maryland physician magazine july/august 2012 issue

ORTHOPEDIC UPDATE:JOINT TUNE UPS

ARE ALTERNATIVE CAREDELIVERY MODELS RIGHTFOR YOUR PRACTICE?

MAKING MARYLANDHEALTHIER WITHHEALTHCARE IT

ORTHOPEDIC UPDATE:JOINT TUNE UPS

ARE ALTERNATIVE CAREDELIVERY MODELS RIGHTFOR YOUR PRACTICE?

MAKING MARYLANDHEALTHIER WITHHEALTHCARE IT

VOLUME 2: ISSUE 2 JULY/AUG 2012

Physician

www.mdphysicianmag.com

YOUR PRACTICE. YOUR LIFE.

MARYLAND

LOVE THE SERVICE. APPRECIATE THE CONVENIENCE. TRUST THE NAME.

call 1-888-972-9700 or visit our website at www.advancedradiology.com

Find us on

JULY/AUGUST 2012 | 3

10 JointTune UpsLifestyle Changes, Shoulder & Hip Replacement

14 Alternative Care Delivery ModelsAre They Right For You?

20 Can Healthcare IT Make Maryland Healthier?DHMH Secretary Sharfstein Reveals the Challenges and Potential of Using IT

F E A T U R E S

D E P A R T M E N T S

ContentsJuly/August 2012 Volume 2: Issue 2

2010 24

Cases | 6 | Limb Lengthening with a New Internal, Controllable Device

Compliance | 7 | If You Accept Plastic,Then ...

Living | 24 | Maryland on theWater: Summer Fun Along theWaterways

Policy | 30 | Cardin Comments on the Affordable Care Act, Supreme Court, Health Priorities

Solutions | 33 | Seven Reasons to Consider a Cloud-Based EMR

Good Deeds | 34 | Life AfterWar:Walter Reed National Military Center Helps Soldiers Get Back to Living

On the Cover: Maryland Department of Health and Mental Hygiene Secretary Joshua M. Sharfstein, M.D.

AAS WE WENT TO PRESS FOR THIS ISSUE, America’s patients, healthcareproviders and politicians – everyone – were bracing for the Supreme Court’s rulingon the constitutionality of the Affordable Care Act (ACA). Political philosophicaldifferences aside and despite having some of the world’s leading-edge providers herein Maryland, most agree the American healthcare delivery system is broken and needsto be fixed.

The “train has already left the station” in many of the ACA’s intended reformswith a number of states having been forward thinking, already undertaking andimplementing some of the goals of the ACA. Maryland is one of the leaders, helpingpatients and their providers gain information via technology, with the intention ofallowing all to be empowered, educated and involved in making informed caredecisions. Informed decisions provide better outcomes and save us money. That’swhat the system needs: improvements and accountability in quality and value.Maryland Physician Magazine Managing Editor Linda Harder and I had interviews withtwo of Maryland’s healthcare leaders, Department of Health and Mental HygieneSecretary Joshua M. Sharfstein, M.D. and U.S. Senator Ben Cardin (D-MD). To learnwhat they are doing to support your practice and how you deliver care to your patients,see Healthcare IT (page 20) and Policy (page 30).

If you’re a private primary care physician reading Maryland Physician, you’re wellaware of the strains reimbursement rates create on the way you practice medicine andmanage your practice. There are options available. Are they right for you? Are theyright for your patients? See our feature, Alternative Care Delivery Models (page 14).

Clinically, our issue spotlights updates in orthopedics with a focus on the hips andshoulders. I had to laugh when one of this issue’s ads was delivered – an image of abicycle rider feet over his head on his way to meet the road. I’ve been that guy; I washit by an SUV late last fall while on my own bike and have been in treatment for avariety of issues since then. I shudder to think what would have happened had I notbeen in good physical condition when my body made contact with the SUV and thenthe road. Via that experience, I’ve been a bit too “up close and personal” with bothWestern and Eastern treatments but I’m back biking and living the Chesapeakelifestyle – on the water – as much as I can. Learn about one of the fastest growing andinexpensive watersports, stand up paddling (SUP), in Living (page 24).

Enjoy some time away from your practice this summer and be sure to share theroad and waterways!

To life!

Jacquie RothPublisher/Executive [email protected]

4 | WWW.MDPHYSICIANMAG.COM

JACQUIE ROTH, PUBLISHER/EXECUTIVE [email protected]

LINDA HARDER, MANAGING [email protected]

CONTRIBUTING WRITERSTracy FitzgeraldJackie Kinsella

CONTRIBUTING PHOTOGRAPHYTracey Brown, Papercamera Photography

www.papercamera.comMark Molesky, Moleskey Photographywww.moleskyphotography.com

ADMINISTRATIONGinger Jenkins

EXECUTIVE ASSISTANT/WEBMASTERJackie Kinsella

Maryland Physician Magazine™ is published bimonthly byMojo Media, LLC. a certified Minority Business Enterprise (MBE).

Mojo Media, LLCPO Box 1663Millersville, MD 21108443-837-6948www.mojomedia.biz

Subscription information: Maryland Physician Magazineis mailed free to Maryland licensed and practicing physiciansand a select audience of Maryland healthcare executivesand stakeholders. Subscriptions are available for the annualcost of $52.00. To be added to the circulation list, call443-837-6948.

Reprints: Reproduction of any contact is strictly prohibitedand protected by copyright laws. To order reprints of articlesor back issues, please call 443-837-6948 or email [email protected].

Maryland Physician Magazine Advisory Board: Anadvisory board comprised of medical practitioners and businessleaders in diverse practice, business and geographic scopesprovides editorial counsel to Maryland Physician. Advisoryboard members include:

KAREN COUSINS-BROWN, D.O.Maryland General Hospital

PATRICIA CZAPP, M.D.Anne Arundel Medical Center

HOLLY DAHLMAN, M.D.Greenspring Valley Internal Medicine, LLC

PAUL W. DAVIES, M.D., FACSKURE Pain Management

GAUROV DAYAL, M.D.Adventist HealthCare

MICHAEL EPSTEIN, M.D.Digestive Disorders Associates

STACY D. FISHER, M.D.University of Maryland Medical Center

REGINA HAMPTON, M.D. FACSSignature Breast Care

DANILO ESPINOLA, M.D.Advanced Radiology

GENE RANSOM, J.D., CEOMedChi

Although every precaution is taken to ensure accuracy ofpublished materials, Maryland Physician and Mojo Media, LLCcannot be held responsible for opinions expressed or factssupplied by authors and resources.

Green logo here

NOW MARYLAND PHYSICIANS CAN ENJOY A NEARLY 90% WINNING RECORD

IN LIABILITY CASES.Maryland physicians love winning liability cases even more than they love crab cakes. That’s why it’s so exciting

that Coverys’ medical professional liability coverage is now available here. For more than three decades, Coverys

has been aggressively defending good medicine. Over 75% of our cases are closed without indemnity payments

and we enjoy a win rate of nearly 90% for those that go to a verdict at trial. Finally, Coverys’ winning record,

financial strength, and wide range of expertise can be yours. Delicious.

www.COVERYS.com

Medical professional liability coverage in Maryland is provided by ProSelect Insurance Company, a member company of Coverys.

Claim data for Coverys member companies Medical Professional Mutual Insurance Company and ProSelect Insurance Company


DISCUSSION Limb length discrepancymay result from congenital, post-traumatic, and developmental etiologies.Differences greater than 1 to 2 cm cancause a limp, back pain, hip pain, and/orarthritis. External shoe lifts can alleviatethese issues but are not typically acceptedby young adults. Surgical lengthening ofthe short limb offers a permanentsolution. Classically, the method tolengthen a short leg required using anexternal fixator for many months.Potential complications include pain,scarring, infection, and fracture afterlengthening. Wearing the external fixatorfor months at a time can be difficult totolerate both physically and

psychologically. Recently, alternativemethods for limb lengthening have beendeveloped that use fully implantabletelescopic intramedullary rods.

In 2001, the first generationintramedullary telescopic rod wasintroduced in the USA. This was theIntramedullary Skeletal KineticDistractor (ISKD). The ISKDlengthened via a one-way mechanicalratchet mechanism. After the bone cutwas performed and the ISKD wasimplanted, the leg was rotated back andforth. This movement caused the ISKD

and the limb to lengthen through thebone cut. Having implanted more than280 of these devices, we have hadgenerally good results, but themechanism was difficult to controlaccurately. As a result, many limbsinadvertently lengthened too quickly ortoo slowly. Lengthening too quickly mayprevent the bone from healing and cancause joint contractures, excessive pain,and even peroneal nerve stretch injuries.

More recently, second generationtechnology has been released. ThePrecice rod, approved by the FDA inJanuary 2012, contains a tiny internalmagnetic motor, gearbox, and telescopicmechanism. Although similar in externalappearance to the ISKD, the Precice rodlengthens only when an external magneticfield generator is placed against the leg.The external magnetic field generator isheld next to the leg for a few minutes topower the magnetic motor inside the rodin a precisely controlled fashion.

In this case, the patient opted to havehis femur lengthened with the Precicerod. Seven days after the Precice rod wasinserted, he started the lengtheningprocess at a rate of 1 mm/day. This ratewas increased to 1.5 mm/day when rapidbone healing was seen on follow-upradiographs. Pain was well controlled withoral analgesics. Joint range of motion wasmaintained throughout the lengtheningprocess during physical therapy sessionsfive times a week. Radiographs wereobtained weekly to ensure that thePrecice rod and the external magnetic

field generator were working properly.The femur lengthened 3 cm unevent-fully over the course of four weeks. Itwas fully healed six weeks afterlengthening was complete. At this time,the patient was allowed to fully weightbear without assistive devices and hasreturned to full activity.

Since January 2012, we haveimplanted 17 Precice rods. Althoughour experience is still early, the Precicerod appears to be a significantimprovement over the first generationISKD technology, providing a moreaccurate rate of lengthening and lesspain than with the ISKD.John E. Herzenberg, M.D., F.R.C.S.C.,

director, Shawn C. Standard, M.D., head of

pediatric orthopedics, and Stacy C. Specht,

M.P.A., research program manager—all at

the International Center for Limb Lengthen-

ing, Sinai Hospital of Baltimore. Contact

Dr. Herzenberg at jherzenberg@lifebridge-

health.org.

Cases

Limb Lengthening with aNew Internal, Controllable Device

CASE: A 15-year-old boypresents with limb lengthdiscrepancy that resultedafter damage to the growthplate of the femur. Theinjury occurred during afootball game 3 yearsearlier. Physical examshowed a healthy youngman who walked with alimp and had full range ofknee motion. The rightfemur was 3 cm shorterthan the right. Surgical andnon-surgical options werediscussed with the patientand his family.

John E. Herzenberg, M.D., F.R.C.S.C., Shawn C. Standard, M.D.,and Stacy C. Specht, M.P.A.

The femur lengthened 3 cm uneventfully overthe course of four weeks. It was fully healed sixweeks after lengthening was complete.


HILE DOCTORS,hospitals and other medical facilitiesare patently aware of the numerousfederal and state laws and regulationsthat govern the use and protectionof patient information, they may notbe aware of certain industry privacystandards applicable to medicalproviders that accept or process creditand debit card payments from patients.

PCI Security StandardsThe Payment Card Industry SecurityStandards Council (PCI SSC) was createdjointly by most of the major credit cardcompanies. It establishes technical andoperational requirements, known as thePayment Card Industry Data SecurityStandards (PCI DSS), which apply to all“merchants” (including medical providers)that accept or process payment cards.The PCI DSS is, in turn, enforced by theindividual credit card companies throughtheir dealings with any entity that acceptspayments from that card company.

Compliance with the PCI DSS isimportant now, more than ever, becauseof the increasing number of transactionsinvolving credit and debit cards, thepotential liability that can arise froma security breach and subsequentcompromise of payment card data, andthe potential revocation of card processingservices by banks and card companies.

A security breach can have far-reaching consequences, includingnotification requirements, litigationcosts and potential financial liabilities.A data breach can also have an impacton goodwill, potentially resulting in aloss of reputation and patients.

Medical providers are vulnerable todata breaches at various stages of paymentcard processing. For example, point-of-saledevices, personal computers or servers,wireless hotspots, paper-based storagesystems, and unsecured transmission ofcardholder data to service providers, allpresent potential points of vulnerability.

Compliance with the PCI DSScan help alleviate these potentialvulner- abilities and protectcardholder data.

Three StepsThere are three steps for adhering to thePCI DSS: assessment, remediation, andreporting.

A medical provider should assess its datasecurity by:1. identifying cardholder data2. taking an inventory of its information

technology assets and the businessprocesses it utilizes for payment cardprocessing

3. analyzing them for vulnerabilities thatcould expose cardholder data.

Generally, small practices may use aself-assessment questionnaire as a self-validation tool to assess PCI DSScompliance. The self-assessmentquestionnaire is provided by the PCI SSC,and requires varying levels of informationdepending on the manner in which amedical practice accepts payment cards.

Remediation can be accomplishedby (i) fixing vulnerabilities, and (ii)most importantly, not storing cardholderdata any longer than absolutely neededto process a transaction.

Finally, required reports should becompiled and submitted to the acquiringbank and/or card brands with which amedical provider does business.

General RequirementsThe PCI DSS also establishes 12 generalrequirements:

Build and Maintain a Secure Network� Install and maintain a firewall

configuration and router configurationto protect cardholder data.

� Do not use vendor-supplied defaultsfor system passwords and other securityparameters.

Protect Cardholder Data� Protect stored cardholder data – in

general, no cardholder data should everbe stored unless it is necessary to meetthe needs of the business.

� Encrypt transmission of cardholderdata across open, public networks.

Maintain a Vulnerability ManagementProgram� Use and regularly update anti-virus

software or programs.� Develop and maintain secure systems

and applications.

Implement Strong Access ControlMeasures� Restrict access to cardholder data by

need-to-know.� Assign a unique ID to each person with

computer access.� Restrict physical access to cardholder data.

Regularly Monitor and Test Networks� Track and monitor all access to network

resources and cardholder data.� Regularly test security systems and

processes.

Maintain an Information Security Policy� Maintain a policy that addresses

information security for employeesand contractors.

A medical provider’s compliance withthese requirements, and with its specificbank and/or card company assessmentand reporting requirements, can helpprotect patient cardholder information,and help prevent a damaging data breach.Barry F. Rosen, Chairman and CEO of the law

firm of Gordon Feinblatt LLC, can be reached at

[email protected]. John C. Morton, an associ-

ate , can be reached at [email protected].

Compliance

WIf You Accept Plastic,Then ...

By Barry F. Rosen and John C. Morton

USCULOSKELETAL(MSK) issues are some of the mostcommon clinical problems necessitatingan imaging study. With a wide range ofdisorders, it can be challenging forreferring physicians to order the rightstudy for a given problem. What if theX-ray does not demonstrate a problembut the patient continues to experiencepain? When is 3T MRI appropriate?When is ultrasound an acceptablesubstitute? When should arthrographybe ordered?

Advanced Radiology offerscomprehensive and complete imagingoptions for your patients. Its MSKexperts have prepared this guide foryour convenience and are available toanswer any of your questions about aspecific patient. Physicians can call888-972-9700 and ask to speak to oneof its many subspecialtymusculoskeletal radiologists. Thepractice also offers treatments,including steroid and anestheticinjections for painful joints.

X-raysRadiographs should always be the firsttest for suspected bone or joint injuryor pain. They often are sufficient tomonitor non-complicated healing forfixation procedures, initial evaluation ofarthritis and nonspecific pain localizedto a joint. Most suspected fractures canbe imaged with plain X-rays or CT.

MSK CTMusculoskeletal CT can be reliablyused to evaluate suspected fractures


Profile SPONSORED CONTENT

MSK Imagingfrom Shoulders to Toes

A Guide to Ordering the Right Imaging Study for each MSK Problem

High strength MRI reveals underlying issues in small joints, from shoulders to toes.

M


or as an alternative to MRI forpatients with pacemakers or othercontraindications to MRI. It also canbe helpful for surgical planning inthe setting of complex fractures,evaluating for avascular necrosisfollowing fixation procedures orassessing complications after hipreplacement. 3D volumetric renderingimages are available upon request toassist clinicians in management.

MSK Ultrasound� Ultrasound (US) is appropriate

for evaluating select soft tissueconditions, including:

� Tendon tears – especially rotatorcuff, biceps, quadriceps and Achillestendons

� Pain in joint with metal implant� Soft-tissue masses such as lipomas� Bleeding or fluid collections in

muscles, bursae and joints, includingpopliteal cysts

� Early rheumatoid arthritis changes

“Ultrasound can be an appropriatefirst modality in many clinical situations,especially for elderly patients,”comments Advanced Radiology'sultrasound expert, Thayer Simmons,M.D., MSK ultrasound expert.

Nuclear MedicineThree phase bone scans are an excellentmodality for the early diagnosis of shinsplints, pars interarticularis defects andstress fractures following a negativeX-ray and unexplained bone pain.Other indications include the evaluationof painful joint replacements anddetermining if osteomyelitis is present.Danilo Espinola, M.D., nuclearmedicine and PET/CT specialist,states, “If a bone scan is non-diagnosticfor osteomyelitis, then a physicianshould order a labeled white bloodcell scan.”

MSK MRIWhen an injury with a negative X-rayis not healing after two weeks, furtherevaluation with a second modality, suchas MRI, is warranted. Loralie Ma, M.D.,Ph.D., Medical Director of GBMC,MRI and PET CT and expert in MRIimaging advises, “For most musculo-

skeletal indications, MR contrast isgenerally not required, except forinflammatory arthritis, suspectedabscess or neoplasm.”

High field (1.5 to 3T) MRIplays a crucial role in MSK diagnosisand treatment planning when otherimaging modalities are insufficient.With its superb spatial resolutionand soft tissue visualization, MRIis ideal to:

� Evaluate patients with pain whohave negative radiographs. It isespecially useful for athleteswith an unresolved soft tissueinjury, or to confirm a diagnosisprior to surgery

� Guide therapeutic managementand help patients avoid long-term consequences such asosteoarthritis

� Diagnose tears in the labrum,cartilage, menisci, ligaments andtendons, as well as tendinitis andtenosynovitis

� Visualize stress fractures, masses andcongenital anomalies

Robert Van Besien, M.D., amusculoskeletal MRI expert, comments,“MRI often shows that the problem isnot what was suspected on clinicalexamination. For example, in the ankle,patients referred to rule out a tendon tearmay instead have a ganglion orosteochondral injury, which can changetheir management.”

When to Use 3TGenerally speaking, 3T MRI shouldbe considered for patients withdamage or injury to the small joints –wrist, hand, ankle, foot or elbow.3T is also useful for diagnosing smalltendon tears and grading articularcartilage abnormalities in the shoulder,knee and hip to improve pre- andpost-surgical treatment planning.

As the continued leader inoutpatient imaging in Maryland,Advanced Radiology has four 3T MRImachines, more than any otheroutpatient imaging provider in the state.Its Crossroads center in Columbia/Ellicott City now offers one of theregion’s first wide-open 3T MRIs.

3T and Cartilage MappingDr. Ma observes, “Cartilage mapping isnow available at two of our 3T locations– at GBMC and Crossroads. It is idealfor patients with ligament or meniscaltears and suspected articularcartilaginous injuries. This software canaid clinicians in detecting subtle occulttrauma and help in operative planning.It can also evaluate cartilage followingautologous osteochondral grafts.”

MR or CT ArthrographyA common use for MR arthrographyis providing fine detail to evaluateglenoid or acetabular labral tears. Itis particularly useful in athletes of allages, whose pain is not resolving afteran injury. By joint, common indicationsinclude:

� Shoulder - labroligamentousabnormalities, capsule and rotatorcuff pathology

� Hip - acetabular labral tears� Wrist - TFC or scapholunate

ligament tears after a fall or work-related injury

� Elbow - ligaments and articularcartilage defects

� Knee - recurrent meniscal tearsafter prior meniscal repair

� Ankle - talar osteochondral injuries,loose bodies

Alison Oldfield, M.D., arthrographyexpert, notes, “Arthrography canprovide the finer detail needed todetermine whether surgical interventionwould benefit the patient or whenregular MRI is not definitive. CT is analternative when MRI is contraindicatedor for more specific bone detail. We alsoperform indirect arthrograms, wherecontrast is injected intravenously.”

Joint Pain TreatmentsAdvanced Radiology can performinjections of steroids or anesthetics totreat patients with pain in any joint.“This service, which is mostcommonly used to treat hip andshoulder pain, is available in manyof our centers,” notes Dr. Espinola.Call 888-972-9700 to speak to an

Advanced Radiology subspecialty

musculoskeletal radiologist.


LIFESTYLE CHANGES,SHOULDER & HIP REPLACEMENT

JointTuneUps

BY LINDA HARDER

PHOTOGRAPHY BY TRACEY BROWN

An aging but active population ofbaby boomers is fueling an explosion inorthopedic problems.To learn the latest,

Maryland Physician spoke with Marylandexperts in shoulder and hip joint

replacements – plus a physiatrist whospecializes in lifestyle changes that help

patients prepare for surgery.

Surgical “Tune-Ups”Improve OutcomesWhile the critical factor in orthopedicsurgery outcomes is the skill of thesurgeon and the technology, physiciansare becoming aware of another importantfactor – nutritional status and lifestylechoices. That’s where Frederick T.Sutter, M.D., M.B.A., a physiatrist whofounded Lifestyle Medicine Consultants,Inc. in Annapolis, comes in.

“When I get a referral for someonewho may need surgery,” says Dr. Sutter,“it’s a superb opportunity to sparkmeaningful patient cooperation tooptimize their nutrition and exercisehabits. Poor lifestyles contribute to poorsurgical results. Many people think thatthey need to change their lifestyle afterthey have surgery, but we like tointervene early on.”

To determine the most effectiveinterventions for the often-intractableproblems of obesity, sedentary lifestyleand poor sleep and nutrition habits, Dr.Sutter spent years combing the literature.“For example, more than 100 peer-reviewed studies have shown thatnutritional factors influence surgicaloutcomes,” he notes.

“We ask patients how long they wantto take to recover. Then we tell themthere are about a dozen things they cando to speed that recovery. We evaluatetheir sleep and exercise habits, nutritionaldeficiencies and stress.”

“That led to us develop our WeightLoss 5x5® lifestyle medicine program,”Dr. Sutter says. “People take five steps,five weeks at a time – they get theirtraining wheels so to speak. We build in alot of accountability, then expand theintervals in between visits and at the endask participants to commit to a one yearmaintenance plan to help them keeptheir good new habits. Diets fail – ourprogram is oriented to lifestyle changessupported by accountability.

“Many overweight people havearthritic problems,” he continues.“Sometimes the surgeon won’t operate ifthe patient doesn’t lose some of thatweight. We provide exerciseprescriptions, rather than just tellingthem to “do more.” We check fornutritional deficiencies and imbalancessince the targeted use of nutrients hasbeen shown to favorably influencesurgical outcomes. We also prescribeexercise to improve muscle tone. Wediscuss sleep hygiene, since pain can leadto sleep disruption and even a Vitamin Ddeficiency, since patients stop goingoutside. Following the No-White Diet toeliminate refined foods can help reduceinflammation and promotes healing.”

Dr. Sutter reminds primary carephysicians that they play a more criticalrole than they perhaps realize. “What canprimary care physicians do? Mostimportant is that they ask their patient tolose weight or make other healthylifestyle changes. Studies have shownthat patients are three to four times morelikely to make a positive change if theirphysician asks them.

“Then, patients need accountabilityand support – such as working out with afriend or having a holiday party whereeveryone brings a healthful dish, then

shares recipes,” concludes Dr. Sutter. “Wesay to patients, ‘Let’s take a stand together.’”

Shoulder Arthroplasty:Often OverlookedFor the past 25 years, Steve Petersen,M.D., orthopedic surgeon, Johns HopkinsOrthopaedic & Spine Surgery at MedStarGood Samaritan Hospital, has focused hisentire orthopedic practice on shoulder

disorders. In that time, he’s performedmore than 600 shoulder replacements,making him one of the highest volumesurgeons in this area. Yet shoulderarthroplasty continues to be eclipsed byhip and knee replacements, which arenow each performed in over 600,000patients a year throughout the country.Given the lower profile of shoulderarthroplasty in the community, it can beoverlooked as an option in the treatmentof shoulder arthritis.

Why is shoulder arthoplasty performedso much less frequently and what are theadvances in the procedure? Dr. Petersensays, “The shoulder joint is subject tostresses equal to body weight, while thehip and knee carry three to five times thatburden. Arthritis may be as common inthe shoulder as it is in these other joints,but it often is much less symptomaticgiven these lesser stresses. Shoulderreplacement has proven to be the goldstandard treatment for severe shoulderpain and disability from arthritis.”

Ideal CandidatesSurgery is not considered an option untilmore conservative approaches, includingNSAIDs, physical therapy, heat/cold andinjections have insufficiently improvedpain and range of motion (ROM).Arthroscopic surgery may be an attractiveoption in someone with mild to moderatearthritis. “The ideal candidate for shoulderarthroplasty is someone with an intactrotator cuff, severe, poorly controlled pain,and limited range of motion,” states Dr.Petersen. “Most candidates are in theirlate 50s to early 70s, with ages rangingfrom 30-90 plus years.”

Dr. Petersen continues, “While theprocedure is not appropriate for someonewith ROM limitations without significant

pain, it’s important that physicians notwait until the patient has begun to wearaway glenoid bone, which cancompromise outcomes. If a patient hasrheumatoid arthritis with progressive lossof bone, it’s a good time to refer to anorthopedist because glenoid bone losscompromises our ability to improvemotion and stability. With osteoarthritis,posterior glenoid bone loss can become a


Michael Anvari, M.D.

“The ideal candidate for shoulderarthroplasty is someone with an intactrotator cuff, severe, poorly controlledpain, and limited range of motion.”

- Steve Petersen, M.D.

concern, creating a challenging situationif surgical treatment is delayed.”

Reverse Shoulder ArthroplastyAppropriate for some elderly andsedentary patients with advanced arthritisand an irreparable rotator cuff tear (rotatorcuff arthropathy), reverse total shoulderarthroplasty enables experiencedshoulder surgeons to treat patients withpreviously insoluble conditions. By usingspecial techniques and prosthesesdesigned to replace the humeral headwith a socket and the glenoid socket witha ball, qualified surgeons can improve thestability of the shoulder and increasemotion that is provided by the deltoid.

Downsides to Robots and MISDr. Petersen is cautious about advocatingminimally invasive surgery (MIS) orrobotic approaches. “If a patient has tohave a partial shoulder replacementrevised, the results are not as predictableor durable as they would have been witha total shoulder replacement.

“The classic total shoulderreplacement has the best outcomes,supported by 20 years of data,” Dr.Petersen adds. “Different resurfacingoptions have been developed for youngerpatients, but long-term follow-up data isnot yet available.”

CAD/CAM and robotics techniqueshave not been proven more effective thantraditional techniques. “We need toprovide reproducible techniques andalternative products that are durable andcost effective. There are some things onthe horizon – using 3D models andcomputer software for more accuratereplacement of components. Thisattractive innovation needs further testing

and well developed clinical studies prior toits release for use,” Dr. Petersen envisages.

“I believe that the future of shoulderreplacements will need to focus more onthe materials used than new techniques.Polyethylene is the most vulnerablematerial we use and there may be alternativematerials in the future that will allow us todevelop more durable arthroplastycomponents,” Dr. Petersen concludes.

Anterior Hip Replacement:Better StabilityMichael Anvari, M.D., joint replacementspecialist, Carroll Hospital Center, isbullish about the anterior approach to hipreplacement; he now performs thisprocedure on virtually all appropriatepatients. He notes, however, “Thisapproach is not ideal for patients withsignificant anatomic dysplasia or a BodyMass Index approaching 35 to 40.”

While not a new procedure, theanterior supine inter-muscular approachto hip replacement is not yet widelyavailable. It requires significant training,and a special radiolucent OR table thatimproves access to the femur is helpful.The table allows supine positioning andpermits precise positioning of theproximal femur. The approach permitsmore accurate and consistent componentpositioning and lower dislocation risk, andthe table facilitates the use ofintraoperative fluoroscopy, whichincreases the accuracy of implantplacement and leg lengths.

The approach is less invasive becauseit takes advantage of the natural gapbetween the gluteus medius and rectusfemoris muscles to enter the hip capsule.Dr. Anvari observes, “Traditional hipreplacement is already a very good

procedure, with 95% patient satisfaction,but the anterior approach is an improvement.In the short term, patients typically reducetheir length of stay, use of narcotics andrehab time, and they can return to activitiesmore quickly. Over the long term, thebiggest advantage is better stability.”

From the health system approach, thecost of the anterior approach is slightlyless than the traditional approach; forpatients, it’s roughly equivalent. Whilethe surgical table costs about $100,000, itcan be used for other procedures such aship arthroscopy and fractures, and thehospital stands to gain by dischargingpatients earlier and requiring less nursingcare. “In my practice,” notes Dr. Anvari,“I have patients who get two weeks ofhome therapy; half of them then need nooutpatient therapy, while the other halfneed it for less time than normal.”


Frederick T. Sutter, M.D., M.B.A.

Advantages of AnteriorHip Replacement� Intraoperative fluoroscopy - precise

positioning of implants, leg lengths

� No muscle cutting

� Faster recovery

� Less post-operative pain/decreases

use of narcotics

� Quicker return of normal function

� Superior stability

� Eliminates traditional hip dislocation

precautions

� Lower dislocation risk long-termSteve Petersen, M.D.

Training InvestmentFor surgeons, however, learning theanterior approach requires a significantinvestment of time that should includeeducation, training programs and cadaverwork. “For me, it was a three to four yearprocess to complete my study andtraining,” says Dr. Anvari. “I don’tbelieve in being an early adopter ofanything. I’m conservative, and don’twant my patients to be one of the first.You have to prove that the new approachis better than the current standard.”

As a result, he took a conservativeapproach to the new procedure. “Mypatients have had a genuinely betterexperience with the anterior approach,”he adds. “Some of them had the posteriorapproach for their first hip and theanterior approach for the other hip, sothey can directly compare.”

A study published in the Journal ofBone and Joint Surgery in 2009 foundsignificantly improved early recovery ofpatients who underwent the anteriorapproach, with a higher rate of dischargedirectly to home, as well as improvedHarris hip scores and lower-extremityactivity scale scores at six weeks.

While an advantage of the anteriorapproach is reduced risk of dislocationpost operatively, Dr. Anvari again strikes aconservative tone. “I believe that the skillof the surgeon most affects the dislocationrisk. For experienced surgeons, the risk isless than 1 percent, regardless of whichapproach is taken.”

However, the anterior approach doespreclude having to take the post-opprecautions necessary following theposterior approach – including usingabduction pillows and avoiding crossingthe legs, deep bending or sleeping on theside for six weeks. Instead, patients canimmediately resume normal activitieswithout restrictions.


Michael Anvari, M.D., orthopedic surgeon,joint replacement specialist, CarrollHospital CenterFrederick T. Sutter, M.D., M.B.A., specialist inPhysical Medicine and Rehabilitation andfounder, Center for Wellness MedicineSteve A. Petersen, M.D., Johns HopkinsOrthopaedic & Spine Surgery at MedStarGood Samaritan Hospital, co-director forthe division of shoulder surgery andassociate professor, Orthopaedic Surgery,Johns Hopkins University School of Medicine

. T O T A L J O I N T R E C O N S T R U C T I O N

. S P O R T S M E D I C I N E

. S P I N E C A R E

. S H O U L D E R , E L B O W A N D H A N D

. O R T H O P A E D I C T R A U M A

. P E D I A T R I C O R T H O P A E D I C S

. M U S C U L O S K E L E T A L O N C O L O G Y

. F O O T A N D A N K L E

For orthopaedic appointments, please call 410-448-6400 or visit umortho.org.

SPECIALTIES INCLUDE:

University of Maryland Faculty Physicians, Inc. at Columbia

5500 Knoll North Drive / Columbia, MD 21045

MEDICINE ON A MISSIONumm.edu

The University of Maryland is available to referring physicians for consults or transfers at OneCall 1-800-373-4111.

Introducing University of Maryland Faculty Physicians, Inc.

at Columbia, where University of Maryland faculty physicians

provide diagnosis and treatment of all orthopaedic problems.

Just like the other orthopaedic locations in Baltimore,

Timonium and Woodlawn, this new orthopaedic site o�ers

patients access to the expert care available through an

academic medical center, yet in the comfort and convenience

of a community setting.

MORE ORTHOPAEDIC LOCATIONS

WITHIN THE STATE

Official Medical ProviderMeduumm. MEDICINE ON A MISSION Official Medical Provider

410-443-RACE (7223) | www.komenmd.org/2012

REGISTER NOW

20TH ANNUAL KOMEN MARYLAND RACE FOR THE CURE®

SUNDAY, OCTOBER 21, 2012 | HUNT VALLEY, MARYLAND

Arethey right

for

YOU?

AlternativeCare DELIVERYMODELS



HYBRID CONCIERGE CAREThe concept of concierge medicine,where patients pay an additional feefor enhanced services, originated inSeattle in the late 90s. While it hasgrown steadily over the years, no hardnumbers of the number of physiciansengaged in this practice are available.The American Academy of PrivatePhysicians estimates that as many as2000 physicians (about 1%) offerconcierge care nationwide. A much

smaller subset is estimated to providehybrid concierge care, where onlysome patients in the physician’spractice participate in the model.Critics contend that conciergemedicine could exacerbate thechallenge of finding a primary carephysician for patients, especially thosewith limited funds, while proponentstout the benefits to both physiciansand patients. The hybrid modelappears to be a way that physicianscan improve their practice viabilitywhile keeping their existing patients.

Concierge Choice Physicians(CCP), based in Rockville Centre,NY, has 200 practices in 20 states,concentrated on the East Coast. Ninephysicians in Maryland offer theirhybrid concierge model. StephenKatz, M.D., based in Severna Park,is one of their participating physiciansand an advocate for the model.“The insurance industry hasn’t raisedreimbursement since 2002. It’sdifficult to make a living in traditionalprivate practice. We initially looked atthe full concierge model, but I didn’tfeel comfortable turning away a lot of

my patients. When I learned aboutCCP, it seemed crazy at first, but itturned out that many patients wanteda more personalized experience andwere willing to pay for it, and I didn’thave to displace anyone.”

Wayne Lipton, founder andmanaging partner of CCP, agrees.“The hybrid model is a way for manydoctors to convert a small portion oftheir practice – typically 3% to 8% –to this model, while increasing theirrevenue by 30% to 100%. It’s awonderful solution to keep doctorsin the community while addressingtheir financial problems.”

Dr. Katz, a participating doctorwith CCP since 2009, has about 140patients in his concierge practice andabout 2700 in the traditional deliverymodel. Patients pay $1600 per year fora physical that is not covered by theirregular insurance. The fee alsoincludes the guarantee of same dayappointments and access to theirdoctor by cell phone. Covered servicescontinue to be billed to the patient’sinsurance plan. CCP receives aboutone-third of the concierge revenues for

WRITTEN BY LINDA HARDER

Strains on care access and delivery have ledsome physicians to create or participate indifferent models to meet patient needs – fromurgent care to concierge medicine. Are any ofthese approaches right for you and your patients?Maryland Physician spoke with some localpractice innovators to find out.

Stephen Katz, M.D.

MOLE

SKY

PHOTO

GRRAPH

Y


the first three to four years.Providers have been somewhat

surprised by the demographics ofpatients who sign up for conciergeservices. Most are middle aged andolder, upper-middle-income peoplewith medical issues, but they tend notto be the oldest or the highest incomepatients in the practice.

Dr. Katz notes that a partialconcierge model is somewhat like theMedical Home model (see PatientCentered Medical Homes Become aReality, Jan./Feb. 2012 issue atwww.mdphysicianmag.com), which hecould not make work in his practice.“We applied for CareFirst’s MedicalHome but found that we couldn’tparticipate because many of our patientswere employed by firms that self-insured. The cost of hiring a coordinatoras required by the model would havecost more than we would have receivedin additional reimbursement.”

A Painless ProcessThe company stations a person in theoffice for four to six months prior,” notesDr. Katz. “They talk with patients andalso hold some group meetings for thosewho are interested. Then we had a fewmonths’ orientation process for staff.The practice didn’t change thatdrastically – we work about the samenumber of hours with slightly lessfinancial pressure. We have certain timeslots scheduled for these patients and ithasn’t been a big challenge for our staff.”

Is Hybrid Concierge Right for You?Dr. Katz believes, “There’s no reasonnot to consider it, and nothing to lose.However, it’s probably not ideal forphysicians with only a few years left inpractice or for physicians who are justgetting started.”

Mr. Lipton observes, “You can rarelyput up a shingle and start practicing byonly offering concierge, but some doctorscan start one or two years into theirpractice. We discuss where the practiceis and how long they’ve been in practice.The number of patients has to besignificant enough to be meaningful tothe doctor – at least 50 conciergemembers if you’re a solo practitioner.

“Hybrid concierge services are akinder, more socially appropriateapproach,” he continues. ‘It’s a wayto tap into private revenue sources tosupport a physician in practice. Itbridges, not severs, the relationshipswith patients. It’s even appropriate forlarger groups and certain specialists.In a group, doctors can have differentnumbers of concierge patients withouta problem. The model can also workfor specialists who deliver some primarycare, such as a clinical cardiologist orgynecologist.”

“My patients love it,” exclaims Dr.Katz. “People have used it appropriatelyand I only get a few calls a week afterhours – only slightly more than before.”

URGENT CAREIn contrast to the fairly slow growth ofconcierge medicine, urgent care centersseem to be sprouting up like weeds,Nationally, there are roughly 8700centers, with about 75 in Maryland.

A growing number of primary carepractices (including Severna ParkMedical Associates) are adding an urgentcare component and a little-known

Maryland law requires bonus paymentsfor after-hours care (see sidebar).

Howard Haft, M.D., medicaldirector of Maryland Healthcare andShah Associates, states, “From myperspective, urgent care arose to fillan unmet demand for primary careand in response to overcrowded andinappropriately used EmergencyDepartments. The ideal situation isfor patients to receive all of their carewithin one tightly integrated caresystem, led by a single primary careprovider. All other systems tend tofragment care. Once there is sufficientsupply on the primary care side, withphysicians and physician extenders, anurgent care support system should nolonger be needed.”

Appointment-Oriented Urgent CareRobert G. Graw, Jr., M.D., a pediatricianstill in practice, started a small pediatricurgent care center in 1989. Now calledRighttime Medical Care, the companyhas grown to nine centers in Marylandthat receive more than 250,000 visitsper year from patients of all ages.

Dr. Graw recalls, “Pediatric urgentcare became needed about the timemothers went back to work. I began thebusiness with eight other pediatriciansworking in our first center called‘Nighttime Pediatrics’. In 1995, we addeda second site and realized that parentscoming in with their children also wantedour care, so we added adult urgent care.And over the years, we’ve expanded tooperate from 7 am to midnight.”

“My patients love it.People have used itappropriately and Ionly get a few callsa week after hours –only slightly morethan before.”

– Stephen Katz, M.D.

Primary CareAfter-Hours BonusPayments

In 2010, MedChi fought for and gotpassed House Bill 435 (HealthInsurance – Reimbursement of PrimaryCare Providers – Bonus Payments),which requires reimbursement forafter-hours care. The legislation re-quires that an insurer must specificallyaddress bonus payments for primarycare physicians when they provideservices to insureds between thehours of 6 p.m. and 8 a.m., weekendsand holidays. The amount of the bonuspayment is subject to negotiation withthe insurer but must be specificallyaddressed in the contract.

Wayne Lipton


In Dr. Graw’s view, the centerscomplement primary care with betteraccess and reduced cost compared to

Emergency Room visits. “We’re very tiedto primary care physicians,” continuesDr. Graw. “I still practice, so I know howimportant that relationship is. We havea physician access line and understandthat physicians want the informationright away. Some of our competitorsare soliciting primary care patients, butnot us.

“Physicians do a good job,” headds, “but we don’t have enough primarycare physicians in Maryland and wehave growing numbers needing medicalcare. Healthcare reform will onlyincrease that.”

Righttime Medical Care has a centralcall center with 47 employees who answerthe phone and triage patients. “Some85% of our patients book an appointment,so we control the patient flow, though wealso accept walk-ins,” says Dr. Graw.“We have a central command center where

we can watch patient flow in real time. Ifa patient has been in the waiting room formore than 15 minutes, we call over.

“Our model is different because wefocus on the retail experience of thepatient. We don’t want people waiting fortwo hours. In fact, we have no waitingroom in our centers. My advice to primarycare physicians who want to see their ownpatients has been to make sure you offeravailability and convenience. Leave someappointments open for sick visits.”

Walk-in Urgent and Primary CarePete Sowers, M.D., founder and CEOof Patient First QUOTE , opened thecompany’s first center in 1981 inRichmond, Virginia. Today, the companyoperates 39 centers in Virginia, Marylandand Pennsylvania. “The first center wasan outgrowth of my personal experienceas an ER doctor,” says Dr. Sowers. “Isaw that patients hated the long ER waitsand discovered a model in Rhode Islandthat operated a full-fledged private ER

in a shopping center. So our model offersextended hours, no appointments, lowercosts and quicker service than an ER.”

In contrast to Righttime MedicalCare, Patient First does not takeappointments. Like Righttime, however,they seek to provide good communicationback to the primary care physician. “Wework together,” notes Dr. Sowers. “About20 years ago, we added primary carebecause of pressure from the insurancecompanies to manage patients who didnot have a primary care physician.”

Nonetheless, he doesn’t believe hiscenters compete with doctors orhospitals. “I think we’re generally seenas benign. Most doctors and hospitalsare as busy as they can be. We referappropriate patients to the ER andinpatient services and go out of our wayto establish relationships withphysicians. I don’t see traditionalprimary care going away, I just thinkthere will be more options. Demand fornon-appointment care is growing.”

Urgent Care as an Extension of aPrimary Care PracticeSome primary care physicians have begunoffering extended hours in their practicesto increase patient access and practicerevenues. Patricia Czapp, M.D., familypractitioner at Annapolis Primary Care,says, “Some primary care practices areactively trying to recapture the patientvisits that go to urgent care centers.These are typically quick, easy visits thatdo not generate a lot of overhead costs.Care-wise and economically, it makessense to accommodate them. Patientsatisfaction soars when that happens.

“Our doctors designed andimplemented a Rapid Access feature thatmimics the Minute Clinic no-waitexperience, with great success,” she adds.“Patients are seen by their own practice,with their own medical records alreadyavailable. This effort is one example ofthe enhanced access model within theMedical Home concept. A patient ofours who works at a local urgent carecenter reacted by saying, ‘We wonderedwhen primary care practices were goingto figure this out!’"

Stephen Katz, M.D., internist, Severna Park Medical Associates. Wayne Lipton, founder and managing partner of Concierge Choice Physicians.

Howard Haft, M.D., MMM, FACPE, medical director of Maryland Healthcare and Shah Associates, a multi-specialty group practice in Southern

Maryland with multiple locations. Robert G. Graw, Jr., M.D., founder and CEO of Righttime Medical Care urgent care centers. Pete Sowers, M.D.,

founder and CEO of Patient First neighborhood medical centers. Patricia Czapp, M.D., family practitioner at Annapolis Primary Care.

“I don’t see traditional primary care going away, Ijust think there will be more options. Demand fornon-appointment care is growing.” – Pete Sowers, M.D.

Robert G. Graw, Jr., M.D.

TRACEY

BROW

N

HE HODES LIVER & PANCREASCenter, established in 2005 at St. JosephMedical Center, was built from theground up with the support of specialty-trained physicians handpicked from theworld’s top academic hospitals. TheHodes Center was the first community-based liver and pancreas center inMaryland to offer a multidisciplinaryprogram for the treatment of patients withcomplex diseases related to pancreatic,liver, colorectal and bile duct cancer.

Saint Agnes Hospital recently joinedSt. Joseph Medical Center by launchinga second location of The Hodes Liver &Pancreas Center, expanding the access ofthis advanced cancer treatment to peoplein the Mid Atlantic Region.

The new Center at Saint Agnes is ledby Mark Fraiman, M.D., M.B.A, F.A.C.S.,a hepatobiliary and pancreatic surgeon

who is one of the few doctors in the areaperforming highly complex proceduresfor the treatment of liver and pancreasdiseases, and is regionally recognized asan expert in the Whipple surgery. RichardMackey, M.D., F.A.C.S., who alsospecializes in liver and pancreas surgery,will serve as the medical director of theCenter at St. Joseph and the assistantdirector of the Center at Saint Agnes.

“We’ve established a reputation foroffering academic tertiary care for thecommunity,” says Dr. Fraiman. “Wecan care for the most complex situations;at the same time, our staff are veryexperienced and provide a personalizedexperience that is comforting to patients.”

Dr. Mackey adds, “We are the primarydecision makers. These two hospitalshave a reverence for patients’ rights,providing a holistic, patient-centered

approach where patients are not treatedas just a number.”

A Team ApproachThe Hodes Liver & Pancreas Centersalso have a highly experienced team ofendoscopic gastroenterologists,interventional radiologists andpathologists who perform the tests neededto diagnose and/or treat liver andpancreatic cancer. These skilled doctorscan make an early, accurate diagnosis tospeed an effective treatment plan andthey can perform advanced therapeuticprocedures such as chemo-embolizationof liver tumors. Endoscopic ultrasound(EUS) enables the detection of smalltumors and biopsies of abnormal areasor cysts. Endoscopic retrogradecholangiopancreatography (ERCP) is alsoavailable to visualize the pancreatic ductal



The Hodes Liver & Pancreas Centers

TMark Fraiman, M.D.and Richard Mackey,M.D. expand servicearea with secondlocation.

Complex Care for the Deadliest Cancer

system and relieve obstructions.“Patients want to be seen quickly and

we can typically book a clinical evaluationwithin a day or two,” says Dr. Fraiman.“We offer highly experienced nurses,including a stable, skilled team in theOR, private rooms and attentive preand post-op care. Yet patients can stillparticipate in the latest liver andpancreatic clinical trials.”

High Volumes, Broad ExpertiseAs with other specialties, selecting ahepatobiliary surgeon with high volumesis important. “We perform more than 100pancreatic cases a year,” Dr. Fraimannotes. “That compares favorably withsome ‘high volume’ centers that areonly doing 15 or fewer cases annually.Over half of what we do at our Centersis to treat malignancies. That translatesto the experience and focus cancerpatients need.”

“Patients with liver or pancreaticlesions should also have a surgicalevaluation,” says Dr. Mackey. “Today,many of these patients do well whentreated in a multi-disciplinary fashionat an experienced center.”

Beyond the treatment ofmalignancies, the Centers provide thegamut of diagnostic and therapeutic carefor an array of liver and pancreaticdisorders. They also diagnose and providemedical/surgical treatment forpancreatitis, disorders of the bile duct,injuries of the bile duct and more.

Latest Treatment Advances“Patients with new-onset diabetes arenow known to be at higher risk ofunderlying pancreatic tumors,” Dr.Mackey states. “When these patientshave abnormal liver function tests orabnormal imaging results, they shouldbe referred early.”

He adds, “There are now expanded

indications for laparoscopic procedures.We are doing a growing number ofminimally invasive pancreatic and liverresections, which offer a faster return toactivities, plus less pain and blood loss.”

The most common referrals forhepatic resection are patients withmetastatic colon cancer to the liver andpatients diagnosed with primaryhepatocellular carcinoma (HCC).Radiofrequency Ablation (RFA), the latesttechnique can be used when a liver tumoris not resectable or as an adjunct tosurgery when multiple malignancies exist.

Whipple Procedure Extended to MoreInvasive CasesPancreaticoduodenectomy, known asthe Whipple Procedure, is a complex,intra-abdominal operation to treatmalignancies involving the pancreas,duodenum or common bile duct. “Withthe Whipple, we’re giving patients abetter quality of life and the chance for acure. Aggressive surgery in combinationwith chemotherapy and radiation offerspatients with pancreatic cancer the bestchance for long-term survival,” says Dr.Fraiman. “The vast majority of ourpatients return to normal gastrointestinalfunction within a few weeks.”

Drs. Fraiman and Mackey performthe Whipple operation together, reducingwhat is typically a six-hour operation atmany university hospitals to a three-hoursurgery. They are now extending thatsurgery to many patients who previouslywould have been considered inoperableor borderline resectable. Tumors withinvasion of the superior mesenteric vein,portal vein or smv-pv confluence can nowbe considered for resection by performingresection and reconstruction of the portalvenous system.

Dr. Fraiman says, “When the cancer isinvading the portal vein, which used to bea criterion of inoperability, we use a very

aggressive approach in cases that are nowconsidered borderline resectable.”

Prior to surgery, patients receivechemotherapy and radiation to neutralizethe edges of the tumor. Then, inconjunction with the Whipple surgery,Drs. Fraiman and Mackey remove theportal vein, occasionally replacing it witha portion of internal jugular veintransplanted from the patient’s neck.

“We’ve had good results with theresection and reconstruction of theseformerly inoperable tumors, allowingmore patients to undergo a potentiallycurable operation,” explains Dr. Mackey.“The only way to cure these cancers isto combine chemotherapy, radiationand surgery. For those patients whosemalignancy remains unresectable, theCenters still play a major role in offeringpalliative care, an important part of ourtreatment algorithm.”For more information or to refer a patient

to either center, call 1-855-88-HODES.


The Hodes Liver & Pancreas Centers Advantages� Experienced, high-volume surgical team with training at top-five academic centers

� Superior outcomes (less than 1% mortality for Whipple procedures)

� State-of-the-art techniques and technology, including EUS and ERCP

� Expanded options for minimally invasive laparoscopic pancreatic and liver surgery

� Central and distal resections of the pancreas and benign liver resections

� A team approach that includes GI, pathology, medical and radiation oncology, and

interventional radiology

� Personalized care with high patient satisfaction

Hodes Servicesat a GlanceEvaluation and Diagnosis> Endoscopic Ultrasound (EUS)> Endoscopic Retrograde Cholan-

giopancreatography (ERCP)> Spyglass (biliary endoscopy)

Advanced Surgical Treatments> Open and Laparoscopic Hepatic

Resection> Open Surgical Radiofrequency

Ablation> Laparoscopic Radiofrequency

Ablation> Whipple procedure> Pancreatic resections> Laparoscopic distal pancreatectomy> Surgical procedures for complex

acute and chronic pancreatitis> Biliary reconstruction for bile duct

injuries> Shunt surgery for Portal

Hypertension

Chemotherapy & InterventionalRadiology> Trans-Hepatic Arterial Chemo-

Embolization (TACE)> CT-Guided Radiofrequency Ablation> SIRspheres> Portal vein embolization> TIPS> Percutaneous transhepatic biliary

decompression

CAN ITMAKE MARYLAND

HEALTHIER?

Healthcare IT

DHMH Secretary Sharfstein Reveals the Challenges and Potential of Using Health IT

BY LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN


Interoperability ChallengesMaryland is ahead of many states increating a system where healthcareproviders can share patient data to treatdisease and keep people well – a fairlydaunting task given the myriad issuesconnecting disparate data systems. Dr.Sharfstein comments, “The governor seta goal of having Maryland be a leader inhealth IT, part of which is the HealthInformation Exchange (HIE), wherehospitals can query other institutions for

information. We now have millions oflab and radiology records, so it’s atremendous resource.”

Afzal reflects, “The goal of CRISP’sfirst two years was getting the HIEorganization up and running, deployingthe technology and making connectionsto data sources. We now have basicconnectivity to permit sharingencounter data, such as an admissionmessage, for all Maryland hospitals.Additionally, we have rich connectivity

Maryland Physicianrecently sat downwithDepartment ofHealthandMentalHygiene(DHMH) SecretaryJoshuaM. Sharfstein,M.D and Scott Afzal,programdirector,HIE,Chesapeake RegionalInformation System forour Patients (CRISP)to discuss the state’sHealth IT progress andchallenges onmultiplefronts.

(labs, radiology, history and physicalsand discharge summaries) for half ofthem.”

Describing the challenges ofconnecting physicians with hospitalsand other providers, Dr. Sharfsteinnotes, “Regional networks aredeveloping and some hospitals areproviding significant communicationand support to primary care doctors.But it may be difficult to have everysystem fully integratedwith every possible model of EHR outthere. The goal is to have commoninteroperability across the state. Forexample, doctors can find out whentheir patients have been admitted ifthey get credentialed through CRISP. Ifwe tried to set all of the specificationsfor every network, we’d probably slowthings down.

“Maryland is the first state to set upthis level of interoperability with thehospital data,” he continues, “but werealize there’s a long way to go. In thenext few years, I think we’ll seeexplosive growth in access to electronichealth information.”

CRISP Query PortalAfzal concurs. “Maryland is the firststate to connect all the hospitals throughan HIE, but we still need substantialdata to make it worthwhile. The CRISPQuery Portal, currently used in manyhospital and ambulatory settings,enables authorized users to access apatient’s clinical data from manysources. Right now, most data availablethrough the HIE has come fromhospitals and large radiology centers,but the amount of data is growingquickly. Log onto http://crisphealth.org/ForPatients/ParticipatingProviders/tabid/241/Default.aspx to see which facilities aresharing data. Afzal notes, “CRISP isonly the conduit forthe data, which continues to belong tothe hospitals and providers.”

“We have a technology that linkstogether all of the disparate medicalrecord numbers a patient might have,”continues Afzal, “so we can enableservices like real-time alerting of aphysician when a patient is hospitalized.At the same time, we know that the

technical and cost barriers to sharingdata from an ambulatory EMR havebeen high.”

The Direct ProjectThe Direct Project is a national effort tocreate common standards to send direct,secure messaging among providers tomake healthcare communication moreefficient. It specifies a simple, secure,standards-based way for participants tosend encrypted health informationdirectly to known, trusted recipientsover the Internet. Maryland is takingadvantage of this to help providersconnect.

“CRISP began offering direct securemessaging in mid May,” notes Afzal. “Itenables participating providers to havean email inbox and share clinical datawith their referral relationships bysimply attaching it to an email message,like a normal email service. However,this service is encrypted and will likelyinvolve a broadly used messagingstandard.”

Pay for Value, Not VolumeIt’s no secret that fee-for-service fails toincentivize providers to keep patientshealthy. Dr. Sharfstein observes, “Thebig picture is aligning the healthcaresystem for health. We have a lot of highquality care, but if you ask if thepopulation is as healthy as it should be

for the money we spend, the answer isclearly ‘no.’ Instead, we spend a lot oftime and money on treating thecomplications. There’s a huge gap inaccess to primary care, particularly. Weneed to better align incentives andplanning so that we get health value outof the state’s investment. I don’t believefee-for-service aligns well with goodoutcomes.”

He adds, “In the future, incentivesshould pay more for the value than forthe volume of services. Patient

Centered Medical Homes (PCMHs) andnew hospital incentives for positiveoutcomes are a step in the rightdirection. Different kinds of smart pay-for-performance incentives will help.”

State Health Improvement ProcessDr. Sharfstein observes that one part ofthe DHMH website, the State HealthImprovement Process (SHIP), aims tofacilitate integrated public healthplanning. “SHIP now has 39 measuresfor what Healthy MD looks like,” hesays. “We have planning coalitions inalmost every county – they put togethertheir priorities for how they’ll movethose measures. There are lots ofdoctors, hospitals and health centers aspart of those coalitions. They delivercare and also create a partnershipbetween providers and public health.”

Fostering InnovationIn partnership with CRISP and theAbell Foundation, the DHMH recentlysponsored a Health Data InnovationContest that encouraged innovative usesof electronic health data to promote ahealthier Maryland, with winnersannounced in late May. Information isposted at https://themarylandprize.maryland.spigit.com/Page/Home.

Dr. Sharfstein explains, “Onewinning idea was to track adverse bloodtransfusion reactions to prevent

problems, some of which can be fatal.Another submission proposed using thedata to provide an algorithm to doctorsto better identify patients at risk ofadverse medical complications fromAlzheimer’s disease. Based on thepatient’s pattern of hospitalizations, thedoctor could identify a very high-riskpatient; the HIE could provide both thedata and some analysis to help thedoctor triage and make decisions.

“We also have an Innovationssection on our website,” Dr. Sharstein


“CRISP BEGAN OFFERING DIRECT SECURE MESSAGINGIN MID MAY. IT ENABLES PARTICIPATING PROVIDERS TOHAVEAN EMAIL INBOX AND SHARE CLINICAL DATAWITH THEIR REFERRAL RELATIONSHIPS... – SCOTT AFZAL

continues. “There, we’ve broughttogether the hospitals, addictions,pharmacy, nursing and statewidedelivery reform group and we’re puttingup different kinds of models up on theweb. It includes model paymentstructures that aren’t fee-for-service, and

model programs that can accomplish theTriple Aim concept of improving thehealthcare experience, improving thehealth of populations and reducing percapita costs. To learn more, visithttp://dhmh.maryland.gov/innovations/SitePages/Home.aspx.

Support for Physician EHRsCRISP, supported by DHMH, is alsoinvolved in the Regional ExtensionCenter (REC) program. This programprovided roughly $1600 to each of 1580primary care providers that signed up,and partnered with 15 state-designatedManagement Service Organizations

(MSOs) to help providers meetMeaningful Use. Additional RECfunding is available as providers movetowards the Meaningful Use goal.

“It’s important to provide fundingand other assistance to get as manydoctors as possible using EHRs,” Dr.

Sharfstein remarks. “While a lot ofphysicians have signed up for theprogram, they then face implementationissues and we want to be as supportiveas possible. One of the excitingchallenges is figuring out what the EHRcan do to truly advance health.”

Afzal adds, “We’ll naturally see somelevel of attrition among that group, assome doctors decide pursuingMeaningful Use doesn’t make sense fortheir practice. While we don’t have morefunds to support sign-ups with the RECprogram, interested physicians can stillwork with our group of trusted MSOs.Dr. Sharfstein, DHMH and the team at

the Maryland Health Care Commissionhave been great partners of ours and wework with them on public health uses ofthe data, such as tracking outbreaks ofdisease in real time to speedintervention.”

“There’s been a real effort to getprimary care doctors connected andwe’ve exceeded all of our goals for bothfunding and number of participatingdoctors,” concludes Dr. Sharfstein. ‘Theoriginal goal of 1000 physicians has beenwell exceeded. I think people realizethat the future requires EMRs andunderstand the advantages they offer forpatients and providers.”For more information on PCMHs, see Mary-

land Physician Magazine’s article, “PCMH in

Maryland: Public and Private Models,” in

the January/February 2012 issue.


Clinical FeaturesMaryland Physician focuses on the latest cancer

developments. We talk with top Maryland specialists to

get their take on the effectiveness of the latest treatments

for prostate, breast and blood cancers.

Healthcare ITIn every issue, Maryland Physician explores a different

facet of the race to implement EHRs to meet Meaningful

Use and other e-health government incentives. Don’t be

left behind – read what Maryland physicians and health-

care IT experts have to say that eases the pain of transition

to an electronic world.

In Every Issue and OnlineCases � Solutions � Compliance � Medical Beat � Policy

Jacquie Roth � Publisher/Executive Editor443-837-6948 � [email protected]

www.mdphysicianmag.com

Joshua M. Sharfstein, M.D., Secretary,

Department of Health and Mental

Hygiene (DHMH).

Scott Afzal, program director, Health

Information Exchange (HIE), Chesapeake

Regional Information System for our

Patients (CRISP).

HOTEL SPA RESTAURANTS WEDDINGS MEETINGS MARINAS FISHING GAMING

Voted Maryland’s Best Southern Region Weekend Resort, Spa Resort, Couples Getaway and Marina by Maryland Life. Voted Best Charity Event by Bay Weekly. Included in the Knot’s 2012 Best of Award for wedding venues. Exquisite Hotel Accommodations, Two Resort-Style Marinas, Casual Waterfront Dining, Waterfront Board Room and Corporate Event Packages, Charter Fishing, Gaming, Salon & Spa, Live Entertainment and Family Fun Packages Available.

CBResortSpa.com 866.312.5596

4165 Mears Ave Chesapeake Beach, MD

D. BRYANT PHOTOGRAPHY

D. BRYANT PHOTOGRAPHY

“WE HAVE A LOT OF HIGH QUALITY CARE, BUT IFYOU ASK IF THE POPULATION IS AS HEALTHY ASIT SHOULD BE FOR THE MONEY WE SPEND, THEANSWER IS CLEARLY ‘NO.”


A NEW KURE FOR YOUR PATIENT’S NECK AND BACK PAIN

Call 800-997-2460kurepain.comNine locations throughout Maryland & DC

Our multi-disciplinary approach means ourphysicians are highly experienced in avariety of procedures that precisely dealwith your patient’s back and neck pain. We often have same day appointments and accept most insurance plans. Before youconsider medication, discover the best wayto “Kure” your patient’s pain.

• Back pain• Neck pain• Arthritis• Work injuries• Degenerative disc

disease

Formerly

Outpatient Procedures• Incision-free treatments• No general anesthesia• No lengthy recovery time• No fusions or hardware

USE YOUR QR READER TO DOWNLOAD OUR APP

MARYLAND PHYSICIAN

GOES MOBILENow your go-to source for the news that matters most to Maryland physicians is available on-the-go on your mobile devices.

most to Maryland physicians isr go-to source for the news that

OES MOBILEYLAND PHYSICIANR

Maryland physicians issource for the news that

S MOBILEND PHYSICIAN

e on-the-go on your mobile devices.most to Maryland physicians is

e-go on your mobile devices.Maryland physicians is

T’S A SATURDAY MORNING INthe dead of summer and you arewracking your brain, trying to think of

a fun way to spend your day. What to do,what to do …

Then it dawns on you. You live inMaryland. Water is … well, everywhere!The Chesapeake Bay is accessiblefrom many points across the state.You really don’t need to drive all theway to the Eastern Shore to takeadvantage of the fun and adventurealong Maryland’s waterways. There areplenty of opportunities available, muchcloser to home.

You lucky Marylander! There aresimply so many options to choose from!

Walking on Water – Paddle BoardIncludedSome people see the water as a placeto relax. Others see it as the spot toget active. Those looking for outdooradventures will find a plethora of optionsat Ultimate Watersports, locatedalongside the Gunpowder Falls StatePark in Baltimore County, in theHammerman beach area. Visitors comehere for kayaking, windsurfing, sailing,and to get on the bandwagon with thelatest outdoor enthusiast trend: standup paddle boarding (SUP).

“Stand up paddle boarding is popularbecause it can be done in any kind ofwater, it does not require a lot of

equipment and the learning curve is veryshort,” said Tylor Streett, Operations andSafety Manager at Ultimate Watersports.“First timers are usually up and feelingcomfortable within an hour.”

And, the benefits just go on. Inaddition to giving your body a thoroughworkout, it will expose you to some ofthe area’s most scenic wildlife. ThroughUltimate Watersports, you can exploreon your own or participate in a guidedwildlife excursion, via stand up paddleboard or kayak, with sunset andmoonlight tour options available.

“We give people the opportunity toenjoy the water in new and differentways, and see wildlife that they never


Living

Maryland on theWater:Summer Fun Along theWaterways Tracy M. Fitzgerald

The fast growing sportof stand up paddleboarding (SUP) andkayaking on ChesapeakeBay waterways – terrificoptions for greatworkouts and scenicadventures.

I

JACQUIE

ROTH

Ipicked up a 2012 Lexus CT 200h F Sport Package from Sheehy

Lexus of Annapolis for a weekend free of commitment and full

of sunny skies, with Chesapeake Beach as the day-trip destination.

Sheehy’s service consultant couldn’t have been more patient

while he walked me through what Lexus has named its sporty hybrid,

the “Black Sheep of Green.” The first test: enough room for 70 lb. Eli,

my set of golf clubs, a full beach bag and a two-legged traveling

companion? No problem! The drive home gave me the chance to test

the drive mode options – from a nearly silent battery power designed

for short distances and ECO optimization to a full tilt sport mode

where performance and steering feel are maximized. FUN!

Saturday’s forecast proved true and off we went on an easy drive

down Solomon’s Island Road to Southern Maryland. While I was busy customizing the performance of the CT and my interior

space, my companion navigated the 10-speaker sound system with a very cool automatic sound levelizer, switching back and

forth from Sirius Satellite radio to an iPod.

We headed straight to Chesapeake Beach Resort & Spa and were struck by the breadth of the Chesapeake Bay. We enjoyed

a walk around the grounds and strolled along the dock offering charter fishing. Eli presented a problem for lunch at the

Boardwalk Café, but Resort owner Wes Donovan suggested a takeout lunch from the Rod n Reel. While waiting for our very

friendly bartender Larisa to bring us our delicious soft shell crab lunch, we had the opportunity to briefly visit The Chesapeake

Beach Railroad Museum located on Resort grounds. What a history! Trains ran from 1900 until 1935, bringing summertime visitors

from Washington DC, Baltimore and nearby Southern Maryland (more on that in the September/October issue’s Living).

I enjoyed the CT for some Sunday eco-friendly errand running and terrific parking maneuverability. I was a bit sad to return

it on Monday, but happy to climb back into my convertible. The only negative on the CT? The sunroof was too small! –J.R.

would see otherwise,” Streett said.“It’s easy to get hooked.”

Local Scuba – It Really Does ExistMany people think that their onlyopportunity to go scuba diving will comeabout when they hop on an airplane andhead to the Caribbean islands, Hawaii orsome other tropical destination. Wrong!These days, locals are suiting up withscuba tanks and diving into quarries andbodies of water such as the ChesapeakeBay and Potomac River. Matt Skogebo,Retail Manager and Master Scuba DiverTrainer at the Annapolis Scuba Center,has led groups in oyster divingexcursions, fossil diving adventures andshipwreck explorations in Maryland andits surrounding states. His company offerstraining, equipment and organized travelprograms, making it easy for Marylandersto make scuba diving part of theireveryday lives rather than just theirvacation plans.

“Eighty percent of divers becomecertified in fresh water and then taketheir skills to travel and scuba dive inplaces all over the world,” Skogebo said.

“If you can tread water for ten minutesand swim continuously for 200 yards,you can become certified.”

Scuba certification is acquiredthrough three phases of training, startingwith online academic courses, thenmoving on to confined water training,which includes two four-hour sessionsfocused on use of scuba equipment andemergency preparedness. The third andfinal phase takes trainees to the openwaters for four open dives. Once certified,divers are prepared to explore theunderwater world to a depth of 60 feet.Skogebo says that going on a scuba diveis like taking a trip to a different world.

“There is no other sport that allowsyou to go into your own world in a waythat is truly unique to only you,” he said.“Even if you dive side-by-side withanother person, you will each seedifferent things. This is a sport that isrelaxing, therapeutic and something youcan truly enjoy doing your entire life.”

Sail Away – A Day (or More) at SeaIf you are eager to get out on the waterbut not necessarily interested in owning

a boat of your own, look no further thanSouth River Boat Rentals. The company’sfleet of sailboats and powerboats,available for rent or charter, make it easyfor you to hop on board for a half day, fullday, or multiple day journey along thewaterways of the east coast.

The Annapolis-based companyallows those with boating experienceto take vessels out on their own, or canprovide captained charters for partiesthat are more interested in sitting back,relaxing and enjoying the ride. Foodand drinks can be brought on board, andfishing gear is available for those whowish to toss a line or two overboardwhile at sea.

“Every single week, I see peoplecome in here stressed out and lookingfor a way to quickly break away,” saidGriff Bell, owner of South River BoatRentals. “They go out on a boat for afew hours, and come back looking likethey hung out with Jimmy Buffett allday long. This is a great way to take abreak from reality; folks come back in asdifferent people after a fun and relaxingday on the water.”


Travels with Eli

JACQUIE

ROTH

FDA-APPROVED IN 2005, THEprocedure is appropriate for manypatients with uni or bi-compartmentalosteoarthritis of the knee who havefailed conservative therapies.

Orthopedic surgeon Hungerford,director of Joint Replacement andReconstruction at Mercy, explains,“MAKOplasty’s RIO Robotic ArmInteractive Orthopedic System usesa three-dimensional model of thepatient's knee to help preciselyresurface the diseased area. Duringsurgery, the RIO provides the surgeonwith real-time visual, tactile andauditory feedback for optimal jointresurfacing and implant positioning.This optimal placement can resultin more natural knee motionfollowing surgery.

“Essentially, we are replacing theworn, damaged and missing cartilagewith an implant made out of metal

and plastic,” he says. “You can thinkabout it like capping a tooth insteadof putting in an implant. The basicstructure of the knee remains – mostof the bone, the ligaments, the skin,

the nerves, the muscles – andwhat we’re doing is putting a newbearing surface on the damagedpart of the knee.”

Dr. Ciotola likens theMAKOplasty® to remodeling akitchen or bathroom instead of

tearing an entire house down.“Patients do dramatically betterand are back exercising in aboutsix weeks.”

Dr. Littleton has similar praise



A More Precise Partial Knee Replacement

MAKOplastyOnly at Mercy Medical Center

A total knee replacement removes 72% morebone than the bi-compartmental MAKOplasty.Obviously, that makes a difference in patients’recovery and post-op use of the knee.

- Kamala Littleton, M.D.

With nearly five millionAmericans – almost 5%of the population age 50and older – getting kneereplacements at a youngerand younger age, aprocedure that canimprove outcomes issignificant to keepingmore boomers active.Three of Mercy MedicalCenter’s orthopedicsurgeons – MarcHungerford, M.D., JosephCiotola, M.D. and KamalaLittleton, M.D. – haveperformed morethan 150 MAKOplasty®

procedures since mid-2011, and all areenthusiastic about itsbenefits. As of summer2012, Mercy remains theonly place in Marylandperforming the procedure.

Marc Hungerford, M.D.

- Kamala Littleton, M.D.


for the robotic technology. “Prior toMAKOplasty, we were hesitant toperform a bi-compartmental kneereplacement or patella femoralreplacement because the design andinstruments were not as good as wethought they should be. With the robot,we can get much more accurateplacement of the implant. The robotallows us to do it well every time.A total knee replacement removes72% more bone than the bi-compartmental MAKOplasty. Savingthis bone is advantageous in youngerpatients where revision surgery willeventually be likely.”

Precision Mapping Includes 3D CTFollowing evaluation, patients who aregood candidates are sent for a 3D CTthat allows surgeons to create a precisepre-op plan determining:

� Component size� Orientation of the components

and bone� Component alignment

“Once we’re in the OR, we validatethe plan and make fine adjustments intra-operatively,” observes Dr. Hungerford.“That virtually guarantees that the parts

will be in the proper position and theligamentous balance will be correct.The robot maps the cartilage and boneremoval precisely to the CT.”

Dr. Littleton agrees, noting, “Withthe robot, we have the advantage of doingpatient-specific surgery with off-the-shelfimplants. We can assess the ligamentoustension in the knee throughout the rangeof motion and make adjustments toensure good tension. Then, we insert thefemur implant and check the articulationbetween the femur and the center of thetibial component. We have a total knee


Benefitsof MAKOplasty PartialKnee Resurfacing

Versus the traditional knee

replacement, the new MAKOplasty

partial knee resurfacing allows

patients to typically experience:

� Preservation of healthy bone

and tissue

� A shorter hospital stay

� Minimal blood loss

� Quicker rehabilitation

� Smaller incision

� Return to active lifestyle

within weeks

...the RIO providesthe surgeon with real-time visual, tactile andauditory feedbackfor optimal jointresurfacing andimplant positioning...result[ing] in morenatural knee motionfollowing surgery.

— Marc Hungerford, M.D.

Marc Hungerford, M.D.

implant on hand in case the arthritis isworse than expected, but only one in20 patients has needed this.”

With this approach, all of theligaments remain intact, maintainingproprioception. That stands in starkcontrast to a total knee procedure inwhich the ACL and sometimes the PCLare removed. “The greatest pain in totalknee replacement results from theincision through the quadriceps tendon,so a partial replacement avoids that pain,”Dr. Littleton says. “Patients come backtwo weeks later on Tylenol and you can’ttell from their walk which knee had theprocedure.”

“Where this procedure really shines iswhen you put more than one componentin,” Dr. Hungerford adds.

When/Who to Refer“The best time to refer is when thepatient is having pain and difficulty withactivities of daily living, but conservativemeasures are not working,” advises Dr.

Hungerford. “With MAKOplasty, we cantreat patients at an earlier stage of theirdisease and take care of uni-compartmen-tal or bi-compartmental disease. Patientshave been able to go back to their every-day activities of walking, shopping,climbing stairs and those who previouslyplayed golf or tennis can often resumethose sports.

“We don’t perform surgery on patientswho are doing well with injections,bracing, and other conservative measures,”he adds. “We reserve surgery for patientsfor whom those approaches are notworking.”

Typically, MAKOplasty patients sharethe following characteristics:

� Knee pain with activity, usually onthe inner knee and/or under theknee cap, or the outer knee

� Start up knee pain or stiffness whenactivities are initiated from a sittingposition

� Failure to respond to non-surgicaltreatments or non-steroidal anti-inflammatory medication

“The younger the patient, the worsetheir clinical situation has to be toconsider surgery,” says Dr. Ciotola.“We consider the risk versus the benefit.Depending on their situation, patientsbetween the ages of 30 and 90 may beappropriate candidates.”

Dr. Littleton observes that patientswith mild to moderate arthritis typicallydo best. “Patients can almost point to thespecific area causing them pain. Weightplays an important role, too. Those withmorbid obesity and severe mal-alignmentare not appropriate candidates.

“With tools like this,” she comments,“we realize we don’t need to give patientsinjections and twice daily ibuprofen forthe rest of their lives. And instead ofenduring pain for years before getting aprocedure, they can do things like playtennis again. In the last decade, we’verealized that we have the tools to allowpatients to enjoy themselves now.”

Data/ResultsThrough June, 2011, about 8000MAKOplasty procedures had beenperformed in the country; as of April,2012, that number had rapidly grownto more than 12,000. While more than50 studies of the procedure are beingconducted nationally, outcome data isnot yet available.

Dr. Ciotola concludes, “The proceduremakes a partial knee replacement moreaccurate and therefore more reliable.There’s no need for uni-compartmentalknee patients to suffer. BeforeMAKOplasty, it was absolutely unheard offor people to go back to the gym within amonth. I would want this procedure formyself, my family and my friends.”For more information or to make an

appointment to determine if your patient

is a candidate for MAKOplasty at Mercy

Medical Center, call 410-539-2227.


Bel AirGrandmotherBowling AgainTheresa M., an active 66-year-old

grandmother from Bel Air, read about

MAKOplasty in a newspaper article

and was intrigued. “I had had several

arthroscopies over time but got to the

point where I couldn’t handle the pain

anymore,” she recalls.

After Dr. Hungerford evaluated her

knee, they jointly determined that

MAKOplasty was an appropriate option.

“Before the procedure, I sat down with

the coordinator, had all my questions

answered and got a binder called the

Joint Journal that had everything

I needed to know. Everything was

planned and all of the staff was so

caring. I only took pain medications

for four days after my procedure and

I came home with minimal pain.”

Ms. M. was so happy with her first

MAKOplasty in September 2011 that,

when her second knee needed a partial

replacement in March 2012, she was

thrilled to learn that it was again a good

option for her. She jokes, “I think my

other knee got jealous.”

Only a few months later, Ms. M.

is busy running after her two-year-old

grandchild and resuming normal

activities. “Now, I’m bowling again,

doing aerobics and walking with my

friend,” she exclaims.

Candidates for MAKOplastyMercy's orthopedic surgeons work with each patient experiencing knee pain to provide

an individualized treatment plan. Potential candidates for MAKOplasty typically have the

following characteristics:

� Knee pain with activity, on the inner knee, under the knee cap, or the outer knee

� Start up knee pain or stiffness when activities are initiated from a sitting position

� Failure to respond to non-surgical treatment such as rest, weight loss, physical

therapy, and non-steroidal anti-inflammatory medication

Joseph Ciotola, M.D.


Q:What have been the keybenefits of the Affordable Care Act(ACA) for Maryland physicians?

The number one advantage is thatyou have everybody in the system –everyone has coverage so everyone ispaying their fair share. Physicians, like allhealthcare professionals, are providingcare to a lot of people who don’t pay theirbills. Now, we’ll have a much strongerpresence in preventive care, which meanswe’ll have a more cost effective system.And hopefully, we won’t have to gothrough what we’ve been going throughfor the past 15 years with the MedicareSGR (Sustainable Growth Rate) formula -and worry every year whether physicians’reimbursement will be slashed.

There are some specific provisionsthat affect physicians such as in thePatient Bill of Rights. Emergencyphysicians supported our efforts to enactthe prudent layperson standard for allpersons with health insurance coverage,so that insurers would have to pay foremergency care based on the patient’ssymptoms rather than the final diagnosis.

Other parts include the right ofpatients to select their own OB/GYNand family care provider. We werealso able to do other things that helporderly healthcare, such as making someparts of the reimbursement structuremore predictable, which should helpphysicians.

The unfinished business was theflawed Sustainable Growth Rate formula.In 2005, when I introduced a bill to

repeal the SGR with my Republicancolleague, Clay Shaw, it was estimated tocost $50 billion over ten years. This yearit was estimated to cost $300 billion. If wedon’t do anything for the next five years,the cost will jump to $600 billion. We’vegot to get that fixed.

Q:Howwill you fix Medicare’s SGR?To me, [repeal of the SGR] should bepart of our baseline, we should correctthis. We’re not going to allow a 30%reduction in payments to physiciansunder Medicare – that would becatastrophic. We should acknowledgethat in our budget and just move forward.

Q:If the Supreme Court dismantlesthe ACA, what can Congress do?It would be a very difficultcircumstance…it would be the SupremeCourt substituting itself for the Congress.It would call into question whetherMedicare and Social Security are

constitutional and it would deny theCongress the ability to deal with 40million people who have no healthinsurance in a rational, effective way.The immediate impact would be on the40 million people sitting outside thehealthcare system. How do we get themcovered and make it less costly for all?By and large, these are workers whoshould take responsibility for theirhealthcare needs. Instead, they get sickand don’t pay their bills. That’s justfundamentally wrong. If you can’t do anindividual mandate, your options becomemore limited. There are options we canexplore but it would be a major stepbackwards.

Policy

Cardin Comments on the Affordable Care Act,the Supreme Court and Health Priorities

LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

Maryland Physician recently interviewed U.S.Senator Ben Cardin, a key champion ofhealthcare reform, about the potential impact ofthe upcoming Supreme Court decision and hishealthcare priorities for 2012/13.

U.S. Senator Ben Cardin (D-MD)


Q:Is there anything physicianscan do?Physicians in America are the best trainedand provide the highest quality service inthe world. The first thing we want to dois make sure we preserve that. If theSupreme Court throws the ACA out, wewill look to provide incentives for ourbrightest to go into healthcare and treatpatients in underserved areas. We cancreate positive incentives for improvingour system and predictability for thosegoing into medical school. But we willhave lost a valuable tool and a rationalhealthcare system.

Q:What has Maryland alreadyaccomplished and how would thatbe affected?Maryland has expanded eligibility forMedicaid and set up Enterprise Zones.We would still try to fund federallyqualified health centers. Maryland isprogressive – for example, we have anall-payer rate structure for hospital careand we now have the best results inthe nation on pediatric dental care.

Maryland is leading the country inHealth Insurance Exchanges and will beready in 2014 to have functionalexchanges that will allow smallcompanies and individuals to buy anaffordable healthcare plan. This would beat risk because, if people only come intothe plan when they’re in need, you’dhave adverse risk selection. It’s hard tosee how universal coverage works withoutthe individual mandate. Yet, Marylandhas offered so many incentives to expandcoverage that I think we’re in bettershape than most states.

Q:Since the ‘train has already leftthe station’ in many areas, what is atrisk if part of the ACA struck down?The fundamental risk is that theSupreme Court would use its power tosubstitute its judgment for the legislaturein a way that moves the nation backwardsin dealing with significant social issues.It would remind me of the Dred Scottdecision, when the Supreme Courtmisused its power to prevent theadvancement of civil rights.

Of course, the closest analogy is

Medicare in the 1960s, which requiredparticipation in a health insurance policybased on age or disability. [Seniors] mustbe in Part A; what’s the difference betweenthat and the individual requirement passedby Congress in 2010 as part of the ACA?Will the court be saying that SocialSecurity or Medicare is unconstitutional?

If the court rules in this direction, itwould be taking away the flexibility ofCongress to carry out its constitutionalpower to deal with national problems…[But] all we can do is initiateconstitutional amendments and workwithin the parameters of the decision. Iwould hope that if they rule any part of itunconstitutional, they would give us clearguidance as to what we can do andenough time to get it done.

Q:What are your healthcareinitiatives and goals for 2012/2013?I’m going to continue with the healthcarepriorities I’ve already championed.Physicians are very impacted by whetherour system’s working right. If it’s workingright, we can talk about how we’llimprove quality. In healthcare, we pay avery heavy price because of lack of accessand racial and ethnic health disparities.In the Affordable Care Act, one of myamendments established the NationalInstitute on Minority Health and HealthDisparities at the National Institutes ofHealth, and Offices of Minority Healththroughout the Department of Healthand Human Services. I want to followthat through to make sure we reduce, andone day eliminate, disparities in America,

I also want to make sure we continueour commitment to dental care forchildren. A major indicator of how wellwe’re doing is how children show up inemergency rooms for dental care. You talkabout a waste of resources! All childrenare now covered for dental servicesthrough the Children’s Health InsuranceProgram and the ACA, and we want tomake sure they have facilities in theircommunity to get quality dental care.I sponsored an amendment thatestablished the national benefit forpediatric dental care. This is one ofseveral prevention-oriented measureswe want to move forward.

In 1997, I sponsored the first major

expansion of Medicare to includepreventive services, including screeningfor breast, cervical, prostate, and coloncancer, diabetes, and osteoporosis, anda few years later I authored a provisionthat allows the list to be expandedwithout Congress needing to come backand amend the law. I want to deal withsome of our most costly and difficulthealthcare challenges – diabetes, heartdisease, obesity – at the earliest stages tosave money for the system.

Further, I want to work with thephysician community to be moreeffective in providing preventive care.I’ve heard from a lot of physicians abouthow healthcare IT is going to help; sothere will hopefully be a busy affirmativeagenda with the healthcare communityto maintain excellence, expand access,and reduce administrative costs.

Q:What can physicians do tosupport your efforts?The first thing I would say to a primarycare physician is ‘thank you for yourcommitment.’ You’re a special person togo into primary care. There are morelucrative specialties, and the amount ofresponsibility that falls on your shouldersis increasing every year.

The primary care physician is the key toour system working right. We want to ensureadequate numbers of primary care providersand allied health professionals, plus the rightallocation of higher-cost specialists. Butcomprehensive healthcare all really revolvesaround primary care. We want theprofessionals to make the judgments andkeep things moving the right way.Ben Cardin has been a national leader on

healthcare and other issues as a member of

the U.S. Senate and House of Representa-

tives. In 2006, he was elected to the Senate,

where he currently serves on the Environment

and Public Works (EPW), Finance, Foreign

Relations, Budget and Small Business &

Entrepreneurship committees.

See Maryland Physician Magazine’s

interview with Lt. Governor Anthony

Brown in the January/February 2012

issue for more information on Health

Enterprise Zones.


Advertiser IndexAdvanced Radiology ....................................................2www.advancedradiology.com

Coverys ................................................................................5www.coverys.com

Advanced Radiology ....................................................8www.advancedradiology.com

University of Maryland FacultyPhysicians, Inc. ..............................................................13www.umm.edu

Komen Maryland .........................................................13www.komenmd.org

Hodes Liver & Pancreas Centers ..........................18www.HodesCenter.com

Chesapeake Beach Resort & Spa .........................22www.CBResortSpa.com

KURE Pain Management ..........................................23www.kure.com

Papercamera...................................................................23www.papercamera.com

Mercy Medical Center ...............................................26www.mdmercy.com

MEDENT EMR .................................................................32www.medent.com

MedMarketer .................................................................32www.medmarketer.com

Lifebridge Health.........................................................35www.lifebridgehealth.org

Washington Adventist Hospital...........................36www.TrustedHeartCare.com

MPM online: more content, moreanswers and more often!

Increase the power of your marketing toMaryland physicians, healthcare executivesand Maryland healthcare stakeholders viaadvertising on mdphysicianmag.com

Jacquie Roth - Publisher/Executive Editor443-837-6948

[email protected]

ONLINEwww.mdphysicianmag.com

Medent Version 19.5Medent Version 19.5

Medent Version 19.5CC-1112-119223-1

http://www.medent.com/onc-atcb.html

MEDENT EMR/EHRWith the Top rated MEDENT EMR many doctors have received their Meaningful Use money!

The MEDENT Patient Portal, which is an option for the EMR has practices seeing productivity gains of 30%!

Request a demo of the ICD-10!

Call 1.315.255.1751today or visit us atmedent.com

Mobile App + Email =

MORE APPOINTMENTS

MedMarketer.com Book More Appointments. Guaranteed.

MedMarketercom.erte

M

M

kMedMar

MarkMede AppoinBook More

MORE APPOINT

Mobile App + Email =

eterkteed.ants. Guaratmenin

SENTMT

Email =


Solutions

Seven Reasons to Considera Cloud-Based EMR

PBy Tim Smelcer

HYSICIANS FACE MANY OPTIONSwhen choosing an electronic medicalrecord (EMR) system. One of the mostimportant decisions is whether toimplement a cloud-based system orserver-based system (one that requireshardware and software installed in thepractice). Cloud-based systems can makehigh-end systems that were previouslyonly in the reach of hospitals or largepractices affordable for smaller practices.They offer an efficient, worry-free andsecure way to meet Meaningful Use.Here are seven reasons a small to mid-sized medical practice should considerthe cloud model.

1 Lower Upfront and Overhead CostsThe cloud-based system reduces upfrontand overhead costs. The initial cost ofinstalling a server-based system withhardware and software can cost $60,000and up. A cloud-based system will save atleast half on these expenses. Physiciansno longer have to invest what can add upto hundreds of thousands of dollars fortheir EMR system. With the cloud-basedEMR, all the functionality is containedin the cloud.

2 Ease of ImplementationHaving the EMR in the cloud sparesa practice from the labor-intensiveinstallation, configuration andmaintenance of an internal server, whichoften disrupts staff routines and deliveryof care. Plus, since the EMR vendorhandles the continuing care andmaintenance of the system, there is noneed to hire an IT specialist to maintainsoftware. When the system requires an

upgrade or a security patch, there’s noneed to tie-up medical office staff; thevendor will handle it.

3 A Greener Approach with MinimalSpace RequirementsWith a cloud-based system, valuableoffice space is not taken up with bulkyhardware. This saves floor space as wellas energy and cooling costs. Somedoctors’ offices have space-consumingsystems installed in closets or breakrooms that become overheated, affectingoffice temperature and requiringadditional air conditioning. A secondway in which a cloud-based system isenvironmentally friendly and efficientis that cloud service in a regional datacenter maximizes the hardware’susefulness by providing it for othermedical offices as well.

4 Enhanced Data Security andAvailabilityPhysicians often worry about the securityof a cloud-based system and areconcerned about hackers and HIPPA-protected information. If the practicechooses the right cloud-based system,

its security will be more sophisticatedthan in-house server systems. Make surethe vendor selected can house the cloud-based system in a reputable data center.Data centers provide services such assecurity, power redundancy, bandwidthand firewalls to protect the EMR system.

5 Access Anywhere, AnytimeProviders can access medical informationon a cloud-based system from any

medical office the physician is affiliatedwith, on the road, or from home. Somesystems can also be accessed from anysmart phone such as an iPhone.

To rely on a cloud-based system, astable Internet connection is necessary,but offices rarely experience an Internetdisruption. To ensure peace-of-mind,there are many good, cost-effective waysto provide backup, such as a cellular 4Gconnection or an i-Pad with cellular datacapabilities. Both options involve aminimal cost.

6 Ready ScalabilityIt’s important for patients to beconfident that their physician’s EMRsupports their diagnosis and care.Cloud-based EMRs offer this peace-of-mind. For a reasonable purchase priceand a small monthly fee, practices canget an extremely powerful, robust,cloud-based EMR system to boostprofitability and patient care services.

7 High-End Systems Customized forSmaller PracticesThanks to attractive pricing and thecloud’s desirability, many vendors areoffering the cloud model to physicianoffices. This means that smaller practicescan now afford more costly, high-endsystems such as GE’s Centricity,AdvancedMD, athenahealth, Bizmaticsand MedPlus/Quest Diagnostics. Lookfor vendors that offer robust, high-qualityproducts that include an integratedpractice management component andresponsive customer support.Tim Smelcer is an IT expert and CEO of

MED Cloud. He partners with GE Healthcare

to provide Centricity Practice Solutions in

the cloud as a Software-as-a-Service (SaaS)

solution to practices in Maryland, Delaware,

Pennsylvania, New Jersey, New York,

Virginia and Washington, D.C.

www.medcloudemr.com

Physicians no longer have to invest what canadd up to hundreds of thousands of dollarsfor their EMR system.


Life AfterWar: Walter Reed National Military CenterHelps Soldiers Get Back to Living

ACH TIME A SOLDIERarrives at Walter Reed National MilitaryMedical Center after being injured incombat, Paul Pasquina, M.D., and histeam develop a treatment plan to addressmuch more than their patient’s physicalneeds. Here, there is as much focus onmental and emotional healing, for thosewhose lives may be forever changed bywhat they saw, heard and felt while atwar. At Walter Reed, it’s about caring forthe patient as a whole, and helping eachget back to living and doing the thingsthey enjoy the most.

“Every patient we see has differentphysical and emotional needs,” said Dr.Pasquina, Chief of the Department ofOrthopedics and Rehabilitation at WalterReed. “Some are here for as long as sixmonth or even a year, undergoingmultiple surgeries or rehabilitation. It’simportant that we give our patients hopeand make them realize they will be ableto go on and enjoy the things they love inlife, whether it’s sports and recreation,creative arts or just being able to go out inthe community to do everyday activitieslike going to a ballgame, museum ormovie theater.”

Recovering soldiers with a love forsports have been able to participate inactivities ranging from skiing, kayaking,fishing and horseback riding to golf,cycling, swimming and basketball (and somany more). Others have gone down amore creative path, focusing on writing,painting or even learning how to playmusical instruments. And on plenty ofoccasions, Walter Reed’s recreationaltherapists have organized group outingsfor patients to attend professional sportsevents, take tours of Washington D.C. orjust hit the town for dinner and a movie.

Pasquina says that without a doubt,keeping patients active can make asignificant impact on their overallrecovery process.

“These activities help patients withtheir physical recovery, but go a reallylong way to support their emotionalwellbeing,” Dr. Pasquina said. “Makingsoldiers realize that they can return totheir communities and giving themoutlets to learn and experience newthings is an extremely important part ofour mission.”

Walter Reed partners with the U.S.Departments of Defense and VeteransAffairs, as well as various non-profitorganizations, to make this programpossible. Some organizations, such asProject Healing Waters, devotethemselves entirely to supportingwounded military personnel and disabledveterans. Project Healing Waters is anational initiative that provides flyfishing, fly casting, fly typing and rodbuilding classes at no cost to itsparticipants. It’s one of many programsthat has been well received by soldiersundergoing treatment at Walter Reed.

“It’s these types of activities that help

our patients think ahead, rather thandwell on their injury or disability,” Dr.Pasquina said. “Our service membershave told us that it helps them reset theirgoals and focus on moving forward.”

Having the opportunity to help andgive back to those who have volunteeredto serve America, willingly putting theirlives on the line, is something that staff atWalter Reed consider a privilege,Pasquina included.

“Every day, I get to witness amazingresiliency and spirit as these patients takesmall steps to recover,” he said. “Seeingsomeone go on to do great things and behappy in life is something I cherish.”

Those interested in making adonation to support the continued growthand availability of recreational programsfor wounded soldiers are encouraged todo so by visiting the Walter Reed Societyweb site at www.walterreedsociety.org.

Good Deeds

Maryland Physician would like tohear about your “Good Deeds.”Please share your ideas with us [email protected].

EBy Tracy M. Fitzgerald

Paul Pasquina, M.D. and his team take a very hands-on approach and focus on treating thephysical, mental and emotional needs of their patients.

WALT

ERREE

DNATI

ONALM

ILITARY

MED

ICALCEN

TER

Good intentions or bad judgment?

There are times we do crazy, misguided things; feats that shouldn’t be possible,and sometimes aren’t. So when you push yourself past your limits, it’s nice toknow there’s a place like the Rubin Institute for Advanced Orthopedics – where doctors perform more total hip and knee replacements and progressive procedureslike hip resurfacing – all combined with the latest rehabilitation services.

Nice work knees and hips – the dynamic duo – when we ask too much of you!www.lifebridgehealth.org

Chris Barritt's 5,000 Mile Journey Began atWashington Adventist Hospital

Chris Barritt, 57, Mount Airy, Heart Tumor Surgery

The Cardiac team at Washington Adventist Hospital o�ers themost advanced treatments in heart care, including:

To refer a patient for acardiac surgery consult,

call 301-891-6101.

For priority transfer of yourcardiac admissions, callCardiac One-Call at866-684-8460.

The Ride of His Life

maryland physician magazine july/august 2012 issue

Documents