maryland physician magazine july/august 2013 issue

ORTHOPAEDIC UPDATE

HELP YOUR PATIENTS GET A BETTER NIGHT’S SLEEP

BEYOND CPOE: CLINICAL ANALYTICS IS KEY

KEEPING PATIENTS SAFE

ORTHOPAEDIC UPDATE

HELP YOUR PATIENTS GET A BETTER NIGHT’S SLEEP

BEYOND CPOE: CLINICAL ANALYTICS IS KEY

KEEPING PATIENTS SAFE

Physic i an Physic i anVOLUME 3: ISSUE 4 JULY/AUGUST 2013VOLUME 3: ISSUE 4 JULY/AUGUST 2013YOUR PRACTICE. YOUR LIFE.

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YOUR PRACTICE. YOUR LIFE.

MARYLAND

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12 Orthopaedic Update: Carpal Tunnel, Complex ACL Tears, Cartilage Repair and MSK Ultrasound

16 Help Your Patients Get a Better Night’s Sleep

F E A T U R E S

D E P A R T M E N T S

ContentsVOLUME 3: ISSUE 4 JULY/AUGUST 2013

1216 30

Cases | 7 | Advanced Digital Replantation

Compliance | 9 | How to Avoid Ten Common Mistakes

Medical Beat | 10 | Maryland Physician and Healthcare Leader News and Awards

Healthcare IT | 20 | Beyond CPOE: Clinical Analytics is Key

Policy | 24 | Keeping Patients Safe

Good Deeds | 26 | Special Camps for Kids with Special Medical Needs

Solutions | 29 | Engaging a Commercial Real Estate Advisor/Broker is Good Medicine

Living | 30 | A Little Piece of Paradise Along Smith Mountain Lake

On the Cover: James York, M.D., orthopaedic surgeon at Chesapeake Orthopaedic & Sports Medicine Center

4 | WWW.MDPHYSICIANMAG.COM

JACQUIE COHEN ROTHPUBLISHER/EXECUTIVE EDITOR

[email protected]

LINDA HARDER, MANAGING [email protected]

MANAGER OF DIGITAL CONTENT AND SOCIAL MEDIA

Jackie [email protected]

CONTRIBUTING WRITERTracy Fitzgerald

PROOFREADEREllen Kinsella

PHOTOGRAPHYTracey Brown, Papercamera Photography

Melissa Grimes-Guy, Location Photography, Inc.Kevin J. Parks, Mercy Medical Center

Randy Sager, Randy Sager Photography, Inc.

BUSINESS DEVELOPMENTEileen Nonemaker

[email protected]

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

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Subscription information: Maryland Physician Magazineis mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52.00. To be added to the circulation list, call 443-837-6948.

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

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

JAMES YORK, M.D. Chesapeake Orthopaedic & Sports Medicine Center

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

“Innovation”is ever present in today’s lexicon. Innovation in medicine is built upon existing knowledge anddiscoveries, driving more accurate diagnoseswith better treatment and outcomes. In every

issue of Maryland Physician, we strive to bring you the latest medical innovationsdelivered by your Maryland peers and colleagues, as well as innovations thatfacilitate more efficient patient care and practice management solutions. Sometimesinnovation is simply raising awareness of treatments that have been available foryears, such as using a patient’s own cartilage to heal joint injury, or using low imaging devices such as ultrasound in new ways. This issue’s cover story is ourannual update on orthopaedic treatments – spotlighting innovations in existingknowledge, discoveries of new uses for existing equipment, and advances in training– all with a focus on improving disease prevention, treatment and outcomes.

Innovation in technology also drives how and where you’re reading MarylandPhysician. Our online readership is poised to exceed our print audience in thecoming issues - maybe even this one, while you’re reading it on your summervacation. For most of us, catching up on sleep is top of the vacation’s “to-do” list.Sleep is a third of our life – time that can’t really be recaptured - but, as our featureon sleep underscores, that has a direct correlation with both mental and physicalhealth. Our experts advise making questions about patient’s sleep habits part of yourH & P, and provide some tips for better treatment of the most common sleep issues.

Everyone who is part of a healthcare delivery system is well aware that technologyinnovations are looming to make a major shift in reimbursement models and theeconomic realities of delivering integrated and coordinated care. In our HIT feature,we’ve explored the value of computerized order entry (CPOE), which providesworkflow efficiencies and clinical analytics with a keen eye on the bottom line.Implementation of CPOE often comes with a resistance to change, but withoutchange, where are progress and innovation?

Enjoy your summer – whether you’re able to sneak away for a long weekend toexplore not too distant waterways like Smith Mountain Lake; enable a special needschild to discover what summer camp is all about while learning how to manage achronic illness; or just enjoy the light and flight of a firefly.

To life!

Jacquie Cohen RothPublisher/Executive Editor [email protected]

@mdphysicianmag

Printed on FSC certified, 100%PCW, chlorine free paper

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Medical Professional Mutual Insurance Company and ProSelect Insurance Company, both Coverys member companies, were recently rated ‘A’ for fi nancial strength by A.M. Best. We earned this distinction as a result of excellent capitalization, strong underwriting results and favorable historical investment income. In short, it means we will be there when you need us. And that should make you feel a lot better.

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JULY/AUGUST 2013 | 7

DISCUSSION Replantation of anamputated part is not a novel idea. Thesurgical techniques have existed for atleast 50 years1 and those required toreplant digital level amputations haveexisted for nearly 40.2,3 The replantationprinciples of “form and function” have notchanged, but surgeons can now sutureblood vessels only millimeters in diameter– once believed impossible. This is adirect consequence of the development ofhand surgery training programs andspecialty “centers of excellence”.

Digit replantation should only beconsidered once a trauma survey has beencompleted and life-threatening injurieshave been ruled out. Too easily, thephysician can be distracted by a mangledlimb and miss a potentially serious hiddeninjury such as tension pneumothorax. Inisolated extremity injuries, bleeding canusually be controlled with elevation and a lightly compressive dressing or directpressure. A tourniquet is rarely neededand can even, by elevating venouspressure, exacerbate bleeding and causethe patient undue pain. Attempting toligate “bleeders” in the hand is stronglydiscouraged. Doing so in an uncontrolledsetting may inadvertently injure potentialusable nerves, arteries, and veins. Thedigit should be placed in a sealablecontainer within a separate container ofice water to slow cellular metabolismwithout injuring the cells.

The indications for digit replantationinclude amputation of the thumb, multipledigits, any digit in a child, or a partnecessary for a vocation or avocation.Contraindications include a grosslycontaminated part, an unsuitable recipientbed, the presence of a life threateninginjury, or a psychiatric condition that couldlimit the patient’s ability to participate inthe requisite postoperative therapy. Anisolated non-thumb digit is oftenconsidered a relative contraindication to

replantation because it is often bypassed,and may impair hand use. Surprisingly,advanced age, smoking, and diabetes arenot strict contraindications.4,5

Digits amputated via a sharpmechanism often survive and functionbetter than those amputated through ablunt or avulsive mechanism.5 Thesurgeon typically completes allmacroscopic work (bone and tendon)prior to performing the microscopic nerveand vessel work. Most digits requirerepair of just one of the two digitalarteries. To prevent venous congestionand resultant thrombosis, the surgeonaims to repair as many digital veins aspossible. If detected early, venouscongestion often can be corrected witheither surgical revision of the venousanastomosis or therapeutic leeching.

If a replant fails, a prosthetic cancamouflage the resultant deformity, but isinsensate and typically does not addfunction. For the failed thumb replant, atoe-to-thumb transfer remains anexcellent reconstructive option. Thissurgery can accomplish all of the samegoals of replantation surgery – restorationof function, preservation of sensibility,and maintenance of aesthetic balance. Ryan Katz, M.D. is trained in plastic and recon-

structive surgery at the Johns Hopkins Hospital

and fellowship trained in hand surgery at The

Curtis National Hand Center in Baltimore’s Union

Memorial Hospital. www.unionmemorial.org

Cases

Advanced Digital Replantation

CASE: In July 2011, MPsustained a near-completeamputation of his left thumbwhile using a power saw. Thesaw had passed through all theimportant anatomic structures,including the nerves, arteries,tendon, and bone. The digit,attached to the hand by only a small skin bridge, wasnonviable. He was transferredemergently to Curtis NationalHand Center in Baltimore,where a trauma survey revealedhis injuries to be isolated to the hand.

In the OR, the part wasfound suitable for replant.After a thorough washout anddebridement, the bone wasstabilized with percutaneouspins. The flexor and extensortendons were then repaired.The nerves, artery, and veinswere repaired using theoperative microscope for optimal visualization.

The patient was admitted tothe hospital for five days postop,where he received serial clinicalexams, subcutaneous heparininjections for DVT prophylaxis,and aspirin to prevent plateletaggregation. He was dischargedwith a viable thumb and anuneventful postoperative course.

By Ryan Katz, M.D.

1) Malt RA, Remensnyder JP, Harris WH. 1972. “Long-term utility of replanted arms.” Ann Surg 176 (3): 334–42.2) Buncke H, Buncke C, Schulz W 1966. “ImmediateNicoladoni procedure in the Rhesus monkey, or hallux-to-hand transplantation, utilising microminiature vascularanastomoses.” Br J Plast Surg 19 (4): 332–7.3) Komatsu S, Tamai S. 1968. “Successful replantation of acompletely cut-off thumb: case report.” Plast ReconstrSurg 1968;42:374–7.4) Sanmartin, Marcos, Francisco Fernandes, A Scott Lajoie,and Amit Gupta. 2004. “Analysis of Prognostic Factors inRing Avulsion Injuries.” The Journal of Hand Surgery 29 (6)(November): 1028–1037.5) Dec, Wojciech. 2006. “A Meta-Analysis of Success Ratesfor Digit Replantation.” Techniques in Hand & UpperExtremity Surgery 10 (3) (September): 124–129.

We created the Tribute Plan to provide doctors with more than just a little gratitude for a career spent practicing good

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Tribute Plan projections are not a forecast of future events or a guarantee of future balance amounts. For additional details, see www.thedoctors.com/tribute.

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OUR MEDICAL LICENSE IS your livelihood and every inquiry from a licensing board is a “big deal”.Licensing boards have almost unfetteredauthority to investigate, prosecute andimpact your ability to practice medicinein Maryland. How you respond to aboard inquiry, no matter howinnocuous, may have substantial andlong-term ramifications.

Licensing boards may initiate aninvestigation based on a specificcomplaint or other information.Investigations usually begin with arequest for the factual circumstancessurrounding the complaint, a subpoenafor records, or access to patient records.The board may seek an interview(informal or under oath) or refer thematter for formal charges.

Failure to answer board inquiries maylead to disciplinary action or formalcharges. Maryland boards areempowered to revoke or suspendmedical licenses, as well as to reprimandor place a licensee on probation. Boardsare required to report disciplinaryactions to the National Practitioner DataBank, which hospitals consult regardingstaff privileges, and which insurancecarriers check for provider eligibility.The provider who mishandles a boardcomplaint risks adverse financial andprofessional consequences. Theimportance of responding appropriatelyto a board complaint or request cannotbe overstated.

Based on our experience, we havesummarized common mistakeshealthcare professionals make followingreceipt of a board complaint or inquiry.We also offer these recommendations tohelp avoid adverse outcomes.Neal M. Brown is founding partner of and

Nicole A. McCarus is a partner at Waranch &

Brown, LLC: [email protected] and

[email protected].

Compliance

By Neal M. Brown and Nicole A. McCarus

YHow to Avoid Ten Common Mistakes

Responding to the Maryland Medical Licensing Boards

1. “It’s no big deal.”

2. “I don’t need to involve myinsurance carrier in this matter.”

3. “I don’t need an attorney torespond to this complaint.”

4. “I’ll get to it when I can –there’s no rush.”

5. “I’m sure I can work it outwith the patient.”

6. “I can just correct thepatient’s chart.”

7. “The patient was notharmed, so the board cannotfind against me.”

8. “I messed up. I should justadmit it and get this over with.”

9. “The board is full of healthprofessionals so I don’t need toexplain the medicine.”

10. “I’m so angry, I can’t seestraight!”

Do not dismiss the allegations as frivolous, meritless or an outright fabrication by the patient. Treatcorrespondence from the board seriously, requiringyour immediate and thoughtful response.

Review your professional insurance policy and contactyour agent to evaluate the situation.

Do not contact the board to discuss the complaintwithout first contacting legal counsel. Promptlyprovide your attorney with all pertinent information,and do not omit significant details with the hope theywill not surface later.

Highlight the due date for the response immediatelyon the calendar, and request an extension if necessary.

Consult counsel before discussing the matter withanyone; if approached for comment, politely decline.This ensures that your lawyer is able to protect yourlegal rights whenever possible.

Do not alter, modify, destroy or dispose of records. If errors or omissions in the original record exist, you may supplement, but only in accordance withpreviously established recordkeeping guidelines.Clearly note the date and reasons for any supplement,amendment or addendum, and produce the originalrecord.

Do not make assumptions based upon the patient’soutcome. Discuss with your attorney whether there is a valid defense to the allegations.

It may be appropriate to express concern for thepatient. However, consult with your attorney to discussdefending or mitigating your care. Even where anadmission of fault is the only option available, the bestpossible terms should be sought before a concession.

In your response, inform board members of anyunique aspects of the case involving your practice orspecialty. It may also be helpful to include citations to medical references or support from consultingphysicians or experts.

Take time to think through your response. Be factual,precise, respectful and cooperative.

Common Mistakes Recommended Actions

This article is not intended to constitute legal advice or create an attorney-client relationship, but is intended for general information only. An attorney or other resource should be consulted regarding individual cases.


AAMC Center Opens Patient-Centered Geriatric Unit AAMC recently opened its 30-bed AcuteCare of the Elderly (ACE) unit. The ACE unitoffers a specialized model of care for older,hospitalized patients with acute illness.AAMC was awarded the Nurses ImprovingCare for Healthsystem Elders (NICHE) facility designation in December 2012 asthey prepared for the ACE unit opening.

NICHE is a national organization strivingto improve the quality of care for hospital-ized older adults, provides evidence-basedgeriatric protocols and geriatric education forhospital staff members so they are betterequipped to care for older adults. NICHE is the largest geriatric nursing program available in the United States.

“Geriatric patients face a variety ofhealth risks. This model of care has proventhat focusing on the unique needs of theelderly enhances clinical outcomes duringand following hospital admission,” saysSherry Perkins, PhD, R.N., AAMC’s chief operating officer and chief nursing officer.

Medical Beat

Hospice of the Chesapeake WelcomesNew Board ChairmanHospice of the Chesapeake announced theappointment of Richard M. Lerner, marketchairman for the Maryland Region of FirstNational Bank, as chairman of the board atthe nonprofit headquartered in Annapolis.

Lerner is formerly Chairman and CEO of Annapolis Bancorp, Inc. and its principalsubsidiary, BankAnnapolis. He assumed hisnew role with First National Bank followingthe company’s merger with BankAnnapolisin April. Lerner’s involvement with Hospice of the Chesapeake dates back to2005 when he first joined the nonprofitFoundation’s board of directors.

In keeping with First National Bank’scommitment to community leadership, the bank established a corporate partnershipwith Hospice of the Chesapeake in Januarythat included a diamond sponsorship of the 2013 Hospice gala held in March, andan event which raised $350,000 for thenonprofit.

University of Maryland Children’s Hospital willunveil a new and enhanced Breathmobile, courtesy of Kohl’s Cares “Keeping Asthma onthe Move” program. Each year this mobileasthma clinic serves more than 500 children byvisiting 19 Baltimore city schools. Clinicians fromthe University of Maryland Children’s Hospitalstaff the Breathmobile to bring diagnostics and

treatments directly to kids at their schools. Asthma causes 640,000 missed school

days each year in Maryland and is the No. 1cause of pediatric emergency room visits. Hospitalization rates among asthmatic childrenin Baltimore are three times higher than the rest of the country. And about half of Baltimorechildren with asthma have had an emergency

department visit in the prior six months.Kohl’s will present a check for $215,088

to continue to support the Breathmobile outreach program. Since 2008, Kohl’s has donated more than $780,000 to support children’s health and wellness programs at University of Maryland Children’s Hospitalthrough Kohl’s Cares.

Kohl’s & University of Maryland Children’s Hospital Unveil New Breathmobile

Dwight Im, M.D., director of Mercy’s Center forGynecologic Oncology at Mercy Medical Center,has formed the National Institute of Robotic Surgery at Mercy. Dr. Im was one of the first sixsurgeons in the United States--and the first in thestate of Maryland--to perform a robotic Single Site Hysterectomy, utilizing one small incisionthrough a woman’s navel.

Some of the benefits of robotic surgery in-clude pinpoint accuracy, the potential for fasterhealing, less blood loss and scarring, and reducedneed for wound management after the surgery.With recent media attention given to robotic

surgery, patients are seeking physicians and centers with the most experience and highestrates of positive patient outcomes.

Mercy’s National Institute of Robotic Surgeryoffers surgical procedures performed by physicianexperts in multiple specialties and sub-specialties,including Urology, General Surgery, Surgical Oncology, Gynecology and Gynecologic Oncol-ogy at Mercy Medical Center.

Dr. Im received his medical degree fromUMDNJ-Robert Wood Johnson and completedboth his residency and fellowship training at The Johns Hopkins Hospital.

New National Institute of Robotic Surgery at Mercy

Northwest Hospital NamesWomen’s Wellness CenterMedical Director

AAMC Nurses Select Outstanding Physician of the YearObstetrician hospitalist Bruce Bolten, M.D.,was recently chosen as Outstanding Physician ofthe Year at AAMC — an honor bestowed by thehospital’s nurses. Dr. Bolten was the top vote-get-ter out of 1,000 cast by the center’s nurses, whowere asked to nominate a doctor considered a role model and who “collaborates and communicates for care.”

Dr. Bolten received his medical degree from Howard University and completed both his internship and residency at Sinai Hospital of Baltimore.

Northwest Hospital has appointed Katharine H. Taber, M.D., FACOG, as the new medical director of its Women’s Wellness Center. Dr. Taberis a board-certified gynecologist and a fellow ofthe American College of Obstetrics and Gynecology.

“Under Dr. Taber’s leadership, I’m confidentthat our Women’s Wellness Center will becomean even more robust resource for women seeking gynecologic care,” says Brian White, president of Northwest Hospital and senior vicepresident of LifeBridge Health.

The Women’s Wellness Center’s comprehensive philosophy emphasizes high-quality care across a broad spectrum of women’shealth needs, from routine exams to leading-edgegynecologic surgery to ensuring patients are up-to-date on their health screenings.

Dr. Taber received her medical degree fromthe University of Virginia School of Medicine and completed her residency in OB/GYN at Duke University Medical Center. Prior to joining theWomen’s Wellness Center at Northwest Hospital, she practiced at Women’s Health Associates in Towson.


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ORTHOPAEDIC UPDATE

CARPAL TUNNEL, COMPLEX ACL TEARS, CARTILAGE REPAIR AND MSK ULTRASOUND

Is It Really Carpal Tunnel Syndrome?Carpal tunnel syndrome (CTS) is prevalent in the U.S., affecting about 5% of the population.Still, its prevalence sometimes clouds the abilityof physicians to accurately diagnose pain ornumbness in the hand.

“The issue with CTS is that the public andphysicians perceive it to be so common thatalmost any hand pain is assumed to be carpaltunnel,” says Mark Deitch, M.D., hand andupper extremity orthopaedic surgeon,OrthoMaryland. “There are many differentcauses of hand pain.”

EtiologyCTS occurs when the median nerve iscompressed within the carpal tunnel. The narrowtunnel also contains nine tendons, making it anarea prone to nerve entrapment. The usualsymptoms of CTS are numbness, paresthesiasand pain in the thumb, index and middle fingers.Patients often complain of numbness atnighttime, or when holding a phone, driving, orwriting. “Gripping activities probably increasethe crowding of the median nerve,” explains Dr.Deitch. “Most people curl up their wrists whensleeping. Bending the wrist for long periods oftime increases pressure on the median nerve,

which is the reason we prescribe braces fornighttime wear.”

The exact etiology of CTS has not beendetermined, but the syndrome is believed to berelated to a combination of genetic, demographicand avocational or vocational factors. Women,whites, those aged 45 to 60, diabetics, arthriticsand those with fluid changes (e.g., pregnancy orweight-related) are at higher risk. While somebelieve keyboarding is a trigger, there is no case-controlled study that shows it causes CTS. “Itcauses symptoms,” Dr. Deitch explains, “butthere is no data to show that it causes thesyndrome. I believe it exacerbates the condition,rather than causes it.”

He explains, “Most CTS is idiopathic. Often, I can diagnose the syndrome when the patientwalks in. It’s a threshold phenomenon. Patientstell me they’ve been doing the same thing for 20years, but it only started bothering them recently.I tell them it’s because their threshold – theirtolerance – has decreased as they age.”

Differential DiagnosisRepetitive Strain Injury (RSI) is not CTS, notesDr. Deitch. “Patients get RSI from repetitivetasks such as working on a conveyor belt. Theinflammation of the tendon lining presses on the


nerve. Flexor tendonitis can give youcarpal tunnel symptoms over time ifswollen tendons crowd the nerve in thecarpal tunnel.”

He adds, “If there is no numbness inthe fingers, it’s usually not CTS. Arthritisin the base of the thumb is common,especially in women over age 50, butthat causes pain without numbness. Aless common possibility is that it’s aslipped disc or pinched nerve in the neck,which can mimic the symptoms of CTS.”

In addition to the history and physicalexam, “EMG and nerve conductionvelocity studies are often useful inmaking the diagnosis,” Dr. Deitchcomments. “They measure the speed ofthe nerve impulses, and slowing at thelevel of the wrist usually indicates carpaltunnel syndrome. Many insurers requirethis test before they will pay for surgery.

“If a primary care physician suspectsCTS, he or she can prescribe a wrist braceat night for several weeks,” he continues.“Then, refer them to a hand specialist ifsymptoms don’t subside. If the patient hasincreasing pain, grip weakness orconstant numbness, they need a fasterreferral to decrease the risk of permanentnerve damage.” Dr. Deitch stresses thatwrist braces generally should not be wornduring the day for CTS, as they can createother problems such as soreness in theupper arm or shoulder.

TreatmentTreatment is initiated with conservativemeasures that, in addition to a nightbrace, may include avoidance of activitiesthat cause symptoms, and when needed,injection of cortisone in the carpal tunnelarea. “Injections can serve as both adiagnostic measure and treatment,” henotes. “Patients can have a pinched nervein their neck as well as carpal tunnel – ifthe cortisone injection eradicates thesymptoms, it’s more likely the handnumbness is due to CTS. I also stress theimportance of proper body positioningrather than special devices – the hips andelbows should be at 90 degrees and theelbow to hands should be neutral. Ideally,the forearm is supported by the chairarmrest. And laptops go on your lap, notthe table top!”

Surgery may be appropriate when:z Persistent symptoms are not relieved

by injection or bracingz Symptoms worsenz Constant numbness is presentz Thenar muscle atrophy is present

Both open and endoscopic surgeriesoffer patients similar long-term results,though Dr. Deitch has performedprimarily endoscopic surgeries for thelast 10 years. “It provides patients afaster return to work by several weeks.After a 30-minute outpatient procedure,patients return home with a softdressing. They can resume most dailylight activities within a week.”

Managing Complex ACL TearsAnterior cruciate ligament (ACL) tearsare common injuries in young athletes,especially females, affecting about

100,000 to 150,000 Americans eachyear. A patient with a torn ACL andsignificant functional instability has ahigh risk of developing further kneedamage, and should therefore considerACL reconstruction.

A surprisingly high percentage of ACLinjuries also involve damage to otherknee structures, including the meniscuscartilages (50%), articular (joint surface)cartilage (30%), collateral ligaments(30%), joint capsule, or a combinationof the above. James York, M.D.,orthopaedic surgeon at ChesapeakeOrthopaedic & Sports Medicine Center,

Mark Deitch, M.D., hand and upper extremity orthopaedic surgeon, OrthoMaryland.


says, “An ‘unhappy triad,’ which isfrequently seen in football players andskiers, consists of injuries to the ACL,the medial collateral ligament (MCL)and the meniscus. In combined injuries,surgical treatment is indicated andgenerally produces better outcomes. Asmany as 50% of meniscus tears thatoccur in association with ACL tears arerepairable, and heal better if the repair isperformed in combination with the ACLreconstruction.”

Therapy and SurgeryDr. York states, “I order physicaltherapy (PT) prior to surgery; patientswho have a stiff, swollen knee lackingfull range of motion at the time of ACLsurgery are less likely to regain motionafter surgery. It usually takes three ormore weeks from the time of injury toachieve full range of motion. Ligamentinjuries that occur along with the ACLinjury are treated with a knee brace inaddition to having the ACL surgery.”

PT is particularly critical post-surgery.Dr. York says, “Much of the success ofACL reconstructive surgery depends onthe patient's dedication to rigorous PT.With new surgical techniques andstronger graft fixation, current physicaltherapy uses an accelerated course ofrehabilitation with more rapid return toplay or to your job than in prior years.”

Repairing Articular (Joint Surface) Cartilage InjuriesDiagnosing articular cartilage damagecan be challenging. Dr. York observes,“The X-ray looks normal, and if verysmall, even an MRI may not detectdamage.”

Articular cartilage in the knee is a“tread” about 3/16” thick and has theconsistency of slippery vinyl. Wheninjured, a painful divot or crater canoccur in this surface. Dr. York says, “Ifthe surrounding cartilage is in goodcondition, then tiny defects – the size ofa dime or smaller – can be repaired usingan arthroscopic microfracture technique,where tiny holes are punched into theaffected area and debrided to promotecartilage healing. Patients are oncrutches for about six weeks post op.”

When articular cartilage damage is the size of a nickel or larger, other moreadvanced approaches are required.“Some procedures use small cartilage‘plugs’ taken from the periphery of theknee to fill the cartilage defect, but that’s

like robbing Peter to pay Paul,” notesDr. York. For older patients with largedefects, he prefers to use osteochondralallografts (tissue bank cartilage). “Iftrauma is the cause of a larger cartilagelesion in an older patient, they may be a candidate for partial or total kneereplacement.”

Growing Your Own Cartilage to Heal Joint InjuryIn patients under age 40 with overallgood cartilage health and no arthritis,Dr. York has successfully used theCarticel Autologous Cartilage

Implantation (ACI) for larger defects(www.Carticel.com). This procedure hasbeen in use in this country since 1995,but is not well known by the public orspecialties outside of orthopaedics.

The first of the two-staged procedureis performed micro-surgically with anarthroscope. A tiny piece of the jointcartilage is harvested and sent to aspecial laboratory to be cultured andgrown to about 16 million “baby”cartilage cells. These cartilage cells arethen implanted back into the knee jointthrough a second open surgicalprocedure about two months later.

Carticel Autologous Cartilage Implantation canoffer the opportunity to return to work and anormal lifestyle. —James York, M.D.

James York, M.D., orthopaedic surgeon at Chesapeake Orthopaedic & Sports Medicine Center

The damaged cartilage is cleaned outof the crater-like defect in the knee jointsurface. A small piece of membrane isthen surgically sewn over the defect,using suture that is as fine as humanhair. Next, the cartilage cells are injectedinto a temporary hole under themembrane that is then sealed over. These new cells adhere to the base of the defect within six hours and begin to grow. Complete healing takes severalmonths, but the joint is returned toalmost pre-injury status.

Dr. York observes, “ACI can offer theopportunity to return to work and anormal lifestyle. The best candidates forcartilage transplant are patients in their20s, 30s and early 40s who do NOThave arthritis.”

MSK Ultrasound Ultrasound (US) is a low-tech imagingdevice that has been available fordecades, yet only recently has it beenused for musculoskeletal (MS) diagnosisand treatment. Ashley Beall, M.D.,FACR, physician director of infusionservices at Arthritis and RheumatismAssociates, P.C., explains, “Focus onuses of ultrasound began in the early2000s, but interest has exploded inrecent years. The American College ofRheumatology (ACR) holds annualconferences on MSUS and I speak locallyon this topic.” A 2012 ACR reportnoted it is reasonable to use MSUS for

patients with “articular pain, swelling,or mechanical symptoms withoutdefinitive diagnosis on clinicalexamination” in various joints thatinclude the shoulder, elbow, wrist, hip,knee and ankle.

Ultrasound provides the ability toobserve the tissue in motion, so it cancreate a dynamic image in real time ofanatomic structures and of blood flowor inflammation. No radiation isinvolved, and it can be performed in theoffice immediately after evaluation. Dr.Beall exclaims, “Patients love to seewhat’s happening. It facilitates aconversation with them and is aneducational tool.”

She continues, “Changes of earlyrheumatoid arthritis and gout can beevaluated with US. On a plain X-ray,you may not see bony damage for years,while US can visualize erosions muchsooner. You can see the crystalsdepositing on cartilage to help diagnosegout, and you can measure indirectly theamount of inflammation in a joint.”

Power Doppler, a special type of colordoppler, detects small blood vessels thatoccur when there is inflammation in thesynovium or the tendon insertion intothe bone. “You can see roughly howmuch inflammation is present in thearea,” Dr. Beall notes.

Rotator cuff tears may be diagnosedwith ultrasound. According to Dr. Beall,“In the right hands, partial or total

rotator cuff tears can be visualized atthe bedside using ultrasound. If a newpatient has shoulder pain and wesuspect rotator cuff injury, we canperform an X-ray to evaluate the bones,then use ultrasound to evaluate softtissue. MRI remains the gold standard,but patients love that ultrasound isquick, and we know whether the nextstep should be orthopaedic surgery orphysical therapy.”

Aspirations and Pain InjectionsDr. Beall now uses real-time US guidanceto withdraw fluid from knees or hipswith osteoarthritis or other conditions atthe bedside, instead of sending patientsto the hospital for interventionalradiology. “Now, after evaluating them,we can inject them at the bedside, usinga 1.5” needle while the patient is supine.We can literally watch the needle go into the joint capsule. Patientsexperience less pain and often enjoybetter outcomes. Once you’reexperienced and set up, you can performan injection under US guidance almost as quickly as one without it.”

Dr. Beall also has found US guidanceuseful in carpal tunnel injections. “Youcan see the nerves in real time and knowprecisely where they are. If the physicalexam is suggestive of carpal tunnel, wecan perform an ultrasound. If the nerveis enlarged, we can perform an injectionthe same day.”


Ashley Beall, M.D.,FACR, physician director of infusionservices at Arthritisand Rheumatism Associates, P.C.

Mark Deitch, M.D., OrthoMaryland,and clinical assistant professor, Orthopaedic Surgery, Johns HopkinsUniversity School of Medicine.James York, M.D., Chesapeake Orthopaedic & Sports Medicine Center, and clinical instructor in Orthopaedics, University of Maryland.Ashley Beall, M.D., FACR, physician director of infusion services, Arthritisand Rheumatism Associates, P.C.


Help Your Patients Get a Better Night’s

SLEEPBY LINDA HARDER

PHOTOGRAPHY BY TRACEY BROWN

SLEEP. It’s a third of our life,and many of us will spend 25 to 30‘years’ of it sleeping. Not gettingquality sleep or sufficient sleep iscorrelated with unhealthy habits andeven disease. Yet until recently, sleepdid not get the respect and attentionthat diet and exercise have had as acornerstone of health.

Ira Weinstein, M.D., medicaldirector of Anne Arundel MedicalCenter’s Sleep Disorders Center, says,“There has to be a reason we sleep athird of our lives. Without sleep,many of our systems don’t work andmuscles can’t repair themselves. It’scommon for sleep to be interrupted

before you get sick, and studiesincreasingly find a correlationbetween sleep issues and diseases suchas prostate and breast cancer, ordementias. It’s logical that sleepwould be a marker of disease becausesleep deprivation affects memory andother brain functions.”

He adds, “I think of sleep asequally important to health as dietand exercise. My advice to referringphysicians is to ask about the patient’ssleep habits during the history andphysical. Many sleep disorders startwhen the patient experiences apersonal issue such as divorce or jobloss, but become habitual.

Psychological issues, including stress,are significant causes.”

Sleep ApneaOf all the causes that bring patientsto a sleep specialist or center, themost prevalent is obstructive sleepapnea – even as some 70 to 80% ofthose with this disorder goundiagnosed. The disorder ischaracterized by repetitive cessationof breathing or shallow breathingduring sleep that lasts 10 seconds ormore. Entailing repeated arousalsfrom sleep and a fall in blood oxygenlevels, it can result from large tonsilsor tongue, excess fat in the upper

airway, blocked nasal passages oranatomical issues in the jaw or airway.

Jason Marx, M.D., chief ofPulmonary, Critical Care, and SleepMedicine at University of Maryland St. Joseph Medical Center, says, “Abouthalf of those who snore have sleepapnea; the only way to diagnose it isthrough a polysomnogram (sleep study).If the patient snores and has one otherrisk factor, or has daytime sleepiness, he or she is a candidate for apolysomnogram.”

Insurers are driving more patients tounattended home sleep studies, ratherthan being evaluated overnight in a sleep

center. Our sleep specialists note thathome studies are appropriate for somepatients, but not those with comorbidconditions or other disorders.

Dr. Marx notes, “The big story is thetransition from inpatient labs to homesleep studies, and some sleep labs areclosing as a result. It’s not necessarilybad medicine, but it’s a new paradigm.”

Who is not appropriate for a home

sleep study? Anita Naik, D.O., medicaldirector of the Sleep Disorders Center,Harford Memorial Hospital andNorthern Maryland Sleep Center,answers, “Those with significant co-morbid conditions such as severe CVA,CHF, or lung disease, or those withsuspected parasomnias. By contrast, ahome study can be adequate for thosewith a high pre-test probability of sleepapnea, such as those with significantobesity, snoring or witnessed apneas.”

Home sleep studies that are diagnosticfor obstructive sleep apnea can befollowed by a formal lab-based CPAPtitration or the patient maybe set up

with an automatic CPAP device. Thesedevices are about 80 to 90% effective.They are not effective at detecting andtreating central sleep apnea, and are notindicated for patients with co-morbiddiseases that could require additionaltherapies such as bi-level therapy orsupplemental oxygen.

“CPAP remains the gold standard fortreatment, but oral appliances are

improving and weight loss is crucial,”Dr. Marx remarks. “If a patient declinesCPAP or cannot tolerate CPAP andwishes to try an oral appliance, makesure the patient is referred to a dentistwho specializes in these appliances. Anewer option is nasal resistance plugs,but I think the jury is still out on theireffectiveness. Also, insurance coveragefor some of these alternative treatmentscould be an issue.”

Document Co-morbid ConditionsWhen ordering a lab-based sleep study, it is important for primary carephysicians to document co-morbiddiseases or a suspicion of other sleepdisorders. A board-certified sleep doctorshould always interpret the test to assure accuracy.

Dr. Marx notes, “Sleep specialists canbe called on to interpret the sleep studyand, if appropriate, consult as well. It’sthe primary care physician’s discretionwhether they or we manage the patient.If you’re having trouble getting what youthink the patient needs, contact a sleepspecialist. We can work with the patientand insurer to select the appropriatediagnostic approach and treatment.”

Increased Anesthesia RiskPhysicians should also be aware thatanesthetics, including conscious sedation used in procedures such as acolonoscopy, make sleep apnea worse.“It’s like a stress test for sleep apnea,”Dr. Marx cautions. “Post-op patients areat higher risk for several days after theirprocedure. It’s important to indicate onyour pre-op notes if a patient has or is at risk for sleep apnea.”

InsomniaInsomnia can be challenging to treat and typically requires both a medicaland a psychological/behavioralapproach. Dr. Naik recommends that the latter approach be tried first. “Goodsleep hygiene is the first step.”

Dr. Weinstein says, “Many cases ofinsomnia start with a personal problemlike a divorce, but then become habitual.Physicians should ask about sleep as partof the history and physical. Review theirmedications to make sure they aren’tcausing problems, and ask about alcohol


If the patient snores and has one other risk factor, or has daytime sleepiness, he or she is a candidate for a polysomnogram. —Jason Marx, M.D.

Jason Marx, M.D., chief of Pulmonary,Critical Care, and Sleep Medicine atUniversity of Maryland St. JosephMedical Center

and family issues.”When good sleep hygiene alone does

not impact insomnia, Dr. Naik is aproponent of cognitive behavioraltherapy, with or without medications. “Itry to empower the patient,” she says.“They can use tapes or CDs, progressiverelaxation techniques, and so on. If asingle approach doesn’t work, try acombination. We often refer patients tospecialists in sleep cognitive behavioraltherapy. If anxiety or depression issuspected, seeing a psychiatrist orpsychologist may be helpful.”

Studies have not demonstrated aconsistent benefit from melatoninsupplements for insomnia but it mayhelp jet lag or circadian rhythmdisturbances. Valerian root andacupuncture have shown some promisein very small, early studies, but moreresearch is needed.

Medications can be very effective,including extended-release versionssuch as Ambien CR (zolpidem). Dr.Naik notes, “Melatonin agonists suchas Rozerem (ramelteon) are useful formany patients and have limited sideeffects. Sedative-hypnotics such asLunesta (eszopiclone) and Sonata(zaleplon) can be effective but should beapproached with caution because theystill have habit-forming tendencies.”

Restless Leg Syndrome and PLMAnother common sleep disorder isrestless leg syndrome (RLS),accompanied in about 80% of patientsby periodic limb movement disorder(PLM). RLS affects from 1% to 7% ofthe population and is more prevalent inthose 50 and older.

RLS is characterized by painfuldysesthesias such as crawling, creepingand/or burning sensations in the legs. “Itusually happens in the evening and whensedentary,” says Pavel Klein, M.D.,director, Mid-Atlantic Epilepsy & SleepCenter, LLC. “The sensations are relievedby movement but it often keeps patientsfrom falling asleep. PLM typically occursonce asleep in the first third of the night.A sleep study can evaluate for PLM andhelp determine the cause.

“The primary cause in youngerpatients is a family history,” he explains.“Iron deficiencies, renal impairment,peripheral neuropathy or Parkinson’s are

Physicians should askabout sleep as part of the history andphysical. Review theirmedications to makesure they aren’t causing problems, and ask about alcoholand family issues.

—Ira Weinstein, M.D.


Ira Weinstein, M.D., medical director of Anne ArundelMedical Center’s Sleep Disorders Center


other possible causes in the older patientpopulation, e.g. in those over the age of50. If there is no identifiable cause, treatsymptomatically. The most commonmedications are the dopamine agonistslike Mirapex and Requip, which increasedopamine transmission between theneurons.”

For patients who do require treatment,the next step may involve anti-seizuremedications such as Gabapentin(neurontin) or Lyrica (pregabalin), andfor those who don’t respond to thistherapy, narcotics may be a last resort.

Dr. Naik notes, “Recent data suggeststhat those with PLM alone should notusually be put on benzodiazepinesunless they are injuring their partner or significantly disrupting their sleepcontinuity.”

Circadian Rhythm DisturbancesNight owls, or those with circadianrhythm disturbances, have sleepschedules out of synch with societalnorms. Dr. Klein comments, “DelayedSleep Phase Syndrome, where the personfalls asleep at 2 or 3 am, is morecommon than Advanced Sleep, where

they fall asleep too early in the evening.It commonly starts in adolescents andmanifests itself in poor academicperformance or being habitually late forschool or work in the morning. Primarycare physicians should be attuned to thisproblem because, while common, it’soften overlooked. Symptoms includehaving difficulty falling asleep at 10 or11 pm, feeling most awake in the lateevening, and feeling extremely sleepy orgroggy, especially in the morning. It’scommon for patients to sleep throughtheir alarm five to six times.”

The treatment is not highly technical,but may be hard to implement exceptduring a long vacation period. “We trainthe brain through regular exposures tobright light,” notes Dr. Klein. “When thepatient naturally wakes up, say at 1 pm,they sit in front of a light box with10,000 LUX for 30 minutes for three tofour days. Then we continue the lightbox therapy while having them get up ahalf hour earlier every three to four daysuntil they return to a more normalwaking time. If done correctly, thetreatment is about 80% effective.”

Sleep is so critical to well being thatsleep disruption, not incontinence or

memory issues, is the reason manycaregivers finally refer loved ones withdementia to a residential facility. Dr.Weinstein concludes, “The deal breakeris often when the person with dementiagets up at night and has their sense ofday and night disrupted. It becomesintolerable for the caretaker to get up at night/worry about them.”

Jason Marx, M.D., chief of Pulmonary,

Critical Care, and Sleep Medicine,

University of Maryland St. Joseph

Medical Center

Ira Weinstein, M.D., FCCP, Annapolis

Asthma, Pulmonary and Sleep

Specialists and medical director of

Anne Arundel Medical Center’s Sleep

Disorders Center

Pavel Klein, M.D., director, Mid-

Atlantic Epilepsy & Sleep Center, LLC

Anita Naik, D.O., medical director,

Sleep Disorders Center, Harford

Memorial Hospital and Northern

Maryland Sleep Center

z Avoid caffeine (including energy drinks) and alcohol after 3 pm. As a depressant, alcohol helps people fallasleep but then disrupts sleep

z Avoid smoking, as nicotine is a stimulant

z Exercise regularly but not close to bedtime

z Don’t go to bed stuffed or starving – instead, have a light snack

z Avoid napping

z Don’t spend more than 20 minutes wide-awake in bed

z 20 minutes before sleep, avoid light exposure from smart phones or any backlit device

z Don’t fall asleep to the television

Dr. Naik’s Recommendations for Good Sleep Hygiene Include:

Anita Naik, D.O., medical director of the SleepDisorders Center, Harford Memorial Hospitaland Northern Maryland Sleep Center


Healthcare IT

B E Y O N D

CPOEAfter decades of talk, the healthcareindustry is finally poised to make majorshifts in care reimbursement, movingfrom fee-for-service to global payments,and providing new incentives to bettermonitor and coordinate care. Anessential component of the newparadigm is CPOE, a system that allowsproviders to enter medical orders andinstructions that are communicatedthrough a computer network.

The potential benefits of CPOEinclude faster order completion;reduction of handwriting, transcriptionor dosage errors; and informatics thatprovide far more comprehensive datathat can ultimately transform caredelivery. Most hospitals are couplingCPOE with clinical analytics to get theoptimum benefit and to survive in thenew reimbursement climate.

CPOE in a Healthcare SystemSome larger health systems have onlyrecently implemented CPOE, whileothers are on their second vendor. Manyof these health systems are migrating toEpic – a software company aimed atmid-size and large medical groups,hospitals and integrated healthcareorganizations – for their CPOE. In all,more than 100 million people, 100,000physicians and 1,000 hospitals use thissoftware. Howard County GeneralHospital, part of the The Johns HopkinsHealth System, is one of those.

“The way we practice medicine ischanging because of economic realitiesand the Affordable Care Act,” says EricAldrich, M.D., Ph.D, vice president ofmedical affairs at Howard CountyGeneral Hospital (HCGH). “We’reswitching from fee-for-service to an

Maryland Physician explores the value of computerized physicianorder entry (CPOE) and clinical analytics in both a Maryland hospital system and a sole community hospital. By Linda Harder

C L I N I C A L A N A L Y T I C S I S K E Y


integrated health system and thefoundation is the electronic medicalrecord (EMR). We need clinical analyticsto determine how to coordinate cost-effective care. To do that, we have toswitch from paper orders and notes to asystem that’s more comprehensive.”

Ironically, electronic clinicaldocumentation may solve existing

problems, but create new ones. “Itrequires you to clean up your practice,”Dr. Aldrich notes. “In a paper world, youmight pre-document. In an electronicworld, you can cut and paste, so everynote is dated, timed and legible, but thecontent of the notes is also more similar.Physicians can also more readily leave adraft note without signing it for severaldays, which you couldn’t do with paper.”

When CPOE was first implemented,the number of ‘errors’ actually increased.Dr. Aldrich explains, “Medication‘errors’ appeared to increase at first,because we were now tracking when theywere given a few minutes early or late.However, giving Tylenol 15 minutes lateis not a patient safety issue. TheUniversity of Pittsburgh, an earlyadopter, published a paper on this topic.CPOE forces you to clean up yourprocess and be more coordinated becauseeverything is documented andscrutinized. Good comes from it, but itcan also be painful.”

He adds, “Our Epic system is morethan orders and documentation. It’sabout workflow – how to create anafter-visit summary and who does themedication reconciliation. To meetMeaningful Use Stage 2, you have toprovide an after-visit summary and themeans to communicate it electronicallyto the patient. A patient portal module,My Chart, allows you to connect easilywith patients.”

Transferring to the new systemrequires significant change managementand a heavy investment of training.

“When we first converted to Meditechyears ago, we got a 30-minute tutorial,”Dr. Aldrich recalls. “Epic requires 12hours of training because it’s complex.Physicians undergo online training beforethey take two six-hour classes, followedby trying it in a practice environment.”

Physicians that don’t come into thehospital, as well as their staff, can

participate in the system through a read-only version called Epic CareLink. Thesystem alerts them when their patients areadmitted or discharged. They no longerwill have to fax a history and physical tothe hospital, but can send it electronically.Physicians can get CME credits for theirtraining time, but Stark law prohibitsreimbursement from the hospital.

The Johns Hopkins outpatient andsurgery centers were the first to roll outthe new Epic system in January 2013,followed by HCGH and Sibley in June2013. Beginning Fall 2013, Hopkins’employed physicians will begin using it,and eventually physicians in privatepractice will be incorporated.

“We can also use CRISP*,” notes Dr. Aldrich, “but this system keeps allthe communication in the family. It letsus coordinate cost-effective care, notdeny care.”

CPOE in the Stand-alone Community HospitalIn 2009, after using a clinical system fornearly 10 years that was more orientedto the needs of nurses, Carroll HospitalCenter began switching to a CPOEsystem to standardize orders andeliminate errors caused by poorhandwriting. After selecting McKesson’sHorizon Suite, they completedimplementation in 2010 and immediatelynoticed an improvement in processingmore than 400,000 orders generatedeach month.

Jed Rosen, M.D., chief of surgery andchief medical information officer at the

hospital, comments, “The averageadmission involves a surprisingly highnumber of orders – 30 to 50 on average.To help our physicians, we created specialorder sets called i-forms. I-forms allowedus to program complex decision supportwith a simple graphic interface (similar toa web page). Order sets are used to guidethe physician’s treatment. The system canhandle any order, from medications tolabs, to stockings to diet. Many ordersare pre-selected, such as the order forprophylaxis for deep vein thrombosis,which helped our compliance rates jumpfrom about 20% to 99%. You can optout of the pre-selected orders, but youhave to explain why.”

He continues, “The hospital is aboutto undergo a new upgrade, this time to asingle integrated database thatincorporates billing, clinical,demographic and materials data. In ourold system, an allergy could appear infour places within the system; with thenew Paragon Hospital Information

CPOE forces you to clean up your process and be more coordinated because everything is documented and scrutinized. – Eric Aldrich, M.D., Ph.D

TRACEY BROWN - PAPER CAMERA

Jed Rosen, M.D., chief medical information officer,Carroll Hospital Center


Healthcare IT

System (McKesson), which goes live mid-September 2013, providers will only haveto enter it in one place. It’s like goingfrom a Chevy to a Cadillac.”

Dr. Rosen notes that the new systemwill make programming simpler. “Wecan mine the data and send it to CRISP,and to the primary care physicianthrough CRISP. With the new Paragonsystem, within 24 hours of admission,the primary care physician is informedand can access information, such as an H & P. We can tailor the information towhat the referring physician wants. Thenew system will also accommodatemobile devices and apps.”

These transitions don’t come without asignificant investment of human andmonetary capital – and a bit of arm-twisting. In addition to requiring the timeof six nursing analysts in the clinicalinformatics department, a significanttime investment is required by more than35 employees of the IT department. “It’sexhausting. Our team works 60- 70-hourweeks,” Dr. Rosen remarks.

From a financial perspective, the cost

of the new system is roughly half that ofthe original CPOE system. Dr. Rosennotes, “It does increase our total cost,but the rate at which it’s growing ischanging from an exponential rate to alinear curve.”

A key barrier to implementing CPOEis provider reluctance to change. “AnEMR takes 120% of the time a paper-based approach does because we’redocumenting more information,” Dr.Rosen reflects. “Yet, after working withan EMR for 18 months, more than 75%of doctors wouldn’t go back to paper,because they get better documentationand outcomes. They’re not missingthings they used to miss. In fact, thephysicians who fought me the most threeyears ago are now glad they’re doing it.”

The hospital discovered a voluntaryapproach didn’t work. Dr. Rosenexplains, “After finding that CPOEdidn’t work unless we mandated it, wenow have 98% compliance. Wedeveloped an extensive educationprogram, using nurses as the backbone.They’re the super-users because they use

order-entry more than anyone else. They‘adopted a doc’ for physicians whoneeded the extra support.”

With CPOE and EMR, CarrollHospital Center was prepared for theadvent of Total Patient Revenue (TPR) in2011, a pilot Maryland reimbursementmodel that pays sole communityhospitals a global fee for all inpatient andoutpatient care. Dr. Rosen concludes,“We can now closely monitor length ofstay and provide case management andgood patient throughput. And we wereone of the first in Maryland to attest toMeaningful Use.”

*Chesapeake Regional Information System for our Patients (CRISP) is Maryland’s statewide health informationexchange entity.

Eric Aldrich, M.D., Ph.D, vice president

of medical affairs, Howard County

General Hospital

Jed Rosen, M.D., chief of surgery and

chief medical information officer,

Carroll Hospital Center

Jacquie Cohen Roth x Publisher/Executive Editor410.837.6948 x [email protected]

www.mdphysicianmag.com

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Clinical FeatureMaryland Physician spotlights the latest innovations in clinical care andtreatment delivered by your Maryland peers and colleagues as well asadvances in medical training which facilitate achieving the highest standards of quality patient care and practice management solutions.

Healthcare ITIn every issue, Maryland Physician explores a different facet of the raceto implement EHRs to meet Meaningful Use and other e-health govern-ment incentives. Don’t be left behind – read what Maryland physiciansand healthcare IT experts have to say that eases the pain of transition to an electronic world.

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

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Fall 2013

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VOLUME 1: ISSUE 1 FALL 2013

MA RY L A N D

YOUR HEALTH. YOUR LIFE.

Wellness


Policy

Keeping Patients SafeBy Linda Harder

L ET’S BE HONEST. Healthcarestill has a pretty weak track recordwhen it comes to patient safety. Whilestrides have certainly been made in thepast decades, the industry lags behindother industries where safety is critical,such as amusement rides and airlines.Fortunately, a host of new organi-zations and initiatives at both the stateand federal level are seeking to addresssafety with renewed zeal.

Patient Safety in Maryland To better tackle patient safety issues inthe state, the Maryland Legislatureestablished the Maryland Patient SafetyCenter in 2003. The center receiveddesignation by the Maryland HealthCare Commission in 2004 and wasincorporated in 2007. The not-for-profit organization was among the firstorganizations in the nation to be listedas a Patient Safety Organization (PSO)by the federal Agency for HealthcareResearch and Quality (AHRQ) underprovisions of the Patient Safety andQuality Improvement Act of 2005.

The center seeks to bring providerstogether to accelerate their under-standing of the factors that harmpatients and implement evidence-basedsolutions. Beyond convening an annualconference and other educationalprograms, their initiatives include:

z Safe from Falls – this initiative seeksto lower the current rate of falls inthis state (currently 3.0 per 1000patient days vs. 4.6 nationally)

z Hand Hygiene – 44 out of 46hospitals are participating in thiseffort, with a goal of 90%participation in proper hand hygiene

z Get Centered – an initiativelaunched July 2013 to providetangible reminders of the importanceof patient safety to hospitals andtheir staff

Provider and Patient EngagementTo move toward safer patient care,Robert Imhoff, president and CEO ofthe center, believes, “Patients and theirloved ones need to take an active role –

is spring, Maryland Physicianattended the Maryland PatientSafety Centerconference, whichaddressed thechallenges healthcareproviders face inkeeping patients safe,as well as state andnational initiatives toimprove safety.


they should ask questions and exploretheir options. Problems arise whenpeople aren’t informed – there should beopen lines of communication betweencaregivers and patients/families.Caregivers can do their part byexplaining the procedure they’re doing,being open to questions and invitingfollow-up questions after the patient hasreturned home and had time to processthe information.”

However, according to Linda Kenney,executive director of MITSS (MedicallyInduced Trauma Support Services, Inc.),the problem is not so much that patientsare unengaged, but that providers oftenaren’t very engaging. Speaking at theconference, she noted that a commontheme from patients who have beenharmed while receiving healthcare is, “I kept telling them something waswrong, but no one listened.”

Another speaker at the conference –Jean Rexford, executive director ofConnecticut Center for Patient Safety –noted that small changes are critical. Her organization found that asking the patient how they’ve been since theirlast visit, rather than weighing them and taking their blood pressure first, was surprisingly powerful.

Patient Safety CertificationAn upcoming initiative from theMaryland Patient Safety Center is a safety certification program forhealthcare providers. First, the safetyofficers at each hospital would beencouraged to participate in anassessment of their training, identifypatient safety issues, and receivecoaching. After the officer receivesindividual certification, the next stepwould be to certify departments withinthe hospital, and eventually the entireinstitution. “There are certifications for

individuals in other states,” says Imhoff,“but certifying the entire institutionwould be unique to Maryland.”

Imhoff also notes, “The center’s focus is primarily on hospitals now, but in the near future, we’ll expand ourreach to other providers, includingprimary care physicians.”

National Patient Safety: The Joint CommissionKeynote Speaker Mark Chassin, M.D.,FACP, MPP, MPH, president of TheJoint Commission, described the barriersto what he calls ‘high reliability’ inhealthcare. At the conference, he notedthat, despite decades of efforts, routinesafety processes are still failing routinely– from hand hygiene to medicationerrors. He cited James Reason’s ‘SwissCheese’ model that explains theoccurrence of system failures. In this oft-cited model, health facilitiesconstruct numerous defenses, but eachdefense has one or more weaknesses or ‘holes’ in it – similar to the holes inSwiss cheese.

Dr. Chassin also observed that otherindustries, such as the airlines, havecreated effective process improvementtools without the Swiss cheese by

identifying problems when smaller and easier to fix. He commented that the impact of the U.S. airline safetyprocesses was a drop from 13.9deaths/million flights in the 1990s toonly 1.6 deaths/million flights from 2002to 2011. Dr. Chassin concluded thehospital industry is roughly 1000 timesless safe than the airline industry, withthe number of annual deaths due toerror estimated at 44,000 to 98,000.

According to Dr. Chassin, healthsystems must embrace three changes tosignificantly improve their safety record:

- A leadership commitment to zeropatient harm

- Adoption of a safety culture- A robust process improvement

system/approachHe also cited three components

that the Commission’s Center forTransforming Healthcare has foundnecessary to get to a nearly zero error rate:

- Recognize that there are multiplecauses – perhaps as many as 30 to 50 –of each problem. Most hospitals dealwith the top three to five causes, but failto address the others.

- Understand that each cause requiresa different strategy.

- Realize that the key causes differfrom place to place, so each place needsa customized strategy.

Dr. Chassin noted that there are manyfactors that may underlie staff’s failureto follow proper hygiene, such as havingtheir hands full, lack of accountability,ineffective education, poor sink location,distraction, and a belief that wearinggloves eliminates the need for handwashing. When the many causes arenamed specifically and then targetedsystematically, according to Dr. Chassin,hospitals can achieve improvements of40 to 60%.

Targeted Solutions ToolThe Commission also has created a web-based Targeted Solutions Tool (TST) tohelp health providers enhance safety. The application guides healthcareorganizations through a step-by-stepprocess to accurately measure theirorganization’s actual performance,identify their barriers to excellentperformance, and direct them to provensolutions that are customized to addresstheir particular barriers. Currently,hospitals using three modules – handhygiene, hand-off communications (fromone shift to the next) and wrong sitesurgeries – have decreased the re-admission rate by 50%. With 1.7 millionhospital-acquired infections per yearcausing 99,000 deaths, using TST isestimated to save 25,000 lives.

The next time you fail to wash yourhands between patients, remember thatyou’re contributing to the industry’spoor safety record, and potentiallyharming your patient.

TRACEY BROWN

The [Maryland Patient Safety] center’s focus is primarily on hospitals now, but in the near future, we’ll expand our reach to otherproviders, including primary care physicians.

– Robert Imhoff

Special Camps for Kids withSpecial Medical Needs

OR MOST YOUNGSTERS, ALONGwith the summertime break from schoolcomes the opportunity to have some fun.There is no shortage of options toconsider when it comes to finding asummer camp for the kid that has a lovefor sports, a desire to explore the greatoutdoors or a passion for art. But whatabout the child who has a challenginghealth condition, preventing them fromfully participating in most of theordinary summer camps out there? Afew local organizations have createdprograms especially for those withspecial medical needs, providing avaluable community service while givingevery child who wants to go to summercamp a chance to do so.

Breathing Easier at Camp AirwaysEvery August, Baltimore WashingtonMedical Center (BWMC) gives kids whosuffer from asthma a chance to breathe abit easier while still enjoying a widerange of traditional summer campactivities, from swimming and arts andcrafts to yoga and yard games. CampAirways teaches kids to live with andmanage their asthmatic conditions,including how to recognize triggers, howto monitor and maintain peak flowlevels, and how to respond in emergencysituations. Campers also learn about theimpact of nutritional choices on theirasthma, the importance of proper handwashing, and the benefits ofincorporating daily exercise and physicalactivity into their schedules.

“Many asthma attacks are exerciseinduced, and a lot of kids will tell usthey don’t exercise because they can’tbreathe,” said Sandy Thomas, directorof Respiratory Care and NeurologyServices at BWMC, who also serves as

Camp Airways director. “We talk a lotabout the importance of staying active,and show the kids how to proactivelyplan and medicate themselves beforephysical activity.”

Camp Airways, held in Severna Park,is staffed by therapists, nurses and juniorcounselors who are often asthmapatients and previous campersthemselves.

“Parents can feel safe sending theirkids here because we know how tomanage asthma and can teach campershow to take care of themselves, whilealso making sure they have a goodtime,” said Thomas.

Keeping Blood Sugar In Check at CampPossibilitiesEach summer, pediatric endocrinologistRachel Gafni, M.D. volunteers her timeto serve as medical director of CampPossibilities, a special program for kidswith diabetes. Held in Harford Countyin late July, the camp invites childrenages eight to 15 for an overnight

experience that some have referred to as“the best week of their lives.”

“Some kids with diabetes don’t knowany other kids who have diabetes,”Gafni said. “Then they come to CampPossibilities and they meet all of thesepeople who understand – who are going

through the same thing. Tremendousfriendships are formed as the camperslearn and have fun.”

The daily itinerary for CampPossibilities is packed with all of thenormal activities you would expect tosee at any other summer camp, fromswimming and sports to talent showsand songs around the campfire. Uponarrival, campers are asked to establishgoals to identify what they hope to getout of their experience and what theyhope to learn over the course of theweek.

“Juvenile diabetes is complicated,”said Gafni. “We want to help these kidsunderstand their disease and learn howthey can best manage their blood sugarlevels in an environment that is safe, funand understanding.”

Grief Camps Get Kids Smiling AgainThe loss of a loved one is tough for anyperson to handle, especially a child.Camp Nabi, available to kids ages six to12, and Camp Phoenix Rising, for those

12 to 18, are both sponsored by Hospiceof the Chesapeake and are designedespecially for kids who are grieving dueto a loss they’ve recently experienced.Individual and group-based therapeuticactivities, outdoor adventures andhealing arts are emphasized at both

Good Deeds

FBy Tracy M. Fitzgerald


“Juvenile diabetes is complicated. Our goal is to help these kids understand their disease andhow they can best manage their blood sugarlevels, in an environment that is safe, fun andunderstanding.”—Rachel Gafni, Medical Director, Camp Possibilities


camps. Each camper is paired up with a“buddy” whose role is to offer supportand to provide a relationship that can becounted on throughout the camp week.

“In many cases camp is the first timethe child has been away from his or herfamily since the loss happened,” saidSandra Dillon Anderson, director ofcommunication for Hospice of theChesapeake. “We strive to help thesekids learn to trust again.”

Similarly, Camp New Dawn is anovernight grief camp for kids ages sevento 17, offered by Hospice of QueenAnne’s County. According to CampDirector Rhonda Knotts, kids who haveexperienced loss can benefittremendously simply by being aroundothers who are dealing with the sameissues.

“We give the campers a chance towrite a letter to their loved one and thenshare it if they wish,” explained Knotts.“It’s a very special time of reflection andremembrance that helps the kids realizethey are not alone. They also participatein a series of five support-group sessionsat Camp New Dawn that address theirissues as they adjust to the changeshappening in their lives.”

FOR MORE INFORMATIONCamp Airways

www.mybwmc.org/camp-airways-0

Camp Possibilities

www.camppossibilities.org

Camp Nabi and Camp Phoenix Rising

www.chesapeakelifecenter.org/

camp-nabi

Camp New Dawn

www.hospiceofqueenannes.com/grieving

Kids with special medical needs can tap into the widerange of specialty summer camps that are madeavailable by local hospitals and healthcare organiza-tions, giving them an opportunity to learn and laughwith others who face similar medical challenges.


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Solutions

Engaging a Commercial Real Estate Advisor/Broker is Good Medicine

By Gary D. Applestein, SIOR

ITH REAL ESTATEoccupancy costs among the largestoverhead expenses in any practice,physicians should recognize that theirlease is actually a desirable asset to anyprospective landlord. Building ownerslike having physicians as tenants becausemedical leases are typically longer andhave higher rental rates. Many physicianpractices are merging into super groupsor joining health systems, providingbetter credit for building owners. As aresult, owners get higher returns if theysell or refinance their building.

Knowing that their lease is desirable,physicians should engage a commercialreal estate advisor/broker who isexperienced at negotiating medical officeleases. All buildings are leased directlyby the owner or are listed with a brokerwhose interests are solely aligned withthe building owner. Therefore, it makessense to hire a broker who onlyrepresents your interest. A tenant advisorcreates an atmosphere of competitionand provides advice. Since the brokerfees are typically paid by the buildingowner, there is no direct cost to thetenant, and the fees generated are sharedwith the building owner or listing agent.

A good broker does more than simplyfind space. Your real estate advisor is thequarterback of the team, and shouldremember there are many other playersthat will join in the effort. The advisorshould have relationships with otherservice providers who are also experts inmedical office transactions; for example,space planners, architects, engineers,contractors, attorneys, IT specialists andfurniture dealers.

Having a good commercial brokeroffers a practical and detailed leasenegotiation process that includes:

z Identifying and Selecting AlternativesWhen selecting a building, consider theproperty location, rental rate, ADAaccess, building age and ownership.

z Space PlanningMedical practices have unique build-outrequirements. A space planner whoknows how to design a medical spaceplan is essential in order to avoid havinga poorly designed space that you will livewith for many years.

z The Initial Request for Proposal (RFP)Once the preferred list of potentialbuildings is developed, your brokershould solicit proposals by sending anRFP to each building owner. A goodbroker understands that the RFP lays thefoundation for subsequent negotiationson both the business and legal terms.

z Analyzing Proposals and Counter OffersThe advisor should analyze eachresponse and prepare a counter offerthat frames the position and provides the basis for further negotiations. Your advisor should prepare a detailedfinancial analysis, comparing alleconomic variables, such as rent, tenantimprovements and annual increases. The counter offer should include itemsthat are pre-negotiated, such asassignment and subletting, exclusivity,tenant guaranties, options to renew andexpansion rights.

z Letter of Intent (LOI)Once the preferred property is selected,it is recommended that an LOI bedrafted between the parties. The LOIwill summarize the agreed-upon businessterms and address certain legal issuesbefore the attorney becomes involved.

z Negotiating the LeaseMost leases reflect forms previously draftedby the landlord and approved by thelandlord’s lender. These forms are writtento benefit the landlord more than thetenant. Your real estate advisor and lawyershould review and comment on the lease.

z Designing the Medical OfficeThe space planner will prepare orcoordinate architectural and mechanicalworking drawings so the generalcontractor can estimate the costs andobtain the permits. Special considerationmust be given to items often used inmedical construction, such as seamlessfloors, special electric, special HVAC andextensive plumbing and cabinetry.

z Construction Process and Move-InDuring construction, your advisorshould meet regularly with the building’sagent and contractor to make certain theoriginal schedule is met. The tenant willneed to coordinate the installation of thephone and data-line infrastructure, andalso contact movers and furnituredealers. This also may be the best time toimplement or complete the conversion toElectronic Medical Records.

Hiring a seasoned commercial realestate advisor makes sense for mostmedical practices. By managing theprocess and creating an atmosphere ofcompetition between property owners,you can reduce occupancy costs. Movingoccurs so infrequently that hiring a realestate advisor with the wisdom gainedfrom experience is good medicine. Gary D. Applestein, SIOR, is managing

director/principal of Baltimore Colliers

International. He can be reached at

[email protected].

W


HEY SAY VIRGINIA IS FORLovers. And nestled in the central part ofthe state, with a skyline adorned by thepicturesque Blue Ridge Mountains, is aplace that can easily be fallen in lovewith – Smith Mountain Lake.

Stretching 40 miles in length, andsituated along 500 miles of shorelinebordering Franklin, Bedford andPittsylvania Counties, the man-madeSmith Mountain Lake was formed in the1960s, with a vision to create year-roundrecreational opportunities for locals andtourists. During the area’s prime season(Memorial Day to Labor Day), there isno shortage of folks out on the water fora day of motor boating, wakeboarding,canoeing, kayaking or sailing, withaccess to the water made easy through astring of full-service marinas and boatrental companies that line the lake.Fishermen come from near and far totake advantage of Smith MountainLake’s bountiful largemouth andsmallmouth bass, walleye and muskiepopulations. The opportunities to catchare so abundant, in fact, that ESPNSports holds an annual competitivefishing tournament every April in thearea, the Blue Ridge Big Bass Classic.

“When you come here, you canexperience the best of many worlds,”said Annette Stamus, marketing andcommunications manager for the SmithMountain Lake Regional Chamber ofCommerce and Visitor’s Center. “Wemake it easy for our visitors to enjoy thelake and all of the activities it offers. Youcan explore the state parks and historicalareas that are just a short distance away,or you can dine, shop and relax. There istruly something for everyone here.”

The U.S. D-Day Memorial and theBooker T. Washington NationalMonument are located within a short

drive of the lake, and those looking for amore interactive historical experiencecan dress in a periodic costume andparticipate in a Civil War re-enactment,or simply spectate as thecommemoration of history unfolds.Visitors looking for a different kind of“playing field” can take to the greens onone of the Smith Mountain Lake area’sfive 18-hole golf courses or threeminiature golf courses, designed forfamily fun. As the sun goes down, makeit a point to venture into downtownMoneta, the newest retail area to bedeveloped along the lake, offering anantique mall, shops and art galleries, avariety of authentic, locally ownedrestaurants and even a drive-in movietheater, complete with a retro diner.

“Smith Mountain Lake is a little pieceof paradise,” said Stamus. “It may take afew hours to get here, but once youarrive, you will see that it was worth it.A lot of vacationers end up retiring here

because there is so much to see, do andenjoy, or they are drawn to the scenicbeauty of the rolling mountains alongthe lake.”

The Smith Mountain Lake RegionalChamber of Commerce recentlylaunched a mobile app to make it easierto travel to the area and explore it. Getinstant access to maps, local websites,images and videos by downloading theapp at www.MyChamberApp.com.

Living

A Little Piece of ParadiseAlong Smith Mountain Lake

By Tracy M. Fitzgerald

T

Mark your calendar for the 25th Annual

Smith Mountain Lake Wine Festival!

This two-day event will be held Septem-

ber 28-29 and is the area’s biggest

event of the year, with 27 participating

wineries and food and crafts available

from 85 vendors! Enjoy continuous live

music as you wine, dine and relax with

friends along the lake.

Watersport enthusiasts appreciate the wide range of activities available in the Smith Mountain Lake area. The scenic Blue Ridge Mountains add a touch of beauty.

COURTESY OF THE SMITH MOUNTAIN LAKE REGIONAL CHAMBER OF COMMERCE AND VISITOR’S CENTER

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

maryland physician magazine july/august 2013 issue

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