What does it cost to maintain a habit in this area? It’s $25 to $50 per day. If you
“There are underlying causes for many of our health problems that should be managed before coming to a crisis.” – Delegate Dan Morhaim, M.D.
other conditions, etc. Evidence-based medicine is a good thing but can be challenging to translate into practice. I try to remind everyone that healthcare is still delivered by people oneon-one. It’s not the hospital that starts the IV – it’s a nurse, physician assistant, or paramedic. The insurance company doesn’t reduce a dislocated shoulder – it’s me. It’s easy to stand on the outside and make comments, but it’s a lot harder on the inside making the decisions.
Tort reform continues to be a major legislative focus in Maryland. What are your views on this subject?
The macro issue is that first, going back to peer review, you really want to do the best you can – have quality and consistency – before a problem arises. Tort deals with issues after they’ve happened. Second, you want to involve patients and families when bad things happen. A lot of times, people just want to know that they’ve been heard and that their problem is acknowleged. You want to quickly take care of an incompetent doctor, but many times, it’s no one’s fault. Going through a long series of legal cases ends up being a random lottery as to who
multiply that by 75,000 addicts, you get to billions of dollars. Some incorrigibles need to be locked up, but I’m strongly for addiction treatment programs. People do have relapses, as they do for any medical condition, but if you get someone in an addiction program today, at least they’re not committing a crime that day. Over time, most can be rehabilitated. I support medical marijuana, which is another topic. Second, most people who kill each other know each other, despite the occasional horrible exceptions like Aurora or Newtown. Domestic violence issues can be dealt with through more aggressive restraining orders, limiting gun access to those who have been identified as having problems, and so on. Third, there are the mentally ill who are dangerous. Most mentally ill people are not dangerous, and most dangerous people are not mentally ill, but there is overlap. Having done mental health assessments in the ER, sometimes you can tell who is at high risk. For example, patients who have a history of hurting animals or setting fires are at very high risk for violent behaviors. Generally our mental health system needs to improve for regular kinds of mental health problems. (continued on page 31) MARCH/APRIL 2013
St. Michaels, Maryland “The Town That Fooled the British” By Jacquie Roth
HE HISTORIC TOWN OF St. Michaels dates back to the mid1600s, when it served as a trading post for area tobacco farmers and trappers. Located on Maryland’s Eastern Shore, St. Michaels is about halfway between the Susquehanna River and the mouth of the Chesapeake Bay. A tiny, well-preserved port, it’s become a destination for wellheeled Washingtonians as well as visitors from around the Bay and beyond. During the War of 1812, St. Michaels gained its name as "the town that fooled the British." Forewarned that British barges were positioned on the waters to attack with cannon fire, the residents hoisted lanterns into the trees above the city. This first successful "blackout" fooled the British into overshooting the town's houses and shipyards. Only one house, forever since known as Cannonball House, was struck. Last April, I took part in the town’s annual and phenomenally popular WineFest. To say I had a wonderful time would be an understatement – the people, the food, the entertainment and of course, the wine selection were fantastic! I left St. Michaels knowing two things for sure: (1) WineFest would be a regular for every April to come, and (2) with so much culture, history and scenery to explore, a return visit during the quieter off-season was a priority. In January, I did just that.
Chesapeake Bay Maritime Museum – A Must See
Whether planning a day trip, weekend getaway or extended stay in St. Michaels, make it a point to visit the Chesapeake Bay Maritime Museum, located on Navy Point, where you can see a comprehensive collection of artifacts and exhibits that capture the 30 | WWW.MDPHYSICIANMAG.COM
history and beauty of the Chesapeake Bay. Here, you can learn about local naval history, watercraft and boat building traditions, seafood harvesting and the wide array of recreational activities along Maryland’s waterways. While on Navy Point, reserve a few minutes for photos of the historical Hooper Strait Lighthouse. Shop, Shop, Shop
Hoping to bring a piece of the Chesapeake Bay with you as you depart St. Michaels? I found two favorite shops. The first is Ophiuroidea - better known in town as “The O.” Owned by local Maryland artisans Shella Kirchner and Kim Hannon, this fun shop features colorful, beach-themed artwork, accessories and furniture inspired by the coastal landscape. Among the many treasures that can be found here are Louise Taylor Crab Art. These collections of crab photography are pieced together to create dynamic “letter art,” capturing the essence of Maryland seafood in custom-made, historically rich tobacco stick frames. The second is Simpatico, offering a wide range of beautiful artisan products including foods and wines directly imported from Italy. Simpatico has an active list serve highlighting its own special events throughout the year. Check-In and Stay for a While
There is no shortage of inns, cabins, resorts and quaint little bed and breakfast inns that you can check into for a longerthan-a-day stay in St. Michaels. Two spots in particular have generated a lot of tourist “buzz” – the first being the Inn at Perry Cabin. This Victorian-inspired resort is known for its luxurious accommodations, fine dining, on-site recreational activities and full range of
spa services. Many of its 78 rooms have fireplaces, designated living rooms and decks, patios or verandas. Another hot spot to stay in town in the Parsonage Inn B&B, also known for its exquisite décor and amenities, and located within walking distance of the Chesapeake Bay Maritime Museum and many shops and restaurants. Those who have stayed here rave about the fresh muffins and pastries served each morning, as a “teaser” for the full hot breakfast that comes out shortly thereafter. Oenophiles’ Paradise … Every April
WineFest 2013 will be held April 27 and 28, featuring hundreds of wines from 19 different venues. This year, the festival offers patrons tastings of new wines that are not yet available for sale in Maryland, as well as samplings from a variety of international winemakers. The popular “VIP Patriot Wine Tasting Cruise” is once again on the agenda, with an upgraded ticket option giving cruisers access to an additional wine tasting event in the courtyard area of The Old Brick Inn. To plan your trip the easy way, visit www.stmichaelsmd.org.
Policy (continued from page 29) Last, we need to greatly improve our juvenile justice system. Too many youngsters are not rehabilitated there, and they need all the help they can get to get on the right track in life. Then, you get to the gun issue. I’m in favor of more restrictions on assault weapons and background checks, but we need to talk about the other issues that lead to violence in the first place. At Healthcare for the Homeless, I’ve seen a lot of men who have committed crimes. Some say, “I did a three-spot” (served three years in jail) as casually as if they were saying they went to the movies last night. I’ve had patients tell me about cold-blooded murders they did. One man said he was 15 when he was in for ten years. He had killed six people as a young kid. The drug dealers would give him two thousand dollars and a gun and have him walk over and kill someone. He did that five or six times and then he got caught. There are others issues as well that lead to terrible crimes, such as elder abuse to human trafficking. So, legislatively, it goes back working on underlying social antecedents.
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many issues as Chair of the Government Operations Subcommittee of the Committee on Healthcare and Government Operations. There, we work to identify efficiencies that will save money without having to raise taxes or cut programs. We also promote programs to help minority, women, small, and veteran owned businesses. I’ve focused on transparency and competition for government contracts, and that has saved millions of dollars. I’m filing a bill to improve our open meetings statute to help ensure greater public participation. We have a serious shortage of certain medications. Generic drugs – primarily sterile injectables – are becoming increasingly unavailable. Hospitals are having trouble finding epinephrine, sodium bicarbonate, atropine, propofol, and other commonly used medicines. Much of the problem is at the federal level, but I’m working on what we can do in Maryland. Dr. Morhaim’s book can be found at www.drdanmorhaim.com, www.thebetter end.com or at Amazon.
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Healthcare IT In every issue, Maryland Physician explores a different facet of the race to implement EHRs to meet Meaningful Use and other e-health government incentives. Donâ€™t be left behind â€“ read what Maryland physicians and health-
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Understanding Meaningful Use Stage 2
By Craig Law
TAGE 2 MEANINGFUL USE begins as soon as 2014. You could have less than a year to be ready, and starting 2016, Medicare will initiate annual reimbursement reductions for all those providers who do not attain Meaningful Use. Practices must report both quantified data (e.g., how many e-prescriptions were sent) and qualified data (reporting through attestation that you performed certain actions). The Stage 2 objectives follow, with changes from Stage 1 noted in parentheses:
Core Stage 2 Objectives
> Computerized provider order entry > > > > > > > > > > > > >
(CPOE) (increased measure and scope to 60%) Drug-formulary checks [moved into e-prescribing (e-Rx)] E-Rx (increased threshold to 65%) Report clinical quality measures to CMS/states (for 9 of 64 approved measures) Clinical decision support rules (increased scope to 5 measures) Drug-drug and drug-allergy interaction checks (combined with CDS measure) Provide patients an electronic copy of their health information (require 5% of patients to use) Provide clinical summaries to patients for each visit (increased delivery to 1 day) Record demographics, including language, race and ethnicity (increased scope to 80%) Maintain a problem list of current/ active diagnoses (no change) Maintain active medication list (no change) Maintain active medication allergy list (no change) Record vital signs (Increased scope to 80% and change in age) Record smoking status for patients
> > > >
13 years or older (increased scope to 80%) Exchange key clinical information between providers of care (combined with other objective) Protect electronic health information through annual security reviews (requirement to encrypt/secure ePHI on any mobile device) Incorporate clinical lab test results as structured data (moved to core and increased to 55%) Record Advanced Directives (moved to core objectives and increased scope and measure for attainment) Generate lists of patients by condition (moved to core objectives and increased scope and measure for attainment) Send reminders to patients for preventive/follow up care (moved to core objectives and increased thresholds for attainment) Medication reconciliation (moved to core objectives and increased threshold to 65%) Provide patients ability to view, download and transmit health information (new and 10% of patients must utilize) Patient Education provided to patients (moved to core objectives) Use secure messaging (new, threshold of 10% of patients using) Submission of electronic data to immunization registries/systems (moved to core objectives with 100% threshold) Electronic Summary of care record for each transition of care/referral (moved to core objectives)
Menu Objectives (providers must select three of six)
> Submission of electronic syndromic surveillance data to public health agencies (moved to core objectives and 100% threshold)
> Imaging results accessible to provider (new and threshold of 40%)
> Electronic note (new and threshold of 30% of patients)
> Family health history as structured data (new and threshold of 20%)
> Report electronically to cancer registries (new and 100% threshold)
> Report to alternative registries (new and 100% threshold) If you havenâ€™t already begun using an EMR, now is the time to take advantage of incentives to offset the cost of conversion. Meeting Meaningful Use criteria also will prepare you for upcoming healthcare changes, such as quality measures and published performance. Consider hiring an experienced consultant to guide vendor selection and implementation; while they charge a fee, they can save considerable dollars by contracting and negotiating effectively on your behalf. A consultant also can save hundreds of hours of time and smooth your EMR transition by knowing which work flows require the most attention, ensuring the correct setup and customizing the platform for use in your environment. In a growing number of practices, an EMR already can enable lab and radiology results, procedures, discharge instructions and ER visit summaries to arrive directly into your EMR without manual intervention. No more lost tests or charts! Know which patients are taking a newly banned medication! The opportunities for improved healthcare delivery are staggering. Make the commitment to meet Meaningful Use targets both to facilitate patient care and to take advantage of Medicare and Medicaid incentives before penalties ensue. Craig Law is president of STATpay, Inc., a Maryland based healthcare consulting firm that provides visit redesign, practice automation, EMR implementation and Meaningful Use attainment.Contact him at Claw@statpay.com. MARCH/APRIL 2013
Putting New Technologies in Patients’ Hands By Tracy M. Fitzgerald
providing resources for researchers to create new opportunities, kick-start ideas and really test if they can work.” Patients undergoing treatment for heart disease at Johns Hopkins Bayview Technology can be used to address behavioral change and create Medical Center are among motivation within patients. the first to reap the benefits of this new these tools will help doctors do their jobs program. After women in the heart better because they will help them disease clinic’s waiting room were understand what is happening ‘right now’ overheard time and time again, sharing with their patients, at any given time.” their personal stories, tips and ideas, a Long-term, the Verizon Foundation concept evolved: intends to expand this program, to patients would likely be more active in include partnerships with additional managing their own health conditions if healthcare organizations that require given the tools and resources to network new technologies to bring good ideas with others on a regular basis. Today, to fruition. patients are encouraged to participate in “We are taking a step back and an interactive heart disease management focusing on learning about communities, program, using a web-based patient identifying ideal partners and portal and personal tablets, funded by understanding how technology can affect the Verizon Foundation. Together, these health outcomes,” said Martinez. “For tools allow patients to converse with one each new partnership or program we “The Verizon Foundation is providing resources create, evaluation is the key. We want to link projects that are happening at various for researchers to create new opportunities, institutions, and bring our partners and kick-start ideas and really test if they can work.” their ideas together for great impact.” Physicians interested in learning – Florence Haseltine, Phd, M.D., founder of the Society for Women’s Health Research more about the role technology can play in helping patients manage chronic another, make contact with their care research-based programs and initiatives health conditions or disease can access providers, track vitals, be continuously geared toward the implementation of an interactive infographic, developed educated and find the support they positive change in the global healthcare by the Verizon Foundation, at need to make critically important lifeenvironment. www.verizonfoundation.org/chronicdisease/. style changes. “Johns Hopkins is one of the richest “This is a great example of how places in the world for research, with technology can be used to address people who are eager and willing to make Maryland Physician would like to behavioral change and create motivation changes to improve patient care,” said hear about your “Good Deeds.” within patients,” said Roselena Martinez, Florence Haseltine, Phd, M.D., Founder Please share your ideas with us at Healthcare Program Manager for the of the Society for Women’s Health firstname.lastname@example.org. Verizon Foundation. “At the same time, Research. “The Verizon Foundation is
OST PEOPLE AGREE – technology is rapidly changing the world we live in. And more than ever before, it is playing a crucial role in the evolution of healthcare delivery in the United States. Recognizing the importance of reducing healthcare disparities, improving access to care and empowering patients to be more active in management of their own health, the Verizon Foundation has introduced a philanthropic program, offering $13 million in grants and in-kind technology donations to healthcare researchers and innovators focused on the provision of quality care for women, children and seniors. The Verizon Foundation has launched the program in partnership with four organizations, to start: the Children’s Health Fund; the National Association of Community Health Centers; the University of California, San Diego; and the Society for Women’s Health Research, which partners with Johns Hopkins Medicine on a number of
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The Evolution of Emergency Room Care, Preventing GERD and Hiatal Hernias from Turning Deadly, Using mHealth for Patient Care, Interview with...