Maryland Physician Magazine March/April 2012 Issue

Tackling Obesityand Diabetes

Fighting for Physiciansand ConsumersAttorney GeneralDouglas F. Gansler

Be Ready for mHealth

Tackling Obesityand Diabetes

Fighting for Physiciansand ConsumersAttorney GeneralDouglas F. Gansler

Be Ready for mHealth

VOLUME 1: ISSUE 6 MARCH/APRIL 2012

Physician

www.mdphysicianmag.com

YOUR PRACTICE. YOUR LIFE.

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MARCH/APRIL 2012 | 3

12 Tackling Obesity and Diabetes

20 Follow Your GutManaging Pancreatic Cysts and Hemorrhoids

24 Be Ready For mHealthWhy physicians should become familiar with mobile healthcare tools

F E AT U R E S

D E PA R T M E N T S

ContentsMarch/April 2012 Volume 1: Issue 6

2012 28

Cases | 7 | Celiac Disease: An Ancient Disease Remains Under-Diagnosed in ModernTimes

Solutions | 8 | FiveWays to ProtectYourself andYour Practice for Under $1,000

Living | 28 | Gearing Up For Spring

Policy | 30 | Interview with Douglas F. Gansler, Attorney General

Compliance | 33 | Common Sense Measures Ensure a HIPAA Compliant Practice

Good Deeds | 34 | “Camp Oasis”Offers Inspiration toYoungsters with Inflammatory Bowel Disease

On the Cover: Richa Bhatnagar, M.D., is a family practitioner with MedStar Physician Partners at Olney Professional Park.

I’M WRITING THIS AS I SIT 37,000 FEET IN THE AIR ON THE WAY TOone of the country’s oldest and most well-attended HIT conferences – the HealthcareInformation and Management Systems Society (HIMMS) conference. Even at thisaltitude, the obesity epidemic, which is this issue’s clinical focus, is clear as the seatsget smaller and some of my fellow travelers get bigger.

Americans are fatter than ever and healthcare technology (HIT) seemingly isn’tmoving fast enough to allow physicians to help their patients lead healthier lives andreduce the chronic conditions associated with obesity.

Where does HIT fit? In this issue, we examine the state of mobile health(mHealth). Get ready for it – more and more of your patients are using it and you wantthem to use it (HIT page 24). Every day, gadgets and apps are being launched to helppeople monitor their body metrics and chronic diseases. These new launches oftenpromote goal setting and rewards for patients living healthy lifestyles, using clinicallyvalid data. Unfortunately, due to a slow-moving FDA train and an onslaught of HITdevelopments, many physicians are challenged to weed through the many toolsavailable and apply the most useful tools to patient care delivery.

Over the next few days, Maryland Physician Managing Editor Linda Harder and I,along with 35,000 others, will be introduced to the future of HIT, which we’re eagerto share with our readers. In the short term, I’m excited about our own step into thefuture with the launch of the Maryland Physician web-based smartphone app and QRcode (page 19), which connects you to Maryland Physician online and more.

Despite a rancorous political climate, the reformation of America’s healthcaresystem is gaining momentum via HIT developments and changes to care access. Werecently had the opportunity to sit with Maryland’s Attorney General Doug Gansler,a leader in protecting consumer health and a physician champion. To learn about theimpacts his office’s actions might have on your practice, see Policy (page 30).

Without a doubt, exercise has a positive impact on your physical and emotionalwell-being. Our new department, Living (page 28), takes you out of your practice toMaryland’s roads and trails, gearing up for spring cycling. I’m personally inspired byour piece; over the next several months, I’m training for Maryland’s Seagull CenturyRide. I hope you’ll let me know if you are similarly inspired!

To life!

Jacquie RothPublisher/Executive [email protected]

4 | WWW.MDPHYSICIANMAG.COM

JACQUIE ROTH, PUBLISHER/EXECUTIVE [email protected]

LINDA HARDER, MANAGING [email protected]

CONTRIBUTING WRITERSAllison EatoughTracy FitzgeraldJackie Kinsella

CONTRIBUTING PHOTOGRAPHYTracey Brown, Papercamera Photography

www.papercamera.comMark Molesky, Moleskey Photography

www.moleskyphotography.com

ADMINISTRATIONGinger Jenkins

EXECUTIVE ASSISTANT/WEBMASTERJackie Kinsella

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

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

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

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

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

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

PATRICIA CZAPP, M.D.Anne Arundel Medical Center

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

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

GAUROV DAYAL, M.D.Adventist HealthCare

MICHAEL EPSTEIN, M.D.Digestive Disorders Associates

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

REGINA HAMPTON, M.D. FACSSignature Breast Care

DANILO ESPINOLA, M.D.Advanced Radiology

GENE RANSOM, J.D., CEOMedChi

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

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DISCUSSION In 50 AD Arelaus theCappadocian stated, “If the stomach beirretentive of food and it passed throughundigested and crude, we call such personsceliacs.” It wasn't until the 1950’s thatcereals were linked to celiac disease.

The disease itself is a heightenedresponsiveness to gluten in wheat,barley, and rye leading to autoimmuneenteropathy and systemic disease. Thereare over 100 different proteins in glutenfound in the endosperm of the grains. Thegluten itself is not directly toxic,but it must be deaminated by tissue

transglutaminase, forming a complex thatis much more antigenic. Celiac disease isfive times more prevalent than Type 1diabetes, with estimates that 1% ofAmericans are affected. Yet 2.1 millionpatients remain undiagnosed.

The vast majority of celiac patientshave one of two types of HLA-DQ. Thisgene is part of the MHC class II antigen-presenting receptor (also called the humanleukocyte antigen) system and distinguishescells between self and non-self for thepurposes of the immune system. The geneis located on the short arm of the sixthchromosome and has been labeledCELIAC1.The receptors formed by thesegenes bind to gliadin peptides moretightly than other forms of the antigen-presenting receptor and activate T cells.

In 1997 the role of tTG (tissueTransglutamase) antibodies was found tobe pivotal to the diagnosis and causation ofthe disease. The tTG binds to the gliadinand forms the antigenic complex. ThetTG antibodies should also be measuredwith serum IgA. If the patient is IgA-deficient, a serum EMA (Endomysial) IgGshould be measured.

The diagnosis must be made with apositive tTG as well as a sufficient biopsyof the small intestine. The positivepredictive value of the antibodies is notsufficient to make the diagnosis.

Celiac disease may affect the brain,skin, lungs, liver, and blood vessels.Symptoms, often present for 10 yearsbefore diagnosis, include increased LFTs,constipation, apthous ulcers, nausea,vomiting, heartburn, pancreatitis, fatigue,arthralgias, myalgias, neurologic ataxia,alopecia, headaches, dental problems,fertility issues, and cognitive defects.The consequences of the disease includeincreased risk of infection, lymphoma,ataxia, malnutrition and skin rash.

The only treatment is a strict gluten-free diet that avoids all products containingwheat, rye, and barley. Only 50 mg ofgluten – a single breadcrumb – willreintroduce the disease. As gluten is foundin virtually every food and in fillers such asin lipstick and medications, a gluten-freediet can be difficult to follow.

More than 75% of patients whopresent to a clinician following a gluten-free diet do not have celiac disease. Theymay have a wheat allergy, but it is morelikely that this is a form of functionaldisease and IBS. The gold standard oftreatment remains consultation with askilled celiac dietitian. Studies revealthat three simple questions can helpphysicians monitor patients:

� Am I able to follow a gluten-free dietoutside my home?

� How many times in the past fourweeks have I been exposed to gluten?

� How important are accidental glutenexposures to my health?

Physicians need to be vigilant aboutthe diagnosis of celiac disease, whether thepatient has reproductive or fertility issues,general GI complaints or skin rash, anemiaor general ill health. Diagnosis starts with atTG and treatment is a lifelong processinvolving a physician and dietitian.

Our patient was not diagnosed untilshe presented to a specialist who orderedthe appropriate antibody testing and smallbowel biopsy. She was referred forappropriate dietary counseling and, withcareful attention to her diet, enjoyed amarkedly improved quality of life. Withintwo years of starting treatment, shedelivered a healthy child.Michael S. Epstein, M.D., F.A.C.G., AGAF, is

the founder of Digestive Disorders Associates

in Annapolis, [email protected].


Cases

Celiac Disease: An AncientDisease Remains Under-Diagnosedin ModernTimes

CASE: A 32-year old femalewho emigrated fromBulgaria several years agopresents with a long historyof crampy, sometimessevere abdominal pain andconstipation, as well as twomiscarriages. She has beento a number of physicians inher home country and toemergency departments inthe U.S. on severaloccasions with no specificdiagnosis. At one point shewas diagnosed with IBS.Her physical examinationwas unremarkable exceptfor small patches ofpapulovesicular eruptionsdistributed symmetricallyon extensor surfaces withblister-like lesions. Labresults revealed a mild irondeficiency with slightlyelevated SGOT and SGPT.ADEXA scan revealedevidence of osteopenia.

Michael Epstein, M.D.

OYOUWANTTOPROTECTyourself and your practice withoutbreaking the bank? The following fivetips for critical yet affordable insurancecoverages are ones that all physiciansshould consider carrying to maximizetheir protection within a budget. This isnot meant to be an exhaustive list.Consulting with an insurance professional isyour best way to ensure that your particularsituation is adequately addressed.

Personal InsuranceOne of the most overlooked areas forphysicians is their homeowners andautomobile insurance. A growing numberof physicians buy their coverage on-lineor with little thought about the actualcoverage provided. Know what coverageyou have in place, and whether it needsto be adjusted. Take a few minutes nowto make sure you are sufficientlyprotected.

1) Upgrade Your Home andAutomobile CoverageYou should upgrade to the maximuminsurance limits on your automobilepolicy, which should be at least $500,000per person, $500,000 per accident, and$100,000 for property damage. A reviewof one physician’s policy found that hehad minimum limits ($30,000) ofinsurance. In other words, if he hadcaused an automobile accident thatinjured others, he had only $30,000 to payfor their injuries! If their medical costsexceeded $30,000, the physician could bepersonally liable for the difference.

On your homeowner’s policy makesure that you have at least $500,000in liability protection. It is also a goodand inexpensive idea to purchase

identity theft protection.Making these upgrades to your home

and automobile coverage should cost youless than $1,000 a year.

2) Add an Umbrella PolicyWhile contemplating the proper limit ofpersonal insurance, another affordableway to increase your personal insurancecoverage is purchasing an umbrella policy.An umbrella policy adds an additional $1million of liability coverage to yourexisting home and automobile liabilitycoverage. In other words, if you have a $1million umbrella policy and a $500,000liability limit on your automobile, thenyou would have $1.5 million worth ofcoverage. Umbrella policies arecommonly available in million-dollarincrements from $1 million to $10million. However, umbrella policies donot give you an extra layer of propertyloss protection.

The cost of a $1 million umbrellapolicy is only about $200 per year.

If you employ a nanny or otherdomestic worker to whom you pay morethan $1,000 per quarter, you are requiredby the State of Maryland to buy adomestic worker’s compensation policy.These policies normally cost less than$1000 a year.

Insurance for the Practice3) Buy Disciplinary Board LegalCoverageEvery physician in private practice shouldbuy coverage to pay their defense costsif they are brought before the Board ofPhysicians. Maryland is contemplatingchanges to the Board, and an increasedemphasis on investigating anddisciplining physicians is anticipated.

Many medical malpractice insurers willnon-renew you if you have a Board action,so it is important to hire an attorney to defendyou. Attorneys’ fees can add up quickly.

The premiums for these policiesrange from $400 - $700 per year.

4) Buy Employment PracticesLiability InsuranceEvery year, there are nearly 2,000employment-related lawsuits broughtagainst Maryland employers. Physiciansare especially susceptible to these claims,which can be extremely expensive todefend. Most insurers who sell thiscoverage will provide free humanresources and legal advice – a great value!

For small practices, basic policiestypically cost under $1,000.

5) Have a Partner? You Should Have aBuy-Sell AgreementIn simplest terms, a buy–sell agreementdictates what happens if one partner dies,retires or becomes disabled. In thesesituations, it can be difficult to buy apartner’s interest with out-of-pocketfunds, and the partner’s spouse maydemand to be paid immediately. Somepractices use simple term life insurancepolicies to fund the buy-out.

Depending on the age of thephysicians, a simple 10 or 20-year termpolicy may cost less than $1,000 per year.Make sure to discuss this with a lawyer.

These five simple and affordablesteps are ones you can take immediatelyto better protect yourself againstpotentially major catastrophic events.Mr. Sherman specializes in medical malpractice

and professional liability insurance with PSA

Insurance and Financial Services. Contact him

at [email protected].


Solutions

FiveWays to ProtectYourself andYour Practice for Under $1,000

DSteve Sherman, J.D.


Profile

N ESTIMATED $25billion is spent annually on treatingchronic wounds. This process oftenentails expensive, repeat hospital visitsand fragmented specialty services.Having access to a comprehensive woundhealing center not only helps reduceexpenses, but affords patients with thelatest, most effective and coordinatedtreatment options. That was the impetusbehind Maryland General Hospital’sstate-of-the-art Maryland Wound HealingCenter, which opened in March 2012.

“We have a high prevalence ofdiabetes and vascular problems in ourcommunity,” says Sylvia Smith Johnson,Maryland General Hospital’s presidentand CEO. “We recognized that therewere limited options for comprehensivewound care with advanced treatment thatincludes hyperbaric oxygen therapy.”

The Maryland Wound Healing Centeris affiliated with National HealingCorporation (NHC), one of the leadingproviders of wound healing centersthroughout the country.

Kapil Gopal, M.D., MBA, medicaldirector, Maryland Wound HealingCenter and associate program director,Vascular Fellowship Program at theUniversity of Maryland Medical Center

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Maryland General’s NewWoundHealing Center

Kapil Gopal, M.D., MBA, medical director, Maryland Wound Healing Center and associate programdirector, Vascular Fellowship Program at the University of Maryland Medical Center and MarylandGeneral with two of the center's hyberbaric chambers.

THE MARYLAND WOUNDHEALING CENTER CENTEROFFERS:

� Joint Commission certified

program

� Skilled, multi-disciplinary team

Experienced medical and program

directors oversee a team of

physician specialists, nurses and

technologists trained to use the

latest assessment and therapeutic

methods.

� Personalized care management

Each patient works with a single

physician and nurse case manager.

� Proven clinical pathways

Uses protocols which rely on

evidence-based medicine,

experience, dedicated research

and best practices.

� Successful outcomes In 2010,

90% of wounds treated in NHC

centers were healed, with an

amputation rate of less than 2%.

� Accessibility Community hospital

convenience, with easy access to

public transportation or the hospital’s

transport team.

To refer a patient to the Maryland

Wound Healing Center or for more

information, call 1-855-866-HEAL

or 410-225-8600.

and Maryland General Hospital, says,“Our program is successful becausewe focus exclusively on wound care,using algorithms and scientificevidence-based protocols, includingHBOT, to develop an individualizedtreatment plan.”

William Anthony, M.D., chief ofmedicine and an infectious diseasespecialist, notes, “I’ve been treatingwounds for more than 30 years. Wemake sure that any underlying medicalissue, such as vasculitis or diabetes, isaddressed with the patient’s physician,who then gives us direction andprovides input into his or her care.”

HBOT is a widely utilizedadjunctive modality that is reimbursedby most, if not all, insurance providers.The data on its efficacy is especiallystrong in treating diabetic foot ulcersclassified Wagner Grade 3 or higher.

The Wound Healing Center ProcessThe center’s multi-disciplinary panelcomprises experienced familypractitioners, vascular and generalsurgeons, infectious disease specialistsand podiatrists that develop acomprehensive care plan tailored toeach patient. The team keeps referringphysicians involved and informed,including providing weekly/monthlyprogress reports and photos.

“Each patient works with a singlephysician and nurse case managerwho help us build a close, trustingrelationship. Patients tell us they lookforward to coming,” says Colleen Miller,RN, program director.

Miller explains the wound careprocess. “We check insuranceauthorization, schedule the patient’sfirst and subsequent appointments, andadvise them what to expect. The firstvisit involves a full history, includingpsychosocial history, and a thorough

assessment of the wound and relevantmedical conditions. The team developsa customized wound care plan thattypically involves weekly treatments untilthe wound starts to heal. If HBOT isordered (about 20% of patients will betransitioned over to HBOT), it involvesabout 30 consecutive ‘dives’ in our single-use, private chamber, which includes atelevision above the chamber for patientsundergoing treatments. We also involveother providers as needed, such as homehealth care or an orthotist.”

The center reports its clinicaloutcomes into a nationwide databasethat can be reviewed against the NHCClinical PathwayTM.

Proximity, Coordinated CareImprove OutcomesMs. Smith Johnson observes, “Withoutclinical pathways and multidisciplinarycare, there’s a high cost of woundcare for payers and society, a higheramputation rate and an emotional andphysical toll on patients and theirfamilies. Our center providescoordinated care that better addressesthe needs of all these groups andimproves outcomes.”

Dr. Gopal adds, “The key to thiscenter is its location at MarylandGeneral, where it’s in close proximityto a large population that needs thisservice. It will help many with diabetesand venous stasis, as well as those withosteomyelitis, pressure sores, burns,post-surgical wounds and other non-healing wounds.”

When to Refer“If a wound isn’t healing after twoweeks and the patient is not makingprogress, I encourage physicians to callus to schedule an appointment,” statesMiller. “Patients can also self refer andmost insurers provide coverage.”


Our program is successful because we focus exclusively onwound care, using treatment algorithms and tested approaches,including HBOT. – Kapil Gopal, M.D.

TacklingObesity andDiabetes

BY LINDA HARDER

PHOTOGRAPHY BY TRACEY BROWN

Not much is harder than losing weight, except,perhaps, keeping it off.

Maryland Physician interviewed three physicians– Drs. Michael Schweitzer, Kristi Silver and

Richa Bhatnagar – for their advice about managingobesity and a common co-morbid condition,

type 2 diabetes.

( )



FOR SEVERELY OBESE PATIENTS,bariatric surgery may be their best hopefor losing and keeping off sufficientweight to improve their health. MichaelA. Schweitzer, M.D., FACS, a bariatricsurgeon at the Johns Hopkins Center forBariatric Surgery stresses, “Bariatricsurgery should never be undertaken forcosmetic reasons.” The purpose ofbariatric surgery is to improve the healthof the patient by reducing or eliminatingtheir obesity-related medical diseases.

CriteriaIn Maryland, patients are fortunate thatstate law requires insurers to coverbariatric surgery when performed forpeople who meet the following criteria:

� BMI of 40 kg/m2 or greater, or 35-40kg/m2 with co-morbid condition(s)

� Tried and failed previous diet(s)

“We have one of the best laws in thecountry,” says Dr. Schweitzer. “Recentlythe FDA approved the laparoscopicadjustable gastric band for patients witha BMI between 30 and 35 with diabetes.Unfortunately insurers do not cover thisprocedure for non-morbidly obesepatients and therefore, patients will haveto pay out of pocket for now. Patientswho have active substance abuse issues,uncontrolled mental health disease orwho cannot cooperate with post-oprequirements are not consideredcandidates.”

He comments, “We do see teenagepatients 16 and older, but they have togo through an intense program thatincludes their parents. Some of the moresuccessful results involve teens whosemother had the procedure first. There’sno definite cut-off among older adults,though most patients are 65 or younger.We have made exceptions andperformed surgery on patients up to75 years old.”

Types of Bariatric ProceduresBariatric surgeons in the U.S. currentlyuse one of four approaches:� Roux-en-Y gastric bypass – the gold

standard and most common. Patientstypically lose 60 to 75% of excessweight within 18-24 months.

� Laparoscopic adjustable gastric band(‘Lap Band’ & ‘Realize Band’)– patients typically lose 30-50% ofexcess weight.

� Vertical sleeve gastrectomy – patientstypically lose 40-60% of excessweight. This procedure is newer andgrowing in popularity.

� Duodenal switch with bileopancreaticdiversion – only used for about onepercent of patients.

ResultsA retrospective cohort study publishedin the New England Journal of Medicine in2007 determined that long-termmortality in the group undergoing gastricbypass decreased by 40% compared tothe control group. The rate of dyingfrom heart disease, type 2 diabetes andcancer was less in the gastric bypassgroup. However, the rate of death fromaccidents and suicide, while small, washigher in the surgery group. “Physiciansshould know that the procedure doesn’tcure mental illness,” Dr. Schweitzernotes. “Mental health counseling evenafter surgery is an important adjunct forsome patients who are dealing with thepsychological issues of losing weight.”

Michael A. Schweitzer, M.D., FACS, is a bariatric surgeon at the Johns Hopkins Center forBariatric Surgery.

Mortality rates at bariatric surgeryCenters of Excellence are lower thanpreviously published death rates whencenters did not exist. “Johns HopkinsMedicine is a tertiary referral centerwhere we are referred high-risk patients;however, our group has a 0.3% mortalityrate, compared with higher mortalityrates seen nationally.”

Pre and Post-Op CareAfter a short hospital stay, patientstypically return to work within two weeks.On a high-protein, pureed diet for abouta month post-op, they start to return to anormal healthy diet. Follow-up with theirprimary care physicians and bariatricsurgeons is an important part of thepostoperative course. Support groupsmeet monthly and specializednutritionists help monitor protein intakeand supplemental vitamins.

Dr. Schweitzer provides additionaladvice for referring physicians:

� For patients with sleep apneasymptoms, get a sleep study beforesurgery and put on CPAP if thepatient has moderate to severeobstructive sleep apnea.

� Seek better glucose control in type 2diabetics. Ensure that the patient’sthyroid medication dosing is adequate.Counsel the patient to stop smoking.

� Patients with ulcer symptoms mayneed an EGD before surgery.

� Consider a hematology work-up forpatients with a personal/family history

of blood clotting.� Consider referring for bariatric surgery

prior to hip/knee replacement surgeryor spine surgery.

� Refer patients to a bariatric dietitianand mental health professional ifneeded post-op.

Regaining WeightWhile bariatric surgery is highlysuccessful, patients may gain back someweight. Dr. Schweitzer says, “The mainreason they regain it is because they eat‘bad’ carbs, such as potato chips. If theyeat a healthy diet slowly, they won’t regainthe weight.” The purpose of surgery is tohelp the patient stay on a healthy diet thatmakes them feel full and desire lesssnacking in-between meals.

Dr. Schweitzer notes that an evenless invasive procedure is on the horizon.“Endoscopic intraluminal trans-oralsurgery is in its infancy. If we can surmountthe current issue of staples not holding,this approach is likely to take off.”

CONTROLLING TYPE 2 DIABETESKristi D. Silver, M.D., acting director ofthe University of Maryland Center forDiabetes and Endocrinology, divides hertime between clinical research ondiabetes and treating patients. “The vastmajority of adults with type 2 diabetesare overweight or obese,” she says.“When people are overweight, insulinresistance develops so their pancreasmakes more insulin but it’s used lessefficiently. When they lose weight, their

insulin resistance usually improves andthey can better control their diabetes.”

Risk Factors for Obesity and DiabetesThe strongest predictors of developingtype 2 diabetes are family history andhigh BMI. Those with metabolicsyndrome are also at increased risk.Dr. Silver notes, “While no one geneaccounts for the majority of genetic riskfor diabetes and obesity, Transcriptionfactor 7-like 2 (TCF7L2) for diabetesand fat mass and obesity associated(FTO) gene for obesity are two of themore important genes identified.”

Adds Dr. Silver, “Lifestylemodifications are the most effective wayto combat the development of type 2diabetes.” In a study published in 2008in the Archives of Internal Medicineby Soren Snitker, PhD, researchersfound that physical activity can largelycounteract the risk of obesity due to agenetic variant in the FTO gene.”

Managing Diabetes“It’s important for patients to see anutritionist and a diabetes educator,”says Dr. Silver. “The multi-disciplinaryapproach has been shown to work. Thenutritionist can take the time to do adiet history and then work with thepatient to develop a meal plan. Meetingwith the diabetes educator helpspatients learn other self -managementskills such as glucose monitoring,prevention of complications and propertreatment of hyperglycemia andhypoglycemia. Diabetes educationclasses allow patients to learn from theirpeers as well as from professionals.”

Dr. Silver continues, “In makingdietary recommendations to patients,instead of changing everything in anunhealthy diet all at once, I recommendthat patients take small steps. Aftermastering one dietary change, they canadd others. When patients try to changeeverything in their diet at one time,they may be successful for a few weeks,but often revert back to their previouseating habits.”

New Medication Options“There are many new medicationoptions today, plus many drugs are indevelopment or awaiting FDA approval,though most are the same class of drugsthat are currently available. Many newerdrugs target specific molecular pathwaysinvolved with insulin secretion orresistance,” Dr. Silver states. “Current


Kristi D. Silver, M.D., is acting director of the University of Maryland Center for Diabetes andEndocrinology.

guidelines recommend that patients bestarted on metformin unless they havecontraindications or can’t tolerate it.Pioglitazone is being used less often dueto recent but not conclusive studiessuggesting that long-term use may

increase the risk of bladder cancer.Newer classes of drugs such as DPP4inhibitors are effective, but can beexpensive. Patients often need severaldiabetes medications to reach theirtarget HbA1c.”

Dr. Silver adds, “Today, we havegood data supporting the use of a long-acting insulin as a basal insulin, with arapid acting insulin to cover meals andcorrect elevated blood sugars. While theregimen requires four injections a day,most patients can be convinced to followit due to improved blood sugar controland increased flexibility in eating.Physicians are sometimes reluctant tostart insulin, but it’s often what patientsneed. With proper training on how togive the shot, fearful patients usually getover their anxiety. ” After startinginsulin, most patients with type 2diabetes on high doses of insulin can’tget completely off it, though their dose

may decrease if they lose weight. Inpart, that is due to the diminishing ofthe insulin producing cells of thepancreas over time, even after lifestylechanges.”

Insulin pumps have become more

sophisticated. Current pumps can helppatients calculate the mealtime andcorrection insulin needed. Newermonitors allow interstitial glucosemeasurements to be sent to a hand heldreceiver that reads the level every fiveminutes. Continuous glucose monitorsare best used to observe trends inglucose levels. Additionally, alarms canbe set to avoid hyper or hypoglycemia.“We can look at glucose patterns andadjust insulin doses accordingly,”comments Dr. Silver.

SUCCESSFUL PRIMARY CAREINTERVENTIONSRicha Bhatnagar, M.D., a familypractitioner with MedStar PhysicianPartners in Olney, says, “In primary care,prevention is key. When a patient comesto the office, in addition to checkingtheir vital signs, I also assess their BMI.If it’s high, then, I counsel them about

making lifestyle changes. I believe thatnutrition is a critical component of health.In fact, I took a nutrition class this pastfall to gain some additional knowledgefor my patients.”

Dr. Bhatnagar incorporates thesediscussions into her office visits. “Ijust find time to do it,” she says. “Manyof my patients have multiple medicalproblems, such as diabetes andhypertension. At their office visits Idiscuss simple lifestyle changes thatwill positively affect their health.”

Like Dr. Silver, Dr. Bhatnagarrecommends that patients make smallchanges over time. “I stress that it’s alifelong process, and they should startby making simple changes, such asdrinking skim milk instead of whole.If they eliminate basic food groups, itis not only unhealthy, but the majorityof patients will eventually return toold eating habits. I often recommendthe Mediterranean Diet and providehandouts that patients can stick ontheir refrigerators.”

Dr. Bhatnagar has found it effectiveto have patients keep food journals forat least two to three days. “After theytrack everything they eat for severaldays, I review the logs and suggestchanges they can live with.”

Research Findings on Diet PlansThe gold standard of diet studies is stillconsidered by many to be a February,2009 study in the New England Journal of


Richa Bhatnagar, M.D., is a family practitioner with MedStar Physician Partners at OlneyProfessional Park.

“Lifestyle modifications are the most effectiveway to combat the development of type 2diabetes.”–Kristi Silver, M.D.

ADVICE FOR

REFERRING PHYSICIANS

> Multidisciplinary approach involv-

ing diabetic educator, nutritionist,

proven effective

> If one drug is not effective, com-

bine 2 drugs rather than change

drugs; if two are not effective,

consider insulin

> Don’t assume patients will resist

insulin – most adapt quickly

> Combine long acting and rapid

acting insulin – provides more meal

flexibility with better glucose control

> Consider using metformin with

insulin

> Refer newly diagnosed patients

and those not meeting goals after

6 months of intensive treatment

to endocrinologist


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Medicine that compared participants’ability to lose weight on diets thatemphasized protein, fat, or carbohydrateconsumption. The authors found thatall of the reduced-calorie diets had similareffects on satiety, satisfaction and weightloss, and that all improved lipid-relatedrisk factors and fasting insulin levels.They concluded that the macronutrientemphasis was not important to the abilityto lose clinically meaningful weight, andthat continued attendance at a groupsession was related to the ability to loseand keep off weight.

Exercise: Simple Steps are Effective“It’s surprising how many patientsaren’t familiar with the 10,000 Stepsconcept, which encourages people tobuild more walking into their dailyroutine,” Dr. Bhatnagar remarks.“Studies have shown that this iseffective.” The concept, whichoriginated in Japan about 40 years ago,encourages people to walk about 5 milesduring the course of each day, far morethan the average American’s 1.5 miles.

Comments Dr. Bhatnagar, “Iencourage patients to aim for 30 to 45minutes of cardiovascular exercise everyday, with the hopes of getting them toexercise at least four to five days a week.They don’t need to spend hours at agym; walking outdoors is a great way toachieve their fitness goals.”

Michael A. Schweitzer, M.D., FACS,

associate professor, surgery at the Johns

Hopkins Center for Bariatric Surgery.

Kristi D. Silver, M.D., associate professor

of medicine, acting director of the

University of Maryland Center for Diabetes

and Endocrinology.

Richa Bhatnagar, M.D., family practitioner

with MedStar Physician Partners at Olney

Professional Park.

“In primary care,prevention is key...I believe thatnutrition is a criticalcomponent ofhealth.” –Richa Bhatnagar, M.D.

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get their take on the effectiveness of the latest treatments

for prostate, breast and blood cancers.

Healthcare ITIn every issue, Maryland Physician explores a different

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FollowYOUR GUT

Maryland Physician spoke with two Marylandgastroenterologists, Sanjay Jagannath, M.D., and RudraRai, M.D., to learn the latest approaches to treating

pancreatic cysts and hemorrhoids.

Managing Pancreatic Cysts and Hemorrhoids

MANAGEMENT OFPANCREATIC CYSTSSanjay Jagannath, M.D.,FASGE, AGAF, director,Pancreas Center at Mercy’sInstitute for Digestive Healthand Liver Disease, is on amission to do for pancreaticcysts what colonoscopy hasdone for colon polyps.

The recent deaths ofcelebrities such as PatrickSwayze, Steve Jobs andWBAL radio host RonSmith have raised publicawareness about pancreaticcancer. Pancreatic ductaladenocarcinoma accounts forabout 90% of these cancers(including Swayze and Smith),with nearly all occurringin the main or branch ductsof the pancreas, whileneuroendocrine canceraccounts for the remaining10% (including Jobs).

“In the old days, we found

these cysts, called intraductalpapillary mucinous neoplasms(IPMNs), only when peoplewere at the end stage ofpancreatic cancer – when thecyst spread outside thepancreas and became lethal,”Dr. Jagannath notes. “Now,we’re finding them early.The explosion in CT and

MRI imaging has increasedthe number of incidentalpancreatic cysts that aredetected, which are presentin 1 to 2% of the population,and higher in older adults.”

Dr. Jagannath explainsthat incidental cysts are oftenfound when patients presentto the ER with abdominal

pain and get a CT scan.He cautions primary carephysicians, “Pancreatic cystsare clinically relevant, incontrast to many liver andrenal cysts, which are commonand not clinically relevant.They shouldn’t be ignored.”

These cysts typicallydon’t cause symptoms until

LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

Location

Branch duct IMPNs

Under 3 mm

3 to 6 mm

Over 6 mm

Main duct IMPN

Guidelines for Follow-up

Yearly exam

CT, MRCP or EUS every 3 – 6 months

Resection

IMPN GUIDELINESSize/Symptoms

Under 1 cm; no symptoms

1 to 2 cm; no symptoms

3 cm or more, contain a mass,

or associated with dilatation

of main pancreatic duct

Yearly exam

Imaging every 3- 6 months; more

aggressive treatment when

symptoms present

Resection


they are so advanced thattreatment options are limited.The dilemma for physiciansis managing them to minimizethe chance of progressionto cancer without subjectingpatients to unnecessarytesting and treatment.

Since 2006, gastroent-erologists have relied on a

set of guidelines that classifypancreatic cysts by size andlocation. Cysts are dividedinto those found in the mainduct and the branch ducts.

“I tell patients that benignis benign and cancerous iscancerous, but with pre-cancerous cysts, it’s hard topredict when or if they’ll

turn cancerous,” says Dr.Jagannath. “The size andlocation of the cyst matter.Cysts in the main duct aremore aggressive and whenthey are greater than 6 mmin this area, studies haveshown that two-thirds ofthese patients will developcarcinoma in situ. These

patients should be resected.When main duct cysts are3 mm to 6 mm, we followthem with repeat imagingstudies. If a patient also hassymptoms, we need tointervene more aggressively.”

Dr. Jagannath continues,“Patients with incidentalbranch duct cysts can betreated less aggressively.Studies have shown that only10 to 20% become cancerousover a 10-year period. They’revery curable if caught earlyand still contained within thepancreas; however, once theyextend outside the pancreas,the 5-year survival rate is lessthan 5%.”

He adds, “Branch ductcysts over 3 cm increase therisk of cancer and should beresected. Smaller cystsshould be followed withrepeat CTs or MRCPs (MRcholangiopancreatography).Older and/or sicker patientsare treated less aggressively.”

“My personal feeling isthat every cyst should bebiopsied once,” he adds.“The best method isendoscopic ultrasound withfine needle aspiration(EUSFNA), which provides abetter view of the cyst. If thecyst changes, we may repeatthe biopsy or goto surgery, depending onother factors. The guidelinesaren’t perfect and involvelots of imaging. In thefuture, molecular analysis toidentify certain DNAmutations in cells will betterdetermine which cysts willturn cancerous.”

He advises primary carephysicians to:� Ask for a family history of

pancreatic cancer. Referthose with two or morefirst-degree relatives toa gastroenterologist forassessment and geneticcounseling.

� Patients with late onsetdiabetes (over age 65) mayhave pancreatic cancer andshould be screened withendoscopic ultrasound.

Sanjay Jagannath, MD, FASGE, AGAF, is a gastroenterologist and director, Pancreas Center, at Mercy’sInstitute for Digestive Health and Liver Disease.

Finally, Dr. Jagannathcautions, “We don’t want topay attention to the tree andignore the forest. A Japanesestudy showed that patientswith a pancreatic cyst had oneand a half times the risk ofdeveloping a new cancerouscyst or mass elsewhere in thepancreas. We need to bevigilant for those as well.”

NEW TREATMENT FORAN OLD PROBLEMPrecision Endoscopic IRCfor HemorrhoidsRudra Rai, MD, MBA, FACG,Assistant Professor at JohnsHopkins University, andDirector of the Gastro Centerof Maryland, is helpinginnovate new technologiesto treat common ailmentssuch as hemorrhoids.

Hemorrhoids areestimated to affect about 75%of adults at some point in theirlives. “It’s one of thosecommon maladies, especiallyfor women after childbirth orthose who don’t get enoughexercise or fiber in their diet.It can also be related toirregular bowel habits,prolonged straining, genetics,obesity and those who doheavy lifting or sit for longperiods,” notes Dr. Rai.

“We always start withconservative therapies, suchas increasing the amount offiber in the patient’s diet,drinking more water, andusing topical steroids,” hecomments. “Patients canalso use a variety of over-the-counter ointments,suppositories or pads.Straining makes the problemworse, so probiotics, stoolsofteners and avoiding sittingor standing for prolongedperiods can help. Whenconservative measures don’twork, we may considertreatments such as bandligation, infrared coagulationor hemorrhoidectomy.”

Dr. Rai advises referringphysicians to rule out otherpotential causes of blood inthe stool. “Patients don’tworry because think they only

have hemorrhoids, but theycan have an inflammatoryor neoplastic process, whichis serious and warrantsinvestigation. Physiciansshould make sure they checkfor a family history and screenfor cancer in patients withrectal bleeding. Before age50, 10% of people will havepolyps, increasing to about athird of the population afterthat age.”

Older non-surgicaltherapies include:� Sclerotherapy, in which

a chemical solution isinjected into thehemorrhoid, does not causepain but is less effectivethan other approaches formost patients and isgenerally limited to use ingrade 1 hemorrhoids.

� Band ligation, which hasbeen used for grade 3hemorrhoids, uses a tinyband to tie off internalhemorrhoids. However, theprocedure causes significantbleeding and discomfort.

Coagulation techniqueshave emerged in the past fewyears as an alternative to theother non-surgical approaches.Infrared Coagulation (IRC) isone such technique, usinglaser-like, focused heat to cutoff the hemorrhoid’s bloodsupply. It also helps shrinkexternal tissue. “The drawbackof this approach includes arelatively crude anoscope withlimited lighting and vision,and limited reach,” says Dr.Rai. It also has had a higherrecurrence rate than someother approaches.

Precision endoscopic IRC,a new approach to coagulationdeveloped by MichaelEpstein, M.D. and colleagues,allows gastroenterologists toadvance the distal tip of thecolonoscope to the cecum.It uses a colonoscope orsigmoidoscope with fiberoptictechnology to provide anunobstructed 360° view.“The new device improvesvisibility and access to the

internal hemorrhoids, andallows precise applicationof the infrared energy,”explains Dr. Rai. “Thismakes the procedure moreeffective. More than onehemorrhoid can be treatedduring the procedure and itis sufficiently painless thatsome patients opt not toreceive sedation.”

He adds, “While IRC hastypically been used in grade1 and 2 hemorrhoids, we arealso seeing great responses inearly grade 3 hemorrhoidsusing precision endoscopicIRC. Thus, we can offer thisto a wider range of patientswith less discomfort. Anotheradvantage is that gastro-enterologists can perform adiagnostic colonoscopy orsigmoidoscopy, and take careof the hemorrhoids in thesame procedure.”

The new IRC approachhas received FDA approvaland has been tested in morethan 100 patients in multiplecenters. The study is beingsubmitted to surgical journalsas Maryland Physician goesto press. Most insurers coverthe procedure.

Hemorrhoidectomy isthe procedure of last resort.It should be reserved forpatients who fail lessaggressive therapies or thosefor whom endoscopy iscontraindicated. Dr. Raiconcludes, “It takes mostpatients up to a week torecover and they oftenexperience significant painand sometimes infection.The problem may alsoreturn in a few years andsurgery is contraindicatedin inflammatory conditionssuch as Crohn’s Colitis.”


Rudra Rai, MD, MBA, FACG is an assistant professor at Johns HopkinsUniversity, and director of the Gastro Center of Maryland. He is a staffgastroenterologist at Howard County General Hospital.


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mHealth

Healthcare IT

Why physicians should become familiar with mobilehealthcare tools / BY LINDA HARDER


What is mHealth? What is mobile health, oftenknownasmHealth?While definitions vary, the termgenerallyrefers to usingmobile devices, such asmobile phones, PDAsand tablets, to support health services or information.Mobiledevices can be used for a variety of health-related tasks,including accessing medical information from the web andhelping patients better monitor or assess a wide variety ofhealth and fitness indicators.

Be Ready for

Current Physician Usage Primarilyfor EducationWhile most doctors are not usingmHealth for patient care, mobile deviceshave become ubiquitous for practicingmedicine. More than 75% of doctors nowuse smart phones, and tablet use withinthe hospital or medical practice isskyrocketing. Popular mobile apps forphysicians include:

� Medscape Mobile – news, full-textjournal articles, CME and referencematerials

� Sermo – doctor-to-doctor socialnetwork enables on-the-go discussions

� MIM Mobile – FDA-approved remotediagnostic imaging tool

� ICD-10 Premium 2011 – details ofICD-10 diagnostic codes

� JEMS Video Consult – HIPAA-compliant viewing of live medicalconsults

Hospitals, an important part of themobile trend, are beginning to usetablets to create helpful tools such ascustomizable dashboards for physiciansto quickly access key patient healthdata such as vital signs, lab results andmedications.

Physicians have been slow toadopt mHealth for patient healthmonitoring. Ed Bennett, director, Web& Communications Technology atUniversity of Maryland Medical Center,says, “There’s a legitimate inertia amongphysicians to use e-devices. Few studiesexist showing its efficacy and physiciansare right to be cautious given theaccompanying legal and privacy issues.”

Suzanne Sysko Clough, M.D., aMaryland endocrinologist and founder/CMO of WellDoc, Inc., one of a smallnumber of Maryland physicians creatinginteractive mHealth tools, concurs.“mHealth adoption by physicians isexactly where it should be, given wherewe are in the life cycle of innovation.

The diffusion of innovation takessome time, but there are early adoptersout there who recognize the ability ofsome of these solutions to move theneedle on health outcomes as well asincrease revenue, both directly andindirectly, to the practice. It will also helpas more mHealth applications receiveFDA clearance.”

Patient Usage is Exploding,Moving Beyond FitnessmHealth tools and applications forpatients are exploding, and the reality isthat many people are or soon will beusing one or more mHealth technologiesin their lives. One estimate puts thenumber of health-related mobile appsat more than 17,000. Most apps havebeen oriented to fitness and weightmanagement, but that’s changing.Emerging applications include:

� Continuous glucose monitoring� Sleep monitoring� Checking blood pressure and other

vital signs� Electrocardiograms� Using saliva and a smartphone to

diagnose infectious disease� Monitoring glaucoma� Screening for genotypes before

administering some medications

The potential for mHealth to extendcare beyond the medical office is vast.“The healthcare system really is built tobest support subacute and acute care,”Dr. Clough says. “Chronic disease is allabout behavior change and givingpatients the skills and confidence toself-manage their disease for the longhaul. mHealth can enable physicians tosupport and encourage behavior change‘virtually’ during those 8,700 hours apatient is out on their own, living dayto day with their disease.”

One of WellDoc’s products isDiabetesManager, an FDA-approvedsoftware-based medical device powered bya proprietary Automated Expert AnalyticsSystem™. It provides real-time patientcoaching plus clinical decision supportto their healthcare providers, extendingcare beyond traditional office visits.

In a study published in theSeptember, 2011 issue of Diabetes Care,patients using this mHealth device hadan average decline in A1C of 1.9%compared to a 0.7% decline seen amongpatients not using the system. In a secondstudy – a recent demonstration projectcalled DC HealthConnect – Medicaid

patients with type 2 diabetes who usedWellDoc’s DiabetesManager for one yearcut their ER visits and hospitalizationsby more than half.

To physicians who believe thatpatients won’t use this type of devicebecause they currently don’t check theirblood glucose levels, Dr. Clough says,“Of course patients aren’t checking themnow – they’re just dumb numbers. Weneed to provide the data in context –tying a blood glucose value to a specificevent and then helping the patient learnfrom the data. This is done via bothclinical and behavioral algorithms,because people have a lot more goingon in their lives than their disease.”

She continues, “Some programsprovide only one-way text messaging. Thatcan be effective for certain health careissues. But complicated chronic diseasesneed more. We’re using analytic toolsgeared to the needs of both patients andproviders. Effective solutions must employadvanced analytics, user segmentation,behavioral change and just-in-timefeedback. Most importantly, solutions mustbe simple to use and encourage users toengage and stay engaged.”

“Don’t assume patients won’t usemHealth solutions because they’re‘non-compliant’ now,” Dr. Clough adds.“The biggest wake up call I’ve had is howmuch of patient non-compliance reallystems from poor health literacy and/orfeeling overwhelmed or frustrated by theirdisease. You would not believe how

powerful something as simple as apositive message about checking theirBG can be. At home, patients get only anumber on a meter that often is not evenlooked at by a physician. There will soonbe a lot of mHealth options out there.Physicians should ask if it has FDAclearance and demonstrated outcomes,if it can be integrated into your practicework flow and determine the expectationsof your involvement with the solution.”

For now, physicians should be awareof what apps their patients are using andwhat mHealth options are available, sothat they can use – and guide patientusage of – these tools as appropriate.


“mHealth can enable physicians to support andencourage behavior change virtually...”– Suzanne J. Czinn, M.D.


HE RAPID GROWTH AMONGthe division of gastroenterology atthe University of Maryland Children’s

Hospital, which now treats nearly 5000patients a year, is not surprising given thatit combines child-friendly care with world-class technology and expertise. Steven J.Czinn, M.D., professor and chair ofpediatrics at the University of Maryland,says, “The staff have created an incredibleexperience for children with digestivedisorders and their families. They’rehighly responsive, getting patients inquickly and bringing cutting-edgetechnology to treat and diagnose virtuallyevery stomach and intestinal disorder.”

The pediatric GI specialists seechildren and teens downtown andacross the state, in the patients’ owncommunities. “We have clinics in Bel Airand Glen Burnie, and we’re also at Mt.Washington Pediatric Hospital severaldays a week,” observes Anca Safta, M.D.,director of endoscopy. “Our team hasgrown to five full time and several parttime physicians, plus a nurse practitioner,six RNs, a dietitian and an infusion tech.”

“Our staff includes Dr. AlessioFasano, the world’s authority on celiacdisease, who is both treating patients andconducting the research to help cure it,”adds Dr. Czinn, who is a recognizedleader in H. pylori research, immunologyand vaccination.

Capsule Endoscopy Peers intothe ‘Black Box’The use of wireless capsule endoscopy(PillCam) is a major advancement in

providing child-friendly care. Nearly100 children at the University ofMaryland have had an accurate diagnosisin the distal colon, which cannot bereached by either a colonoscopy or anendoscopy.

“This ‘black box’ as it’s called, hasnow been opened,” notes Dr. Safta.“We can tailor the treatment for thedisorder, rather than treating the childblindly. We can see problems such asinflammatory changes and ulcerationthat lead to an accurate diagnosis andsave years of improper treatment.”

Dr. Safta explains the procedure.“After the child swallows the capsule,

(s)he wears a belt with a special receptorfor eight hours. Soon thereafter, we candownload the images and give the familyan answer in a day or two. Thanks to thistechnology, a teenage girl with severepain was diagnosed with celiac diseaseafter other tests indicated she was inremission. She is now doing well on agluten-free diet and Remicade.”

Comfort Reigns at Infusion CenterPatients who need bimonthly infusionsof biologic therapies such as Remicade, orIV iron and fluid repletion are treated asoutpatients in the Pediatric GI InfusionCenter, where skilled pediatric nursesadminister care in a comfortable settingcomplete with flat screen televisions.“We can keep most children out of thehospital thanks to this infusion center,”says Dr. Czinn.

Comprehensive ProceduresThe University of Maryland Children’sHospital provides everything to diagnoseand treat pediatric GI disorders exceptfor ERCPs and ultrasound endoscopy,including:

� Upper endoscopy� Sigmoidoscopy� Colonoscopy� Feeding gastrostomy and

gastro-jejunal tubes� Gastrostomy closures� Liver biopsies� Breath testing to evaluate carbohydrate

malabsorption and bacterial overgrowth� Capsule endoscopy� Impedance and pH probe testing� Antroduodenal, anorectal, colonic

manometry� Variceal banding and/or sclerotherapy� Polypectomy� Suction rectal biopsy

Treatment of Virtually all GI DisordersVirtually all stomach and intestinaldisorders are treated, including:

� IBD – Crohn’s disease and ulcerativecolitis

� Celiac disease� Liver disease, including pre/post

transplant care, biliary atresia

Profile

A Near-Normal Childhood for Thosewith Digestive Diseases

SPONSORED CONTENT

Components of thePediatric Digestive

Disease Center

� Pediatric IBS Center

� Celiac Center

� Pediatric Infusion Center

� Eosinophilic Center

� Multi-disciplinary Care

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“The staff have created an incredible experiencefor children with digestive disorders and theirfamilies." – Steven J. Czinn, M.D., professor and chair of pediatrics

The University of Maryland Children’s HospitalIs Child-Friendly in Every Respect

T

� GERD� Eosinophilic esophagitis and

gastroenteropathies� Hepatitis B and C� Organic and functional GI disorders,

including IBS, chronic abdominalpain, functional constipation,dyspesias

� Carbohydrate malabsorption� Failure to thrive and special needs� Metabolic disorders� Short bowel syndrome

Medication regimens are tailored foreach individual patient. Many childrenalso benefit from working with the on-staff dietitian, who creates a tailored dietplan that ensures the child gets thenutrients needed for growth – with foodshe or she likes and will eat.

Surgery is a last resort. “The needfor colectomy is decreasing, thanks tobetter medications,” explains SamraBlanchard, M.D., division head ofpediatric gastroenterology. “However,when it’s necessary, our pediatricsurgeons are experts at using the latestminimally invasive procedures to reducetrauma and recovery time.”

When to Refer A ChildConsider referral when a child has:

� Recurrent reflux, constipation,abdominal pain, or diarrhea

� Rectal bleeding� Unexplained weight loss� Delayed growth and development

“Our goal is to diagnose GI disordersbefore they cause delayed developmentor irreversible harm,” Dr. Blanchard says.“With timely diagnoses, children canreach their full potential and live a nearlynormal childhood.”


"[Using capsule endoscopy], we can seeproblems such as inflammatory changes andulceration that lead to an accurate diagnosisand save years of improper treatment."

– Anca Safta, M.D.

Anca Safta, M.D., director of endoscopy at The University of Maryland's Children Hospital.

For more information, physiciansmay contact all University ofMaryland physicians and servicesat 1-800-373-4111 or PediatricGastroenterology directly [email protected].

HERE IS NO BETTER WAY TOsee the country than from the seat of abicycle, where not even a windshieldstands between you and the miles ofbeautiful landscape.

For many physicians like RobertStroud, M.D., a radiologist who spendshours in dark rooms reviewing patientfilms and images, bicycling is the perfectescape from their busy schedules.

“Biking is an ideal way to get outsideand see 20, 30, 40miles of gorgeous scenery,”Dr. Stroud said. “And it’s great exercise.”

Whether pedaling down roads or trails,physicians across Maryland have embracedcycling as a stress relieving pastime. Thestate offers a variety of riding options,ranging from casual group rides through

the hills of Baltimore County, along the C& O Canal and the long-distance racesalong the Eastern Shore.

“Whether you’re going riding withyour kids, long distance biking, racing,mountain biking, or commuting to work,bicycling is a lifetime sport,” explainedMarc Lefkowitz, vice president of RacePace Bicycles.

Not only does biking accommodatemany different lifestyles, it alsopositively affects some of the world’shealth and environment issues.“Bicycling is completely healthy, goodfor the environment, and takes care ofso many of today’s problems, such ascarbon footprint and obesity. Biking isall good,” Lefkowitz further offers.

It All Starts With The FitFor the best and most comfortable ride,it all starts with the fit. Bike frames andcomponents must be designed a specificway to fit women and men, and toaccommodate different-sized people. Inthe shop, small adjustments can then bemade to the seat height and handlebars,but to guarantee a perfect fit, a custombike can be built to your exact measure-ments and preferences.

Fitting a rider to a bike is an art; anexperienced fitter will take into accountexactly what the rider wants. Along withfitted measurements, custom bikes alsooffer uniqueness, flexibility in design,and practicality if your bodily proportionsare far from typical.


Living

Gearing Up For Spring

T

Allison Eatough and Jackie Kinsella

COURTE

SYOFSE

AGULL

CEN

TURY

Sponsored by Salisbury University, the Sea Gull Century Ride is a 100-milebike ride with about 8,000 participants from around the globe.

Fit is paramount, but once themeasurements are right, choose the bikethat most appeals to you.

“Finding the right bike is essential,”advised Stephen Jack, co-owner of BikeDoctor in Annapolis. “First, determinethe types of riding you want to do and towhat degree. With road, mountain orcyclocross, the more miles a cyclist plansto ride in a month, the better thecomponents need to be on the bike.”

A solid riding bike can cost anywherefrom $500 to $5,000. When deciding onthe right bicycle budget to fit yourlifestyle, it is important to remember thatspending more buys a lighter bike withsmoother shifting, braking, and moredurability.

When figuring out a budget, “Don’tforget the accessories, such as helmets,padded shorts, gloves and bright clothingso drivers notice you,” Jack added. Formore competitive cyclists, a small bikecomputer is a great investment,measuring distance, speed and time.

Physicians On The Open RoadGarth Smith, M.D., an orthopedicsurgeon in Annapolis, and Patrick Cooper,M.D., a military neurosurgeon at WalterReed Military Medical Center inBethesda, prefer early morning rides torelax and clear their minds before a longday of work.

“The rare times that I am notobligated to pick kids up from schoolor Tae Kwon Do, I will ride into work,”Cooper commented. “Weekends whennot on call are optimal, but on morethan a few occasions, I’ve been pagedto an emergency while in the middle ofa great ride up at Schaeffer Farms (inGermantown).”

“Finding fellow cyclists to ride withalso helps,” said Smith, who rides withseveral other physicians on a regularbasis. “It is a good way to get together.”

Not only is riding with a group saferthan riding alone, but it also adds a nicefriendly competition to the ride andcauses you to challenge yourself and yourskill level against other riders.

“Another option is riding with abike-shop sponsored group,” Dr. Stroudcontributed.

Joining a bike-shop sponsored groupis an excellent way to meet others thatshare your passion. Throughout theyear, group and weekend rides areoffered in shops all over Maryland. Race

Pace Bicycles, which has locationsthroughout Maryland, offers indoortraining rides and mountain bike ridesamong other types.

Getting CompetitiveFor physicians who want to pushthemselves even further, there are dozensof bike races throughout Maryland inspring, summer and fall.

In preparation for races and long

rides, Dr. Smith recommends road ridersstart with an individual time trial in whichcyclists’ race alone against the clock. “It’sbasically the race of truth. There are noaccidents with another cyclist.”

“Roadies looking for more of anendurance challenge could tackle a100-mile race like the Sea Gull Centuryin Salisbury,” Dr. Stroud said. “Just beprepared to log some training milesbeforehand.”


If you long to feel the electricity at the starting line of arace, here are a few area events to get you moving:Church Creek Time Trial (road) Date: June 23, 2012 & August 18, 2012.

The Church Creek Time Trial is a 40-kilometer smooth, fast and scenic course in

Church Creek, just outside of Cambridge. Hosted by the Annapolis Bicycle Racing

Team, the time trial is usually part of the Time Trial Series.

Sea Gull Century (road) – Date: October 6, 2012.

The Sea Gull Century is a 100-mile or 100-kilometer bike ride hosted by Salisbury

University. The ride takes participants through Wicomico, Somerset and Worcester

counties. www.seagullcentury.org.

Bay Country Century (road) – Date: September 1, 2012.

The Bay Country Century includes a 25-, 50-, 62- and 100-mile bike ride hosted by

the Annapolis Bicycle Racing Team. The ride takes participants along the

Chesapeake Bay’s western shore. www.abrtcycling.com.

MoCoEpic (mountain) – Date: October 14, 2012.

The MoCo Epic is a 25-, 35-, 50- and 62-mile ride hosted by Denis Chazelle that

crosses up to 10 different Montgomery County parks. www.mocoepic.com.

Greenbrier Challenge (mountain) – Date: April 29, 2012.

The Greenbrier Challenge race course is 5.7 miles long, and the number of laps

depends on the racing class. Hosted by Potomac Velo Club, the race is held in hilly

and rocky Greenbrier State Park in Boonsboro. www.greenbrier.potomacvelo.com

The Sea Gull Century takes participants throughout the scenicroads of Wicomico, Somerset, and Worcester counties.

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Q: You are the first AttorneyGeneral to work with physicians topass the Assignment of Benefits Law,which dealt with assignment ofbenefits for non-preferred providers.Why did you take on that issue?Everyone needs a doctor at some point.We want to make sure that doctors havean advocate in state government andthat’s the role I took upon myself…doctors have to get more politicallyactive. Planners fashion the debate andshape it as they want it to be. Doctorsthink they’re immune from it… Theythink, ‘I’m just here to take care ofpeople.’ I think MedChi has grown ininfluence in more recent years… somedoctors are getting more involved andrealize that what happens in Annapolisdoes indeed affect them and consumers.

Q: Why were you the lead in filingan amicus brief to the U.S. SupremeCourt supporting the Affordable CareAct (ACA)?

We were the lead state in the amicus briefthat supported the Patient Protection andAffordable Care Act. Not because weagree with all of the provisions of the act– most of us, like most Americans,haven’t read all of it. Our role in that wasto say yes, the federal government doeshave the authority to address thehealthcare crisis and does have the abilityto pass laws…

The Department of Justice asked us totake the lead because of our role in some ofthe cases in the lower courts. We were ableto speak from the perspective of statesregarding issues of the federal government…The Supreme Court took on four issues…The biggest one was, ‘Does congress havethe ability to pass this law?’…

Q: What challenges will statesface in implementing this law?The states will have great challenges inimplementation. One of the great thingsabout the PPACA is that, from the 30,000-foot level, it’s a federal solution to a

Policy

Interview with Douglas F. Gansler,Attorney General

Maryland PhysicianPublisher/ExecutiveEditor Jacquie RothandManaging EditorLinda Harder recentlysat down with AttorneyGeneral Douglas F.Gansler to discuss hisefforts to supportphysicians and protectconsumers. He alsocomments on speculationsthat he will run forgovernor in 2014.

LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN


national problem, but they give states theability to fashion the essential services asthey choose. I’m on a commission that thegovernor set up to look at implementationin 2014... Josh Auerbach is our principalcounsel at the Department of MentalHealth and Hygiene (DHMH) workingwith Secretary [Joshua] Sharfstein on thisissue. So, Maryland is in the forefront. If forsome reason it does get overturned over bythe Supreme Court, we will still be able toimplement much of what is in the act.

Q: What is the likelihood that theSupreme Court will uphold the law?It should be a 9-0 decision. The federalgovernment can make you pay SocialSecurity and get a driver’s license, theycan take your children to die in warsacross the world…. clearly, they can haveyou buy health insurance. But theRepublicans made this a political issue...The problem is that everyone needs toavail themselves of the healthcare systemat some point… That said, this is perhapsthe most political Supreme Court we’veever had… and these are difficult cases todefend based solely on jurisprudence.Most people think this will be a 5 to 4decision, not withstanding the absurdityof the argument.

Q: What are your greatesthealthcare accomplishments?Each legislative session, we try to supportat least one MedChi-sponsored bill.Tanning and truth in advertising are two2012 session issues that they’ve identifiedfor us. The ‘truth in advertising’ bill is sothat you know who you are seeing, whatdegrees they have, what they’re supposedto be practicing. The bill hasn’t beendrafted yet, but the concept is one that wewould embrace. We also support MedChion not having children use tanning booths.

Our Healthcare Education andAdvocacy Unit (HEAU) is probably, on aday-to-day basis the thing that affectspeople the most... It’s the unit thatmediates between patients and theinsurance companies. The bread andbutter of an AG’s office is protectingconsumers, especially the small personagainst the big guy. When the insurancecompany denies you coverage, you haveno recourse. To hire a lawyer to addressyour claim would cost more than whatyou’re entitled to recover. The insurancecompanies bank on that… What the

HEAU can do is, at no cost, is mediate;they will come in and ask the insurer whythey didn’t cover the procedure… That’sthe most important thing we’ve done.

… Kathleen Sebelius [secretary,Department of Health and HumanServices] came to our office and wastouting our program as a national model.We have a large federal grant to educatepatients and providers about the program.Many providers don’t know that they cando it on behalf of the patient. Theoutreach coordinator has been going toproviders’ offices to educate them...

I’m President-elect of the NationalAssociation of Attorneys General(NAAG), and one of the initiatives I putforward is the prescription drug take-backprogram… We’re working on the wholestate of Maryland becoming a take-backstate so that anyone who has expiredprescription drugs in their home, can takethem back to the pharmacy where theywill dispose of them in an environmentallyfriendly way… We’re going to try to getall 1200Maryland pharmacies to participate.

The antitrust exemption for theinsurance companies is outrageous. We(NAAG) sent a letter to Congress tryingto get that removed in 2010.

The other thing we do is that we’vebrought literally millions and millions ofdollars back to Maryland for our casesagainst the drug companies for off-labelmarketing and other issues.

One of the things MedChi brought tous early on was the issue of physician‘tiering’ by insurance companies. Patientswere using that ranking to determinewhere they were going to go for theircare... The problem was that the insurersdidn’t explain that cost factors were partof that rating. Patients thought that itmeant that the doctor was rated the best.We brought that issue to the task forceand… insurers were forced to disclose[their methodology] as a result.

Q: What impact has the HEAU hadon insurance complaints?We received 1934 consumer complaintsthrough November 30, 2011. Some ofthose are not legitimate or are referred toMIA because it doesn’t fall into ourjurisdiction. If we can get it and we havejurisdiction over it, we have a great successrate. We mediated 919 of them, and 781 ofthose had positive results – that’s an 85%success rate. We recouped $961,000through November 30th for Maryland

consumers… If we had more people, wecould do more, and if more people knewto avail themselves of the unit, I imaginethose numbers would go up.

Q: Are you planning to run forgovernor in 2014? To what do youattribute your successful fundraising?There’s no campaign going on right now…I have two events a year – one in Baltimoreand one in Montgomery County – we’vebeen doing that for about 14 years and wehaven’t changed that component...

I like to think that people in Marylandthink we’re doing a good job protectingconsumers, protecting and helping doctorsis a piece of that. The great thing aboutour job is we’re against criminals and wehelp a lot of people in a lot of differentways… Right now, we’re looking atGoogle’s new privacy statement. All thesethings add up. I was the first state-wideadvocate for same sex marriage and a lotof people think that’s the right thing to do.I don’t have a natural constituency… butwe’ve been fortunate to have peoplesupport our efforts.

Q: If you were to run for governor,what would your healthcare initiativesbe?I’m not running for governor so I don’thave a platform or whitepaper on that.We have been very involved in healthcareissues such as access. That said, it’s amoving target. We’re in a crossroads rightnow, from the old way medical serviceswere delivered to having a new way by2014. Lending a supportive role on thelegal side is critical… My overridingmessage, whatever I run for, is that I amsupportive of doctors. I have the utmostrespect for them. I think they get into theprofession not to make money but to helppeople… Doctors work really, really hardand for very little money while they learntheir trade. I think we ought to make surethat our government supports our doctors.

Note: HB 585, which regulates the use of

physician rating systems by carriers, took effect

in 2010. The bill prohibits carriers from using a

physician rating system unless the system is ap-

proved by a ratings examiner. Note: The Health

Education and Advocacy Unit offers a mediation

service to consumers who have a billing dispute

with their health care provider or a coverage

dispute. File appeals online at www.oag.state.md.

us/consumer/ HEAU.htm or call 410-528-1840.


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

PNC Bank ............................................................................5www.pnc.com

Northwest Hospital.......................................................6www.lifebridgehealth.org

Lifebridge Health ...........................................................9www.lifebridgehealth.org

Maryland General Wound Center.......................10www.marylandgeneral.org

Med Marketer ...............................................................16www.medmarketer.com

Hospice of the Chesapeake ....................................16www.hospicechesapeake.org

KURE Pain Management ..........................................17www.kurepain.com

Anne Arundel Medical Center Gala ...................18www.aahs.org

The Doctors Company ...............................................19www.thedoctors.com

Sandy Spring/Neff ......................................................23www.sandyspringbank.com

Aertight Systems .........................................................23www.aertight.com

University of Maryland Children’s Center ......26www.umm.edu/pediatrics

Papercamera...................................................................32www.papercamera.com

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

University of Maryland ............................................35www.umm.edu/diabetes

Adventist Healthcare .................................................36www.adventisthealthcare.com

MPM online: more content, moreanswers and more often!

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

Jacquie Roth - Publisher/Executive Editor443-837-6948

[email protected]

ONLINEwww.mdphysicianmag.com


RE YOU AND YOURstaff confused by the many evolving rulesof HIPAA (Health Insurance Portabilityand Accountability Act of 1996) andoverlapping state laws? Are you tired ofattending mind-numbing seminars? If so,you have lots of company. As non-compliance can be costly, a few commonsense tips to help your staff adhere toHIPAA rules follow.

HIPAA has several aspects, includingthe “Privacy Rule” and the “SecurityRule.” In 2009, the Security Rule wasaffected by the HITECH Act (HealthInformation Technology for Economicand Clinical Health). The Privacy Ruleand Security Rule apply when “coveredentities” (healthcare providers, healthplans and clearinghouses) transmit orstore information in electronic format.The only practices exempt from HIPAAare those very few that have entirelypaper-based medical records and claimstransmissions.

HIPAA implementation hasgenerated a series of complicated andunread legal forms, such as:

� Notice of Privacy Practices (notifyingpatients as to how a covered entity usestheir protected health information)

� Business Associate Agreement (multi-page contractual obligations requiredfor businesses that assist the coveredentity’s provision of healthcareservices).

Like many legal documents, theseforms only become important to theaffected parties after they are breached.Even the term “protected healthinformation” (PHI), which has a preciselegal meaning, should be thought of, inday-to-day practice, as medical recordsand health insurance information.

The first obligation of HIPAAcompliance is to use common sense toprotect medical records. Providers must

follow the Security Rule’s specificstandards that require administrative,physical, and technical safeguards forrecords.

Administrative standards includeoffice training and policies andprocedures designed to protect theconfidentiality of personal healthinformation.

Physical safeguards refer to thephysical protection of records.

Technical safeguards refer totransmission and other such data transferissues. Many security issues cross severalof these areas.

HIPAA’s implementation is designedto be on a “sliding scale,” according tothe size of the practice. Thus, a largeteaching hospital will be held to a higherstandard than a solo practice physician.However, failures in HIPAA securityimplementation often arise from a failureto think through what the HIPAAstandards really mean: protecting theconfidentiality of protected healthinformation from reasonably anticipatedthreats. When evaluating its securitymeasures, a practice must assess:

� Its size, complexity and capacity� Its technical infrastructure� The cost of security measures� The probability of potential risks to

electronic information

As a practical matter, this means thatoffice staff should be trained to absorbthe concept behind patientconfidentiality. For example, in eachcovered entity’s office, staff shouldconsider how breaches are likely to occur.The answers will vary from office tooffice and may include:

� Re-designing office space (e.g., addinglocked filing cabinets or a separatemedical records room, or reconfiguringthe reception area so that the

receptionist’s computer screen is notvisible to visitors).

� Training staff (e.g., teaching staff not tohand patients a stack of referral slips toallow the patient to look for his own).

� Purchasing a paper shredder.� Programming desktops to require a

password to log in and to log the useroff after a period of inactivity.

� Implementing a system to track theactivity of computer users.

� Requiring the use of passwords onelectronic portable devices that can beeasily lost or stolen.

� Requiring staff to sign an annualconfidentiality reminder.

� In a high-crime area, enhancing thephysical security of the area where therecords are stored.

Proper HIPAA implementation willalways require that staff be trained not tosearch for medical records for which theydo not have a bona fide, work-relatedneed. Many HIPAA breaches aretriggered by a simple desire to satisfycuriosity. Physicians must enforce aprohibition against removing records fromthe office (or, if those records are to beremoved, such as to allow an employee towork from home, ensure that the recordsbe encrypted).Sigrid C. Haines practices law at Lerch, Early

and Brewer where she chairs the firm’s Elder

Law and Healthcare groups. She can be

reached at [email protected]

Compliance

A

Common Sense Measures Ensure aHIPAA Compliant Practice

By Sigrid C. Haines


“Camp Oasis”Offers Inspiration toYoungsterswith Inflammatory Bowel Disease

ORE THAN 1.4million Americans have been diagnosedwith inflammatory bowel disease. Ofthose, approximately 140,000, or 10%,are children. Recognizing the challengesfaced by young people who suffer thiscondition, each year the Crohn’s andColitis Foundation of America (CCFA)offers “Camp Oasis” in locations acrossthe country, giving youngsters with thedisease a chance to come together in asafe and under-standing environmentto learn, interact and perhaps mostimportantly, just be kids for a weekof summertime fun.

In 2011, Jeff Schwartz, M.D., divisiondirector of Gastroenterology at MarylandGeneral Hospital for the past three years,volunteered his time to serve as medicaldirector for Camp Oasis in High View,West Virginia, which attracted 52 campersfrom surrounding states, ranging in agefrom seven to 18. While administeringmedication and tending to the generalhealth and medical needs of the camperswas Dr. Schwartz’s primary focus, anotherequally important role was to simply tobe available to support and encourage agroup of kids who face an abundance ofchallenges in day-to-day life.

“Kids with inflammatory boweldisease often have unpredictable lives,”said Dr. Schwartz, who will return toCamp Oasis to serve as medical directoragain in 2012. “They come to camp andcan ask questions or tell stories that theyare not comfortable talking about in other

environments. It givesthem a chance to relateto others.”

Campers get toparticipate in a variety ofactivities, ranging fromarchery and baseball toswimming, arts andcrafts, games and othergroup-oriented events.In addition to interactingwith Dr. Schwartz, theyare supported by a campnurse, a mental healthspecialist and a teamof camp counselors,many of whom haveinflammatory boweldisease themselves.

“The counselors are incredible rolemodels. They have had similarexperiences but have gone on to do greatthings,” Dr. Schwartz said. “It is reallyimportant for the younger kids to seethat. It motivates them and makes themrealize that they can be successful too.”

Since its launch in 1997, over 4,250children have participated in Camp Oasis,which has grown from a small program toone that is positively impacting children,

and their ability to cope with theirdisease, across America. In 2011, a totalof 12 camp sessions were offered in 11locations coast to coast. Caneka McNeil,Mid-Atlantic Regional Education andSupport Manager for CCFA, who is aCrohn’s disease patient herself, says that

some participants call Camp Oasis a truehome away from home.

“Many of these kids have never metanyone else with the disease,” McNeilsaid. “Here, they can be themselves andbuild friendships with people whounderstand what they are going through.They get to do a lot of things that theynormally cannot do, and they feel goodabout it.”

McNeil encourages physicians whoencounter patients with inflammatorybowel disease to utilize the CCFA website, which features an InformationResource Center to support thosediagnosed and their caregivers.This resource, along with further information

about Camp Oasis, is available by visiting

www.ccfa.org or calling 1-888-694-8872.

Good Deeds

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

“Kids come to camp and can ask questions ortell stories that they are not comfortable talkingabout in other environments. It gives them achance to relate to others.”–Dr. Jeff Schwartz

MBy Tracy M. Fitzgerald

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Dr. Jeff Schwartz spent time answering questions and providingadvice to those who participated in Camp Oasis last summer. Hewill return to serve as medical director for the West Virginia camponce again, in 2012.

University of Maryland Medical Center22 South Greene Street6th Floor NorthBaltimore, MD 212011-888-567-5468umm.edu

Maryland General Hospital821 N. Eutaw Street Suite 300Baltimore, MD 21201443-552-2960marylandgeneral.org

Baltimore Washington Medical Center300 Hospital Drive Suite 119Glen Burnie, MD 21061410-787-4940mybwmc.org

Shore HealthMemorial Hospital219 S. Washington StreetEaston, MD 21601410-822-1000, ext. 5757shorehealth.org

Upper Chesapeake Medical CenterPhysician Pavilion II Suite 510Bel Air, MD 21014443-643-3200uchs.org

umm.edu/diabetes | University of Maryland OneCall for Physicians: 1-800-373-4111

beware diabetes:across maryland, there’s a network of experts

empowering patients to control you.

With 5 locations across the state, the University of Maryland Center for Diabetesand Endocrinology provides the highest level of diabetes care. In Baltimore, Bel Air,Easton and Glen Burnie, the multidisciplinary teams of experts attack diabetes from all angles, arming patients with the medical, educational, and emotional support needed to control their disease. Here’s a warning to diabetes and other endocrinology disorders: the University of Maryland Center for Diabetes and Endocrinology takes charge of diseases like you.

Documents

Maryland Physician Magazine March/April 2012 Issue