WNY Physician Magazine V1 2022

Western New York

PHYSICIAN the regional voice of practice management and the business of medicine

VOLUME 1 / 2022

Enhance Care, Patient Experience and Financial Performance with Innovative Solutions and Approaches

SPECIALT Y PROFILE

Moving Past the Frontlines: Investing in a Brighter Future

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Patients Can Find Relief from Allergy Symptoms

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Contents WESTERN NEW YORK PHYSICIAN I VOLUME 1 I 2022

Medical Research

27 Honing in on Shared Network of Cancer

Genes

25 Early Troponin Monitoring Can Help Detect Immunotherapy-Related Myocarditis

28 Sensitivity to Chemotherapy May Guide Treatment of Patients with Stomach Cancer

COVER STORY

05

Enhance Care, Patient Experience and Financial Performance with Innovative Solutions and Approaches

Healthcare delivery and operations face numerous challenges to successfully navigate the complexity of today’s landscape calling for streamlined financial performance, enhanced patient care and improved patient engagement. To meet these challenges, innovative companies have designed useful tools to help health systems and practices meet the need.

21 Fungal Pathway Leads Roswell Park Researchers to New Treatment Target for Pancreatic Cancer

Clinical Features 18

Cancer Surgery

20 Optimize Prevention of Hepatitis

SPECIALT Y PROFILES 13

Robotics Leading the Way in Lung

and Liver Cancer: Awareness, Education and Noninvasive Detection at

Patients Can Find Relief from Allergy Symptoms

the Point of Care

12

‘Immune Distraction’ from Previous Colds Leads to Worse COVID Infections

Legal Insight

Risk Management

15 So, You’re Thinking of Moonlighting for a National Telehealth Company?

03 Recent Webinar Focused on Cybersecurity Challenges, Best Practices, and Innovation

23 Documentation Considerations for EHR Open Notes

In the News 11 Newsweek Names Roswell Park Among World’s Best Specialized

Financial Perspective 17

Hospitals for Cancer

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from the publisher

Western New York

Visit us Online www.WNYPhysician.com

PHYSICIAN the local voice of

practice management and the business of medicine publisher

Welcome to the latest issue of Western New York Physician – where you will find informative stories and articles about and for physicians in western NY.

Andrea Sperry creative director

Lisa Mauro writers

Randi Minetor

Welcome to this issue of Western NY Physician Magazine.

It’s a brave new world in the business of healthcare. As systems and providers seek new and innovative ways to improve the delivery of care while efficiently improving outcomes, deepen patient engagement and all while keeping a keen eye on improving financial performance. It’s no surprise that forward-thinking technology companies are working to develop novel tools to help answer this call.

In this issue, we look at some of these new technologies and hear from a handful of early adapters to understand how these technologies are making an impact.

Our next issue focuses on Aging and • Telemedicine Delivery • Gastroenterology • Issues in Men’s Health • Strategies in Retirement Planning New column in 2022 – Physician-to-Physician an opportunity for medical experts to share with their colleagues the important innovations in their area of practice. Suggest a topic or expert for an upcoming discussion. More info to come.

As always, we thank each of our supporting advertisers— your partnership and support ensure that all physicians continue to enjoy this regionally-based resource and benefit from the collaborative sharing of information.

Best in Health

medical advisory board

Joseph L. Carbone, DPM John Garneau, MD Thomas Hughes, MD Chuck Lannon Johann Piquion, MD, MPH, FACOG Catherine C. Tan, MD Michael Silber, MD James E. Szalados, MD, MBA, Esq. John R. Valvo, MD, FACS contributors

Al Kinel Bill Lavoie Brigid M. Maloney, Esq. Geoff Blyth URMC Roswell Park Cancer Institute Michalene Kinsler Nancy Reau, MD contact us

For information on being highlighted in a cover story or special feature, article submission, or advertising in Western New York Physician WNYPhysician@gmail.com Phone: 585.721.5238 reprints

Andrea

Reproduction in whole or part without written permission is prohibited.

To obtain pricing for an open PDF License of articles appearing in the magazine, please contact the Publisher. Although every precaution is taken to ensure the accuracy of published materials, Western New York Physician cannot be held responsible for opinions expressed or facts supplied by its authors. Western New York Physician is published bi-monthly by Insight Media Partners.

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Recent Webinar Focused on Cybersecurity Challenges, Best Practices, and Innovation

By Michalene Kinsler Securing sensitive patient data and privacy is an important part of any cybersecurity strategy. Current situations require that an organization’s entire technology landscape be secured to ensure continuous operations, patient and staff safety, and to allow unfettered access to the data that is critical for clinical, financial, and business operations.

between risk and function and then vet initiatives and vendors against Bill Lavoiendards.

Both organizations find that vendors are being responsive to the market expectations and are advancing their security solutions to meet the needs of their customers. In addition to having well-defined standards, both organizations agreed that

A recent webinar sponsored jointly by the HIMSS New York chapter, NY-Israel Chamber of Commerce, the Government of Israel Economic Mission and the Israel Export Institute, and Strategic Interests, brought together industry leaders and solution vendors to discuss the current challenges in security and privacy, share best practices and learn from innovative vendors in the space. Over 100 attendees participated in this timely event.

Following opening remarks from Al Kinel, President of Strategic Interests, and Anat Katz of the Israel Economic Mission, the first session dove right into the biggest challenges facing organizations right now. The panel was moderated by Dan Didier, VP of GreyCastle Security, and featured panelists Kathy Hughes, CISO of Northwell, and Avivit Kotler, CISO of Clalit Health Services. These leaders shared thoughts on balancing security and access, finding the right level of security, and working with multiple vendors to bring the right tools together that reduce risk while remaining nimble to the constantly evolving cybersecurity needs of a large health system.

Both CISOs noted that due to the growing challenges and threats, there is a feeling that “nobody wants to be me” among those responsible for cybersecurity. For instance, the rapidly expanding number of devices found in a typical hospital or health system is truly astounding. Each device, whether it be an IV pump, router, or cell phone presents a potential entry point for bad actors. Their advice is to start with a clear definition of the minimum standards that represent a balance

a top priority should be segmentation - especially of those devices that connect to the EMR. Segmentation is considered a core control in a robust security plan.

Another core control is the ability to monitor your networks including all devices. The Security Operations Center (SOC) needs to have visibility into all potential points of entry while not interfering with patient care. Third-party vendors often provide necessary and innovative solutions but represent a frequent source of security breaches. The minimum standards must be well defined, but a thorough upfront vetting of each vendor to those standards is equally important. Due diligence would include an evaluation of each vendor’s business continuity plan, disaster response and recovery plan, and risk assessment.

The panelists talked about the shift in cybersecurity thought leadership to replace “if ” with “when”. They acknowledge that attacks have become much more common in just the past few years, making preparation even more imperative. Scheduled downtimes for planned events such as upgrades are very different from those due to an attack that is unplanned and with an unknown duration. Attacks often involve investigation and forensic review to assess the threat and ensure it is fully addressed before full function is restored.

Next, the Executive Director of the Israeli National Cyber Directorate, Tom Alexandrovich, shared “Best Practices from Israel – Addressing Cybersecurity Challenges Facing Healthcare”. He discussed the central importance of having standard

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procedures in place that protect all potential points of entry.

He confirmed the previous discussion that breaches in healthcare data are even more common than typically thought.

Mr. Alexandrovich shared that 82% of healthcare organizations have experienced an IoT-focused cyberattack in the past year (Irdeto industry survey 2019). In most cases, attackers are successful in encrypting patient data. He highly recommends using automation to enforce processes and procedures to achieve better controls and fewer errors. This includes vulnerability scanning, analytics, and asset management for the numerous devices found in and around patient care areas.

The first vendor, Cynerio, directly addresses the vulnerabilities from the increasing number and complexity of medical devices. Leon Lerman, the CEO and co-founder, described how cyber-attacks impact the ability of a healthcare organization to deliver consistent quality care to its patients and to maintain stable financial and operational activities when under attack. In just one example, an attack in Maine exposed the health records of 50% of that state’s population.

The threat from IoT and IoMT devices is equal (and may soon surpass) the threat from phishing. Cynerio is solely focused on healthcare and effectively finds and prevents attacks while providing actionable insights to rapidly address and mitigate risks. Cynerio has received awards and recognition from Gartner, Forester, and KLAS and has offices in Israel and New York.

Ohad Plotnik, the US General Manager and co-founder of AirEye discussed another type of vulnerability: network airspace. Most healthcare organizations have low visibility into the security of their wireless networks. AirEye constantly monitors all of the wireless channels to find points of vulnerability in real-time. It can then identify violations and prevent attacks. After, it provides a forensic analysis of the attack or potential attack and the devices that were involved. The AirEye solution can be very rapidly deployed and immediately allows for constant monitoring of network airspace. For example, at Hadassah in Israel, it was implemented in just one hour

across their two medical campuses. AirEye has found that it detects and prevents, on average, over 10 attacks daily for each of its customers.

Remarks from the Israeli Economic Mission and Strategic Interests concluded the session. Attendees were invited to join a breakout room with either Cynerio or AirEye to learn more about these solutions and ask questions. Healthcare organizations must understand the new cybersecurity landscape and the attendees to this webinar benefited from the direct industry insights and learned strategies and tools to advance their ability to successfully address cybersecurity in their organizations or with their customers.

Cybersecurity threats can be the thing that keeps leaders of healthcare organizations up at night. Modern hospitals and health systems have 1000s of devices, both on and off-premises, connecting to their networks and often also to the EMR and other core software platforms. These devices provide essential functionality for clinical care and operations but also present enormous challenges for the cybersecurity team. In addition, there is often a complex web of vendors that need to be managed to ensure security and privacy. Threats and risks to an organization’s cybersecurity are coming from multiple directions and those tasked with leading policies and procedures for cybersecurity are under tremendous pressure to identify, minimize, address and mitigate these problems.

What is the Value of Advertising in WNY Physician Magazine?

- Reach Every Physician in Buffalo and Rochester - Maintain and Build Referrals - Highlight Clinical Leadership - Describe New Technology and Services - Introduce New Providers To discuss a customized marketing program or Column Sponsorship contact: Andrea at 585-721-5238 or wnyphysician@gmail.com

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cover story

Enhance Care, Patient Experience and Financial Performance with Innovative Solutions and Approaches Al Kinel and Bill Lavoie

The Current Situation in Healthcare Healthcare providers are facing a complex set of significant challenges in 2022. Prior to the pandemic, serious financial pressures existed from reduced reimbursement, increased expenses, a muddied shift from fee for service (FFS) to valuebased payment (VBP), and heightened competition from disruptors transforming healthcare such as Amazon and CVS. Patients want a better experience and more value from their providers and have begun switching if their expectations are not met. COVID has exacerbated these threats and introduced many new ones such as limited staff, dramatic changes to care delivery, and reduced volumes. As a result, margin and profitability have eroded, creating existential threats for many:

•

• •

Private practices are so overwhelmed that partners are selling their entity to health systems for a small payment and a job; far less than the large payout they once envisioned to reward them for building a thriving practice that delivered quality care with a strong reputation. Some are just closing their doors and physicians are retiring.

Nursing homes are teetering on the brink of closure, some searching for a lifeline to be acquired by a health system or a larger entity.

Community hospitals are questioning the independence that has defined their mission to serve the local population for over a hundred years.

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To increase the FFS revenues, providers must ensure loyalty of their current patient base and find ways to grow the number of patients and residents they serve. Providers that offer positive outcomes and experience can help grow through referrals, direct outreach, social media presence, and other approaches.

The transition to VBP involves changes to reimbursement - contingent upon the quality of the care provided, resulting patient outcomes, and total cost. Examples of these programs from the federal government include the Medicare Shared Savings Program, the Quality Payment Program, and the Patient Centered Medical Home. Commercial payers increase payments to providers associated with quality scores such as HEDIS and risk-sharing programs and Accountable Care Organizations (ACOs).

Historically providers addressed specific challenges as they emerged, applying resources and creative solutions as required.

Now entities must simultaneously attempt to enhance care and improve the patient experience while increasing revenues, lowering costs, and effectively embracing VBP models. This is especially true for primary care and specialty practices, operators of nursing homes and others serving the aging population, and of course health systems that include all types of providers. Novel solutions are available that can simultaneously be deployed to help collectively pursue these objectives.

We believe that effective approaches should center on the most important objective, efforts to improve care. While there are many ways to improve care, the most effective include: • Changes that positively impact diagnoses, associated procedures, and protocols to address care • Population health and disease management to identify gaps in care for specific patient cohorts • Engaging patients to receive care and adhere with instructions between appointments, and • Interventions to effectively address gaps uncovered For purposes of this article, we will focus on ways in which providers can improve outcomes by changing patient behavior to receive care and follow instructions, while leveraging positive experiences to grow revenues and improve financial strength.

Improving outcomes is contingent upon patient behavior, yet many patients do not take responsibility for all that they can do to help themselves. Proactive providers have deployed solutions to encourage and help patients and their caregivers play a more active role in their care.

Solutions to Enhance Patient Engagement A myriad of solutions exist that can help providers heighten patient engagement. The following is a list of the functionality providers and payers are utilizing: • Virtual Care including, telehealth, remote patient monitoring, and more • Patient portal and patient health records • Education on conditions and alternative choices for care • Access to care through provider search and ability to request appointments • Decision support / transparency applications to select providers • Appointment reminders, scheduling, bill pay, etc.

• Care coordination and management – helping patients across the continuum of care • Address barriers to care including ability to pay and other social determinants • Adherence to care plans including appointments, labs, medications, rehab, and more Much attention has been given to solutions that address many of the capabilities described above. However, less attention has been paid to-date to solutions that help patients understand the importance of things within their control – screening, appointments, and their behavior between appointments. One solution that has demonstrated value for health systems comes from a company called Lirio.

Lirio is a behavior change AI platform that unites behavioral science with artificial intelligence to apply Precision NudgingTM across populations.

Lirio has launched a Precision Nudging™ solution that promotes health through AI-powered behavior change. The solution was co-developed with Rochester Regional Health (RRH) to encourage more women to follow recommended well visit schedules. The Lirio platform scales personalized consumer journeys by determining the next best action for each person and delivering tailored behavioral interventions to overcome their specific barriers. With omni-channel communication and integration options and behavioral reinforcement learning to engage each person with the right message at the right time in the right manner, Lirio introduces an intelligence layer for consumer insights and deeply relational patient engagement.

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“Rochester Regional

Their AI then personalizes our digital outreach in a

Health strives to en-

way that gets people to act. Their messaging resonates

hance the lives and

with our patients in such a unique and impactful

preserve the health of

way. For example, they’ve helped us move women

the community with

who are overdue for mammograms to schedule and

access to high-quality

attend screenings, and we’re identifying cancers at

affordable care. We work

earlier stages than we otherwise might. Ultimately,

with many community members, organizations, and

getting people to engage with our health system and

businesses including Lirio to fulfill this mission and

with their care providers helps improve and save

vision. Lirio’s IA technology is one example of this

lives. Lirio increases our chances of doing so.”

partnership. The platform encourages women to have an active role in their health by scheduling and maintaining routine care. Lirio's Well Visit solution allows us to reach a larger population with personalized messaging and drive better health outcomes for women in our community."

Meghan Aldrich, DNP, Vice President of Women's Health.

Lirio is finding success elsewhere in the nation, including Bon Secours, a large health system in the Mid-Atlantic.

“Lirio is helping us in ways no one else can. They have a deep understanding of why people might not adopt certain health behaviors, and they understand how to overcome those barriers with behavioral science.

Erin Hurlburt, MD, Chief Medical Officer, Population and Community Health, Bon Secours Mercy Health

Measuring Patient Experience and Patient Satisfaction It is important for every industry to capture customer satisfaction and utilize that information to improve the customer experience and leverage that information to improve and grow.

Healthcare has addressed this need with outdated, ineffective approaches that are tied to quality reporting.

Compliance with VBP programs requires hospital systems, practices, and providers to measure, collect data and demonstrate follow up to address and improve patient experience and patient satisfaction.

Traditional methods such as Consumer Assessment of Healthcare Providers and Systems (CAHPS) have been utilized for years, commonly sent to recipients once or twice a year following up on in-patient or outpatient care. The drawback of such methods is that the results are broad based and reported months or up to a year following the rendering of care, limiting the ability to take corrective action.

Innovative solutions have emerged that enable providers to rapidly access and deepen the understanding of the patient experience and utilize the information for mutual benefits.

One innovative company with a presence in our region is Well iQ, a startup from San Diego, CA that offers these capabilities:

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•

Immediacy – through mobile phone technology, patients can be enrolled and then sent surveys immediately following (or even during) their encounter or televisit.

• Staff feedback - Previous survey methods focused on the facility or a single provider while newer methods provide feedback on specific staff yielding ability to immediately enhance operations and reward desirable behavior.

Public reviews and growth – Providers can leverage positive experiences to grow through websites, public review sites (such as Google, Yelp), and other aspects of social media tools.

Well iQ’s Scott Strother says that the hospital systems and providers that are proactive in this area “now WANT patients to have a chance to provide feedback, and as an organization, want to show that they are willing to ‘do something about it’.” He added that patients have a role in improving healthcare: “Well iQ helps empower the patient to impact their own experience- creating a bond between patient outcomes and staff behavior, which allows practices to move from reactive, to proactive, to preemptive models for care.”

Well iQ has been completely integrated with the MEDENT EMR which reduces the time to deploy and utilize the simple and powerful capabilities. Integration with athenahealth and other EMRs is underways.

Well iQ has quickly become one of MEDENT’s leading partners, and it is helping practices from Buffalo to Florida to learn and grow from the feedback.

“Since implementing WelliQ as part of the patient visit process, Google Reviews for Urban Family Practice and GBUAHN have significantly improved.

The amount of 5-star ratings G-Health received in one month of utilizing WelliQ exceeded our expectations. Patients love that they can leave feedback for the specific people they saw through fun, eye appealing badges and value that we are addressing the whole patient experience from the start of the visit to completion. G-Health was missing one key resource to make impactful changes and this platform was it.”

Program Director of G-Health Enterprises, a primary care practice and health home serving the urban population of Buffalo.

We’re different, we’re better

Simplicity and usefulness drive better results

Knowledgeable

Warm Greeting

Superstar

Great Attitude

Professional

Explained Clearly

And more!

Great with Kids

Exceeded Expectations

Reviewed My Medication

Best of the Best

Clean Office

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Mark Wolbert, former VP Business Development and Marketing for Buffalo-based Excelsior Orthopaedics, a large multi-site practice serving the suburban population, had similar positive remarks:

“We utilize Well iQ to survey our patients and make sure that their patient experience is on par with our standards…Well iQ has been a game changer on two

physical therapy. It also allows us to engage with and reward the staff for a job that we knew they were doing but now we can quantify it. Our dashboard allows us to view results by facility and by doc and they are competitive – they want to have more reviews and five-star reviews! It’s good to see and a reminder that we are always trying to get better.”

You can learn more about Well iQ and their integration with MEDENT at https://www.welliq.org.

fronts – to survey each patient that ‘walks through the door” and capture that data electronically but also to allow them to leave a review online. It allows us to have real time visibility into a patient’s experience whether it’s a first-time patient or a recurring

What Does That Mean?

Encouraging patients to come into the office to address their clinical needs can help enhance quality. Rapidly capturing and utilizing feedback from patients can help improve operations and can also grow the business – IF – a practice harnesses the information and synchronizes it with their marketing and social media strategies and tactics.

The organization gets instant, tangible feedback: • Patient Satisfaction Reports • Staff performance and interactions, tied to specific employees • Quality of facility Benefit for the patients By participating, they’re helping create a better patient experience for ALL patients & their families.

Benefit for staff They get recognized for the direct, personal impact they’re having on the patient experience.

Benefit for the practice Create a culture that positions you as a trusted source for patients & families who have a choice of where they receive care.

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Practices, health systems, and long-term care providers Butler/Till a results-driven media and communications can simultaneously improve quality and increase revenues agency with a focus on healthcare, has also seen the benefits by planning and implementing appropriate solutions. of enabling patient action through turn-key digital experiEnhancing the ability to identify and address gaps in care ences. Healthcare has been in Butler/Till’s DNA for its entire for populations served, heightening patient engagement, and 20+ year existence. The agency supports a portfolio of more more effectively capturing feedback, can enable a provider to than 19 client organizations and more than 40+ brands across improve operations and can increase awareness and referrals the pharmaceutical, biotechnology, medical device, health with a more impactful social media presence. and hospital systems and health insurance industries. For five consecutive years, Butler/Till has been recognized as Medical Marketing & Media’s “Top 100 Healthcare Agencies.” Capabilities include media, analytics, and creative content. For more information, visit https://butlertill.com.

Butler/Till’s Senior Account Director, Nicole Hamlin, noted that COVID-19 dramatically increased the reliance on Reaching Every Physician in Western NY digital-first communication sources Western NY Physician Magazine, the only physician-to-physician publication in the region, and that having systems in place to offers advertising partners innovative opportunities for strategic content marketing and brand positioning. Let’s discuss a strategy to elevate visibility, promote new products or services capture feedback and commentary and highlight your unique expertise. from patients, such as Well iQ, will Volume 2 Men’s Health continue to be essential to drive awareTelemedicine Delivery ness and consideration. Consumers exOrthopaedics and Rehab A look at the latest in care and diagnostic Imaging Advances pect authentic experiences before sharand surgical tools to treat specific health Vascular Medicine issues in the male patient. The growth of ing their data. By gathering feedback Urology in-office procedures and improving the and acting on that feedback, medical patient experience.

Close Date: April 20 practices, nursing homes, hospitals and other providers can appear to be more Volume 3 Women’s Health genuine and can create messages that Oncogynecology Mental Health: Covid Burnout are meaningful for their audiences.

Mental health takes center stage, beating

Editorial Calendar 2022

2

“In the digital realm, driving rele-

3

ing authentic content from people

4

Volume 4 Pancreatic Cancer

Cancer Care in WNY

Year-end Tax Planning Trusts and Estates Imaging Advances

Managing patient backlog, the new patient experience, new therapies and diagnostics in treating cancer, treating the treatment.

just like them goes a long way

Close Date: Aug 31

towards creating connections

Volume 5 Eye Disease Legal Issues Palliative Care / End-of-Life Joint Replacements

with patients, inspiring them to take positive steps towards better

burnout, advances in Alzheimers and utilizing telemedicine to expand access.

Close date: June 22

vancy and simplicity is the key to positive patient experiences. See-

Alzheimers Medical Liability Update Gastroenterology

5

Close Date: Oct 19

Geriatric Health Coordinating the complex care of the geriatric patient at home and onsite, managing chronic disease and pharmacology and elevating patientcentered care.

health. www.WNYPhysician.com 10 I VOLUME 1 I 2022 WNYPHYSICIAN.COM

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in the news

Newsweek Names Roswell Park Among World’s Best Specialized Hospitals for Cancer Peer survey places Buffalo-based cancer center 39th among oncology facilities globally

Roswell Park Comprehensive Cancer

Center has been named to another prestigious ranking of top cancer centers: the World’s

Best Specialized Hospitals for Oncology

2022, compiled by Newsweek in collaboration with the respected research firm Statista,

based on a global peer survey of healthcare

professionals.

Roswell Park has been named a 2022

World's Best Specialized Hospitals for Oncology.

Roswell Park is the only Upstate New

York center listed within the top 50 centers

Presidential Chair in Leadership Candace S. Johnson,

included on the full list of 250 top cancer hospitals

changing science have been at the core of Roswell Park’s

in oncology, and the only Buffalo-area center to be

PhD. “Innovation and successful stewardship of life-

internationally.

culture throughout our history, and that legacy shines in

Newsweek and Statista invited experts all over the

the high-impact clinical and research advances that earn

world to participate in their online surveys across 10

our center recognition today.”

2021. Roswell Park was ranked 39 in a listing of

provide for patients and providers worldwide “the

more than 40,000 doctors, health care professionals and

performance across countries.”

did not suggest a list of hospitals, and Statista checked

institutions,” says Newsweek Global Editor in Chief

areas of specialty, collecting data from June to August

international cancer centers based on that survey of

hospital managers across the world. The questionnaire

Newsweek’s goal in compiling these rankings is to

best data-based comparison of hospital reputation and “Consistency in excellence is the hallmark of these

all data to prevent self-nomination.

Nancy Cooper. “What has set the world’s leading

out even across a global field of esteemed centers,”

highest-quality patient care and conduct critical medical

“We are proud to see our accomplishments stand

says Roswell Park President, CEO and M&T Bank

hospitals apart is their continued ability to deliver the research even as they focused on battling COVID.”

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clinical

‘Immune Distraction’ from Previous Colds Leads to Worse COVID Infections URMC

At the beginning of the COVID pandemic, we were hopeful that pre-existing immunity to the common cold could protect you from COVID, but new evidence suggests that sometimes the opposite can happen. A new University of Rochester Medical Center study shows that prior infection and immunity to one of the common cold coronaviruses may have put people at risk of more severe COVID illness and death.

The study, published in the Journal of Infectious Diseases, examined immunity to various coronaviruses, including the COVID-causing SARS-CoV-2 virus, in blood samples taken from 155 COVID patients in the early months of the pandemic. Of those patients, 112 were hospitalized and provided sequential samples over the course of their hospitalization.

These hospitalized patients experienced a large, rapid increase in antibodies that targeted SARS-CoV-2 and several other coronaviruses. While big boosts in antibodies – protective proteins generated by the immune system – is usually a good thing, in this case, it wasn’t.

The study showed that these antibodies were targeting parts of the spike protein (which sits on the surface of coronaviruses and helps them infect cells) that were similar to common cold coronaviruses the immune system remembered from previous infections. Unfortunately, targeting those areas meant the antibodies could not neutralize the new SARSCoV-2 virus. When levels of these antibodies rose faster than levels of SARS-CoV-2 neutralizing antibodies, patients had worse disease and a higher chance of death.

“In people who were sicker – those who were in the ICU or died in the hospital, the immune system was responding robustly in a way that was less protective,” said lead study author Martin Zand, MD, PhD, who is the senior associate dean of Clinical Research at URMC. “It took those patients longer for the immune system to make protective antibodies… unfortunately, too late for some.”

This study adds to a growing pool of evidence that a phenomenon called immune imprinting is at play in COVID immune responses. Zand, who is also a co-director of the University of Rochester Clinical and Translational Science Institute (UR CTSI), likens this phenomenon to ‘immune distraction’: immunity to one threat (seasonal coronaviruses) hijacks the immune response to a new, but similar threat (SARS-CoV-2). Immune imprinting has been linked to poor immune responses to other viruses, like flu, and can have implications for vaccine strategies.

By some predictions, COVID is likely to be with us for a long time – with new, milder strains emerging and circulating on an annual or seasonal basis. If those predictions hold true, the study suggests that we will need to regularly develop new vaccines targeting the new strains of SARS-CoV-2. While none have come to market yet, pharmaceutical companies like Pfizer and Moderna have been developing and testing new versions of their COVID vaccines as new variants of concern have emerged.

“We should expect that development of new vaccines is a good thing," said Zand. "It doesn’t mean the original science was wrong. It means nature has changed. If we want an immune system that pays attention to the right stuff, we need to teach it new tricks with different vaccines.”

The study also analyzed 188 blood samples collected in the pre-COVID era (prior to December of 2019) as controls. Some of the blood samples analyzed for the study were provided by the UR CTSI’s COVID-19 Biobank, a repository of blood samples from hundreds of patients with and without COVID infections that was developed by the UR CTSI and URMC Shared Resource Labs.

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SPECIALT Y PROFILE

Patients Can Find Relief from Allergy Symptoms Randi Minetor

With hay fever season approaching on the near horizon, patients will begin to mention their nasal and chest congestion, runny nose, red and watery eyes, and sneezing in an otherwise routine office visit. Some of these patients will follow their litany of symptoms with a dismissive coda: “It’s just my allergies.”

Patients who take over-the-counter medications like antihistamines or multi-symptom allergy pills throughout allergic rhinitis season, however, may be better served by understanding what exactly it is they are allergic to, said Jeanne Lomas, MD, director of allergy and immunology services for WellNow Allergy Urgent Care. “People downplay their symptoms with their primary care physician,” she said. “They think it’s not severe enough to see an allergist. But that’s because they are not educated about all the things that are available to them.”

“People downplay their symptoms with their primary care physician” Jeanne Lomas, DO

The Asthma and Allergy Foundation of America (AAFA) reports that as many as 19.2 million adults and 5.2 million children in the United States suffer from allergic rhinitis alone, while a staggering 50 million people have an allergy to something in their environment—a food, medication, insect, latex, or airborne substance.

Primary care physicians should consider referring their patients to an allergist when one of two things happens, said Dr. Lomas. “One, their symptoms are bothersome—affecting their quality of life, work, or school. If the symptoms are bothersome enough and you’re at all curious about if there

could be some trigger to them., it’s time to see a specialist.” Pollen, pets, or simply the dust in a person’s home can produce symptoms, but testing is required to determine which environmental factor triggers the reaction.

Secondly, if the symptoms only occur seasonally, that’s a good indication that an allergy is at work. “A lot of allergies are cyclical or seasonal,” Dr. Lomas said, “so there are people who are totally asymptomatic in the winter, but when the pollen comes out, they will start to have symptoms.” At some allergy practices, appointments for testing must be scheduled

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months out, so the patient’s symptoms clear up before they can see a specialist. “So they cancel the appointment,” she said, “or even if they do get tested and find an allergy, they won’t do anything about it until the symptoms come back the following year.” This delays treatment that can help patients become desensitized to their triggers, so the next allergy season is not as uncomfortable.

At WellNow Allergy Urgent Care, patients don’t require a referral, nor do they need to wait months for an appointment, said Dr. Lomas. “A lot of patients are self-referred,” she said.

“Here we can see you while you still have symptoms, in real time, during your season while you’re worse. We can find out if therapies don’t work, so we can take the next step.”

Patients can schedule their appointment online at their convenience, with evening and weekend hours that allow them to see a specialist outside of the normal work day. With a full understanding of the source of their allergies, they can proceed with treatment options that may eliminate the need for antihistamines and other medications over time.

Allergy shots, given at regular intervals, can lead the patient to build up a tolerance to the substance to which they are allergic—pollen, pet dander, or dust. The shots contain tiny amounts of the pollen or dander, teaching the patient’s immune system to become tolerant of the substance. Each dose contains a little bit more of the allergen, so the body builds up

“Here we can see you while you still have symptoms, in real time, during your season while you’re worse. We can find out if therapies don’t work, so we can take the next step” resistance to it over time. For it to be effective, however, the shots must be administered at regular intervals—often weekly.

Making and keeping weekly appointments can be challenging for patients who work full-time or have child care or other responsibilities during the day.

While this kind of therapy has been in use for more than a century, many patients believe it doesn’t work, often because of failed attempts to use it decades ago. Early therapies were more generalized and less effective, Dr. Lomas said. “There was a time when the injections were one-size-fits-all, with people getting injections for things they weren’t allergic to.

Now it’s all personalized for the patient. The science has come a long way to where we’ve fine-tuned the dosing.”

Equally important, WellNow Urgent Care offers appointments at its four locations throughout western New York—in Clarence, Orchard Park, Wheatfield and Batavia—at times convenient to many patients, including evenings and weekends. This allows patients to maintain their regular injection schedule and build up a true tolerance to their allergy trigger.

“People can come after work, after school, and get up to a full therapeutic dose in a few months,” said Dr. Lomas.

In addition, not every allergy manifests as upper respiratory afflictions. Allergies can occur in any part of the body— asthma in the lungs, for example, or eczema in the skin. Some allergies cause anaphylaxis, a life-threatening reaction that comes on suddenly and rapidly. Others manifest as hives or contact dermatitis. WellNow Allergy can test for allergies to food and medications, as well as lower respiratory issues including the causes of asthma.

Plans for expansion of the allergy urgent care practice in 2022 include facilities in Rochester, Syracuse, and Albany, Dr. Lomas said. “We are looking forward to bringing our services to people throughout upstate New York, and bridging the gap to treatment with more flexible hours. We will offer allergy diagnosis and treatment to more people who would otherwise not be able to commit to the therapy.”

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legal insight

So, You’re Thinking of Moonlighting for a National Telehealth Company?

Physicians are well aware of the options available to them to offer virtual care services to their patients via a telehealth platform. However, many are not yet aware of the opportunities available for providing telemedicine services to patients of other providers. By adding this service, a physician may be able to supplement their income while enjoying a more flexible schedule, working from home, increasing their patient volume, etc.

With the explosion of national digital telehealth companies such as Teladoc, Doctor-on-Demand, and One Medical, the demand for part-time physicians who are willing and able to take telemedicine calls has likewise increased. National entities that offer patient care services in every state must contract with physicians who are licensed in each of those states to create a network of physicians that would be able to handle the volume of telehealth calls they receive. There are many opportunities for physicians who may be interested in doing this type of work full-time, or in addition to the job they already hold. Our health law attorneys at Lippes Mathias LLP regularly advise digital telehealth companies, as well as physicians in need of guidance as they consider whether one of these positions is suitable for them. Below are some issues which a physician should carefully consider before agreeing to provide telemedicine services on behalf of a national telehealth company.

1.Contractual Restrictions: Before you commit to moonlight with a national telehealth provider, be sure to carefully review your employment agreement with your current employer to make sure the telemedicine activities you are contemplating do not conflict with any restrictions on competition or outside activities that may be included in your employment agreement.

2.Corporate Practice of Medicine (CPOM): Many national digital telehealth companies are, at their core,

Brigid M. Maloney, Esq

general business corporations that are often built around a software platform they have developed in the delivery of telemedicine services. However, many of these standard business corporations are not permitted to practice medicine or offer medical services in approximately 30 states., including New York. As such, those companies typically partner with one or more “friendly P.C.s”, which is a medical practice that is owned by a physician who is licensed to practice in any state / geographic location the P.C. has patients. Before you a sign a contract to perform telemedicine services, make sure the entity you are contracting with is qualified to furnish medical services in New York State (and any other state where your patients may be located).

3. Fee Splitting: Related to CPOM, physicians in New York State and elsewhere are prohibited from sharing fees for professional services with a person or entity in return for patient referrals. Since your patient encounters will be directed to you by the national telehealth company, you must make sure your compensation is not structured in a way that allows the telehealth company to withhold a percentage of your billings or collections.

The safest way to structure compensation under these circumstances is a flat fee per encounter.

4. Record Keeping: Before you take your first call, make sure you understand where and how you are expected to document the patient encounter. Typically, the national telehealth company will have its own software application and EMR solution. Be sure your contract gives you the right to access those records at some point in the future if needed, (e.g., to respond to an insurance audit, professional conduct investigation, or malpractice claim).

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5. Professional Liability: If you are expected to furnish your own malpractice insurance, check with your carrier to ensure that telemedicine activities are covered.

Claims of malpractice liability involving telemedicine are relatively rare, although that is expected to change following the rise in telemedicine usage during COVID. 6. Informed Consent: Although you are not always required to obtain a patient’s informed consent prior to rendering a telemedicine service, it is important to know / understand your state’s laws, as well as the telehealth company’s policies on informed consent. In New York, telepsychiatry requires informed consent.

7. Licensure: Physicians are only permitted to treat patients located in states where the physician holds a valid medical license, with some exceptions. Physicians who wish to practice telemedicine across state lines should pursue licensure in the states where they are interested in practicing. The Interstate Medical Licensure Com-

pact (or Telemedicine Licensure Compact (“IMLC”)), streamlines the licensing process for physicians so they can obtain licensure on an expedited basis in order to practice medicine in multiple states. Currently, 25 states participate in the IMLC. 8. Legal Guidance: Many national telehealth companies are start-up companies that haven’t fully developed systems that legally comply with all aspects of the law in every state. For that reason, it is particularly important to consult with a healthcare attorney who understands the laws of your state before you sign on and begin seeing patients on behalf of a national telehealth company.

Brigid M. Maloney is a partner and team co-leader of Lippes Mathias LLP’s Health Law Practice and has over 20 years of experience in health care related matters. She can be reached at bmaloney@lippes.com or 716.853.5100.

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financial perspective

Moving Past the Frontlines: Investing in a Brighter Future Geoff Blyth SVP and Chief Investment Officer and Portfolio Manager

The world, as a whole, has experienced unprecedented times over the last two years. From healthcare to housing, supply shortages to inflation, it’s no surprise the general public has been on edge. While many workers were told to go home in response to the Coronavirus, those on the frontlines stood at the threshold of health and safety, with the responsibility to treat the sick while assuming monumental personal risk. As the pandemic now becomes more manageable, healthcare workers have the opportunity to think about life postCOVID again. That includes taking the time to consider a comfortable retirement and achieving it by using time-tested strategies that will set them up for a less stressful and far more secure future.

Beat the Bull A decade-long stock bull market continued its charge through 2021, juxtaposed against a low interest rate environment earning fixed assets measly returns. That’s why it’s so easy to see how newer investment strategies that support “get rich quick” ideology, and a belief in missing out on something huge, are increasing in popularity. Nevertheless, it’s important to remember that while it might seem like growing wealthy can be hurried along, the steady compounding of returns over years is historically more reliable and more lucrative. Much like the delayed rewards of medical school and a subsequent residency lead to a long career ahead, looking at the long term is helpful when planning for your retirement.

Skip the Scares When it comes to determining an investment strategy, it’s never been about timing the market – it’s been about time in the market. While it can be tempting to restructure portfolios based on what is read and seen in the daily news, keeping money diversified by utilizing long-term, disciplined investment strategies offers the best opportunity at funding future lifestyles. It’s also a less stressful approach than constantly changing ideas.

Between 1980 and 2020, the average annual return for the S&P 500 was +9%. When reviewing the market trends

over this time period, it was normal to see dramatic peak-totrough drops of almost -14% in each of those calendar years.

Remarkably though, the S&P 500 ended 31 out of those 41 calendar years with a positive annual return - a 75% success rate over the past four decades. So, while the media might use scare tactics to convince the public into thinking the market is collapsing, that has not been the case. In fact, up market periods can last years longer than market downswings, meaning if you leave your money in traditional investment plans without shifting strategies, you’ll recover from the expected market dips much sooner than if you reacted (bailed out) due to media-induced fear and delayed getting back into the market.

It can be difficult to stay the course when others around you are extremely vocal about their near-term successes; but you have to remember that every time your long-term strategy is met with emotional short-term interruptions, you’ll likely be decreasing your retirement nest egg.

Invest without the Stress Our team of investment advisors has always educated our clients using a researched-based and non-reactionary philosophy for protecting and growing their investments, a strategy that will make great sense to data-loving physicians. The best way to avoid the market noise and media hype during downturns is to let sound investment advice guide you. By combining market history and investor behavior in your perspective, you’ll be able to move through life with less investment stress surrounding your financial future.

When it comes your investment strategy, persist, ignore the noise and stay resolved. Don’t let the latest headlines tempt you into changing your game plan. Remember, by focusing on your long-term goals and not the market, you will achieve what you planned to when you first began investing for your future.

Geoff Blyth is the Senior Vice President, Chief Investment Officer and Portfolio Manager for Tompkins Financial Advisors. Learn more about Geoff on the Tompkins Financial Advisors website.

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clinical

Robotics Leading the Way in Lung Cancer Surgery Laura A. Fahrenthold

Imagine your patient comparing the pain of undergoing lung cancer surgery to less than that of getting a tooth pulled?

That’s how Deeta Hill of E. Aurora, NY, described her experience of undergoing robotic-assisted thoracoscopic surgery (RATS) with a relatively new system called the daVinci® Surgical System. Its pioneering maker, Intuitive, continues to create and refine robotic systems, giving surgeons the added benefits of technology to help extend their capabilities.

“I think going to the dentist would have been more painful,” she told Western New York Physician Magazine. “I was home the very next day and was able to go Christmas shopping three days later.”

The 80-year-old grandmother and mother of four had something to compare it to. Her first “traditional” operation for lung cancer was back in 2016, before the advanced surgery system became available.

“The pain and recovery was absolutely excruciating with the first operation,” she recalled. “It took months to get back on my feet. It was so difficult to even think about going through that again when the cancer came back.”

Enter her new physician, Dr. Mark Jajkowski, Director of Thoracic Surgery at Catholic Health in Buffalo, NY whose recent findings presented to all physicians at Catholic Medical Partners attested to robotic-assisted lobectomy—the removal of cancerous lobes of the lungs and nearby lymph nodes—for early stage lung cancer.

While traditional open thoracotomy surgery requires large incisions between the ribs before manually spreading them to access the chest cavity, robotic lung cancer surgery is becoming one of the most promising developments in lung cancer treatment.

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With state-of-the art robotic-assisted technology, surgeons are provided 3D high-definition views that are magnified 10 times to what the human eye sees of the surgical field by inserting tiny surgical equipment and a camera for viewing the affected area on a video screen from a surgical console.

“The magnification offers crystal clear views of the surgical area,” Dr. Jajkowski reports, explaining that the daVinci system enables surgeons to perform the complex procedure using controls broadcast on a viewing screen to move three robotic instruments and a camera inside the chest cavity via small incisions. The system translates every hand movement in realtime to bend and rotate the instruments using tiny, wristed instruments when performing lobectomy, segmentectomy and wedge resection to remove the lung cancer with increased vision, precision, dexterity, range of motion, and control.

“This poses significant advancement as a minimally invasive technique,” says Jajkowski. “With the enhanced visualization, I am able to remove many more lymph nodes, which can be analyzed to provide a more complete picture of the patient’s cancer.”

He cites that while traditional and standard video-assisted thoracoscopy (VAT) is still widely used, it can be more invasive and result in greater postoperative discomfort than robotic-assisted surgery.

“This has been my experience when comparing my patients before the addition of robotics. The advantage of videoassisted thoracoscopic surgery (VATS) over thoracotomy for anatomical lung resection has been extensively reported with the results of robotic video-assisted thoracoscopic surgery (RVATS) compared to VATS coming out as very promising.”

Performing robotic-assisted thoracoscopic surgery (RATS) using the daVinci® Surgical System since 2016, Dr. Jajkowski has been tracking a statistic important to physicians and their patients over the last year: More than 25% of his patients like Ms. Hill go home the day after surgery and 85% are discharged within two days—compared to an average hospital stay of four to five days for the same or similar surgeries reported in nationally published thoracic surgery literature.

Alongside shorter hospital stays, patients typically experience minimal scarring, less bleeding and pain, not to mention fewer complications and faster recoveries.

“The drawback to any open thoracic surgery is the long recovery times of eight to twelve weeks, in addition to long delays before patients can return to their everyday activities,” he says.

Quicker recoveries result in another major benefit: Patients are experiencing little or no need for pain-relieving narcotic medications. He reports that 75% of his lung cancer surgery patients are going home without narcotic pain medications

and one third never require narcotics while in the hospital.

“It’s such an important consideration given the ongoing opioid addiction and overdose crisis across the country,” he says, adding that 75% are going home without narcotic pain medications and one-third never require narcotics at all while in the hospital. “Reducing the chance for patients to become addicted to prescription pain medications will hold significant impact.”

Dr. Jajkowski also stresses the importance of annual lung cancer screening for high-risk patients. According to the National Cancer Institute, lung cancer represents 12.7% of all new cancer diagnoses in the United States but 22% of all cancer deaths. It ranks as the second most common cancer diagnosis in the United States, resulting in more annual deaths than breast, prostate and colon cancers combined.

Lung cancer screening is recommended for older adults who are longtime smokers and who don't have any signs or symptoms of lung cancer. An annual low-dose computerized tomography (LDCT) scan of the lungs can detect early-stage cancer, making it more likely to be cured with early-intervention and treatment.

“If we can catch lung cancer at an early stage, there is a much better chance that these patients can be treated and cured,” he says.

Dr. Jajkowski believes robotic-assisted lobectomy will become the gold standard of care. “If lung cancer surgery is part of a patient’s treatment plan, I would encourage them to discuss all surgical options with their care team and weigh the benefits of robotic surgery.”

ADVERTISERS St. Ann’s Community – inside front cover MLMIC Insurance Company -- back cover Plastic Surgery Group of Rochester - pg. 21 General Physicians, PC - pg 26 Roswell Park - pg 16 GBUACO - pg 24 Tompkins Financial Advisors - pg 27 WellNow - pg 22

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clinical

Optimize Prevention of Hepatitis and Liver Cancer: Awareness, Education and Noninvasive Detection at the Point of Care World Hepatitis Day (WHD), July 28, 2022, is an opportunity to remind physicians of their role in disease awareness, patient education and prevention. This is especially important for patients living with chronic hepatitis B virus (HBV) and hepatitis C virus (HCV), both often silent, major risk factors for cirrhosis and liver cancer.

Significantly, the total number of reported acute HCV cases tripled from 2009 to 2018. New cases were highest among people ages 20–39 where rates increased nearly 300%. Among adults ages 30 to 39, rates increased about 400%. This risk is in direct parallel to injection drug use.

Approximately 70% of new HCV infections occurred among people who inject drugs, which has been escalated by the opioid epidemic. In 2018, the largest proportion of chronic HCV cases occurred among people ages 20–39 and those ages 50–69, who had almost equal infection rates. Only about 61% of adults with HCV knew that they were infected.

Prevention is vital, especially in this environment of vaccine hesitancy. The U.S. Centers for Disease Control and Prevention (CDC) recommends that all children and adults at risk should get the HBV vaccine to reduce the risk of hepatitis and liver cancer.

The CDC, American Association for the Study of Liver Disease, (AASLD) and U.S. Preventive Services Task Force (USPTF) now recommend that all adults aged 18 to 79 years get screened for HCV, including those who are asymptomatic and have no liver disease. They also recommend periodic screening for those with ongoing risk.

In 2014 the first all oral HCV therapy was approved, revolutionizing HCV therapy. Current first line therapy is pangenotypic, safe and promises cure rates of nearly 98% in

Nancy Reau, MD Professor of Medicine Richard B. Capps Chair of Hepatology Chief, Section of Hepatology Associate Director, Solid Organ Transplantation Rush University Medical Center

8-12 weeks. This has really shifted the treatment paradigm to become more inclusive, not just for patients but also providers.

Treatment of chronic HCV infection can eliminate the virus in most people, which in turn lowers the risk of liver related complications, including cirrhosis, decompensation and hepatocellular carcinoma, as well as improving all-cause mortality. However, the benefit of cure is highest if given before a patient progresses to advanced disease.

Identify and Cure Chronic Illness Earlier A large proportion of chronically HCV-infected persons in the U.S. are now about 50 – 70 years old and have lived with HCV infection for about 25 – 45 years, which substantially increases their risk for advanced fibrosis. The diagnosis of HCV in this group and linkage to curative therapy can identify those with long-duration chronic disease before they develop complications. More than one-third of HCV-infected individuals progress to advanced fibrosis and cirrhosis, and among those with cirrhosis, about 3 – 5% per year develop decompensated cirrhosis and/or hepatocellular carcinoma (HCC).

HCV-related comorbidities are strong predictors of high hospitalization rates and costs. One study found potential benefit in early identification and treatment of HCV for reducing hospitalization costs driven by extrahepatic conditions.

The risk of liver complications is much higher in people with chronic viral hepatitis and other liver injuries, including alcohol use disorder, iron overload, or HBV and HCV co-infection. However nonalcoholic fatty liver disease (NAFLD)—the accumulation of excess fat in the liver of people who drink little or no alcohol—and its more severe form nonalcoholic steatohepatitis (NASH) is a common and modifiable risk factor.

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Nearly one-third of adult Americans and 1 in 10 children have NAFLD. With approximately 85 million Americans with NAFLD, and 20% with NASH. Obesity, Type 2 diabetes and NAFLD have all been shown to increase the risk of disease progression in those with viral hepatitis and reduce the impact of controlling the virus.

One study on how NAFLD impacts patients treated and cured for HCV found that NAFLD identified in patients prior to treatment persisted after curing their HCV infection.

Among those with NAFLD before treatment, 6.25% still had significant liver scarring after their HCV infection was cured. It is now recommended that individual with HCV and NAFLD be monitored for progressive liver disease after HCV cure even if they lacked significant scar tissue and the time of viral eradication.

Weight Management and Early Detection NAFLD can be reversible if caught in the early stages. Research suggests that weight management is the best approach to controlling or reversing NAFLD. Even a loss of 3-5% can improve liver health. Also, exercise and diet therapy can

reduce the fat accumulation in the liver and improve hyperlipidemia, hypertension and insulin resistance.

Staging or assessing for fibrosis is vital in all liver diseases because fibrosis is the strongest predictor for liver related complications. Vibration-controlled transient elastography (VCTE), the most commonly used imaging-based fibrosis assessment method in the United States, is a non-invasive, painless and quick examination. What’s more, VCTE tools are covered by Medicare, Medicaid and many insurance plans, and can be operated by a medical assistant for immediate interpretation by a healthcare professional.

One example of this technology is FibroScan, a medical non-imaging modality that quantifies the stiffness of liver tissue. A growing number of providers use these rapid results and test scores to gain additional information and data they can use in real time to refer patients to a specialist or recommend changes to their overall care plans, if needed.

When it comes to addressing viral hepatitis and liver disease, physicians should take a “whole person” approach to patient engagement and support behavioral changes that will lead to better outcomes and higher quality of life.

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risk management

Risk Management Tip: Documentation Considerations for EHR Open Notes

The Risk The 21st Century Cures Act was enacted, in part, to increase communication among healthcare providers and remove some of the barriers patients face when trying to obtain their health information. To accomplish this, the Act affords both providers and patients greater access to more complete patient histories and empowers patients to become more engaged in their healthcare decisions. This improved patient engagement allows providers the opportunity to improve documentation accuracy, enhance patient safety, increase patient compliance, develop stronger patient relationships, improve efficiency of care and enhance the overall patient experience.

Considering increased patient access to their health information, the following strategies can help your patients better understand their records, become active participants in their healthcare and create stronger physician-patient relationships.

Recommendations for Managing Open Notes in the EHR 1. Confirm with your EHR system vendor that all required information can be accessed by your patients and review how that information will appear on their screens.

2. Understand and maximize the format and function of your EHR. For example, ensure applications, such as portal access, spell check and reminder notifications, are functioning properly.

3. Consider the health literacy level of your patient. Use plain language in your documentation whenever possible:

1. Avoid the use of jargon.

2. Define medical terms when possible. Consider providing a list of terms and abbreviations frequently used in

your documentation.

4. Remember that how you document an encounter can have an effect on your patient. Consider the following in your docu mentation:

1. Be careful to not sound judgmental in your notes. Avoid terms that may be offensive or emotionally charged.

For example, document “Patient reports s/he did not the take medications” vs. “noncompliant” or “unreliable.”

2. Use objective measures like BMI vs. “obese” or “overweight.”

3. Be careful using abbreviations. For example, “[Patient] is ‘SOB’.”

4. Use a supportive tone when possible: “Lost five pounds and is motivated to continue” vs. “Still needs to lose another 15 pounds.”

5. Document as though you are writing instructions: “Weigh yourself every morning” vs. “Patient needs to monitor weight.”

6. Avoid using the copy and paste feature of your electronic record system. The information copied and pasted may be redundant, outdated or inaccurate and could create the wrong perception about your records.

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5. Engage your patients and solicit feedback from them:

1. Consider dictating or typing notes with the patient present; talk during the visit about what you are docu menting.

2. Encourage your patients to refer to the notes as this may help increase compliance with the treatment plan.

6. Ensure that your practice has the resources in place to support increased patient engagement. Have written policies and procedures to address:

1. how patients and their representative can access their health information;

2. the confidentiality of minors’ information; and

3. how to address patient comments or questions about the documentation of their encounter.

7. Provide educational information to patients on open notes:

1. Implement practice policies that address questions on patient access.

2. Increase communication and access through media such as:

1. email;

2. the patient portal;

3. your website;

4. social media; and

5. information sheets and/or flyers in the office.

Reprinted with permission from www.MLMIC.com. All Rights Reserved. No part may be reproduced or transmitted in any form or by any means, electronic, photocopying, or otherwise, without the written permission of MLMIC.

5

REASONS TO JOIN GBUACO

1 Reduce Costs & Increase Savings 2 Strategic Partnerships with Other Providers 3 Increase Retention & Acquisition of Patients 4 More Control Over Patient’s Care 5 Access to More Advanced Technologies Phone: (716) 247-5282 GBUACO Main Office: 564 Niagara Street, Building 2 Buffalo, NY 14201

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clinical

Sensitivity to Chemotherapy May Guide Treatment of Patients with Stomach Cancer Roswell Park study finds that preoperative chemosensitivity can predict the need for chemotherapy after surgery A study led by scientists at Roswell Park Comprehensive Cancer Center shows that chemotherapy after surgery for gastric adenocarcinoma is significantly associated with longer survival in patients with chemosensitive disease, but not in those with very sensitive or refractory disease. These findings, which were recently published in the journal JAMA Network Open, suggest that assessing how responsive a tumor appears to be to treatment with chemotherapy before surgery can be used to guide decisions regarding postoperative chemotherapy, thereby personalizing treatment of patients with this type of stomach cancer.

“Many patients with gastric cancer who are eligible for surgical resection, or removal of stomach tissue, receive chemotherapy both before and after surgery to maximize their chance of survival,” says first author Lei Deng, MD, a Hematology-Oncology Fellow at Roswell Park. “However, patients do not respond to chemotherapy equally. Some patients will have no cancer cells at the time of surgery or will learn that their tumors have shrunk, while others may be told that their tumors have stayed the same size or even grown larger.”

To better understand these different responses to chemotherapy and ultimately determine whether a patient’s response to chemotherapy before surgery can provide enough information to guide treatment decisions after surgery, the researchers examined data from 2,382 patients with clinical stage 2 or stage 3 gastric adenocarcinoma who were treated with preoperative chemotherapy and curative-intent resection — excluding radiation therapy. Data were pulled from the National Cancer Database, which covers more than 70% newly

diagnosed gastric adenocarcinomas in the United States, for the period of 2006 to 2017.

Preoperative chemosensitivity was measured as the change in cancer stage before and after preoperative chemotherapy and surgery. While most patients (62%) had refractory disease, meaning that the cancer has stopped responding to treatment), 38% showed good responses to chemotherapy, indicating high preoperative chemosensitivity, with 31% showing sensitive disease, and 7% showing highly sensitive disease.

Most patients (64%) did not receive postoperative chemotherapy. The likelihood of receiving postoperative chemotherapy was significantly lower among patients who were older or had a comorbidity, longer time from chemotherapy initiation to surgery, less sensitivity to preoperative chemotherapy and longer hospitalization after surgery.

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Overall, the researchers observed that preoperative chemosensitivity was significantly associated with a survival benefit from postoperative chemotherapy. Patients with sensitive disease who received postoperative chemotherapy lived longer than those who did not, with five-year survival rates of 73.8% and 65%, respectively. However, the researchers found no significant difference in survival among patients with very sensitive or refractory disease who were treated with postoperative chemotherapy compared to those who were not.

“In this national cohort of patients with clinical stage-two to stage-three gastric cancer, those with a residual but smaller tumors had better outcomes if they also received chemotherapy after surgery,” says Sarbajit Mukherjee, MD, MS, Assistant Professor of Oncology at Roswell Park. “In contrast, two groups of patients appeared not to benefit from postoperative chemotherapy: those with tumors that were so sensitive

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to chemotherapy that they could not be found at the time of surgery, and those with tumors so resistant to treatment that they stayed the same size or even became larger.”

The findings from this study suggest that preoperative chemosensitivity may provide useful information to help clinicians make decisions regarding postoperative treatment for patients with gastric cancer.

“If our results are validated in prospective studies, we would confidently provide postoperative chemotherapy for those who need it and avoid those who do not,” says Dr. Mukherjee, who notes that further research is planned at Roswell Park to explore novel blood biomarkers for determining sensitivity earlier on in the course of chemotherapy.

This work was supported by National Cancer Institute grant P30CA016056 involving the use of Roswell Park’s Biostatistics Shared Resource.

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of two ICI drugs, ipilimumab and nivolumab, increased the risk of immunotherapy-related myocarditis. Patients in this program were monitored every week for the first six weeks of ICI immunotherapy, and any patient showing an elevation in troponin levels or signs of cardiotoxicity, such as angina or arrhythmia, was referred to a cardio-oncology team for complete evaluation, including ECG, echocardiogram or cardiac MRI. Among the 1,001 patients who received ICI therapy during the four-year study period, 15 patients (1.5%) showed evidence of probable ICI-related myocarditis (11 cases were severe, and 4 cases were mild). The Roswell Park team identified troponin as the earliest and most reliable predictor of myocarditis among all the biomarkers studied, and high levels of this protein were significantly associated with serious outcomes during the early phase of ICI cancer treatment. The researchers also found that the troponin-monitoring program led to earlier detection of myocarditis, earlier initiation of steroid treatment and better outcomes among immunotherapy patients.

“It is critical to not only detect these rare cases of myocarditis early but also understand why this type of toxicity develops and how to prevent it,” says Igor Puzanov, MD, Senior Vice President of Clinical Investigation, Chief of Melanoma

ROSWELL PARK Early Troponin Monitoring Can Help Detect Immunotherapy-Related Myocarditis Roswell Park research suggests levels of this protein can predict a rare but fatal side effect of cancer treatment A multidisciplinary team led by Roswell Park Comprehensive Cancer Center has identified troponin, a protein that enters the bloodstream only when the heart is damaged, as an early and reliable predictor of myocarditis in cancer patients receiving immunotherapy with immune checkpoint inhibitor (ICI) drugs. Findings of this retrospective study, which have been published in the Journal for ImmunoTherapy of Cancer, suggest that weekly troponin monitoring during the first six weeks of treatment could help physicians detect this rare but potentially fatal side effect of cancer immunotherapy.

Immunotherapy has emerged as a promising cancer treatment, particularly for solid tumors like melanoma. A handful of FDA-approved drugs such as nivolumab and pembrolizumab are increasingly used in certain types of immunotherapy to “supercharge” the patient’s immune system to recognize and attack cancer cells. Although it occurs in fewer than 1% of cases, potentially fatal inflammation of the heart muscle called myocarditis can occur as a result of ICI immunotherapy.

Early detection of myocarditis, which carries a 40% to 50% risk of death, is critical, but there are currently no clear ways to accurately predict or identify this type of ICI-associated toxicity.

In an effort to more accurately detect myocarditis among immunotherapy patients, a multidisciplinary team Building Healthcare Practices, Together headed by experts in the fields of pharFor Doctors, Dentists and Veterinarians macology, cardiology and oncology at Roswell Park retrospectively reviewed the records of 1,001 cancer patients treated with one or more ICIs at Roswell Park over a four-year period from 2016 to 2020. The investigators paid Healthcare professionals are crucial to the strength special attention to the significance of of our communities. When planning your financial specific prognostic biomarkers, includstrategy, consider the difference Tompkins can provide ing troponin, B-type natriuretic pepas you work toward building your practice. tide and creatine kinase to determine their ability to predict myocarditis.

During this study period, Roswell Park clinicians also began routinely monitoring troponin levels in melanoma patients who were starting ICI 877-243-8030 | BankofCastile.com treatment, as previous Roswell Park research indicated that a combination

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and Director of the Center for Early Phase Clinical Trials at Roswell Park, first author of this collaborative study. “It’s important for comprehensive cancer centers like Roswell Park to develop standard operating procedures to guide all doctors on how to offer the best possible treatment for their patients.

Our findings offer a simple, proactive approach to more effectively diagnose and treat this life-threatening condition early, when it is most treatable.”

The results of this study support the use of outpatient troponin surveillance for the crucial step of early detection of ICI-associated myocarditis. Weekly monitoring of troponin levels led to earlier detection of myocarditis and thus earlier treatment with corticosteroids, which helped stop disease progression and improved the overall outcome. The findings also stress the importance of a multidisciplinary approach to cancer treatment, including prompt cardiac evaluation for patients displaying cardiac symptoms during cancer immunotherapy.

Fungal Pathway Leads Roswell Park Researchers to New Treatment Target for Pancreatic Cancer Team uncovers fungi-mediated release of interleukin-33 that fuels disease progression Scientists at Roswell Park Comprehensive Cancer Center have identified a potential new target for the treatment of pancreatic cancer. The study, published today in Cancer Cell, outlines the team’s discovery of a fungus-activated pathway that fuels the production of a molecule present in cancerous cells in the pancreas, opening a possible new treatment avenue for patients with this devastating disease.

A team led by Prasenjit Dey, PhD, of Roswell Park has discovered a fungus-activated pathway that fuels growth of pancreatic cancer — and proposed a strategy for overcoming these processes.

Pancreatic ductal adenocarcinoma (PDAC), which accounts for more than 90% of all types of pancreatic cancer, is an aggressive and largely incurable disease, with limited therapeutic options and a 5-year survival rate of about 12%. PDAC tumors are dominated by cells that suppress the immune response to cancer and fuel disease progression, and currently available chemotherapy drugs often cannot penetrate the dense stroma surrounding PDAC tumors, making PDAC highly aggressive and resistant to therapies.

“Pancreatic ductal adenocarcinoma is projected to become the second deadliest cancer by 2030 because it is so difficult to treat,” says Prasenjit Dey, PhD, Assistant Professor of Oncology in the Department of Immunology at Roswell Park and senior author of the study. “Most current therapies are

palliative and cannot provide long-term survival, so there is an urgent need for new therapeutic targets.”

A hallmark of PDAC is mutation of the Kras gene, which initiates the formation of tumors and drives cancer progression. Using a preclinical model, Dr. Dey and colleagues discovered that in PDAC cells, a particular oncogenic mutation — KrasG12D — triggers the production and release of the protein interleukin-33 (IL-33), which in turn stimulates tumor growth. In a proof-of-concept study, the Roswell Park researchers confirmed that genetic removal of IL-33 decreased tumor burden and prolonged survival. Surprisingly, they also found that the IL-33 pathway driving tumor growth depends on fungi within the tumor microenvironment.

“A healthy pancreas is typically sterile, with the notable exception of pancreatitis,” says Dr. Dey. “This is one of the first studies to show the presence of a fungus inside a tumor. Our work revealed an important connection between the fungal mycobiome and the secretion of IL-33 in tumors, which could change the way we treat PDAC.” In the new study, the team identifies two types of fungi, Malassezia and Alternaria, that can invade the pancreas from the duodenum, promoting tumor progression. In a preclinical model, antifungal treatment significantly decreased PDAC tumor progression.

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“This cooperative interaction between fungi and cancer cells in the tumor identifies a potential therapeutic strategy for PDAC,” says Dr. Dey. “Although the definitive link between fungal components and IL-33 secretion remains to be defined, our study suggests that antifungal treatment, combined with chemotherapy or immunotherapy to reduce or eliminate IL-33 in tumors, might be an effective treatment option for patients with this form of pancreatic cancer.”

Dr. Dey and colleagues are currently investigating whether the combination of an antifungal agent and immune checkpoint inhibitor can improve antitumor immune responses and outcomes in patients with PDAC. URMC Honing in on Shared Network of Cancer Genes Wilmot Cancer Institute researchers are a step closer to understanding the complex gene interactions that cause a cell to become malignant. In a new Cell Reports study published today, the group used network modeling to hone in on a set of such interactions that are critical to malignancy, and likely to be fertile ground for broad cancer therapies.

Discrete genetic mutations that can be targeted by drugs have only been identified for a small fraction of cancer types.

But those mutations rely on a downstream network of nonmutated genes in order to cause cancer. Those downstream genes – and their intricate interactions – may be common across many cancers and could offer a giant leap forward in cancer therapy.

One of the lead authors of the study, Hartmut “Hucky” Land, Ph.D., who is the deputy director of the Wilmot Cancer Institute and the Robert and Dorothy Markin Professor of Biomedical Genetics at the University of Rochester Medical Center and has worked to identify common core features of cancers for over 10 years. His goal is to find cancers’ shared vulnerabilities and exploit them.

“Targeting non-mutated proteins that are essential to making cells cancerous is a broader approach that could be used in multiple cancers,” said Land, “but it’s hard to find these non-mutated, essential genes.”

That is why Land turned to Matthew McCall, Ph.D., MHS, a Wilmot Cancer Institute investigator who is an associate professor of Biostatistics and Computational Biology at URMC, for collaboration. McCall, who is the other lead author of the study, developed a new network modeling method, called TopNet, that the group paired with genetic experiments in cells and mice to pinpoint functionally relevant gene networks.

Land’s group previously identified a very diverse set of non-mutated genes that are crucial to cancer. In this study, the group wanted to see how those genes interact – starting with a subset of 20 genes. Increasing or decreasing the expression of one gene in cultured cells would have numerous effects on the expression levels of the other genes in the set.

“There were so many interactions, you could waste a lot of time, energy and money testing interactions that might not be useful,” McCall said. “To hone in on the interactions that are more likely to be useful, we used network modeling, and compared our model networks back to the lab findings,” McCall said.

For context, the number of possible gene network models considered by TopNet was many times greater than the estimated number of atoms in the universe. After weeding out models that didn’t closely fit the observed data and further focusing in on gene interactions that appeared in at least 80 percent of the models, the team was left with a manageable set of 24 high-confidence gene interactions. Subsequent experiments demonstrated that these interactions often play an important role in malignancy.

“Dr. McCall’s elegant and mind-boggling methodology is essentially helping us disentangle a hairball of genetic networks,” said Land. “These networks are usually very messy and it’s nearly impossible to extract useful information from them.

But Dr. McCall has found a way to cut through this Gordian knot.”

The group has already tested a sampling of the genetic interactions revealed by TopNet, and confirmed via experiments in cells and mice that the interactions are functionally linked.

Next, the group intends to test the limits of TopNet, with the intent to use this method to find potential cancer therapies that are broadly effective.

This work was completed as part of a $6.3M National Cancer Institute Outstanding Investigator Award granted to Land in 2015 and a K99/R00 grant from the National Human Genome Research Institute to McCall. Helene McMurray, Ph.D., assistant professor of Biomedical Genetics and Pathology and Laboratory Medicine at URMC was the first author of the study.

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