AAMC Offering LINX® Device Implant for Heartburn

 Anne Arundel Medical Center (AAMC) now offers treatment to patients with severe acid reflux with a new procedure that inserts a tiny magnetic device shaped like a bracelet at the base of the esophagus. The implant has been shown to improve life for gastroesophageal reflux disease (GERD) sufferers more effectively than prescription medicine.

“This new device will be life-changing for many GERD patients,” says Adrian Park, M.D., chair of the Department of Surgery at AAMC. “It is an innovative, flexible band of magnets enclosed in titanium beads. The magnetic attraction between the beads helps keep a weak esophageal sphincter closed to prevent reflux,” explains Dr. Park. The LINX® Reflux Management System is implanted with a standard minimally invasive laparoscopic procedure.  Editor’s Note: Dr. Park contributed to Maryland Physician’s Feature “Preventing Gerd and Hiatal Hernias from Turning Deadly” 

Sinai’s Institute for Maternal-Fetal Medicine Receives Accreditation for Fetal Heart Imaging Test

Sinai Hospital’s Institute for Maternal-Fetal Medicine has been awarded accreditation in fetal echocardiography from the Ultrasound Practice Council of the American Institute of Ultrasound in Medicine (AIUM). This important and highly specialized prenatal imaging test has the potential to be lifesaving.

“Fetal echocardiography allows us to diagnose fetal heart defects as early as possible – while a woman is still pregnant – and determine what diagnostic measures can be performed during the pregnancy to further advise the parents,” says Pedro Arrabal, M.D., one of Sinai’s high-risk pregnancy specialists and director of the Institute for Maternal-Fetal Medicine.

Sinai is one of two hospitals to be the first in Maryland to receive accreditation in fetal echocardiography ultrasound by the AIUM.

 Sinai Division of OB/GYN Appoints New Chief

Sinai Hospital has appointed Karen A. Engstrom, M.D., as its new chief of Obstetrics and Gynecology. For the past 10 years,Dr. Engstrom has been the division’s associate chief, and she has served as the interim chief since the retirement of David Schwartz, M.D., last July.

Dr. Engstrom, who has been a faculty physician at Sinai Hospital for the past 30 years, has been the chair of the Obstetrics and Gynecology division’s Advisory Committee for the past six years and chair of Continuous Quality Improvement for the division for the past five years. She also serves as a clinical instructor at Johns Hopkins Hospital. For several years, she was Sinai’s director of Ambulatory Services and was involved with the hospital’s lactation services.

Dr. Engstrom received her medical degree from the University of Michigan School of Medicine and completed her residency and internship at the University of Michigan Hospital.

UPDATE ON THEODORE C. HOUK, M.D.

As a champion of HIT in a solo practice Maryland Physician interviewed Dr. Houk, the physician who was struck by a vehicle while jogging to work late March, in the November/December 2011 Healthcare IT feature  “Should You Store EHR Data Onsite or Offsite?” http://tinyurl.com/cy46v6r. MedChi, together with the family of Dr. Houk, would like to make sure the most accurate and current updates on Dr. Houk’s condition are available. The family has created a health journal on the CaringBridge website that can be accessed by visiting www.caringbridge.org/visit/tedhouk. The family hopes to provide daily updates on the site.  PHOTOGRAPHY BY TRACEY BROWN

Carroll Hospital Center moves forward on $28M renovation

Carroll Hospital Center is breaking ground on a $28 million renovation and addition to its Dixon building. The project calls for a 43,000-square-foot addition, for a total building size of 68,500 square feet. The building will house the Westminster hospital’s new William E. Kahlert Regional Cancer Center and the Tevis Center for Wellness. Construction should be completed within 18 months.

The project is largely being supported by the hospital center’s $22 million fund-raising campaign, “Campaign to Cure & Comfort, Always.” About $12 million will come from the fundraising campaign; the remainder will come from the hospital’s operating revenue and reserves,” said Ellen Finnerty Myers, chief development officer for the hospital.

“The 23,000-square-foot cancer center is intended to offer a comprehensive approach to cancer treatment, with resources for every step in the process. “

Saint Agnes “Heart-to-Heart” Initiative Receives Grant

The Saint Agnes Hospital Foundation is the recipient of The AstraZeneca HealthCare Foundation’s Connections for Cardiovascular Health^SM. The grant will support the St. Agnes Foundation’s “Heart-to-Heart” initiative, allowing it to partner with a variety of local churches to provide key cardiovascular screenings, with a particular focus on African-American women.

African-American women are at highest risk for developing heart disease. Those determined to be at high risk will gain access to ongoing education, health, lifestyle and exercise classes geared towards reducing heart disease in our community. Progress will be measured by clinically significant improvements in laboratory and risk profile results at four and ten month intervals.

Heart-to-Heart is a new companion program to Red Dress Sunday, a heart disease outreach program for African-American women, which has been running for nine years across 130 congregations. Heart-to-Heart will be implemented at nine Baltimore City churches where each is a site for heart risk screenings and intervention programs.

HOWARD COUNTY GENERAL HOSPITAL CELEBRATES 40 YEARS OF SERVING THE COMMUNITY’S HEALTHCARE NEEDS

This year marks the 40^th anniversary of Howard County General Hospital, a leading acute-care hospital in the heart of Howard County, Maryland. What began as a 59-bed medical facility in 1973 has grown to become one of the region’s premier healthcare providers.

“While the landscape of our hospital has certainly changed dramatically over the past 40 years, we have stayed true to our mission of providing the highest quality care to improve the health of our entire community,” says Victor A. Broccolino, HCGH’s President and CEO. “Since 1973, HCGH has been a trusted member in the lives of generations of families throughout the community. We now look toward the future and plan for new and innovative ways to care for the next generations.”

Health Enterprise Zones

The O’Malley-Brown Administration has awarded several health enterprise zones in the first few days of the 2013 legislative session – keeping true to its promise on diminishing healthcare disparity in Maryland. The new enterprise zones awarded and approved from various parts of Maryland all have a physician component to their programs; the Eastern Shore grant includes The Maryland State Medical Society (MedChi) as a co-recipient.  Lt. Governor Brown announced the designation of the State’s first Health Enterprise Zones in five locations:  Capitol Heights in Prince George’s County, Greater Lexington Park in St. Mary’s County, Dorchester and Caroline Counties, West Baltimore, and Annapolis.  Community coalitions in each area will receive a range of incentives, benefits, and grant funding to address unacceptable and persistent health disparities.

MedChi CEO Gene Ransom explained “The lack of adequate access to a physician is a critical factor in the incidence of health disparities. Hopefully, these programs can begin to remedy that problem.”   It has been well documented that Maryland faces significant physician shortages across the State; shortages that are especially notable in medically underserved areas.  Ransom went on to explain “Recruitment and retention of primary care physicians specifically in areas demonstrating high incidence of health disparities is essential to succeeding in the elimination of disparities.”

Health Enterprise Zones (HEZ) were created by an Act of the General Assembly in 2012, and were designed to reduce health disparities among Maryland’s racial and ethnic groups and between geographic areas, improve health care access and health outcomes, and reduce health care costs by providing a variety of incentives to defined geographic areas with high rates of disparities.

Mr. Ransom, states “MedChi appreciates the O’Malley-Brown Administration commitment and hopes the HEZ awards mark an increased and continued commitment to incentives aimed at addressing physician shortages and other access to care barriers in Maryland’s underserved areas.”

2013 Legislative Preview of Maryland HealthCare Issues

By: Gene M. Ransom III

The 2013 Maryland General Assembly has convened, and healthcare will remain a major issue considered by lawmakers.  Implementation of federal healthcare reform remains a priority for the O’Malley Administration. However, little legislative action is required as most legislation implementing Health Care Reform passed two years ago.  One piece, the creation of a Maryland State based Health Insurance Exchange, should be operational next year. However, lawmakers need to deal with the issue of how to pay for the new Exchange.  Several proposals under consideration include a tax on insurers, a tax on tobacco, or a tax on healthcare practitioners.  Any tax on physicians has been strongly opposed by MedChi, The Maryland State Medical Society, and this issue has the potential to be contentious in the upcoming session.

During the 2013 session the Board of Physicians statute will be reviewed.  The Board of Physicians licenses and disciplines Maryland doctors and has come under fire from legislative auditors who found over sixty deficiencies in a recent audit.  Physicians and MedChi plan to work to enhance legal protections to ensure that the Board’s disciplinary process is fair, transparent, and results in the consistent and efficient resolution of complaints with adequate due process protections. The General Assembly must act with regard to the Board during this 433^rd session as the Board’s statue is set to expire.

Tort issues continue to be a major concern for the healthcare industry.  Healthcare and business groups will continue to strongly oppose trial lawyer attempts to increase the “cap” on damages in medical malpractice cases, as well as oppose the abolition of  the defense of contributory negligence, and otherwise work to protect and strengthen the legal liability environment in Maryland. This issue has increased its profile as the Maryland Court of Appeals current considers repealing the doctrine of contributory negligence, and two Baltimore hospitals were recently hit with multi-million dollar malpractice verdicts.

Other major healthcare issues under consideration include the Medicaid budget, scope of practice issues and various public health concerns. To track healthcare legislation during the session, visit www.medchi.org. MedChi keeps a running list of healthcare bills considered by MedChi’s Legislative Committee, with positions taken by the committee and status of each.

Gene is the CEO of MedChi, The Maryland State Medical Society, MedChi is the largest physician organization in Maryland. Gene can be followed on twitter @GeneRansom and can be emailed at gransom@medchi.org

LifeBridge Health CEO Warren Green retiring; Neil Meltzer to take over

LifeBridge Health CEO Warren A. Green is retiring at the end of June after 21 years with the medical system he helped create and Sinai Hospital of Baltimore President Neil Meltzer is taking over for him.

Meanwhile, Sinai has hired the chief operating officer of Mount Sinai Medical Center in Miami Beach, Fla., as president of Sinai Hospital and executive vice president of LifeBridge Health, Sinai’s parent company. Amy Perry will transition into Sinai as president in early March.

Green joined Sinai Hospital as its president in 1991. He helped merge Sinai with Northwest Hospital in Randallstown to form LifeBridge Health in 1998. LifeBridge also includes Levindale Hebrew Geriatric Center and Hospital and Courtland Gardens Nursing & Rehabilitation Center. In all, LifeBridge has 1,187 beds and 6,250 employees. The health system reported gross revenue of $1.22 billion in 2011, making it one of the largest health systems in the Baltimore area, after Johns Hopkins Health System, MedStar Health and University of Maryland Medical System.

Green received the American College of Healthcare Executives Regent’s Lifetime Service Award in 2012.

Meltzer will take over for Green on July 1.

AAMC selected as one of 106 new Accountable Care Organizations (ACOs) in Medicare

AAMC has been selected as one of 106 new Accountable Care Organizations (ACOs) in Medicare, ensuring as many as 4 million Medicare beneficiaries across the United States now have access to high-quality, coordinated care, Health and Human Services (HHS) Secretary Kathleen Sebelius announced today.

Doctors and health care providers can establish Accountable Care Organizations in order to work together to provide higher-quality care to their patients. Since passage of the Affordable Care Act, more than 250 Accountable Care Organizations have been established. Beneficiaries using ACOs always have the freedom to choose doctors inside or outside of the ACO. Accountable Care Organizations share with Medicare any savings generated from lowering the growth in health care costs, while meeting standards for quality of care.

The Centers for Medicare & Medicaid Services (CMS) has established 33 quality measures on care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and patient and caregiver experience of care.  Federal savings from this initiative are up to $940 million over four years.

Maryland Organization of Nurse Executives Names AAMC Nurse President

The Maryland Organization of Nurse Executives recently elected Sherry Perkins, PhD, RN, chief operating officer and chief nursing officer at Anne Arundel Medical Center (AAMC), as president of the organization.

Perkins joined AAMC in 2006 as chief nursing officer.  Perkins serves on several AAMC boards including Pathways Alcohol and Drug Treatment Center, the Executive Quality Council, Board Quality and Patient Safety Committee, and provides executive insight and support at regular meetings of the Medical Executive Committee and the Board of Trustees.

Perkins also co-leads the state-wide effort to improve transition to practice under Institute of Medicine recommendations for nurse residency, serves on the Maryland Hospital Association Council on Clinical Quality and the Board of Trustees of the Maryland Patient Safety Center.

 Igor Belyansky, M.D., Joins AAMC Surgical Specialists Practice

General surgeon Igor Belyansky, M.D., has joined AAMC Surgical Specialists. The practice includes Adrian Park, M.D., chair, Department of Surgery; Alex Gandsas, M.D., director, Weight Loss and Metabolic Surgery Program; and Kevin Stitely, M.D.

Dr. Belyansky is certified by The American Board of Surgery and is a fellowship-trained laparoscopic surgeon. In addition to hernia repair, Dr. Belyansky has clinical interests in esophageal surgery, complex GI surgery, anti-reflux procedures, surgical treatment of achalasia, and minimally invasive surgical treatment of colon cancer and solid organ pathology.

Dr. Belyansky has research interest in quality of life outcomes after hernia surgery and is a strong proponent of patient education and informed decision prior to surgery. He is a co-investigator of several research grants and has authored 16 publications, six book chapters, and several invited commentaries. He frequently presents at national and international surgical meetings and has received numerous research related awards.

While at Carolinas Medical Center, Dr. Belyansky and his co-workers developed an electronic application, CeQOL, which aids at predicting quality of life after undergoing an inguinal hernia repair. The use of this application has been widely embraced by hernia specialists around the world.

UMMC REMAINS ONLY EAST COAST HOSPITAL RECOGNIZED 7 YEARS IN A ROW AS A LEAPFROG TOP HOSPITAL

UMMC ranks among the nation’s top hospitals for the seventh year in a row, according to the annual Leapfrog Group survey, an analysis of patient safety and quality performance measures from nearly 1,200 hospitals. UMMC is one of only two hospitals in the country – and the only hospital on the East Coast – to make the list every year since its inception in 2006.

The Leapfrog Group’s annual hospital survey measures hospitals’ performance on a number of key patient safety and quality outcomes, and hospitals must meet Leapfrog’s stringent criteria including standards focusing on core areas of hospital care, such as Computerized Physician Order Entry (CPOE).

Leapfrog’s standard for CPOE measures the extent to which a hospital has adopted CPOE, and whether decision-support tools are working effectively. To fully meet this standard, physicians must enter at least 75% of medication orders through a CPOE system and demonstrate that an inpatient CPOE system can identify at least 50% of common, serious prescribing errors.

In 2010, the Leapfrog Group named UMMC one of two Top Hospitals of the Decade for patient safety and quality of care because of its consistently high performance in the annual survey.

 Early this spring, I cherished the gift of celebrating my dad’s 87th birthday with him. As a child, I used to love to pick his handsome face out from his medical school graduating class photograph. Being raised as to know no boundaries of what I could do and who I could be, I was always surprised that there were only two women in that 60-year-old photo.  Now I realize that those two women were most certainly pioneers who were ‘leaning in’ long before that phrase was part of our lexicon.

 This issue also celebrates the 2^nd anniversary of the launch of Maryland Physician Magazine. As a young girl, I was always asked if I wanted to grow up and be a nurse to help my dad, the doctor. That was the mindset of the 60s and early 70s. My answer was always the same, “No, I want to be a doctor and his boss,” (an inkling of my rationale in naming my company ‘Mojo’?). Although when I started college I was taking a pre-med curriculum, my professional and personal journey ultimately took me away from a medical career. However, the route I took eventually brought me back to my intellectual passion  - medicine and wellness.

 Over the last two years, the staff of Mojo Media and Maryland Physician has grown and now boasts two mother-daughter teams – one of them, being one of my three daughters, Kyle Marisa Rothand myself (Kyle has been named Director of Finance and Operations of Mojo). I’m proud to have built a team of very smart, creative and driven people, all of whom happen to be women who share the goal of being able to balance family and professional life. We’re actively ‘leaning in’ and I hope, leading by example.

 Since the inception of Maryland Physician, our advisory board has helped to guide us in content development and our advertisers have enabled us to get that content out to you. When you’re making the business decisions which support your practice, no matter the size, please consider our advertisers. Without them, our stories of commitment, dedication and inspiration – all with a focus on improving quality of patient care throughout Maryland – wouldn’t get to you.

Thanks for the inspiration, Dad! – JCR

By: Brenda Brouillette , RN, BS

The reputation management buzz in the healthcare industry, and more specifically surrounding physicians, is growing at tremendous speed. Physicians must understand what is necessary to portray and maintain a solid image to build their practice. So what is Reputation Management?  It is your online image being monitored, managed, and promoted.

In the past, physicians were at the center of control of their image and reputation. However, with the explosive emergence of real time communication, social media and an empowered consumer, this control has shifted. At present, consumers can instantly review, reflect, and report their opinions and reactions.  In the future, online rating and grading sites are projected to either make or break a physician’s reputation. A major concern is that no internet regulations regarding these sites exist.

The chief contributors to the challenges of reputation management are the lack of:

1. Physician interest
2. Knowing what to do
3. Regulations in internet marketing

The key to successfully deal with this paradigm is to strategically plan and execute a reputation management program. Taking a proactive and positive approach will help a practice deal with its online presence and embrace opportunities to engage in social media.

Fear and Lack of Interest

Fear has been a major obstacle for physicians to embrace reputation management.  Physicians should understand that a small percentage of posts are negative, and if dealt with correctly, they present an opportunity to improve an internal process or to educate the consumer.

As reported in the Journal of General Internal Medicine, (www.ncbi.nlm.nih.gov/pubmed/20464523), “Dr. Lagu and colleagues examined online reviews of 300 physicians on 33 different physician rating sites and found that nearly 90% of the reviews were positive. The negative comments were mostly actionable criticisms that physicians could address immediately without compromising patient confidentiality.”

Some 35% of patients leave a physician’s practice due to issues with staff and office processes rather than the physicians themselves. According to the Journal of General Internal Medicine, “Most negative comments are made on the management of the practice itself with wait times (61%) as well as office staff and appointment access being the most common.”

Knowing What to Do

The first step is to monitor your online presence.  One free, but limited solution is to sign up for www.googlealert.com. A better solution is to invest in a program that will thoroughly monitor, analyze, and assist with positive social media. An optimal choice is to select one company that offers comprehensive services that include monitoring and digital marketing initiatives to include patient and referring physician engagement. Such services can cost from $150 to $1000 per month.

The best way to address the online negative review is to first acknowledge it with a simple, professional message without attacking the reviewer. Next, take the discussion off line by inviting them to contact your office. Most importantly, to protect you from a potential HIPPA violation, NEVER acknowledge that the reviewer is a patient or divulge any patient information. Crafting a scripted response can positively portray the practice as caring and patient-focused, deflecting the negativity. If the reviewer includes a name, the office should follow up with some good old-fashioned service recovery tactics.

While it may not be wise for a practice to address certain negative posts, it is usually better not to ignore them, which can make you seen as aloof, thus adding fuel to the fire.

The best tactic is to implement a strong, aggressive campaign for posting positive comments and reviews to overshadow the negative ones, in combination with addressing negative posts. This tactic should be followed with lots of online educational information and communication to establish the practice as a thought leader and medical expert.

Developing a Program

Implementing a program can be done in increments.  A number of tactics can be utilized in each phase to create an overall program that will help to communicate, educate, develop relationships, and ultimately grow a practice.

• Listen – Actively monitor and capture conversations to understand the perception
• Participate – Proactively post and publish content on social media platforms as a one-way conversation
• Engage – Actively interact with conversations

Brenda Brouillette, RN, BS, is principal of Savvy Marketing Solution, a healthcare consulting firm.

By: Sanjiv Lakhanpal M.D., FACS

Case: LM, a 78-year old female was seen in the emergency room with leg pain and localized swelling in the calf.  The patient had no significant past medical history except for varicose veins, no history of prior leg clots or family history of clotting disorders. On physical exam, a tender, reddened, indurated area over the lower thigh and medial calf was seen. Ultrasound of the left leg, done in the Emergency Department, showed a superficial thrombophlebitis involving the superficial calf veins and the great saphenous vein.

The patient presented for further evaluation in the office and her pain and redness had improved with mild residual induration. Repeat ultrasound in the office showed extension of great saphenous venous thrombus into the common femoral vein.

She started treatment with Lovenox and continued on Coumadin for 3 months. Follow-up ultrasound in three months showed reflux in the great saphenous vein and resolution of the deep venous thrombosis.  Patient underwent radiofrequency closure of the great saphenous vein as an outpatient procedure without complications. Coumadin was stopped after the follow-up.

Discussion:  Superficial Thrombophlebitis (SVT) refers to a clot in a superficial vein associated with surrounding inflammation. The usual clinical presentation is pain, tenderness, induration or erythema along a superficial vein. It is usually treated with NSAIDS (Ibuprofen, etc), compression stockings and warm compresses.

SVT is associated with varicose veins, malignancy, pregnancy, estrogen therapy, travel and history of prior leg clots.

Although SVT is less studied than deep venous thrombosis (DVT), it is seen more commonly in the general population. The incidence of SVT is about 3-11%, compared to DVT, which is about 1%. It may involve the great saphenous vein in 2/3 of the patients. It is generally considered a benign, self-limited disorder, but it may be complicated by extension of thrombus in the deep venous system.

The aim of treatment is not only to relieve local symptoms but also to prevent thromboembolic complications. But the role of anticoagulation is controversial. Most studies have been small and have shown benefit over placebo, but the evidence was of low quality. The CALISTO Study (Comparison of Arixtra in Lower Limb Superficial Thrombophlebitis with Placebo) was recently published which showed benefit of Fondaparinux (Arixtra 2.5mg/d for 45 days)  over placebo in 3000 patients with lower limb SVT > 5cm,  with lowered incidence of venous thromboembolism, recurrent SVT and extension of SVT.

Based on these studies, the American College of Chest Physicians issued new guidelines in February 2012, recommending anticoagulation for patients with SVT who are at increased risk for venous thromboembolism (SVT>5cm, proximity to deep veins <5cm, positive medical risk factors). Positive medical risk factors include prior clots, cancer, surgery, thrombophilia, estrogen therapy or prolonged travel. Fondaparinux 2.5mg daily or enoxaparin 40 mg daily for a period of 4 weeks is recommended. If DVT is present, the patient should be fully anticoagulated.

Ligation of the great or small saphenous vein may be considered for patients in whom anticoagulation is contraindicated. Otherwise, surgery for SVT was found to be associated with a higher risk for thromboembolism.

Patients with isolated SVT and no associated risk factors may be diagnosed by physical exam and treated with NSAIDS, compression stockings and ambulation. Repeat physical exam should be done in 7-10 days to evaluate for extension or resolution. Duplex ultrasound should be done in patients with SVT >5cm, involvement of GSV or SSV, presence of phlebitis above the knee, or extension of phlebitis on serial exam.

__________________________

Sanjiv Lakhanpal M.D., FACS, is President/CEO of Maryland-based Center for Vein Restoration. www.centerforvein.com

REFERENCES

Decousus H, Quéré I, Presles E, et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Intern Med 2010; 152:218.

Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev 2007; :CD004982.

Decousus H, Prandoni P, Mismetti P, et al. Fondaparinux for the treatment of superficial-vein thrombosis in the legs. N Engl J Med 2010; 363:1222.

Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e419S.

As technology improves and reimbursement trends to global or performance-based pay, telehealth is becoming a more important way to deliver care. Maryland Physician spoke with early adopters to learn how legislation is reducing barriers and how this technology is being used in practice.

Legislative Initiatives

H. Neal Reynolds, M.D., associate professor at the University of Maryland School of Medicine, and director of Program Development for the Maryland Critical Care Network, was a member of the state telemedicine task force two years ago. This year, in concert with the Maryland State Medical Society (MedChi),and others, he fought for significant legislative reform. Dr. Reynolds says, “There are three main barriers to the expansion of telemedicine – 1) reimbursement, 2) the burden  of duplicative credentialing in multiple hospitals and 3) interstate licensure. Legislation requiring private insurers to reimburse telemedicine passed last year, but Medicaid was given a mandate to justify non-participation. Legislation introduced this year (HB 931/SB 496) aimed to enhance State of Maryland Medicaid reimbursement for telemedicine services. Unfortunately, the bill that passed will dramatically limit Medicaid reimbursement for telehealth to select conditions in the emergency department.”

He continues, “Credentialing was another push this year – The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) agreed that the originating hospital (defined as where the patient is located) can accept a consulting physician’s credentials from the hospital providing telemedicine, but Maryland is the only state that has a Code of Maryland Regulations (COMAR) regulation that requires ‘primary source’ credentialing of every telemedicine consultant.”

SB 798/HB 1042 (Hospitals – Credentialing and Privileging Process – Telemedicine) reduces  the credentialing burden of a telemedicine consultant by permitting “proxy privileging.”  MedChi amendments were negotiated with the Maryland Hospital Association and require the telemedicine consultant to be a Maryland licensed physician and the credentialing and privileging decision to be approved by hospital medical staff.

“This legislation is a big step,” notes Dr. Reynolds. “Telehealth will be cheaper and doctors will be more likely to participate in telemedicine programs thanks to this legislation. For physicians, the burden of multiple hospital privileging packets can be totally overwhelming.”

Another bill (HB 934, SB 776) that aims to reconvene and fund the telemedicine task force passed both houses easily; it addressed its structure, linking to CRISP (Maryland’s initiative to connect providers electronically), setting up a state registry and other operational issues. A fourth bill (SB 494/HB 937) that sought to enhance the security of Personal Health Information (PHI) via a cooperative and knowledge-sharing relationship with the Maryland Cyber Security Commission did not pass.

Extending Primary Care

While this year’s legislative battles ensued, Seth Eaton, M.D, MPH, medical director of MedPeds in Laurel, took advantage of the new reimbursement for telehealth to offer this service to patients. Launched in March 2013, Dr. Eaton and his four physician partners and three nurse practitioners use telehealth to provide after-hours urgent care to their patients. They also use telehealth to provide some mental health visits and follow-up care after discharge.

“There are two issues where primary care telemedicine is needed – first, to expand availability when the office is not open and second, to improve coordination between hospitals and primary care after discharge,” notes Dr. Eaton. “The latter is now possible thanks to new Medicare rules allowing reimbursement and the private carriers will likely follow. Primary care providers can use the new billing code to coordinate care following discharge.”

Since MedPeds participates in CRISP, they have access to real-time data about their patients following discharge from the hospital. Their participation in the state’s Patient Centered Medical Home (PCMH) program enables their care coordinator to reach out to the patient at home. Patients need high-speed Internet access plus a computer that includes a camera and microphone.

Of course, any telemedicine visit must be HIPAA compliant, which the practice solves by using ExamMed, a special internet-driven software platform that’s a considerable step up from Skype. Patients register for the telemedicine service by clicking on a link on MedPeds’ web site, which takes them to the ExamMed site to register securely for an appointment.

Dr. Eaton concludes, “Some patients initially may be reluctant to use telehealth, but that’s changing and I’m confident they’ll see the value. It’s an opportunity to increase quality and decrease costs.”

Filling Gaps in Behavioral Health

Radiology and behavioral health are generally more advanced in the provision of telehealth than primary care. For years, radiologists have used teleradiology to read imaging studies remotely. In behavioral health, however, availability has not always equaled use.

“Telepsychiatry has been available for years,” says David Pruitt, M.D., director of the Division of Child and Adolescent Psychiatry at the University of Maryland. “It’s critically important for children and adolescent psychiatry, as nearly half of psychiatric disorders start in childhood and we have a major shortage of pediatric specialists. And the shortfalls will deepen with the Affordable Care Act, which is expected to bring in 600,000 new Medicaid recipients, 40% of whom will be children.”

Dr. Pruitt adds, “We have to extend our reach if we’re to be relevant. We’re trying to develop new collaborative care models with primary care physicians, schools and the Medical Home model. Telehealth provides a partial solution. Technological advances have made it viable and it offers significant benefits for both patients and providers.

According to Dr. Pruitt, the DHMH has advocated for telehealth for roughly the past decade. “Hopkins, University of Maryland and the health departments in Garrett and Somerset Counties operate several pilot sites, and the medical centers are linked with school teams in Prince Georges County and Baltimore City.”

One of the barriers is the need for providers to be at the other end, either with the patient or receiving consultative input. “It’s an added cost that needs to be built in,” Dr. Pruitt observes. “We’re not there yet, but as we move to outcomes-based reimbursement, this model will be more viable. The COMAR does a good job of regulating equipment and encrypted data to avoid privacy violations.”

On the receiving end, Mountain Laurel Medical Center, a small federally qualified health center (FQHC) in the Garrett County town of Oakland, is expanding telehealth beyond the local health department. The center is also starting its third year in the state PCMH program. “The health department has a partnership for pediatric psychiatric telehealth with the University of Maryland,” comments Don Richter, M.D., medical director of the center and family practitioner/geriatrician.

“There is only one full time adult psychiatrist in the county and there’s no pediatric psychiatrist,” notes Dr. Richter. “Our closest referral system to the east is Cumberland and to the west is Morgantown, and it’s hard to cross state lines. While we also need access to consultative services with medical specialists in areas such as rheumatology and endocrinology, mental health, and especially pediatric mental health, is one of the area’s biggest needs. Telehealth will help to fill that gap.”

With some funding from the DHMH, the partners provided a consultative role rather than direct care – helping providers handle behavioral issues in children with ADHD, for example, and teaching them how to approach the child’s parents about managing their disorder. The new telehealth program will allow them to provide direct care as well. “The Learning Collaborative has been helpful in getting this program underway,” Dr. Richter adds.

H. Neal Reynolds, M.D., associate professor at the University of Maryland School of Medicine, and director of Program Development for the Maryland Critical Care Network

Seth Eaton, M.D, MPH, medical director of MedPeds in Laurel

David Pruitt, M.D., director of the Division of Child and Adolescent Psychiatry at the University of Maryland

Don Richter, M.D., medical director of Mountain Laurel Medical Center and family practitioner/geriatrician

By: Tracy M. Fitzgerald

Some call it a favorite pastime. Others call it a hobby, a passion or perhaps just a good reason to break away from the “every-day grind” to get outside and enjoy the sunshine along with some good company. It’s one of the few activities that can be relaxing, peaceful, challenging and rewarding all at the same time; it’s the game of golf. Today, more people than ever before are taking to the greens across the state of Maryland.

“People love the game because it can be so rewarding and is the ultimate test from a mental perspective,” said Chad Craft, PGA Head Golf Professional at the Hyatt Regency Chesapeake Bay Golf Resort on the eastern shore town of Cambridge. “It’s a great way to enjoy ambience, nature and relaxation after a long day at the office.”

Craft and his team at the Hyatt’s River Marsh Golf Club see about 21,000 golfers on an annual basis, who are drawn to the 18-hole Keith Foster award-winning facility, complete with a 20-station practice putting green. While more accomplished golfers will appreciate the challenges presented by the course’s Par 3 gold tees, private instruction, afternoon family golf programs and a specialized “Starting New at Golf Course” are also offered, to accommodate golfers of all levels of experience and interest.

“Because professional golf is on TV, people think it is much easier to pick up and learn than it truly is,” said Craft. “The truth is that it takes patience, effort and a solid work ethic.”

John Anderes, director of Golf and Grounds at Queenstown Harbor Golf, explains how a lot of his customers hit the green for a unique environmental experience. The facility features two 18-hole championship courses as well as a practice facility with a driving range, two putting greens, practice bunkers and a designated short-game area. The course is distinguished for its surrounding scenery and wildlife, as well as its commitment to environmental conservation. In fact, Queenstown Harbor earned the national 2012 Environmental Leader in Golf Award, recognizing its leadership in water and energy conservation along with wildlife preservation and management.

“Golf is a great game that you can play for a lifetime in some of the most beautiful surroundings you can access,” expressed Anderes, who sees roughly 55,000 golfers each year at Queenstown Harbor. “Come play the back nine of our River course one evening as the sun is dropping slowly over the Chesapeake Bay and the deer are emerging from the tree lines, and then let me know if you are breathing any easier. Our courses are unique because they are very casual and serene.”

Nestled between Baltimore and Annapolis, Compass Pointe Golf offers yet another premier public golf facility. With 36 championship-caliber holes consuming more than 800 acres in Pasadena, the course’s “four nines” – North, South, East and West offer diversity and variety for golfers of all levels of experience. In addition, a wide range of amenities are featured on-site to help those who are hoping to learn or improve their game. The facilities include a putting green, chipping green and driving range with grass and matted tees. Compass Pointe offers a number of golf leagues and clinics with programs for men, women, co-eds, beginners and those in need of some “refresher” tips.

For those who live, work or travel in a more “northbound” direction, Mountain Branch Golf Club offers a uniquely challenging course, along with the breathtaking views of Harford County’s rolling greens; an added bonus for any golfer.  Best known as a public course with private club amenities and conditions, Mountain Branch offers men’s and women’s golf leagues, a specialized ladies clinic as well as private instruction for those who crave to improve their game. Carol McCarthy, general manager and director of Sales and Marketing for Mountain Branch, says that the golf industry as a whole is starting to see some major shifts in terms of who is playing these days.

“One misperception that people have is that golf is expensive and that it’s an ‘older man’s game.’ Women are the biggest growth area in golf, followed by teenagers,” said McCarthy. “There are great, inexpensive golf courses out there and programs available for every age. Golf can be played any time of day, from one hour on the range to five hours on the course.”

Marylanders who golf or plan to start golfing are fortunate, as there is no lack of options in terms of where to play. According to golflink.com, the state boasts 231 courses to choose from. While many offer course options for the most novice to the most advanced golfers, those who have committed to the game and are in search of the state’s more challenging courses may want to explore Wakefield Valley Golf in Westminster, Caves Valley Golf Club in Owings Mills, Woodholme County Club in Pikesville, Maryland Golf and Country Club in Bel Air, or Bulle Rock in Havre de Grace, are recognized as some of the top most challenging golf courses in the Baltimore area.

“What I enjoy most about my job is that I have the chance to see people enjoy the great game of golf,” admitted Craft. “It can be a lifelong, enjoyable experience.”

Photographer:  Photo Courtesy of the House of Ruth

 The statistics are simply staggering: research consistently shows that one in every four women will be in a physically abusive relationship in her lifetime. Of the 35,000 individuals who took part in the survey conducted by the CDC, 89% of the women interviewed, claimed to have been subject to verbal abuse.

Recognizing that women in dangerous or even life-threatening situations sometimes have no place or person to turn to, the House of Ruth was founded in 1977 to provide a “safe haven” for victims of domestic violence. What started at that time as a small shelter staffed by one, has evolved and grown ten-fold. Today, the Baltimore-based organization is recognized as one of the nation’s leading domestic violence centers, providing a comprehensive line of services and support to women and children who want and need a place to go, or perhaps a helping hand as they strive for a fresh start.

“We are known for our emergency shelter services but this is just one piece of what we do,” said Sandi Timmins, Executive Director of the House of Ruth. “We help women who can’t go home find transitional housing or apartments, and provide resources and support to help them become independent over time. We also manage a legal clinic, staffed by 20 local attorneys who work pro bono to help women obtain protective or peace orders, as well as a team of counselors and therapists, who work with moms and their children who have endured trauma.”

While they may not come with any visible scars or bruises, women who suffer verbal and emotional abuse are also able to take advantage of the full spectrum of services offered by the House of Ruth. According to Ellyn Loy, Director of Clinical Services, this kind of abuse can range from yelling and screaming, to intentional manipulation and diminishment of someone’s feelings, with the abuser’s need for control being a key factor.

“The abuser will try to control the victim by attacking their self-esteem, isolating them or threatening them,” said Loy. “In many cases the abuser will deny that he is being verbally or emotionally abusive, and this makes it harder for the victim to find her reality.”

In 2012, Timmins, Loy and their team of 120 staff members and over 300 local volunteers provided support and services to approximately 15,000 women and children. Day-to-day operations rely heavily on grant funding, private monetary and in-kind donations, and proceeds from annual fundraisers. Funds that are generated through these efforts help assure that House of Ruth facilities can be maintained and that programs can be continuously implemented and supported, as the need for support continues to rise.

“If a woman is on a path to leaving, on average she will come and go seven times before she will make it permanent,” Timmins said. “Our role is never to tell her what to do, but instead to provide her with information, acknowledge her choices and make sure she knows we are here for her.”

Women who are seeking support are not the only people the House of Ruth is working hard to educate. Raising community awareness about the prevalence of domestic violence and teaching people how to identify the signs that can indicate someone else is in trouble, is another priority for Timmins and her staff. Often, what is happening in the workplace can be a key indicator.

“You have to remember that both victims and abusers are often employed,” Timmins explained. “We have a program called ‘When Intimate Partner Violence Comes to Work’ and the goal is to meet with human resources teams, managers and supervisors, to help them understand what do to, when they are working with someone who may need help.”

To learn more about the House of Ruth’s workplace education program, or for a schedule of upcoming fundraising events that you can attend, which will support the organization’s mission, please visit www.hruth.org.

Photography by: Tracey Brown, Kevin J. Parks, and Melissa Grimes-Guy

Continuing our yearly tradition, Maryland Physician interviewed female physicians we admire for their exceptional commitment to leadership. They remind us of the importance of mentors, family support and following your passion.

Using Epidemiology to Control Cancer

As a child, Kathy Helzlsouer, M.D., MHS, director, The Prevention and Research Center at Mercy Medical Center, had Broadway dreams, but with a mother who was a nurse and a father who was a physician, the odds were probably stacked in favor of a health career. She recalls, “My interest in medicine was a gradual thing. It wasn’t until I was a sophomore in college that I began to get interested in the possibility of medicine as a career. Because I went to a small college, it was harder to get into medical school but I was fortunate to be accepted at the University of Pittsburgh School of Medicine. There I had my first exposure to epidemiology and eventually got a Masters degree while training in oncology.”

Facing and Fighting Discrimination

Female physicians of Dr. Helzlsouer’s generation still had to fight to be accepted. Women comprised only 20% of her medical class. “If a woman said something, then a male physician said the same thing, he got the credit,” she recalls. “I even had a male colleague tell me that I had an abstract accepted just because I was a woman. Today, discrimination in the work place is still there, but it’s more subtle and harder to detect. It’s particularly challenging for women who are starting out to achieve any work life balance. We were expected to work 60 to 80 hours a week even after residency.”

Achieving Balance

“I have a wonderful husband – he gave up his career path to support mine. As a consultant, he’s more flexible. My priority is to work hard but family always comes first. Men want that life-work balance now, too. Interestingly, though, it wasn’t until a male doctor came to a meeting with his young son in a backpack that Hopkins finally got onsite childcare. The women wouldn’t dream of showing up at a meeting with their children!”

In academia, balancing career goals with caring is another tightrope that many female physicians walk. “It truly is publish or perish. Women have a harder time saying ‘no’ to committees and other service work that can take away from that.”

Cancer Prevention and Survivorship

Ironically, Dr. Helzlsouer has experienced the tragic impact of cancer first hand, losing her one-year old daughter to leukemia. This has influenced her research path.  She joined Mercy in 2004 to spearhead its clinical research and programs in cancer risk assessment and cancer survivorship. She has chaired or served on numerous cancer committees throughout her career and was an associate editor for the Journal of the National Cancer Institute. As a result of her contributions to the field, she is the recent recipient of the Martin D. Abeloff Award for Excellence in Public Health and Cancer Control.

Much of her current work involves prevention and counseling. “We conduct a genetic counseling assessment for women who’ve had cancer or a strong family history of colon, breast or ovarian cancer.”

Dr. Helzlsouer has also focused her considerable talents on improving life after cancer. When she came to Mercy, she started the Mind/Body Program, based on the one at Harvard. “Breast cancer can be very traumatic and lead to persistent fatigue. The Mind/Body approach can reduce fatigue by 40% without medications. Complementary medicine is so important and so undervalued. We need to think about cancer rehab in the same way that we do cardiac rehab. Improving quality of life really motivates me. I hope to expand the research and programs to help all cancer patients, especially women with ovarian cancer.

“We’ve researched the underlying causes of aromatase inhibitors, which increase joint pain, and how we can prevent or minimize the problem,” she adds. “Our survivorship program is critical for cancer patients, who otherwise would fall through the cracks. Medical professionals tend to be too focused on the cancer the patient had and not enough on the ones that they’re at risk for in the future.”

Dr. Helzlsouer has passed on her commitment to those she has trained. “I enjoy teaching. It’s rewarding to realize that some of the leaders in the field today trained with me. My advice to young physicians is to find a great mentor. I had some wonderful mentors who helped me find research work that makes a difference.”

Sports Medicine Picked Me

It’s not surprising that Leigh Ann Curl, M.D., who helped the Baltimore Ravens win their second Super Bowl this year while being a mother to two young children, has always been a high achiever. “I’ve always gotten by with little sleep,” she notes. “I’m up by 5 am most mornings after six hours of sleep. It takes a lot of self discipline and I have always pushed myself personally and professionally.”

The second oldest of six children in a close-knit family, Dr. Curl, who is an orthopaedic surgeon at the Center for Sports Medicine and Shoulder Surgery at MedStar Harbor Hospital and the Head Orthopaedic Surgeon for the Ravens, had an early morning paper route as a child. She was the first in her family to earn a college degree and was class valedictorian at the University of Connecticut. However, she nearly missed a key deadline to declare for medical school. “I made a final decision to apply about four weeks before most of the deadlines. In medical school at Johns Hopkins, I had an immediate positive reaction to orthopedics. You could say that sports medicine picked me. The positives have to outweigh the negatives of what you choose and it’s easy to work hard when you enjoy what you do.”

Times Have Changed

When Dr. Curl interviewed for her orthopedic residency, she encountered no other females during the interview process. “I was fortunate to have some excellent mentors and faculty at Hopkins who fostered my interest in orthopaedics despite it being a nontraditional career path for women at the time,” she recalls. “I realized early on that the surgical attendings were most interested in how well you did your job, but I may have had less margin for error than the men.” She never sensed blatant discrimination during her training at Hopkins, but she does recall that she was asked some inappropriate questions in her residency interviews at other institutions, such as whether she was planning to have children or if she could physically handle the job. She laughs, “I was probably physically more capable than some of the interviewers.”

A Long Sports Career

Serving the Ravens is the culmination of a long sports career with top-notch teams. Dr. Curl was herself a Division I basketball star at the University of Connecticut. After becoming an orthopedic surgeon, she served in various capacities as team physician for the University of Maryland Terrapins, the New York Mets, Baltimore Orioles, USA Women’s Basketball, USA Women’s Rugby, Johns Hopkins University and St. John’s University in New York.

“My initial team physician experience was with the Mets and St. Johns during my fellowship training before returning to a faculty position at Hopkins,” she remembers. “Then I was recruited to University of Maryland to help start their sports medicine program and work with the Ravens and College Park. You just chip away at the barriers.”

Her initial reluctance to be in the locker room with male athletes vanished in her time with the Mets. “An equipment guy directed me back to the locker room training area after practice, jokingly telling me the guys didn’t have anything I hadn’t seen already. Today, it’s not a big deal. I used to be acutely aware of being a woman, but now there are growing numbers of female sports physicians and trainers.”

Football is a Year-Round Commitment

“It’s really a year-round job that consumes what would otherwise be mostly free time,” notes Dr. Curl when describing her job with the Ravens. A new season “starts” with preparation for the draft at the NFL Combine each February. “We do physicals on over 300 potential draft picks and are buried in the bowels of the stadium looking at MRIs and other test results. There’s the draft, free agency, off season workouts and then the true start of the season in July. Football probably occupies 30 weekends a year on average, and the Super Bowl makes it an especially long season. But I love what I do.”

Quality, Comfort, Dignity at the End

Lakshmi Vaidyanathan, M.D., medical director of the Shore Health System Palliative Care Program and Shore Home Care Hospice, was destined to become a physician. “Even as a child, I play-acted the care taker, never tiring of pretending I was a doctor. I was the first in our family to become a doctor, with my cousin and brother closely following suit. My parents, who truly honor medicine as a ‘noble profession,’ were always there to lend encouragement. They sacrificed generously to help me see my career goals through.”

Fortunately, she encountered little gender discrimination in her training. “When I completed medical school in Mumbai, India in the late 1990s, half of my classmates were women. While most of the professors were male, I felt women students were treated equally to men.”

As did many women physician leaders, Dr. Vaidyanathan enjoyed the support of excellent mentors during her residency in Pittsburgh. “My mentors not only were excellent clinicians but also humane, dynamic physicians who believed in close interaction with their patients. One who was particularly inspiring spearheaded a robust palliative care program that was ahead of its time. His vision was a great example for me.”

That experience influenced her pursuit of certification by the American Academy of Hospice and Palliative Medicine. During her tenure as Chief of Staff at Shore Hospital System, she started the palliative care service with the blessings of senior leadership. Initially located at the Memorial Hospital, Easton, the program has expanded to Dorchester General Hospital and has grown threefold. Her efforts to launch this program were recognized when she received the 2012 Arthur B. Cecil, Jr., M.D. Award for Excellence in Healthcare Improvement.

“Palliative care is not about death and dying – it’s about living your best life in the time you have left,” observes Dr. Vaidyanathan. “We strive to maximize patient well being, and tailor their care to what serves their needs best under difficult circumstances. We minimize excessive testing and intervention that may do more harm than good, but we don’t give up on them– our multidisciplinary team approach seeks to do the right thing at the right time.”

She acknowledges, “Physicians now recognize the value of requesting a palliative care consult. Most palliative care programs start in the inpatient setting, but as they grow, they expand to outpatient and home settings because we want to provide timely interventions instead of waiting until patients need emergency care.”

The Cecil Award honor has helped to raise the profile of Shore Health’s palliative care program. She comments, “That’s been a fantastic boost to our efforts. One of our goals for the coming year is to raise public awareness so that patients and their families know to ask for palliative care.”

A Family Juggling Act

Being married to a urologist and coming home every evening to care for two young children is challenging but also a great joy. “My husband is one of my inspirations,” she enthuses. “Maybe because he’s retired Army, he just rolls up his sleeves to pitch in when he comes home to ‘accomplish the mission’ as he puts it. We strive to spend quality time with our children and are very involved in their school. I believe the old cliché, ‘it takes a village.’ This  rings especially true in our busy household as we balance raising our children and maintaining a healthy home and career.”

Follow Your Passion and Be Part of the Solution

Regina Hampton, M.D., FACS, breast surgeon, medical director of Comprehensive Breast Care Center at Doctors Community Hospital, didn’t follow a traditional route to becoming a surgeon. After graduating from college, where she wasn’t interested in taking traditional pre-med classes, she worked for two years as a radiation therapist. Fortunately, the Medical College of Pennsylvania took non-traditional students. “I was a little more focused than those who went straight through,” she recalls.”

Her love of surgery came as a surprise. “I thought I would like family practice or pediatrics, but I didn’t. I was surprised to find that I loved my surgical rotation. But I worried that I wouldn’t be able to have a family if I was a woman in surgery. After talking with lots of female surgeons, though, including one who took a full day off each week to be with her children, I realized I could do it.”

She started her career as a general surgeon, but began receiving a disproportionate share of breast cases. “In the last four years, I’ve focused exclusively on breast surgery,” she says. “It’s very gratifying to focus on this ever-changing field that is moving to customized treatment for each woman. And today, most of my patients will survive their cancer.”

Nipple Sparing Breast Surgery

One of the most significant advances in breast surgery is nipple-sparing surgery. “If the woman has a small tumor, we leave the nipple and the skin fold. We fill in the breast with an implant or abdominal tissue (TRAM) and hide the scar under the breast so it looks normal.”

Dr. Hampton is also enthusiastic about having more treatment options. “Every patient can make the choice that’s best for them. We’re learning that breast cancer is different in every person. A small tumor can spread quickly, while some large tumors will not. Young women often don’t want to have to get a mammogram every six months for the rest of their life – they want to go back to the peace of mind they had before they were diagnosed. They may opt for bilateral mastectomies and benefit from our ability to give them great cosmetic results.”

Family Support

As with so many other female physician leaders, Dr. Hampton credits her husband and in-laws with allowing her to have a young child while managing a busy practice. “Their support really helps,” she states. “It’s allowed me to run and grow my practice, and even to do speaking engagements or participate in weekend health fairs.”

She encourages female physicians in training to follow their passion. “The best advice I ever got was not to choose my career path based on a concern about its lifestyle implications. You can adapt your career to your lifestyle and find a spouse that understands the demands of your career.”

Leadership and Legislative Involvement

Dr. Hampton is a past president of the Prince George’s Chapter of MedChi. where she was involved in supporting relevant legislation. “I always had the attitude that’s it better to be part of the process,” she says. Prior to her MedChi work, she had served on several hospital committees, including the Operating Room and Medical Executive committees. “I want to be at the table for things that are relevant. You can’t just sit back and complain – you need to be part of the solution.”

Kathy Helzlsouer, M.D., MHS, director, The Prevention and Research Center, Mercy Medical Center and adjunct professor of Epidemiology at the Johns Hopkins University Bloomberg School of Public Health

Lakshmi Vaidyanathan, M.D., medical director of the Shore Health System Palliative Care Program and Shore Home Care Hospice

Regina Hampton, M.D, FACS, breast surgeon, medical director of Comprehensive Breast Care Center at Doctors Community Hospital

By: Tim Faith

The HiTech Act in 2009 set in motion a series of changes to the HIPAA rules that govern the use, disclosure and protection of protected health information (PHI). The Department of Health and Human Services (HHS) subsequently issued interim regulations in response to these changes in the law, and this year issued a final regulation as of March 26, 2013 that requires compliance by covered entities and business associates within 180 days. These final regulations make a number of important changes that may impact your relationship with the vendors that provide electronic health record (EHR) licensing and support.

First, prior to HiTech, business associates of covered entities were not required to comply with the security rules and standards set forth in the HIPAA security regulations. HiTech changed the applicability of the security regulations to include business associates. The final regulation from HHS implements this provision of the HiTech Act, but with a twist: subcontractors to business associates are also defined as business associates within the final regulation. What this means is that EHR vendors and their subcontractors must fully comply with the HIPAA security rules, not just with “reasonable” security measures.

Second, prior to HiTech, there was no federal requirement that a covered entity or business associate report a security breach that resulted in the disclosure of protected health information (“PHI”). HHS subsequently issued interim regulations to implement these notification requirements, and as of March 26, 2013, HHS issued final regulations that alter the assumptions and exceptions to what constitutes a “breach” under HIPAA.  In addition, business associates and subcontractors are obligated to report security breaches to covered entities.

Providers selecting an EHR vendor should have an attorney review any proposed contract between your organization and the vendor to ensure that the business associate provisions comply with the final regulations. If you already have an existing relationship, work with your attorney to ensure that the contract in place complies with the final regulatory requirements. All business associate agreements must come into compliance with the final regulations by September 2014.

In recent years, some EHR vendors have moved to cloud-based data storage and access solutions for their clients. These cloud systems store data collected by the EHR at a remote data center, and make it available over an Internet connection with the provider. Some EHR vendors subcontract with a third party to provide the cloud data storage. More likely than not, that subcontractor is now a business associate under the final regulations and takes on the same obligations as the EHR vendor with regards to your data. The final regulations require a covered entity’s contract with their business associate to include subcontractor compliance with the final security regulations.

Beyond compliance issues, providers will want to evaluate whether an EHR vendor that hosts your data in the cloud has really made sufficient security provisions. Such an evaluation makes good business sense because of the incredibly negative consequences of any security breach that results in a loss of PHI for a health care provider. For example, does the vendor comply with a recognized, national security standard like NIST?  Is the EHR vendor, or the data center it uses for storing your data, audited against an SAS standard like SAS-70?  What are the security practices and security devices in place at the EHR vendor to protect your data?  If the vendor will host your data, what are its disaster recovery and data backup procedures? Are those procedures regularly tested?

Providers and their counsel should also evaluate what, if any, additional provisions should be negotiated into any final agreements to require the EHR vendor’s compliance with a security standard, commitment to security procedures, and related obligations (such as maintaining appropriate encryption for data during its transmission).

The changes in HIPAA compliance mean that providers cannot simply rely on the EHR vendor’s representations that they know best regarding security. Further, because the scope of HIPAA now covers most subcontractors of business associates that handle PHI, more entities risk substantial fines for failing to comply with the applicable security standards. All providers should work with their counsel to analyze and address compliance with the final regulations.

Tim Faith is an attorney with a private practice focused on technology issues that intersect with legal ones. www.faithatlaw.com

A Conversation with Carolyn Quattrocki

Coordinating the components of the state’s healthcare reform initiatives is a big job. Fortunately, Carolyn Quattrocki, executive director of the Governor’s Office of Health Care Reform, is up to the task. Maryland Physician spoke with her near the close of the 2013 General Assembly session to learn what her office has accomplished and what is planned.

What is the role of your office and how do you support federal healthcare reform?

In May 2011, the Governor created the Office of Health Care Reform to lead and coordinate Maryland’s implementation of the federal Patient Protection and Affordable Care Act (ACA) of 2010.  Essentially, my office has a coordinating role/oversight function with respect to healthcare reform efforts in the state. Maryland Lieutenant Governor Anthony G. Brown has taken a hands-on leadership role, so we work closely with his office.

It’s a complicated process. In the first year, together with our partners in the General Assembly, we enacted legislation to set up the governance structure and framework of the Maryland Health Benefit Exchange. Maryland has been at the forefront among states in launching the health insurance marketplaces, or exchanges, required by the ACA. This year, in our third and final big legislative push, we are putting in place the last pieces, which include Medicaid expansion, a funding stream for the Exchange, and policies to ensure continuity of care for Marylanders moving between Medicaid and commercial insurance, or between different insurance policies.  We are working closely with a terrific team from the Exchange, the Department of Health and Mental Hygiene, and the Maryland Insurance Administration.

We will have the legislation in place by the end of the session. Marylanders can begin enrolling in qualified health plans starting October 1, 2013, with coverage starting January 1, 2014. The goal is to make health insurance affordable and accessible for all Maryland residents, including the approximately 750,000 who are currently uninsured.  By the end of the decade, we hope to cut this number in half.

How will the Exchange Work?

The Exchange, which will be known as the Maryland Health Connection, will offer insurance to individuals and small businesses. Small businesses purchasing through the Exchange will qualify for a tax credit of up to 50% of their contribution to their employees’ premium. They also will be able to offer employees greater choice among plans tailored to their individual needs and greater insurance portability if they change jobs.  In addition, individuals with incomes below 400% of federal poverty guidelines will receive federal subsidies for coverage.

Establishing the Exchange and building the IT system to support it is an enormous and complicated undertaking.  We have received $157 million in federal grants to fund this development and to support operations through 2014.  A dynamic, nine-person board oversees this effort, and the Exchange now has a terrific staff. We are also developing a robust consumer assistance program that will help enroll and support people in the Exchange.

This education and outreach campaign will be a key to the Exchange’s success in reaching the people who can benefit most. The Maryland Health Connection will divide the state into six regions, with one umbrella “Connector” entity responsible for enrollment in each region.  The Connector entities will hire staff and partner with other community organizations to get the word out to people in every corner of their region. They will need to make special efforts to target specific populations that historically have had cultural, linguistic, or other barriers to obtaining insurance.

All insurance carriers currently doing business in Maryland have expressed their intent to participate in the Exchange, and we are also pleased to have a few new entrants into the market.  The ACA also established Consumer Operated and Oriented Plans (CO-OPs), and at least one, the Evergreen Health Cooperative in Howard County, intends to operate in the Exchange.

Interested parties can visit the following websites for information:

1. Exchange stakeholders – www.marylandhbe.com
2. Office of Healthcare Reform – www.healthreform.maryland.gov
3. Individuals and small businesses– www.marylandhealthconnection.gov

What are some of the key challenges you face?

Ongoing challenges remain, the most immediate of which is the sprint from here to October when the Exchange must “turn the lights on.”   As I said, though, we have a great team that is making every day count.

Over the longer term, we need to continue to find ways to decrease the underlying costs of health care.  A subcommittee of the Health Care Reform Coordinating Council is looking at new and promising models for care delivery such as Patient Centered Medical Homes (PCMH) and Accountable Care Organizations (ACO).

What are your goals for this year and beyond?

My immediate goals are to ensure passage of the Maryland Health Progress Act and to help the team at the Exchange be ready to begin operations on October 1^st.   Over the longer term, we want to focus on workforce development.  As we get more people into coverage, we need to ensure that we have the right professionals in the right place to meet their health care needs.  In Maryland, we have decent ratios of providers to patients, but we still have problems with access and distribution.

Thus, we are exploring ways to increase access to primary care and to address other shortages, like the lack of behavioral health practitioners on the Eastern Shore. The Health Enterprise Zones, through which communities may seek grants and other financial incentives to attract and retain the allied health professionals necessary to address health disparities, is one promising initiative. (see Maryland Physician’s interview with Lt. Governor Brown from Jan/Feb 2012 Volume 2: Issue 1).

Another exciting initiative is the Governor’s EARN program (HB 227 – Employment Advancement Right Now) legislation passed this year, which provides grant dollars to match Marylanders seeking new or better jobs with the workforce needs of state employers. The program will bring together businesses, government, and educational institutions to create training programs that help prepare people for jobs in high-demand fields.  While not limited to the healthcare sector, this program will help address health workforce needs.

What have been your office’s greatest successes?

While some people have said the ACA is too prescriptive, it actually gives states a lot of tools and discretion to implement reform in a way that works for us.  So I’m proud of involving the full panoply of stakeholders – physicians, insurance carriers, hospitals, consumer advocates, unions, insurance brokers and small businesses – in this process.  We recognized early on that we needed the input and expertise of everyone who would be affected by reform in order to implement it most effectively. Our efforts have been inclusive and collaborative, and I believe this has been key to our success.

This issue celebrates Maryland women in medicine. What unique skills have you brought and what challenges have you faced as a woman in today’s healthcare environment?

My legal background has been helpful in drafting and sheparding bills through the General Assembly, and in negotiating the compromises that are critical to successful legislation. My work in policy development under Joe Curran, Maryland’s former Attorney General, was also important.   Most of all, I’ve been lucky to have had wonderful mentors, several of which were ahead of their time in recognizing the challenges women face and helping me succeed while I was raising four children.  Beginning with Attorney General Curran and his deputies, and now working for the Governor and Lieutenant Governor, I am extremely grateful for the importance they have placed on making women integral and successful members of their team.