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Contents 10

May/June 2012 Volume 2: Issue 1




10 Simply Inspirational Women Physicians Who Go Beyond the Norm

14 Thyroid and Lung Cancer on the Rise 16 The Revolution of Children’s Hospital Care From Facilities to Care Delivery, Pediatric Hospitals Have Taken a Great Leap Forward

20 Patient Portals Path to Increased Productivity and Happier Patients D E PA R T M E N T S


| 7 | Tics: Screen for Neuropsychiatric Comorbidities


| 13 | EMRs:Worth the Pain?


| 24 | Harper’s Ferry: A Getaway Worth Exploring


| 26 | Recap: Physicians Gain Ground in 2012 Maryland General Assembly Session


| 29 | Six Ideas to Help Improve Internal Control Processes within Your Practice

Good Deeds

| 30 | Lending Much-Needed Helping Hands to the People of Africa

On the Cover: Briana Walton, M.D., director, Female Pelvic Medicine and Reconstructive Surgery, Anne Arundel Health System.


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APPY 1ST BIRTHDAY to Maryland Physician Magazine! This issue launches our second year of production and as we did in our May/June 2011 inaugural issue, we’re celebrating Maryland women in medicine. After the first issue was out, I received some congratulatory messages from readers. One, a retired physician, wrote to me that he sent the issue on to his granddaughters who were planning careers in medicine for some inspiration. There is no better compliment than to hear that I’m doing just what I set out to do when I launched of Maryland Physician: inspire and connect Maryland physicians with a commitment to achieving the highest standards of quality patient care. In this issue, we’re showcasing just a few of many, many inspirational female Maryland physicians (page 10). The story of one of the docs, AAMC’s Briana Walton, M.D., led us to this issue’s Good Deeds focus (page 30), a spotlight on the International Organization for Women and Development (IOWD). While we chatted during the cover photo session, Dr. Walton shared her experiences in treating Rwandan girls and women with fistulas with heart wrenching stories of young girls and women who have survived genocide, malnutrition and now are societal outcasts, suffering from humiliating and debilitating gynecologic conditions. Back home here in Maryland, pediatric patients and their families are blessed to have four pioneering pediatric hospitals, two of which opened new centers earlier this spring. The adaptability for care, growth and research each center provides allows for much needed flexibility in treating pediatric patients and often leads to innovative treatments benefitting adult patients (page 17). In 1960, John Steinbeck took a 10,000-mile trip around the United States in a pickup with a retrofitted camper on its back, and a large Standard Poodle named Charley. He wrote about what he saw and did along the way in Travels with Charley. Steinbeck’s literary style, stories of a simple America and his four-legged travel companion have forever inspired me to write and experience America from the road with an easy going travel companion of my own. Travels with Eli is the first in a series of my Steinbeck-inspired travels across and around Maryland with my own Standard, Eli. The first travel stop: Harper’s Ferry – the destination in this issue’s Living department (page 24). Many of you are planning your own summer trips which very well may include a good deed trip of your own. We’d love to hear from you and share your experiences with your fellow Maryland Physician readers. Throughout this issue and online at, you’ll find a number of ways to connect with us online and via social media. Please do and safe travels! To life!

CONTRIBUTING PHOTOGRAPHY Tracey Brown, Papercamera Photography Mark Molesky, Moleskey Photography 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 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@ 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 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 4 |


Green logo here

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

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









Tics: Screen for Neuropsychiatric Comorbidities Mark DiFazio, M.D.

CASE: An 8-year-old presents with a chief complaint of chronic cough and previous treatment for sinusitis, allergy and possible mild asthma. Her pediatrician, an allergist and a pulmonologist have performed a number of tests and prescribed several inhaled medications for presumed reactive airway disease. She is otherwise healthy, a good student and an avid dancer. Family history is notable for a brother with ADHD and a mother with anxiety and obsessive-compulsive behaviors. Two years ago the patient was seen by a neurologist for possible seizure secondary to repeated eye-rolling movements. The patient had a negative electroencephalogram and normal physical examination. DISCUSSION Movement disorders are common in children and often provoke parental anxiety. Tic disorders, seen in 20 to 30% of children, are the most common pediatric movement phenomenon. Tourette syndrome, defined by vocalizations as well as motor tics occurring for more than one year, is also common, affecting up to 4% of the population. Tics can be simple (cough, sniff, eye blinking) or complex (touching in patterns, coprolalia). Named for Gilles de la Tourette, a

French neurologist in the late 1800’s, Tourette syndrome was characterized as a neuropsychiatric condition several decades ago. More recently, it has become better understood as an organic neurologic disorder with a number of psychiatric comorbidities. Although it has gained media recognition, Tourette remains infrequently recognized by primary care providers and parents. Physicians may attribute eye rolling to absence seizures, eye blinking and “irritation� to allergy, and cough, sniffing and throat clearing to sinus disease. While reasonable to initially attribute these symptoms to medical problems, chronic conditions should prompt consideration of tic disorder to minimize unnecessary evaluation and treatment. Why is the early identification of tic so important? Aside from the worry it causes parents, it is crucial to screen these children and adolescents for comorbid neuropsychiatric conditions. More than 50% of children with Tourette have attention deficit disorder; approximately 40% have a learning disability and a significant proportion have anxiety, obsessive-compulsive disorder or depression. Our patient is typical of many who have undergone a number of previous evaluations by non-neurologic subspecialists prior to a final diagnosis and management. Siblings often manifest similar comorbidities and have unrecognized tic disorder. Parents can be affected by anxiety, attention deficit or obsessive-compulsive behaviors. Tourette is clearly genetically mediated; however, a specific gene or gene product has not yet been identified. There is no consistent evidence that all tic disorders have infectious triggers such as group A streptococcus, despite efforts to establish this hypothesis. At the same time, some series appear to demonstrate an infectious trigger of tic,

possibly accompanied by obsessivecompulsive disorder or anxiety. Research in this area is fraught with possible confounders. Tic disorders are highly prevalent, often wax and wane and can be precipitated by stressors. Group A Strep can have an asymptomatic carriage rate of 15% in school age children. Tics will often flare up upon return to school, coincident with re-exposure to infectious agents. At present, there is not a consistent test that proves causation. Pediatric Acute Neurologic Disorders Associated with Strep or other infectious agents (PANDAS) should be established by a pediatric neurologist or specialist with expertise in movement disorders in children. Testing or empiric antibiotics for all children with tics are not presently indicated. Surveillance and intervention for psychiatric comorbidities is requisite, however. Medical treatments where warranted can help treat the tic and the psychiatric comorbidity. Education from physicians and support groups such as the Tourette Syndrome Association is always helpful. While disabling in its severe form, tics may convey a selective advantage for people who tend to be compulsive or detail-oriented. In fact, some of the most successful people in history probably had Tourette. Samuel Johnson, Mozart and many others appear to have been affected. Our patient did not warrant treatment, as her current tic was mild and not disabling. Parental reassurance was sufficient in this case. Our patient and family left reassured, and happy to avoid medication. Mark DiFazio, M.D. is director of Pediatric Neurosciences at Shady Grove Adventist Hospital and assistant professor of Neurology at the Uniformed Services University of the Health Sciences,


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10 Years, 4000 patients, 350,000 lbs. lost Dr. Isam N. Hamdallah, Dr. Andrew Averbach, Dr. Kuldeep Singh (not pictured Dr. David von Rueden)


Saint Agnes Bariatric Program offers safest, most effective treatment for obesity

N THE PAST DECADE, BARIATRIC surgery has become the safest, most effective treatment for severely obese patients. In contrast to non-surgical treatments that produce a 95% recidivism rate and long-term Excess Body Weight Loss (EBWL) of only 20%, surgical treatments yield low recidivism (under 35%) and an EBWL of over 50%. “Today, bariatric surgery’s morbidity and mortality rates are on a par with simple surgeries like laparoscopic appendectomy,” says Andrew Averbach, M.D., FACS, FASMBS, director, Bariatric Surgery, Saint Agnes Hospital. “It’s the only workable treatment for morbid obesity. At Centers of Excellence like ours, mortality rates are 0 to 0.1%. As a result, close to half of the patients now come to us after their physician talks to them. The fact is that bariatric surgery works.” 8 |


The Bariatric Program, designated a Center of Excellence by the American Society for Metabolic and Bariatric Surgery (ASMBS) and multiple insurers, recently celebrated its 10-year anniversary and has performed more bariatric surgeries than any other hospital in Maryland. It now has four skilled surgeons – Dr. Andrew Averbach, Dr. Isam N. Hamdallah, Dr. Kuldeep Singh and Dr. David von Rueden – who have performed more than 4,000 surgeries. The Saint Agnes program is one of only two in Maryland to offer surgery using the state-of-the-art da Vinci robot, which provides surgeons with enhanced visualization and greater precision compared to standard laparoscopy. The Bariatric Center of Excellence has evolved into the cornerstone of the Maryland Metabolic Institute, which also

encompasses the Diabetes Center and well4life, an innovative non-surgical weight loss and healthy lifestyle program. The center’s success can be attributed to the expertise of its physicians, the dedication of the support team (including nurse coordinator Cathy Carr-Dardin, R.N., C.B.N. – a patient herself) and the commitment to furthering minimally invasive techniques. Kim Fabian, director, Maryland Metabolic Institute, comments, “In addition to our excellent surgeons, our team of dietitians, behaviorists, nurses and other professionals supports patients before, during and after their bariatric procedure. This team approach ensures that we are meeting all aspects of the patients’ needs to foster their success.” The surgery has health benefits far beyond the weight loss, addressing key

comorbidities such as heart disease, diabetes, hyperlipidemia, arthritis and psychological wellbeing. “Surgery is only one part of a whole program,” adds Dr. Averbach.“Obesity is a chronic disease and patients need to stay with the program for life, including annual visits to the surgeon.” He concludes, “The surgery dramatically enhances a patient’s quality of life and ability to perform simple tasks such as buckle a seatbelt, fit in a booth at a restaurant and take care of personal hygiene – things that most people take for granted.” BARIATRIC SURGERY INDICATIONS

Using National Institutes of Health guidelines, appropriate candidates must have:  Evidence of previous non-surgical weight loss attempts  Body Mass Index (BMI) of 40 or higher, or a BMI of 35 or higher with defined co-morbidities  Absence of psychiatric conditions and addiction that could prevent adequate preoperative teaching and compliance PROCEDURE OPTIONS

The most widely performed laparoscopic procedures are:  Roux-en-Y gastric bypass – the gold standard. Patients typically lose 70% of EBWL in the first three years.  Vertical sleeve gastrectomy – patients lose up to 70% of EBWL. Newer and growing in popularity.  Laparoscopic adjustable gastric band

(‘Lap Band’ & ‘Realize Band’) – patients typically lose about 40% of EBWL.

to the public but require reservations. Call 1-866-690-9355. WELL4LIFE PROGRAM

Choosing the right procedure is based on body mass index, co-morbidities and patient preference. “I recommend to primary care physicians that, rather than advising patients to undergo a specific procedure, they leave that decision to the surgeon and patient,” Dr. Averbach advises. Gastric bypass and sleeve gastrectomy produce a substantially higher percentage of EBWL in the first three years compared to banding (70% vs. 40%). The resolution rate of co-morbidities also is higher after bypass and sleeve gastrectomy. However, successful band patients continue to lose weight over time, while up to 35% of bypass and sleeve gastrectomy patients experience weight regain. Patients are advised that, in 25% of cases, the band requires maintenance and is removed after 10 years. These patients eventually undergo bypass or sleeve surgery. BARIATRIC SUPPORT GROUPS AND SEMINARS

Twice a month, Saint Agnes offers free bariatric support groups for patients, family members and friends to gain support from others who have had surgery or are considering bariatric surgery. Free, informative seminars on surgical weight-loss options, including laparoscopic gastric banding, gastric bypass and sleeve gastrectomy, are also offered three times a month. These seminars are open

Now Offers Options for Bariatric Patients

The first program of its kind in Maryland, well4life is a multidisciplinary, nonsurgical weight loss and healthy lifestyle program. In addition to the basic well4life program, a Pre-Operative Bariatric Track is offered to provide patients the documented weight loss, dietary education and behavioral consultation required for approval of bariatric surgery. In addition, pre- and post-operative bariatric patients can benefit from weekly exercise classes. The eight-month basic well4life program also can help bariatric patients who are one or more years beyond their surgery and wish to maintain their weight, or for those who have gained weight back and would like to lose more. Participants receive a health assessment, biometric screenings, educational classes, health coaching, fitness classes, support groups, a web companion, and medical oversight. Call 410-368-3228. For more information on bariatric surgery, view videos of Saint Agnes bariatric surgeons discussing weight loss surgery on the Live Well channel at To sign up for a bariatric surgery seminar, call 1-866-690-9355. Saint Agnes was awarded Center of Excellence designation for bariatric surgery by: • CIGNA • United/Optum • Aetna • CareFirst Blue Distinction • American Society for Metabolic and Bariatric Surgery (ASMBS)






Restrictive/malabsorptive procedure creating small proximal pouch with bypass of distal main stomach, duodenum and proximal jejunum with variable length intestinal shunt (Roux limb)

Resection of 80% of lateral stomach with construction of sleeve-like tubular stomach

Restrictive procedure placing inflatable silastic band around subcardia of stomach with minimal gastric pouch above band


0 – 0.2%

0 – 0.2%

0 – 0.1%


30 Day: 10- 15% LT: 5-10% Ulcers, intestinal obstruction, hypoglycemia, nutritional deficiencies

30 Day: 10% LT: 5-10% Gastric leaks, strictures, GERD

30 Day: 4% LT: 25-30% Erosion, GERD, esophageal ectasia, insufficient wgt. loss


Procedure of choice for all BMI, especially patients with diabetes and multiple disabling co-morbidities

Any BMI range; can be an alternative when gastric bypass contraindicated

Preferred BMI <45; young/teenage patients with minimal or no co-morbidities; first-line treatment for BMI 30-35


1 yr: 65-70% 5 yr: 55%

1 yr: 65-70% 5 yr: 55%

1 yr: 35% 5 yr: 50%


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Simply Inspirational

Cynthia Plate, M.D., chief of surgery and president-elect of the medical staff, Washington Adventist.


10 |



Even on a good day, being a woman physician presents its share of challenges, especially when a spouse and children are part of the picture. Yet some female physicians rise above the expected, inspiring others to achieve more themselves. Maryland Physician celebrates our annual Women in Medicine issue by speaking to four such physicians. We discuss why these women chose their career path and how they leave the world a better place. Male Influences for Medical Pursuits

Perhaps surprisingly, all four physicians were chiefly influenced by one or more men in their lives to go into medicine. Judy Destouet, M.D., FACR, chief of mammography at Advanced Radiology, recalls, “After leaving a job as a research assistant at USC, I was going to be a medical technologist. I loved being in the hospital but wanted to be with people. My boyfriend (now husband) told me I was smart and should go to medical school. I took his advice. At Baylor College of Medicine, not only were women only about 10% of the class, but I was one of the older students.” Cynthia Plate, M.D., chief of surgery and president elect of the medical staff, Washington Adventist Hospital, wanted to be a nurse since she began putting bandaids on her dolls. Her father argued that, “If you study a little bit longer, you can be the one making the decisions.” His advice helped launch her medical career, although she frequently had to ignore well-intentioned advice from wives of family friends who told her she ‘couldn’t have it all’ if she became a surgeon. She says, “During my surgical rotation, I was the first one to arrive each morning and I loved the almost militaristic chain of command of the assured surgeons at Howard University Hospital.” Like Dr. Plate, Briana Walton, M.D., director, Female Pelvic Medicine and Reconstructive Surgery, Anne Arundel Health System, subjected her Barbie dolls to medical treatment at a young age, and was persuaded to seek a professional career by her father. In college, she discovered she was good at math and science, and the next logical step seemed to be medical school. Similarly, a psychiatrist father helped launch the medical career of Rosa Mateo, M.D., infectious disease specialist and

medical director of infection control at Shore Health System. “My siblings and I used to be angry that my father was late picking us up from school because he didn’t want to cut short his time with a patient, but he taught me how doctors should address patients and that gaining their trust is what’s important. I never forgot those lessons.”

insurers realized that you could save dollars by catching breast cancer early, so they supported it. But when my chairman promoted a male to a full professorship over me, I decided to accept an offer in private practice in Maryland, where I brought this model with me.”

Choosing a Specialty

Dr. Destouet says, “I loved surgery but wanted to have a family, so I fell in love with radiology – it was like being a detective. In the 70s, when I was doing my residency, it was an exciting time. It was the dawn of the CT scan – radiology was really coming into its own after years of relying on X-rays and primitive ultrasound.” “Once in medical school,” Briana Walton, M.D., director, Female Pelvic Medicine and reminisces Dr. Walton, “OB Reconstructive Surgery, Anne Arundel Health System. picked me, not vice versa. I liked Dr. Destouet had been lecturing cutting, but I kept being pulled back to around the country to help others OB. I enjoy taking care of women, and implement the new model. “I was also urogynecology provides a great blend of tired of traveling all the time and surgery and taking care of people.” welcomed the opportunity to do some“In Peru, where I spent my first 12 thing different,” she adds. The East Coast years, the most common problem is infection. The smartest person was always was slower to adopt the new practice, and Dr. Destouet encountered increasing the infectious disease specialist because regulation from the FDA and others. Yet the specialty is so broad. And ID usually she persevered, to excellent results. sees the sickest patients in the hospital,” “I never doubted for a moment that comments Dr. Mateo. Like Dr. Destouet, screening mammograms were the right she was attracted to the ‘detective-like’ thing to do,” Dr. Destouet continues. aspects of infectious disease. “I love the “The data supported what we were doing. challenge. And being bilingual helps me It’s been especially heartwarming to see explain what’s happening to patients in disadvantaged women get screening, their native Spanish.” especially since breast cancer is often more aggressive in the African American Screening Mammography Pioneer; population.” Breast Cancer Survivor Ironically, Dr. Destouet is now a When Dr. Destouet began performing breast cancer survivor herself. “I was mammography, a physician could only diagnosed in 2008. It adds to my ability to perform about five film-based relate to patients. I believe very strongly mammograms a day in women who had signs and symptoms of breast cancer, as all in mammography on both a professional and a personal level.” mammograms were “diagnostic” mammograms. She recalls, “In the early 80s, Swedish radiologists began Giving Rwandan Women a Second Chance performing screening mammograms on In sharp contrast to her focus on robotic asymptomatic patients. I became the head surgery with its highly technical of mammography at Mallinckrodt equipment and specialized ORs in the Institute of Radiology in St. Louis and we U.S., Dr. Walton has been extensively embarked on a screening mammogram involved in women’s health care in program where we eventually performed developing countries, specializing in more than 100 mammograms a day. The fistula repairs in Ghana, Niger and MAY/JUNE 2012

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three times a year for two weeks each. This April 2012, she had her first experience as Team Leader of a group of eight physicians. Because many older, more experienced physicians were killed during the genocide in Rwanda, one of the team’s critical roles was teaching young, inexperienced providers to safely deliver care to women. Hospital Leader, Honduran Healer

Like Dr. Walton, Dr. Plate is lending her surgical skills to developing countries. In March 2012, she returned from the first of what she hopes will be many trips to Honduras. There, she was part of a team of four volunteer surgeons who performed gallbladder and hernia surgeries on more than 100 patients. She reflects, “The patients were unbelievably grateful. And since I am fluent in Spanish, I could help interpret.” These visits extend her tradition of service here in the U.S., Rosa Mateo, M.D., infectious disease specialist and medical direc- where she participates in tor of infection control at Shore Health System and Judy Destouet, breast cancer and other M.D., FACR, chief of mammography at Advanced Radiology. screenings. Dr. Plate’s service also extends to being a medical leader Rwanda as a member of the International within the hospital. Partially through her Organization for Women and Development (IOWD). “Part of the reason three-year term as Chief of Surgery, she began serving as the President-Elect of I got involved with fistula care is that I the medical staff in January 2012. She’s have Crohn’s Disease and had problems the first female to serve in either role. with fistulas myself. I sympathized with “I thought about this long and hard,” others who had this type of problem, she reflects. “My partners and the which can be devastating.” administration were very supportive. During her fellowship at Harvard, It gave me confidence to know that Dr. Walton made her first trip overseas – everyone felt I was ready.” to Ghana – alone. “Providing care for a population of women who were outcast from their villages and families moved me Saving Lives In Community and to partake in international care. It was part Hospital Settings of my calling as a physician. Furthermore, “Saving a life gives me satisfaction,” notes the indirect message of being a role model Dr. Mateo. “I feel that someone is guiding as a woman and a woman of color inspired my hands and that there’s something more me to continue my work. However, I powerful than us. Sometimes patients get realized that I needed to be part of a well against all odds – like a 90-year-old group. I first went to Niger with IOWD in patient on DNR who was so sick 2006, and since 2009, I’ve gone with them overnight that we thought he would die to Rwanda. The presentation of fistulas in by morning; yet miraculously, he Rwanda is different and the health care recovered. But sometimes the bad system is more established. And although outcomes teach us the most. I had female genital mutilation from traditional established a good relationship with one circumcision does not occur, women have patient who knew he was dying of lung been subjected to horrific acts of violence disease secondary to HIV. I told him it during Genocide.“ was time to be in peace. I couldn’t change Her IOWD group goes to Rwanda his outcome, but I made his last hours the 12 |


best they could be, which is as important as curing someone. My oncology rotation gave me good training in how to approach dying patients.” Dr. Mateo works closely with the Talbot Health Department to control infections in the community as well as the hospital. She recounts, “My phone rings all day long when I’m on call. If they have questions about an outbreak, they call me. Several years ago, when we had the H1N1 outbreak, we determined who should receive treatment with antivirals. We’ve had gastroenteritis, measles, a few cases of TB, and HIV, especially since many young people come back here from the city to be with their families once diagnosed. We’re now faced with a population that will live many years with HIV but they’ll suffer medication side effects – we can help them manage.” Unique Attributes

Dr. Walton says, “I’m proud that I stayed married for 20 years because you evolve a lot during that time. I’m true to myself and my job hasn’t changed who I am or what I want to be. Most women have good emotional intelligence so it makes it easier for us to remain faithful to our core.” “As a woman, my leadership style is to listen to everyone, then wrap it up without belaboring a point,” notes Dr. Plate. “ As surgical chief, I gained a deeper understanding of how the system works and I learned to tie things together better. I believe in providing clear explanations so that people understand why we do something a certain way. I strive to be a good leader and role model to our residents, while taking great care of my patients.” “My advice for women doctors is to work harder than their male counterparts,” concludes Dr. Destouet. “We do ourselves a disservice if our male counterparts consider us just ‘part time.’ A woman’s work ethic is not different than a man’s and many of us have to multi-task by raising a family.”

Rosa Mateo, M.D., infectious disease specialist and medical director of infection control at Shore Health System. Judy Destouet, M.D., FACR, chief of mammography, Advanced Radiology. Cynthia Plate, M.D., chief of surgery and president elect of the medical staff, Washington Adventist Hospital. Briana Walton, M.D., director, Female Pelvic Medicine and Reconstructive Surgery, Anne Arundel Health System.


EMRs: Worth the Pain? By Seth R. Eaton, M.D.


ARYLAND PROVIDERS are faced with the difficult task of selecting and implementing electronic medical records (EMRs) to improve and engage patients in their overall care. A large percentage of providers continue to operate with paper charts, which are neither efficient nor safe. With the various government incentives available to encourage adoption of electronic records, medical professionals understand the advantages and care improvements that EMRs supply, although most are unequipped to adjust to the inevitable hurdle of a significant practice workflow transformation. Implementation of an EMR can be a challenge at first; however it is well worth the investment in the end. A practice’s return on investment (ROI) depends upon choosing a solution that is a fit for the practice. To ease the difficult selection process, Maryland’s Health Information Exchange (HIE) provides support and recommendations for a select number of EMR vendors. Support from CRISP and HIE networks

Chosen as Maryland’s Regional Extension Center by the Office of the National Coordinator of Health Information Technology, Chesapeake Regional Information System for Our Patients (CRISP) helps achieve improved outcomes and practice efficiencies. The program helps healthcare providers in Maryland implement and use EHRs efficiently and share clinical data across the state. EMR Selection

Developing a plan and asking the tough questions is a vital first step in selecting an EMR vendor. First, identify your practice’s goals and objectives. Next, speak to fellow colleagues and other medical professionals for recommendations on EMR vendors. Selecting an EMR system that associates are using will assist in the initial learning curve and

implementation process. Certain platforms will be easier to implement, so check before purchasing to see which system has the serviceability needed. Additionally, EMRs will provide the tools to integrate with health information exchange networks. After evaluating various systems, conclude which solution best fits your practice’s goals. The path to fully implementing EMRs can be a bumpy one. Many practices face difficulties for at least six months while everyone from providers to the front office staff adjust to the change. However, after climbing over the initial speed bump you will see a return on your investment, quality improvements throughout your practice and improved care between primary, specialty and hospital systems. Quality Improvements after Implementation

Different EMR systems and different offices experience varied adoption rates. Hopefully your practice will experience a rapid adoption by providers and deploy after only a short period. Once it is complete, the clinical quality of care will improve immediately; patients will have the tools to communicate with specialists and physicians will have more information to coordinate and improve care. Records will be readily available and better communication with specialists will enhance care. Other advantages experienced with robust EMR systems are:  Legible, thorough and accurate progress notes  Fast receipts of and easy location of test results to improve communication with patients  Letter generation and mailings, calls and electronic messages for more efficient follow-up care  Patient records available over a secure

network, improving coordination of care during after-hours on-call, hospital rounding, and other times when the provider is not at the practice site but needs to render medical judgment  Easy and secure access to lab results, medication refill requests and referral management when patients access the patient portal Patient Engagement

The key goal of an advanced EMR system is to improve the patient’s experience. The patient portal allows patients to communicate with their doctor and access important information over the Internet. It facilitates preventive care, providing patients 24/7 access to medical information from the comfort and privacy of their home or office. It gives patients the tools to better manage their health by:    

Requesting and creating appointments Request prescription refills Pay bills online Receive health maintenance reminders

National Recognition

MedPeds, LLC, selected eClinicalWorks in 2004 because it was the most userfriendly and intuitive EMR with the fastest learning curve. eClinicalWorks provides the tools to further enhance the practice’s ability to engage patients and families and support the medical home model of healthcare delivery. In December 2010, MedPeds was recognized by the National Committee for Quality Assurance (NCQA) for achieving Level 3 Physician Practice Connections®-Patient-Centered Medical Home™ (PCMH) status. PCMH is a model of delivering primary care that is accessible, continuous, comprehensive, family –centered, coordinated, compassionate and culturally effective. Seth R. Eaton, M.D., is board certified in both Internal Medicine and Pediatrics. He started the MedPeds, LLC practice in Laurel in 1982.


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Thyroid & Lung Cancer On the Rise Both thyroid and lung diseases are on the increase in the U.S., especially in women. Maryland experts weigh in on the latest advancements in detecting and treating these diseases. BY LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

Increase in Thyroid Cancers

In the past 30 years, the incidence of thyroid cancers has more than doubled and now represents the fastest growing cancer for women. Endocrinologists suspect that the increased iodine consumption in developing countries is associated with chronic inflammation, sometimes leading to cancer. Others suggest that radiation from dental X-rays and mammograms are possible culprits, and encourage women to use thyroid shields during such procedures. While women are three times as likely to develop thyroid cancer as men, the most common thyroid cancers - papillary (80%) and follicular (15%) - have a good prognosis. Nicholas Argento, M.D., endocrinologist, observes, “Thankfully, the majority of cancers, often detected on MRI or CT of

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the neck or chest, or during carotid ultrasound, are indolent. The more aggressive cancers are typically found in older patients.” More Active Lymph Node Surveillance

Following thyroid surgery, with more advanced ultrasound testing available in place of repeat nuclear scans, surveillance of lymph nodes has improved. “We used to have to withdraw people from thyroid medication for a month to do the test, and had to perform recurrent tests,” Dr. Argento states. “Now, we often only perform one nuclear scan and prepare the patient using an injection of synthetic TSH. Neck ultrasound is then used for further follow up. The ultrasound is painless, more specific and cost effective. Using fine needle aspiration, patients can get a biopsy at the same time.”

Decreasing Use of Radioactive Iodine

When lymph nodes are cancerous, doctors are increasingly likely to perform a second surgical procedure in lieu of radioactive iodine treatment. Dr. Argento notes, “There’s been a big shift in the emphasis on radioactive iodine, as we realize that it entails more risk and is less effective for most patients than once believed.” When prescribed, radioactive iodine is more frequently given at a lower dose and on an outpatient basis for patients who meet the criteria. Hypothyroidism during Pregnancy

The evidence is mounting that untreated or undertreated hypothyroidism may increase the risk of miscarriage and decrease fetal IQ. Women with known hypothyroidism should be retested early in

Riny Karras, M.D., on the left and Gavin Henry, M.D. on the right – both from Franklin Square.

pregnancy, with monthly testing for the first 20 weeks. Even women without known problems should be considered at potential risk, but whether they should get routine thyroid screening is still controversial. Dr. Argento says, “Women with certain conditions, such as a history of goiter, type 1 diabetes or family history of thyroid disease, should definitely be screened.” The most recent recommendation from the American Thyroid Association is that women with known hypothyroidism should receive a 30% to 50% increase in thyroxine early in their pregnancy. Says Dr. Argento, “Physicians should seek to keep the thyroid stimulating hormone (TSH) level below 2.5 in the first trimester and below 3.0 in the remaining trimesters.” “The patient guides at the website are a great resource,” concludes Dr. Argento. Lung Disease in Women

While breast cancer receives most of the media attention, lung cancer is on the rise for women and has become their leading cause of mortality since 1987. Further, more than twice as many women as men are diagnosed today with chronic bronchitis and more women have died from COPD than men every year since 2000. Advances in imaging have led to earlier detection of lung disease, but lung screening is not yet reaching sufficient numbers of those at risk. Lung Cancer Not Just a Smokers’ Disease

Surprisingly, 20 to 30% of lung cancers occur in former smokers age 55 and older who have not smoked for 15 or more years. Riny Karras, M.D., thoracic surgeon at Saint Agnes Hospital, notes,

“The National Lung Screening Trial demonstrated that lung cancer screenings are critical for this population. It also determined that CT was superior to chest X-ray for detecting cancers and that low dose CT scans were effective in detecting small masses, enabling patients to reduce radiation exposure.” Dr. Karras adds, “Another 10 to 15% of lung cancers occur in those who have never smoked. Detecting lung cancer as early as possible dramatically affects survival rates. When caught at Stage 1, the 5-year survival rates are 90 to 95%, while Stage 4 survival rates are only 10 to 15%.” Precise Localization with Pleural Dye Marking

Localizing and treating tiny peripheral nodules used to be challenging and involved large incisions. Pleural dye marking, a newer approach developed at Franklin Square employs navigational bronchoscopy and CT in real time to detect these nodules. “The dye allows physicians to mark the pleural surface adjacent to the lesion, and can detect even the more elusive “ground-glass” lesions. A bronchoscopic biopsy can be performed during the same procedure,” says Sy Sarkar, M.D., interventional pulmonologist at Medstar Franklin Square.

Robotic-Assisted Lobectomies

Saint Agnes Hospital is one of a small percentage of hospitals offering roboticassisted lobectomies. “We can do things we could do with VATs but less invasively,” says Gavin Henry, M.D., thoracic surgeon at Saint Agnes. “The robotic-assisted procedure is appropriate chiefly for Stage 1 and 2 lung cancers. It typically involves less pain because the robot allows us to use ¼ to ½ inch incisions. It also provides better angles to reach the tumor and affords surgeons better depth perception – more of a 3D view, compared to a 2D view with VATs. Patients leave the hospital as early as one to two days post-op.” Seamless Care

Many hospitals now have nurse navigators to provide easy access to services and a 24/7 resource for patients. Ruth Evans, R.N., thoracic coordinator at Medstar Franklin Square, says, “Patients just call me and I can access our physicians on their behalf. We help to keep costs down by preventing repeat testing, such as a pre-op blood draw. We also facilitate a patient’s treatment, typically involving surgery, medical oncology and radiation.”

VATS (Video-Assisted Thoracic Surgery)

While some 60 to 70% of lobectomies in the U.S. are still performed using an open incision, specialists in Maryland are moving to videoscopic-assisted thoracic surgery (VATS) and robotic-assisted lobectomies. “If the bronchoscopic biopsy is unrevealing, a surgical biopsy can be performed within 24 hours using the pleural dye as a localization technique,” Dr. Sarkar notes. “This speeds the process from detection to treatment.” A woman with uterine cancer who developed sub-centimeter pulmonary nodules illustrates the advantages of this approach. Her oncologist wanted to verify that the nodules were metastatic and referred her for the bronchoscopic biopsy and pleural dye marking for localization. The procedure did not reveal anything; however, the dye allowed the thoracic surgeon to readily locate the nodule, determine that it was metastatic and remove it using the VATS procedure the next day. The patient could immediately start chemotherapy.

Sy Sarkar, M.D., interventional pulmonologist and Ruth Evans, R.N., thoracic coordinator, Medstar Franklin Square

Nicholas Argento, M.D., endocrinologist, Maryland Endocrine, PA. Sy Sarkar, M.D., interventional pulmonologist, and Ruth Evans, R.N., thoracic coordinator, MedStar Franklin Square Hospital Gavin Henry, M.D., and Riny Karras, M.D., thoracic surgeons, Saint Agnes Hospital


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The (R)evolution

of Childrenâ&#x20AC;&#x2122;s Hospital Care From facilities to care delivery, pedatric hospitals have taken a great leap forward

Giant puffer fish are suspended from the ceiling at the new Johns Hopkins Children's Center.


To learn how inpatient pediatric care is evolving, Maryland Physician spoke with the heads of pediatrics at Johns Hopkins, University of Maryland, Sinai and Children’s National Giant yellow puffer fish suspended from a soaring ceiling. Abstract rhino sculptures in the courtyard. Marine motifs and live broadcasts from the National Aquarium. Pediatric ICUs where both parents can stay overnight. Many of today’s spacious pediatric facilities only vaguely resemble hospitals of the past, with family-friendly, private rooms that are stuffed with electronic amenities like video games and flat screen TVs. Why are pediatric facilities enhancing services when vaccines and treatment advances result in fewer and shorter hospitalizations? In part, the ability to treat formerly lifethreatening conditions, such as congenital heart disease and fetal neurology deficits, has increased the need for intensive pediatric care. “Across the country, community hospitals are questioning whether they should partner with a tertiary hospital or get out of the pediatric business,” says David L. Wessel, M.D., senior VP, The Center for Hospital-based Specialties, Children’s National Medical Center. “There’s a focus on inpatient service being tertiary and quaternary.” Flexible, Innovative Facilities

With the help of private donations, all four of Maryland’s local children’s hospitals are investing multiple millions in their facilities, staff and technology to dramatically alter care delivery. Sinai Hospital opened its new 23,000 sq. ft. Herman & Walter Samuelson Children’s Hospital in mid March, Hopkins opened the new 205-bed, 560,000 sq. ft. Charlotte R. Bloomberg Children’s Center on May 1st, and UMCH and Children’s National have added new facilities and completed major overhauls of existing ones. Todays’ rooms are large, private and replete with high tech features. One or both parents can sleep overnight with their child, even in the ICU. Teens enjoy high-tech options in separate lounges so they don’t have to mix with younger children.

George J. Dover, M.D., director, Johns Hopkins Children's Center

Flexibility is key. Medical/surgical rooms can be converted to ICUs simply by increasing the nurse staffing ratios. Joseph M. Wiley, M.D., FAAP, chief, Department of Pediatrics, the Herman and Walter Samuelson Children’s Hospital at Sinai, says, “In our new children’s hospital, we designed the flex unit to have three pods, each with two rooms; the rooms can be used as an ICU so we don’t have to move sicker patients.” “The strength of our new facilities is that we can adapt to change quickly so that we can still take care of patients in 20 years,” notes George J. Dover, M.D., director, Johns Hopkins Children's Center. “We’ve also designed the new hospital so that new technology can be available to both children and adults. Further, we’ve grouped related pediatric services on the same floor. For example, we’ve grouped our new NICU, delivery suites, ORs devoted to C-sections, and a nursery on the same floor. On another floor, we have a large PICU adjacent to a suite of pediatric ORs that can handle both MAY/JUNE 2012

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Left to right: Steven J. Czinn, M.D., professor and chairman, Department of Pediatrics, University of Maryland Medical Center. David L.Wessel, M.D., senior VP, The Center for Hospital-based Specialties, Children’s National Medical Center. Joseph M. Wiley, M.D., FAAP, chief, Department of Pediatrics, the Herman and Walter Samuelson Children’s Hospital at Sinai.

same-day and complex procedures, a huge recovery area and pediatric radiology.” Sinai’s solution to the confining isolation rooms of the past is to create a wing where four isolation rooms have glass on three sides and anterooms. The entire facility is also HEPA-filtered to reduce infectious transmission. “We now have a physical facility that matches the way we want to practice medicine,” remarks Dr. Wiley. “Our approach is to invest our dollars to get the maximum return,” says Steven J. Czinn, M.D., professor and chairman, Department of Pediatrics, University of Maryland Medical Center. “We’ve built a new pediatric hybrid cardiac catheterization lab and are finalizing plans for a new state-of-the-art NICU. We have often retooled existing space to use the dollars efficiently. For example, we converted existing space to mostly private rooms and separate teen, toddler and family lounges.”

The strength of our new facilities is that we can adapt to change quickly so that we can still take care of patients in 20 years. – George Dover, M.D.

Growth in Pediatric Subspecialized Care

Hospital pediatrics has become highly intensive and subspecialized, encompassing more than 20 subspecialties, including pediatric emergency physicians, pediatric gastroenterologists, neuro-surgeons, oncologists, cardiologists and anesthesiologists. “One of the biggest transformations is in pediatric ICU care,” Dr. Wessel observes. “In the near future, nearly 50% of our beds will be ICU beds. In addition to a 54-bed NICU and 39-bed PICU, we opened a new cardiac ICU with 26 beds in early 2012. Even though we built the unit for growth, we already are nearly full.” Children’s National has had success with a hypothermia program to cool newborn body temperatures to 32 to 34 degrees Celsius following cardiac arrest. They also are expanding fetal and transitional medicine, with specialized services in utero that 18 |


extend to advanced post-delivery care. In the brain, doctors can now determine brain development by measuring brain folding and metabolism. “It’s a very exciting area and we rebuilt a whole suite for fetal medicine,” enthuses Dr. Wessel. “We have the only pediatric hybrid cardiac catheterization lab in the state, or perhaps the region,” says Dr. Czinn. “We spent $3 million to provide both cardiothoracic and interventional cardiology services in the same lab.” Another area of strength at UMCH is its pediatric GI program that includes pediatric anesthesia, a GI infusion center, and wireless capsule endoscopy to evaluate the small bowel. Dr. Wessel notes, “Our whole east tower inpatient unit is only two years old. We have the only dedicated cardiac PICU in the area. We can open an aortic valve in a preemie weighing less than two pounds in that ICU, a procedure that would have been impossible eight to 10 years ago.” The survival of infants and children with serious conditions has led to the need for new services to treat them as they grow up. UMCH offers a Pediatric Oncology Survivorship Program to examine and monitor the most common side effects that develop in children who have undergone radiation and chemotherapy treatments. Dr. Czinn comments, “If we see them at regular intervals, we can prevent problems.” Dr. Dover says, “Hopkins has the largest cystic fibrosis program in the region. Those children have now grown up and we’ve had to train internal medicine providers to deliver cardiac, pulmonary and other care to them as they’ve become adults.” Pioneering and Rapid Adoption of Advances

Whether pioneering new technology in infants, or more quickly adopting adult advances to children’s care, these facilities drive change. Dr. Dover comments, “At Hopkins, we don’t wait for things to be developed in adults first. From the operation to repair the congenital heart condition, Tetralogy of Fallot, in 1944 to today, advances often start in pediatrics.” Dr. Wessel notes that the first reported use of Viagra was treating pulmonary hypertension in a 6-week old girl in the late 90s. He also cites the heart/lung machine as an example of technology that was adopted for use in adults only after it was developed for children.

Family Centered Care

Adds Dr. Czinn, “Because there is a larger market for adult advances, technological advances tend to occur first in the adult world and trickle down to children. We’re committed to speeding the adoption of those advances to pediatric care.” Community Hospitals Adapt

Dr. Dover says, “There’s a new model of community pediatric hospitals that was started at Howard County General, is now at GBMC and Franklin Square, and is spreading to Upper Chesapeake and Bayview. In this model, pediatric ER, observation and inpatient services are all staffed by a shared set of pediatric nurses and hospitalists. We’ve developed protocols that guide when to transfer children needing more specialized care to us, to keep as many patients at the community hospitals as we can.” IT Transforms Care Delivery

Telemedicine is facilitating the communication between community hospital pediatric staff and tertiary centers. Children’s National has developed telemedicine technology to network area community hospitals with its emergency and inpatient specialists, Hopkins is launching telemedicine in its new hospital, and UMCH has telemedicine pilots underway. Dr. Wessel says, “We have media rooms that connect to other centers across the country. A community hospital can do a cardiac ultrasound and feed it to us. We can make the diagnosis and transport the child when necessary. We transport more than 6500 patients a year.” “With telemedicine,” Dr. Czinn remarks, “we can speak to the referring physicians, look at the child’s lab and imaging results in real time and make a decision to transfer them here or treat them there. It will dramatically influence the value of the healthcare dollar.” Both Hopkins and Sinai have advanced electronic medication ordering systems in which medications are delivered directly to a locked cabinet in each patient’s room. Dr. Wiley notes, “Nurses no longer have to retrieve medications from a med room, where they risk being interrupted. They can check the dose and scan the bar codes to match the medication to the child.” Dr. Dover adds, “Hopkins will soon assign a pharmacist to each floor to work with the providers there as a team.”

Making pediatric care more familycentered is not just a nice touch, it’s good medicine. In most facilities, both parents can be accommodated for overnight stays, and bathrooms are designed with adult needs in mind, as well as the child’s. At Children’s National and Sinai, their family-centered rounds intimately involve the family. “Research has demonstrated that this approach increases information accuracy, reconciles medication dosing with the child’s condition and lets the family know what diagnoses we’re considering so there are no surprises,” Dr. Wiley states. Adds Dr. Wessel, “We invite parents to join us every morning, even in the ICU.” Parents are even allowed to stay during cardiac resuscitation of their children if they wish, and under certain conditions. Child Life specialists add a critical dimension of care. According to Dr. Dover, Hopkins has one of country’s oldest child life programs. These specialists have a strong background in child development and family systems so they can provide emotional support to the entire family as well as the hospitalized child’s development. “Normal play can be the best therapy,” observes Dr. Wiley. Easy Single-Point Access

Tertiary hospitals used to be infamous for their lack of access. While they have worked on improving access for years, these hospitals are striving to make additional enhancements. Sinai has Pediatric One Call and has developed a reputation for being well connected to its referral base. Dr. Wiley claims, “As long as a bed is available, we can get the patient in. The ED can be bypassed as appropriate.” At Children’s National, Kurt Newman, M.D., the new president and CEO, has set ambitious goals to have a single person and number to call for each service. “His single greatest focus is to increase access,” says Dr. Wessel. In addition to UMCH’s One Call system, Dr. Czinn says, “Pediatricians can keep one phone number on speed dial – mine. My commitment is that doctors can call me directly at 410-328-6777.” Dr. Dover concludes by commenting, “Pediatrics is the jewel in the crown for Hopkins.” With new facilities and care paradigms, it’s clear that pediatric care is a shining jewel for all four of these specialty hospitals.

Joseph M. Wiley, M.D., FAAP, chief, Department of Pediatrics, the Herman and Walter Samuelson Children’s Hospital at Sinai. George J. Dover, M.D., director, Johns Hopkins Children's Center, professor of Pediatrics, professor of Oncology, Given Professor and director, Department of Pediatrics David L. Wessel, M.D., senior VP, The Center for Hospital-based Specialties and division chief, Critical Care Medicine, Children’s National Medical Center Steven J. Czinn, M.D., professor and chairman, Department of Pediatrics, University of Maryland School of Medicine, and Physicianin-Chief, University of Maryland Children’s Hospital


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Healthcare IT



PORTALS A Path to Increased Productivity and Happier Patients BY LI N DA H A RD ER • PHOTOGRAPH Y BY TRACEY BROWN

Physician offices barely began to pass Stage 1 of Meaningful Use requirements before it was time to gear up for Stage 2, where a key requirement is to increase the electronic information shared with patients. Maryland Physician spoke with two area primary care physicians who have experienced patient portals first hand.

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Patient portals are not new. David Rowe, global director of Product Marketing at GE Healthcare IT, remarks, “We’ve had a patient portal for more than 10 years, but it was dormant until Meaningful Use reawakened that marketplace. It’s a way for physicians to provide patient information easily and quickly.” Portals Aid Two Measures in Stage 2

Patient portals help physicians meet two core measures of Stage 2. The first measure requires providing a clinical visit summary to at least half of your patients within three business days. The second measure requires physicians to electronically provide lab results, medication lists and the like to patients upon request. Most portals provide a range of functions that may include:  Prescription renewals  List of medications  Lab and other test results  Clinical summaries  Personal medical history  Secure SMS messaging  General health reminders

 Appointment requests  New patient registration Not Just Another IT Headache

Patient portals may seem like just one more IT headache. Yet the early experience of doctors who have implemented portals in their office – sometimes under protest – suggests that once the hurdles of implementation and training have been crossed, the office will be more productive, with happier patients and providers alike. Take the experience of Andrew McGlone, M.D., a family practitioner with Annapolis Primary Care. Early adopters of EHRs, they switched from an earlier EHR system to Epic in May of 2009. In 2010, they added Epic’s patient portal, called MyChart, which can be branded to the health system. “At first,” confesses Dr. McGlone, “I was leery of yet another responsibility that I wouldn’t be reimbursed for. Now, my biggest complaint is that not enough of my patients are using the portal.” Noting that about 20-30% of his patients have signed on, he adds, “I was amazed by the amount of time the entire office

Greater Baltimore Medical Associates (GBMA), believes that portals have value, but is somewhat reserved about their cost-to-benefit ratio. GBMA, a practice that encompasses 69 primary care providers and other providers, uses the fully integrated portal from eClinicalWorks. Only a few months after the portal launched in January 2012, more than 9000 patients had signed up. “The biggest advantage is that the portal is an alternative to another phone call,” states Dr. Lamos. “The portal works well if the question is succinct, and providers can select from recorded messages to save time. At worst, it’s a breakeven and it probably saves time.” Patient Participation and Satisfaction

Andrew McGlone, M.D., a family practitioner with Annapolis Primary Care. Right: Mark Lamos, M.D., internist, president of Greater Baltimore Medical Associates, and staff.

could save while also providing more immediate and better patient care. “Before the portal,” Dr. McGlone continues, “if a lab result showed a patient’s thyroid needed adjustment, I’d compare a piece of paper with the chart, then call the patient, often having to leave a message, then eventually having a conversation to confirm the dose and the pharmacy. In the patient portal, everything is right there. In a few keystrokes, I can relay the result and new dose adjustment, electronically prescribe the new medication, and order follow-up lab testing.” Dr. McGlone enthuses, “You can respond on your time and patients can reply back at their convenience. There is no need for additional documentation, as

Types of Portals and Costs

Essentially, patient portals come in three “flavors.” Some are integrated with the vendor’s EHR, including portals provided by Epic, NextGen, and eClinicalWorks. In a second model, vendors such as GE and Allscripts have interfaced third-party portals (Kryptiq

Patients of all age groups are using it and overwhelmingly, they’re happy. – Mark Lamos, M.D. the correspondence takes place in the medical record. If a patient’s lab or imaging results are normal, you provide them reassurance in seconds. Another aspect that made me a convert is that patients can send a message directly to me in their own words, not translated through the staff. The portal removes a lot of barriers to care. It allows us to engage in a productive dialogue with our patients, and we have the system set up to protect us from irrelevant or emergency requests.”

and Intuit Health, respectively) with their EHRs. A third model involves a relationship between the EHR vendor and an independent portal vendor, which could entail additional work for staff if they have to re-enter information. Costs for the portals vary. With the Epic and GE Centricity systems, the flat fee paid for the EHR also covers the patient portal module, but some vendors charge an additional monthly fee. Mark Lamos, M.D., president of

He continues, “Patients of all age groups are using it and overwhelmingly, they’re happy. We used to have to mail their records to them and now we can quickly post them online. However, we still send a letter if something is questionable. A portal is not an excuse to avoid communicating with a patient.” Perhaps surprisingly, even older patients welcome the portal if they are comfortable with technology and


 First convert your records from paper to electronic.  Select a software vendor with a proven functional portal.  Before you promote the portal to all of your patients, test it on a small number of patients and make sure employees can handle their questions.  Don’t delay implementation; future pay-for-performance based plans will require them


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computers. Dr. Lamos notes, “The tool is simple enough that patients can use it easily.” “To encourage participation, we have computers in our front lobby and seniors who volunteer to serve as tutors,” adds Dr. Lamos. “The front desk staff asks patients if they want to sign up, we have signs in the waiting rooms, and I and other staff wear buttons that say ‘Ask Me About the Portal.’” GBMC also developed an instructional video for patients. *Other practices report that sending postcard reminders to patients and having technologists and other extenders discuss the advantages of the portal before patients leave the office can be effective tools to increase participation. “Compared to the challenge of the Patient Centered Medical Home, this is a piece of cake,” comments Dr. Lamos. However, he cautions, “It’s not a weekend process. It takes days to weeks of effort to implement.” Mobile, Rapid Results

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Patients can use the web-based Epic portal from most laptops or android or iPhone platforms. “We often have same day turn around on laboratory and imaging results which patients receive with our interpretation and instructions on their mobile devices. The efficiency of electronic correspondence for routine medical care allows more time in the day for phone conversation to address urgent or concerning results,” Dr. McGlone exclaims. “One of my favorite things is providing reassurance and follow-up through the portal,” he concludes. “We can send quick messages to stay in close contact with sick patients and track changes from medications in real time. Patients are more active participants in their own health. We can even set the system to remind them of flu shots, mammograms or other screening tests when they are due.”

Andrew McGlone, M.D., family practitioner, Annapolis Primary Care. Mark Lamos, M.D., internist, president of Greater Baltimore Medical Associates (GBMA), the GBMC HealthCare-owned group of more than 40 multi-specialty physician practices.

*The myGBMC portal is located at; the video is available at video:

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History lovers, adventure seekers and romantics at heart easily find common ground in Harper's Ferry, where there is much to see, do and explore. Many who visit find themselves returning time and time again, to enjoy a getaway that can be reached easily and relatively quickly, from just about every point in the State of Maryland.


T’S THE TYPE OF PLACE THAT is sought out by people of all interests and likes. Some come to relax. Others come to explore, enjoy nature, seek adventure or learn. Those who have visited, be it for a fun family weekend, a romantic getaway or for a few simple and quiet days of solitude, would say that there is something for just about everyone in Harper’s Ferry, the little town that is perched where Maryland, Virginia and West Virginia, as well as the Shenandoah and Potomac rivers, meet. A History Lover’s Paradise

History buffs will have more than enough sites to see and stories to hear while visiting Harper’s Ferry. The town became a favorite 24 |


retreat hot spot for U.S. presidents in the late nineteenth and early twentieth centuries; in fact, Thomas Jefferson himself was once quoted, referencing Harper’s Ferry as “a beautiful spot that is worth a trip across the Atlantic.” Perhaps most notable in history books read today was the 1859 raid against the federal armory at Harper’s Ferry, orchestrated in an attempt to end the institution of slavery in Maryland and Virginia. The act, led by abolitionist John Brown, who was captured during the raid and later hung for his conviction, is commonly cited as a pivotal movement in history that spurred the start of the Civil War. Today, the town’s “John Brown Wax Museum” showcases 87 life-sized wax figurines to


Harper’s Ferry: A Getaway Worth Exploring Tracy M. Fitzgerald

show and tell the complete story. And that’s not all. The first steel structural bridge in the world was constructed in Harper’s Ferry, and marks the spot where the first railroad crossed the Potomac River. American manufacturing was forever changed when in the industrial district of town, it was proven that interchangeable parts could and should be used to develop goods. And, in 1865, Storer College opened its doors in Harper’s Ferry, becoming the first institution to offer educational opportunities to freed slaves who aspired to read, write and develop new skills. Well before its time, the school helped encourage African Americans to pursue entrepreneurial paths.

Touring the Town

Self-guided historical tours of the town have proven to be a popular way to take in all that’s there to see. Those who are eager to learn some new things during their stay may opt to participate in a chartered or group tour. O’ Be Joyfull Historical Tours and Entertainment gives Harper’s Ferry tourists a chance to experience the town’s most notable historical spots, with entertainment inspired from the Civil War days. Those who crave a bit of “spooking” will want to take American’s oldest ghost tour, which includes a one-hour walking expedition around Harper’s Ferry’s “lower town,” where a number of ghostly phenomenons have been reported. Exploration and Outdoor Adventure

Those who visit Harper’s Ferry to navigate the great outdoors may find the National Historic Park to be a good place to start, with over 2,300 acres stretching across three states, giving site see-errs plenty to explore. In fact, the park contributes to the many reasons why art history experts have described Harper’s Ferry as “the most painted town in America because of its beautiful scenery.” Some choose to spend their time meandering along the miles upon miles of hiking and biking trails, perhaps stopping off to toss out a fishing line or snap a few photos along the way. Others take advantage of the chance to saddle up and go for a horseback ride through the Blue Ridge Mountains or along the outskirts of the Potomac River. Those seeking

excitement and adventure have plenty of options too, with whitewater rafting trips, tubing, canoeing and zip line canopy tours all available. Wine and Dine with a Local Flair

There is no shortage of dining options to be found in town. Those wishing to continue their historical-themed experience may want to dine at The Town’s Inn Restaurant and Pub, known for its cuisine from the Civil War era. If locally grown food and wine are priorities, be sure to put the Canal House Café and the Grandale Farm Restaurant on the go-to list. Additionally, a number of deli’s, café’s and taverns are open year-round in the heart of town, and serve everything from pizzas, burgers, subs and salads, to hearty soups, barbeque and seafood entrees. Homemade ice cream and candy shops are also plentiful, for a mid-day snack or after-dinner sweet treat. Call it a Night

Because there is so much to see and do, staying overnight in Harper’s Ferry may be a good idea. Armory Quarters, neighboring the National Park and within walking distance of many restaurants, shops and battlefields, is a good option for those who want to see and do it all. As a special bonus, Hollywood Casino and Charles Town Races are only about five miles away. For those seeking more quaint and quite accommodations, perhaps for a special weekend away, a dozen-or-so bed and breakfasts are open for business. And for the true nature and

Local Harper’s Ferry Doc Gets Youngsters Moving Some people who live in or near Harper’s Ferry know Dr. Mark Cucuzzella because of his work as a family medicine physician in the community. Others know him because of the active role he plays in encouraging young people to get out, get active and be healthy, through his leadership in developing the “Tiger on the Trail” hiking program, a partnership between Harpers Ferry Family Medicine, the middle schools in Jefferson County and Harpers Ferry National Historic Park. Dr. Cucuzzella can often be found leading groups of students on hikes throughout the park, promoting the importance of physical and activity and healthy living, along the way.

outdoor enthusiasts? Book a site at one of Harper’s Ferry’s campgrounds, each lending themselves to beautiful river views and sun-up to sun-down access to hiking trails, watersports and other outdoor activities. Resources and tips for planning a visit to Harper’s Ferry, as well as a listing of upcoming events, can be found at

Travels with Eli JACQUIE ROTH


fter an early spring visit to Fort Sumter in Charleston, the battle site which launched the Civil War, I was inspired to visit another pivotal Civil War site, Harper’s Ferry. With thanks to Fitzgerald Auto-Mall Annapolis and homage to John Steinbeck, my Standard Poodle Eli and I set off to Harper’s Ferry in a 2012 Volkswagen Passat V6. VW is legendary for its German engineering and premium standard features in an automotive class ripe for comparison. Does it deserve those impressive accolades as “2012 Car of the Year”? Having experienced German engineering and VW’s – including a Super Beetle that needed to be jump started, heading downhill to pop the clutch and one spanking new BMW traded in after my first baby was born for a VW Jetta with 116,000 miles – the Passat didn’t disappoint. We had a gorgeous spring day to test the Passat’s drivability and fun factor. Always eager for a ride, Eli wasn’t shy about jumping right into a very roomy rear seat and I was excited to see if the Passat was as much fun to drive as my ‘80s VW GTI. Living up to its family’s reputation, it was. The V6 engine and relatively low weight added spunk and easy maneuverability as we navigated our way to Harper’s Ferry. Lots of modern technology with user-friendly controls and navigation system made me feel snug, safe and secure in my driver’s space. The iPod doc, impressive Fender sound system and large sunroof added to the trip’s enjoyment factor. So, do Eli and I believe that the 2012 deserves to be named best in class? The photo of Eli’s fuzzy head poking out of the Passat along the Shenandoah’s riverbank says it all with his Poodle grin – yes!


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Recap: Physicians Gain Ground in 2012 Maryland General Assembly Session LINDA HARDER • PHOTOGRA PHY BY TRACEY BROWN

Maryland Physician interviewed Gene M. Ransom, III, Esq., CEO of MedChi, to discuss highlights of the 430th General Assembly session. DESPITE THE FACT THAT legislators did not approve the state budget in time, on the whole, it was a highly successful legislative session for Maryland physicians, with the MedChi Legislative Committee reviewing a total of 222 bills and proposals. At press time, it was anticipated that a Special Session will be called to pass a budget. Mr. Ransom observes, “From the perspective of physicians, we had an incredible legislative session. It would have been a home run if Medicaid had passed, and I’m cautiously optimistic that it will pass in a Special Session.” MEDICAID REIMBURSEMENT

“The Senate version of the bill, which would have increased E&M (evaluation and management) codes for all specialties by nearly $70 million, won out over the House version,” notes Mr. Ransom. “But because the budget was not passed, the legislation is currently in limbo. An increase in these codes could positively affect the existing deterrents for accepting Medicaid patients, which will be even more critical when health care reform creates a larger Medicaid population.” The fee increases will not occur unless there is a Special Session that enacts the related revenue measures necessary to fully fund the Budget. LEGISLATION THAT PASSED

The following bills were passed by both Chambers and await Governor Martin O’Malley’s signature. Prior Authorization Reform Bill (SB 540/HB470)

Both Chambers passed identical versions of this Bill, which was MedChi’s top priority 26 |


for 2012. It calls for insurance intermediaries to adopt a single electronic method for submitting prior authorization requests. It will allow a physician to access insurance websites to determine preauthorization requirements and then request it electronically, using unique tracking numbers. Most drugs will be eligible for real-time preauthorization by July 2013. Mr. Ransom comments, “Physicians are currently spending inordinate amounts of time contacting insurance companies for authorization. The Maryland Health Care Commission has laid out a plan to move to a standardized, electronic system for filing and processing requests, and this legislation will empower them to hold insurers accountable. This bill provides a game plan for the next three years.”

However, two other telemedicine bills that deal with credentialing and licensure were not acted on favorably. Says Mr. Ransom, “The other bills raised a variety of complex issues and will best be addressed next year after discussion by various stakeholders.” Health Benefit Exchange (SB 238/HB 443)

The Maryland Health Benefit Exchange Act of 2012, as it is called, creates an option for individuals and small businesses seeking to purchase health and dental insurance under the federal Affordable Care Act. The exchange must be operational by fall 2013 and begin offering coverage Jan. 1, 2014. Truth in Advertising (SB 395/HB 957)

This complex legislation, which dealt with advertising, badges and information regarding how healthcare practitioners describe their services, was scaled back but moves the issue forward. HIPPA /Privacy (SB 954)

Health Disparities/Enterprise Zones (HB 439/SB 234)

The Administration’s legislation on disparities provides $4 million in new money for physicians in certain underserved zones, the location of which is yet to be determined. This bill was a top priority of the MedChi Disparity Committee for 2012, which arose from the disparity report completed by University of Maryland Medical System Dean Albert Reece, M.D., in 2011. Mr. Ransom comments, “We testified in favor of the bill, which takes effect July 2012. We’re polling our members to see who is interested in applying for the funds to better serve areas with health disparities.” Coverage for Telemedicine Services (SB 781/HB 1149)

This legislation requires covered insurers to reimburse providers when medical services are delivered via telemedicine.

With the help of Attorney General Douglas Gansler, MedChi supported amendments to this bill, which was introduced by CareFirst. “The legislation, which initially lessened privacy restrictions, became a very good bill that protects patient privacy, while allowing for positive data sharing within Patient Centered Medical Homes and ACO programs,” says Mr. Ransom. KILL(ED) BILL(S)

Physicians successfully defeated several pieces of legislation, including multiple bills dealing with scope of practice. “We were especially concerned about a bill that would have created a licensing board for naturopaths, which was tabled,” notes Mr. Ransom. “We stopped the encroachment from other groups where they don’t have the level of training or expertise to practice.” Visit for a more complete review.

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here are limited options for Maryland families with pediatric hospice needs. In response to community outcry from both healthcare professionals and families in need, Hospice of the Chesapeake has added to its child focused programs with the launch of two programs. Both are holistically centered under the umbrella of Chesapeake Kids. The Perinatal and Infant Loss Support program is designed to support families who have received the devastating news that their unborn child has a condition which may result in stillbirth or early death. The program is designed to support families through all aspects of the journey they are about to take, from planning through pregnancy, birth and death. While honoring the family’s wishes, Hospice of the Chesapeake facilitates lasting memories of the family’s pregnancy and baby. The challenges of caring for a child with a life-limiting illness can be overwhelming and can take a toll on the entire family. As part of its commitment to care and support families, the second pediatric program was launched and created to care for children living with advanced illness. Hospice of the Chesapeake provides support and care in the home, surrounded by family members and memories providing much needed comfort. An interdisciplinary team of healthcare professionals, chaplains and trained volunteers provide the care, comfort and support for infants through young adults living with advanced illness and the associated treatments while providing education and support for the caring family. The support continues as the family works through its needs when faced with the grief from the loss of their child. Chesapeake Kids also includes Hospice of the Chesapeake’s grief camps for children, Camp Nabi and Phoenix Rising as well as its ongoing grief counseling support programs for children hosted through The Life Center. For more information please call, 1-877-462-1103 or visit MAY/JUNE 2012

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Six Ideas to Help Improve Internal Control Processes within Your Practice By Bob Galiszewski, CPA and Cory Chaney, Senior Accountant


HILE OPERATING A practice, a physician is forced to delegate duties to trustworthy employees. Sometimes, this trust is not warranted and the temptation to take something knocks down the protective walls of honesty. A good adage to keep in mind is that fraud is typically committed by someone we trust. Understanding how and why fraud occurs can help you prevent it.

all employees from the top down are in compliance. The most common ways that employee dishonesty or fraud occurs is paying fictitious invoices or absconding with receipts of the business and marking accounts paid. To prevent these types of fraud, we recommend the following steps:

There are three major reasons that individuals commit fraud:

1. The bank statements should be received unopened each month by a trustworthy employee, or preferably the physician. This individual should not have any responsibility for maintaining the accounting records, paying bills, billing, etc. When the statement is received, the physician or designated employee should carefully review the signatures on the checks for any improprieties or forgeries. Physicians should also look at the payees to ensure these are vendors with whom your business is dealing. Another precaution you should take is to watch for double endorsements on canceled checks, which could be a sign that funds have been diverted from the original intended payee. A reputable business is not going to co-endorse their checks. 2. All incoming mail, especially the payments on account, should be opened and received by an individual who has no accounting, billing or bookkeeping duties. All posting to accounts receivable records should be done by reports generated from the deposit slips or the actual deposit slips themselves. If someone is going to abscond with cash, they will mark an open account as paid and divert the payment. Do not make the mistake of thinking that, because the customer is issuing a check to your business, these funds cannot be diverted. Horror stories abound about individuals who

 Pressure – pressures from an employee’s personal life, such as financial need, debt, lifestyle or gambling addictions, can be the driving force behind these acts  Opportunity – the employee works in an environment where his or her work goes unchecked due to the stress of the day, time constraints or negligence. Exceptions are frequently made by various employees for a variety of reasons and often go unnoticed. The organization lacks proper segregation of duties and adequate checks and balances, so that errors in accounting are often undetected  Rationalization – employees believe that their actions are warranted in some way. They may say to themselves, “I’ll pay it back,” “They won’t miss it,” “I’m underpaid” or “I didn’t get a raise from my last review.” Medical practices in today’s economy are constantly facing reductions in reimbursement and other outside factors that affect revenue generation. The last thing a practice needs is to suffer additional losses due to internal fraud. A practice can reduce the potential for fraud by recognizing the reasons why employees may commit fraud and by immediately establishing and maintaining an environment where

have opened up corporate accounts with falsified documents. Banks will open up an account with a board of director’s resolution and financial paperwork. Both of these can be falsified. 3. Spot-check any voids or credits to your accounts receivable records and ensure that these were properly authorized and warranted. In the medical profession, there are substantial writedowns. You should receive a report of these on a monthly basis. 4. Pay careful attention to sales returns and voids of the medical supply sales. This is a common way that a dishonest employee can pocket supplies. 5. On a monthly basis, review reports that show accounts receivable aging, services by procedure, checks made to cash, and miscellaneous and voided checks. 6. Carefully inspect what you sign or pay. “Rubber stamping” or signing documents without thought creates a temptation for your staff. The above suggestions can be easily implemented to improve your practice’s internal control processes – and your bottom line!

Bob Galiszewski, CPA, Shareholder, Cory Chaney, Senior Accountant and chair of KatzAbosch’s Medical Practice Services Group,


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Good Deeds

Lending Much-Needed Helping Hands to the People of Africa INTERNATIONAL ORGANIZATION FOR WOMEN AND DEVELOPMENT

By Tracy M. Fitzgerald


HILE VISITING AFRICA in support of the U.S. State Department’s International Information Program in the early 2000’s, Barbara Margolies had the unique opportunity to meet with Madam Aicha Foumakoye, the then Minister of Social Development in Niger. Through her conversations with him, she learned about a complex and debilitating health condition called vesico vaginal fistula, impacting thousands of Nigerian women. And right away, she knew she had to do something about it. “What I learned and what I saw literally brought me to tears,” Margolies said. “These women, some as young as 13 years old, were suffering and needed help.” In 2003, she led the establishment of the International Organization for Women and Development (IOWD), with a goal to rally surgeons and nurses together to provide volunteer medical assistance for women in Africa who required surgery. Vesico vaginal fistula is a result of prolonged, obstructed labor without medical assistance, causing the formation of a hole in the wall between a woman’s bladder and vagina, and leading ultimately of the leakage of urine. With extremely limited access to doctors, medical facilities and medications, more than 200,000 African women have become outcasts in their own society as a consequence of this extremely humiliating and uncomfortable condition. With Margolies’ leadership, IOWD’s first medical mission took place in October 2003, and since then, more than 1,000 African women have been treated by U.S. doctors and nurses, who have volunteered their time and talent to not only performing surgeries and providing 30 |


Left to right: On a recent mission trip, GBMC’s Dr. Joan Blomquist (pictured right, in blue), worked with Rwandan doctor Victor Mivumbi, to surgically repair a fistula. Teaching the Rwandans physicians is a key priority for IOWD. Dr. David McDermott from Anne Arundel Medical Center recently performed a six-hour surgical procedure for young Eric. Today, he is no longer incontinent.

medical care, but also serving as teachers for African physicians, originally in Niger, and more recently in Rwanda. IOWD has organized teams of 25 to 30 obstetricians, gynecologists, anesthesiologists, urologists and nurses, and has returned to Africa nearly 30 times, making strides with each visit toward the establishment of a sustainable program for the repair of fistulas. “The key is to go back again and again,” Margolies said, who has worked to develop partnerships with King Faisal Hospital and Kibagabaga Regional Hospital, both in Rwanda. “Over time, this is what has helped us earn the trust and respect of the people there. They know we care and want to help them, and they welcome us whole heartedly when we arrive each time.” Four physicians from Maryland have taken part in IOWD’s mission efforts, three of which represent Anne Arundel Medical Center: Dr. Briana Walton, a pelvic medicine and reconstructive surgeon; Dr. David McDermott, a urological surgeon; and Dr. Claudia Hays, OB/GYN. Dr. Joan Blomquist,

a urogynecologist from GBMC, has also volunteered. Margolies believes that the physicians who get involved are people with special gifts and hearts. “The doctors come and see what the needs are, and most importantly the impact they can have … and then they come back,” she said. “Coming on these mission trips gives our doctors a chance to use their skills in a new way, and they like that.” Mission trip planning is a constant priority for Margolies, and she is actively seeking new volunteers for upcoming visits to Rwanda. Her most significant need is for physicians and nurses who specialize in obstetrics, gynecology and urology. Those interested in learning more about how to get involved can contact Margolies directly by sending an email to

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

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To refer a patient for a cardiac surgery consult, call 301-891-6101. For priority transfer of your cardiac admissions, call Cardiac One-Call at 866-684-8460. Chris Barritt, 57, Mount Airy, Heart Tumor Surgery

Maryland Physician Magazine May/June 2012  

Cover Story: Simply Inspirational, Women Physicians Who Go Beyond the Norm; Feature: Thyroid and Lung Cancer on the Rise, The Revolution of...