Maryland Physician Magazine January/February 2013 Issue

PhysicianVOLUME 3: ISSUE 1 JAN/FEB 2013

MORE TAILOREDCARDIOVASCULARTREATMENTS

HIT: PROTECTINGPATIENT DATA

PROGRESS & PROMISE:MARYLAND STEM CELLRESEARCH

MORE TAILOREDCARDIOVASCULARTREATMENTS

HIT: PROTECTINGPATIENT DATA

PROGRESS & PROMISE:MARYLAND STEM CELLRESEARCH

PhysicianYOUR PRACTICE. YOUR LIFE. VOLUME 3: ISSUE 1 JAN/FEB 2013

www.mdphysicianmag.comwww.mdphysicianmag.com

YOUR PRACTICE. YOUR LIFE.

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10 Cardiovascular Update:MoreTailoredTreatments

16 Progress and Promise:The State of Stem Cell Research in Maryland

20 Protecting Patient Data in a Digital Age

F E A T U R E S

D E P A R T M E N T S

ContentsVOLUME 3: ISSUE 1 JAN/FEB 2013

2010 24

Cases | 7 | RoughWeather Cardiac Care

Compliance | 9 | Dealing with Difficult Patients

Living | 24 | Live a Little...Visit Delray Beach, Florida

Solutions | 29 | Create a“WOW”Experience forYour Patients

Good Deeds | 30 | Restoring Rhythm in Bangladesh

On the Cover: Paul A. Gurbel, M.D., director of the Sinai Center for Thrombosis Research at Sinai Hospital of Baltimore

4 | WWW.MDPHYSICIANMAG.COM

JACQUIE ROTH, PUBLISHER/EXECUTIVE [email protected]

LINDA HARDER, MANAGING [email protected]

CONTRIBUTING WRITERSTracy FitzgeraldJackie Kinsella

CONTRIBUTING PHOTOGRAPHYTracey Brown, Papercamera Photography

www.papercamera.com

EXECUTIVE ASSISTANT/WEBMASTERJackie Kinsella

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

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

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

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

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

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

PATRICIA CZAPP, M.D.Anne Arundel Medical Center

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

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

MICHAEL EPSTEIN, M.D.Digestive Disorders Associates

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

REGINA HAMPTON, M.D. FACSSignature Breast Care

DANILO ESPINOLA, M.D.Advanced Radiology

GENE RANSOM, J.D., CEOMedChi

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

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

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

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

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

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

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

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

Jacquie RothPublisher/Executive [email protected]

@mdphysicianmag

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

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ouis and Phyllis Friedman Neurological Center at Sinai Hospital, our full range of inpatient and

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DISCUSSION Primary angioplasty astreatment for acute ST ElevationMyocardial Infarction (STEMI) has beenshown to dramatically improve clinicalendpoints, yet it requires promptimplementation to obtain maximumclinical benefit.1 Urgent patient transportand availability of specialized healthcareteams can be problematic during disasterconditions.2 In this instance, hospitalpreparedness, and the on-site availabilityof all crucial cath lab team members,resulted in a successful patient outcomeduring the pre-dawn hours of HurricaneSandy.

Primary angioplasty for thetreatment of acute myocardial infarctionhas been in clinical practice for almost30 years.3 However, in 1993, thePrimary Angioplasty in MyocardialInfarction (PAMI) Investigators publishedthe landmark multihospital, prospective,randomized trial establishing thesuperiority of primary angioplasty overother treatment strategies for STEMIpatients at tertiary care hospitals withon-site open heart surgery (OHS).4

This strategy suffered from relativeinaccessibility to the majority ofSTEMI patients, who presented tohospitals which lacked on-site OHS.Helicopter transfer remains aneffective strategy for transport fromNON-OHS to OHS hospitals.Unfortunately, inter-hospital transferadds an average of 40 minutes to doorto balloon time.5 Also, weather isfrequently unacceptable for helicoptertransport and helicopters are subject tomechanical failure, or worse.6

Seeking to expand the availability ofprimary angioplasty, in 1996 the MarylandHealth Care Commission approvedinitiation of the Cardiovascular PatientOutcomes Research Team (CPORT)primary angioplasty study. This multi-hospital, prospective, randomized trial,which was led by Dr. Thomas Aversanoof the Johns Hopkins Medical Institutions,determined the feasibility, efficacy, and

safety of primary angioplasty at NON-OHS hospitals.7 The trial found noangioplasty-related complications thatrequired emergency coronary artery bypassgrafting (CABG). While patients wereappropriately transferred to OHS hospitalsif coronary angiography demonstratedsignificant left main coronary stenosis orcoronary anatomy better suited for CABG,almost none of these were emergencyinter-hospital transfers. Furthermore,CPORT side-benefits included improvedequipment, resources, and staff trainingat all critical care areas of participatinghospitals, benefiting non-cardiac as wellas cardiac patients.

As of 2011, most patients in theentire state of Maryland and the Districtof Columbia are within minutes of the13 NON-OHS Maryland hospitalswith on-site primary angioplasty, or the13 Maryland/DC OHS hospitals thatalso accept transport from hospitalslacking primary angioplasty capability.Controversies regarding OHS comparedwith NON-OHS strategies for primaryangioplasty will continue as newtechnologies emerge. Nonetheless,when STEMI strikes and transportationis problematic, sometimes the nauticaladage, “any port in a storm” works best.Daniel Woronow, M.D., FACC is a member

of the Cardiovascular Patient Outcomes

Research Team (CPORT) and has served as

Principal Investigator at Holy Cross Hospital,

Silver Spring, Md.

1Brodie, Stuckey & Wall, et al in Journal of the American

College of Cardiology 32 (1998): 1312-1319.2www.nejm.org/doi/full/10.1056/NEJMp1213486.html3Woronow, Zinsmeister & Lindsay in American Journal

of Cardiology 56 (1985) 1007-8.4Grines, Browne & Marco, et al in New England Journal

of Medicine 328 (1993) 673-79.5Anderson, Nielsen & Rasmussen et al in NewEngland

Journal of Medicine 349 (2003) 733-42.6www.cnn.com/2011/12/26/us/florida-medical-helicopter-

crash/index.html7Aversano, Aversano & Passamani, et al in Journal of the

American Medical Association 287 (2002): 1943-51.

Cases

RoughWeather Cardiac Care

CASE: It was called the “perfectstorm, Hurricane Sandy.” At 2a.m. on Oct 30, 2012, a 66-year-old college professor collapsedwith chest pain while bailing outhis basement during the storm.Within minutes of the 911 call,he arrived in theERwith crushing,substernal chest discomfort and“tombstone” ST segmentelevation onhis electrocardiogram.Anticipating such an occurrence,the on-call cardiac catheterizationlab team remained camped-outin the hospital during the storm,knowing that a frantic drive tothe hospital would be impossiblegiven the multiple road closuresthat night.

Within minutes after ER arrival,the patient had given informedconsent and the cardiac catheter-ization/primary angioplastyprocedure was underway. Theteam had reperfused his com-pletely occluded right coronaryartery (RCA) and implanted anintracoronary stent. Despiteharsh weather conditions, theoverall “door to balloon” timewas 31 minutes. When theprofessor was discharged fromthe hospital two days later, hesaid, “When you are tenured inacademia, you either retire verti-cally or horizontally. Thanks tothis hospital’s heart attack team,I am not in the latter category.”

Daniel Woronow, M.D., FACC

The ICD-10 transition is coming October 1, 2014. The ICD-10 transition will change every part of how you provide care, from software upgrades, to patient registration and referrals, to clinical documentation, and billing. Work with your software vendor, clearinghouse, and billing service now to ensure you are ready when the time comes. ICD-10 is closer than it seems.

CMS can help. Visit the CMS website at www.cms.gov/ICD10 for resources to get your practice ready.

2014 COMPLIANCE DEADLINE FOR ICD-10

Official CMS Industry Resources for the ICD-10 Transitionwww.cms.gov/ICD10

NEWICD-10 DEADLINE:

OCT 1, 2014


HIS ARTICLE WILL PROVIDErisk management strategies to helpphysicians and practice staff:� Better work with those patients who

seem difficult� Minimize the risk of liability represented

by patients who persist in the behaviorthat earns them the label “difficult”

“Difficult” patients exist in everyclinical setting. These patients may rangefrom those who are noncompliant withtheir healthcare provider’s orders oradvice to those who exhibit abusivebehaviors. Approximately two-thirds ofdifficult patients are noncompliant.Communication issues may beresponsible for the behaviors of somenoncompliant patients, while otherpatients are noncompliant by choice.

Noncompliance Due toCommunication IssuesThe first step in addressing noncomplianceis to identify its potential causes anddevelop strategies to improve patientunderstanding and adherence. A partiallist of causes and strategies forimprovement follows:

The patient forgot the verbal instructions.> The provider should provide written

instructions, presented in easy-to-follow steps and written with minimalwords in simple lay terms with oralinstructions.

The patient finds a drug or treatmentregimen too complex.> Include the patient in the treatment

regimen, reviewing all medicationsprescribed by all providers.

> Consider a pharmacy consultation towork out a realistic schedule forpatients with multiple medications.

The patient is angry or depressedabout the chronic condition that

necessitates treatment.> The provider needs to determine the

level of the patient’s understanding ofhis/her problem or disease and thepatient’s goals.

> The provider should considerresources to provide ongoing supportand shared community for patientswith chronic diseases.

The common thread in dealing withpatients who are not noncompliant bychoice is the need to communicate clearlyand frequently regarding the purpose,goals and alternatives for treatment andmedications. Some patients may notunderstand their behavior as noncompliant.Specifically naming their behavior maybring understanding – to both sides.

Noncompliance by ChoicePatients who are noncompliant by choicemay fall into one of the categoriesdescribed below. Potential strategies fordealing with each situation are included.

The patient threatens to sue, “go to thepapers” or go online with complaintswhen his/her wishes are denied.> The provider should not allow the

patient to intimidate or manipulate himor her, nor should he or she succumb tothreats or respond in anger.

> Doing and documenting what ismedically justified can be argued farmore successfully in a malpractice casethan giving into a patient whosedemands are unrealistic and may bebased on questionable websiteinformation.

The patient does not pay his/her bill,even with reminders when appointmentsare scheduled.> Billing practices should be posted in a

visible place and patients should beinformed of the billing and paymentpolicies at their first visit.

> A payment schedule workable for thepatient should be developed.

> Consideration needs to be given toterminating the professionalrelationship with the patient who is achronic or persistent non-payer.

> Until that step is taken, thepractitioner needs to continue to seethe patient. Medicine takesprecedence until the patient has beenformally terminated from the practice.

The patient becomes verbally orphysically abusive when informed thatthe provider is running late due to anemergency or will not give him/herwhat he/she wants.> The practice needs to develop and

maintain a policy addressingmanagement of the patient whoexhibits violent behavior in the office.The policy should include steps up toand including isolating the individualto prevent injury to self and others.

> The staff should try to calm thepatient.

> Police should be summoned if apatient becomes physically violent ordemonstrates threatening behavior.

Difficult patients often are both afrustration and a challenge. Terminationof the professional relationship should notbe the first response to these individuals.Rather the “difficult” behavior needs tobe identified and addressed with thepatient. However, if efforts areunsuccessful, physicians have the right topractice in a safe environment, to havetheir professional ability valued and tohave themselves, their schedules andtheir staff respected. When those rightsare violated or irretrievably compromisedby the patient’s actions or inactions,termination of the professionalrelationship may be a viable option.Tara R. Gibson, CPCU, RPLU is vice president of

Risk Management, Coverys www.coverys.com

Compliance

By Tara R. Gibson

TDealing with Difficult Patients

CardiovascularUpdate


BY LINDA HARDER

PHOTOGRAPHY BY TRACEY BROWN

Clopidogrel is Ineffective for 30% of PatientsIn the process of helping to develop ticagrelor (Brilinta,Astra Zeneca), an oral antiplatelet medication that rivalsclopidogrel bisulfate (Plavix, Sanofi, Bristol Myers Squibb),Paul A. Gurbel, M.D., director of the Sinai Center forThrombosis Research at Sinai Hospital of Baltimore haslearned just how long it can take to go from bench researchto FDA approval of a new antiplatelet drug.

He began studying mechanisms of thrombosis whilea cardiology fellow at Duke University in 1987. In thelate 1990’s, his lab at Sinai Hospital discovered thepharmacodynamic limitations of clopidogrel when studyingits effects on patients undergoing stenting. Thisgroundbreaking research provided a major rationale forthe development of antiplatelet agents with a more rapid,predictable and potent pharmacodynamic effect. Theseminal observations of response variability and resistanceto clopidogrel, the most widely used antiplatelet agentof its type worldwide, initiated the field of personalizedantiplatelet therapy.

Although approved one year earlier in 28 countries,it took until July 2011 for the FDA to finally approveticagrelor. Dr. Gurbel and his research team led the designand conduction of international pharmacodynamic andpharmacogenetic studies of ticagrelor that started in 2006.The data gathered from these studies demonstrated thesuperiority of ticagrelor’s antiplatelet effect as compared toclopidogrel. This key laboratory information was submittedto the FDA and other regulatory agencies around the worldand was influential in the decision to approve ticagrelor forthe treatment of patients with acute coronary syndromes.These data are now in the labeling of Brilinta.

More Tailored TreatmentsW

Maryland Physicianinterviewed threecardiovascular specialistsfor the latest updates inantiplatelet medications,deep vein thrombosisand heart disease inwomen. In each case,patients benefit frommedicine’s betterunderstanding ofindividual responsesto therapies.


Paul A. Gurbel, M.D., director of the Sinai Center forThrombosis Research at Sinai Hospital of Baltimore


“This proceduresignificantlydecreases themorbidity ofpost thromboliticsyndrome.”

– Justin Nelms, M.D.

Justin K. Nelms, M.D., vascular surgeonat Baltimore Washington Medical Center

Clopidogrel’s LimitationsClopidogrel is an inactive pro-drug thatrequires hepatic bioactivation via variousenzymes, including cytochrome P450(CYP)2C19. Therapy with clopidogrelreduces the likelihood of coronary arterythrombosis by specifically inhibiting theplatelet ADP receptor, P2Y12.

However, a large proportion of thepopulation (~25% of those of Europeanancestry, ~30% of African ancestry and~50% of East Asian ancestry) has a variantof the CYP2C19 gene, termed a “loss-of-function allele” that results in non-functional gene product. These patientsmay therefore less effectively metabolizeclopidogrel. Dr. Gurbel and his team firstreported the relation of genotype toclopidogrel’s pharmacodynamic effect in aPCI (percutaneous coronary intervention)population. The FDA has now written aboxed warning regarding the influenceof genotype on clopidogrel metabolism.

Dr. Gurbel recommends that, in high-risk patients undergoing stenting who aretreated with clopidogrel, strong considerationbe given to assuring that an adequateantiplatelet effect is present by testingplatelet function. He says, “We call this,

‘personalizing therapy.’ If the effect is notdesirable, then the patient can be switchedto a new, more expensive and more pharm-acodynamically potent and predictableagent such as ticagrelor or prasugrel.”

These recommendations forpersonalizing antiplatelet therapy are nowaddressed in American and Europeancardiology treatment guidelines. “Giventhat clopidogrel is one of the most commonlyprescribed medications for patients withvascular disease, and that it became ageneric drug in 2012, it is important forclinicians to identify those who shouldreceive the more costly alternativetreatments,” Dr. Gurbel remarks.

Finally, Dr. Gurbel emphasizes that,“Clopidogrel is pharmacodynamicallyeffective in about two thirds of patientsundergoing PCI; these patients do nothave high platelet reactivity (HPR).Ischemic risk is much greater in patientswith HPR. Therefore, selectively treatingtwo thirds of patients with genericclopidogrel may provide significant costsavings. Unselected therapy with the newP2Y12 receptor blockers is associated withincreased bleeding. We believe thatclinicians should strive to find the

antiplatelet therapy that achieves theoptimal level of platelet inhibition for thepatient, regardless of cost. If genericclopidogrel is indeed pharmacodynamicallyeffective in the patient, offering themthis less expensive option appears to bea win/win scenario.”

The FutureDr. Gurbel and his team are involved inmany more studies. They are planninga large multicenter internationalinvestigation of personalized antiplatelettherapy in high-risk patients undergoingcoronary artery stenting. They are currentlyinvestigating the antiplatelet effects ofHDL by intravenously administeringpurified HDL to patients with coronaryartery disease. Another investigationinvolves the first administration in humansof a novel intravenous antiplatelet agentthat blocks the ability of thrombin toactivate platelets.

Studying the effectiveness ofticagrelor in other patient populations isalso underway. In July 2012, AstraZenecaannounced that it plans to conductEUCLID, a new global clinical trial ofticagrelor that will compare its efficacyto that of clopidogrel in reducingcardiovascular deaths, myocardialinfarction or ischemic strokes in patientswith peripheral arterial disease.

New Treatment for AcuteIliofemoral DVTDeep vein thrombosis (DVT) affects350,000 to 600,000 Americans (half ofthem women) each year, and theseconditions may contribute to 100,000deaths every year. Even when physicianscan restore blood flow around the lowerextremity clot, about half of patientsshow residual evidence of thrombus orstenosis one year later and the underlyingvalves are typically compromised.Patients with significant DVT are likelyto experience post-thrombotic syndrome,a disorder characterized by lowerextremity swelling, discomfort, eczema,pruritis, ulceration and cellulitis, venousstasis, venous reflux, and chronic edema.

Justin K. Nelms, M.D., a vascularsurgeon at Baltimore Washington MedicalCenter (BWMC), has introducedpercutaneous mechanical thrombectomyand thrombolysis, the newest treatmentfor acute iliofemoral DVT, to the hospital.

“This procedure significantlydecreases the morbidity of post

thrombolitic syndrome,” states Dr.Nelms. “However, it’s not indicated forfemoral or popliteal DVT, only casesinvolving the iliofemoral veins.” Itsgreatest benefit is in situations whereextensive thrombus burden is present.These tend to be DVTs that involvethe iliac and femoral veins.

A committee of vascular experts,under the direction of the Society forVascular Surgery and the AmericanVenous Forum, developed evidence-based practice guidelines for earlythrombus removal strategies. Theyrecommend pharmaco-mechanicalstrategies over catheter-directedpharmacologic thrombolysis alone ina first episode of iliofemoral DVT ofless than 14 days in duration, especiallyin patients with limb-threateningischemia due to iliofemoral venousoutflow obstruction.

Percutaneous MechanicalThrombectomy DescriptionDr. Nelms describes the procedure,“We introduce a catheter through thegroin to the thrombus. A thrombolyticagent (diluted tissue plasminogenactivator) is infused directly into thethrombus, softening it to facilitate itsremoval. We then use high-speed waterjets in the catheter to create a vacuumthat sucks in the thrombus, breaking itinto minute fragments that are evacuatedback through the catheter.”

He continues, “The procedure isperformed in the endovascular suite andmost patients have an overnight hospitalstay. Intravenous ultrasound can be usedto display the venous interior and crosssections in real time. With this technology,we can assess the adequacy of ourintervention as well as identify any areasof narrowing. If the patient is found tohave an underlying stenosis, angioplastyand possibly a stent may also be used.”

Percutaneous mechanical thrombectomyhas a number of benefits, including:� Rapid removal of the thrombus with

restoration of blood flow� Faster symptom resolution� Shorter procedure time, shorter hospital

stays and subsequent cost savings

In a small fraction of patients, theprocedure may cause bleeding or resultin hemolysis that damages the kidneys.

Dr. Nelms notes, “Patients also

receive thrombolytic therapy tofacilitate removal of the thrombus andpreserve venous valve function. Themain utility of percutaneous mechanicalthrombectomy and thrombolysis lies inits ability to decrease the incidence andseverity of post-thrombotic syndrome.”

Refer Patients with IliofemoralDVT Early“All patients with acute, symptomaticiliofemoral DVT who present to the ERshould be referred to a vascular surgeonfor evaluation,” Dr. Nelms advises.“The fresher the clot, the more likely thethrombolysis is to be effective. Within oneweek of symptom onset is ideal, thoughI advocate the procedure up to fourweeks post event. A venous duplex studyremains the gold standard for diagnosis.

“Many practitioners may not realizethat you can or should do thrombolysisfor this type of DVT,” concludes Dr.Nelms. “Percutaneous mechanicalthrombectomy and thrombolysis hasgained wide acceptance in academiccenters and increasingly is available incommunity hospitals.”

Women’s Heart Disease:Shifting to PreventionIt’s still apparently a challenge for womenand even some physicians to grasp thatcardiovascular (CV) disease, not cancer,is the number one killer of women.“Women should start thinking about CVdisease in their 30s or 40s, when they canstill prevent it,” says Shannon J. Winakur,M.D., cardiologist and medical directorof the Women’s Heart Center at SaintAgnes Hospital.

“Age and family history are the onlyrisk factors you can’t change,” she claims.“Yet, many women are not taking timeto care for themselves or go to the doctoruntil they’re sick. Further, manypractitioners still don’t take a familyhistory of heart disease as seriously forwomen as for men.”

Dr. Winakur’s advice is underscoredby data pooled from five studies thatwere presented at the American HeartAssociation Scientific Sessions inNovember 2012, indicating that healthyhabits in middle age can extend longevityby as much as a decade.

Her comments are also supported bythe preliminary results of a new Europeanstudy presented as an abstract at the 2012Acute Cardiac Care Congress meeting in


Turkey. The study found that, comparedwith men, women with ST-elevationmyocardial infarction (MI) had a longerdelay in calling for medical assistance andreceiving reperfusion once at the hospital;perhaps as a result, they were more thantwice as likely to die of MI (9% vs. 4.4%of men).

Women: Know Your NumbersDr. Winakur stresses that, “Women needto make sure they know their numbers.At our center, we offer a 60-minutescreening with our certified cardio-vascular nurse for $60. Women receive ablood pressure screening, BMI, an EKGand blood work that includes a lipidprofile and hemoglobin A1c. Theseresults, combined with responses to aquestionnaire, create a personalized riskfactor profile. Depending on the results,we then educate each woman about hercardiac risk factors and make personalizeddiet, exercise and smoking cessationrecommendations as appropriate. Wealso make referrals for a full cardiologyconsultation if needed.

“This service supplements what aprimary care physician can do,” shecontinues. “Being a primary carephysician these days is so difficult –you have to do everything in 10 minutes.We’re here to help them.”

It’s especially critical that womenstop smoking as early as possible. Arecent prospective study of more thanone million women in the UK, published

online in The Lancet, showed thatwomen who smoke triple their risk ofearly death and that smoking cessation inmiddle age can largely reverse that risk.

Dr. Winakur states, “Other CV riskfactors include autoimmune diseases,radiation therapy and other cancertreatments. Survivors of childhoodcancers need to be monitored throughouttheir lives because they’re at highercardiovascular risk. Physical and sexualabuse survivors are also at greater riskof heart disease.

“I would love to see more women forcardiac prevention, before treatment ofan event,” she adds. “I want to empowerwomen to take control. Patients aresometimes sheepish – they worry thatit might be a false alarm, but it’s nevera waste of time to get checked out.”

The issue of different symptompresentation continues to stymie promptattention to possible cardiac disease inwomen. According to Dr. Winakur,“Fatigue and shortness of breath arecommon symptoms. Of course, thewoman’s physician needs to rule outthyroid disease, anemia and other causesof fatigue.”

Staying abreast of current researchrequires vigilance. Dr. Winakur notesthat, “A new look at the EPIC trialsuggests that dietary calcium is betterthan taking calcium supplements, whichcorrelated with a doubling of MI riskin a study of 24,000 German women.Newer hormone replacement data alsosuggests that taking lower doses of HRTwhen women are in their 50s, closer tothe onset of menopause, does notincrease the risk of death and MI, and insome cases may lower the risk. Thisreinforces the importance of consideringindividual patient history whenprescribing treatment.”

“My hope is that we can be assuccessful at increasing awareness ofheart disease in women as Komen hasbeen in getting attention to breastcancer,” she concludes.


Paul A. Gurbel, M.D., director of the

Sinai Center for Thrombosis Research at

Sinai Hospital of Baltimore

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at Baltimore Washington Medical Center

Shannon J. Winakur, M.D., cardiologist

and medical director of the Women’s

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Shannon J. Winakur, M.D., medical director ofthe Women’s Heart Center at Saint Agnes Hospital.


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THE STATE OF

IN MARYLAND

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

of medicine at Johns Hopkins Bayview Medical Center,

PROGRESS AND PROMISE:

STEM CELLRESEARCH

espite initial setbacks inembryonic stem cell research under theBush Administration, stem cell research isforging ahead with an emphasis on stemcells derived from adults. Maryland isfortunate to have the Maryland Stem CellResearch Fund (MSCRF), created in2006 by the state legislature to overseethe funding of stem cell research projectsin the state. The Fund has provided over$91 million for 258 research grants in itsfirst six years. Much, though by no meansall, of the stem cell research in Marylandcenters around researchers at JohnsHopkins University School of Medicineand University of Maryland MedicalCenter (UMMC).

Dan Gincel, Ph.D., executive directorof the Maryland Stem Cell ResearchFoundation, says, “We use a competitiveprocess – the best science wins. Proposalsare submitted and evaluated once eachyear and we can typically fund 10 to 20%of the applications we receive. We’reunique; very few states have dedicatedstem cell funding mechanisms. We’re alsoworking in collaboration with researchersfrom California and elsewhere to leverageour funding and prevent duplication of

efforts. That lets us get research resultsto the market faster.”

Stem Cell CategorizationMany different types of stem cells areunder investigation for clinical use,including:� Embryonic – a small portion of what

is funded� Adult mesenchymal stem cells

(MSCs) – adult stem cells isolatedfrom bone marrow, adipose tissue, orblood that can generate bone, cartilage,fat, cells that support the formation ofblood, and fibrous connective tissue

� Hematopoietic stem cells – adultstem cells that can give rise to bloodcell types

� Induced pluripotent stem cells (iPS) –adult skin cells or, more recently, bloodcells, that are reprogrammed to a statesimilar to that of embryonic stem cells

Drug DevelopmentOne of the areas of great promise for stemcells is to permit testing of drugs onhuman cells in a laboratory setting. Thisis especially helpful for diseases whereanimal testing yields poorer results.


BY LINDA HARDER


THE NATION’S FACTORY OF ALS STEM CELLSJeffrey Rothstein, M.D., director for the Brain Science Institute at Johns Hopkins, is a patient man. A researcher at Hopkins for the past

27 years, he’s worked on understanding glial cell functions and how they affect disorders such as Amyotrophic Lateral Sclerosis (ALS) for

decades. He comments, “Some of the latest research involves stem cells. In the 1980s, gene therapy was heralded as the future. But it

takes a long time to develop biologics. What we know today is very rudimentary. We started in 2000 and thought it would take a few years

to develop treatments. But it takes 13 to 15 years to get to FDA approval even when the steps for a new drug are known, and costs more

than $1 billion. And for every 13 drugs that make it to the FDA, only one exits successfully.”

Dr. Rothstein continues, “In most neurological diseases, when brain cells die they are lost for life. It’s challenging to get cells back into

the neurologic system and have them function. Pluripotent cells can be differentiated to become brain cells, creating an ideal tool to study

potential drugs for ALS. It’s hard to replicate the ALS defect in mice, so having stem cells is exciting. Using them may or may not be faster

but it’s a potentially more accurate approach.

“Our ALS clinic sees about 350 patients per year,” he comments. “We make the nation’s factory of ALS stem cells from skin biopsies of

our ALS patients. We now have 40 different stem cell lines; we can preview the effect of drugs in the dish, and then cull them down to

the ones that work best in humans. Using iPS cells not only bypasses ethical problems but is better than using embryonic stem cells.”

D

Curt I. Civin, M.D., director, Center for Stem CellBiology and Regenerative Medicine, Universityof Maryland Medical Center


Dr. Gincel notes, “We’re using stemcells for drug discovery, to provide agreater effect with fewer side effects. It’sa great tool for treating diseases such asALS, Parkinson’s and Gaucher’s disease.Dr. Ricardo Feldman at UMMC is usingdisease-specific human embryonic stemcells to model and treat Gaucher'sdisease. The controlled differentiation ofiPS cells can provide an unlimited supplyof patient-specific cells for diseasemodeling and drug discovery. The endgoal is to repair the genetic defect of theGaucher-specific iPS cells and engraftrepaired autologous hemangioblasts tocure the disease.

“Drug companies are now using stemcells to screen drugs – looking for the one

effect on the cell that doesn’t exist in ourbody,” he continues. “With iPS, you canreproduce a cell into the millions so thatyou have an unlimited supply.”

At UMMC, for example, Aaron P.Rapoport, M.D., is addressing the higherincidence of cancer following a bonemarrow transplant by working onimmunization strategies. His work examineshow T cells can be re-engineered torecognize and reject the cancer cells thatcause diseases such as leukemia.

Curt I. Civin, M.D., director, Centerfor Stem Cell Biology and RegenerativeMedicine at UMMC, says, “Some stemcells are beginning to reach the clinical trialstage. We’ve used our stem cell research toreverse the usual proliferation of cancer

cells and instead shut them down. We havenew leukemia drugs moving to clinical trialthat inhibit growth. That’s quicker thantransplanting the cells themselves.”

Burns and Wound HealingStem cells are also currently used topromote tissue repair and regenerationfor patients with burns or non-healingwounds. Using an extracellular matrixpatch containing mesenchymal stem cellsthat secrete various factors to promotehealing has been shown to increase cellsurvival and proliferation and reducescarring. “Mesenchymal cells are like asmall factory that slowly and continuouslyrelease these factors,” Dr. Gincel states.

Cell-based TherapiesResearchers hope to use stem cells as arenewable resource to replace damagedcells in diseases ranging from heartdisease to diabetes, rheumatoid arthritis,dementia and spinal cord injury.

“Cardiac stem cell transplants areFDA-approved but not quite in clinicaluse yet,” says Dr. Civin. “Sunjay Kaushal,M.D., Ph.D., a pediatric cardiac surgeon

Dan Gincel, Ph.D., executive director of theMaryland Stem Cell Research Foundation

TISSUE REPAIR: REGENERATING HEART MUSCLEGary Gerstenblith, M.D., cardiologist and Professor of Medicine, and Peter Johnston, M.D., interventional cardiologist and Assistant

Professor of Medicine, both in the Division of Cardiology at Johns Hopkins University School of Medicine, have extensively researched

the regeneration of heart muscle tissue in patients with left ventricular dysfunction (LVD) following a myocardial infarct (MI). After working

on this issue for nearly a decade, they recently published two studies with promising results.

Dr. Gerstenblith notes, “Our goal is to regenerate heart muscle and restore function. Current therapies are helpful in addressing

symptoms but don’t address the underlying cause.”

The CADUCEUS trial, published in the March 10, 2012 issue of The Lancet, (in collaboration with the Cedars Sinai Medical Center in

Los Angeles, CA) extracted heart tissue from patients with this disease and re-implanted the autologous stem cells 6 to 12 weeks later.

The POSEIDON trial, published in the Journal of the American Medical Association on November 6, 2012 (in collaboration with the

Miller School of Medicine in Miami, FL), compared the safety and efficacy of using mesenchymal stem cells (MSCs) from patients with LVD

with MSCs from healthy donors. “This small pilot study showed that both healthy allogeneic cells and autologous cells are safe and benefi-

cial in patients with chronic LVD,” says Dr. Gerstenblith. “The cells were effective even though most of these patients had had heart failure

for 10 years or longer.” In fact, injection of MSC generally improved patients’ functional capacity, quality of life, and ventricular remodeling.

Future research will explore the mechanisms to the beneficial effects of stem cell therapy for patients with heart disease, what type of

cell is best and how to optimize cardiac regeneration.

Dr. Johnston adds, “The ability to use allogeneic stem cells will make it possible to have nearly on-demand/off the shelf availability of

cell therapy for the heart, which will be considerably more efficient from a cost and time standpoint compared to autologous cells. The op-

timal time for cell delivery after a heart attack has yet to be determined – that’s a topic being actively researched.”

We’ve used our stemcell research to reversethe usual proliferationof cancer cells and in-stead shut them down.– Curt Civin, M.D.


Curt I. Civin, M.D., director, Center for

Stem Cell Biology and Regenerative

Medicine, University of Maryland

Medical Center

Dan Gincel, Ph.D., executive director,

Maryland Stem Cell Research Fund and

VP, University Partnerships, TEDCO

Jeffrey D. Rothstein, M.D., Ph.D., John

W. Griffin Director for the Brain Science

Institute; professor of Neurology and

Neuroscience, and the founding

director of the Robert Packard Center

for ALS Research at Johns Hopkins

University School of Medicine.

Gary Gerstenblith, M.D, Professor of

Medicine, Division of Cardiology,

cardiologist, and Peter Johnston, M.D.,

Assistant Professor of Medicine, Division

of Cardiology, interventional

cardiologist, Johns Hopkins University

School of Medicine.

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at UMMC, is addressing hypoplastic leftheart syndrome in infants by extractingpieces of the right atrial appendage that isremoved in the first surgical procedure.They are loaded with cardiac stem cells;we grow them in the lab and inject themback into the infant’s heart in asubsequent procedure. That avoidsmultiple surgeries.”

In the lab setting, Hopkinsresearchers have used a patient’s stemcells to correct the genetic defect thatcauses sickle-cell disease. However, moretime is needed to translate this work topatient care. Dr. Gincel notes, “In thenear future, we’ll be able to use stem cellsto treat this and other blood disorders. Wealso hope researchers will create a geneticmutation that will prevent the HIVreceptor CCR5 against HIV-1 acquisition.Treating neurodegenerative and otherdegenerative diseases is farther away,because it will take years to grow cellsafter severe damage is already done.”

Dr. Gincel views stem cells as thefourth ‘pillar’ of healthcare, behindpharmaceuticals, medical devices andbiotech development. He predicts, “Inthe future, we’ll have stem cell therapiesthat provide a permanent fix, not justmanagement of a disease.”

Dr. Civin concludes, “Thecombination of genomics and stem celltherapies will be very powerful. Whena child is born, he or she will getinformation about their entire DNAsequence to predict genetically baseddiseases. Stem cell therapies will be ableto do something about it.”

Healthcare IT

PPrrootteeccttiinngg PPaattiieenntt DDaattaa


BY LINDA HARDER


Mike Fierro, principal of Dynamed Solutions

IN A DIGITAL AGE


security without knowing what the totalbudget will be over time,” SteveRutkovitz, CEO, Choice Technologies,states. ‘We help them to see down the road so they’re not faced with surpriseafter surprise.”

Security solutions vary significantly in cost and scope, but mid-size practicesmight expect to spend $2,500 to $10,000for auditing, documentation andimplementation.

As a starting point, practices canconsider hiring a professional IT firm toconduct a security audit. This audit shouldinclude an assessment of your trainingpolicies for staff and the security of yourhardware and software. The audit maytake one or more days to complete.

Mr. Rutkovitz describes the typicalprocess, “The first thing we do is an auditof everything, asking everything from ‘how is the data stored and backed up, is there remote access, to where is the fire extinguisher kept?’ We look at itholistically. Then, we provide an analysisreport that identifies the risks and securitygaps so that we can work with the practiceto address them with different options.”

Role-Based User AccessMike Fierro, principal of DynamedSolutions, contributes, “When we workwith a physician’s office, we first have thepractice determine which staff should haveaccess to what information. For example,

With Meaningful Use incentives as a carrot, many physiciansare successfully converting their patient records from paper todigital format. However, even the most ambitious and forward-thinking practices may not be paying sufficient attention to acritical area: the privacy and security of that patient data in adigitized age. Maryland Physician spoke with some local ITvendors who have helped physician practices protect their dataonsite and off. Here’s their advice.

Expanded Fees and ThreatsIn addition to the cost of lost business,the potential cost of a data breach hasgrown significantly under the HITECH(Health Information Technology forEconomic and Clinical Health) Act of2009, part of the American Recovery and Reinvestment Act (ARRA). This act modified existing HIPAArequirements, with most changes takingeffect in early 2010.

Under HITECH, the penalties forpatient data violations have increasedsignificantly, from a prior cap of $25,000per year to a cap of $1.5 million for theworst privacy breaches. State attorneysgeneral can now enforce the law. Andbusiness associates are now also liable for securing patient data. Should a breachoccur where data is not encrypted,practices and affected business associatesmust notify affected patients within 60 days of the date of discovery.

With the ready transmission of digitaldata, practices must be prepared to protecttheir data far beyond the limits of theiroffices. And threats can come frommultiple fronts – everything from adisgruntled employee to inaccurate dataentry to an anonymous hacker.

Undertake a Security Audit and Implement a Plan“Physicians need to be proactive aboutprotecting their data. They often get into

>>

the front desk staff may only need access to scheduling information, while a nurse or other clinician may needclinical information access. Manypractices initially think that all staff needsaccess to everything, but that’s often notthe case. Front desk staff may need toknow that lab results came in, but theyprobably shouldn’t be able to access theactual results. That’s called role-baseduser access.”

Mr. Fierro also encourages practicesto consider who needs ‘read only’ access versus who can edit/enter newinformation in the patient record. “Oncethe roles are established, we incorporatethat into the EMR training. It’s notuncommon for roles to change over time,as we always try to maintain a balancebetween security and efficient workflow,”he notes.

Compliance policies should alsodescribe formal sanctions againstemployees who fail to comply withsecurity policies and procedures.

Wisely Select an ITProvider/AdvisorWhile you can rely on your IT providerfor assistance, ask some basic questions toensure that they are providing sufficientoversight and are adequately certified.“Ask your firm what certification theyhave,” Mr. Rutkovitz recommends. “The highest certification level is theCompTIA [Computing TechnologyIndustry Association] SecurityTrustmark™, which identifies businessesthat follow security best practices. Theyare the gold standard; it takes more than a year to qualify.”

Data EncryptionWhile HITECH surprisingly did notmandate data encryption, it’s critical thatmedical practices encrypt any data that is being electronically transmitted.Encryption keys cannot be stored on thesame device as the protected data. Dataencryption must be validated and shouldmeet Federal Information ProcessingStandards 140-2 issued by the NationalInstitute of Standards and Technology(NIST).

Managing Mobile Devices: BYOD?The challenge has expanded to includeenabling, securing, and managingdevices, apps, and data outside the

firewall and in the cloud when theycontain sensitive patient data. Whenusing a mobile device for generalreference data, such as to look up a drug,these guidelines don’t apply.

Pat Cooley, president and CEO,RelianceNet, observes, “Securing yourconnections between offices, desktopsand notebooks is no longer enough.Mobile and cloud services open up newareas that require a comprehensive andproactively managed security approach.Even practices that have internal ITsupport seem to be slow in responding toprotect this critical area appropriately.Practices with no internal IT shouldconsider engaging a managed servicesprovider who can provide the expertisethat is needed on a flat-rate, predictablemonthly cost.

Mr. Cooley continues, “Mobiledevice use is one of the fastest growingtrends and it’s expected to continue togrow stronger.” He recommends:

� Security for patient data has toconsider all devices used to access andstore patient data, including mobiledevices (smartphones, tablets, etc.).

� Patient information on a mobile phonecan put the practice at risk of HIPAAviolations. Mobile devices must besecure and password-protected if theyhave access to any patient data.

� Have a plan based on the devices youchoose to support and a policy thatclearly defines whether the practice willprotect and support only practice-owneddevices or if it will also allow and protectBYOD (Bring Your Own Device).

Broader Patient AuthorizationMr. Fierro recommends that patientauthorization forms be written generallyenough to cover devices that yourpractice may use in the future to connectwith patients. For example, if yourcurrent approach uses phone calls toremind patients about appointments ormedications, but future approaches mightinvolve text messaging or email follow-up, make sure your patient authorizationform is sufficiently broad to cover thesefuture approaches.

Care Coordination/Interfacingwith Other ProvidersAnother newer risk facing medicalproviders is that interfacing with other


Healthcare IT

PATIENT HEALTH INFORMATION SECURITY CHECKLIST

> Determine role-based privileges and

log-on/password requirements

> Establish physical and logical access

controls

> Develop sanctions for intentional

unauthorized access to PHI

> Establish automatic timeouts for all

applications

> Secure network and application

servers

> Secure and log backup medium and

medium re-use

> Develop an incident response plan

> Create rules for securing PHI in

portable devices or sending secure

messages, including data encryption,

archiving, and deletion

> Annual review of all business

associates’ agreements and

compliance

> Perform a security risk analysis

> Establish rules to prevent download

of malicious software


providers through a Health InformationExchange (HIE) or Patient CenteredMedical Home (PCMH) requires logginginto a separate system that is not trulyintegrated with your own. To avoidprivacy issues, many systems use alertsthat merely inform physicians that newinformation is available without divulgingany PHI.

In Maryland, for example,Chesapeake Regional InformationSystem for our Patients (CRISP) hasinitiated a service that allows physiciansto "subscribe" to patient informationalerts for patients under their coordinatedcare. Whenever a patient has a healthcareencounter that CRISP knows about, analert is sent to the physician that there is new information about that patientavailable in the secure portal. No actualpersonal health information is sent withthe alert; physicians receive only areminder to login and check the updatedrecord. As of November 2012, CRISPhad eight organizations that were live,with 210,000 patients subscribed,covering 471 doctors and sending about175 alerts a day.

While new legislation has made itincumbent on practices to be moreguarded when obtaining, storing andtransmitting patient data, the key is tofind a balance between protecting dataand allowing appropriate access. “Becautious but don’t restrict access so muchthat you diminish patient care,” cautionsMr. Fierro.

Steve Rutkovitz, CEO, Choice

Technologies

Mike Fierro, principal, Dynamed

Solutions

Pat Cooley, president and CEO,

RelianceNet

Pat Cooley, president and CEO, RelianceNet

5 KEYS TO A MOBILE DEVICE MANAGEMENT STRATEGY User and App Access: identify and validate the people, apps, and devices that are

connecting and accessing business assets

App and Data Protection: Both apps and data must have controls and protection

appropriate to the company and industry.

Device Management: establish policies to manage and secure appropriate mobile

devices as well as PCs and other office-based devices

Threat Protection: Good threat protection should protect mobile devices from external

attacks, rogue apps, unsafe browsing, theft, and even poor battery use.

Secure File Sharing: Businesses should have full administrative control over distribution

of, and access to, business documents on any network, especially in the cloud.

Adapted from Symantec information

elray Beach, Florida isknown for its eclectic varietyof activities. I’d heard greatthings about it so whilelooking for an easy-to-get-to

sunny destination, I decided it was timeto go. Despite waiting out HurricaneSandy, it was a perfect choice! The waveswere incredible to witness and brought in some crazy sailboarders I had theopportunity to watch.

(Lots of) Stuff to Do.Beachgoers and golfers will stumble intomore than enough local spots to stayhappy. Funky boutiques line the streetsand practically guarantee a treasure findsits way into your carry-on. Music and artsdevotees will want to make it a priority tospend some time at Delray’s famous “ArtsGarage,”presenting live performances,foreign and documentary films. Ifrelaxation is of utmost importance on yourtrip, a visit to the DU20 Holistic Oasis is amust-do. Treat yourself to a medicinal tea,

followed by an acupuncture treatment to relive stress, or spend some time in afloat-meditation tank, designed to allowthe body to achieve pure relaxation byresetting hormonal and metabolic balance,through floating.

Good Eats.There is no shortage of options when itcomes to finding good eats in Delray.From tiki style bars to fine dining hotspots that share the posh trends fromMiami and nearby Palm Beach, therestaurants alone are reason enough totravel here. Put The Green Owl on yourtravel itinerary as a great “locals” spot andmust-do for an out of this world breakfast.As your day rolls on and it’s time for aspot to kick back and relax with happyhour cocktails in the sand, stop intoSandbar at Boston’s on the Beach. For anupscale dining experience, check out Salt7, Delray’s newest hot spot, serving steak,sushi and a wide variety of raw baroptions, or 50 Ocean, with floor-to-ceiling

windows that treat diners to amazingviews of the Atlantic Ocean. My personalfavorite was Brule Bistro, which started asa local market and has evolved over theyears to offer classic, French influenced,modern, American cuisine. It was freshand unique. A mojito inspired tequila-based cocktail served up with a flamingsprig of rosemary was memorable.

Stay and Sleep.There are an abundance of choices forwhere to stay during your time in DelrayBeach. While the Colony Hotel &Cabana Club on Atlantic Avenue is ahistoric hotel with a Caribbean vibe,travelers with more of a traditional tastemay want to make reservations at theSeagate Hotel and Spa or the Marriott. I opted for new and hip with the HyattPlace Delray Beach. Located in thePineapple Grove Arts District and withinwalking distance to the shops, dining andentertainment of Atlantic Avenue, theHyatt Place Delray Beach is asconvenient as it is beautiful.Complimentary breakfast was an addedbonus, as well as the rooftop pool and hottub, which I made good use of betweenafternoons of local boutique shopping andevenings out on the town. Staying at theHyatt made it easy to take in thePineapple Grove nightlife. Win, win!

Pick Up and Go.I was told that Delray is the kind of place for hard chargers looking for a townwhere flip flops and cutoffs are theuniform for just about everywhere. Mykind of place! A straight-shot, 20-minutedrive from the West Palm Beach airport,it is easy to get to and can make for aperfect getaway to refocus, recharge orsimply relax. For further information, alisting of upcoming events that arehappening in town, and tips for planningyour trip to the Delray Beach area, visitwww.downtowndelraybeach.com.


Living

Live a Little...Visit Delray Beach, Florida By Jacquie Roth

The Pineapple Grove Arts District of Delray Beach offers an eclectic mix of boutiques, galleries,cafes and spas. Public artwork and working artists are open for visitors throughout the district.

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Clinical FeaturesMaryland Physician focuses on the latest cancer

developments. We talk with top Maryland specialists to

get their take on the effectiveness of the latest treatments

for prostate, breast and blood cancers.

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facet of the race to implement EHRs to meet Meaningful

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

left behind – read what Maryland physicians and health-

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

to an electronic world.

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Solutions

Create a “WOW” Experiencefor Your Patients

By Nancy R. Smit

EDICAL PRACTICEShistorically have been slow to embracethe “customer first” mentality thatdefines corporate America. Despite the fact that patients who are treatedwith kindness and respect are more loyal and much more likely to refer their friends, far too many patientsexperience a “cranky receptionist” or“poor bedside manner” when they visit their doctor’s office.

Now, more than ever, customerservice and patient satisfaction need tobe top priorities for your practice. Underthe Affordable Care Act (ACA), one offive key measures that will be directlytied to Medicare reimbursement is the“patient/caregiver experience of care.”With greater transparency and use ofsocial media, online customer serviceratings and comments can either drivepatients to the practice or drive themaway. But perhaps one of the mostsignificant benefits of a positive patientexperience is the legal buffer it provides.Statistics show that the single biggestsource of malpractice suits is the lack of a positive relationship betweenpatient and provider.

Exceptional customer service meansexceeding your patients’ expectationsany time they make contact with yourpractice. According to Dr. Neil Baum, a urologist and leading expert on medicalmarketing, “if you create and maintain a ‘WOW’ experience for your patients,you will build an army of loyalsupporters who will continually tellothers about your practice.” Everyperson that comes into contact with your practice forms an impression thatthey will share with others, not just

your patients. High-level customerservice must extend to your referralsources, hospital staff andrepresentatives and the community.How can you create a “WOW”experience for your patients?

STEP 1 - Create a positive and dynamic work environment.Your staff’s attitude is the single mostimportant factor influencing yourpatients’ experience. Employees whoare happy and feel valued will conveythat positive feeling to your patients.Create an environment that encouragesemployees to share their suggestions,make sure they are well trained, andfocus on their positive contributionsrather than their mistakes.

STEP 2 - Treat each patient as youwould like to be treated.Ask yourself and your staff, “Would youlike to be a patient is this practice?” Showeach patient that you are thankful theychose your practice, that you arecompassionate and that you and your staffare eager to please them. Remindeveryone to smile, make good eyecontact, and say “thank you” to everypatient – so simple yet so often forgotten.

STEP 3 - Continually strive to see your patients on time.Carefully monitor your schedule andmake efficient scheduling a high priority.If you are running late, have your staffexplain to patients truthfully why youare not on time and give them the optionto wait or reschedule. If you habituallyrun late, it is time to re-evaluate yourscheduling process and parameters.

STEP 4 - Under promise and overdeliver.Too often, practices tell patients thattheir test results will be back in a weekwhen it actually will take 10 days,creating patient calls and frustration. If,however, you tell your patients that theirresults will be back in two weeks, andthey have them in 10 days, they arethrilled! Solicit staff suggestions aboutways to reduce patient frustration simplyby changing expectations.

STEP 5 - Differentiate your practice.Brainstorm with your staff about ways tomake your patients feel special, such asmaking follow-up calls to new patients towelcome them to your practice, sendinga small gift to patients followinghospitalization or surgery, recordinginformation about family members orvacations that you can ask about duringthe visit, and writing thank you noteswhen patients refer others.

Creating a culture of serviceexcellence and high customer service inany organization takes a team effort. Itneeds to begin at the top with leadership,and be continually monitored and re-enforced throughout the organization. Asyou begin this New Year, make time tomeet with your staff and discuss theimportance and value of customer serviceto your practice. Rally your team to make“Kindness, Respect and Gratitude” thehallmarks of your practice. It is truly thebest insurance you can “buy” for yourpractice and the only cost is the timespent with your staff.Nancy Smit, MBA, RPT, RRT, is

president and CEO, SHR Associates, Inc.

www.shrassociatesinc.com

M


Restoring Rhythm in Bangladesh

ARDIOLOGIST RAFIQUEAhmed, M.D., PhD, FACC, has quietlycreated the groundwork for thousands of Bangladesh residents with heartarrhythmias to live normally again,without fear of heart failure or death.

A native of Bangladesh, Dr. Ahmedhas worked for more than a decade todevelop the first electrophysiology (EP)services in this country of over 150million people. In the capital of Dhaka,four heart hospitals provide many heartservices and even heart surgery, but thecountry had no EP services until Dr.Ahmed intervened. Yet a common andtreatable EP problem, supraventriculartachycardia (SVT), affects more than400,000 people in the country.

In 2001, Dr. Ahmed began bringingdonated EP equipment and otherphysicians to help establish two labs inDhaka. But the critical component oftraining Dhaka cardiologists to performthese services themselves wasn’t begununtil February, 2005, when he returned to Bangladesh with a fellow Marylandcardiologist to train local cardiologists in

ablation, a procedure that uses electrodecatheters and radio waves to return theheart to its normal rhythm.

“This is a highly cost effective formof treatment,” observes Dr. Ahmed.“Once an electrophysiology laboratory isestablished, the subsequent maintenancecost is low. Most of the materials can beused many times.”

Thanks to Dr. Ahmed, more than

2000 cardiac ablations have beenperformed to date in Dhaka. “Theadvantage of cardiac ablation is that,when successful, it’s a cure,” he notes. “It makes a tremendous impact in thepatient’s life. We had one teen thatcouldn’t participate in any sports until hehad the procedure. After the ablation, hislife was changed. Another patient was ahousewife who used to pass out from hertachycardia. The ablation changed herlife so much that she came a long distancejust to thank me the next time Ireturned.”

“We’ve had over a 90% success ratewith our ablations,” he adds. “That’scomparable to rates in the U.S.”

Dr. Ahmed has also helpedBangladesh nurses, cardiologists andcardiac anesthesiologists come to the U.S.for training. He has contributed his homeand his own funds to support many ofthese efforts, as well as soliciting donatedequipment and catheters from Marylandhospitals. “When Western MarylandHealth System was upgrading their EPlab, they donated their old equipment,

which was in excellent condition, to theNational Institute of CardiovascularDisease, the main teaching hospital inDhaka,” he recalls.

In addition to patients withsupraventricular tachycardia, a growingnumber of Bangladesh residents suffer from coronary disease andcardiomyopathy. EP services arenecessary to evaluate these patients

and reduce their risk of sudden deathusing defibrillators and/ or biventricularpacemaker defibrillators.

Dr. Ahmed continues. “As the team is now fully trained in ablation for tachycardia and pacemakers, for the last two years, I’ve begun focusing my training on the management ofhypertrophic cardiomyopathy. And, I canexpand to other areas of the country. I’malso working on developing the educationcurriculum so that it’s as close to what weget in the U.S. as possible.”Rafique Ahmed, M.D., PhD, FACC, is an

attending cardiac electrophysiologist with

Chesapeake Cardiovascular Associates.

Good Deeds

C

“We’ve had over a 90% success rate with our ablations. That’s comparable to rates in the U.S.”

– Rafique Ahmed, M.D.

By Linda Harder

Thanks to the efforts of Dr. Ahmed and his colleagues, more than 2000 residents ofBangladesh have received cardiac ablations.

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

Good intentions or bad judgment?

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

Climbing with Confi dence

After Catheter Ablation

at

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To refer a patient for a cardiac surgery consult,

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Documents

Maryland Physician Magazine January/February 2013 Issue