maryland physician magazine march/april 2013 issue

THE EVOLUTION OFEMERGENCY CARE

THERE'S AN APPFOR THAT

INTERVIEW WITHDELEGATE DANMORHAIM, M.D.

GERD AND HIATALHERNIAS

VOLUME 3: ISSUE 2 MAR/APR 2013VOLUME 3: ISSUE 2 MAR/APR 2013

Physician

THE EVOLUTION OFEMERGENCY CARE

THERE'S AN APPFOR THAT

INTERVIEW WITHDELEGATE DANMORHAIM, M.D.

GERD AND HIATALHERNIAS

PhysicianYOUR PRACTICE. YOUR LIFE.

www.mdphysicianmag.comwww.mdphysicianmag.com

YOUR PRACTICE. YOUR LIFE.

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MARCH/APRIL 2013 | 3

12 The Evolution Of Emergency Room CareBeyond fast track

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how to detect them and when to take action.

24 There’s an App ForThatUsing mobile health for patient care

F E A T U R E S

D E P A R T M E N T S

ContentsVOLUME 3: ISSUE 2 MAR/APR 2013

1812 30

Cases | 9 | Diagnosing and Managing Colon Cancer in theYoung

Compliance | 11 | Top 10 New HIPAA Changes for Physicians

Living | 28 | St. Michaels, Maryland: Culture, History andWine

Policy | 30 | Addressing the Social Antecedents of Health Problems and End-of-Life Issues

Solutions | 33 | Understanding Meaningful Use Stage 2

Good Deeds | 34 | Putting NewTechnologies in Patients’Hands

On the Cover: Drew White, M.D., emergency physician and chairman of Emergency Medicine at Washington Adventist Hospital

4 | WWW.MDPHYSICIANMAG.COM

JACQUIE ROTH, PUBLISHER/EXECUTIVE [email protected]

LINDA HARDER, MANAGING [email protected]

CONTRIBUTING WRITERSTracy FitzgeraldJackie Kinsella

PHOTOGRAPHYTracey Brown, Papercamera Photography

www.papercamera.com

EXECUTIVE ASSISTANT/WEBMASTERJackie Kinsella

Maryland Physician Magazine – Your Practice. Your Life.™is published bimonthly by Mojo Media, LLC. a certified MinorityBusiness Enterprise (MBE).

Mojo Media, LLCPO Box 949Millersville, MD 21404443-837-6948www.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

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

CHRISTOPHER L. RUNZ, D.O.Shore Health Comprehensive Urology

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.

Happy New Year! Welcomingthe New Year is a time for inspiration and thisissue is spot on. Our content ranges from theresearch and development of an oralantiplatelet medication by one of the state’sforemost cardiologists, to leading-edge stemcell research here in Maryland, to treatingheart arrhythmias in Bangladesh.

February is recognized as American Heart Month, honoring heart healthprofessionals, researchers, and ambassadors – some of whom are showcased in thisissue – whose dedication enables countless Americans to live full and active lives. Thisyear’s National Wear Red Day® is the 10th annual, taking place on Friday, February1st. The day encourages everyone to unite in The Heart Truth’s life-saving awareness-to-action movement by putting on a favorite red dress, red shirt, or red tie to remindus that women need to protect their hearts against their #1 killer.

By mid-February, we’re often ready for a break from the bleak winter skies andlook to get away or plan ahead for a family spring break trip. The Living section ofMaryland Physician has featured an easy-to-get-to destination, offering a sneak peek ofa city or town we recommend for a quick getaway. Until now, we’ve featured local hotspots within a three-hour drive from Baltimore and DC. This issue, we’re taking aslightly different approach; I’ve recapped highlights from my recent trip to DelrayBeach, Florida – a less than three-hour flight destination (see Living page 24).

Key features of the Affordable Care Act include more access to care andimprovements in the coordination and quality of patient care. As patients becomemore educated about their rights as healthcare consumers, as in any customer-centricbusiness, providers may very well find their patients more demanding in theirexpectations for care. Social media and online ratings are impacting where healthcareconsumers go for care. We deliver two articles that help you create a positive patientexperience within your practice – lowering your exposure risk for malpractice andbringing in more patients (see Compliance page 9 and Solutions page 29).

This issue’s HIT feature, Protecting Patient Data in a Digital Age (page 20),underscores the critical need for providers to have patient data protected far beyondthe limits of the physical office – including smartphones and cloud services. Via theuse of smartphones and their apps, patients are becoming engaged and moreempowered to take control of their health. Better care management lowersreadmission rates, improves quality of care and directly impacts the revenue stream ofany provider. The Maryland Physician March/April 2013 HIT feature will spotlightmHealth (mobile health), with a look at some of the apps in place today. We’d love tohear from you about what you personally use or what your practice has put into place.Shoot me an email or tweet @mdphysicianmag.

Wishing you good luck with your New Year resolutions and good health!

Jacquie RothPublisher/Executive [email protected]

@mdphysicianmag

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DISCUSSION The value of routine coloncancer screening is widely recognizedboth in the lay public and in the medicalcommunity. As a result of implementingroutine colon cancer screening at age 50,the overall incidence of colon cancer hasdeclined. On the other hand, colon cancerin younger populations continues to rise,according to the National CancerInstitute. The case above illustratesseveral issues that arise in diagnosing andmanaging younger patients.

Colon cancer increases with age.Nonetheless, about 10% of all cases occurin those under age 50. Certain youngerpopulation groups such as African-Americans are at high risk. There isongoing discussion as to whether routinescreening exams should begin at an earlierage in that group, perhaps at age 45.

The onset of screening is not theissue for this patient; rather, she hassymptoms that necessitate evaluation.Sometimes patients will say, “But I’m not50; I’m too young for colonoscopy.”Physicians should explain that agedictates when asymptomatic patientsshould be evaluated, but not when thosewith symptoms should.

The symptom of bleeding is anespecially common and important one.Repeated episodes of bleeding requireevaluation, almost without exception.Deciding whether to perform asigmoidoscopy or a colonoscopy in ayoung patient may be difficult, andshould in part be based on his or her age,degree and duration of associatedsymptoms, and other risk factors. Afamily history of colon cancer may tipthe scales toward a more completeevaluation. The point is that someanatomic evaluation must be done.

Many patients deny the significanceof their symptoms. Patients often initiallyreport that they have no bleeding, butwhen pushed, report bleeding that they

discounted as being due to hemorrhoids.It is important to question carefully forthis symptom. The myth that ‘bright redblood is not serious’ may also need to beaddressed. Unfortunately, a rectal canceris as likely to produce bright red blood asis a hemorrhoid. Hemorrhoids are notinherently dangerous; however, falselyattributing dangerous symptoms to themmay be. The long-standing presence ofhemorrhoids does not preclude patientsfrom developing other more seriouspathology. Physicians should address allof these issues when discussing the needfor a sigmoidoscopy or colonoscopy.

Interestingly, at the same time thatpatients are outwardly denying theseverity of their symptoms, they often arequite worried about the possibility ofcancer. This should be addressed as well.Young patients should understand thatrectal bleeding should be evaluated.While hemorrhoids are the most likelycause, if more serious pathology is found,it is more likely to be inflammatory ratherthan neoplastic in nature. The goal is toinform the patient and convince them ofthe importance of further workup withoutoverly frightening them.

This patient proved to have a ratheradvanced cancer, which is not unusual ina younger population. The reasons forthis are unclear but may have to do withmore aggressive tumors in the young,and/or diagnosis later in the diseasecourse. Fortunately the outcome herewas favorable.

Most young patients with diarrheaand rectal bleeding will prove to havebenign disease such as irritable bowelsyndrome and hemorrhoids, or perhapseven inflammatory bowel disease.Nonetheless, a workup to exclude coloncancer is essential even in patientsunder age 50.Jonathan Schreiber, M.D., is a gastroenterologist

at Mercy Medical Center.

Cases

Diagnosing and Managing ColonCancer in theYoung

CASE: In 2003, a 38-year-oldAfrican-American woman wasseen in the emergency roomwith crampy lower abdominalpain and diarrhea. She wasdiagnosed with irritable bowelsyndrome and referred to herprimary care physician. Ananti-spasmodic was prescribed;when her symptoms persisted,she was referred to agastroenterologist. Evaluationandmanagement of irritablebowel syndrome wasdiscussed. The patient initiallydenied any rectal bleeding.With further questioning, shereported, “Sometimes myhemorrhoids bleed when Ihave diarrhea.” A sigmoid-oscopy was recommended.The patient did not have thattest and did not return untilfour months later. Her crampyabdominal pain and diarrheacontinued, with occasionalepisodes of bleeding. Acolonoscopy demonstrated awell-differentiated adeno-carcinoma of the sigmoidcolon, later staged as T3/N2.The patient underwent lowinterior resection and adjuvantchemotherapy. She is now10 years post-operative andpost-chemotherapy withoutsigns of recurrence.

By Jonathan Schreiber, M.D.

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people like Patricia Gardner-Smith a renewed sense of hope. Following a stroke, Patricia experienced right-sided

weakness, which caused her difficulty walking, talking and even swallowing, but our team of dedicated physicians,

therapists and nurses helped her regain her strength and relearn functional skills such as eating and grooming.

Now at home with her husband, she continues to progress every day.

ouis and Phyllis Friedman Neurological Rehabilitation Center at Sinai Hospital, we’re committed to giving

ke Patricia Gardner-Smith a renewed sense of hope. Following a stroke, Patricia experienced right-sided

, which caused her difficulty walking, talking and even swallowing, but our team of dedicated physicians,

s and nurses helped her regain her strength and relearn functional skills such as eating and grooming.

me with her husband, she continues to progress every day.

rological Rehabilitation Center at Sinai Hospital, we’re committed to giving

enewed sense of hope. Following a stroke, Patricia experienced right-sided

walking, talking and even swallowing, but our team of dedicated physicians,

ain her strength and relearn functional skills such as eating and grooming.

nues to progress every day. Learn more at lifebridgehealth.org/sinairehab.

r at Sinai Hospital, we’re committed to giving

wing a stroke, Patricia experienced right-sided

allowing, but our team of dedicated physicians,

functional skills such as eating and grooming.

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HE LONG-AWAITED CHANGESto HIPAA were released on January 25,2013, overhauling physicians’ currentobligations. Practices should beginreevaluating their business associates,policies, training and notice of privacypractices to come into compliance bySeptember 23, 2013. The top 10 HIPAAtopics for physicians follow.

1. Business AssociatesFor the first time, business associatesand downstream subcontractors mustenter into agreements with theirsubcontractors ensuring protectedhealth information (PHI) issafeguarded. Conduits or those whohave custody of PHI are nowconsidered business associates.

2. Access of Individuals to ProtectedHealth InformationPhysicians must send record copiesdirectly to another individual whenrequested in writing by the patient.This request must be signed by thepatient and clearly identify thedesignated person and their address.

Individuals will now be able torequest electronic copies of theirPHI that is maintained in anelectronic health record (EHR) orother electronic designated recordset. Covered entities must provide anelectronic, “machine readable copy”accommodating individual requestsfor specific formats, if possible.Physicians may charge a reasonablefee that complies with state law.

3. Disclosures About a Decedentto Family Members and OthersInvolved in CarePhysicians may disclose a decedent’sinformation to family members andothers who were involved in the careor payment for care of the decedent,

unless inconsistent with any priorexpressed preference of theindividual.

4. Disclosures of StudentImmunization to SchoolsPhysicians may provide schoolimmunization records with the assentof a parent, guardian, or person actingin loco parentis as long as thisagreement is documented andcomplies with state law.

5. MarketingAuthorizations are required fortreatment or other communications,if the physician receives financialremuneration from the third party ofthat product or service. Exceptionsexist for subsidized refill remindersor communications about a currentlyprescribed drug or biological, as wellas certain face-to-face communicationsor gifts of nominal value.

6. Sale of PHIA physician must obtain anauthorization before receiving director indirect remuneration in exchangefor the sale of PHI, except for certainactivities related to public healthactivities, research, treatment, thesale or other business consolidation orrecord copy fees.

7. FundraisingThe Privacy Rule permittedphysicians to use or disclose certainPHI to a business associate or relatedfoundation for fundraising purposeswithout an individual’s authorization,as long as an opt-out was provided(e.g., a toll-free number or emailaddress). Once the individual optsout, physicians cannot provide furtherfundraising communicationsdescribed in the opt-out.

8. ResearchConditional and unconditionalauthorizations for research arepermitted, if they differentiatebetween the two activities and allowfor an opt-in of unconditional researchactivities, such as data repositories andtissue. Future research studies maynow be part of a properly executedauthorization, except for psycho-therapy notes, which may be combinedonly with another authorization fortheir use or disclosure.

9. Right to Request a Restriction ofUses and DisclosuresIndividuals may now restrict certaindisclosures of PHI to a health planwhere the individual, family memberor other person pays out of pocket infull for the healthcare item or service,noting the restriction in the medicalrecord. Physicians can submitrestricted information for requiredMedicare and Medicaid audits.

10. Modifications to the BreachNotification RulePhysicians must report breachesof unsecured electronic PHI toindividuals and HHS, along with themedia, if more than 500 individualsare affected. Harm is no longer aconsideration in defining a breach.If more than 10 notifications toindividuals are returned asundeliverable, substitute noticemust be provided “as soon asreasonably possible” within therequired 60-day notification period.Reports are valid even if the mediafails to publish the breach; however,posting a general press release on awebsite is insufficient.

Sarah Swank, a principal in Ober Kaler’s

Health Law Group, can be reached at

[email protected].

Compliance

By Sarah E. Swank

TTop 10 New HIPAA ChangesFor Physicians

THE EVOLUTIONOF

EMERGENCYROOMCARE

BY LINDA HARDER

PHOTOGRAPHY BY TRACEY BROWN

>> BEYOND FAST TRACK

Maryland Physicianinterviewed fouremergency physicianleaders to learn howvarious area emergencydepartments (EDs)have found better waysto evaluate patients,coordinate betweenshifts, provide humanepsychiatric care, andeven detach ED carefrom the hospital.

hese advances take place againsta backdrop of dramatic growth in

emergency services; nationally, ED visitsdoubled in less than a decade, with waittimes increasing 25% from 2003 through2009. Population growth and aging,physician shortages and healthcarereform all make it likely that this trendwill continue. Innovative approachessuch as the ones described here enhancepatient safety and convenience in thesefast-paced environments.

Rapid Medical Evaluation:Keeping Patients VerticalFor decades, the traditional model oftreating a patient in the emergencydepartment (ED) involved ‘serialprocessing’ – having a triage nurse assessthe patient and then having them waituntil the physician or mid-level providercould treat them. Even the advent ofFast Track systems did not significantlychange this serial approach. A program at


T


Washington Adventist Hospital has alteredthat model by having a team consisting ofa nurse, physician and patient caretechnician see each patient as they arrive.

Drew White, M.D., emergencyphysician and chairman of EmergencyMedicine at Washington AdventistHospital, initiated a pilot Rapid MedicalEvaluation (RME) program in 2009. Hesays, “Nationally, the door-to-doctortimes have been increasing in the past 15years, and a long wait time is a predictorof bad patient outcomes. Our modeladdresses that gap by having a care teamtriage the patient, perform an initialexam, provide initial treatment and assignthe patient to the appropriate level ofcare. If a treatment room is available,we start that process right in the room.”

Dr. White notes that, whileWashington Adventist did not invent themodel, they were one of the first tolaunch it in this region. “What makes itsuccessful is the way we implemented it

and that we have been able to sustainour gains,” he explains. “We performedintensive staff training, conducted focusgroups, solicited input from people onthe front line, and provided lots of dataand feedback. For the first few weeks,we had frequent huddles to discuss howto address issues that arose and alteredthe plan as needed.”

The hospital found that the modelwas most useful during peak times,typically 11 am to 9 pm. The modelemploys an additional full-time physicianor physician assistant during these hoursand dedicates two rooms to the RME.However, the costs of more staff andsignificant coordination are more thanoffset by other savings and benefits. “OurLWBS (left without being seen) patientswent from about 4% to about 0.5%,versus a national average of 1% to 2%,”Dr. White comments.

Other RME advantages relate toreductions in unnecessary testing, faster

treatment, and improved patientsatisfaction. “Studies have shown that upto one third of patients don’t need to besubjected to lots of testing,” notes Dr.White. “We can address their medicalissues right from the start and give themwhat they need to get better. Lots of EDshave triage nurses that can issue standingorders, but by using physicians and mid-level providers, we can customize theorders and decrease unnecessary testing.We order the correct tests for the patientand start the optimal medical treatmentearlier, including giving IV fluids andmedication. When we finish the initialtriage and exam, everyone, including thenurse, tech, and patient, know the planof care and what to expect.”

He concludes, “Other advantagesof this approach are decreased testingdenials and the ability to stay offdiversion far more often, so more peoplecan come here for care. Our patientsatisfaction is now among the highest in

Drew White, M.D., emergency physician and chairman of Emergency Medicine at Washington Adventist Hospital.


“Patients needingmedical stabilizationmust be clearedmedically in themain ED beforethey come to us.”

– Eric Weintraub, M.D.

the country and our ED has had a highergrowth rate than the regional average.”

Safer Sign Out: Bedside RoundingDr. White and the team also sought toaddress the highly variable and high-risksign out process among ED physiciansduring change of shift. “An estimated80% of serious medical errors involvemiscommunication between caregiverswhen patients are transferred or handedoff,” he explains, “with 24% of EDmalpractice claims involving these faultyhandoffs. The Joint Commission hasidentified this as a National Patient SafetyGoal. In place of the typical process,which involves giving a quick verbalreport to the incoming physician, we nowhave a standardized communication tooland process for bedside rounding on allpatients at shift change. The incomingdoctor meets the patient instead of merelyreviewing a chart.”

Dr. White continues, “We will bepresenting this concept at the MarylandPatient Safety Conference in April. Itseems like a common sense idea, but it isa revolutionary change in practice. Themore times you round on a patient, themore likely you are to pick up something.

With this approach, the incoming doctorknows what tests the patient is waiting forand, during the rounding, the physicianmay pick up on changes in the patient’scondition since they last checked him orher. We piloted this program at CalvertMemorial Hospital, Washington AdventistHospital, and some of the other hospitalswhere Emergency Medicine Associatespractices, and then we expanded it to allof our hospitals.”

Dedicated Psychiatric EmergencyServicesIn contrast to many EDs, where mentalhealth care typically consists ofpsychiatric consultants and a smallsection of the main ED, the psychiatricemergency services (PES) departmentat the University of Maryland MedicalCenter (UMMC) focuses solely onpsychiatric/addiction evaluation and carefor those in crisis. Medical Director EricWeintraub, M.D., was recruited in 2010to head up this new service, which seespatients from as far away as Frederickand the Eastern Shore. During his tenure,volumes have grown from about 2500 to3500 patients/year.

PES patients enter through a central

Medical Director Eric Weintraub, M.D.at the University of Maryland Medical Center

triage area shared with the main ED.Those deemed to require psychiatricintervention and who do not have anacute medical problem go directly to thePES department, located within the samebuilding. “We have parameters for bloodglucose, blood pressure and other clinicalsyndromes such as chest pain,” notes Dr.Weintraub. “Patients needing medicalstabilization must be cleared medicallyin the main ED before they come to us.”

A team of attending psychiatrists,psychiatric nurses, psychiatric residentsand social workers staffs the PES. Anattending psychiatrist is available from8 am to 9 pm on weekdays and 8 am to4 pm on weekends. The space includesboth an unlocked and locked area andpatients are triaged to either sideaccording to the acuity of their symptoms.The locked side can accommodate about15 patients on reclining chairs and thataccounts for nearly 80% of the totalpatient volume. The unit also includesa shower, a small room for interviews,and two seclusion rooms that can be leftopen or closed.

“The advantages of this model,”Dr. Weintraub enthuses, “are that wecan identify the patient’s major mentalhealth issue(s) and then better managethe crisis, including starting patientson medications, performing crisisinterventions with a variety of therapiesand when appropriate referring patientsto other appropriate mental healthresources. We can forge a therapeuticalliance with the patient, and prevent alot of hospitalizations. It’s not uncommonfor patients to spend the night here sothat we can watch and evaluate themovernight. Many people come inintoxicated from alcohol, cocaine, or otherdrugs including synthetic marijuana; aftera few hours, their behavior often changesand you can get a much better assessmentthan you could have upon arrival.”

“To the best of my knowledge, ourPES is unique in Maryland,” continuesDr. Weintraub. “We refer patients toother great mental health services suchas Baltimore Mental Health Systems,Baltimore Crisis Response Inc. andHealthcare for the Homeless. Where wecan refer them is dependent in large parton their insurance and where they live.”

Dr. Weintraub encourages referringphysicians to call the PES before theyrefer a patient. He advises, “We dependon family, friends and physicians for

collateral information. We like to knowwhat medications the patient is on, whattheir issue is, and what might have causeda crisis. Patients often tell us, ‘My doctorjust told me to come in.’ We’re happy tospeak with doctors by phone to get theinformation we need to better care fortheir patients.”

Freestanding EDs Come of AgeBy the early 2000s, explosive populationgrowth and traffic congestion in upperMontgomery County had conspired tomake it challenging at best for ambulancesand those needing emergency care toget to an ED. The closest EDs were atShady Grove Adventist in Rockville,which was handling some 90,000 visits ayear and Frederick Memorial Hospital.Ambulance service was hampered by longout-of-service times required to travelto and from the available EDs.

The solution? After years of addressinglegislative and regulatory concerns abouta freestanding center, in 2006 ShadyGrove Adventist was able to open thefirst freestanding ED in Maryland inGermantown. Brett Gamma, M.D., chiefof emergency services at Shady GroveAdventist Emergency Center atGermantown, describes the results.

“The goal was to increase emergencyaccess for upper Montgomery Countyresidents and we’ve accomplished that,”he notes. “We have 19 private beds in a17,000 square foot facility that sees about37,000 patients a year. We diagnose, treatand stabilize patients, then transfer themto the hospital if needed. Most patientsare discharged back home. Today, some8 to 10% of our patients are transferred,up from 2006 when people were lesseducated about our ability to handletrue emergencies.”

Dr. Gamma explains that the free-standing ED can treat all emergencies.Patients who require surgery, cardiaccatheterization, or a labor and deliverysuite are stabilized and transferred to thehospital. He comments, “We can stabilizeheart patients and get them to the cathlab at the hospital, which is a Cycle IIIChest Pain Center, in a comparableamount of time as patients who presentto the hospital directly. For strokepatients, we can give TPA beforetransferring them for definitive care.”

In fact, the transfer times forST-Elevation Myocardial Infarct(STEMI) patients from the Emergency

Center at Germantown to the cathete-rization lab in the main hospital is in thetop 15% of the nation. The Center pridesitself on being part of a hospital systemthat received a Gold Achievement Awardfor cardiac care and is an accredited ChestPain Center and Primary Stroke Center,with one of the best door-to-TPA times inthe state. The freestanding center alsoscores well on other clinical outcomemeasures, such as providing appropriateuse of blood cultures and antibiotics topatients with community acquiredpneumonia. “Our goal is to provide theseto 100% of all community-acquiredpneumonia patients within specified timeframes,” comments Dr. Gamma.

The center has comparabletechnology to that at a hospital-basedED. “We have all the technology weneed, including ultrasound, highresolution CT and a dedicated lab thathas incredibly fast turnaround becausewe’re not sharing it with inpatients,”Dr. Gamma continues. A PictureArchiving Communication System(PACS) provides digital imaging toradiologists at the hospital.


Brett Gamma, M.D., chief of emergency servicesat Shady Grove Adventist Emergency Center

The hospital recognized that it wouldbe critical for the freestanding EDproviders to have the same training andexperience as those at the hospital – infact, the same board certified emergencyphysicians rotate between the two EDs.

The majority of patients who aredischarged to home are discharged inless than 150 minutes.

“Patient satisfaction is high, butperhaps no one is happier than thoseinvolved with EMS. They can now returnto service for the next patient muchfaster,” he adds.

Starting 2010, legislation requiresthe state to set reimbursement ratesfor freestanding emergency facilities inMaryland, bringing them under theauthority of the Health Services CostReview Commission and making themavailable for Medicare and Medicaidfee-for-services reimbursement.

The Germantown ED is no longerthe only one in the state; in 2010, asimilar freestanding ED, the QueenAnne’s Emergency Center, opened on theEastern Shore. The growth in freestandingfacilities in Maryland mirrors a nationaltrend; as of 2009, there were more than240 freestanding EDs in the country.

Point of Care Testing ExpandsPoint of Care testing (POCT) has beenavailable to some extent for more thana decade, but several newer tests thatdeliver results in minutes rather thanhours or days are now in use. Since2007, the market for cardiac, strokeand infectious disease (especially HIV)POCT has roughly doubled.

POCT includes the measurement ofblood glucose, blood gas and electrolytes,rapid coagulation, rapid cardiac markers,drugs of abuse, urine strips, pregnancytesting, fecal occult blood, foodpathogens, hemoglobin, infectiousdisease and cholesterol.

While POCTmay not decrease overallED time significantly, “It gives the bestcare in the most efficient time,” accordingto Dov Frankel, M.D., assistant director oftheEmergencyDepartment at SinaiHospitalof Baltimore. “We can get results in lessthan twominutes using two drops of blood.”

Dr. Frankel states, “POCT involvingcardiac enzymes has made a huge differencein getting patients to the cath lab on time,and is especially valuable in anyone withan equivocal story that may or may not becathed depending on the troponin results.

Since time is muscle, these tests areimportant for speeding treatment.”

The most commonly tested cardiacmarkers (enzymes or proteins that tendto be concentrated when a cardiac eventis likely to or has occurred) are TotalCPK (creatine phosphokinase), CK-MB(creatine kinase) and troponin I/T.Myoglobin levels may also be tested.Testing for these markers can reliablyindicate when intervention is or isn’tnecessary. Lab-based tests can take upto 1.5 hours, which has driven demandfor the point-of-care products that candeliver “stat” results.

For patients with suspected MI whoare first seen by their own physician, Dr.Frankel advises referring physicians to runbasic chemistries or check INR instead ofsending people to lab or ED to check.

The Sinai ED also has found thatPOCT has improved the ability todetermine which patients can benefitfrom TPA. “Using POCT to test theInternational Normalized Ratio (INR)for patients with suspected strokes hasallowed ED physicians to decrease thetime to administer TPA so that morepatients can receive it within the three-hour window,” Dr. Frankel notes.

POCT is also useful for patientssuspected of having internal bleedingwith signs of pallor, shortness of breath,etc. “They can get a hematocrit inminutes, compared to an average of onehour for a ‘stat’ lab test. That allows usto give that patient a blood transfusionfar faster,” says Dr. Frankel.

However, Dr. Frankel believes thereare certain conditions that should bediagnosed and treated even before the

labs come back, such as heart failure andsepsis, which are based on the clinicalpresentation. He comments, “These labsare still useful but patients should betreated before the lab results are back.”

Those using POCT need rigoroussystems to ensure ongoing quality. AtSinai, providers scan their badge, thepatient’s badge and then the cartridgeused in the POCT. Quality Control staffchecks the machines weekly andrecalibrates them as necessary. Dr.Frankel says, “I tell residents to ensurethat the test result matches up with thepatient’s clinical presentation, or redo it.”

While the Sinai ED doesn’t yet offera POCT CBC test for white counts,platelets and infections, Dr. Frankelacknowledges that this test would beuseful. Perhaps surprisingly, however, hefinds another valuable POCT test is theblood quantitative pregnancy test. “Onein eight patients in our waiting room ispregnant. They came in due to a problemsuch as vaginal bleeding, but they oftendon’t know they’re pregnant.”


DrewWhite, MD, MBA, FACEP, chairman

of Emergency Medicine and president of

the Medical Staff, Washington Adventist

Hospital.

Eric Weintraub, M.D, associate professor

and division head, Psychiatry, University

of Maryland Medical Center

Dov Frankel, M.D., assistant director,

Emergency Department, Sinai Hospital of

Baltimore

Brett Gamma, M.D., chief of Emergency

Medicine, Shady Grove Adventist Hospital.

Dov Frankel, M.D.,assistant directorof the EmergencyDepartment atSinai Hospital


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18 | WWW.MDPHYSICIANMAG.COMColleen Christmas, M.D., geriatrician and associate professor

of medicine at Johns Hopkins Bayview Medical Center,

OUR GI EXPERTS DISCUSS WHY UPPER GI/ESOPHAGEAL

CONDITIONS MAY GO UNRECOGNIZED, HOW TO DETECT

THEM AND WHEN TO TAKE ACTION.

PREVENTINGGERDANDHIATALHERNIAS FROM

TURNINGDEADLY

BY LINDA HARDER

OME 25 MILLIONAmericans are believed to suffer on adaily basis from gastroesophageal refluxdisease (GERD) – better known asheartburn – and as much as 40% of theadult U.S. population are estimated toexperience it less frequently. Some ofthese patients also suffer from a hiatalhernia, which is typically asymptomatic.For most patients, these conditions area serious nuisance, but not a serioushealth hazard. The challenge forphysicians lies in determining how totreat these common disorders before theybecome dangerous, without subjectingpatients to unnecessary treatment.

The rise in GERD, believed relatedto the epidemic of obesity and otherlifestyle factors, is associated with an

increase in esophageal adenocarcinoma.This cancer has grown six-fold in the past30 years, while squamous cell carcinoma(often associated with smoking andalcohol use) has declined. Given itsformer obscurity, physicians trainedseveral decades ago may be less likelyto recognize the potential for chronicGERD to turn cancerous.

To manage GERD, patients shouldavoid alcohol, greasy foods, sodas, mints,licorice, chocolate and smoking. Theyshould eat smaller, more frequent mealsand avoid a large meal within a fewhours of bedtime. Losing weight isalso helpful. “Modest weight loss anda prudent diet are often sufficient tomanage symptoms,” notes A. StevenFleisher, M.D., chief, Division of


A PATIENTRESOURCE:ECANTo educate the public about the link

between heartburn and cancer, a new

advocacy group called the Esophageal

Cancer Action Network (ECAN) was

formed here in Maryland. Mindy Mintz

Mordecai founded ECAN in 2009

after her husband died from late-stage

esophageal adenocarcinoma. Visit

www.ecan.org.

Steven Fleisher, M.D., chief, Division of Gastroenterology; and director, Interventional Gastroenterology Program at Medstar Franklin Square Medical Center.

S

TRACEY

BROWN


Gastroenterology; and director,Interventional GastroenterologyProgram at Medstar Franklin SquareMedical Center.

If chronic use of over-the-counterantacids is necessary, patients shouldconsult their primary care physician. Inturn, primary care doctors should referpatients to a gastroenterologist if refluxcontinues for several years. While GERDmedications are generally safe andeffective, chronic use not only mayindicate the need for further evaluation,but also may lead to osteoporosis andan increased risk of infections such asclostridium-difficile (C. diff). “Makesure the patient’s vitamin D levels areadequate so they can absorb calcium,”Dr. Fleisher advises.

Barrett’s EsophagusCompounding the issue is the fact thatpatients’ heartburn symptoms maydecline or disappear not only withmedication but also as their diseaseprogresses. Chronic reflux can cause theesophageal lining to be damaged sosignificantly that it resembles stomachlining and causes discomfort to abate atthe same time that the risk of cancerincreases. This condition, called Barrett’sesophagus, is a strong risk factor foresophageal adenocarcinoma. The normalprogression is from the initial stage ofmetaplasia to low grade dysplasia, highgrade dysplasia and cancer; however, aDanish study published in the October13, 2011 issue of the New England Journalof Medicine found that the annual risk ofthis cancer was only0.12%, lower than the previously assumedrisk of 0.5%.

In the December 2, 2012, issue ofthe Annals of Internal Medicine, theAmerican College of Physicians

published guidelines for using upperendoscopy in GERD patients, as wellas guidelines for screening for Barett’s(see sidebar). Patients with GERDshould receive endoscopy if they alsoexperience dysphagia, bleeding, weightloss or recurrent vomiting, or if theyhave not responded to medication afterseveral months.

If Barrett’s is found, Dr. Fleisheradvises endoscopy surveillance at leastevery three years for patients who haveBarrett’s without dysplasia and as often asevery six months for those with dysplasia.

Treatment: EMR and AblationGastroenterologists often performendoscopy to evaluate the mucosa ofthe esophagus for strictures and thepresence of Barrett’s. Until 2007, whenthe Prague C & M (circumferenceand maximal extent) criteria weredeveloped, consistent assessmentcriteria were lacking.

Dr. Fleisher says, “Our practiceuses the Prague Criteria, which isbecoming the accepted classificationfor endoscopically-suspected Barrett’s.In non-dysplastic Barrett’s, four quadrantbiopsies should be obtained every twocentimeters in the involved esophagealsegment. Barrett’s is suspectedendoscopically when the normal pearl-pink mucosal lining is replaced with asalmon-pink appearing mucosa. We alsooften see associated hiatal hernias. Thelength of the Barrett’s segment correlateswith more significant cancer risk. Whileit’s unusual, some patients have one thirdto one half of their esophagus affected.”

“If any nodular components arepresent,” he continues, “we perform anendoscopic mucosal resection (EMR).EMR can be a cure for very early stageadenocarcinoma and it can be performed

at the time of initial endoscopy, but oftenisn’t. Endoscopic ultrasound is oftenperformed to assess for depth of invasion,and local lymphadenopathy prior toresection of sub-centimeter lesions. If thepathology shows disease limited to thelamina propria or muscularis mucosae, inthe absence of lymph node metastases,lymphovascular invasion, or poordifferentiation EMR provides definitivetherapy. Nevertheless, these patient needclose short term endoscopic surveillance.”

Dr. Fleisher adds, “EMR involvesusing an endoscope with tools tosuction up the affected tissue. A bandis deployed around the lesion, whichis then removed with a snare andelectrocautery. We may inject submucosalsaline to lift the lesion away to facilitatebanding. When the sub mucosa isinvolved, medically fit patients will needesophagectomy. More extensive diseasemay need chemotherapy and radiationbefore or after surgical resection.“

Following EMR, the remainingaffected tissue is ablated, typically usingradiofrequency (RF) ablation. A studypublished in the September 2012 issueof Gastroenterology found that initial RFablation might not be cost effective forpatients with Barrett’s in the absence ofdysplasia, but may be appropriate forconfirmed and stable low grade dysplasia,and is superior to endoscopic surveillancein high grade dysplasia.

Dr. Fleisher notes, “RF ablation isrecommended along with photodynamictherapy and EMR for eradication of

WHO SHOULDBE SCREENEDFOR BARRETT’S?Males over age 50 with:

� GERD symptoms for 5 years

� Smoking history

� High body mass index, esp.

abdominal fat

� Hiatal hernias

� Dysphagia, bleeding, weight loss or

recurrent vomiting

Source: American College of Physicians

“Our practice uses the PragueCriteria, which is becoming theaccepted classification for endo-scopically-suspected Barrett’s.”

– Steven Fleisher, M.D.


Barrett’s esophagus according to aMarch 2011 position statement on themanagement of Barrett’s esophagus bythe American GastroenterologicalAssociation (AGA). In selected cases, wealso perform cryoablation, a techniquethat is still investigational for themanagement of dysplasia in Barrett’sesophagus. Prospective studies thatdemonstrate its comparable effectivenessare not yet completed. Cryotherapyfreezes the involved tissue using liquidCO2 or liquid nitrogen. We use the latter,applying it for about 20 seconds in two tothree applications. Patients appear totolerate the procedure well other thansome chest discomfort.”

When to Treat HiatalHernias SurgicallyHiatal hernia, the most commondiaphragmatic hernia, is a broad termthat covers a variety of conditionsin which an anatomical structure piercesthe membrane of the diaphragm. While

the cause is often unclear, thesehernias occur more often in women,those who are overweight, and thoseover age 50. Because a hiatal hernia maynot create symptoms until there is anemergent situation, it is often discoveredincidentally.

Hiatal hernias are classified as TypeI through Type IV, with Type I denotinga sliding hiatal hernia (roughly 80%of hiatal hernias) where the gastro-esophageal (GE) junction followed bythe body of the stomach protrudesthrough the esophageal hiatus and abovethe diaphragm. In the less commonparaesophageal hernias (Types II – IV),the fundus is displaced into themediastinum above the GE junction.Type IV denotes a large defect in thephrenoesophageal membrane that allowsother organs, including the colon orspleen, to slip up into the chest.

Adrian E. Park, M.D., MIS/GIsurgeon and department chair of Surgeryat Anne Arundel Medical Center,

explains, “Most hiatal hernias developover a long period of time. Patients mayhave had GERD 10 to 15 years ago butthen their symptoms subsided. However,if they get full quickly when they eatand have shortness of breath, they mayhave a hiatal hernia. The danger is thatthe hernia can twist suddenly andstrangle the stomach, requiring urgentsurgical intervention.”

“Only 1 to 2% of these hernias needsurgery,” continues Dr. Park, “but it’s achallenge to determine when surgery isnecessary. Data shows that if we plansurgery electively, the mortality andmorbidity rate is 1/5th to 1/20th that ofemergency surgery. As a result, we’velearned to err on the side of beingaggressive. The great judgment requiredis when to intervene with patients whoare not highly symptomatic. The wayI approach it is to talk with the familymembers about the patient’s eatinghabits, their activities of daily living andwhether they’re losing weight.”

Adrian E. Park, M.D., MIS/GI surgeon and department chair of Surgery at Anne Arundel Medical Center


Dr. Park notes that many patientshave lost their exercise tolerance andcan’t walk around the mall or grocerystore. “It happens so insidiously andslowly that patients often are worked upfirst for cardiac and pulmonary issues,”he comments. “Once it is determinedthat they have a large or paraesophagealhiatal hernia, surgery often allows themto improve their pulmonary function and,as a result, their exercise tolerance.”

Laparoscopic surgery has greatlyimproved surgical outcomes for hiatalhernia repair. Dr. Park declares, “If youcan prevail laparoscopically, you should;patients get up much more quickly andthat makes all the difference. While 98%of patients are elderly, they can go homewithin two days and usually spend lessthan two hours in the OR.”

Though not a fan of GI roboticsurgery, Dr. Park says, “The camerasystems and instruments used in thelaparoscopic procedure are continuouslyimproving. The interest in a singleincision approach has waned and fourto five incisions of 5mm are morethe norm.”

Dr. Park advises, “When seeking asurgeon, referring physicians should lookfor a surgeon who does at least severalprocedures per month with good pre andperi-op education and a nurse andnutritionist on the team. Some of theseprocedures are extremely complex andshould be concentrated in select centers.The mortality rate should be under 1%and the complication rate less than 6%.”

Unless patients are willing to makelong-term adjustments to their lifestyle,the surgery may not be worthwhile. Dr.Park comments, “I tell patients that ifthey can’t commit to lifestyle and dietarychanges, which in fact constitute ahealthier way to eat and live, such aseating smaller and more frequent mealsdaily and chewing their food well, deepbreathing and core/aerobic exercises,then they shouldn’t undergo surgery andwe’ll part as friends.”

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A. Steven Fleisher, M.D., general and

interventional gastroenterologist; chief,

Division of Gastroenterology; and

director, Interventional Gastroenterology

Program atMedstar Franklin Square

Medical Center.

Adrian E. Park, M.D., general surgeon and

department chair, Surgery, Anne Arundel

Medical Center

Healthcare IT

THERE’S ANAPP FOR THAT


BY LINDA HARDER

USING MOBILE HEALTH FOR PATIENT CARE


While attendingthe 2012 mHealth

Summit justoutside D.C.,

Maryland Physicianexplored how

providers can selectamong some 15,000apps to connectmeaningfully withtheir patients.

Last year, in our March/April 2012 issue,Maryland Physician reviewed the nascentstate of mHealth (mobile health) andnoted that physicians primarily used it forreference and clinical decision support.While that continues to be the primaryuse of mHealth today, patient monitoringand compliance tools have exploded, andmore insurers, health systems, wirelesscarriers and entrepreneurs are taking thenecessary first steps to use these tools toimprove patient health.

In the process, the doctor visit isbecoming a smaller piece of the healthdelivery pie. Using an app, providers cangenerate automatic reminders to patientsto take medications or administerinjections, or monitor their cardiac healthon a daily basis, rather than waiting fortheir next doctor’s visit. Even the FCC isoptimistic that mHealth can facilitate lesscostly, more efficient and more frequentcare interventions for patients.

Nearly every organizationinvolved in healthcare is looking atmHealth to improve an aspect of care,whether reducing readmission rates,preventing and monitoring chronicdiseases, improving medication andtherapy compliance, or allowing patientsaccess to mental health care withoutstigmatization. The approachesrange from simple text messages tosophisticated wireless devices thatremotely monitor more complexconditions.

The role of mobile devices isgrowing so rapidly that the FCC’smHealth Task Force’s goal is to havemHealth technology become a routinemedical best practice within five years.By 2020, 160 million Americans will bemonitored and treated remotely for atleast one chronic condition, accordingto Nerac, a Connecticut research firm.

With app availability burgeoning,how can physicians determine whichapps make sense for their practice andtheir patients? A partial list of sourcesphysicians can use to find medicallyvalidated apps follows.

FDA CLEARED APPS (THOSEINVOLVING A “MEDICAL DEVICE”)To ensure the soundness of apps thatinvolve a medical device to monitorpatient health, physicians can turn to theelite group of apps that have receivedFDA clearance. Such clearance iscurrently required for apps that entail theremote use of a medical device or thattransform a mobile device into a medicaldevice (e.g., electronic stethoscopes orglucose meters), unless they otherwisefall under the exempted Class I devices.

Examples of products that haveobtained FDA approval are WellDoc’sDiabetes Manager (discussed in ourMarch/April 2012 issue), Airstrip OBand RPM (remote patient monitoring),Proteus Biomedical’s “Raisin” skin patchand “intelligent pill” sensor, andAliveCor’s and Corventis’ Nuvantwireless heart monitors.

APP CERTIFICATION ANDPRESCRIPTION PROGRAMHapptique (www.happtique.com), asubsidiary of GNYHA Ventures, Inc., thebusiness arm of the Greater New YorkHospital Association, may be a useful toolfor sorting among the thousands of appoptions. The company allows providersto prescribe health apps via its secure,developer-agnostic platform, and inearly 2013, Happtique launched anApp Certification Program (note: as ofpublication, their standards were still ina draft state.) This program can helpproviders and consumers determinewhich apps not requiring FDA clearancehave reliable content and meet highoperability, privacy, and securitystandards.

APPS VALIDATED BY MAJORHEALTH SYSTEM STUDIESMajor health systems such as JohnsHopkins and Geisinger are collaboratingwith mHealth entrepreneurs to designand test patient applications. Suchpartnerships can provide evidence-baseddata about the efficacy of various apps.

Johns Hopkins University’s WilmerEye Institute worked with MEMOTEXT,a company that developed a proprietarymethodology, algorithm and communi-cations platform to improve medicationcompliance – a huge issue for providersand costly to payers. “The key topositively affecting the kind of behaviorchange required in patients who are non-compliant are personalized programs that

address their individual issues or barriersto adherence,” says Amos Adler M.Sc.,founder and president, MEMOTEXT.“We understand that for technology towork in the mHealth space, we have toask patients what the best means tocommunicate with them is, and what isimportant to them about their condition.”

For 60 to 90 days, patients wereasked how they were feeling and theircomplaints were triaged to theappropriate provider. If patientsexperienced side effects, they were askedif they had reported them. The studyfound a 31% increase in adherence todaily therapy.

Geisinger Medical Center testeda “medical home” initiative amongMedicare patients that uses textmessaging and other technology toincrease patient adherence to treatmentregimens. The program decreasedhospital admissions by 8% and overallhealth costs by 4% in the first year.

WATCH MAJOR INSURERSMajor insurers also have jumped into themHealth market with both feet in aneffort to improve communication andservice to members, as well as to improvehealth. Take Aetna, which purchasediTriage to help its members initiallydiagnose their health symptoms andmatch them to an appropriate provider intheir area. It recently launched Carepass,an mHealth technology platform that canconnect a wide variety of apps and thatencourages entrepreneurs to develop newapps. Carepass encourages subscribers tomanage their health by providing easyaccess to insurance information, an IDcard, doctor’s visits, nutritional and healthand fitness programs, including over 20health-related apps such asMapMyFitness or GoodRx.

Kaiser Permanente views mHealth asa new, “fourth site of care” for healthcaredelivery that supplements care deliveredin hospitals, clinics and the patient’shome. Kaiser launched a mobile-optimized website and created apps forboth Android and iPhone users to allowits nearly nine million members 24/7access to their medical informationanywhere in the world from a mobiledevice. Members can email theirproviders, check lab test results, orderprescription refills, and manageappointments.

A study published in Health Affairsin 2010 found that glycemic, cholesteroland blood pressure measures improved2% to 6.5% in more than 35,000 KaiserPermanente patients with diabetes,hypertension, or both by using securemessaging for two months.

OTHER APPROACHESThe number of studies validatingmHealth approaches is growing on allfronts. For example, a winning abstractat the mHealth Summit presented theresults of a smartphone-based platformfor preventing alcohol relapse. Some 349patients participated in the randomizedclinical study through June 2011;participants had significantly fewer riskydrinking days than did the control group.

An online publication for medicalprofessionals, patients, and analysts calledimedicalapps (www.imedicalapps.com)offers reviews of apps under the directionof a team of physician editors.

Apple has a list of 80 recommendedapps for healthcare professionals thatincludes every type of app from referenceand clinical decision support apps topatient education and personal care apps.However, the rationale for their selectionprocess is not clear, and providers shoulduse other sources to validate the efficacyof apps on this list.

RECOGNIZE THAT PATIENTSWANT mHEALTHSome physicians have not yet realizedhow ready patients are for mHealthsolutions. A recent study found that aboutthree quarters of respondents would liketo receive email reminders for doctor’svisits, schedule a doctor’s visit online, andemail directly with their doctor.

Another global study, conducted forPwC Global Healthcare by theEconomist Intelligence Unit (EIU),found:

� About half of consumers believemHealth will improve healthcareconvenience, quality and cost in thenext three years.

� Nearly half expect mHealth to changethe way they manage chronicconditions, medication use and overallhealth.

� 59% of consumers using mHealthservices say it has replaced some visitsto doctors or nurses.

� The top three reasons consumers wantmHealth is to have more convenientaccess to their provider, reduce out-of-pocket healthcare costs and takegreater control over their health.

Even Medicare is contributing tothe move to mHealth approaches, asits 30-day readmission rule is makingremote monitoring technologies anattractive tool to help keep patientshealthy and at home.

The bottom line is that, whileproviders are right to tread cautiouslywhen recommending, prescribing orusing apps for their patients, theyshould start now to explore thepotential for vetted apps to improvetheir medical practice.What are your favorite patient care apps or

sources for learning about apps? Email us at

[email protected] or leave your comments

at [email protected].


Healthcare IT

Physician Useof mHealth� 93% said physicians used mo-

bile technology in day-to-dayactivities.

� 80% percent said physiciansuse mobile technology toprovide patient care.

� Pharmacy managementcurrently is likely to be the areaof care receiving the mostbenefit from mHealth.

Source: The 2nd annual HIMSS Mobile Technol-ogy Survey, 2012, that surveyed 180 HIT profes-

sionals with mHealth responsibilities.


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Q:What led you to become apolitician? There were so many thingsI saw as a career emergency physician –first as Chairman of Emergency Medicineat Franklin Square for 14 years whilebuilding a six-hospital group practice.When I got elected to the legislature in1994, I moved over to Sinai Hospital, alevel-2 trauma center. So many of thecases I was seeing had social antecedents– such as diabetes and preventabletrauma. Emergency rooms admit about70% of patients seen in the hospital, soit’s a focal point. I kept seeing patientswith problems that could have beenbetter dealt with beforehand. There areunderlying causes for many of our healthproblems that should be managed beforecoming to a crisis.

In the early 90s, I attendingcommunity meetings and asking why we

didn’t have curbside recycling. The endresult was that I was appointed to thecity/county task force on recycling. Wedesigned a system that would work, andnow we have recycling in BaltimoreCounty and City. It gave me a sense thatgoverning is hard work and requiresattention to details, but that it makes adifference. That experience – and wantingto raise my three children in a world thatwas healthy and safe – contributed to mydecision to run for office.

Q:How did being an ER doctorinfluence you? As an ER doctor, you get adirect and immediate indication of what’sgoing on in the community, and you takecare of every kind of person. That requireslearning to deal with everyone from a richperson to a drug addict to a young child, aswell as the other health providers involvedin care delivery.

I finally stopped doing emergencymedicine about three or four years ago. Icalculated that I had not slept at night for 30days in a row from 1974 to 2007. Over theyears, I’ve treated about 170,000 patients.

The last three years I worked atHealthcare for the Homeless, and nowI’m on their board. And 12 years ago, Ijoined the faculty of Hopkins BloombergSchool of Public Health, where I doteaching and research. One of the papersI wrote was the data substrate for mybook, The Better End: Surviving (andDying) on Your Own Terms in Today’sModern Medical World (Hopkins Press,www.thebetterend.com).

Q:What are the most significantend-of-life issues physicians shouldbe aware of? What’s your message tothem? We are not comfortable talking

about end-of-life care, but the more wedo, the more comfortable we’ll be. Wehave a strong cultural and medical tabooagainst talking about death and dying,but we’re the first generation that likelyhas a say in how, when, and where we die.The good news is that technology hashelped us live longer, healthier lives. Thechallenge is that, if you have widespreadmetastatic cancer, do you really want toend up in an ICU in your last days?

There are free legal documents –advance directives – that have beenaround about 20 years. We did a study atHopkins and found that only about a thirdof Americans have advance directives.

Policy

Addressing the Social Antecedents of HealthProblems and End-of-Life Issues

As part of our ongoinginterviewswith keyMaryland policymakersthat spotlight initiativesimpactingphysicians,Maryland Physicianrecently sat downwiththe only physician in the188-memberGeneralAssembly.His views onaddressing commonhealth problems andtheir social causes follow.

TRACEY

BROWN

An Interview With Delegate Dan Morhaim, M.D.Maryland House of Delegates, Democrat, 11th District


A lot of emergency medicine hasbecome geriatric. I found myself doingthings to patients in the name of carethat is not care. A 95 year old comes infrom a nursing home in extremis, andthe ER staff jumps to full CPR mode,and that person may survive a few hoursor days. In a culture that valuesindividual rights and freedom so much,patients can and should have a role inmaking these decisions. Completing anadvance directive doesn’t mean adiminution of care. It’s care according toyour wishes and values. But wecollectively abdicate on this issue. It’simportant to empower people becausewe can influence this process that we’reall going to confront. And our studyshowed the people want to discuss thiswith their physician.

End-of-life care costs a lot of money.About 30% of Medicare expenses arefor end-of-life care, and expenses areconsiderable for Medicaid andcommercial insurance as well. Presumablyif the rate of advance directives went up,more people would choose less intensecare and less money would be spent. Butwe’d be spending less money the rightway – through individual decision-making. Technology can serve us, but itcan also separate us from the process ofdeath and dying. This all starts with theindividual filling out the forms. Only youcan do the paperwork.

Q:Describe some of the legislationyou’ve been involved with.A lot of mypolitical actions were informed by myemergency medicine experience. Forexample, the worst night of my life wasseeing three children killed in a drunkdriving accident, and so I’ve been involvedwith bills related to drunk driving.

I’ve worked on expanding andimproving addiction treatment programsand legislation on the issues of advancedirectives and end of life care. I’vedone a lot of health care bills, with afocus on helping patients and supportingproviders. At this point in my legislativecareer, I often choose to work on others’bills and don’t feel the need to be thelead legislator as often.

I also work to streamline governmentoperations, savingmoney through consoli-dation and efficiency. I’ve also worked on

numerous bills promoting the environment,education, jobs, and public safety.

Q: Tell us about your peer-reviewlegislation.When I started years agothere wasn’t any particular orientation topeer review. When I was in emergencycare, I evolved with my colleagues to areasonably good system, but it wasn’t aswell structured or as valuable as it couldhave been. It’s an important part ofhealthcare. It’s not just pushing papersaround. It actually has to have integrityand value in improving the quality of care.But even the simplest things in healthcareare complicated – treating a sore throat, forexample: you have to at a glance evaluatethe tonsils, look for exudate, dentition,

other conditions, etc. Evidence-basedmedicine is a good thing but can bechallenging to translate into practice.

I try to remind everyone thathealthcare is still delivered by people one-on-one. It’s not the hospital that starts theIV – it’s a nurse, physician assistant, orparamedic. The insurance companydoesn’t reduce a dislocated shoulder –it’s me. It’s easy to stand on the outsideand make comments, but it’s a lot harderon the inside making the decisions.

Q: Tort reform continues to be amajor legislative focus in Maryland.What are your views on this subject?The macro issue is that first, going backto peer review, you really want todo the best you can – have quality andconsistency – before a problem arises.Tort deals with issues after they’vehappened. Second, you want to involvepatients and families when bad thingshappen. A lot of times, people just wantto know that they’ve been heard and thattheir problem is acknowleged. You wantto quickly take care of an incompetentdoctor, but many times, it’s no one’s fault.Going through a long series of legal casesends up being a random lottery as to who

wins, and often doesn’t help the patient.The solutions can include mediation,

no-fault, open discussions when thingsdon’t go well, and aggressively addressingsystemic problems. The tort system we’recurrently using is cumbersome,expensive, and rarely fair or helpful.

Q:Gun control – do you think it willpass and what is your position? I thinkit will pass, and I’m pretty sure I’llsupport it. However, what you really wantto do is prevent murders before theyhappen. The bulk of murders can betraced back to several things.

Most shootings are related to drugs.What does it cost to maintain a habit inthis area? It’s $25 to $50 per day. If you

multiply that by 75,000 addicts, you get tobillions of dollars. Some incorrigibles needto be locked up, but I’m strongly foraddiction treatment programs. People dohave relapses, as they do for any medicalcondition, but if you get someone in anaddiction program today, at least they’renot committing a crime that day. Overtime, most can be rehabilitated. I supportmedical marijuana, which is another topic.

Second, most people who kill eachother know each other, despite theoccasional horrible exceptions like Auroraor Newtown. Domestic violence issuescan be dealt with through moreaggressive restraining orders, limiting gunaccess to those who have been identifiedas having problems, and so on.

Third, there are the mentally ill whoare dangerous. Most mentally ill peopleare not dangerous, and most dangerouspeople are not mentally ill, but there isoverlap. Having done mental healthassessments in the ER, sometimes you cantell who is at high risk. For example,patients who have a history of hurtinganimals or setting fires are at very high riskfor violent behaviors. Generally our mentalhealth system needs to improve for regularkinds of mental health problems.(continued on page 31)

TRACEY

BROWN

“There are underlying causes for many ofour health problems that should be managedbefore coming to a crisis.”

– Delegate Dan Morhaim, M.D.

HE HISTORIC TOWN OFSt. Michaels dates back to the mid-1600s, when it served as a trading postfor area tobacco farmers and trappers.Located on Maryland’s Eastern Shore, St.Michaels is about halfway between theSusquehanna River and the mouth of theChesapeake Bay. A tiny, well-preservedport, it’s become a destination for well-heeled Washingtonians as well as visitorsfrom around the Bay and beyond.

During the War of 1812, St. Michaelsgained its name as "the town that fooledthe British." Forewarned that Britishbarges were positioned on the waters toattack with cannon fire, the residentshoisted lanterns into the trees above thecity. This first successful "blackout"fooled the British into overshooting thetown's houses and shipyards. Only onehouse, forever since known asCannonball House, was struck.

Last April, I took part in the town’sannual and phenomenally popularWineFest. To say I had a wonderful timewould be an understatement – thepeople, the food, the entertainment andof course, the wine selection werefantastic! I left St. Michaels knowingtwo things for sure: (1) WineFest wouldbe a regular for every April to come, and(2) with so much culture, history andscenery to explore, a return visit duringthe quieter off-season was a priority. InJanuary, I did just that.

Chesapeake Bay Maritime Museum –A Must SeeWhether planning a day trip, weekendgetaway or extended stay in St.Michaels, make it a point to visit theChesapeake Bay Maritime Museum,located on Navy Point, where you cansee a comprehensive collection ofartifacts and exhibits that capture the

history and beauty of the ChesapeakeBay. Here, you can learn about localnaval history, watercraft and boatbuilding traditions, seafood harvestingand the wide array of recreationalactivities along Maryland’s waterways.While on Navy Point, reserve a fewminutes for photos of the historicalHooper Strait Lighthouse.

Shop, Shop, ShopHoping to bring a piece of theChesapeake Bay with you as you departSt. Michaels? I found two favorite shops.The first is Ophiuroidea - better knownin town as “The O.” Owned by localMaryland artisans Shella Kirchner andKim Hannon, this fun shop featurescolorful, beach-themed artwork,accessories and furniture inspired by thecoastal landscape. Among the manytreasures that can be found here areLouise Taylor Crab Art. These collectionsof crab photography are pieced togetherto create dynamic “letter art,” capturingthe essence of Maryland seafood incustom-made, historically rich tobaccostick frames. The second is Simpatico,offering a wide range of beautiful artisanproducts including foods and winesdirectly imported from Italy. Simpaticohas an active list serve highlighting itsown special events throughout the year.

Check-In and Stay for a WhileThere is no shortage of inns, cabins,resorts and quaint little bed and breakfastinns that you can check into for a longer-than-a-day stay in St. Michaels. Twospots in particular have generated a lot oftourist “buzz” – the first being the Inn atPerry Cabin. This Victorian-inspiredresort is known for its luxuriousaccommodations, fine dining, on-siterecreational activities and full range of

spa services. Many of its 78 rooms havefireplaces, designated living rooms anddecks, patios or verandas. Another hotspot to stay in town in the Parsonage InnB&B, also known for its exquisite décorand amenities, and located withinwalking distance of the Chesapeake BayMaritime Museum and many shops andrestaurants. Those who have stayed hererave about the fresh muffins and pastriesserved each morning, as a “teaser” forthe full hot breakfast that comes outshortly thereafter.

Oenophiles’ Paradise … Every AprilWineFest 2013 will be held April 27 and28, featuring hundreds of wines from 19different venues. This year, the festivaloffers patrons tastings of new wines thatare not yet available for sale inMaryland, as well as samplings from avariety of international winemakers. Thepopular “VIP Patriot Wine TastingCruise” is once again on the agenda,with an upgraded ticket option givingcruisers access to an additional winetasting event in the courtyard area ofThe Old Brick Inn.

To plan your trip the easy way, visitwww.stmichaelsmd.org.


Living

St. Michaels, Maryland“TheTownThat Fooled the British” By Jacquie Roth

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Last, we need to greatly improveour juvenile justice system. Too manyyoungsters are not rehabilitated there,and they need all the help they can getto get on the right track in life.

Then, you get to the gun issue. I’min favor of more restrictions on assaultweapons and background checks, but weneed to talk about the other issues thatlead to violence in the first place.

At Healthcare for the Homeless, I’veseen a lot of men who have committedcrimes. Some say, “I did a three-spot”(served three years in jail) as casually as ifthey were saying they went to the movieslast night. I’ve had patients tell me aboutcold-blooded murders they did. One mansaid he was 15 when he was in for tenyears. He had killed six people as a youngkid. The drug dealers would give him twothousand dollars and a gun and have himwalk over and kill someone. He did thatfive or six times and then he got caught.

There are others issues as well thatlead to terrible crimes, such as elderabuse to human trafficking. So,legislatively, it goes back working onunderlying social antecedents.

Q:What other legislative initiativesare you involved with? I work onmany issues as Chair of the GovernmentOperations Subcommittee of theCommittee on Healthcare andGovernment Operations. There, we workto identify efficiencies that will savemoney without having to raise taxes orcut programs. We also promote programsto help minority, women, small, andveteran owned businesses.

I’ve focused on transparency andcompetition for government contracts,and that has saved millions of dollars. I’mfiling a bill to improve our open meetingsstatute to help ensure greater publicparticipation.

We have a serious shortage of certainmedications. Generic drugs – primarilysterile injectables – are becomingincreasingly unavailable. Hospitals arehaving trouble finding epinephrine,sodium bicarbonate, atropine, propofol,and other commonly used medicines.Much of the problem is at the federallevel, but I’m working on what we cando in Maryland.Dr. Morhaim’s book can be found at

www.drdanmorhaim.com, www.thebetter

end.com or at Amazon.

Policy(continued from page 29)


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left behind – read what Maryland physicians and health-

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Solutions

Understanding MeaningfulUse Stage 2

By Craig Law

TAGE 2 MEANINGFUL USEbegins as soon as 2014. You could have lessthan a year to be ready, and starting 2016,Medicare will initiate annual reimbursementreductions for all those providers who donot attain Meaningful Use.

Practices must report both quantifieddata (e.g., how many e-prescriptions weresent) and qualified data (reportingthrough attestation that you performedcertain actions). The Stage 2 objectivesfollow, with changes from Stage 1 notedin parentheses:

Core Stage 2 Objectives> Computerized provider order entry

(CPOE) (increased measure andscope to 60%)

> Drug-formulary checks [moved intoe-prescribing (e-Rx)]

> E-Rx (increased threshold to 65%)> Report clinical quality measures to

CMS/states (for 9 of 64 approvedmeasures)

> Clinical decision support rules(increased scope to 5 measures)

> Drug-drug and drug-allergyinteraction checks (combined withCDS measure)

> Provide patients an electronic copyof their health information (require5% of patients to use)

> Provide clinical summaries topatients for each visit (increaseddelivery to 1 day)

> Record demographics, includinglanguage, race and ethnicity(increased scope to 80%)

> Maintain a problem list of current/active diagnoses (no change)

> Maintain active medication list (nochange)

> Maintain active medication allergylist (no change)

> Record vital signs (Increased scopeto 80% and change in age)

> Record smoking status for patients

13 years or older (increased scopeto 80%)

> Exchange key clinical informationbetween providers of care (combinedwith other objective)

> Protect electronic health informationthrough annual security reviews(requirement to encrypt/secure ePHIon any mobile device)

> Incorporate clinical lab test results asstructured data (moved to core andincreased to 55%)

> Record Advanced Directives (movedto core objectives and increased scopeand measure for attainment)

> Generate lists of patients bycondition (moved to core objectivesand increased scope and measurefor attainment)

> Send reminders to patients forpreventive/follow up care (movedto core objectives and increasedthresholds for attainment)

> Medication reconciliation (movedto core objectives and increasedthreshold to 65%)

> Provide patients ability to view,download and transmit healthinformation (new and 10% ofpatients must utilize)

> Patient Education provided topatients (moved to core objectives)

> Use secure messaging (new, thresholdof 10% of patients using)

> Submission of electronic data toimmunization registries/systems (movedto core objectives with 100% threshold)

> Electronic Summary of care record foreach transition of care/referral (movedto core objectives)

Menu Objectives (providers mustselect three of six)> Submission of electronic syndromic

surveillance data to public healthagencies (moved to core objectivesand 100% threshold)

> Imaging results accessible to provider(new and threshold of 40%)

> Electronic note (new and thresholdof 30% of patients)

> Family health history as structureddata (new and threshold of 20%)

> Report electronically to cancerregistries (new and 100% threshold)

> Report to alternative registries (newand 100% threshold)

If you haven’t already begun using anEMR, now is the time to take advantageof incentives to offset the cost ofconversion. Meeting Meaningful Usecriteria also will prepare you for upcominghealthcare changes, such as qualitymeasures and published performance.

Consider hiring an experiencedconsultant to guide vendor selection andimplementation; while they charge a fee,they can save considerable dollars bycontracting and negotiating effectively onyour behalf. A consultant also can savehundreds of hours of time and smooth yourEMR transition by knowing which workflows require the most attention, ensuringthe correct setup and customizing theplatform for use in your environment.

In a growing number of practices, anEMR already can enable lab and radiologyresults, procedures, discharge instructionsand ER visit summaries to arrive directlyinto your EMRwithoutmanual inter-vention. No more lost tests or charts! Knowwhich patients are taking a newly bannedmedication! The opportunities for improvedhealthcare delivery are staggering. Makethe commitment to meet Meaningful Usetargets both to facilitate patient care and totake advantage of Medicare and Medicaidincentives before penalties ensue.Craig Law is President of STATpay, Inc., a

Maryland based healthcare consulting

firm that provides visit redesign, practice

automation, EMR implementation and

Meaningful Use attainment.Contact him

at [email protected].

S


Putting NewTechnologies in Patients’Hands

OST PEOPLE AGREE– technology is rapidly changing theworld we live in. And more than everbefore, it is playing a crucial role in theevolution of healthcare delivery in theUnited States. Recognizing theimportance of reducing healthcaredisparities, improving access to care andempowering patients to be more activein management of their own health, theVerizon Foundation has introduced aphilanthropic program, offering $13million in grants and in-kind technologydonations to healthcare researchersand innovators focused on the provisionof quality care for women, childrenand seniors.

The Verizon Foundation haslaunched the program in partnership withfour organizations, to start: the Children’sHealth Fund; the National Association ofCommunity Health Centers; theUniversity of California, San Diego; andthe Society for Women’s HealthResearch, which partners with JohnsHopkins Medicine on a number of

research-based programs and initiativesgeared toward the implementation ofpositive change in the global healthcareenvironment.

“Johns Hopkins is one of the richestplaces in the world for research, withpeople who are eager and willing to makechanges to improve patient care,” saidFlorence Haseltine, Phd, M.D., Founderof the Society for Women’s HealthResearch. “The Verizon Foundation is

providing resources forresearchers to create newopportunities, kick-startideas and really test if theycan work.”

Patients undergoingtreatment for heart diseaseat Johns Hopkins BayviewMedical Center are amongthe first to reap thebenefits of this newprogram. After women in the heartdisease clinic’s waiting room wereoverheard time and time again, sharingtheir personal stories, tips and ideas, aconcept evolved:patients would likely be more active inmanaging their own health conditions ifgiven the tools and resources to networkwith others on a regular basis. Today,patients are encouraged to participate inan interactive heart disease managementprogram, using a web-based patientportal and personal tablets, funded bythe Verizon Foundation. Together, thesetools allow patients to converse with one

another, make contact with their careproviders, track vitals, be continuouslyeducated and find the support theyneed to make critically important life-style changes.

“This is a great example of howtechnology can be used to addressbehavioral change and create motivationwithin patients,” said Roselena Martinez,Healthcare Program Manager for theVerizon Foundation. “At the same time,

these tools will help doctors do their jobsbetter because they will help themunderstand what is happening ‘right now’with their patients, at any given time.”

Long-term, the Verizon Foundationintends to expand this program, toinclude partnerships with additionalhealthcare organizations that requirenew technologies to bring good ideasto fruition.

“We are taking a step back andfocusing on learning about communities,identifying ideal partners andunderstanding how technology can affecthealth outcomes,” said Martinez. “Foreach new partnership or program wecreate, evaluation is the key. We want tolink projects that are happening at variousinstitutions, and bring our partners andtheir ideas together for great impact.”

Physicians interested in learningmore about the role technology canplay in helping patients manage chronichealth conditions or disease can accessan interactive infographic, developedby the Verizon Foundation, atwww.verizonfoundation.org/chronicdisease/.

Good Deeds

M

“The Verizon Foundation is providing resourcesfor researchers to create new opportunities,kick-start ideas and really test if they can work.”

– Florence Haseltine, Phd, M.D., founder of the Society for Women’s Health Research

By Tracy M. Fitzgerald

Caption here.

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

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

MP_Mag_Layout 1 2/25/13 6:16 AM Page 35

Guillaume Marçais, 37, Montgomery County, Treated with Heart Ablation for Atrial-Fibrillation

Climbing withConfi dence

After Catheter Ablation

at

For priority transfer of your cardiac admissions,

call Cardiac One-Call 866-684-8460.

To refer a patient for a cardiac surgery consult,

call 301-891-6101.

maryland physician magazine march/april 2013 issue

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