Orlando Medical News February 2014

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February 2014 December 2009 >> $5


Alix G. Casler, MD ON ROUNDS

Impacting the Local Community

Osceola Regional maintains healthy mix of capital improvement projects, new and improved services, and national accolades By LyNNE JETER

KISSIMMEE— Bob Krieger had a robust first year as CEO to report about Osceola Regional Medical Center in its Annual Com- Bob Krieger munity Benefits Report 2013. Krieger, whose resume includes stops at Delray Medical Center, HCA’s Orange Park Medical Center, and Humana hospitals in Miami and Louisville, Ky., took the leadership post early last year, when the 257-bed HCA hospital

Preparing for ICD-10 Conversion Practice management consultant shares 8 steps for physicians to take now ... 6

had many projects in the hopper, including its new 60-bed Patient Tower. The year before, the hospital had opened a $3.4 million employee parking garage. Just before Thanksgiving, Osceola Regional broke ground on a new freestanding emergency department in Hunter’s Creek, slated to open this summer. All total, Osceola Regional has spent $17 million in capital investment projects, based on a 5-year annual aver-


Accommodating Snowbirds Sheridan Healthcare’s plan for ER demand expedites patient flow while also reducing expenses By LyNNE JETER

SUNRISE—Even though Orlando healthcare providers are accustomed to the dramatic increase in older patients visiting Florida hospitals and ERs during the winter months, healthcare administrators remain challenged to meet staffing demands – juggling physicians, stretching hours, bringing in doctors per diem. Setting throughput goals and having

core measures in place helps improve efficiency in patient flow and quality of care in Florida ERs, said Catherine Polera, DO, MPH, chief clinical officer for the Division of Emergency Medicine at Sheridan Healthcare. The Sunrise-based company, established in 1953, is the nation’s leading physician staffing provider for emergency medicine, anesthesia, neonatal management and radiology services in hospitals and ambulatory surgery centers. (CONTINUED ON PAGE 4)


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Alix G. Casler, MD

Pediatrician, Physician Associates Orlando Health By JEFF WEBB

ORLANDO - Caregiving is a craving for Alix Casler, and satisfying that urge is a 24/7 quest that stretches from her clinic to her kitchen table. “The thing that makes me feel good about myself is taking care of other people,” said Casler, 52. As medical director of pediatrics at Physician Associates Orlando Health, where she has treated young patients for almost 20 years, and as mother to five teenagers in a blended family, Casler has had a steady supply of caregiving responsibilities to feed her feel-good vibe. Some of it she inherited from her parents as she grew up in Niantic, Conn., playing French horn, running on the cross-country and track teams, and working as a beach lifeguard and camp counselor. “My parents were THE influences in my childhood,” said Casler. Her father is a PhD pharmaceutical research chemist and her mother is an Ivy League philosophy and mathematics major who, Casler said, “was a stay-at-home mom until I was in college and she went back to work as a math teacher. Mom was always totally supportive of all of my involvements and activities, making them possible by giving up her professional life for me and my (younger) brother. She became a different woman when she went back to work.” That example, said Casler, “made me realize the importance of achieving a balance between a profession and mothering, both of which are equally important.” Just as inspiring, Casler said, was her father’s “can-do” attitude. “He taught me to milk the essence out of life … to do, do, do, give, give, give and live, live, live!” she said. Clutching her high school valedictorian award, Casler went to Dartmouth College where she majored in 18th century French literature and minored in chemistry and molecular physics. “I studied what I loved and figured that my career goals would evolve as they should,” said Casler. While dabbling in singing and acting, it wasn’t until her sophomore year that she began to think about medicine. “I knew I wanted to work with children. I just did not know how. Something about them gives me breath and life,” explained Casler. “I knew I did not want to teach (because) teachers work too hard for not enough respect and pay, and I did not want to be a nurse (because) I did not want someone else to define my work. I wanted to be in charge. So, medicine made sense,” Casler remembered. But as she studied at the University of Connecticut School of Medicine, Casler said she “got a little derailed because I loved everything. OB/GYN was so cool because of the miracle of delivering babies and the excitement of doing surgery. Psyorlandomedicalnews


chiatry was totally fascinating, but sort of depressing at times. Internal medicine was an intellectual rush.” But one night Casler was at a party “having had one glass of wine too many while talking with a new acquaintance,” she said, “and it all became clear. I was bemoaning my difficulty in choosing a field to pursue and he said ‘When you talk about pediatrics, you sparkle. That is what you need to do.’ I never turned back and have never been sorry.” After graduating medical school in 1987, Casler said she “needed to leave the New England culture,” and she embarked on her internship and residency in a bold way at Children’s Hospital Los Angeles. “It was a very hands-on inner-city program. I learned by doing. I was in my 20s and admitting 20 patients a night. It was the best way for me to become an expert in what I did at one of the top three (pediatrics) programs in the country,” she said. But the cost of living there was prohibitive so she followed her compass east to Florida, starting a private practice from scratch in Brevard County. “I made a big mistake by going into practice by myself and building from the ground up. I got very busy very quickly. I couldn’t do it all,” Casler said. “I was brought up to believe that I could do everything. But I can’t. I can do anything, but I can’t do everything,” and that is a lesson that is “relevant

to all women” she said. “I have had to learn, over and over, to compromise and to prioritize.” Casler had friends and colleagues in Orlando and they welcomed her to PruCare, which is the corporate predecessor of Physician Associates, one of largest multi-specialty practices in Central Florida with 25 locations. “We worked very hard to transition. I’m proud to have been a part of that,” said Casler, who now oversees 20-plus providers as she devotes “100 percent of my time toward clinical care and improving patient health and outcomes.” During her 20 years in Orlando, Casler’s reach has extended beyond her patients. She was an on-air radio and television personality for seven years, answering questions about pediatrics, and she remains a go-to source for local television stations when they need a physician’s perspective on breaking health news. Casler is also on the faculties of the University of Central Florida and the Florida State University colleges of medicine. Her affiliation with UCF has given

her the opportunity to engage in humanitarian missions to the Dominican Republic, where “we deliver much-needed care to some very, very poor areas,” she said. Casler and her husband John, a retired U.S. Navy officer and an optics engineer for Lockheed-Martin, are restoring their home, a 112-year-old house near Lancaster Park. “It’s an ongoing labor of love and my husband does most of the work. I’m the designated sander and painter,” she said. The hub of the Casler home is the kitchen. “I am a foodie. It is part of my essence in life to make lunches for my children every day and to provide dinner for my family every night I possibly can. Preparing food is an expression of love for me, and cooking is a creative outlet. I like to eat, too, (but) I also love to just hang out with my family,” she said. Her family includes five young adults, ages 19, 19, 19, 16 and 16. “We are a blended family and I have twins. They are involved in everything: Air Force ROTC, (CONTINUED ON PAGE 5)

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Impacting the Local Community, continued from page 1 age, according to FY 2012 statistics. In other moves, Osceola Regional last month officially partnered with Pediatrix Medical Group’s 11 boardcertified neonatal physicians, who have been involved with Osceola County’s only NICU Level II since it opened. Pediatrix Medical Group also cares for hospitalized pediatric patients at Arnold Palmer Hospital for Children and newborns at Winnie Palmer Hospital for Women and Babies. Osceola Regional also added singleincision robotic surgery to the da Vinci Robotic Surgical Program. Last year, the hospital was recognized for: • The highest 3-star rating in heart surgery, placing the program in the top 13 percent nationally. • The Joint Commission’s “Top Performer Key Measures in Quality” designation, one of only two hospitals in Central Florida to achieve the distinction. • The Joint Commission’s Excellence in Disease-specific certifications in hip and knee replacement, lung, colon and breast care. • The American Heart and Stroke Association (AHSA) Gold Plus Performance Achievement Award for consistent quality stroke care for the fourth consecutive year. • One of only 14 hospitals in Florida

to receive the AHSA “Target: Honor Roll” Achievement award. • The American Heart Association Gold Performance Award for Heart Failure. • Other highlights: • Osceola Regional represents the nation’s first healthcare system to perform a routine blood test to screen newborns for kernicterus, easily treatable if diagnosed immediately. The hospital’s leadership role with a March of Dimes national study to minimize or eliminate elective deliveries before 39 weeks gestation has resulted in new standard operating procedures in HCA hospitals. Also, HCA installed the AIRSTRIP OB monitoring system to allow obstetricians to remotely view vital patient information on their smart phone. • The Kissimmee hospital sponsors internal medicine and general surgery residents through the UCF College of Medicine and also plans to sponsor OB/GYN residents through the American Osteopathic Association. • The STEMI (ST-Elevation Myocardial Infarction) Initiative in the Central Florida Cardiac & Vascular Institute at Osceola Regional has effectively reduced the amount of time to reestablish blood flow to an average of 60 minutes, 30 minutes less than recommended by the Joint

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Commission, American College of Cardiology and American Heart Association. “One of our goals at Osceola Regional,” said Krieger, “is to make sure everyone who enters our facility goes home with nothing but a positive experience, one they can brag about to their family and friends.” Last month, Krieger fielded calls about The Institute for Health & SocioEconomic Policy naming the hospital the 28th most expensive in the United States, noting that “patient payments are mostly related to the type of coverage patients have rather than charges. Although terms such as hospital costs, payments and charges are often used in-

terchangeably, government programs such as Medicare and Medicaid determine how much they reimburse hospitals. Both insurance plans and the uninsured have negotiated payments, discounts or are eligible for charity care.” Osceola Regional’s annual report recapped its 2013 community impact summary with 141,008 total patients treated. Including more than 7,000 patient visits from a 7-county area to the Wound Healing Center, the hospital reported 18,027 admissions and 90,838 emergency visits. The hospital, which staffs 1,712 employees, 469 physicians and 126 volunteers, reported a Medicaid market share of 37 percent, and uninsured market share of 40 percent.

Accommodating Snowbirds, continued from page 1 “Getting to see a doctor faster really drives patient satisfaction,” said Polera. “Our job is to do what’s needed to find an optimal way to get us shorter door-to-doctor time.” Dr. Catherine Polera

Covering the Floor For starters, Sheridan Healthcare creates a productive environment for its staff. For example, physicians’ hourly rate is a type of pay-for-performance: good quality, metrics and patient satisfaction are the measures. To provide sufficient ER physician coverage, the company uses the demand capacity staffing model, and makes sure it aligns with the nursing staffing model. Some overflow days are anticipatory, such as those following major holidays. “It’s typical for the day after Thanksgiving to be the busiest ER day of the year,” she said. “Eating sodium-rich and fatty foods prompts trips to the ER. People hold off as best they can not to be in the ER on a holiday.” The ER was busier than usual last February and March. Last fall, ER patient volume increased earlier in the snowbird season, which begins in October. “It sparked unusually high ER activity,” said Polera, a former snowbird who served as chief medical officer at Saint Michael’s Medical Center in Newark, NJ, and chief medical officer at MedExcel USA Inc. in New Windsor, NY, before joining Sheridan Healthcare. “That’s a challenge for staffing. Usually, we increase our coverage by day or by hour as trends dictate. Many times, our own doctors will pick up extra shifts, but we also employ part-time doctors, who may also be snowbirds themselves. I’ve been talking to more of those doctors who are getting really sick of cold weather and looking at ways to change their lifestyle. Some emergency medicine doctors have work that allows them to be almost semi-retired and contract part-time in warmer climates. Also, many more doctors are calling me,

saying they wouldn’t mind taking shifts in the winter, or downsizing their shifts and coming to Florida. That helps.” The PCP Component Significant changes sparked by healthcare reform have already affected the way primary care providers (PCPs) practice medicine in ways that alleviate pressure on ERs. Some PCP groups open longer on certain days of the week, or are more accessible using the Patient Centered Medical Home (PCMH) model. Also, the influx of urgent care clinics is taking some of the ER load. Yet there’s much ground to cover for PCPs and ER doctors to work together more effectively, noted Polera. “Hospitals are under a great deal of pressure to have good patient satisfaction, good relationships in the community, and make sure patients are seen as soon as possible,” said Polera, pointing to lack of communication – verbally and via electronic medical record (EMR) systems – as major stumbling blocks to ER physicians providing optimal patient care. “If I could call their office to get patient records, it would help lower healthcare costs tremendously. Knowing a patient’s medical history would make a huge difference in the patient’s ER care. We wouldn’t repeat a CT scan, for example. Getting medical history is a big challenge, especially in the wintertime.” If PCPs decreased their door-to-doctor time, it would ease the burden on ERs, said Polera. “If patients see they’re in for a long wait at the doctor’s office, they’ll check online to see the fast wait times at ERs, where they can also get labs, x-rays and CT scans,” she said. “The McDonald’s mentality is impacting the way people choose healthcare. Why wait when everything can be done at once? The overall mindset may be changing from loyalty to a particular doctor to another direction.”




Alix Casler, MD continued from page 3 FSU cheerleading, substitute teaching, lacrosse, yearbook, mock trial, chorus – you name it. They keep my calendar full,” Casler said. But that does not stop Casler from adding formidable pursuits to her bucket list. She already is fluent in French, but she is determined to conquer Spanish as her next language. She would like to write a book “from the perspective of a pediatrician mom, about bringing up children while working. I’ve had a lot of experience on both sides of that subject,” she said. Yet another goal combines her love of food and being outdoors. “I want to move to Tallahassee and raise sheep and make cheese. I like being outside, good food and being creative,” said Casler. “I have a colleague who has a similar fantasy, but with goats. Maybe she’ll do her chevre and I’ll do my feta and we’ll meet up at the Aspen Food and Wine Festival. We’ll raise herbs, too, and we’ll have bees and make our own honey. My husband will handle the wine pairings.” In the meantime, Casler said, she will continue to dish out what fills her up. “All I have to do is give and feel good. There aren’t very many people who get to do that for their whole lives. It sounds oversimplified, but it’s a very emotional thing for me.”

Supersizing CHS

HMA acquisition complete, nation’s largest chain of hospitals scoops forward By LyNNE JETER

Despite staunch opposition from various circles, Community Health Systems (NYSE: CHS) easily sealed its $3.9 billion acquisition of Naples, Fla.-based Health Management Associates (NYSE: HMA) three days shy of six months. On Jan. 27, trading of HMA stock ceased at $10.50 per share, with HMA stockholders also receiving .06942 shares of CHS stock for every HMA stock. Among concerned parties, the American Federation of Teachers (AFT) criticized the CHS-HMA transaction, saying the deal has “apparent conflicts of interest” and “also has complications” related to Department of Justice (DOJ) investigations at both for-profit hospital operators. One probe: alleged Medicare fraud related to admissions practices. The AFT’s interest emerged from its role in managing $1 trillion in public pension plans, with a portfolio including $68 million and $34 million, respectively, in CHS and HMA stock. Nurses also expressed worries. On the morning HMA shareholders voted on the pending deal needing 70 percent approval, RNs challenged the CHS buyout of HMA, saying the massive hospital monopoly of

206 mostly rural-based hospitals in 44 states would threaten patient access and quality of care. RNs from West Virginia, Ohio, California, Pennsylvania and Florida represented National Nurses United (NNU), the largest U.S. organization of nurses, at a press conference before the shareholders meeting at HMA headquarters in Naples. Months earlier, NNU had filed a formal complaint with the Federal Trade Commission (FTC), noting “vigilant antitrust oversight is essential to prevent the predictable ills of an irreversible market consolidation” that would threaten patients and the public interest. “The deliberate practice of setting these disgracefully high charges, especially in communities where patients and families have nowhere else to go for hospital care, CHS and HMA are exposing countless numbers of people to financial ruin – or discouraging them from seeking care when they need it due to the cost,” said NNU copresident Jean Ross, RN, pointing out that CHS-affiliated hospitals are the sole provider of healthcare services in more than 55 percent of markets served. “This is exactly why the merger, which would give these irresponsible hospital executives even more monopoly clout, should be stopped.”

HMA shareholders weren’t swayed; the pending deal garnered 82 percent approval. The FTC approved the acquisition after the Franklin, Tenn.-based company agreed to divest two acute care facilities: Riverview Regional Medical Center, a 281-bed hospital in Gadsden, Ala., and Carolina Pines Regional Medical Center, a 116-bed hospital in Hartsville, SC. “This transaction provides us with increased scale and broader geographic reach as we work to create strong healthcare networks across the nation,” said CHS CEO Wayne T. Smith. “Our larger organization is well positioned to address the changing dynamics in our industry and dedicated to providing quality care for millions of patients and all the communities we serve.”

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Preparing for ICD-10 Conversion

Practice management consultant shares 8 steps for physicians to take now By LyNNE JETER

An experienced practice management consultant best described the looming ICD-10 conversion “as though 19 percent of the GDP will be required to start speaking French to each other … and if grammar, pronunciation and punctuation aren’t perfect, no money will move.” The “frighteningly large change” coming Oct. 1 has caught many physician practices off guard, said Jennifer O’Brien, MSOD, a practice management consultant with KarenZupko & Associates Inc. “We’re finding that some practices have done absolutely nothing to prepare.” According to the latest Workgroup for Electronic Data Interchange (WEDI) ICD-10 readiness survey results, representing a mix of practices and hospitals, “it’s clear the industry continues to make slow progress, but not the amount of progress that’s needed for a smooth transition.” Only one in three practices were conversion-ready, with the remainder citing significant obstacles to progress: competing priorities and other regulatory mandates. “All industry segments,” the report concludes, “haven’t gained sufficient ground to remove concern over meeting the Oct. 1 compliance deadline.” “Apparently, there’s still a lot of hope

on the part of providers that it’ll be postponed again,” said O’Brien. (The ICD-10 conversion was originally slated for Oct. 1, 2013. In 2012, an extension was announced.) “BeJennifer O’Brien cause of the healthcare.gov debacle, people are thinking that CMS will postpone it again. The experts are saying another postponement is highly unlikely.” Noting that “denial is only going to make it more painful,” O’Brien recommended eight steps for every physician provider to take in early 2014. Physician providers in a practice that

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allows them to control their own salary or draw should reduce that amount by 25 percent now. “Don’t pay out the rest,” she said. “You’ll likely need it to pay yourself during the fourth quarter (Q4).” By planning for little to no Q4 revenue while also reducing the draw in the first three quarters of 2014, “you can pay yourself in Q4.” O’Brien explained: “Because the entire industry will make a change of such magnitude on the first day of Q4, the revenue cycle is going to be disrupted. Either the practice is going to make mistakes coding, payors are going to have difficulty processing the claims, or both. For practices that don’t adequately prepare, Q4 could be bone dry.” By comparison, Canadian physicians reported a productivity reduction of up to 50 percent during their conversion. Secure a substantial Line of Credit (LOC) with a bank to cover payroll and operating expenses in Q4. “Like an insurance policy,” she pointed out, “a LOC must be secured before needed.” Scale back in 2014. “This isn’t the year for capital expenditures, other purchasing and hiring that’s not absolutely necessary,” she said, noting the strategy applies to personal expenditures also. “2014 isn’t the year for physicians to build that dream vacation home.” Because of increased expenses and decreased productivity, let employees know now that year-end bonuses are highly unlikely. “It’ll be a belt tightening year,” she said. Order ICD-10-CM books, software or apps. “Physician practices don’t need ICD-10-PCS, just ICD-10-CM,” she said, noting that CPT will continue to be used to report procedures and services for physicians; ICD-10-PCS is the book hospitals use to report services and procedures. (See “Quick Definitions.”) Depending on the practice, run a frequency report of the top 25 to 75 most commonly used ICD-9 codes with nomenclature. “For specialty and subspecialty practices, the most common 25 diagnosis codes should be sufficient, but for internal medicine, emergency medicine, and other practices with a broader scope, there will likely be more than 25,” cautioned O’Brien. “Once you have the list of your most commonly used ICD-9-CM codes, use your new ICD-10-CM books to

crosswalk them to correct, complete ICD10-CM codes. Don’t leave this up to the office staff. Do it on your own or with your staff. The process of converting your most commonly used diagnoses to ICD-10-CM will likely demonstrate a need for you to change your documentation of diagnoses and may show a one-to-many crosswalk. That is, what used to be covered with one code will now require additional information to select the correct code from a list of many.” Don’t plan on leaving the conversion up to internal billing staff or an external billing service. “When asked, ‘What are you doing to prepare for ICD-10-CM?’ we’ve had physicians and managers respond, ‘Our billing service is going to take care of that.’ Guaranteed disaster! ICD10-CM requires significant, documented input and details from the clinician for accurate, complete codes. There’s no billing service or even computer program that can crosswalk ICD-9-CM codes to ICD10-CM codes without additional details and input from the clinician.” Research available ICD-10-CM training. “Many national specialty societies, hospitals and practice management software companies and other organizations are offering ICD-10-CM training for physicians and their staff,” said O’Brien. “If your practice is large enough, it may be cost effective to hire the ICD-10-CM trainer to come to you and your staff. Plan to spend the next several months learning the ICD-10-CM coding system and changing your documentation. Don’t think you can cram for this by going to one or two seminars in the summer. This is like board examinations; only in this case, if you don’t study, prepare and perfect well in advance, the failure could mean financial ruin.”

Quick Definitions ICD-10-CM: The clinical modification of the World Health Organization’s ICD-10, which consists of a diagnostics classification system. In the United States, ICD-10-CM includes the level of detail needed for morbidity classification and diagnostics specificity and provides code titles and language that complement accepted clinical practice. The system consists of more than 68,000 diagnosis codes. ICD-10-PCS: Developed to capture procedure codes, this procedure coding system of 87,000 procedure codes is much more detailed and specific than the short volume of procedure codes included in ICD-9-CM.



Chronic Venous Insufficiency/Pearls and Pitfalls in the Diagnosis Venous disease is estimated to affect 25 million people in the United States. Venous ulcers, the most significant complication, affect approximately 500 thousand people. More than 2 million working days are lost each year and approximately 3 billion dollars is spent treating venous disease. In addition, venous disease is estimated to account for 1 to 3 percent of the total healthcare budget. Although venous disease cannot be avoided, greater awareness in the general population and especially among physicians can diminish the impact.

undertaken if there is a significant obstructive component in the deep system. I see a large number of patients who have had a venous evaluation at an outside lab and 99% of these exams are inadequate for evaluation of venous insufficiency. Patients with severe type I diabetes or known arterial disease should have an arterial evaluation to rule out significant disease, which might contraindicate compression or venous therapy.

Early skin changes consist of pink to red discoloration which may be blotchy and dry (stasis dermatitis). The Risk factors include heredity, age, gender (females > underlying tissue may be firm. These areas should be males), hormonal (estrogen and progesterone), pregnanlubricated and massaged at least two times a day. With cy, obesity, jobs with prolonged standing, trauma, and time a darker brown discoloration develops and the previous superficial or deep vein thrombosis. Graduated tissue becomes firmer. This is referred to as lipodermacompression stockings are the first line of therapy for tosclerosis. The cause is inflammation, secondary to patients that show any signs of varicose veins, significant metalloproteinases, lymphocytes, macrophages, and red spider teleangiectasias, ankle edema and skin changes, cells that traverse the capillary membrane because of the pregnant women, or those who have jobs that entail hydrostatic pressure of gravity. The brown discoloration standing for prolonged periods of time. Patients someis the end result of red cell destruction with deposition times complain they are hot or hard to get on, but we of feratin. This tissue is very vulnerable to ulceration. must be firm and tell them about the problems that Some patients will go on to develop lymphedema with Further tissue degeneration can follow. Insurance companies often insist on 3 to 6 swelling of the foot because the lymphatics in the lower months of conservative therapy with compression stockleg are fibrosed by the inflammation. Flare ups of this ings prior to approving any treatment. tissue frequently occur with long periods of standing and the tissue can become erythematous and even exude fluid. Sometimes The majority of patients with advanced skin changes have superficial this fluid has a scaly appearance or can even appear as a white exudate. venous valvular insufficiency. Many will also have perforator or deep vein It is important to recognize this as an exacerbation of stasis dermatitis, involvement. Patients with peripheral arterial disease and or significant an inflammation, not cellulitis, an infection. In these times of concern type I diabetes must be treated cautiously. If pulses can’t be detected, or about noscomial and opportunistic infections, we must avoid using the patient has an ankle/arm index less than 0.5, compression is conantibiotics for this condition. The erythema will often persist for weeks traindicated. In patients with chronic swelling or pain in an extremity, and if left on antibiotics for that period of time, patients are vulnerobvious varicosities, or florid patterns of teleangiectasia (spider veins), able to fungal infections, MRSA, and clostridia difficil colitis. The best the vascular lab is the first step in the treatment algorithm. But, a word treatment is to focus on the underlying veins, but this takes time. Use of warning, when a venous evaluation is ordered, most hospitals and of hydrocortisone cream, elastic compression, and elevation are bridge diagnostic labs perform a test for venous thrombosis. One must specifimaneuvers. Biopsy of the skin should never be an option. The only place cally ask for an evaluation for venous insufficiency and even then, most for a biopsy is at a site of long standing ulceration, or an ulcer, which is exams are inadequate. A study should be performed with the patient refractory to optimal therapy to rule out cancer. standing using valsalva and compression maneuvers to check for valvular reflux. The deep, superficial, and perforator systems should be studied We must be aware of patient’s complaints of aching, heaviness in the leg, and reflux times should be noted along with the vein diameters. This and swelling as the day progresses. Varicose veins can lead to significant exam reveals wheter a patient has evidence of old deep vein thrombosis problems and should not be treated as merely a cosmetic concern. Early with scarring or obstruction. Therapy for superficial veins should not be attention can avoid later problems. Stasis dermatitis with inflammation Not cellulitis- infection

Presented in Partnership by Orlando Medical News and Vascular Vein Centers

Samuel P. Martin, M.D. F.A.C.S., Founder & Medical Director Dr. Samuel P. Martin is a vascular specialist with over 33 years of experience. He is board certified in general and vascular surgery and received the phlebology board in 2008. (A phlebologist is a vein specialist). He is also registered by the American Registry for Diagnostic Medical Sonography (RPVI), a board which recognizes special qualification to interpret venous and arterial diagnostic studies. He also has certification by the American Board of Wound Management which recognizes expertise in treating venous ulcers and other wounds.






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How Much Does it Cost You to be HIPAA Compliant? By GLENN HANKS

How much does it cost you to be HIPAA Compliant? Once upon a time, doctors simply had an office full of patients, as well as medical assistants and supporting staff members that maintained sensitive medical records. In today’s medical practice, doctors have to contend with the addition of computers and advanced medical equipment. The goal of these computers and equipment is to add speed, efficiency, reliability and security to the doctor’s workflow. By adopting electronic practice management and electronic health records software, the medical practice in theory gets the speed, efficiency and reliability the computers provide. Rooms with never ending rows of paper records now fit on a thumb drive you can put in your pocket. Doctors and their staff can now access this sensitive data from anywhere securely and reliably. But first, there are a number of things that must be taken into consideration. As you begin the planning, shopping, testing of your new platform, experts on the subject matter become the most vital tool in the growth of your practice and its compliance with new regulations. Now, enter the first of two very important people in this endeavor, the software expert. The software expert can range from the software provider themselves to a consultant that is seasoned in various software solutions and work flow, aiding the practice to choose the right software for their environment as well as training the staff within the new platform. The second person, the hardware specialist, or IT professional, which brings a combination of technical expertise that can enhance the workflow experience by overseeing the network infrastructure and the integration of new software, ensuring all elements are meeting their respective level of efficiency. Understand, there are choices that have to be made with the computer hardware that can be very expensive, which can either hinder or enhance your practice. With HIPAA, HITECH, “Meaningful Use” and the Affordable Care Act, all doctors will be affected; making the wrong choices can be very costly. For the purpose of this discussion we will refer to them as regulations. Once the right software is selected, the next decision is to determine the best way to store the data, software and manage workflow. Until recently there was only one way and that was to install a server that stored

everything on site and allowed the users access to all the necessary information. While this is a good solution it does have its problems. The biggest issue is its initial and ongoing costs. Hardware is very expensive and the ongoing cost of its maintenance becomes a heavy burden on the wallet. No to mention most of these hardware components have to be replaced every three to five years. In addition to housing the server in house, it can require a dedicated IT person on staff that understands and maintains regulatory compliancy. The Internet and advancements in global networking in recent years have provided another alternative; cloud computing. This is a privatized offsite environment, which, by the nature if its design, is in full compliance with all the new regulations. In addition, cloud-based software and data storage are maintained remotely eliminated considerable hardware and maintenance costs. Most companies offering cloud services take care of all the day-to-day IT tasks that you don’t have the time, energy or luxury to focus on. Some of these tasks are, but not limited to, implementation of new hardware or software, upgrading and troubleshooting hardware already in production. Cloud IT professionals take care of all these administrative tasks as well as provide you security with reliable backups and a stable network you can trust. Network issues are resolved nearly four times faster than the traditional on site server in a cloud environment. Switching to a cloud environment will enable you to: • Avoid heavy, out-of-pocket expenses for upgrading, expanding and supporting your current computer network • Significantly reduce ongoing IT maintenance costs • Have a built-in backup and disaster Recovery • Secure remote access to information from anywhere (office, home etc…) • Collaborate with colleagues from anywhere with network access, including a smartphone or tablet • Have better record retention – unlimited storage • Obtain automatic software updates and integration • Use mobile devices and apps for both patient information and your calendar • Have secure patient records that are protected thru both hardware and software (CONTINUED ON PAGE 10)



Next Challenge Facing Medical Professionals? Marketing to Gen Y By FRANK NATHE

In today’s competitive marketplace, many medical professionals are being forced out of their comfort zone and into the world of marketing to grow their patient base. This is the case whether a sole practitioner, group practice or hospital chain. Additionally, with the increasing number of mergers and acquisitions in the medical field, it is imperative the branding of the combined entities is designed to retain existing patients while growing with new patients. Competing with the nearly 5,000 marketing messages an average person sees each day, medical professionals today are faced with the unique challenge of developing an effective marketing strategy that appeals to 30-somethings who have grown up accustomed to tuning out marketing messages and turning to their iPhones and other mobile devices for information on everything from which restaurant they want to go to, to finding a new health care provider. Technology, advertising and the abundance in choices for medical care make it more important than ever for medical professionals to differentiate themselves in the market. Patients demand more information, attention and communication than ever before. Today’s patients want their information when they want it, where they want it and how they want it. Another matter of critical concern is reputation management; any negative review must be dealt with properly in a proactive manner. Balancing marketing, brand strategy and image has become a growing concern for practitioners who have traditionally been able to focus on their patients more than their blogs. The first step in identifying the best marketing strategy for your practice or business is understanding the market and how your brand is represented in the industry. Recently, our company, Proforma, a marketing and brand management company, was approached by a client in the medical field who wanted to identify two major problems they were experiencing in their practice: Why were certain patients leaving and what was the market’s perception of their business? Our market research showed that patients were leaving because they didn’t fully understand the client’s complete service offerings and they were unhappy with the lack of communication they were receiving from their physicians. Clear branding can help revitalize image. The client/company needed to refresh their brand and the way they communicated with their patients. By refocusing their brand with specific marketing goals in mind, we created a new marketing and branding plan that was in line with their target market. The first step



was making a change in the way the practice communicated with clients. Technology is playing a major role in how patients expect to communicate with almost every business or service they use. An up-todate, modern website is imperative. Consistent brand management is as important for maintaining a respected image in a business, as it is for communicating the offerings of a practice or hospital to its patients. An eCommerce solution can put all the pieces in place for the medical client to improve their brand consistency, and save time and money in the ordering process. Company uniforms, branded promotional items including stress relievers, journal books, slide charts, pens, apparel and more were added to the eCommerce site. By coordinating everything from their forms and pamphlets to their websites and social media, medical professionals can create a sense of professionalism and instill confidence in their patients. eCommerce solutions also can serve as a platform for creating brand consistency on a broad scale. Medical systems with multiple buyers can manage purchasing in one place. Products can range from promotional items for patients, staff uniforms and medical supplies for physicians. How patients experience the office visit with their physician can also be streamlined to give them access to more information. Wristband USB drives allow patients to keep their medical information close at hand and it gives a quick and easy way to for physicians and patients to share information. Matching barcodes help eliminate common medical errors that plague the system. Medical errors cost billions of dollars every year and puts patients at risk. Matching barcodes ensure medical information is recorded, documented and shared accurately and quickly. Using barcodes helps medical professionals be sure they are giving the correct medication in the correct dosage to the right patient at the right time with a simple scan. Putting all the refreshed components together, helped the client reposition their brand in the industry and improve patient relations. Communication and consistency proved imperative in improving patients overall impression of the practice. Modern updates to an old marketing strategy helps every generation feel connected and invested in their medical provider.



STATE-OF-THE-ART NEURO-ONCOLOGY: 2ND ANNUAL MEETING Friday, April 11, 2014 Sheraton Sand Key Beach Resort, Clearwater, Florida MOFFITT.org/neurooncology2014

This one-day conference will cover various topics that include primary gliomas, metastatic brain tumors and spinal cord tumors in a format using plenary lectures, case presentations and discussion.

1ST ANNUAL MOFFITT PATHOLOGY SYMPOSIUM: PRACTICING PATHOLOGY IN A CHANGING WORLD Saturday, April 12, 2014 Sheraton Sand Key Beach Resort, Clearwater, Florida MOFFITT.org/Pathology2014

A focused symposium on advances in contemporary pathology practice and technology contributing to advances in personalized medicine.

BEYOND THE PROMISE: ADDRESSING EVIDENCE AND VALUE IN PERSONALIZED MEDICINE May 16-17, 2014 Grand Hyatt Tampa Bay, Tampa, Florida MOFFITT.org/PersonalizedMedicine

Join us as we bring together experts in the field of personalized medicine for a one and a half day conference program exploring the following topics: Genomics, Pharmacogenomics, Biomarkers & Biobanking, Decision Making, Advocacy and Ethics, Information Sharing & Platform Sequencing and Personalized Immunotherapy. Conference will feature: presentations, panel discussion, Q & A sessions, lunch and dinner presentations, industry exhibits and networking opportunities.


Frank Nathe is the owner and operator of Proforma NextGen Printing Plus, the Orlando area Proforma office. With over 30 years of experience and more than $430 million in sales, Proforma remains focused on providing solutions to businesses worldwide for their marketing and branding communication needs. Visit Nathe at www.proforma.com/nextgen or he can be reached at frank.nathe@proforma.com. H. LEE MOFFITT CANCER CENTER & RESEARCH INSTITUTE, AN NCI COMPREHENSIVE CANCER CENTER — Tampa, FL

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HIPAA Compliant?, continued from page 8 • Gain improved flexibility, office procedures and workflow changes are quick and simple • Remotely monitor and service your software • Have predictable monthly budgeting, typically on a per user basis • Have reports such as event monitoring, security detection, usage and more • Save energy with an environmentally friendly system utilizing 30 percent less energy These 14 benefits will ensure you are HIPAA compliant for significantly less than yesterday’s solution. Compare these points with a server in your office or your current solution. Consult with IT experts and determine if they provide you with hosting solutions based on traditional on-site infrastructure based in traditional servers or a cloud environment. In addition, you want to ensure they have the knowledge and expertise to evaluate and understand the workflow within your practice providing you with all the necessary information to make the most educated choice in moving your practice in this new direction. Medical offices that converted to a cloud environment have seen their production increase by as much as 135-145 percent, all the while achieving compliance to all the new regulations. Glenn Hanks is CIO of Medical in the Cloud, focused on helping healthcare businesses make wise investments in technology solutions and resources, and helping manage those resources. He has been developing and implementing medical software hosting solutions for nearly 10 years. His previous experiences include network/software architecture for various Fortune 100 companies stretching over a 25 year career. To contact him visit www. medicalinthecloud.com.

GrandRounds Florida Pain is Enrolling Patients in a Research Clinical Trial Chronic pain is a growing health issue in the U.S. today. Defined as pain lasting longer than six months after an injury has healed, it is estimated that more than 100 million Americans suffer from chronic pain annually. Chronic pain can impact a sufferer’s ability to lead a productive working, social and family life. Many patients undergo years of testing and doctors’ visits without a long-term solution. Neuropathic pain is induced by an injury or disease of the nervous system. A common cause of neuropathic pain is postsurgical nerve damage, which occurs in up to 35 percent of patients who undergo hernia surgery and 50 to 85 percent of patients who undergo amputations. Other causes include nerve damage caused by trauma or diseases such as Complex Regional Pain Syndrome (CRPS). Neuropathic pain is difficult to treat. Strong medications like opioids can provide relief, but may not always be an effective long-term treatment option. For many years, neurostimulation has been used to treat neuropathic pain. One of the most popular forms being stimulation of the spinal cord where leads are implanted in the epidural space, an area around the spinal cord. A neurostimulator sends pulses to the leads. It is implanted in the abdominal wall or buttock, and is controlled via an external remote control. Dr. Stan Golovac of Florida Pain Merritt Island is participating in a national study along with nearly two dozen sites across the country to evaluate a potential new therapy for chronic lower limb pain. The investigational Axium™ Neurostimulator System is the only spinal cord stimulation system

that targets a branch of spinal cord called the dorsal root ganglion (DRG).The Dorsal Root Ganglion (DRG) plays a critical role in the development and maintenance of chronic pain, as it processes pain signals as they travel to the brain. By stimulating the DRG, the Axium System interrupts pain signals before they travel to the brain. Recently published European data from a non-randomized study found that 78 percent of patients experienced pain relief in the lower limbs. Florida Pain is now enrolling patients in the ACCURATE study, a prospective, randomized, multi-center, controlled trial to determine the safety and efficacy of the Axium™ Neurostimulator System for chronic neuropathic pain affecting their lower limbs (such as the leg, foot, or groin). To qualify for the ACCURATE study, patients must fit the following inclusion/exclusion criteria: • Male or Female between the ages of 22 and 75 • Have had chronic pain affecting lower limbs for at least six months • Have not seen lasting success with other treatments and • Have not previously used spinal cord stimulation for chronic pain. For more information, or to see if your patient may qualify for the ACCURATE study, please visit www.ACCURATEstudy. com or call 888-978-8397. CAUTION: The Axium Neurostimulator System is an investigational device and is limited by United States law to investigational use.

Orlando Pain and Spine Center Opens Amr Badawy, MD, celebrated the open-

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GrandRounds ing of the Orlando Pain & Spine Center this past November. It is conveniently located across from Dr. P. Phillips Hospital, at 7364 Stonerock Cr, in Orlando. Badawy is a Board Certified Pain Medicine Specialist. He completed his training in aesthesiology at Hahnemann University in Philadelphia and interventional pain management at Mount Sinai hospital in New York. Dr. Badawy’s philosophy includes a multidisciplinary approach to treat pain and suffering. The Orlando Pain & Spine Center offers advanced treatment options to restore quality of life, treating back pain, neuropathic pain, knee and hip pain, cancer pain, headaches, whiplash injury, post laminectomy pain, complex regional pain and myofacial pain. www.orlandopainandspine.com

MedMal Direct Announces New Reinsurance Treaty Jacksonville-based MedMal Direct Insurance Company (MedMal Direct) announces its new reinsurance treaty with a panel of international reinsurance companies. With combined assets of $125 Billion, MedMal Direct’s reinsurance partners include Lloyd’s of London, Bermuda, Germany, Switzerland and U.S. based reinsurers, all of which have a financial stability rating of A+ (Superior) or A (Excellent) from A.M. Best. MedMal Direct’s reinsurance program augments the company’s financial stability by providing multiple layers of protection for the company and its policyholders. This integral relationship allows MedMal Direct to continue providing the most competitive medical malpractice insurance premiums, superior customer service and aggressive litigation management with exceptional financial stability. MedMal Direct is the only medical malpractice insurance carrier to exclusively offer its policies direct to physicians.

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St. Cloud Regional Medical Center Opens Heart Catheterization Lab St. Cloud Regional Medical Center is proud to announce the opening of its new multipurpose cardiac catheterization lab. Now patients have access to the latest cardiovascular services they need without having to travel far from home. The new lab, an investment of $1.5 million, will allow physicians to perform cardiac catheterizations, as well as peripheral vascular cases and interventional radiology procedures. By early next year, the lab is slated to have an additional certification for even more advanced cardiac interventions. Dr. Atul Madan, Cardiologist and a Medical Director for St. Cloud Regional’s cath lab, performed the first diagnostic catheterization on Tuesday, January 7, 2014. The lab is equipped with high-tech imaging and hemodynamic monitoring equipment, allowing physicians to observe blood flow and pressure to better diagnose and treat cardiovascular events. “The opening of the multipurpose cath lab is one more way we are demonstrating our firm commitment to providing the very best healthcare close to home,” said Mari Jones, Interim CEO at St. Cloud Regional Medical Center.


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