August 2017 Orlando Medical News

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New Medical Center Obtains Final Approval, Determines Direction

North Florida

North Florida

Center will have an open process for granting access to physicians

By PL JETER

LAKE NONA—Deborah German, MD, is checking off another item on the impressive to-do list she compiled in 2009 as founding dean of the University of Central Florida (UCF) College of Medicine: to establish a hospital that advances teaching

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and clinical research programs.

Before the end of 2018, construction is slated to begin on UCF Lake Nona Medical Center, with a January 21, 2019 deadline for site preparation, foundation permit, footprint completion and foundation forming, with placement of concrete and steel for the facility.

Last month, Florida’s Agency for Health Care Administration (AHCA) gave its final stamp of certificate-of-need approval on the project. The 100-bed medical/surgical hospital is slated to open by the end of 2020.

The Florida Board of Governors, which oversees the state’s 12 public uni-

versities, approved the public-private hospital after AHCA green-lighted the preliminary certificate of need in March.

“This hospital and its research mission are part of the economic impact we promised the community when the medical school was built,” said German, also UCF’s (CONTINUED ON PAGE 4)

PHYSICIANSPOTLIGHT

Asim A. Jani, MD, MPH, FACP Hospital Epidemiologist, Orlando Health

In other words….

Editor’s note: This month begins a divergence from our usual format for Physician Spotlight features. In response to several requests, we are not only introducing readers to notable physicians in the Orlando area, but are also encouraging them to share their thoughts on issues in healthcare, research projects, charitable projects or anything else meaningful to our physicians. If you would like to share your thoughts with us, please let us know.

In January 2016, Asim A. Jani joined Orlando Health as Hospital Epidemiologist

under Corporate Quality & Patient Safety, after several years as Director of the Preventive Medicine residency program at the Centers for Disease Control and Prevention (CDC). His specialty areas include Infectious Diseases, Public Health and General Preventive Medicine and Internal Medicine. He began his CDC career as an Epidemic Intelligence Service (EIS) officer in 2003 and served as a commissioned medical officer in the U.S. Public Health Service.

(CONTINUED ON PAGE 5)

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HEALTHCARELEADER

Todd Goodman Discusses New Florida Hospital Program Adventist CFO reveals Community Care Program to improve health and lower costs Todd Goodman who serves as Senior Executive Officer and CFO of Florida Hospital and the Central Florida Division of Adventist Health System was kind enough to spend time with Orlando Medical News discussing a caring new Florida Hospital community health program.

Goodman has worked at Florida Hospital and Adventist Health System more than 25 years and has served in a number of positions. Prior to his current role he served as senior finance officer of Florida Hospital and the Florida Division of Adventist Health System, CFO for the Florida Hospital Heartland Division, and a variety of other roles in finance and business development.

Goodman received his MBA from the University of Central Florida and is a licensed CPA.

What is the Florida Hospital Community Care program?

The Florida Hospital Community Care program is a new initiative in the Orlando metro to help the most financially and physically vulnerable people in our community. Our goal is to improve patients’ health, while also reducing health care costs, readmissions and inappropriate emergency department visits. The Orlando program is modeled after a similar program that launched in Volusia County in 2014, which later expanded to Flagler.

As an organization, we have seen significant results from these efforts, and we’re eager to provide the same support to the Orlando community.

How does the program work?

In metro Orlando, the Community Care team consists of a social worker, a nurse and a dietician. As qualified patients come into the emergency department, we tell them about the program and ask if they want to sign up. If they do, the Community Care team works with the patient to ensure they understand their prescriptions, take the medicine, have a stable home, and educate them about community resources, such as medical homes for the uninsured that will allow them to have consistent care.

What is innovative about this program?

In addition to the multidisciplinary team, we are using technology such as MedMinder to help patients remember to take their prescriptions. MedMinder notifies a nurse if the patient doesn’t take orlandomedicalnews

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their medication at the appropriate time, so the team can follow-up. This technology not only ensures compliance; it also allows our team to monitor the care needs of the participants.

Who would benefit the most from the Florida Hospital Community Care program?

This program focuses on patients of the hospital who have chronic diseases, are uninsured and are unable to pay for their health care. It is not unusual for these patients to visit the emergency department several times a year. That’s troublesome because it shows us their health isn’t being managed or improved, they need help monitoring and controlling their illness, and there may be larger barriers, such as lack of housing, social, emotional or financial resources.

Why is Florida Hospital launching this program?

As an organization, we are committed to helping our community become

healthier, and that means finding innovative ways to help the most physically and financially vulnerable in Central Florida.

We want patients to seek appropriate care at the most appropriate setting. By partnering with our patients in this program, we can focus on the whole person, and not just their medical emergency. We are committed to providing exceptional care that is focused on whole-person health — physical, spiritual and emotional. This is a good example of both doing good and doing well.

What have you seen in Volusia and Flagler counties that you hope to model in the Orlando program?

We’ve seen a notable reduction in emergency department visits, and a reduction in inpatient stays for this group of patients in Volusia and Flagler counties.

This has led to improvements in health as well as a direct cost savings of more than $350,000.

In Volusia and Flagler counties, college students have been a part of the suc-

cess of the program. Students are trained as “health coaches” and offer greater assistance in the patients’ homes. We’re working with Adventist University of Health Sciences to rollout a program in metro Orlando that teaches students in our community how to perform this task starting in January.

What are some results you’d like to see in the Orlando metro area from this program?

We want to improve the health of our community and reduce the amount of people who live with chronic conditions and are not able, or don’t know how, to manage them. Our ultimate goal is to help the Orlando metro community lead a healthier life, and this program is one of the steps we’re taking to make that happen while reducing the cost of care within the community.

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New Medical Center Obtains Final Approval, continued from page 1 vice president for medical affairs. “In the United States and around the world, the best health systems have an academic component at their heart and the best medical schools have teaching hospitals.”

UCF President John C. Hitt calls the hospital project one of UCF’s most important decisions of the decade. “We look forward to strengthening our community’s health, training more doctors, and powering economic growth through research,” he said, adding the College of Medicine is at full enrollment, with 480 students.

The Board of Governors’ approval allows UCF to grow the hospital to up to 500 beds without further approval.

HCA’s Role HCA North Florida Division will provide $175 million to build and begin operating the hospital, while UCF will contribute its strong academic brand and 25 acres of land adjacent to the medical school the university acquired in 2012.

UCF will have 20 percent ownership in addition to equal governance. The eightmember governing board will have four each HCA- and UCF/College of Medicine-appointed members.

No state dollars will be used to build the UCF Lake Nona Medical Center.

The hospital project exemplifies HCA North Florida’s strategy to meet the fastgrowing region’s needs through new facilities and services, said Michael P. Joyce, FACHE, president of HCA’s North Florida

Division. “We’re excited to expand our partnership with UCF in the development of a new hospital in Lake Nona,” he said.

Two years ago, UCF and HCA formed a consortium to boost muchneeded residency programs in the heart of Florida. Since 2015, the partnership has reaped 14 new residency programs and one new fellowship in HCA’s North Florida Division hospitals in Gainesville, Kissimmee and Ocala.

“We just started our first fellowship in endocrinology,” said UCF College of Medicine spokesperson Wendy Sarrubi. “Once the new hospital reaches as many beds and patients as needed, it will give us an opportunity for even more residency programs.”

The consortium’s residency programs represent 250 physicians-in-training. By the time the hospital opens in 2020, additional resident physicians are anticipated.

Benefits for Medical Education “Our students right now do their third and fourth year clerkships with partner hospitals like Orlando Health, Florida Hospital. They’re at Heart of Florida in Davenport, they’re in Flagler, in St. Pete, they’re at Bay Pines, VA Center in St. Pete. Flagler’s in Saint Augustine.

“They’re all over and we think that’s an important part of our training. They’re also here at the VA and here at Nemours because the more diverse experiences they have the better so they can see different kinds of hospitals, different patient populations, different business models so that

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AUGUST 2017

won’t change with this new hospital. We want our students to be at partner hospitals all across the community and all across the state, frankly. This will give us additional opportunities for medical students right next door,” said Sarubbi.

“Our goal is to be partners with everybody and to really ensure that our students have that diverse experience because it’s invaluable. It gives them so many different experiences and different electronic health records and different patient tools.

Every med student at UCF spends time in their training caring for veterans, our nation’s heroes. That’s important to us. We need them to be in diverse locations to see the excellent care in this community and to have all those experiences to learn from it.”

Community Perks Increased research, interprofessional education opportunities, open hospital privileges, and bridging the gap of adult care in Lake Nona are among additional benefits the new hospital will bring to the community.

Despite scant speculation otherwise, UCF College of Medicine’s clinical research expansion isn’t tied to the absence of Lake Nona neighbor Sanford-Burnham-Prebys Institute.

“We’ve been talking about establishing a hospital at the medical school since it was founded,” said Sarrubi. “In partnership with HCA, the hospital will give us a site to truly expand our clinical

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research and more translational research between the basic science that’s being conducted at our Burnett School of Biomedical Sciences.”

The hospital will also expand opportunities for interprofessional education via a living-learning lab to train medical, nursing, pharmacy, physical therapy and social work students in team-building and communication skills. “Medicine is a team sport and students can see the importance of it in caring for patients,” said Sarrubi.

Importantly, the new facility will have an open process for physicians to access hospital privileges, emphasized Sarrubi, adding that non-HCA and College of Medicine physicians will work side by side with independent and other hospitalemployed physicians.

“Dr. German has said repeatedly that our goal is to continue to partner with every hospital and to expand those partnerships,” said Sarrubi. “We believe the new hospital will help in those areas.”

The hospital will also bridge the gap of community patient care not being served

by Lake Nona’s Orlando VA Medical Center and Nemours Children’s Hospital.

The Orlando metropolitan area is among the nation’s fastest growing cities and Lake Nona has been recognized among the nation’s 10 fastest-growing communities.

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PHYSICIANSPOTLIGHT

Asim A. Jani, MD, MPH, FACP continued from page 1 Over the last two decades, he has worked as an infectious disease clinicianeducator, public health physician, consultant and medical epidemiologist. After EIS, he did his CDC Preventive Medicine practicum assignment in the Coordinating Office for Global Health (COGH), where he later worked as a medical epidemiologist on A/H5N1 and pandemic preparedness while being the Geo Team lead for India-CDC programs.

He also served in the role of physician advocate at the community level in Central Florida for vulnerable populations to reduce health disparities and promote health during his tenure at the Orange County Health Department.

His clinician-educator roles included service as teaching staff and ID consultative care at Orlando Health for over 10 years.

He has held numerous academic teaching appointments at USF, FSU and UCF, including most recently adjunct faculty in Epidemiology at the Rollins School of Public Health with Emory University. He is an invited speaker having given over 150 major presentations during his career, with over 30 abstracts, peer-reviewed articles, and book chapters and other scholarly products.

His consultative and scholarly interests primarily focus on population health, medical education, hospital epidemiology, and clinical infectious diseases but also include workforce development, systems-thinking and integrative medicine.

Dr. Jani obtained his degrees, BA in Psychology, MD and MPH as well as his ID Fellowship training at the University of South Florida Colleges of Medicine and Public Health and completed his Internal Medicine residency training at Orlando Regional Medical Center.

He has subsequently served in the role of Assistant Director of Medical Education at Orlando Health twice, when he was a founding faculty member of the Orlando Health Infectious Diseases Fellowship.

In 2010, he successfully completed the two-year Fellowship in Integrative Medicine, Univ. of Arizona Center for Integrative Medicine. In 2015, he finished the Population Health Academy training at the Jefferson College of Population Health in Philadelphia.

From Dr. Jani:

In other words…

1978 – ‘What is Past is Prologue’ In front of the National Archives Building in Washington, DC, the statue by Robert Aitken, called “Future” bears the inspiration, “What is past is prologue.” In that one Shakespearean line, we can see our past as an introduction to a greater future. And so it is with health care, when in 1978 global health leaders convened at Alma Ata (now Kazakhstan) to inspire urgent action by the “world community to promote and protect the health of all the people of the world.” Through the famous Declaration of Health at Alma Ata orlandomedicalnews

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(DHAA) - this International Conference on Primary Health Care heralded in a new era of health, characterized by the broad consensus that not only is health a “fundamental human right” but its attainment is “a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.”

In other words, achieving health goes beyond the efforts of the individual, and yet like any right, there is an accompanying

lated to factors such as widening income inequality. Fragmentation of care, medical errors, medical litigation, workforce shortages and burnout compound the picture. Commodification of health will obligatorily continue to fuel apparently unresolvable debates on how best to pay for health care for all US populations.

And yet social justice, equity, and community engagement are currently relevant principles that hearken back to those from Alma Ata and support some of the most

... achieving health goes beyond the efforts of the individual, and yet like any right, there is an accompanying shared responsibility –between patient and primary medical provider ...

shared responsibility –between patient and primary medical provider in that sacred space of trust and confidence they are supposed to mutually nurture.

Why is this relevant in 2017 especially in the US? The development of the current U.S. health care system, and related challenges and debates regarding access, quality and costs have many complex associated causes, interrelationships and events that are beyond the scope of this editorial. Three themes emerge for which there is almost universal consensus – current health care spending is unsustainable (=17% of GDP), the U.S. population has poorer health outcomes and shorter lives relative to comparable affluent nations, and marked health disparities exist re-

progressive initiatives aligned with what has now become known as the Quadruple Aim: the prior three aims of improving population health outcomes, decreasing costs, strengthening patient experience of care plus improving the work life of providers and staff. Consumer engagement and population health are just two of the many emerging common strategic themes for health care leaders. In contrast to the tenets of any well-run industry, health care has more waste, harm and inefficiency than anyone finds acceptable. The challenges are great - with over 10,000 people turning 65 years old every day, and ~80% of our most common, chronic and disabling diseases being largely preventable through informed lifestyle choices (e.g., exercise, healthy diets, stress

reduction, tobacco cessation, sugar consumption, etc.). So “health systems” are obligated to proactively respond to community needs and go beyond caring for the sick and injured to preventing disease, promoting health and collaborating with public health entities. Sadly, only ~3% of our over $3.2 trillion national health expenditures is devoted to prevention activities, so for sure it’s an uphill political climb but having healthier populations will truly bend the cost curve.

The overarching influence of Alma Ata was seen in the way primary health care was considered the backbone of a strong health system, nationally, regionally or locally, with a natural interdependence with the patients’ communities.

Participating nations were expected to build an effective network of primary care providers (e.g., strong medical education, incentives and relative status) and mobilize community development, engage community health workers, develop a “health-in-all-policies” view, and use “practical, scientifically sound technology” (DHAA). David Kindig’s work shows that 80% of the determining factors contributing to one’s health map to one’s socioeconomic status, behavioral choices, and environments, with only 20% in the clinical care domain. The medical profession can still have profound impact on the other domains through new approaches – preventive medicine, social medicine, geomedicine, lifestyle medicine, and integrative medicine.

Rishi Manchanda (from www.healthbegins.org) makes the case for providers to go more ‘upstream’ and address social determinants of health. The current Robert Woods Johnson “Culture of Health” movement reinforces this message and more. Moving forward, upstream oriented providers can accelerate their efforts through a broader deeper knowledge of their communities as derived (CONTINUED ON PAGE 8)

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CPASPEAK

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Doctors Guide to Establishing and Executing Successful Tax Planning

By DALIA CANTOR, CPA

No one likes April 15th surprises that involve writing large sums of your hardearned dollars to Uncle Sam, hence it is important to stay proactive and implement effective tax strategies throughout the year.

I suggest my clients review current year tax situation at least twice during the year and at times more frequently, if the circumstances call for it: • Review your tax projections sometime in July when you have 6 months of practice results ready and at that time usually have a fairly good idea where the year is going; • Revisit your tax plan and estimates in November or early December to make sure you are on track and if things changed you still have enough time to make tax advantageous decisions before the year is over; • Be aware of life events that may affect your tax situation such as marriage, divorce, changes in dependents, sale or purchase of assets, retirement, etc. Should you have one or more of these changes

occur, it is always wise to review your tax plan and make changes accordingly; • Keep in touch with your trusted tax adviser to stay current with tax law changes and how they may affect your individual tax situation. This is especially important this year as we have tax reform on its way that will most likely impact many of us.

So, your practice is thriving – you made all the right changes to increase collections by tightening your billing and receivables process, you achieved efficiencies in controlling your overhead and your profitability is rising …. along with the taxes that you will end up paying on those profits. I often hear physicians say – I am better off making less so I don’t have to give it all to the government. It is not true if you take the right steps to take advantage of the many opportunities to implement right tax strategies on the practice and personal level that will minimize your tax burden yet allow you to keep the excess profits.

Some of the tax savings tools seem obvious yet are still being overlooked by many physicians and their tax advisers.

Just to name a few: • Pretax contributions to retirement

plans such as a 401(k), 403(b), 457 plan or, in certain cases, tax-deductible contributions to Traditional IRAs. Many physicians will not be able to deduct their IRA contributions and should consider a “backdoor Roth IRA contribution” strategy; • Defined benefit retirement plans (also known as “pension plans” or cash balance plans) allow self-employed physicians and doctors who are shareholders in their medical practices to deduct contributions to these plans and defer income tax to a later date. In addition to contributions to 401(k) plans, younger physicians might contribute an additional $30,000 to a defined benefit plan while doctors approaching retirement might contribute up to $180,000 per year, deferring somewhere between $12,000 and $72,000 in federal income taxes (assuming the 39.6% tax bracket). This tax strategy requires careful business planning an often involves the services of a pension actuary or “third party administrator” and other

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professionals such as an attorney, and a registered investment advisor; • Purchasing needed medical equipment before the year is over to take advantage of accelerated or bonus depreciation. Even if you finance the equipment purchase you can still take full advantage of the write off; • Tax-loss harvesting which is selling a losing investment in a taxable account to intentionally realize the loss. The first $3,000 of losses can be used to offset ordinary income, saving the average physician $1,000 to $1,500. The remaining capital loss can be carried forward for up to 20 years and used to offset future capital gains; • Student loan interest is not deductible for most physicians due to high income limitations and phase outs. However, physicians can use a home equity line of credit (HELOC) or a cash-out refinance to get cash to pay down student loans, thereby converting the interest into a tax deduction; • Loss from a rental property is also often disallowed for physicians due to high income limitations, however, mortgage interest and property taxes on a rental home can be deducted as itemized deduction for a second home.

Some of you are ready to scale back as you near your retirement age and therefore need to reevaluate your tax strategies to take into account reduced production and properly align your salaries and income tax withholding. Most of us are so focused on putting money away for our retirement when we are actively working, yet many fail to properly execute the exit.

You know how to climb up the hill but do you know how to go down?

There is no cookie cutter when it comes to individual tax planning – every client and their situation is unique. Now is a great time to get together with your CPA to review your tax planning strategies and get creative.

Dalia Cantor, CPA, has been practicing as an accountant and tax advisor since 1997. She is a Certified Public Accountant in the states of Florida and New York, and graduated Dowling College with a Bachelor’s Degree in Accounting. Dalia is a member of the American Institute of Certified Public Accountants and the Florida Institute of Certified Public Accountants. Prior to establishing her own practice, Dalia worked in public accounting managing both domestic and foreign audit and tax clients. In private industry, she was involved in the regulatory environment, specializing in technical accounting, internal controls, and SEC reporting for publicly held companies. She can be reached at Dalia@mycpasolutions.com

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HEALTH INNOVATORS

A Warning for the Post-Augmented Age Note from Kelli Murray, MedSpeaks Playing an active role in the health innovation community enables me to have access to some of the foremost thought leaders and experts in technology. You’ve seen contributor pieces in previous editions from the likes of John Nosta, the world’s leading influencer on digital health, Dr. Arlen Meyers, MD, President of the Society of Physician Entrepreneurs (SOPE), and Dr. David Lee Scher, a cardiologist, digital health expert and award-winning blogger.

Today, you’re getting the inside scoop by Robert Scoble, a legend in his own right for his visionary perspectives on the application of cutting edge technologies. His piece, although not directly related to healthcare, will give you a jarring perspective on how technology is transforming our world, and ultimately how human engagement and knowledge will dramatically shift as a result. It may also make you long for the days of old when life didn’t seem to move at an uncatchable pace. Brace yourself. Things are about to get real.

By ROBERT SCOBLE, Futurist, Technology Evangelist, and Mixed Reality Authority

We are moving: From analog to augmented.

From flat screens to VR (virtual reality) and AR (augmented reality).

From desktops to eye glasses.

From music played on instruments to music made on computers.

From centralized economies to decentralized crypto currencies.

From repetitive, boring, jobs to artificial intelligence smart jobs.

From human help to robotic help.

From call centers to bots.

From physical screens to virtualized ones.

From family newsletters to instant videos on a map in Snap.

From rotary phones to WeChat, Whats App, Snap, Facebook Messenger, with more on their way.

From neighborhood parties to NextDoor.

From Yellow Pages to Yelp.

From big speakers to subwoofers/ haptics you wear.

From emotional intimacy to Twitter and Facebook.

From drugs you took as a pill to drugs we get through the light delivered via our screens.

From rockets we use once, to ones that land on a barge.

From rumors to deep data.

From inefficiency to smart cities.

From tractors to IoT and automation.

From incandescent light to LED. From privacy to satellites that make a 3D image of the entire world every few minutes.

From terabytes of data to zetabytes.

From mass market to mass personalization.

From interruptive advertising to products that stand for something.

From SEO-influenced sales leads to sensor-influenced customer acquisition.

From pixels to polygons to voxels.

From books and libraries to Google Assistant.

The cultural shifts we are seeing happen in politics, music, photography and life itself are BECAUSE of our technology.

Remember when the electric guitar came? What happened? The 1960s music revolution. The Beatles. Elvis.

What is going on now? VR and AR are bringing new forms of entertainment like http://microdosevr.com/. No longer are we forced to stare at a flat monitor, or hold a flat screen in our hands, or go to a play where the action is on a rectangular stage.

We are moving to a world where photography, videography, are moving from grids of pixels to volumetric and then light field where we can live inside the video or stills. Ansel Adams had his hands in Dektol. We have our hands in Snapseed.

Google Photo lets us find all of our photos by the objects in them.

We are moving from a world where

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taxis were not reliable to a world where Lyft, Didi, Uber and others serve us, deliver us, in a new way thanks to the data layers those laid on top of the analog world. Soon self-driving cars will take us where we want to go and will be far cheaper, safer, and more reliable.

But, with these mind-blowing technology shifts comes a blowback.

Turns out this is a LOT of change for humans to handle so we are seeing a blowback toward the analog. The old school.

We’re seeing it in our politics. In much of the popularity of older musical forms from Jazz to Classical to Country (I’m going to Nashville in a few weeks to study this up close).

As we are dealing with AI potentially taking our jobs, not to mention maybe even humanity itself, and augmented reality adding new data layers onto everything we see and touch, there’s a hunger for meaning.

Values. Virtues. Trust. Kindness.

Why is vinyl still popular in a world where we can pull up nearly every artist and every song on Spotify and other services? It’s analog. It is a blowback to an earlier age where life was simpler. Not as busy. Not as connected.

Even though we can pull up nearly every song on Spotify (and its artificial intelligence is getting darn amazing in picking new music for us to hear) we hunger for the smooth wave of analog.

As we augment our stores (Sephora lets you try virtual makeup on in its augmented reality app, and see augmented displays in the stores) we hunger for a time

when customer service was a real human that knew us well. Even in the augmented age we’ll seek products and services that demonstrate compatibility with our intentionality. Our intentions not to use child labor, or poisons in our food, or weird genetic modifications that might lead to new environmental or health distress.

We’ll seek products that stand for something.

Help someone.

Make the world a little bit better, or, at least, don’t add to the distress we see all around us.

As we get self-driving cars, which will save many lives and remove the dull commutes we increasingly have to do around the world, stuck in traffic, we hunger for that mechanical age when we knew how our machines worked and didn’t have nightmares of being hacked. Driving an old Chevy to the levee starts to sound more and more romantic even as our new Chevy drives itself to the same levee.

Your brand and company must not just react to these shifts, but get ahead of them to really thrive in this post-augmented age.

To navigate the cultural changes that we are in early phases of seeing and will roil us all for the next decade or more you need to think different. Communicate differently. Play differently. Work differently.

How? Let’s talk, but first I will go live in the analog. We used to call that vacation.

Follow Robert’s latest insights at www.facebook.com/RobertScoble.

CALL FOR INVENTORS! Are you interested in showcasing your innovation?

Tell us about it by emailing kelli@medspeaks.com or call 407-917-7075.

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By SONDA EUNUS, MHA, CMPE, CPB Orlando Medical News continues this series of answers to questions from readers dealing with issues faced by practice managers in our healthcare community. We encourage readers to send questions they face in everyday practice. Use the subject Practice Management Challenges to editor@orlandomedicalnews.com Questions selected for inclusion in the September edition will receive a complimentary 300 x 600 pixel ad with animated gif on our website.

How can our pediatric practice improve our HEDIS Quality Measure scores?

Practice performance on quality measures is becoming increasingly important, and good performance can lead to substantial financial rewards.

Additionally, Medicaid payers feel more comfortable assigning more patients to practices that have demonstrated that they can meet quality measures and provide superior medical care to their patients.

Many practices have dedicated employees to work solely on meeting HEDIS measures and closing care gaps,

PRACTICEMANAGEMENT

PHYSICIANSPOTLIGHT

Overwhelmed Yet?

continued from page 5

or have contracted with outside consultants to take care of this function.

The designated HEDIS specialist can use the monthly reports generated by the Medicaid payers—which can be obtained from your Provider Relations representative for that payer—to reach out to the patients who have care gaps such as missing their last well child check (WCC), not being up-to-date on immunizations, needing nutrition or physical activity counseling, etc. Many quality measures can be met by simply keeping your patients up-to-date with the WCC schedule as well as the immunization schedule as recommended by the CDC. Other trickier measures include ensuring that your patients have had their yearly dental visit, which may be out of your hands, but you are still responsible for educating the patients and parents on the importance of appropriate dental care. Other measures such as yearly Chlamydia screening for girls over 13 years of age require that your practice be very diligent in performing the right screenings on each patient. Still other

measures focus on your documentation, such as ensuring that the child’s BMI is being measured and entered in the chart, documenting counseling given by entering the appropriate codes even if they are non-covered codes, etc.

Most importantly, practices must realize that these quality measures will only become more prevalent, and that commercial payers also have similar programs. It is therefore crucial to hire and train a detail-oriented and persistent employee to stay on top of these care gap reports, reach out to the patients to schedule necessary appointments, communicate with providers and clinical staff about the importance of complete documentation, and ensure that all care gaps are being closed. After all, the main objective of the HEDIS program is to ensure that quality care is being provided to patients—the financial incentives are simply a nice bonus for doing what we should be doing for our patients regardless.

Asim A. Jani, MD, MPH, FACP from Community Health Needs Assessments and accompanying Community Health Improvement Plans, now widely mandated in the US. Alternative payment models and innovation have enabled advancements such as the medical home, medical neighborhood and accountable health and accountable care communities, all close philosophical siblings of the ground-breaking Community Oriented Primary Care (COPC) and Communities of Solution (CoS - 1967 Folsom Report) models. The CoS is a “powerful, motivating framework because of its ability to balance the often-competing philosophies of social and individual responsibility.”

Whole community approaches can often transcend differences in the local political arena. And recent studies unequivocally show county-level geographic disparities in life expectancy, reinforcing the mixed reality that communities are where people work, pray, eat, live but also prematurely die. Fortunately, evolving thought in both health care and public health are arriving at similar conclusions, i.e., that community integrated prevention and care models linking medical and social services can improve outcomes, increase access, and reduce costs.

The Alma Ata Declaration of Health

(CONTINUED ON PAGE 10)

(CONTINUED ON PAGE 10)

Did You Know: People with Dementia with Lewy Bodies and Parkinson’s Disease Dementia Frequently Exhibit REM Sleep Behavior Disorder?

Individuals with dementia with Lewy bodies (DLB) or Parkinson’s disease dementia (PDD) frequently exhibit REM sleep behavior disorder (RBD) – a serious condition where a person physically and/or vocally acts out their dreams

NOW ENROLLING: a clinical study evaluating an investigational medication as a potential treatment for RBD in people with DLB or PDD • Be at least 50 years of age • Have a diagnosis of dementia with Lewy bodies (DLB) or Parkinson’s disease dementia (PDD) • Experience REM sleep behavior disorder (symptoms include abnormal sleep behaviors such as acting out or vocalizing dreams) • Be willing to take part in overnight sleep lab studies Study-related medical care is provided at no cost.

To learn more about local study participation, please call: (800) 501-0684

*Additional eligibility criteria apply 8

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MEDICAL MARKETING

sponsored by

Social Customer Service and the Big Reason It Matters to Your Practice

By JENNIFER THOMPSON

Just when you think you’ve finally gotten your head around why you need to be on social media, and what you need to be doing on Facebook and Twitter (sharing, educating, interacting with followers, etc.), the rules go and change again.

That’s right, social media is evolving yet again; and it’s imperative for you to keep up with the times by putting your best foot forward with social customer service.

So, what is social customer service?

Consider it like a marriage - the joining together of social media and customer service (without the tax benefits). Not only are your patients able to ‘Like’ you on Facebook, but now they’re encouraged to share everything they may dislike about you as well.

Oh, and the offspring of this perfect union?

Your online reputation.

The State of Social Customer Service and Reviews Worldwide, there are nearly 2 billion active users on Facebook including 1.28 billion who login daily and spend an average of 35 minutes on the social platform.

Twitter, although significantly smaller, has 328 million users. The firm SocialBakers suggests that more than 80 percent of customer service requests on social are happening on Twitter.

Whether you like it or not, Facebook encourages patients to make recommendations and post reviews. Just like visiting an online dating site to connect with a potential partner, your patients are actually doing something very similar in peeking around on Healthgrades, Vitals, RateMDs, Yelp and Google before they book their first appointment. Heck, once you’ve been on your first ‘date,’ more often than not, patients are discussing how things went to their friends and even rating the experience online, especially on Facebook and Twitter. If you’re really unlucky, they’ll even tell their distant relatives about the experience (these are the typical online physician review sites you know and love).

your negative reviews and it’s impacting your ability to attract new patients.

The Most Common Complaints Aired on Facebook About Medical Practices • Long wait times • Front office staff • Poor follow-up • Unnecessary tests • Physician/staff not listening • Differing of opinion (commonly shows up something like: ‘The doctor doesn’t know what he’s talking about’)

Who Should Manage the Online Review Process at Your Office?

Managing your medical practice’s social media presence generally falls to the marketing department (or outside consulting agency), but responding to online reviews and managing customer service inquiries should include somebody with an operational role within your practice to review the patient’s records and investigate what actually happened with staff and, sometimes, the physician.

The relationship between marketing

and customer service has very quickly gone from casual to an official marriage. The process will be different for every practice but it’s vital to actually have a process when the reviews come in - and they will. This marriage isn’t ending anytime soon.

Jennifer Thompson serves as President at Insight Marketing Group. She founded the medical marketing company in 2006 after an unsuccessful run for political office (which she went on to win in 2010 & 2014). Jennifer has two decades experience in marketing in the areas of technology, retail and medical for small businesses and Fortune 100 companies.

For more, email Jennifer at Jennifer@ InsightMG.com or visit InsightMG.com.

You’ve Got a Following and Reviews. Now What?

Listen and respond. It’s important to pay attention to what your patients are saying online. Common, recurring complaints could be symptoms that something is actually in need of improvement at your practice; or, the patient could just be upset and is venting. Either way, in most cases, it’s important that you respond because no response is still a response.

Considering 92 percent of all consumers admit to allowing online reviews to shape their purchasing and service decisions, patients are paying attention to orlandomedicalnews

.com

AUGUST 2017

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Overwhelmed Yet?, continued from page 8 How can our medical practice increase our patient payment collections?

Patient accounts are hardest to collect after the patient has already walked out the door after their visit. It is therefore important to communicate your practice’s collection policies to your patients up front, and to make sure that they are aware of them when they first register as a new patient.

It is a good idea to create a document outlining all of your billing policies and to have the patient read and sign it along with your other office policies and patient registration forms. This way, the patient cannot claim that they weren’t aware that co-pays and co-insurances were due at the time of visit, that they did not know that they would be responsible for the visit if their insurance plan’s deductible is not met or their coverage is inactive, etc.

Some patients may try to be seen without making a necessary payment at time of service, or may avoid paying a past balance when they are at your office by claiming that they forgot their wallet, or that they are not getting paid until next week, and other such reasons.

It is important to remain polite but firm

in such situations, and to explain that your practice’s policies were very clearly outlined in your new patient paperwork.

By setting clear expectations, it is much easier to keep such patients accountable.

Furthermore, your front office and billing employees must be trained on how to ask for payment prior to checking the patient in for their appointment, both for time of service collections as well as for previous account balances. They should be prepared to answer questions about what the payment is for, as well as explain previous balances.

With improved communication between your practice and its patients, as well as appropriate staff training on patient payment collections, your practice will be able to greatly improve your patient payment collection rates.

Sonda Eunus, Founder & CEO of Leading Management Solutions has a background in managing a multi-location pediatric primary care practice, and truly enjoys medical practice management. She holds a Master of Healthcare Management, and a BA in Psychology.

Leading Management Solutions is a healthcare management consulting firm, that assists medical practice managers and physician owners in the successful management of their practices. She can be reached at sonda@ lmshealthpro.com

WSFOTA.ORG PHYSICIANSPOTLIGHT

Asim A. Jani, MD, MPH, FACP, continued from page 8

Thank you to Florida Hospital Fish Memorial and RS&H Architects for including Pennington & Associates, Inc. in the recently completed Fish Memorial Executive Office Project

CHUCK HOLLIS, CCIM | VICE PRESIDENT O 4 0 7 . 6 7 9 . 2 2 1 4 | M 3 0 9 . 3 0 3 . 4 4 6 6 | W W W. P E N N I N G T O N - A S S O C . C O M

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was just that – a declaration on health, how it arises, how it is promoted and how it is protected. It was not a manifesto on disease management, nor relevant policy guidance on how disease management systems can be created. It was instead an affirmation in and of itself. Our health professions education systems for medicine, nursing and even public health have traditionally focused on disease and pathogenesis, identifying risk factors and natural history pathologic processes that culminate in disease, injury and death.

And yet wholeness and wellness across the dimensions – body, mind, spirit, relationship, environment, occupation and social context are what we need to create for our patients and for ourselves as healers. This is the contrasting model of salutogenesis (saluto = health/wellness; genesis = creation), as coined by Aaron Antonovsky.

Don Berwick and other luminaries have extended the concept that salutogenesis must be aspired for as the basis of any true health system.

As our patients pursue happiness and joy even as they reclaim their health from disease, injury or even near-fatal events, they also have responsibilities, as we all do – since in the realm of health we are all at risk for being patients, getting ill, and having varying levels of imbalance throughout our lives. But medical and nursing providers can reassure people they are

not alone in creating and maintaining health. We can try to mitigate risk and promote our own well-being through our individual, collective and social realms.

The Declaration is duly diligent to the themes of “self-reliance” and “self-determination” (DHAA). Once again, we find our future course charted in past wisdom via the futuristic and yet perennial words of Alma Ata, “people have the right and duty to participate individually and collectively in…their health care” (=patient engagement).

Recent evidence-based monographs have artfully speculated about the future of primary care, health and health care, and even public health in 2-3 decades (www.altfutures.org). Reflecting on those monographs may well be touchstones for that inscription and statue by Aitken, and most of all for the year 1978, when the global community came together to shed light on how we can have a functional health system - a system that is itself healthy and just, flexible and informed, proactive and efficient, frugal and strategic to ensure people are healthy.

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Patient Radiation in Diagnostic Imaging

By DR. WILLIAM F. SENSAKOVIC

Wilhelm Roentgen serendipitously discovered x-rays in 1895. Scientists and physicians, eager to improve patient care, immediately applied the new technology to imaging the human body. By 1897 reports began to surface of hair loss and skin reddening and in that same year it was confirmed that x-rays induce biological changes when they were used to treat nevi (hairy moles) on the back of a 5-year-old girl.

Extensive research over the last century using animal models and epidemiological data from events such as the atomic bombings of Hiroshima and Nagasaki and Chernobyl has improved our understanding of radiobiological effects. This research has definitively demonstrated that radiation may cause cancer, epilation, sterility, cataracts, erythema, desquamation, tissue necrosis, and death. Further, radiobiological effects are of particular concern for children and pregnant women. Research has demonstrated that children are more sensitive to radiation induced cataracts, hypothyroidism, thyroid nodules, and many forms of cancer. An irradiated embryo/ fetus is at risk for miscarriage, childhood cancer, growth retardation, organ malformation, and intellectual disability.

These severe radiobiological effects coupled with the ubiquity of medical imaging are often a source of anxiety for both patients and physicians. Add in damning exposés in the news, exaggerated journal articles, and a general lack of education about radiation and it creates a hysteria that may cause both physicians and patients to avoid essential imaging.

To understand the effects of radiation and gauge its danger one needs to understand how we measure radiation.

Though the field is vast, for our purposes it will suffice to say that tissue radiation absorbed dose is measured in Grays (Gy). All radiobiological effects, except cancer, require a minimum dose (threshold) before they occur.

Computed tomography (CT), nuclear medicine, and fluoroscopy typically give orlandomedicalnews

.com

the highest radiation absorbed doses (up to 0.1Gy to tissue and up to 0.03mGy fetal). The lowest dose that produces noncancerous biological effects is 0.25Gy in adults and 0.1Gy in utero. Thus, a typical diagnostic scan will not cause biological tissue effects in adults or a fetus. It should, however, be noted that interventional procedures and radiotherapies can that approach a level of concern.

Radiation dose measurements are modified to account for the varying potential of cancer induction in different tissues.

This modified dose is called the effective dose and is measured in Sieverts (Sv). CT typically delivers the highest effective dose (~0.002-0.01Sv) with radiographs and fluoroscopy below that. Though there is some controversy, currently accepted models assume any amount of radiation may induce cancer. That being said a 0.01Sv CT scan increases a typical person’s cancer risk from ~40% to ~40.1%. Similarly, a pelvic CT of a pregnant woman increases the fetal risk of childhood cancer from ~0.3% to ~0.5%. Thus, the risk from imaging is very low. However, given the ubiquity of scanning and the possibility of multiple scans on the same patient, it is recommended that radiation is limited to what is diagnostically necessary.

Given the small risk of cancer it would be ideal if we could minimize dose; however, this is not possible. Although the exact relationship is complex, image quality generally decreases as dose decreases. Thus, minimizing dose would result in non-diagnostic image quality. Instead, management of patient radiation should follow the principles of justification and optimization.

Justification states that an exam should only be performed if it does more harm than good. A good mnemonic is .DAM (dot DAM): Don’t Order Tests that Don’t Affect Management. The physician looking for guidance on appropriate imaging should refer to The American College of Radiology (ACR) Appropriateness Criteria®. These are “evidence-based guidelines to assist referring physicians and other providers in making the most

appropriate imaging or treatment decision for a specific clinical condition.” By ordering the lowest-dose exam that still conveys relevant clinical information the referring physician can play a large role in reducing patient radiation dose.

Optimization entails ensuring that modern technology is utilized and that imaging protocols are set such that excess radiation is not delivered to the patient.

New technology such as iterative reconstruction and automatic exposure control when properly used create images of sufficient quality at reduced dose. How that technology is implemented is determined by the scanning parameters, which have a tremendous impact on image quality and patient dose. The protocol that describes these parameters should be periodically reviewed by a team consisting of, at a minimum, a radiologist, qualified medical physicist, and technologist. The radiologist reviews image quality, the physicist reviews the technology and dose, and the technologist reviews workflow integration and implementation feasibility. Many resources exist to guide optimization. These include journal articles, ACR practice parameters, and publications from Image Wisely, Image Gently, and the American Association of Physicists in Medicine. This information can help a practice provide the best care for their patients by ensuring that patient radiation dose is As Low As

Reasonably Achievable (ALARA).

The radiation delivered during imaging is essential for diagnosis, but brings with is a small risk to the patient. It is important that physicians keep this risk in mind, but also in perspective when ordering imaging studies and performing patient scans. Diagnostic imaging exams, when performed correctly, should not induce non-cancerous effects. The probability of inducing cancerous effects is also low to negligible. Qualified Medical Physicists are experts in the application of radiation in healthcare and should be consulted when optimizing protocols, imaging vulnerable populations, and when questions related to dose and image quality arise.

Dr. William F. Sensakovic received his undergraduate degrees and PhD from the University of Chicago. His research focused on image processing, computer-aided detection, and imaging biomarkers. He is certified by the ABR for Diagnostic Medical Physics and by the American Board of Magnetic Resonance Safety (ABMRS) as a MR Safety Expert. He is Chair of the AAPM Imaging Physics Curricula Subcommittee and task group on establishing an image quality registry, editor for the physics section of both RadExam and Radiology Assessment and Review (RADAR). He is president-elect for the State of Florida AAPM, the ACR councilor-at-large for Medical Physics, a board member for the ABMRS, and on the board of associate editors for Medical Physics. He is currently a Medical Physicist at Florida Hospital.

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Botox Use in the Trigeminal Pain System: A Review Figure 1

Botox is a 150-kDa dichain protein composed of a 100-kDa heavy chain and a 50-kDa zinc-dependent light chain which are linked by a disulfide bond. Both, the heavy chain and the light chain consists of two distinct domains: a carboxyl terminal (COOH) and an amino terminal (NH2)

Active toxin

By DR. BRIAN FUSELIER, DR. MELVIN FIELD, AND DR. BARRY LOUGHNER

Abstract Following FDA approval for Botox on October 15, 2010 to treat headaches in adult patients with chronic migraine, the authors of this paper have administered Botox to over 600 co-morbid patients using off-labeled prescriptions in the trigeminal system. Taken together, the co-morbidities of these patients consisted of variances of TMJ dysfunction, facial migraine, trigeminal neuralgia type 1 and type 2, postherpetic neuralgia, multiple sclerosis, and post-traumatic neuropathic pain. The authors have found the clinical use of these off-labeled prescriptions to be helpful as an adjunctive therapy in the setting whereby all conventional standards of medical care have failed. In some cases, the relief of pain has continued in the trigeminal system beyond the usual 3-month period. A legion of research publications and reviews have explained the motor neuron mechanism of action of Botox on the alpha motor end plate, and explained the anti-nociceptive effect on small-diameter, peripheral somatosensory neurons. Based on our review of the literature our conclusion uniquely summarizes that failed exocytosis of neurotransmitters produced by the mechanism of action of Botox is equivalent in both sensory and motor neurons in the trigeminal system. In our clinical experience, the identic action of Botox results in an advantage which creates more effective and longer lasting clinical relief in a population of co-morbid patients with different etiologies associated with pain.

Structure and Function of Botox

Neurotoxin onabotulinumtoxin A (BoNT/A) is one of seven serotypes of the core neurotoxin proteins derived from bacterium Clostridium botulinum. BoNT/A is considered to be the most potent of

these neurotoxins with the most prolonged action. The therapeutic success of Botox results from its potent inhibition of neurotransmitter release in both motor neurons and sensory neurons with a duration measured in months.

Botox is a 150-kDa dichain protein composed of a 100-kDa heavy chain and a 50-kDa zinc-dependent light chain. These two chains are linked by a disulfide bond. Endocytosis of Botox into motor or sensory neurons is performed by the heavy chain.

The heavy chain acts as the receptor- binding and endocytotic vehicle. The light chain is unable to be internalized into neurons without being initially bound to the heavy chain. The pharmacological action of Botox is due to the light chain which causes protease activity within the neuron which leads to inhibition of neurotransmitter exocytosis.

Molecular Mechanisms of Botox Both, the heavy chain and the light chain consist of two distinct domains: a carboxyl terminal and an amino terminal, respectively (Figure 1). Successful endocytosis of Botox involves the carboxyl terminal of the heavy chain which binds with high affinity to glycoprotein receptors on the synaptic vesicle proteins type 2 (SV2). These specialized synaptic vesicles are expressed on the plasmalemma in areas where synaptic vesicles fuse with the neuronal membrane followed by endocytosis. SV2 is expressed abundantly throughout the nervous system. The ubiquitous nature of the SV2 receptors suggests that they perform a function common to all synaptic vesicles. The tertiary structure of the amino terminal of the heavy chain forms an iontotropic channel that allows Botox access into the SV2 synaptic vesicle. Once the Botox/SV2 complex is internalized into the neuron, it forms an endosome. The low pH conditions prevailing in the endosome cleaves the disulphide bond and allows the light chain to exit osmotically into the

NH2

light chain

COOH

heavy chain Figure 2 SNARE exocytotic protein complexes in the cytosol are a universal mechanism providing a substratum network necessary for neurotransmitter release in eukaryotic cells which includes all motor and all sensory neurons. SNAP-25 proteins are essential for SNARE complexes to cause the transport of synaptic vesicles containing neurotransmitters to reach the cell surface, fuse with the neuronal membrane, and allow normal neurotransmitter release.

(CONTINUED ON PAGE 14)

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Botox Use in the Trigeminal Pain System: A Review, continued from page 12 cytosol via the amino terminal of the heavy chain.

The second mechanism of action of Botox is failure of neurotransmitter exocytosis. The light chain which is a highly specific endopepdidase (protease) cleaves a 25KDA synaptosome-associated protein (SNAP-25).

Snap-25 is responsible for the formation of SNARE protein complexes (i.e. soluble nethylmaleimide-sensitive factor attachment protein receptors) in the cytosol (Figure 2).

SNARE exocytotic protein complexes in the cytosol are a universal mechanism providing a substratum network necessary for neurotransmitter release in eukaryotic cells which includes all motor and all sensory neurons. SNAP-25 proteins are essential for SNARE complexes to cause the transport of synaptic vesicles containing neurotransmitters to reach the cell surface, fuse with the neuronal membrane, and allow normal neurotransmitter release.

SNARE proteins represent a universal mechanism providing a substratum network necessary for neurotransmitter release in eukaryotic cells which includes all human motor and sensory neurons. SNAP-25 proteins are essential for SNARE complexes to cause the transport of endosomes containing neurotransmitters to reach the cell surface, then subsequently fuse with the neuronal membrane and result in normal neurotransmitter release.

The intracellular proteolytic action of the light chain of Botox cleaves SNAP25, thus causing inactivation of the entire SNARE transport system. The result is failure of exocytotic release of neurotransmitters into the extracellular milieu. Operant neurotransmitters in the trigeminal nociceptive system include a neuropeptide (e.g. Substance P) and an excitatory amino acid (e. g. glutamate). The release of calcitonin gene-related peptide (CGRP) from cutaneous tissue innervated by the trigeminal nerve is also blocked by Botox On the other hand, Botox is unable to block protonmediated CGRP. Taken together, the successful endocytosis of Botox, and the failure of exocytosis of neurotransmitters incorporates the therapeutic action of Botox. The extensive distribution of SV2 proteins and SNAP-25 proteins indicate that both are expressed on motor and sensory neurons. In alpha motor neurons, Botox binds to SV2 receptor sites on motor nerve terminals, enters the nerve terminals, cleaves SNAP-25, and inhibits the release of acetylcholine (Ach). What follows is inactivity of the motor end plate and paralysis of localized muscle fibers.

In somatosensory nociceptors, Botox binds to SV2 protein receptor sites on free ending terminals, enters the somatosensory terminal, cleaves SNAP-25, and prevents the release of substance P, glutamate, and CGRP which are key mediators of neurogenic inflammation (Figure 3).

Skeletal muscle contains both peripheral terminals of alpha motor neurons and free ending terminals of group III and group IV nociceptors. Injection of Botox at therapeutic doses into skeletal muscle causes inhibition of Ach release from alpha motor neurons leading to partial chemical denerva-

tion of the muscle and localized reduction in muscle activity. In addition, Botox blocks the release of pro-inflammatory agents from free ending terminals of group III and IV nociceptors. Pain relief within 24 hours following treatment suggests that the antinociceptive effect of Botox on the sensory neuron may be independent of its motor end plate activity since Botox-induced paralysis takes at least 5 days to become clinically evident. This theory that the dual actions of Botox are independent is further supported by clinical evidence which is demonstrated by the effect of Botox on pain that occurs in areas devoid of muscle. Matthew and his colleagues (2008) published a case study of 4 patients with primary headache characterized by chronic moderate pain localized in the parietal area of the scalp that is absent of underlying muscle. Botox was focally administered in these painful parietal areas.

All patients experienced a reduction in pain lasting on average approximately 14 weeks.

Repeated injection gave the same degree of improvement.

Figure 3 Functional endocytosis and dysfunctional exocytosis of neurotransmitters incorporates the therapeutic action of Botox.

In alpha motor neurons and nociceptors, Botox binds to SV2 receptor sites on nerve terminals and enters the nerve terminal (left side). The light chain exits the synaptic vesicle into the cytosol, cleaves SNAP-25, thus inhibiting the release of neurotransmitters (right side).

Botox Effect on Central Sensitization Not only has the analgesic effect of Botox been considered independent of its motor end plate activity, but also Botox has been demonstrated to have a more complex mechanism of action on the pain system compared to the motor system. In addition to the documented molecular mechanism of action on the peripheral nociceptive terminals, Botox has been demonstrated to have a central effect located at the first proximal neuronal interface.

Botox inhibits peripheral sensitization by inhibiting neurogenic inflammation. This mechanism of action prevents the release of pain-related neurotransmitters and neuropeptides such as substance P and glutamate from the peripheral terminals of primary trigeminal and cervical afferents, thereby, indirectly reducing central sensitization since central sensitization commences as a result of tonic nociceptive input. Therefore, the consequence of inhibiting these peripheral signals inhibits central sensitization. Moreover, Botox appears to have a direct inhibition of central sensitization. When peripherally injected into muscle, Botox is conveyed by retrograde transport via microtubule-dependent transit along sensory axons of peripheral nerves resulting in inhibitory effects at the level of the medullary dorsal horn. Retrograde transport of Botox is further supported by a formalin-induced facial pain rat model demonstrating that injection of Botox into the rat whisker pad or sensory trigeminal ganglion reduced nocifensive responses (Figure 4). When colchicines, which block microtubule-dependent transport, was administered, the antinociceptive effect of Botox was eliminated. Interestingly, three days following the subcutaneous injection of Botox into the rat whisker pad, Botoxcleaved SNAP-25 was observed in the trigeminal nucleus caudalis of the medullary dorsal horn.

Figure 4 One mechanism of action of Botox is failed exocytosis. Failed exocytosis inhibits peripheral sensitization at the free ending terminal by inhibiting neurogenic inflammation, thus preventing the release of pain-related neurotransmitters and neuropeptides such as substance P, glutamate and CGRP. This neuronal peripheral inhibition indirectly reduces central sensitization (left side). Botox also appears to have a direct inhibition of central sensitization. When injected into muscle, Botox is conveyed by retrograde transport via microtubule-dependent transit along axons of peripheral nerves resulting in failed exocytosis of pro-inflammatory neurotransmitters (right side) resulting in inhibition of central sensitization at the level of the medullary dorsal horn.

(CONTINUED ON PAGE 16)

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Botox Use in the Trigeminal Pain System: A Review, continued from page 14 Botox Therapy in the Trigeminal Pain System Botox has been used in patients suffering from a variety of pain problems originating from the trigeminal system. Three of the most common problems are temporomandibular dysfunction (TMD), migraine, and neuropathic pain.

Numerous studies have been published demonstrating the safe and successful, off-labeled use of Botox for the treatment of TMD - a group of pathological conditions affecting the function of the temporomandibular joint (TMJ) and/or muscles of mastication. The hyperactivity of one or more of the four elevator muscles of the mandible is a common clinical presentation. In an off-labeled study of 46 patients with chronic TMD for an average of 96 months were treated with 150 units of Botox. This study showed that extraoral injection of the masseter and temporalis muscles resulted in significant improvement based on a pain visual analog scale, functional index, tenderness to palpation and interincisal oral opening. Whereas, the motor-end plate effect of Botox is transient, this study revealed that the muscular healing effect is significantly more longstanding than the average 3- month duration of Botox.

Another TMD condition occasionally observed clinically is subluxation of the mandibular condyle involving excessive anterior dislocation of the condyle beyond the crest of the articular eminence which results in a wide open locked position of the mouth.

In a case study of 5 elderly patients, with persistent episodes of subluxation caused by complications of a neurological or severe systemic disease, were treated with two extraoral injections of 25-50 units of Botox into the lateral pterygoid muscle immediately following reduction of the dislocation by manual repositioning of the condyle. One injection site was 1cm below the central zygomatic arch, and the second injection site was in the area of the insertion of the lower belly of the lateral pterygoid muscle in the fovea of the condylar neck of the mandible. The depth of the Botox injection was in the range 3-4 cm as measured with CT imaging. Mandibular fixation with elastic bands was required for 4-5 days. All treatment was successful with no recurrence for 3 months to 2 years.

The FDA has approved the use of Botox for chronic migraine in patients who have failed numerous preventative protocols. Pooled data from trial 1 and 2 of the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) studies (n=1384) demonstrated a mean decrease in frequency of headache days per month compared to placebo. In addition, significant group differences favoring Botox were observed that included less hours of headache during headache days. Critical analysis of chronic migraine based on these randomized, double-blind, placebo-controlled trials showed that the group differences were modest (8.4 headache-free days/month for Botox vs. 6.6 days/month for placebo). An

earlier study conducted by the Seymour Diamond group in Chicago demonstrated similar modest gains. Forty-one patients were randomized to 100 units of Botox vs. placebo using a fixed site and fixed dose paradigm. Severe headache frequency was reduced from 13.1 to 10.1 episodes/month compared with placebo-treated episodes that actually increased from 14.6 to 15.4 episodes/month. Taken together, these modest studies along with the high cost, places Botox as a second-line therapy for prophylaxis of chronic migraine.

Neuropathic pain has been defined by the International Association for the Study of Pain as “pain initiated or caused by a primary lesion or dysfunction in the nervous system.” The probable effectiveness of Botox has been demonstrated in a select group of neuropathic conditions including traumatic nerve injury, post herpetic neuralgia, peripheral neuropathies, and neurovascular compressionevoked neuralgia – all of which have been observed in the trigeminal system. The postulated mechanisms of action of Botox in the treatment of neuropathic pain include blockade of substance P, glutamate, and CGRP from the peripheral primary afferent free-ending terminal. One other offlabeled trigeminal pain therapy proposed by these authors is the introduction of 25 total units of Botox into the masseter muscle, temporalis muscle insertion, and the insertion of the inferior belly of the lateral pterygoid muscle utilizing EMG guidance.

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Botox is a relatively non-systemic protein. The pharmokinetics of Botox, using currently available analytical technology, reveals negligible titers of Botox in the peripheral blood following intramuscular injection at recommended doses. In addition, Botox is considered a low risk biologic since neutralizing antibodies that may develop are not likely to cross react with endogenous proteins, and exhibit low clinically detectable levels of antibodies when compared with other approved biologic products. On the other hand, if present in high concentrations, antibodies can inhibit the biological activity of Botox, possibly by its interaction with its neuronal receptors.

Direct effects of Botox on the CNS

have not been reported, since its large size of 150-kDa cannot penetrate the blood-brain barrier. Alternatively, Botox could reach the CNS by retrograde axonal transport, since Botox has been detected at the first central synapse with radioactively labeled botulinum neurotoxin. Previously, transsynaptic transport had not been observed.

Recently, however, Marino and colleagues (2014) showed that the performance of Botox on spinal events related to nociceptive processing had a direct transsynaptic effects. At present, transsynaptic effects have not been completely elucidated. Further research of the putative transsynaptic effect of Botox may be helpful in enlightening this mechanism of action, and thus maximizing its therapeutic employment and minimizing safety concerns.

Conclusion

The study of the molecular mechanisms of short-lived plasticity of synaptic modulation is important to understand pain processing in the peripheral and central nervous system. Botox modulates neuronal plasticity by impairing, on a time contingent basis, all types of neurons that express SV2 proteins on its surface and require SNAP-25 proteins for synaptic vesicle fusion. Under these conditions, Botox blocks Ach release in muscle fibers resulting in localized decreased muscle contraction. Moreover, in addition to its function as a spasmolytic, Botox also exerts its effect on peripheral sensitization by blocking the release of pro-inflammatory neurotransmitters such as substance P, glutamate, and CGRP. Botox can also be conveyed to the CNS via retrograde transport, thus mitigating the processes associated with central sensitization. The successful use of Botox as a novel analgesic is providing renewed hope in patients with refractory chronic pain involving the trigeminal system.

Brian D. Fuselier, DDS and Barry A. Loughner, DDS, MS, PhD, are members of the American Dental Association.

Melvin Field, MD, FAANS is a member of the Facial Pain Association, American Association of Neurological Surgeons, North American Skull Base Society, and the World Federation of Neurologic Societies. Dr. Fuselier and Dr. Loughner are in private practice at Central Florida Oral and Maxillofacial Surgery in Orlando. Dr. Field is a partner at Orlando Neurosurgery in Winter Park, and operates at Florida Hospital Orlando and Orlando Regional Medical Center. For contact information visit their websites: Dr. Fuselier and Dr. Loughner are at www.cforalsurgery.com.

Visit Dr. Field at www.orlandoneurosurgery.com

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GRANDROUNDS Central Florida Vein & Vascular Center Physician Receives Prestigious Certification Central Florida Vein & Vascular Center is proud to announce that Dr. Harry Agis has passed the American Board of Venous & Lymphatic Medicine (ABVLM) certification.

To become an ABVLM diplomate, an applicant must complete the necessary training and experience qualifications, meet the continuing medical education requirements and pass a stringent certification examination in the field of venous disease.

Less than 700 physicians in the United States have achieved this status and only a handful of them are located in the Central Florida area. We’re proud that Dr. Agis has joined Central Florida Vein & Vascular Center’s Dr. John D. Horowitz in this elite group of physicians.

Central Florida continues to be a leader in healthcare and we are extremely fortunate to have these talented physicians living in and serving our community.

Dr. Harry Agis started his medical career with undergraduate education at the University of Puerto Rico, his homeland, followed by him obtaining his medical degree from UNC, Argentina. His surgical education took place at Morristown Medical Center, Columbia University College of Physicians and Surgeons. Dr. Agis is Board Certified by the American Board of Surgery. He has been involved in the training of many medical students and residents, he has authored scientific papers, book chapters, and clinical presentations in the US and abroad.

Dr. Agis has been practicing General and Vascular Surgery since 1988. A commitment to compassionate medical care and the use of the latest technological advances in the diagnosis and treatment of venous disorders have yielded an impressive track record of successful outcomes.

Meyer and Associates, Counselors at Law, PLLC Opens in Lake Nona Justin Meyer, Esq. is proud to announce that his new firm, Meyer and Associates, Counselors at Law, PLLC, has opened its office on Tavistock Lakes Boulevard in Lake Nona. Meyer and Associates handles all phases of business for professionals, including formation, employment issues, and business sales. The firm has attorneys licensed in Florida, New York, and New Jersey.

Meyer and Associates, Counselors at Law, PLLC; 6900 Tavistock Lakes Blvd, Suite 400, Orlando, FL 32827 321-888-3334, jmeyer@meyeresq.com

Emergency Department at Nemours Children’s Hospital Receives Prestigious Award For a second consecutive term, the Emergency Nurses Association has recognized Nemours Children’s Hospital Emergency Department with its prestigious Lantern Award™. The award is given to

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emergency departments that exemplify exceptional practice and performance in core areas, a presence of a healthy work environment, and accomplishment in incorporating evidence-based practice and innovation when delivering emergency care.

“This award signifies a lot of hard work by our team and it’s a recognition that goes beyond the walls of our ED,” said Helen Case, operational vice president and chief nursing officer at Nemours Children’s Hospital. “It is a true team effort by associates who are always partnering with other departments to ensure we provide worldclass patient centered care on a daily basis, while keeping Nemours’ commitment to quality and safety front and center.”

Across the United States, only 22 emergency departments were awarded the Lantern Award this year. Nemours was one of only two emergency departments in Florida and the only one in Central Florida to earn the award.

“Every year we acknowledge departments that meet rigorous standard in leadership, practice, education, advocacy and research,” said Emergency Nurses Association president Karen K. Wiley, MSN, RN, CEN. “The fact that 22 emergency departments have met these standards and more in 2017 speaks volumes to the outstanding work in emergency departments across the country.”

Some of the evidence Nemours Children’s Hospital used to support that the emergency department model is working efficiently and is incorporating innovative practices, include: bold - REACH Program - Nemours Children’s Hospital developed a new model for providing care to children with autism spectrum disorder, developmental delays and other behavioral conditions. The redesigned care model is specially designed to reduce poor outcomes and negative experiences caused by sensory overstimulation in a typical emergency department setting.

Named “Respecting Each Awesome Child Here” or REACH, it is one of the first in the country to adapt care to the needs of children within the emergency department.

Several research studies are now underway to evaluate the pilot program - bold - Boo Boo Care Team – In many hospitals, only physicians suture wounds but at Nemours Children’s Hospital, paramedics are trained to suture wounds in the ED. They are trained for six months on how to repair lacerations, treat nail-bed injuries and remove foreign bodies in soft tissue.

Since the program was launched in the summer of 2014, the total length of stay for patients needing a suture was reduced a full hour per patient. bold - RN Turnover is just 15 percent, with a zero percent turnover rate for controllable resignations.

In 2014, Nemours was eligible to apply for the award and was selected as one of the few emergency departments to meet the rigorous standards. A considerable accomplishment for one of the newest pediatric hospitals in the country.

The Lantern Award designation is valid until the year 2020. Nemours’ emergency department team will be recognized with other awardees throughout the Emergency Nursing Conference in St. Louis and at the Hall of Honor Reception in September.

Florida Hospital and the Second Harvest Food Bank Partner to Donate Many economically disadvantaged Central Florida families often face an impossible choice: either food or shelter.

In fact, according to a recent study, 70 percent of area households said they had to choose between buying food or paying their mortgage or rent at least once during the previous year.

Many of those families rely on Second Harvest Food Bank’s local network of feeding partners to get the food they need to survive.

And now, Florida Hospital is launching an initiative that will give thousands of pounds of food to the community each month through a partnership with Second Harvest.

From pot roast to bread to chicken, Florida Hospital prepares thousands of meals daily for patients, visitors and employees who eat at campus cafeterias. Now, extra food is carefully packaged and stored for donation to Second Harvest, which in turn donates the fresh food to area soup kitch-

ens and other organizations through its Second Helpings program.

Florida Hospital recently launched the program at its Orlando campus, and will eventually extend it to all its hospitals in Central Florida. An average of 1,500 pounds has been donated monthly to Second Harvest from the Orlando campus alone.

One in six Central Floridians turns to charitable food assistance programs that are part of the local Second Harvest Food Bank network each year. On average, that’s nearly 500,000 low-income people who seek help with food more than 71,000 times per week.

They are working poor families, seniors, children, veterans, homeless and others.

To make their struggles even more serious, these populations face a disproportionately high rate of preventable, food-related health challenges.

According to Second Harvest’s Faces of Hunger report: • 27 percent of Central Florida households have at least one member with diabetes • 53 percent have a member with high blood pressure • 51 percent have members who are uninsured “When you consider the sheer numbers of people who are facing food insecurity, (CONTINUED ON PAGE 18)

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GRANDROUNDS it’s not hard to see the potential impact that access to healthy food can have on overall community health,” said Dave Krepcho, president and CEO of Second Harvest Food Bank. “In fact, food and nutrition are one of the relatively few things that actually could be a game-changer when it comes to prevention and effective management of disease.”

ORMC Recognized with Gold Plus Award for Heart Failure Care Osceola Regional Medical Center and its Heart and Vascular Institute Heart Failure Clinic have received the Get With The Guidelines® (GWTG) - Heart Failure Gold Plus Quality Achievement Award for implementing specific quality improvement measures outlined by the American Heart Association/American College of Cardiology Foundation’s secondary prevention guidelines for patients with heart failure.

The hospital’s Heart Failure Clinic has been also recognized by the US News & World Report 2016-2017 for high performing ratings. Get With The Guidelines-Heart Failure is a quality improvement program that helps hospital teams follow the most up-to-date, research-based standards with the goal of speeding recovery and reducing hospital readmissions for heart failure patients.

Numerous published studies have demonstrated the program’s success in achieving patient outcome improvements, including reductions in 30-day readmissions.

Osceola Regional Medical Center earned the award by meeting specific quality achievement measures for the diagnosis and treatment of heart failure patients.

These measures include evaluation of the patient, proper use of medications and aggressive risk-reduction therapies, such

as ACE inhibitors/ARBs, beta-blockers, diuretics, anticoagulants, and other appropriate therapies. Before patients are discharged, they also receive education on managing their heart failure and overall health, get a follow-up visit scheduled, as well as other care transition interventions.

“Osceola Regional’s Heart and Vascular Institute continues to focus on improving the quality of care for our heart-failure patients,” said Osceola Regional Medical Center CEO Davide Carbone. “And thanks to our implementation of the American Heart Association’s Get With The Guidelines-Heart Failure program, we are able to accomplish this goal by tracking and measuring our success in meeting internationally respected guidelines.”

American Heart Association Recognizes ORMC’s Commitment to Quality Stroke Care Osceola Regional Medical Center received the American Heart Association/ American Stroke Association’s Get With The Guidelines®-Stroke Gold Plus Quality Achievement Award with Target: StrokeSM Honor Roll Elite. The award recognizes the hospital’s commitment to providing the most appropriate stroke treatment according to nationally recognized, researchbased guidelines based on the latest scientific evidence.

Hospitals must achieve 85 percent or higher adherence to all Get With The Guidelines-Stroke achievement indicators for two or more consecutive 12-month periods and achieve 75 percent or higher compliance with five of eight Get With The Guidelines-Stroke Quality measures to receive the Gold Plus Quality Achievement Award.

To qualify for the Target: Stroke Honor

Special Lifetime Achievement Award Presented to Maurice A. Ramirez, DO, PhD The American Academy of Disaster Medicine presented a special Lifetime Achievement Award to Maurice A. Ramirez, DO, PhD, BCDM, BCEM, CNS, CMRO, one of the first physicians to receive certification as a Disaster Medicine Specialist.

The award was presented recently at the Annual Scientific Meeting of the American Association of Physician Specialists, Inc.® held in Ft. Lauderdale, FL. “Dr. Ramirez was recognized for his vast contributions to the discipline of disaster medicine,” said AADM Immediate Past President Heidi Cordi, MD, FAADM. Dr. Ramirez, who resides in Lake Wales, FL, was a founding board member of the American Board of Disaster Medicine®, a Member Board of the American Board of Physician Specialties®.

Dr. Ramirez is a former Senior Physician/Federal Medical Officer, Emergency Room Doctor, and Bioterrorism/Hazmat

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Maurice A. Ramirez, DO, PhD expert with clinical and field response experience spanning over 2 decades. He has served on expert panels for pandemic flu preparedness, healthcare surge capacity planning, disaster healthcare and disaster behavioral health with Congressional and Cabinet Members as well as scientific review committees for federal disaster healthcare research.

Dr. Ramirez was among the first physicians to complete the National Disaster Life Support (NDLS®) Instructor Training and Train the Trainer programs, FEMA/VA Mass Decon for Healthcare First Receiver Train the Trainer program, FEMA Mass Fatality Management Train the Trainer

Roll Elite, hospitals must meet quality measures developed to reduce the time between the patient’s arrival at the hospital and treatment with the clot-buster tissue plasminogen activator, or tPA, the only drug approved by the U.S. Food and Drug Administration to treat ischemic stroke. If given intravenously in the first three hours after the start of stroke symptoms, tPA has been shown to significantly reduce the effects of stroke and lessen the chance of permanent disability.

Osceola Regional Medical Center earned the award by meeting specific quality achievement measures for the diagnosis and treatment of stroke patients at a set level for a designated period. These quality measures are designed to help hospital teams follow the most up-to-date, evidence based guidelines with the goal of speeding recovery and reducing death and disability for stroke patients.

Osceola Regional Medical Center has also met specific scientific guidelines to be recognized as the only Joint Commission Certified Advanced Primary Stroke Center in Osceola County, featuring a comprehensive system for rapid diagnosis and treatment of stroke patients admitted to the emergency department.

Encore at Avalon Park to Launch Virtual Reality Pilot Program with MyndVR Only at Encore at Avalon Park will seniors be relaxing on a virtual beach. They’ll be hearing great music at 1950’s styled jazz clubs. They also will be able to play games like Sudoku in a fully immersive, Japanese garden. And, these experiences will be taken safely from the innovative center.

The assisted living community has been chosen by Dallas-based MyndVR as the (CONTINUED ON PAGE 19)

program, NYIT Psychological Impact of Disaster Train the Trainer program.

As an internationally recognized author and professional speaker, Dr. Ramirez has published numerous articles in professional and scientific journals. He has been citied in over 24 textbooks and authored chapters in three business books. He is the creator of the Rinse, Lather, Repeat kindergarten preparedness curriculum and the Continuous Integrated Triage™ framework used at the Louis Armstrong International Airport following Hurricane Katrina. In addition, Dr. Ramirez co-authored The Complete Idiot’s Guide to Disaster Preparedness (Alpha Books, 2009), Making Sense of Disaster Medicine (Oxford Univ. Press, 2010) and was the Technical Advisor for Spike TV’s Surviving Disaster and 1,000 Ways to Die. Dr. Ramirez is the Emeritus Medical Director for High Alert Institute, Inc. The Institute is nation’s first and only 501c(3) public charity dedicated to empowering individuals, families, communities, businesses and organizations to be disaster ready.

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GRANDROUNDS Lucas Hill and Chelsea Newman Join Synovus Mortgage in Orlando Lucas Hill and Chelsea Newman have joined Synovus Mortgage as market sales leader and mortgage loan originator, respectively. They are located at the Synovus Bank of Florida Orlando office at 450 South Orange Boulevard.

Hill has 15 years of mortgage experience and was previously with Fifth Third Bank for seven years. Neman has three years of experience and was previously with PNC Bank.

Synovus Bank is a Georgia-chartered, FDIC-insured bank. Synovus Bank, together with its affiliates, provides commercial and retail banking, investment, and mortgage services to customers through 28 locally-branded divisions, 248 branches, and 327 ATMs in Georgia, Alabama, South Carolina, Florida, and Tennessee.

Lucas Hill

Chelsea Newman

Encore at Avalon Park,

other creative method of providing a great life to its residents,” says Brickler.

third pilot location for its studies on how virtual reality can help improve the lives of seniors and trigger memories with an array of music, nature, art, travel with amazing 360 visual stimulation.

“Our goal for Encore is to provide active lives for our residents without the use of drugs and other debilitating treatments,” says Beat Kahli, President & CEO of Avalon Park Group, owners of Encore at Avalon Park. “Using virtual reality technology to provide incredible experiences is just another step to creating a place where seniors can truly enjoy life.”

The use of virtual reality will add to the list of more than a dozen non-pharmacological, therapies used at Encore for seniors to boost health and cognitive stimulation.

The residents at Encore can experience new and unique treatments, using horticulture, dolls, music, art and much more.

The residents can also have multisensory experiences in the Snoezelen Rooms, a place where all five senses are impacted at once. The VR pilot project starts on July 12 and will involve 20 residents at Encore at Avalon Park.

During the field pilot, the residents will have time to explore virtual worlds created and curated by MyndVR. The group recently completed successful pilot projects in Texas and Kansas.

“We are extremely passionate about providing seniors with a new genre of recreational and therapeutic experiences, and we are thrilled with the response from senior residents in our early pilots,” said Chris Brickler, CEO and co-founder of MyndVR. “This is a very new and promising technology. Our goal is to put smiles on faces, and we are seeing that happen time and time again. “Encore at Avalon Park has a track record of being one of the more innovative facilities in the country with their use of students, music, art, pets and just about any

Digestive and Liver Center of Florida Announces New Gastroenterologist

continued from page 18

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Gastroenterologist Jessica Narváez-Lugo, MD, brings 14 years of clinical experience in caring for people’s digestive health needs as she joins Digestive and Liver Center of Florida.

Dr. Jessica Narváez-Lugo, a boardcertified Gastroenterologist, obtained her medical degree in 2003 from Ponce Health Sciences University in Puerto Rico, formerly known as Ponce School of Medicine. After completing her internal medicine residency at the VA Caribbean Healthcare System, she pursued an additional year as a training program leader becoming a Chief Resident.

She acquired a high-quality training during her fellowship in gastroenterology at the University of Puerto Rico School of Medicine and its affiliated hospitals.

Dr. Narváez-Lugo believes “patient care starts with engaged providers dedicated to intellectual commitment and compassionate care.”

Dr. Narváez-Lugo is passionate about diagnosing and treating all gastrointestinal disorders but has special interest on Abdominal Pain, Anemias, Gastrointestinal Bleeding, Constipation, Diarrhea, Diverticulosis, Swallowing Disorders, Gallbladder Disorders, Gastroesophageal Reflux Disease (GERD), Liver Diseases such as Hepatitis C (HCV), Inflammatory Bowel Disease (IBD, such as Ulcerative Colitis and Crohn’s Disease), Irritable Bowel Syndrome, and Peptic Ulcer Disease.

Dr. Narváez-Lugo said she “makes it a priority to listen to her patients to understand their concerns in order to provide an individual care plan that effectively and safety addresses the patient’s unique needs.”

She is a member of the American Medical Association, American College of Gas-

troenterology, the American Gastroenterology Association, and the American Society for Gastrointestinal Endoscopy.

Dr. Jessica Narváez-Lugo is bilingual in Spanish. To schedule an appointment with Dr. Jessica NarváezLugo, call Digestive and Liver Center of Florida at 407-384-7388.

CPA Solutions, Inc. Accelerates Growth with 3rd Location CPA Solutions, Inc., one of the leading CPA firms in Orlando, is set to open a new office in the heart of Celebration, FL, on August 15, 2017, to leverage the areas rapid growth and the diverse business and individual client base.

In addition to the two existing offices in downtown Orlando and Avalon Park, the new office space will provide additional convenience to its existing clients and also support the company’s growth strategy.

CPA Solutions will also be adding additional accounting staff to accommodate growth in the client base.

About CPA Solutions CPA Solutions, Inc. is a full-service Orlando based licensed firm that offers a broad range of services for business owners, medical professionals and independent professionals. CPA Solutions combines its exceptional reputation and expertise with personal attention to each client and their needs. CPA Solutions embodies vision, skill and experience to create and sustain long lasting client relationships. For more information on CPA Solutions, visit www. mycpasolutions.com or call 407-650-9088.

Contact: Dalia Cantor, CPA Solutions, 407650-9088, dalia@mycpasolutions.com.

St. Cloud Physician Management Joins Seven Practices Under One Medical Group St. Cloud Physician Management is bringing together seven healthcare practices, under one name -- St. Cloud Medical Group -- and has added several features which make finding and using a healthcare provider easier and more convenient for patients. The seven practices now coming together under one name have been providing quality healthcare to Osceola County residents and the surrounding communities for over 30 years. The practices will continue to operate in each of their current locations throughout St. Cloud and Kissimmee.

St. Cloud Medical Group brings more convenience to the consumer through one group website, StCloudPhysicians. com, and one phone number to reach any provider for appointment scheduling. As well, select providers in St. Cloud Medical Group are among the first in the area to offer a real-time online appointment booking service. Increasing the convenience of the service, some appointments are available for same-day or next-day visits to a primary care provider’s office.

St. Cloud Medical Group is a multispecialty medical group affiliated with St. Cloud Regional Medical Center. Providers

specialize in cardiology, family medicine, gastroenterology, general surgery, internal medicine, occupational medicine, otolaryngology, urology and vascular surgery.

St. Cloud Medical Group has convenient locations throughout St. Cloud and Kissimmee, Florida. All of the providers are board certified or fellowship-trained in each of their specialties and are members of the medical staff of St. Cloud Regional Medical Center.

“This alignment will make it easier for patients to gain access to quality medical care through our multi-specialty group’s convenient access points, including one website and phone number for all providers.” said Brent Burish, CEO of St. Cloud Regional Medical Center. “Patients expect and deserve high-quality, convenient access to healthcare services and we want to make it easy for them to choose our affiliated physicians as their healthcare partner in their community,” he added.

St. Cloud Medical Group providers can be reached by calling 407-891-2900 or through StCloudPhysicians.com.

East Orlando Chamber of Commerce Names Andrew Cole Director Andrew Cole has been named new Executive Director for East Orlando Chamber of Commerce.

“I am pleased to announce Andrew Cole has received a well-deserved promotion to become the new Executive Director of the East Orlando Chamber of Commerce. Andrew has been with the East Orlando Chamber since 2013 most recently as Director of Events. During his tenure, he has played an integral role in establishing a sound foundation for the Chamber’s future. He has a passion for our Members and the East Orlando Business Community, and he is dedicated to leading the way for the Chamber’s growth and relevance in Central Florida as a connector for the the region. I invite you to introduce yourself and congratulate him in his new position,” said, Jennifer Schmitt, Board Chair, Orlando Law Group.

Representing local businesses including Central Florida’s powerful high-technology research park and state of the art healthcare corridor, the mission of the East Orlando Chamber of Commerce (EOCC) is to be the leading resource in business advocacy, community engagement and regional connectivity. We help to create a positive business climate and a sense of unity throughout the region by providing various resources, including: leadership development, community Involvement, networking opportunities and educational programs.

Since 1946, the chamber has been committed to the growth and development of the area’s businesses and community. We proudly serve the communities of Avalon Park, Bithlo, Central Florida Research Park, Christmas, Innovation Way, Lake Nona, Orlando International Airport, Semoran Corridor, UCF, Union Park, Vista Lakes, Waterford Lakes, and Wedgefield.

AUGUST 2017

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