Western New York
buffalo and the great lakes
PHYSICIAN the local voice of practice management and the business of medicine
VOLUME 6 / 2017
Saving Limbs Using Advanced Endovascular Techniques Outside the Hospital Setting An innovative private practice reduces amputations and restores tissue health
The First Wave of the Future of Medicine Is Already Here
New Study Underscores Need for Greater EHR Education, Training
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Contents WESTERN NEW YORK PHYSICIAN I VOLUME 6 I 2017
buffalo and the great lakes
Year-End Tax Planning Tips
Medical Research 15
FDA Approves Landmark Cancer Therapy; Wilmot Positioned Among First to Offer It
Parkinsonâ€™s Disease: A Looming Pandemic
Finding Potential Interventions for
05 Saving Limbs Using Advanced Endovascular Techniques Outside the Hospital Setting: An innovative private practice reduces amputations and restores tissue health
Common, Serious Liver Disease
Dr. Azher Iqbal an endovascular specialist helping patients preserve limbs using advanced therapeutic options in a community-based, private vascular treatment center. As an accredited vascular lab, Buffalo Vascular Care allows Dr. Iqbal and his team to streamline the treatment plan for patients providing evaluation, on-site diagnostic testing and treatment all in the comfort of a non-hospital setting.
21 Roswell Park Patients Will Have Expanded Access to Medical Records Through NYS Health Foundation Grant
17 Clinical Features
Finding Potential Interventions for Newest Data Links Inflammation to Chemo-brain
13 The First Wave of the Future of Medicine Is Already Here
20 Cure One, Get Three Free Bariatric Surgery Addresses
Much More than Obesity
10 Innovative Models of Caring for Seniors in Upstate New York
New Study Underscores Need for Greater EHR Education, Training
Practice Management 24 GBUACO: Leading a Revolution in Health Care
Whatâ€™s New in Area Healthcare
2018 Editorial Calendar
WNYPHYSICIAN.COM VOLUME 5 I 2017 I 1
from the publisher
Western New York
Visit us Online www.WNYPhysician.com
PHYSICIAN the local voice of
practice management and the business of medicine
Welcome to the latest issue of Western New York Physician – Buffalo and the Great Lakes where you will find informative stories and articles about and for physicians in western NY. Western NY Physician Magazine is always keen to highlight innovative new advances in medicine – a new approach, medical device or tool that helps physicians improve care, better outcomes or offer new options to patients. If you or your practice are frontiers in medical innovation, we want to hear your story! In this issue we meet Dr. Azher Iqbal, Medical Director of Vascular Interventional Associates. With 20 plus years in this specialty practice, Dr. Iqbal established Buffalo Vascular Care, an office-based and accredited vascular lab conveniently located in the community to serve patients throughout the region. Our story highlights this newer and improved approach to vascular treatment of arteries and veins and the benefits to patients. Coming up in Western NY Physician Magazine… • Cardiac Care & Rehabilitation in WNY • Women in Medicine • Sports Medicine • Innovations in Robotics
Andrea Sperry creative director
Lisa Mauro writer
Randi Minetor marketing director
Aileen Semler medical advisory board
Michael Silber, MD Chuck Lannon contributors
Julie A. Doerr Randi Minetor Ethan McKenney, CFP Annie Deck-Miller Peter J. Papadakos, MD Val Migliore Julie Nusbaum Roswell Press URMC Press Jacobs Institute Press reprints
Join the Conversation Sharing your expertise is a valuable way to communicate with your medical colleagues. We invite your feedback and article suggestions. Please drop me an email or call to discuss taking part in an upcoming story or to submit an article. In the meantime, please enjoy the numerous other articles within the issue. As always, we thank each of our supporting advertisers -- your continued partnership ensures that all physicians in the region benefit from this collaborative sharing of information and provides the WNYP editorial staff with a deep pool of expert resources for future interviews and articles. All the Best in 2018
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. contact us
Andrea WNYPhysician@gmail.com (585)721-5238
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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
Advanced Primary Care Takes Off Strategic Interests Helps ACO (GBUACO) Transform Care for Safety Net Population with APC
In 2016, The New York State Department of Health authorized the Greater Buffalo United Accountable Care Organization (GBUACO) to operate as a Medicaid accountable care organization (ACO). An ACO is a patientcentered care model that aims to raise care quality, reduce costs and streamline health care delivery. GBUACO is the first Medicaid ACO in New York State.
“Before us (GBUACO), New York was not on the map,” said GBUACO CEO Dr. Raul Vazquez. “About seven other states have Medicaid ACOs, but New York never had one. And we put New York State on the map – from Buffalo.” The GBUACO model operates under a value-based payment structure that rewards providers on the quality, instead of the quantity, of health care services delivered. GBUACO providers have to meet clearly defined quality metrics on prevention and managing chronic diseases. Providers are incentivized for keeping their patients in the ACO healthy and minimizing expensive emergency room visits and hospital stays. In the year since New York State authorized GBUACO to operate as a Medicaid ACO, the organization has amassed a network of more than 500 health care providers, representing thousands of patients who are the ultimate beneficiaries of the work of the ACO. GBUACO also provides technical infrastructure, workflow redesign, and guidance to the practices and is blazing a path for how organizations can thrive in the new world of healthcare. Effective ACOs also support patients with care management, education and support for the social determinants of health. GBUACO helps patients with transportation to appointments, rationalizing conflicting treatments from different doctors, and confusion over being prescribed multiple medications. Recently, GBUACO embarked on a partnership with Strategic Interests, a consulting firm from Rochester, N.Y., to implement the Advanced Primary Care program (APC) and help succeed with GBUACO’s complex payment structure. CMS, NYS DOH, and the New York eHealth Collaborative (NYeC), are offering free services to help providers implement IT, manage change in payments for healthcare services, and improve outcomes. • Advanced Primary Care (APC): prepares PCPs for payment reform with transformation and ongoing education • Practice Transformation Network (PTN): helps PCPs and specialists gain strategic, business, operational and technical capabilities for the future • Behavioral Health Information Technology (BHIT): helps agencies providing home and community based services to patients on Medicaid select and implement EMR systems • Eligible Providers (EP2): SI helps specialists serving the Medicaid population with administrative, technical, and vendor support to attain MU. WNYPHYSICIAN.COM VOLUME 6 I 2017 I 3
John D. Craik, JD, Executive Director of the Population Health Collaborative of WNY is encouraging practices to leverage APC. “We feel that primary care practices should take advantage of the opportunity to participate in the APC program as it offers helpful guidance and support for practitioners as they prepare for the brave new world that health care is rapidly becoming.” NYS DOH has enlisted the Population Health Collaborative to be the designated regional partner of the APC program and will convene discussions with the local payers to maximize value.
“primary care practices should take advantage of the opportunity to participate in the APC program as it offers helpful guidance and support for practitioners” Strategic Interests (SI), is the only firm to support NYeC on all four programs, so they gain synergies while addressing the needs of different organizations. APC is the most recent program SI offers to practices in Western, NY and it is starting to take off. The program includes: • A practice assessment and evaluation to identify gaps and map out a work plan to prepare for value-based care (VBC) • Transformation services and support to implement team-based care, care coordination, and care management that lead to cost savings and enhanced outcomes and patient satisfaction • Support and advise on IT needs to ensure that practices leverage services available from HealtheLink, the organization that serves the region with efficient access for authorized users to clinical information on patients with encounters at hospitals, labs, radiology practices, PCPs and specialists • Customized curriculum and skilled coaching to successfully implement workflow changes and achieve transformation milestones • A series of education and collaboration discussions on a multitude of topics with other practices throughout the state • Tracking 2014 PCMH programs to 2017 recognition and help for practices enrolled in CPC+ 4 I VOLUME 6 I 2017 WNYPHYSICIAN.COM
“We are thrilled to help providers in Western, NY transform care and leverage IT to prepare for the future with NYeC services and our expertise,” says Al Kinel, President of Strategic Interests. “GBUACO is already advanced and does many things well. We look forward to helping them advance even further and enhance their IT infrastructure with innovative solutions. We also look forward to linking PCPs and specialists in multiple programs to integrate behavioral health, enhance screening rates for cancer, vascular and other diseases, and improve ordering of advanced diagnostic tests to ensure the right test is ordered and to eliminate unnecessary redundant tests. This will improve morbidity, cost, and quality of life for patients in Western NY.” “We are pleased to be working with Strategic Interests on APC and PTN to accelerate efforts to transform and prepare our GBUACO network of providers for the value-based payment system, and utilize the latest technologies to do so,” said Vazquez.
Saving Limbs Using Advanced Endovascular Techniques Outside the Hospital Setting An innovative private practice reduces amputations and restores tissue health Randi Minetor
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t’s a familiar scenario for patients with diabetes: skin tissue breaking down under the big toe and along the ball of the foot. These skin breakdowns progress to ulcers, a non-healing wound due to reduced blood flow from Peripheral Arterial Disease (PAD). These non-healing areas may quickly become complicated by infection and gangrene. Until recently, doctors have had few options for treatment. The most common traditional surgical treatment for a nonhealing wound has been the most devastating: loss of some or all of the foot or leg through amputation. In 2016, Azher Iqbal, MD, Medical Director of Vascular Interventional Associates (VIA), an early pioneer of endovascular techniques, established Buffalo Vascular Care, an office-based center for diagnosis and treatment of vascular disease (both arteries and veins) in Lancaster, NY. He brought cutting-edge, specialized endovascular procedures out of the hospital and into the community at this New York State accredited facility. The endovascular treatment is much like cardiac catheterization, in which an endovascular specialist makes a tiny puncture and inserts a long, thin tube into the affected artery to perform an angiogram, finding and treating blockages in the arteries. In recent years, catheters and endovascular devices have become so miniaturized that they can travel through the narrow arteries at the bottom of the leg and into the foot. This has made it possible for doctors like Iqbal to use advanced techniques to restore blood flow in areas that were unreachable before. In the case of a limb with a diabetic ulcer, the endovascular specialist inserts a small catheter into arteries through a tiny puncture and guides it on an imaging screen with live X-ray to the target blockage. The specialist can then guide miniature tools to the blocked or narrowed artery. A variety of techniques including lasers, rotational atherectomy, balloon angioplasty, stents, and others are then used to restore blood flow. Oxygen, nutrients and antibiotics reach the wound/ulcer with the established blood flow and start the healing process, minimizing the risk of amputation. These outpatient endovascular procedures are highly effective and carry lower risk than traditional surgery because they don’t involve general anesthesia, large incisions, hospitalization, or long recovery time. After the procedure, the patient can go home after a few hours on that same day. This outpatient endovascular approach offers new treatment options previously unavailable through traditional vascular surgical techniques. Dr. Iqbal chose to offer these advanced therapeutic options for arteries and veins on an outpatient basis in a community
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private practice setting. He has practiced this specialty for more than twenty years at Buffalo General Hospital and St. Joseph’s Hospital. “In a hospital system, you are given a block of time to take care of patients in an angiography suite,” he said. “Your time is limited. If there are emergencies, you and your patient may get bumped out and have to wait. This all led me to believe I could do this and provide better care in a
different setting.” Buffalo Vascular Care is accredited by New York State and provides the same level of care and technology, but in a setting more convenient for patients. “This allows our patients to be seen in a timely manner and in a central location,” he said. “Overall, this improves accessibility to quality care.”
A focused, patient-centric practice When VIA established Buffalo Vascular Care, “word got out,” Iqbal said, and the practice has become a very busy place. “Patients themselves find out from their friends and families,” he continued. “They hear that our approach is multidisciplinary. We work with a team of specialists who are like-minded. Patients are seen based on acuity and urgency of their condition. When a patient comes in with a threatened limb, they will be seen in twenty-four to forty-eight hours, leading to the earliest possible treatment.” Multidisciplinary approach in management of ulcers/ wounds has been gaining national recognition in the medical field. “Wound healing in diabetics is a complex process. Most
people think you put something on a wound and it heals,” said Iqbal. “But you have several components. Wound care is of limited efficacy if there is little blood flow bringing in oxygen and other required nutrients for wound healing. With the restoration of blood flow, we also need to address local wound care, diabetic glucose control, infection, and so on. That’s our reason for approaching amputation prevention as a team.” High-risk patients who don’t clear for traditional vascular surgery with anesthesia often find the relief and restoration they need here. Dr. Iqbal recently treated a 101-year-old woman for leg pain at rest due to artery blockage. “She did not develop an ulcer, but when she laid down, the blood would not get to her toes,” he said. “She was very spry, still working in the family business. She had been to specialists who told her they would do nothing because of her age. So she came to us.” Dr. Iqbal and his staff performed an endovascular intervention and treated the blockage in an artery in her leg. The patient went home the same day. Because of the practice’s specialization, unique approach, and fast response times, VIA sees patients from as far as
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The endovascular treatment is not, however, just for patients with diabetic foot ulcers. Peripheral arterial disease (PAD), which causes reduced blood flow to a leg, can affect patients who have history of smoking, kidney failure, high cholesterol and high blood pressure. PAD can manifest initially as pain in the calf muscle when walking. The condition can then progress to foot discoloration, pain and ulcers when the blood flow is further compromised. Buffalo Vascular Care provides evaluation and management for all stages of PAD.
Getting the word out
ninety miles away from Buffalo. “Our patients come from Rochester, Batavia, Erie, Dunkirk, Olean, and more,” Iqbal said. “We complete most of the testing onsite with our accredited vascular lab, saving patients unnecessary trips. As far as treatment is concerned, there’s no general anesthesia and almost no downtime.”
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Despite the availability and proven track record for the new endovascular interventional techniques in reducing amputation rate, some patients never hear that they have this alternative. “If you’re going to someone who’s not an endovascular specialist, you may not hear about this catheter-based therapy,” said Iqbal. “The sad reality is that one in two people who undergo amputation do not even get an angiogram—they proceed straight to limb amputation.” Awareness of this technology will evolve, he noted, just as it has in treatment modality for coronary artery disease. “For the heart, the first solution is not bypass anymore; it is the catheter-based endovascular therapy. Most patients don’t need to have their chests opened. So it’s the same change in mentality in lower extremity vascular intervention as well. This is a new field in evolution.” Randi Minetor is a medical journalist and freelance author based in Rochester, NY.
Cure One, Get Three Free Bariatric Surgery Addresses Much More than Obesity
Obesity has increased at an alarming rate over the last few decades; so much so that it is now considered a global epidemic. Obesity is associated with several comorbid conditions that decrease life expectancy and increase health care costs. Patients often struggle for years with many of these conditions as well as the social stigma attached to severe obesity. Diet therapies are often ineffective in the long-term treatment of obesity, and guidelines for the surgical therapy of morbid obesity (BMI ≥ 40 or BMI ≥ 35 in the presence of substantial comorbidities) have since been established. Since those guidelines were established, the number of bariatric surgical procedures performed each year has significantly increased. The outcomes appear to have validated the
guidelines with significant mitigation of several comorbidities including diabetes, obstructive apnea, and dyslipidemia. “Patients come to us for a variety of reasons, many of which are lifestyle issues, but they soon discover that bariatric surgery can have a profound effect on many of the health issues they’ve been coping with for years,” said Dang Tuan Pham, MD, bariatric surgeon and chief of bariatric surgery, Trinity Bariatric Surgery. A “Cure” for Diabetes For more than 20 years, the idea that bariatric surgery may “cure” diabetes has been recognized in the medical community. Recently released five year reporting from the randomized-controlled Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial1 demonstrated that compared intensive medical therapy alone, intensive medical therapy plus surgery (Roux-en-Y gastric bypass or sleeve gastrectomy) in 150 patients with
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type 2 diabetes produced superior results in controlling hyperglycemia. Approximately 89% of patients in the surgical groups were not taking insulin at five years and maintained an average glycated hemoglobin level of 7.0%, whereas only 61% of patients in the medical-therapy group were not taking insulin at five years, with an average glycated hemoglobin level of 8.5%1. Studies that analyzed patients who saw complete resolution of their Type 2 Diabetes revealed that the type of bariatric procedure plays a role. 98.9% of the patients studied who underwent biliopancreatic diversion with duodenal switch (BPS+DS) had complete resolution within eight years, while slightly less than 50% of vertical gastric bypass procedures saw resolution of their Type 2 Diabetes. Complete resolution was also observed in 83.7% of RYGB patients. Interestingly, the clinical resolution of diabetes via RYGB and BPD+DS, the most effective procedures, was associated with the duration and severity of the disease. Specifically, improvement of diabetes was most pronounced in patients with a milder form and shorter duration of the disease, or in patients with less central obesity as measured by waist circumference1. Conversely, patients whose diabetes did not resolve were usually older or had a more prolonged preoperative disease course2. Breathe Easier Obstructive sleep apnea (OSA) is the most prevalent subtype of sleep-disordered breathing. It can result in daytime hypertension, cardiac arrhythmias, increased risk of stroke, coronary artery disease and congestive heart failure. The prevalence of OSA among obese individuals is high and correlates with increasing BMI. In fact, in severely obese individuals, the prevalence ranges from 55% to 100% A number of studies have demonstrated that weight loss, even a modest amount, can effectively manage OSA. As such, the positive effect of bariatric surgery on OSA has been widely reported. “In general, patients are feeling better, they are more mobile, and tend to have more energy, so it’s not surprising to have them report less daytime sleepiness,” said John Rutkoski, MD, bariatric surgeon, Trinity Bariatric Surgery. “It’s important to remember, however, that although OSA events may be significantly reduced with weight loss, patients are not necessarily cured completely and ongoing diagnostic sleep testing with repeat polysomnography should be pursued even when a goal weight or stable weight is attained.”
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Go with the flow Atherogenic dyslipidemia, or elevated triglycerides, apolipoprotein B, small low-density lipoprotein (LDL) particles, and low high-density lipoprotein (HDL) cholesterol is strongly associated with visceral obesity. Dyslipidemia in association with hypertension, insulin resistance, proinflammatory/thrombotic states and visceral obesity is collectively referred to as the metabolic syndrome (MetS)3. MetS patients with coronary heart disease die twice as frequently than those without MetS and patients with preexisting cardiovascular disease die four times more frequently than those without. Overall mortality was increased in patients with MetS and in those who also had pre-existing cardiovascular disease this rate was even higher. Patients with even one or two MetS-related risk factors are at increased risk of death from coronary heart disease and cardiovascular disease. Once again, bariatric surgery offers hope Several studies examining the effect of bariatric surgery on dyslipidemia have reported significant improvement in lipid profiles after bariatric surgery. There are marked reductions in LDL, increased HDL and decreased triglycerides. An analysis of one study revealed that hyperlipidemia, hypercholesterolemia and hypertrigly-ceridemia were significantly improved across all surgical procedures at 2 year follow-up. The percentage of patients whose conditions improved was typically 70% or higher. Additionally, among patients in the STAMPEDE trial, the number of medications needed to treat hyperlipidemia and hypertension was significantly lower in the surgical groups than in the medical- therapy group1. These studies clearly suggest that bariatric surgery not only allows for sustained weight loss, but is a viable treatment option for correcting dyslipidemia in morbidly obese individuals. “Primary care physicians as well as specialists need to have open and frank conversations about obesity-related medical issues and bariatric surgery options with their patients. It can be a difficult subject to broach, but obesity brings with it a serious range of health issues that many patients may never be able to overcome otherwise,” said Dr. Pham. n engl j med 376;7 nejm.org February 16, 2017 Ann Surg. 2003 Oct; 238(4):467-84; discussion 84-5 Schauer, Bhatt, Kirwan, Wolski, Aminian, Brethauer, Navaneethan, Singh, Pothier, Nissen, Kashyap Diabetes and hypertension in severe obesity and effects of gastric bypass-induced weight loss. Sugerman HJ, Wolfe LG, Sica DA, Clore JN Ann Surg. 2003 Jun; 237(6):751-6; discussion 757-8. 3 Review Dyslipidemia in visceral obesity: mechanisms, implications, and therapy. Chan DC, Barrett HP, Watts GF Am J Cardiovasc Drugs. 2004; 4(4):227-46.
Year-End Tax Planning Tips
Ethan McKenney, CFP Senior Wealth Management Consultant Manning & Napier
he uncertainty surrounding potential tax law
proposals). When it comes to tax planning, most
changes has dominated headlines in the past
strategies must be completed on a calendar year
few weeks. While the tax landscape for 2018 is still
basis. As we quickly approach the holiday season and
up in the air, we know what the laws are for 2017
the end of 2017, it is important to take time to think
(assuming none of the potential changes are made
about tax savings strategies that can benefit you and
retroactively, which appears unlikely based on recent
WNYPHYSICIAN.COM VOLUME 6 I 2017 I 11
Maximize retirement plan contributions by year-end. Not only does this help you to better prepare for retirement, it also may reduce this year’s tax bill and set you up for tax-deferred growth over your investment time horizon. If you are not on pace to maximize your contributions by year-end, consider increasing your deferral rate to direct extra dollars to your retirement account during the last few remaining pay periods of 2017. Maximize Traditional IRA / Roth IRA contributions by 4/1/18. Roth IRAs grow tax-free and are not subject to mandatory distribution rules (Required Minimum Distributions), making them great both for retirement planning and as multi-generational planning tools. Contributions to Traditional IRAs can be tax-deductible in the year that you make them (depending on your income), so maximizing IRA contributions, in addition to 401(k)/retirement plan contributions, can be another great way to reduce your taxes for the year. Explore additional ways to contribute to taxadvantaged accounts. These can include cash balance plans, spousal IRAs, non-deductible IRA contributions, and “back-door” Roth IRA contributions. Take Required Minimum Distributions by year-end to avoid a 50% IRS penalty. Required Minimum Distribution tax rules apply to Traditional, Rollover, and Inherited IRAs.
Consider an IRA Qualified Charitable Distribution (QCD) to fulfill RMD and charitable goals. IRA owners wishing to lower their adjusted gross income can use QCDs as a strategy to disperse money to a charity of their choice and to provide charitablyminded IRA owners with an opportune tax deduction. Make charitable gifts of highly appreciated stock. This will help to fulfill your charitable desires and mitigate current year income taxes. Rather than selling stock and realizing capital gains, consider donating it directly to charity. 12 I VOLUME 6 I 2017 WNYPHYSICIAN.COM
Contribute to 529 College Savings Plans for your children, grandchildren, or others. Thirty-three states offer a full or partial tax deduction or credit for 529 Plan contributions. Make annual exclusion gifts (up to $14,000 per spouse, per person). These gifts can help you achieve multi-generational gifting goals and reduce the value of your estate.
Other Tips and Considerations
Consider tax-loss selling. Securities sold at a loss can often times be used to offset securities that are sold at a gain, helping to mitigate potential capital gains taxes. You should review your tax situation with your accountant prior to any tax-loss selling. You should also understand that tax-loss selling can impact an investment strategy, as securities sold at a loss should not be repurchased for more than 30 days to avoid adverse tax implications (wash sales). Consider the timing of the sale of securities. For individuals with highly-concentrated and appreciated stock positions that are looking to diversify their investments and risk, consider a plan to sell some shares prior to year-end and then additional shares early in 2018. This will help to reduce stock specific risk while spreading the tax liability across multiple tax years. Explore converting all or a portion of your IRA to a Roth IRA. Converting an IRA to a Roth IRA is a taxable event, meaning that you may owe taxes on the amount converted. However, Roth IRAs are not subject to Required Minimum Distributions (for the owner) and have the ability to grow tax-free which is a beneficial factor when considering tax planning. Get ready for 2018. Since it appears that the tax system may be at least partially overhauled over the near-term, it is important to sit down with your advisors and determine if any changes need to be made to your overall plan.
The First Wave of the Future of Medicine Is Already Here A
medical device innovation center located in the heart of the Buffalo Niagara Medical Campus in Buffalo, NY, known as the Jacobs Institute (JI), tackled a challenging topic in its recently published book The Future of Medicine. The center’s chairman of the board is business leader and philanthropist Jeremy M. Jacobs, chairman of Delaware North a family-owned hospitality company. He and the JI released the book, which was written by a group of futurists and covers a wide array of topics—from previvors to artificial intelligence (AI) and robotic surgery to a physician morale crisis. Future is about the possibilities that lay before us, if physicians and health care systems work together to push for change that ultimately benefits patients. The JI is already using some of the futuristic technology featured in the report and developing partnerships with other companies.
Robotics Surgical guidance and robots aren’t a new proposition. In fact, if you are an ENT, urologist, gynecologist, orthopedic surgeon, general surgeon, or neurosurgeon, you may
already use a surgical robot. Companies such as Corindus, Mazor Robotics, Stryker, and Synaptive Medical, have robots on the market that are used to treat patients at Kaleida Health’s Gates Vascular Institute (GVI)—just one floor below the JI. Corindus offers a paired system with a surgical robot that inserts devices for percutaneous coronary interventions and a remote lead-lined cockpit with controls so the surgeon can stay safe from radiation. Mazor X and Stryker’s Mako offer robotic arms that are predominantly used for spine surgeries at the GVI. Synaptive Medical’s BrightMatter has a surgical guidance and robotic surgical arm, which work together, for invasive neurosurgical procedures such as tumor removal. Surgical systems can be pricey, with a da Vinci laparoscopic robot system running about $1.5-$2 million, not including annual service contracts and the cost of single use tools and supplies. Orthopedic robots can cost approximately $1 million. At current prices, there is a case minimum required in order for a hospital to see a return on its investment. With improved cost containment models and improved outcomes, the economics will ultimately prevail,
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with more hospitals adapting this tech wave. Creative payment models, such as pay-per-procedure, will also make robotic surgical systems more attainable, even for small town hospitals. Robotic technology is improving at a rapid pace. Promises of smaller robots with better access into difficult sites and greater flexibility for use across specialties, make them even more appealing. Additionally, the incorporation of AI into instrumentation and visualization will be a game changer. The end game is robots that perform surgeries autonomously, allowing a single surgeon to oversee multiple operations concurrently. This translates into a cost saving for hospitals and patients alike. 3D Printing/BioMimics The traditional approach to medical education will see a disruption, Future notes, with a focus on adaptive learning. This shift to self-directed medical coursework is already underway at Stanford and through Khan Academy. The push to provide students with greater hands-on experience in simulated environments will grow exponentially. Medical simulators have existed for a long time, but the latest computing advances offer a more interactive, realistic experience. The JI houses a Mentice vascular simulator, which allows hands-on experience in selecting and inserting the appropriate devices for endovascular procedures. There is also an explosion of virtual reality (VR) products on the market for medical simulation. Additive manufacturing—also known as 3D printing—is making a significant splash in the medical realm, with 14 I VOLUME 6 I 2017 WNYPHYSICIAN.COM
education being only one of its facets. 3D printer manufacturers are doing due diligence by partnering with hospitals, researchers, and surgeons to determine how to leverage their technology to provide value. At the end of 2017, Stratasys announced BioMimics, a fee-for-service model for hospitals and surgeons to order custom-made, realistic models for orthopedic and cardiac surgery delivered to their facility for research, surgery, or device testing. This technology offers a level of sophistication and customization previously unimaginable. The JI’s biomedical engineers have long collaborated with University at Buffalo (UB) and Stratasys, to develop our signature 3D vascular flow models. Since the JI is located below UB’s Clinical and Translational Research Center and above the GVI, it is well-positioned—literally—to put the 3D models to use for training, testing, and planning. Through a grant from the James H. Cummings Foundation and a partnership with Stratasys, the JI was able to procure an Objet 500 Connex 3, which is a multi-color, multimaterial 3D printer. Such cutting-edge technology allows for more realistic anatomical designs for endovascular procedure planning, medical training, and endovascular device testing. We offer these upgraded models to everyone coming to the JI. UB neurosurgical residents and medical students visit for training sessions, thrilled by the chance to try their hand at retrieving a clot from the same 3D models that Dr. Adnan Siddiqui, our chief medical officer, uses to plan for complex endovascular surgeries. These models provide precisely the high-quality, hands-on training that medical students need for the most realistic educational environment. The scenarios laid out in The Future of Medicine can become reality if physicians and health care systems open our minds to the possibilities. Some forward-looking technology is already in use or well within reach. There is much at stake and much in store for WNY in the coming years, with the ever-changing healthcare landscape.
For the complete book, please visit: http://www.futureof.org/medicine-1-0
be a part of the
Conversation Editorial Calendar 2018 Jan / Feb – Vol 1
July / Aug – Vol 4
Mental Health /Pediatrics Coordinated Care in Mental Health Trauma in western NY Studies on Concussion
Cardiac Care & Rehabilitation Accountable Care Imaging Advances Women in Medicine
Sept / Oct – Vol 5
Mar / Apr- Vol 2
Treating Cancer in Western NY Navigating Survivorship The State of Medical Marijuana in NY Immunotherapy
Men’s Health Sports Medicine Robotic Update Eye Disease
Nov / Dec – Vol 6
May / June – Vol 3
The Senior Patient Coordinated Care Orthopadics: Hips & Knees Neurology
Women’s Health Urological Issues Fertility Imaging Advances
What’s My Liability? • Risk Management • Financial Insights In–Between Patients • Practice Tips • Medical Innovations • Healthcare Transformation
To secure a spot in one of the 2018 issues and join the conversation – contact Andrea Sperry at (585) 721–5238 or WNYPhysician@gmail.com. WNYPHYSICIAN.COM VOLUME 6 I 2017 I 15
Innovative Models of Caring for Seniors in Upstate New York By Julie Nusbaum
As upstate New York’s senior population continues to rapidly grow, several models of innovative care have emerged to meet the needs and interests of its aging community. Many of the trends address the individual’s interest to retain autonomy, and remain in the least restrictive environment for as long as is possible and feasible. Often, the least restrictive environment is initially homebased care, and for the past thirteen years, Dr. Diane Kane, who is president and founding physician of Pillar Medical Associates, PC, has pioneered a model of care that brings medical services to seniors in their place of residence, wherever that may be. “Our patient is the center of this model, and our care is patient-centered care,” she says. “Our model is predicated on the belief that the more we can keep our patients out of emergency rooms and hospitals, the better off they will be.” Pillar Medical Associates seeks to treat the patient holistically along the entire continuum of care, and according to Dr. Kane, “our team will follow the individual throughout their journey.” Such a journey might begin in an independent setting, and if a patient becomes more frail or has memory issues, continue into to assisted living, assisted living memory care, and finally to skilled nursing home care if needed. The advantage of 16 I VOLUME 6 I 2017 WNYPHYSICIAN.COM
this model of care is that, in addition to expertise in traditional internal medicine, “we bring to the table geriatric expertise and a palliative skill set which is unique,” adds Dr. Kane, who is Board-certified in Internal Medicine, Geriatrics, and Hospice and Palliative Care. In addition to her responsibilities with Pillar Medical, Dr. Kane is Chief Medical Officer of St. Ann’s Community in Rochester. Dr. Kane explains that the premise of this model is that “the individual can live independently with the assistance of a team and an engaged family” and that “we can bring medical services to the individual to keep them out of a nursing home for as long as possible.” Perhaps, she says, “with hospice, individuals can even die in their homes in an independent setting.” The Pillar Medical Associates team includes Dr. Kane and Dr. Brian Heppard as well as a Registered Nurse and a Nurse Practitioner. The practice serves about 200 patients, with expansion plans that include “identifying established senior communities and bringing medical services to them,” explains Dr. Kane. One of their first ventures is at Valley Manor High Rise Senior Community, Episcopal Senior Life, where every week, “we go floor to floor to bring medical care to our clients there,” she continues. “We have applied this model successfully within our four walls at St. Ann’s, and now we will be bringing it out into the community.” Central to Pillar Medical Associates’ care is a MOLST plan, or Medical Orders for Life Sustaining Treatment. On the very first patient visit, the patient fills out the MOLST form and reveals their goals of care in such areas as code status, lung failure, hydration wishes, and hospital or treatment in place plans. “Once those goals are stated, everyone has to honor the goals,” emphasizes Dr. Kane. “We take it very seriously.” Additionally, whenever a patient has a change in their health status, the MOLST form and goals of care are reviewed and adapted accordingly. To complement its practice, Pillar Medical has developed partnerships with mobile services to bring needed diagnostic services directly to their patients, including X-Rays, phlebotomy testing, or chest, bone, heart and belly ultrasounds. Fully electronic health records can be accessed during home visits, and are especially helpful in reconciling medications to identify
side effects and potential drug interactions. After each patient visit, Pillar Medical Associates provides the patient with a list of their current medications and what each medicine is for. “We help older adults navigate the complex network of health care services and advocate for our patients with compassion, understanding and expertise,” asserts Dr. Kane. “For those of us who do this, it is a passion and a privilege, and it is the right thing to do,” she adds. Jewish Senior Life ( JSL) in Rochester recently debuted another exciting and dynamic model of care for aging seniors, its newly completed Green House Cottages. Three new three-story buildings contain nine long-term care homes on the Jewish Senior Life campus and serve 108 residents who moved there from the Jewish Home Farash Tower. Each floor contains a home for 12 residents, complete with kitchen, common area, and private rooms and bathrooms. Every new home has its own staff and self-managed care team. According to Michele Schirano, RN and senior vice president/administrator of the Jewish Home of Rochester, “the Green House Project® is a new model of care about creating a home environment for our residents.” Research has shown that a homelike environment offers a more natural way of living; it enriches seniors’ lives qualitatively and is cognitively, emotionally and physically beneficial. Residents of the Green House Cottages have more autonomy and independence in every aspect of their daily routine. This autonomy might include deciding when to wake up, when and what they will eat, and even offering input about the menu. “The staff members, who are specially trained certified nursing assistants (CNAs), are empowered to help residents make decisions and set their rhythm every day,” states Schirano. Staff
members, called adireens, provide housekeeping, cooking and personal care, and work to make the cottages feel like home for the residents. Whether sharing in meals or attending cultural activities, family members are actively involved in many aspects of the Jewish Senior Life experience, and feedback has been enormously positive both from the residents and from their families. In the short time since their relatives moved into the cottages, families report that their loved ones are more social, more relaxed and more attuned to their natural schedules. Residents are more engaged in their surroundings and empowered by their ability to make choices day to day. The Green House Cottages are part of a larger transformation project for the Jewish Home of Rochester, which is also renovating the floors of its Farash Tower to incorporate the home model, featuring private rooms and bathrooms, and more common areas for socializing and gathering. Jewish Senior Life’s Green House Cottages were built in conjunction with the nationally-accredited Green House Project® and Schirano reports that outcomes such as “decreases in anxiety, changes in appetite and mood, and increases in family, resident and staff satisfaction” were key factors in bringing Green Houses to Jewish Senior Life’s campus. This ambitious project makes Jewish Senior Life the third largest Green House community in the country and Rochester’s only Green House model all on one campus. “Green House Cottage residents are coming out of their rooms, making friends, eating better, making decisions, adjusting to their new way of living, and in effect, coming to life,” observes Schirano. “Living in this environment improves physical
WNYPHYSICIAN.COM VOLUME 6 I 2017 I 17
and emotional health and well-being, and improves the overall health of our residents.” Happier at Home, a non-medical companion care company based in Buffalo, New York, offers yet another model with the aim of keeping seniors in their homes as long as possible. By employing caregivers who assist clients with activities that are challenging for them, such as errands, cooking, laundry, housekeeping and even doctor’s visits, Happier at Home helps seniors maintain their quality of life in their home environment. With 32 caregivers who “help to provide companionship and mental stimulation to our clients,” Happier at Home offers “comfort and palliative services to fulfill clients’ wishes to remain in their own homes as long as it is safe and feasible,” says President Trent Voelkl. The caregiving business was not a far stretch for Voelkl, whose family has owned Buffalo Pharmacies for over 50 years. “Over the years, we offered free home delivery for medicine and equipment,” Voelkl notes. “Providing good service for our clients is our main goal, and gave us the impetus to branch out into the companion care business,” he adds. Family involvement is key to Happier at Home’s success. Typically, family members are the initial point of contact for Voelkl, and often he interacts with the family as much if not more than the individual client. Together with the individual and the family, Happier at Home develops a care plan which details day-to-day activities and hours per week. In addition, “lines of communication are always open with our families,” Voelkl remarks. “I talk to most of my clients’ families weekly, and provide updates on their progress as well as address any 18 I VOLUME 6 I 2017 WNYPHYSICIAN.COM
issues that arise.” Often, companion care services are a 6-9 month transitional measure to keep a family member in their own home until that is no longer possible. All of the caregivers are employed directly by Happier at Home and bonded and insured. Screening is extensive, and includes a check of personal references, a state and federal backTrent Voelkl ground check and a 12-panel drug screen. In addition, Happier at Home employees are registered in the New York State LENS program, which notifies employers of personal and criminal infractions. “Our goal is to do what we can to help our clients fulfill their wish of staying in their own home,” says Voelkl. “We want to provide continuity of care, and encourage as much independence as possible, to maintain peace of mind for clients and their families.” Whether providing companion care or in-home medical services throughout the health care continuum, or creating a nurturing home setting for seniors, Happier at Home, Pillar Medical Associates and Jewish Senior Life are working on behalf of upstate New York’s older adults to ensure that they age gracefully and independently while aiming to keep them in their home environments as long as possible.
New Study Underscores Need for Greater EHR Education, Training
he United States has invested billions of dollars to encourage providers to adopt electronic health records (EHRs) into the healthcare system—enabling rapid access to critical health information, improving physician satisfaction, and lowering costs. But are EHRs all they were promised to be? While the digitization of the medical record has been hugely beneficial to help providers and patients manage and share information, the EHR has also introduced many unanticipated medical liability risks. EHRs were designed by IT professionals, instead of the physicians, nurses, and technicians who use them daily. These systems were developed to help the healthcare industry transition to a payfor-performance payment system—not to optimize workflow and communication at the bedside. Because of the billing information required by regulators, notes had to be templated to contain required information. Checkboxes with dozens of options can lead to medication and dosing errors, frequent alerts cause alert fatigue, and autopopulation provides excessive amounts of information that can overwhelm the provider. System factors are just part of the reason why the number of EHR-related medical malpractice claims has risen over the past 10 years, according to a new study from The Doctors Company, the nation’s largest physician-owned medical malpractice insurer. User errors—including data entry, copy-andpaste mistakes, and alert fatigue—showed up in 58 percent of the claims in the study, compared with system factors, which contributed to 50 percent of
Peter J. Papadakos, MD, FCCM, FAARC
the claims. Many doctors believe these systems will protect them from errors, so studies like this are important to get the word out about the errors that do occur with EHRs. One of the biggest drawbacks of the EHR is the potential negative impact on the doctor-patient relationship. In written form, notes would give an individualized “feel” for each patient, their concerns, and their care. With checkboxes and fill-in blanks, the narrative of disease is lost. And most importantly, patients frequently complain that the screen is a barrier between them and their doctor or nurse. When the provider focuses on the screen and makes no eye contact with the patient, the EHR has impacted a patient’s ability to trust and communicate with their provider. I’ve encountered a total lack of knowledge on these common problems and their legal implications in my many meetings with physicians and providers across the nation. EHRs represent the most rapid introduction of technology in our history—yet they were adopted without widespread formal education for both doctors and patients on how they should interact with this technology. Hospitals, professional schools, and providers need to develop programs to educate staff and develop protocols for proper documentation, integration, and oversight of EHRs. Facilities need to understand that EHRs do not free providers from errors and should provide human-to-technology interfacing education. At the University of Rochester, we introduce the EHR in a unique way. We’ve pioneered making the
WNYPHYSICIAN.COM VOLUME 6 I 2017 I 19
computer the “third person in the room” by spending time introducing the patient to the technology and showing how it may benefit their care. We encourage physicians to introduce the computer to patients, helping patients understand that the computer is assisting in their medical care by providing rapid access to information, labs, and images. We also educate the provider about all the pitfalls of the EHR— from checklists, to the dangers of cutting and pasting, to the robust pharmacologic libraries that may cause the provider to click on the wrong dosage. Patients also have the responsibility to interact with the EHR and advocate for their own care. Patients need to be educated to utilize their ability to interact with EHRs, review the data, and actively communicate with their provider about any errors or problems. As a patient, you can—and should— interface with the EHR to check to see if the list of your diseases, medications, and medical history is correct.
Safer patient care starts with each of us. For the EHR to evolve into a true patient care tool, it is incumbent on the industry to redesign these systems to be less IT-focused and more healthcare-focused and for each one of us, whether a patient, physician, or hospital, to learn about potential errors and take proactive steps to make the EHR the trusted healthcare partner we need. Peter J. Papadakos, MD, is director of critical care medicine at the University of Rochester Medical Center and professor of anesthesiology, neurology, surgery and neurosurgery at the University of Rochester. Dr. Papadakos was one of the first experts to identify the potential for distraction from smartphones and to popularize the term “distracted doctoring.” An expert on the impact of technology on medical care, Dr. Papadakos and his co-editor Stephen Bertman recently edited Distracted Doctoring Returning to Patient-Centered Care in the Digital Age, a Springer publication.
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Finding Potential Interventions for Common, Serious Liver Disease
ew clues to non-alcoholic fatty liver disease (NAFLD), which affects nearly all obese adults and a rising percentage of obese children, have been reported in a paper by senior author Susan S. Baker, MD, PhD. “These results suggest that components in the bile acid signaling pathway, including bile acid metabolizing bacteria in the gut, are new targets for the treatment of NAFLD.” Lixin Zhu, PhD, Assistant professor of pediatrics “Because NAFLD patients often progress to liver inflammation, fibrosis, cirrhosis and eventually liver transplantation, it is imperative that new treatment modes be explored and developed,” explains Baker, professor and co-chief of the Division of Gastroenterology in the Department of Pediatrics.
Incidence of NAFLD is Rapidly Rising The incidence of NAFLD, found in 90 percent of obese adults and rarely found in individuals who are not obese, is quickly rising, as is the incidence among children. The annual cost of the disease is estimated at $103 billion. Baker said the rising incidence of the disease, especially among children, is worrisome. “NAFLD often goes unrecognized in children because pediatricians do not routinely assess liver function,” says Baker, who sees patients at UBMD Pediatrics. In 2006, she added, when the prevalence of obesity among children was less than it is currently, the prevalence of fatty liver was 9.6 percent in children ages 2 to 19 in California. Since the prevalence is likely similar for
WNYPHYSICIAN.COM VOLUME 6 I 2017 I 21
the entire U.S., approximately 6.5 million children and adolescents have fatty liver disease and are at risk for the disease’s most serious consequences. Drawing on Highly Cited 2013 Research Baker’s current work draws on her pioneering 2013 research that revealed that NAFLD patients have altered gut microbiomes characterized by increased abundance of alcohol-producing bacteria within the gut — a seemingly paradoxical finding given that the condition is called “non-alcoholic” fatty liver disease. That paper, published in Hepatology, was the most highly cited original research article submitted by a UB researcher within the past five years, according to Web of Science. “The new research reveals that the gut microbiome may affect the physiology and pathology of NAFLD patients in many other ways, too,” Baker explains. According to the new research, the microbiome in NAFLD modifies bile acids, which help digest and absorb fats, and also help regulate fat and sugar metabolism. The investigators observed elevated levels of primary and secondary bile acids in NAFLD, which is likely the cause of impaired bile acid-mediated signaling in the liver. Baker and her colleagues are studying NAFLD in children as participants in the National Institutes of Health.
D VVEER R T I TS IE S R SE R S AA D
Results Suggest New Targets for NAFLD Treatment The researchers studied 16 NAFLD patients and 11 healthy controls, as well as laboratory animals on high-fat diets designed to result in a condition mimicking NAFLD. Total serum bile levels were elevated for the individuals with NAFLD, with levels approximately three times as high as the healthy controls; they also had a higher percentage of secondary bile acids. “These results suggest that components in the bile acid signaling pathway, including bile acid metabolizing bacteria in the gut, are new targets for the treatment of NAFLD,” says co-author Lixin Zhu, PhD, assistant professor of pediatrics. Exploring Possible Interventions The researchers are beginning to explore possible interventions. “We are looking into finding out which bacterial species in the gut are missing in patients who are obese and have NAFLD,” says Zhu. “Our novel idea is that probiotics should be personalized, based on the microbial composition of each individual,” he adds. “For NAFLD patients, the most effective probiotic species should be those that will help to reconstitute a healthy microbiota, leading to more balanced bile acid signaling.”
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FDA Approves Landmark Cancer Therapy; Wilmot Positioned Among First to Offer It UR Medicine’s Wilmot Cancer Institute will be among the first sites in the world to offer CAR T-cell therapy —a new type of immunotherapy—to adults with aggressive lymphoma. The engineered gene therapy has been described as a revolutionary “living drug” and one of the most powerful cancer treatments to emerge in recent years. The U.S. Food and Drug Administration recently approved Kite Pharma’s therapy, called Yescarta. It works by boosting a patient’s immune system to seek and kill the cancer cells involved in diffuse large B-cell lymphoma, a type of blood cancer for which there is no cure. Wilmot is expected to be the only cancer center in upstate New York and between Michigan and Boston, to provide Yescarta therapy. “This is potentially transformative therapy for a subset of patients with relapsed, aggressive lymphomas who have few other options,” said Wilmot Director Jonathan Friedberg, MD, MMSc, and a lymphoma expert. “Wilmot was the only center in New York state outside of New York City to participate in the clinical trials for this new treatment and has the experience to administer CAR T-cells. We’re excited to launch the region’s first CAR T-cell program for lymphoma, and expect to serve patients from New York, Pennsylvania, Ohio, Canada, and beyond.” CAR T-cell treatment, which was originally developed at the National Cancer Institute, involves extracting millions of a patient’s own T cells, a type of white blood cell that usually fights infection. The cells are then flown to Kite’s manufacturing center near Los Angeles. There, scientists use bioengineering techniques to reprogram the immune cells to attack a protein called CD19 that sits on the surface of diffuse large B-cell lymphoma cells. That process takes about 17 days. The patient receives special chemotherapy. Then, the CAR T-cells are flown back to the treating hospital and infused into the patient through an intravenous catheter, which takes less than 30 minutes. For the next several days, the patient’s immune system goes into overdrive while a team of doctors and nurses manage the severe and sometimes life-threatening side effects from inflammation. Later, doctors conduct imaging tests to find out if the CAR T-cell therapy wiped out the cancer. “We’re excited about the potential of this therapy,” Reagan said, “but we’re also mindful that it’s very new and that patient safety is our primary objective. We have the expertise and we plan to roll it out slowly and carefully.”
Lymphoma is the most common blood cancer in the U.S. but there are dozens of different types. It starts when lymph tissues and cells in the immune system become malignant. Diffuse large B-cell lymphoma is one type that occurs fairly often. About two-thirds of B-cell patients go into remission after standard chemotherapy and other treatments. But in one-third of the patients, the cancer is resistant to chemotherapy or the patient suffers a relapse with aggressive disease. For people in these situations, little has been available until immunotherapy therapy was introduced. Kite Pharma is working with insurers nationwide and regionally to determine cost and coverage for the treatment.
Parkinson’s Disease: A Looming Pandemic New research shows that the number of people with Parkinson’s disease will soon grow to pandemic proportions. In a commentary appearing today in the journal JAMA Neurology, University of Rochester Medical Center neurologist Ray Dorsey, MD and Bastiaan Bloem, MD, PhD, with Radboud University Medical Center in the Netherlands, argue that the medical community must be mobilized to respond to this impending public health threat. “Pandemics are usually equated with infectious diseases like Zika, influenza, and HIV,” said Dorsey. “But neurological disorders are now the leading cause of disability in the world and the fastest growing is Parkinson’s disease.” In their commentary, the authors point out that between 1990 and 2015, the prevalence of Parkinson’s more than doubled and it is estimated that 6.9 million people across the globe have the disease. By 2040, researchers believe that number of people with Parkinson’s will grow to 14.2 million as the population ages and the rate of growth will outpace Alzheimer’s. These estimates are likely conservative due underreporting, misdiagnosis, and increasing life expectancy. To combat this growing pandemic, the authors argue that the medical community should pursue the same strategies that, in 15 years, transformed HIV from an unknown and fatal illness into a highly treatable chronic condition. “People with HIV infection simply demanded better treatments and successfully rallied for both awareness and new treatments, literally chaining themselves to the doors of pharmaceutical companies,” said Bloem. “Today, HIV has become a treatable, chronic disease. This upcoming increase in the number of Parkinson patients is striking and frankly worrisome. We feel it is urgent that people with Parkinson’s go to the pharmaceutical industry and policymakers alike, demanding immediate action
WNYPHYSICIAN.COM VOLUME 6 I 2017 I 23
are at risk for the disease’s most serious consequences. to fight this enormous threat.” The authors contend that the Parkinson’s community must come together and focus its activism in support of: developing a better understand the environmental, genetic, and behavioral causes and risk factors for Parkinson’s to help prevent its onset; increasing access to care – an estimated 40 percent of people with the disease in both the U.S. and Europe do not see a neurologist and the number is far greater in developing nations; advocating for increases in research funding for the disease; and lowering the cost of treatments – many patients in low-income countries do not have access to drugs that are both lifesaving and improve quality of life. “For too long the Parkinson’s community has been too quiet on these issues,” said Dorsey. “Building on the AIDS community’s motto of ‘silence=death,’ the Parkinson’s community should make their voices heard. The current and future burden of this debilitating disease depends upon their action.”
Finding Potential Interventions for Common, Serious Liver Disease UBMD Press New clues to non-alcoholic fatty liver disease (NAFLD), which affects nearly all obese adults and a rising percentage of obese children, have been reported in a paper by senior author Susan S. Baker, MD, PhD. “These results suggest that components in the bile acid signaling pathway, including bile acid metabolizing bacteria in the gut, are new targets for the treatment of NAFLD.” Lixin Zhu, PhD, Assistant professor of pediatrics “Because NAFLD patients often progress to liver inflammation, fibrosis, cirrhosis and eventually liver transplantation, it is imperative that new treatment modes be explored and developed,” explains Baker, professor and co-chief of the Division of Gastroenterology in the Department of Pediatrics.
Incidence of NAFLD is Rapidly Rising The incidence of NAFLD, found in 90 percent of obese adults and rarely found in individuals who are not obese, is quickly rising, as is the incidence among children. The annual cost of the disease is estimated at $103 billion. Baker said the rising incidence of the disease, especially among children, is worrisome. “NAFLD often goes unrecognized in children because pediatricians do not routinely assess liver function,” says Baker, who sees patients at UBMD Pediatrics. In 2006, she added, when the prevalence of obesity among children was less than it is currently, the prevalence of fatty liver was 9.6 percent in children ages 2 to 19 in California. Since the prevalence is likely similar for the entire U.S., approximately 6.5 million children and adolescents have fatty liver disease and 24 I VOLUME 6 I 2017 WNYPHYSICIAN.COM
Drawing on Highly Cited 2013 Research Baker’s current work draws on her pioneering 2013 research that revealed that NAFLD patients have altered gut microbiomes characterized by increased abundance of alcohol-producing bacteria within the gut — a seemingly paradoxical finding given that the condition is called “non-alcoholic” fatty liver disease. That paper, published in Hepatology, was the most highly cited original research article submitted by a UB researcher within the past five years, according to Web of Science. “The new research reveals that the gut microbiome may affect the physiology and pathology of NAFLD patients in many other ways, too,” Baker explains. According to the new research, the microbiome in NAFLD modifies bile acids, which help digest and absorb fats, and also help regulate fat and sugar metabolism. The investigators observed elevated levels of primary and secondary bile acids in NAFLD, which is likely the cause of impaired bile acid-mediated signaling in the liver. Baker and her colleagues are studying NAFLD in children as participants in the National Institutes of Health Nonalcoholic Steatohepatitis Clinical Research Network.
Finding Potential Interventions for Newest Data Links Inflammation to Chemo-brain URMC Press Inflammation in the blood plays a key role in “chemo-brain,” according to a published pilot study that provides evidence for what scientists have long believed. The research is important because it could lead to a new practice of identifying inflammatory biomarkers in cancer patients and then treating the inflammation with medications or exercise to improve cognition and other symptoms, said senior author Michelle C. Janelsins, PhD, associate professor of Surgery in the Cancer Control and Survivorship program at the Wilmot Cancer Institute. Published in the Journal of Neuroimmunology, the preliminary research is believed to be among the first studies to look at cancer patients in active treatment and whether inflammation is involved in their chemo-brain symptoms. Results showed that among 22 breast cancer patients taking chemotherapy, those with higher levels of inflammatory biomarkers in their blood did worse on neuropsychological tests for visual memory and concentration. Chemo-brain, or cancer-related cognitive impairment, is estimated to impact 80 percent of people in treatment. Patients report fogginess, forgetfulness, and difficulty with multitasking
and other problem-solving skills. Researchers discovered that one particular biomarker for acute inflammation—tumor necrosis factor-alpha—was the strongest indicator of cognitive problems. Generally, higher levels of inflammation can be caused by cancer, its treatment, or other health problems; but until lately little had been known about the interplay of inflammation, cancer, and quality of life. Last year another study led by Janelsins —one of the largest to date for this problem—showed that women with breast cancer continued to report cognitive deficits for as long as six months after finishing treatment. That study not only validated that chemo-brain was pervasive, but Janelsins and her team also began parsing the data to understand the biological mechanisms, such as inflammation, that may put some patients at greater risk for chemo-brain. “I’m happy that my team’s research is starting to shed light on what might be causing cognitive problems in patients with cancer,” Janelsins said, “and I’m hopeful that we’ll be able to come up with treatments in the future.”
Roswell Park Patients Will Have Expanded Access to Medical Records Through NYS Health Foundation Grant $125,000 award will fund implementation of ‘OpenNotes,’ to be integrated into MyRoswell patient portal
care, medications or other interventions, prognosis and followup care. First established in 2010 at Beth Israel Deaconess Medical Center in Massachusetts, the OpenNotes concept is now being implemented at several centers across New York State. The grants announced this week to Roswell Park and six other centers are the first awarded by the NYS Health Foundation to organizations in Upstate Western New York in support of this initiative. “Note-sharing is one of the quickest and most effective ways for clinical care providers to keep patients informed and to engage them in the treatment planning process. The New York State Health Foundation grant has given us such a great platform for being creative with how we integrate OpenNotes into our patient portal and tailoring it to the needs of Roswell Park patients, whose diagnoses and treatment care plans are often very detailed and complex,” says Everett Weiss, MD, Roswell Park’s Chief Medical Information Officer. Implementation of OpenNotes at Roswell Park will begin in 2018 and will be phased, with both outpatient clinic visit notes and inpatient discharge summaries to be available for every adult patient on the existing MyRoswell portal. Interactive features will allow patients to highlight sections of a note where they have questions, save key sections they’d like to discuss at their next visit and access a personalized glossary of medical terms to improve their comprehension of note contents.
By Annie Deck-Miller
• Note-sharing empowers patients, can improve clinical outcomes • Cancer center will be one of the first NYS facilities to implement the concept • Interactive features to be added through MyRoswell secure portal A newly awarded grant will enable easier, more interactive access to medical records for Roswell Park Cancer Institute patients. The comprehensive cancer center will become one of the first centers anywhere in New York State to implement the OpenNotes concept and integrate note-sharing into its secure digital portal, MyRoswell, thanks to a $125,000 award from the New York State Health Foundation. “Information-sharing is a critical piece of the care we provide,” says Roswell Park Chief Medical Officer Boris Kuvshinoff II, MD, MBA. “Access to information about medical care not only empowers patients, it actually can help improve their clinical outcomes, because the clinical team and patient are communicating more thoroughly and effectively.” OpenNotes is an international movement advocating for patients’ expanded access to medical notes — accounts by medical staff in each patient’s written records that document important details and guidance about a patient’s diagnosis,
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medical records for Roswell Park
Cancer Institute patients. The
comprehensive cancer center will become one of the first centers
anywhere in New York State to
implement the OpenNotes concept
and integrate note-sharing into its secure digital portal, MyRoswell,
thanks to a $125,000 award from the
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of a note where they have questions,
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Israel Deaconess Medical
Center in Massachusetts, the
OpenNotes concept is now
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The grants announced this week to Roswell Park and
six other centers are the first
awarded by the NYS Health
Foundation to organizations in Upstate Western New York in support of this initiative.
“Note-sharing is one of the
quickest and most effective
ways for clinical care providers to keep patients informed
and to engage them in the
treatment planning process.
The New York State Health
Foundation grant has given us
such a great platform for being
The experts at the Vascular & Endovascular Center of Western New York provide minimally invasive surgical care and superb diagnostic testing utilizing state-of-the-art technology. • • • •
Five board-certified vascular surgeons Minimally Invasive Vein Care in both Buffalo and Niagara Falls Seamless care coordination with specialty providers Top 3% nationally-ranked vascular surgery practice
Affiliations with Catholic Health, Kalieda Health and Catholic Medical Partners
creative with how we integrate
OpenNotes into our patient
portal and tailoring it to the
needs of Roswell Park patients,
WNYPHYSICIAN.COM VOLUME 6 I 2017 I 27
Texting Medical Orders Presents Serious Risks and correctness, rather than information security, authentication or documentation issues.”
The texting of medical orders remains a significant concern for patient safety. The Institute for Safe Medication Practices (ISMP) conducted a survey of readers from June through August 2017, to assess opinions about the texting medical orders in healthcare. The ISMP authors’ findings noted, “Respondents reported that the five most concerning risks associated with texted orders were associated with safety issues impacting order clarity, completeness
These five risks are: • unintended phone/device auto correction; • use of potentially confusing abbreviated text terminology; • potential for patient misidentification; misspellings; and incomplete orders. Although the technology of texting has become commonplace, the risk that it poses in healthcare precludes its use until such time as the associated safety and technological issues have been resolved. Additionally, The Joint Commission continues to ban
the texting of medical orders in its accredited organizations, asserting that computerized provider order entry is the preferred method for submitting orders, as it allows providers to directly enter orders into the electronic health record. • To read an article from FierceHealthcare discussing the study findings, click here. • To read the ISMP Medication Safety Alert, click here. • To read The Joint Commission’s position on the texting of medical orders, click here. This blog entry has been reproduced with permission from The MLMIC.com Blog (original publication date), published by MLMIC, 2 Park Avenue, Room 2500, New York, NY 10016. Copyright ©2017 by MLMIC. All Rights Reserved. No part of this entry may be reproduced or transmitted in any form or by any means, electronic, photocopying, or otherwise, without the written permission of MLMIC.
How to Protect Yourself from Your Computer by Marc-Anthony Arena
Available anywhere books are sold Are you frustrated with your computer? Bombarded by error messages? Plagued by constant update notifications? Which ones should you believe? The world of computers is a mysterious one. How to Protect Yourself from Your Computer outlines the basic concepts Plain English. Author Marc-Anthony Arena realized that all his customers were doctors, lawyers, or business executives, yet each initial phone call to him starts out with “I feel stupid”or “I feel intimidated by technology”. He discovered that it wasn’t the users who were stupid, but rather careless product design that bring about all the helplessness we know so well. We are increasingly reliant on technology, yet it’s increasingly complex and unreliable. We are talked into performing constant scans and updates, but do they actually help? The author explains why everything we’re doing is a placebo, and why all of the worries and woes are preventable if you’re aware of The Four New Threats. Marc explains how those we trust to protect us are often unaware of the new threats, or unaware of proper backup. In these cases, we lose all our precious data when ransomware scams walk right into our machines. He also exposes some of the scandals in the industry such as vendor lock-in and software rentals, where companies try to lock customers in for life instead of competing on merit.
Find out why there's no need for any of this fr ust ration! 28 I VOLUME 5 I 2017 WNYPHYSICIAN.COM
Independent Perspective | Real-World Solutions
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Heart Center physicians from L to R: Joseph Gelormini, MD, FACC, FSCAI, Medical Director of Catholic Healthâ€™s Cardiac Service Line; Harsh Jain, MD, FACS, cardiothoracic surgeon with Mercy Hospital Cardiothoracic Surgical Associates; Aravind Herle, MD, FACC, Chief of Cardiology at Mercy Hospital; and Stephen Downing, MD, FACC, FACS, Chair of Cardiothoracic Surgery at Mercy Hospital and Medical Director of the hospitalâ€™s TAVR program.
Quality is at the Heart of Everything We Do For the second year in a row, Mercy Hospital has received the GWTG Platinum Performance Achievement Award from the American College of Cardiology NCDR Action Registry. Mercy is one of only 193 facilities nationwide to achieve this distinction. Together, the highly skilled physicians, nurses and associates at Mercy and Trinity Medical Cardiology deliver advanced, quality comprehensive cardiac care.
Visit chsbuffalo.org/heartcare to learn about cardiac care at Catholic Health. To make a referral to Trinity Medical Cardiology, call their new Centralized Cardiac Procedure line at (716) 204-1915. Catholic Health
Heart Center at Mercy Hospital of Buffalo
Azher Iqbal, MD, Medical Director of Vascular Interventional Associates (VIA), an early pioneer of endovascular techniques, established Buff...
Published on Jan 29, 2018
Azher Iqbal, MD, Medical Director of Vascular Interventional Associates (VIA), an early pioneer of endovascular techniques, established Buff...