KRISTIThe “Faces of Influenza” campaign and why

Kristi encorages everyone to get vaccinated

Med MonthlyNovember 2011

the chronic disease

issue

THE SICKLE CELL TREATMENTAnd why patients with sickle cell are being treated so poorly

HOW TO USE YOUR

WEBSITE FOR PATIENT EDUCATION

HEALTHY APPSSomething for doctors and patients!

BONE LOSS & preventable fractures

contents

24 FACES OF INFLUENZA And why health care works need to get vaccinated

20 CELIAC AND CROHN’S DISEASEThe quest for a better diagnosis

26 OSTEOPOROSISBone loss and preventable fractures

research and technology

8 SICKLE CELL

your practice

10 MOBILE HOME HEALTH12 USING A BLOG FOR PATIENT EDUCATION14 APPS FOR MANAGING HEALTH CARE17 BY THE NUMBERS

legal18 NEW ACO RULES

the arts32 HEALING THROUGH ART

healthy living34 GREENS AND GRAINS

the kitchen37 HOMEMADE APPLE CRISP

features

in every issue4 publisher’s letter8 news briefs

48 classified listings52 top nine

COVER PHOTO COURTESY NOAH BERGER OF NOAH BERGER PHOTOGRAPHY

37Apple crispYUMMO!

24 Why flu vaccines are important

(p)860.951.3004 ROBERTBENSONPHOTO.COM

Publisher

Philip Driver

Publisher

Contributing Editors

Creative Director

Contributors

Marketing Manager

4 | NOVEMBER 2011

publisher’s letter

T he November issue of Med Monthly focuses on chronic disease. From a feature about new medication and treatment option for Celiac and Crohn’s patients to a story on Ken Ataga, M.D.’s research on sickle cell

anemia, this month we present articles that will assist physi-cians and medical providers in the diagnosis and treatment of these potentially life threatening illnesses.

Our November cover story is about Influenza and the need for everyone to be vaccinated. Norman Edelman, M.D. explains us why it is so important for health care providers and workers need to get vaccinated and our cover girl, Kristi Yamaguchi, along with her mother Carole are putting a face on immunizing for the flu season.

We also hear from James Rupp, M.D., a gynecologist who writes about bone loss, preventable fractures and the impor-tance of DXA scans, even for younger patients.

Mary Pat Whaley, a nationally renounced practice consul-tant, talks about the shifting demographics of baby boomers and the fast adoption of smart devices empowering patients. Elizabeth Witherspoon, Ph.D. continues the discussion about smart apps and how they enable medical practitioners to read lab reports or scans and monitor patients remotely.

And finally, Kim Licata explains the new ACO rules that were finally released late last month. This represents a major step forward for transforming Medicare and Medicaid. The options for participating in health care reform will affect every doctor and their approach to treating patients.

Med Monthly also debuts its Medical Resource Guide this month. We invite medical vendors to utilize this section to inform health care providers about their goods and services.

We hope you enjoy reading Med Monthly and remember to tell a colleague to check us out anytime for free online.

Med Monthly

Publisher

Contributing Editors

Creative Director

Contributors

Marketing Manager

Philip Driver

Ashley AustinMollie Doll

Courtney Flaherty

Mary Pat Whaley, FACMPE Kimberly LicataElizabeth Witherspoon, PhD.James P Rupp MD FACOGAshley Acornley, R.D., L.D.N.Shirin Peters, M.D. Marla BroadfootNorman Edelman, M.D.Ashley AustinWhitney Howell

Will O’Neil

Med Monthly is a national monthly magazine committed to providing

insights about the health care profession, current events, what’s

working and what’s not in the health care industry, as well as practical

advice for physicians and practices. We are currently accepting articles to

be considered for publication. For more information on writing for Med Monthly,

check out our writer’s guidelines at medmontly.com/writersguidelines.

November 2011

Subscription InformationSubscriptions are $69 for one year or $89 for two years. Individual copies are $5.95 each. To subscribe call 919.747.9031 or

visit medmonthly.com

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Online 24/7 at medmonthly.com

Mary Pat Whaley, FACMPE is board certified in health care man-agement and a Fellow in the Ameri-can College of Medical Practice Executives. She has worked in health care and health care management for 25 years. She can be contacted at marypatwhaley@gmail.com.

Shauna Smith Duty has written and edited numerous websites, articles, advertisements, and blogs. She is president and C.O.O at Modern Dental Practice Marketing, an internet marketing company that caters to the dental and medical communities. Learn

more about Duty at moderndentalmarketing.com.

MEDMONTHLY.COM |5

James P. Rupp M.D., FACOGDr. Rupp is a native of Philadelphia. He received his M.D. from Thomas Jefferson Medical College in 1980, and finished his residency at Temple University Hospital in 1984. Dr. Rupp has been a practicing Gynecologist in Seaford, Del. for over 25 years. He interprets approximately 1000

DXA scans each year. In addition to practicing medicine, Dr. Rupp is an avid golfer, musician, and enjoys watching his beloved Philadelphia pro sports teams.

contributors

Ashley Acornley, R.D., L.D.N.holds a B.S. in Nutritional Sciences with a minor in Kinesiology from Penn State University. She completed her Dietetic Internship at Meredith College and is currently working on completing her Master’s Degree in Nutrition. She is also an AFAA certified personal trainer. Her blog

can be found at: ashleyfreshfromthefarm.wordpress.com.

Shirin Peters, M.D.earned an M.D. from New York Medical College and completed her residency training at two differ-ent NYC hospitals. She worked as a primary care provider at Bethany Medical Center in High Point, N.C. as well as a Physician Investigator

at Peters Medical Research. She now lives in New York City and is owner of Urban Orchid Medical, a medical practice with a focus on nutrition, weight loss, physical health and skin care.

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ManageMyPractice.comYour go-to resource for health-care practice management

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About the expert

Mary Pat Whaley, FACMPE, is board certified in health-care management and a fellow in the American College

of Medical Practice Executives. She has worked in health care and health-care management for over 25 years. Mary

Pat is also a well-respected author and highly sought-out speaker

and consultant.

Manage My Practice is the go-to online source of technology, information and resources for practice management professionals, and it is visited by over 10,000 medical-practice managers and medical providers each month.

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research & technology

There was nothing to shorten the sickle cell patients’ pain episodes or prevent them from happening in the first place.

What’s worse, many of Ataga’s fellow physicians assumed that because these sick patients kept showing up on their doorstep they must be addicts jone-sing for more drugs.

“It became clear to me that some-one had to do something,” said Ataga, who is now an associate professor of medicine and director of the Sickle Cell Program at University of North Carolina at Chapel Hill.

Ataga was still in his medical train-ing when hydroxyurea, the only drug available for these episodes, entered the scene. Because the drug was pre-viously used as a chemotherapy agent it came with its own set of risks, but it was the only option available for des-perate patients. Ataga wanted to pro-vide other options. When he voiced his interest to sickle cell researcher

Clearing sickle cell disease’s clogged pipes During his residency, Ken Ataga, M.D., was distressed by the poor treatment given to some of the people that came into his hospital. Those patients — who had the blood disorder sickle cell disease — would show up in excruciating pain, get pain meds and IV fluids, and be sent on their way.

By Marla Vacek Broadfoot

Gene Orringer, M.D., he was met with unbridled enthusiasm.

“He went out of his way to encour-age me to pursue this as my focus, and because he was so enthusiastic about it I actually found his enthusi-asm infectious,” said Ataga, who later was mentored by Orringer on his path to clinical research through the N.C. Translational and Clinical Sciences (NC TraCS) Institute K30 program. “I decided it would be a good goal to pursue, to explore the disease and see if I could develop new treatments. It is not like I grew up saying I wanted to work on the disease, but looking back I am glad I did that because it has been a real eye opener.”

Ataga is originally from Nigeria, where as many as one to two percent of its population of 250 million are afflicted with the disease. In Nigeria, sickle cell disease is a common health problem; if you don’t have it yourself, you have a friend or relative that does.

In the United States, it is a different story: less than 200,000 people are di-agnosed with sickle cell. Ataga thinks this difference is to blame for what he has seen as a general disinterest of pharmaceutical companies to pursue research on sickle cell disease. If drug discovery is a numbers game, Ataga says that money makers like diabetes and hypertension will win out over what is seen in the Western world as a rare blood disorder.

In sickle cell disease — as the name suggests — the body’s red blood cells assume an abnormal, rigid, sickle shape. The sickling is caused by a defect in the gene for hemoglobin, the molecule responsible for carrying oxygen in the blood. Normally red blood cells are very supple and move easily through veins and arteries, but the abnormally shaped cells of sickle cell disease can get stuck in small blood vessels and block blood flow and oxygen to parts of the body.

“You can imagine if the blood ves-sel is a pipe with cells flowing through it and blood cells are sticking to the side of the wall, the cells get stuck to the blood vessel wall and cause an obstruction of blood flow,” said Ataga. “This decreased blood flow to organs and tissues can cause patients to develop pain. And because blood flows to every part of the body, sickle cell disease can affect just about every organ of the body. For a clinician that can make it an interesting disease to study, but for a patient that is obvi-ously not interesting at all.”

One of the aspects of sickle cell disease that has piqued Ataga’s inter-

est has to do with another type of blood cell, the platelet. When a wound suddenly appears, platelets are the first group of cells that are activated and form clots to stop the bleeding. But platelets are also very active in people with sickle cell disease, though no one knows exactly why. So Ataga joined forces with Leslie Parise, Ph.D., profes-sor and chair of biochemistry at UNC, to look more closely at the molecular players responsible for turning on platelets. They focused on a compound called CD40 ligand that first pops up on the surface of activated platelets and then gets chopped by enzymes into a substance that circulates in the blood.

Ataga and Parise, as well as Sher-itha Lee, a former graduate student in the laboratory of Parise, looked at the levels of CD40 ligand on the platelets and in the blood of sickle cell patients when they were healthy and when they were in crisis, and then com-pared those levels to people without sickle cell disease. They found that the patients had lower levels of this com-pound in their platelets and higher levels in their blood than the healthy controls. The differences became even more pronounced when the patients were having a painful crisis. So Ataga wondered if keeping the platelets from releasing this compound into the blood could temper these painful episodes in sickle cell patients.

“The treatment we give patients in 2011 in the U.S. is the same treatment they have received for the last fifty years,” said Ataga. “We simply don’t have any treatment that can shorten or terminate these pain episodes [which can last from hours to days]. Let’s compare that to treatments for heart attacks: if a patient comes in with chest pain and is having a heart attack, you give them medicine or do an angioplasty to bust up the clot and minimize that episode. We don’t have a similar approach for sickle cell dis-ease – which is not to say that people

haven’t tried; it is just that nothing has worked so far. So what I am trying to do is to test a drug that potentially could either terminate or reduce the duration of the pain episode.”

That drug is called eptifibatide, which is already in use for acute coronary syndrome. It also happens to block the release of CD40 ligand from platelets, decreasing the stickiness of platelets so they don’t aggregate as much during a crisis. Right now Ataga is using the Clinical and Translational Research Center (CTRC), the clinical unit of NC TraCS Institute, to conduct a double-blinded placebo-controlled study assessing the effects of eptifiba-tide on patients. Ataga hopes the drug will help decrease the vicious cycle that occurs during the painful crisis, potentially reducing the amount of time his patients are in pain. So far, the treatment appears to be well-tolerated, but Ataga will not know until the end of the study whether it has made the crisis period shorter and

more tolerable.Ataga has been through the clini-

cal trial rigamorole before. He helped take, Senicapoc — a drug designed to hydrate red blood cells and make them sickle less — through phase I, II, and III trials. Then the trials stopped when the UNC Data and Safety Monitoring Board found that the drug did not decrease the frequency of painful crises. Because sickle cell is a complicated disease, Ataga says, no one knows what is going to work and what is not going to work until it goes through trials. And those trials take funding, something that is in short supply when dealing with a “rare” dis-ease and a tough economic climate.

“I get frustrated, but I can’t change the system all by myself,” said Ataga. “I am a physician so I feel like my primary responsibility is to take care of patients the best I can, meaning that research is often secondary. But that doesn’t mean I have given up hope that one of the new approaches I am trying will work.”

Unlike these normal blood cells, sickle cells are rigid with abnormal shape

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your practice

One of the most exciting trends in modern health care can be found at the intersection of two larger

societal changes: the shifting demo-graphics of an aging baby boomer population, and the fast adoption of smart mobile devices and mobile ap-plication platforms. As robust, secure and intuitive mHealth applications are adopted, patients are more empow-ered to monitor and share their health data outside of a traditional medical office or hospital setting. As the health care delivery system already short on providers becomes even more taxed, mHealth applications will allow the system as a whole (patients, caregiv-ers, loved ones and payers) to navigate health decisions in a more efficient and informed way.

What are the advantages of pushing home health medical data from the source to the care provider?

Minimum lag time between data collection and the clinician’s ability to review it. Reduction in errors associated with human intervention in data entry.Intuitive and simple interfaces promote active patient involvement and caregiver communication in

health care management. Secure sharing of PHI (Protected Health Information) with patient, family members and approved internal and external stakeholders in health.Here are just a few of the compa-

nies and products available now (or in the near future) that might change your mind about where and how health data is captured and shared. Each of these products automates the capture of health data and the transfer

of the data in a usable format to an electronic health record.

Near Field CommunicationsNFC (Near Field Communications)

is a wireless technology that allows for quick transfer of data between two sensors that are fairly close (an inch or two) together. The secure trans-fer allows for seamless data track-ing inside caregivers’ workflow. For

mHealth gives home health a whole new meaning

By Mary Pat Whaleymangaemypractice.com

Smart products change date tracking and better monitor patients

‘‘example: medical supplies, drugs, in-jectables and fluids can be fitted with low cost sensors that are swiped past a patient’s sensor to indicate they will be administered to the patient, and then again past the provider’s sensor to indicate a finished procedure, cap-turing time of administration, dosage and patient information without slow-ing down the care to enter this critical data by writing them down, typing them in or just resolving to remember them for later entry.

Gentag makes the data sensors and applications that manufacturers can use to send data via cell phone to the hospital or physician for seamless inclusion in the electronic medical record (EMR). Monitoring of blood pressure, fever, weight management and urinalysis are just a few of the ways Gentag has improved data cap-ture in health care.

iMPak Health makes a cholesterol monitor the size of a credit card that accepts a small blood sample to pro-cess for triglyceride levels. The data is uploaded wirelessly to a cell phone that transmits it to a health provider.

Smart Fabrics and Wearable Monitors

Researchers at the Universidad Carlos III de Madrid in Spain de-veloped a fascinating concept for an “intelligent t-shirt” that uses sensors woven into a washable fabric to create a hospital garment that does more than preserve the patient’s modesty. The sensors in the fabric can detect and record temperature, bioelectric impulses (for ECG monitoring), as well as the patient’s location, current resting position and level of physical activity.

Copenhagen Institute of Interac-tion Design graduate Pedro Nakazato Andrade designed a dynamic cast called Bones that collects muscle

activity data around a fracture area by using electromyographic (EMG) sen-sors to report the patient’s progress to physicians automatically. This could reduce the need for follow-up visits

Boomers view tech-enabled health products as a way to foster control and ongoing independence for themselves, especially in light of the rise in incidence in chronic disease with aging, and their desire to reduce costs.”

The Deloitte Center for Health Solutions 2010 Survey of Health Care Consumers

that can run on any device. As with any networked application of sensitive data, security and availability are ma-jor factors in a successful deployment. Unless patients can count on the pri-

and imaging, or change the specifics of rehabilitation.

The Basis Band is a wristwatch-type accessory that monitors heart rate by directing light into the skin to image blood flow. It also uses a heat sensor for skin temperature changes, an ac-celerometer for recording movement and activity and sensors for galvanic skin response. The band also gives customers access to a free, web-based health dashboard to oversee the data the device collects and transmits.

There are still some considerable hurdles to full adoption of mobile home health monitoring. Very few pa-tients use only one medical device, so not only do monitoring devices need to work with networked electronic health record (EHR) technologies, they have to be integrated with each other to present a comprehensive pic-ture of health to providers and Health Information Exchanges (HIEs).

Also, as patients navigate the system of generalists, specialists and emergency care providers, the pos-sibility of encountering multiple software and hardware platforms will require flexible, integrated solutions

vacy of their data and providers can count on the uptime of their software, health care systems won’t be able to realize the full benefit of mHealth installations. On top of that, more monitoring of patient health means that there will be even more data to be collected on each patient and on the population as a whole. While more data means more opportunity for large scale research and analysis for the public benefit, it also means more data has to be secured and protected as a part of the health record, requir-ing even more security and storage resources. And finally, the Food and Drug Administration (FDA) will have a large say in the future of mHealth application development through in-dustry regulation. Device makers and application developers will certainly have to work within a governmental framework.

With all that being said, the oppor-tunity to meet the demographic chal-lenges of an already stressed health care system with mobile home health monitoring and EHR will be one of the major themes of the future of both the heath and technology industries.

MEDMONTHLY.COM |11

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12 | NOVEMBER 2011

Learn how to leverage your website & blog for patient education

By Shauna Smith Duty

your practice

Your target market

Most health care professionals prioritize patient education, because an educated patient makes wise, informed deci-sions for treatment. This translates into

higher case acceptance rates for your practice. While personal consultation combined with videos, im-ages, and print materials are important in patient education, don’t overlook the most convenient and customized tool in your arsenal: your website and blog.

The Nucleus for Patient CommunicationYour website should be created to (i) reflect the

brand and philosophy of your office; (ii) increase your visibility to potential patients through search engine optimization; (iii) provide a resource for new patients to find your contact information and loca-tion; (iv) provide a resource for current patients to find post operative instructions, office news and emergency contact information.

You can also integrate your blog, newsletter and pa-tient recognition program into your website. In some states and for some medical disciplines, a website also creates an opportunity for patients to share testimo-nials. In addition to all of this, your website should also provide a custom library of patient educational

Find a competent copy-writer to compose search

engine optimized content that’s clinically accurate, yet easy for patients to under-stand.

Read and edit every page that will be placed on your

website. Your license and repu-tation are at stake.

Make sure that all of the services and library pag-

es on your website contain original content (not found on other websites) that reflects your practice philosophy and treatment preferences.

Post a separate page for every service, tool,

post-operative instruction and symptom that you consider important in your practice.

Make sure that your web-site host and designer

appropriately organize the pages so that they are easy for patients and your office team to find.

Make sure that your web-site host and designer

include metadata and search engine optimization (links, headers, etc.) to maximize your online presence for each page on your website.

Your copywriter should compose, optimize and

post at least one new entry per week on your practice blog. The text should address servic-es you provide, in addition to news about your practice and about healthy living.

On your website and blog, include a search feature

so that your team members and patients can quickly find information on any topic.

Train your team to refer to your website when patients

email or ask questions. The website pages, since they re-flect your professional opinions and offerings, can be used for patient education in the office, as well as in patients’ homes and places of work.

Include your website and blog domains on all

print materials in your office and on your signage too.

1

UPDATING YOUR WEBSITE & TARGETING YOUR BLOGCheck out these tips on leveraging your website for patient education:

materials, including text, diagrams, images and/or video.

AccuracyMedicine is a rapidly evolving

field, particularly in this age of tech-nological advancements. Traditional print materials for patient education can quickly become outdated as re-search, tools and protocols change.

For instance, if a dentist adds laser periodontal treatment to his treatment options, he may need to find and replace all patient educa-tion materials in the office regarding traditional periodontal treatment. At the least, he should supplement the materials with information about the new laser treatment option. On a website, the information can be added instantly. Furthermore, you’ll enjoy the added benefit of search engine optimization for the new procedure.

Convenience A wall of brochures can be over-

whelming to a patient, and busy people don’t want to take time to watch patient education videos. Let’s consider WebMD.com. This website allows people to pinpoint health concerns and then find potential reasons for their symptoms. From there, users can review informa-tion relevant to their situation and narrow down potential causes of symptoms.

Of course, the Internet should not be used for definitive diagnosis or treatment recommendations. How-ever, people appreciate the conve-nience of quickly finding informa-tion that applies to their situation, instead of pouring through texts or wading through brochures and reports that may result in a great waste of time.

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14 | NOVEMBER 2011

your practice

Whether it’s count-ing calories, track-ing training runs or managing a chronic

disease, “There’s an app for that.” Now more than ever people are using applications for smartphones and tablets to manage their health and fitness regimens.

Medical practices, hospitals and government health institutions are getting in on the act too, with mo-bile-optimized websites for phones or specially customized apps for their patients or the public. The level of sophistication ranges from basic location and contact informa-tion to comprehensive health infor-mation and interactive capabilities, such as appointment setting. On the practice side, there are a host of apps that let a medical practitioner use a phone or tablet to read lab reports or

On the smallest screen

By Elizabeth Witherspoon, Ph.D.

Apps are tools for managing health

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“We don’t ever diagnose anybody. We provide people with information that helps them make decisions,” said Wayne Guerra, M.D., a practicing emergency physician and chief medi-cal officer of Healthagen, in Lakewood, Colo. “All the content is written specifi-cally for the mobile device. When you have something wrong with you, the last thing you want to do is get some information and there’s five pages to read.”

In classically mythical inventor style, Guerra, and partner, Peter Hudson,

nition and Response App. Developed by Jason Mihalik, Ph.D., a specialist in exercise, sport science and head trauma at the University of North Carolina at Chapel Hill, and Gerry Gioia, Ph.D., a pediatric neuropsychol-ogist, at Children’s National Medical Center in Washington, D.C., it helps athletic trainers and coaches recognize the sometimes subtle signs and symp-toms of concussion and guides them through the next steps on the sidelines of a ball field.

Apps for Runners and DietersA quick check of popular apps re-

veals, there are too many to count and they vary widely in level of sophistica-tion, which is a good thing. Depending on a person’s needs, they may want a simple calorie counter that does only that – adds up the calories for food you’ve eaten in a day and lets you know how many calories there are in that tuna sandwich and bag of chips you had for lunch. Other calorie coun-ters, like MyFitnessPal, let you pull up menus from restaurants and select the items to have it calculate your intake.

For runners, gmap-pedometer.com isn’t actually a phone app, per se, but a website. Want to map out a training run of, say, five miles from your front door or your hotel in an unfamiliar city? Zoom into the world map to find the location and see all the streets in the surrounding neighborhood. Place pins at the start and end points, find the exact route, distance and even calo-rie count for a given run.

Marcia Noyes of Golden, Colo., swears by the RunKeeper app as she trains for marathons. RunKeeper uses the GPS feature built into the phone, enabling a runner to track how far they’ve gone, how long it took, pac-ing, even heart rate monitoring; it then synchronizes it to a website history

scans and monitor a patient remotely. Many ask what the best apps are to use personally and to recommend to patients.

“There’s a whole world of what you can do. I think we are just scratching the surface as far as what is possible,” said Samuel Park, president of Pa-thos Ethos, a web strategy company in Research Triangle Park, N.C., that designed an app for WakeMed Health & Hospitals, based in Raleigh, N.C. Park said the WakeMed app is “another touch point” for consumers to find lo-

M.D., also an emergency physician and CEO of Healthagen, came up with the idea of iTriage – and literally drew it on a napkin – several years before the iPhone was introduced. Once the timing was right, they developed and began marketing iTriage.

Guerra uses the analogy of the telephone book white pages vs. yellow pages to explain both iTriage’s opera-tion and business model. Location information is provided on as many as 500 emergency departments or urgent care centers nationwide, which can be important if the user is traveling. Or-ganizations that want to enhance their listings with more detail can do so by buying advertising.

Another example of a new decision support app is the Concussion Recog-

‘‘We don’t ever diagnose anybody. We provide people with information that helps them make decisions. All the content is written specifically for the mobile device. When you have something wrong with you, the last thing you want to do is get some information and there’s five pages to read.”

cations for treatment, including turn-by-turn GPS directions from your cur-rent location, a doctor-finder feature searchable by location, specialty and even the type of insurance accepted. The app also lets you store a photo of your insurance card and health profile listing your current medications and connects to the hospital’s Twitter and Facebook feeds. Down the road, he said they may add emergency depart-ment wait times, along with other new features.

iTriage is one free app to consider for those emergency moments. As the name implies, iTriage helps users determine how serious a set of symp-toms or a situation is, whether it needs immediate treatment and where to go for help.

MEDMONTHLY.COM |15

16| NOVEMBER 2011

and even share data with the runner’s community via Facebook and Twit-ter. Important to Noyes, the app also provides the data audibly through ear buds.

“I’ve found RunKeeper to be a Baby Boomers God-send! In my last marathon, I realized that I could no longer see my split times with my deteriorating near vision. When I found out about RunKeeper, I discovered that the technology was there for me to get everything right in my ear with regard to pace, mile-age, times, etc.,” she said.

Noyes said she also often uses the LoseIt app as well, when she is focusing on weight loss, because “I love knowing how much I’m putting into my body and how much I’m exerting.”

Another popular app is MyFit-nessPal, mentioned above, which claims to be “the easiest to use food diary on the web” with over 1 mil-lion food items listed in the data-base, including name brand grocer-ies and restaurant items. Users can even upload their own recipes for calculating calories, tracking carbo-hydrates, fats, proteins, fiber, etc., and find support for popular diet plans like Atkins, South Beach and Zone. It contains over 350 exercises (both cardiovascular and strength training) and social media connec-tions for finding and giving support to others in healthy living.

“I really am enjoying it because it is accessible, easy to use, has a variety of features that allow you to monitor your progress,” said Gayle Harris, director of the Dur-ham County (N.C.) Public Health Department.

Apps for Credible Health Information

Besides tracking calories or miles run, sometimes what you need most is health information from a trusted source to answer questions, research

conditions and help you determine next steps in your care when not in an emergency. Government health agencies, academic institutions and other private health enterprises in recent years have greatly enhanced all manner of their web-accessible health information and social media efforts. Here are a few things you can now do, or recommend to pa-tients that they do, through a phone or tablet: Quit smoking with the help of the Smokefree QuitGuide app from the National Cancer Insti-tute. Find information on seasonal flu, H1N1 flu, public health emergencies and more from the Centers for Disease Control and Prevention through its mobile website at m.cdc.gov. Manage Type 2 diabetes with the help of DiabetesManager, an FDA-approved app from Well-Doc that was recently shown in a randomized controlled trial as effective in lowering patients’ A1C blood glucose levels. Results are published in the September issue of the American Diabetes Asso-ciation’s journal Diabetes Care. Check symptoms, identify pills, search drugs, treatments and a host of health conditions at the free mobile version of WebMD.In July, the FDA proposed guide-

lines for mobile health applications, and accepted public comments until Oct. 19. One thing is certain, this whole area of using technology — particularly in terms of mobile phone applications — to manage health and fitness is only likely to grow. With increasing emphasis on prevention and self-management of chronic conditions in an atmo-sphere of cost containment, phone apps are no longer just for calcu-lating how old you are in monkey years – though there really is an app for that.

There isn’t an app for this.

Live, learn, and work with a community overseas.

Be a Volunteer.

peacecorps.gov

MEDMONTHLY.COM |17

National Provider IdentifierA National Provider Identifier or NPI, is a 10-digit

identification number issued to health care providers in the United States. The number is issued by Centers for Medicare and Medicaid Services (CMS).

The NPI began replacing the unique provider identification number (UPIN) in 2006 as the required identifier for Medicare services and other payers, including commercial healthcare insurers. The change to the NPI was mandated as part of the Administrative Simplifications portion of the Health Insurance Por-tability and Accountability Act of 1996, and the first numbers were issued in October of 2006.

The NPI was proposed as an eight-position al-phanumeric identifier. However, many stakeholders preferred a 10-position numeric identifier with a check digit in the last position to help detect keying errors. The NPI contains no embedded intellegence; that is it contains no information about the health care pro-vider, such as the type or location.

All individual HIPAA covered healthcare providers (physicians, physician assistants, nurse practitioners, dentists, chiropractors, physical therapist, athletic trainers, etc.) or organizations (hospitals, home health care agencies, nursing homes, residential treatment centers, group practices, laboratories, pharmacies, medical equipment companies, etc.) must obtain an NPI for use in all HIPAA standard transactions, even if a billing agency prepares the transaction. Once assigned, a provider’s NPI is permanent and remains with the provider regardless of job or location changes.

More information regarding NPI numbers can be found at http://nppes.cms.hhs.gov.

DEA NumberThe Drug Enforcement Administration (DEA) is a U.S.

Department of Justice law enforcement agency tasked with enforcing the Controlled Substances Act of 1970. It shares concurrent jurisdiction with the Federal Bureau of Investigation in narcotics enforcement matters.

A DEA number is a series of numbers assigned to a health care provider (such as a medical practitioner, dentist, veterinarian) allowing them to write prescriptions for controlled substances. Legally the DEA number is solely to be used for tracking controlled substances. The DEA number, however, is often used by the industry as a general “prescriber” number that is a unique identifier for anyone who can prescribe medication.

A valid DEA number consists of two letters, six num-bers, and a one check digit.

More information regarding DEA numbers can be found at www.deanumber.com.

NPI and DEA numbersBy the numbers...

What you need to know about the National Provider Identifier and the Drug Enforcement Administration numbers

your practice

Staff reports

18| NOVEMBER 2011

legal

On Oct. 20, 2011, the Centers for Medicare and Medicaid Services (CMS) released an advance copy

of the final rule for accountable care organizations (ACOs). Additional gov-ernmental guidance was issued to ad-dress antitrust and tax considerations. The following article summarizes the government’s key points in the final rule.

ACOs Represent a Model for Seamless and Coordinated Care

In its announcement of the final rule, the government highlighted that ACOs represent a major step forward for transforming Medicare and Med-icaid to help assure high quality and seamless health care for continuous improvement. The government’s defi-nition of “seamless and coordinated care” refers to the patients’ require-ments. Patients want time with doctor and coordinated care that makes sense. Patients want their doctors working together so they don’t get confused or lost in the system. They want better communication, from reminders for

appointments to more information about medical decisions. They want a promise that their own doctor will provide a reference to a specialist if an issue arises.

To obtain this type of seamless and coordinated care, it’s recognized that fundamental change to the way ser-vices are reimbursed must occur. Pay-ment for services on a fee-for-service basis led to patients receiving pieces of care versus coordinated care. CMS is encouraging coordinated care through various payment reforms, including bundled payments, payments based on episodes of care. With ACOs, care and reimbursement can be reorganized so that care (and associated charges) makes sense.

Options for Participating in Health Care Reform

The government remains focused on attaining the triple aim: better health, better care and lower cost to all Americans. It sees ACOs and many other initiatives as designed to attain the triple aim, but recognizes that there are barriers to providers partici-pating in these initiatives. The high

cost of infrastructure (and the lack of necessary capital to invest in building this) needed to operate as an ACO led to the announcement of the Advance Payment Model (APM). Under the APM, providers receive payments to offset setup costs that will be recouped later as the providers receive savings. APM is viewed as another “on ramp” for providers who want to participate in health care reform.

ACOs and their associated programs and rules are part of a larger menu of options to reform health care. The gov-ernment recognizes that ACOs alone will not accomplish the triple aim nor health care reform. Additional pro-grams and opportunities are needed, and numerous initiatives have been announced including:

Partnership for Patients: Awards up to $1 billion from the U.S. Depart-ment of Health and Human Services for improved care models. Bundled Payment Initiative: Pay-ment reform initiative designed to improve care by fostering improved coordination and quality through defined models of care. Comprehensive Primary Care

ACO final rule is finally releasedBy Kim Licata

Initiative: This CMS-led multi-payer initiative promotes payer collabora-tion to strengthen primary care for Americans. Private payers are invit-ed to join Medicare to test service and payment models to implement quality improvement and change. Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration: This dem-onstration will test the effectiveness of doctors and health profession-als working as teams in the FQHC setting. State Demonstrations to Integrate Care for Dual Eligible Individuals: Fifteen states have been awarded contracts to participate in this dem-onstration to identify and validate delivery system and payment integration models of health care for beneficiaries eligible for both Medicare and Medicaid. Multiple Payer Advanced Primary Care Practice Demonstration: Eight states will participate in a dem-onstration project to evaluate the effectiveness of doctors and health professionals across the care system working in a more integrated fash-ion and receiving payment through congruent methods across govern-ment and commercial payers. State Engagement Models: Pro-grams designed to achieve an inte-grated care approach for individu-als who are eligible for Medicare or Medicaid. We should expect this list to grow

and change as service and payment models evolve.

Key Principles in the Final Rule

In developing the final rule, CMS focused on: Creating a much stronger busi-ness case for participation than in the proposed rules. Staying true to the principle that

CMS wanted organizations to come in to the Shared Savings Program (SSP) using different tracks: (i) one-sided risk, (ii) two-sided risk, and (iii) Pioneer model track. CMS wanted to reward increased risk, while encouraging innovation through a variety of tracks. Maintaining the principle that higher quality scoring provid-ers will have the opportunity for greater savings. CMS focused on what it perceived as the key indica-tors of quality care. Changing the rules for gover-nance to be more flexible. Increasing the flexibility for ben-eficiary assignment to include more rural providers. Better balancing the need for ACOs to know beneficiary assign-ment upfront (as opposed at the end of the savings period) and the current reality of beneficiaries who change locations and care patterns over time. Assignment will be a rolling process, still protecting ben-eficiaries and their ability to choose their care. Keeping a strong commitment to help ACOs with data from Part A & B while maintaining patient privacy. Being committed to a strong partnership and collaboration with Federal Trade Commission, De-partment of Justice and Office of Inspector General to give provid-ers flexibility to form ACOs, while remaining true to antitrust, fraud and abuse concerns.Government leaders have vocalized

their excitement about the final rule and the opportunities it provides.

Key ChangesCMS identified the following signifi-

cant changes to the proposed final rule: Providers will be able to partici-pate in an ACO and share in sav-

ings with Medicare without risk of losing money. ACOs will be able to start sharing in the savings earlier rather than letting Medicare retain all the initial savings. The number of quality measures that ACOs will have to meet to qualify for performance bonuses was reduced from 65 to 33. The ACOs will also be told up-front which Medicare beneficiaries are likely to be part of their system. Under the earlier rule, ACOs would not know which patients were in the ACO until their contract ended. Community health centers and rural health clinics will be allowed to lead ACOs. They were left out of the prior proposal, and CMS has reconsidered this. Unlike the relative vagaries of the

proposed rule, the final rule sets specific requirements for documents (from organizational documents to contracts between participants and providers), a compliance program, and data use and access. Providers will have some significant contracting work ahead of them to get an ACO off the ground.

What Does the Final Rule Mean for Providers?

While the final rule’s changes in-creased participation, the SSP clarifies that ACOs are just one part of the government’s plan to effectuate health care reform through service and payment model changes. Whether or not ACOs are successful, this final rule is a harbinger of things to come and marks a fundamental change in the way the government views (and pays for) health care. Providers must actively educate themselves on the many reform opportunities with this in mind. Providers should apply for programs that fit their practice and capabilities because change is coming. Change is inevitable.

MEDMONTHLY.COM |19

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research & technology

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By Whitney L.J. Howell

If you’ve ever had a patient with unexplained abdominal distress, you’ve likely grappled with whether to assign a diagnosis of Celiac Disease or Crohn’s Disease. With their similar – and ambigu-

ous – symptoms, pointing definitively to one of these conditions can be complicated. Treating them can be even harder.

In recent years, however, health care researchers have made significant advancements, giving you new tools to not only make disease identification easier, but also to offer additional therapies.

CeliacOnce thought to be a rare disease in the United

States, Celiac Disease (CD) actually affects one out of every 133 Americans. In fact, debate has swirled in recent years about whether the incidence of the condition is rising. The health care industry can thank the advent of a simple blood test for making diagnosis easier and more accurate.

“The blood test is easy for both patient and provider,” says Sheila Crowe, M.D., a University of California-San Diego gastroenterologist and CD ex-pert. “By identifying the antibody transglutaminase, the test helps physicians rule out other gastrointes-tinal problems and diagnose Celiac without putting the patient through a colonoscopy.”

Better diagnosing

of celiac and crohns

Gluten can be a huge problem for people with Celiac Disease.

22| NOVEMBER 2011

The antibody test doesn’t diagnose CD, but it does pinpoint the patients with whom you should discuss a small bowel biopsy. An additional genetic test can identify if your patient has the HLA (human leukocyte antigen) DQ2/DQ8 genes needed for CD to develop. Since nearly one-third of people have these genes, their presence only detects who has a congenital predisposition for CD not who has the full blown disease.

Enhanced diagnosis techniques aren’t the only development fueling chatter about a spike in CD incidence, Crowe says. Research in 2009 from Joseph Murray, M.D., a gastroenterologist at the Mayo Clinic in Rochester, Minn., found CD is actually four times more common today than 50 years ago.

Murray studied stored blood sam-ples collected from Army soldiers in the same barracks during World War II. Although it’s impossible to state definitively if the men had the dis-ease, Murray’s team identified the CD marker present in all sufferers. This finding, Crowe says, points to one of two changes over generations: a dietary movement toward high-gluten grains and away from gluten-free grains has resulted in a poor body reaction or the hygiene hypothesis is true.

“Our society has become so sterile that people aren’t exposed to patho-gens. So, at least in Western societies, we’ve seen a rise in allergies,” she says. “We’ve changed the thermostat on how the body responds to infection, and when you change that balance, because there’s a lack of childhood illness, you see a jump in autoimmune disorders.”

Currently, the only treatment you can prescribe for your CD patients is a gluten-free diet – one that relies on fruits, vegetables, meatss and dairy. However, there is another therapy in the works that could alleviate the stress and worry associated with accidentally eating a small amount of gluten.

The oral medication known as Larazati completed its phase III clinical trials last year with promising results.

Basically, the drug works much like pills designed for patients with lac-tose intolerance who wish to enjoy dairy products. When taken regu-larly, research findings show, Larazati strengthens the lining of the intestines to prevent gluten from infiltrating and harming the tissue. Trial results also indicated the pharmaceutical could potentially repair previous damage.

It’s unlikely Larazati will eliminate the need for a gluten-free diet, Crowe says, but it could ensure someone with the disease who accidentally eats gluten won’t experience a flare up of symptoms.

Crohn’sAs with CD, there are new diagnosis

and treatment strategies available for Crohn’s that will help identify which of your patients are living with the condi-tion and how to alleviate their symp-toms. These advancements are particu-larly important because, historically, differentiating between Crohn’s and ulcerative colitis has been difficult.

Two new blood tests can help you diagnose the 10 to 15 percent of your patients who have “indeterminate colitis.” These tests search for the anti-bodies pANCA (perinuclear anti-neu-

on the standard barium test to pin-point the source of abdominal pain, many providers are turning to CT and MRI scans to find out what’s going on in the small intestines, says Edward Loftus, M.D., a Mayo Clinic gastroen-terologist and Crohn’s expert.

“A CT or MRI scan makes it a lot easier to know what’s going on,” Lof-tus says. “The scanning method can improve diagnosis and detection of problems with the bowel wall, fistula and abscesses.”

CT scans can also help rule out ap-pendicitis, as well as guide you during abscess drainage.

Although MRI hasn’t been used widely with Crohn’s in the past, the health care industry is looking into whether MRI enteroclysis can be an effective alternative to conventional enteroclysis. Researchers have found MRI enteroclysis can catch possible disease outside the intestine, and it gives better images where the bowel folds over itself.

When it comes to treatment, there’s one drug in the pipeline that could help Crohn’s sufferers control how the condition impacts their daily lives, Loftus says. Known as Vedolizumab, this medication is currently in phase

trophil antibody) and ASCA (anti-Sac-charomyces cervisiae). Patients with Crohn’s are more likely to have ASCA and not pANCA in their blood, and those with ulcerative colitis tend to have pANCA rather than ASCA. The test isn’t absolute, however, because some Crohn’s patients can only have the pANCA antibody.

In addition, many of your colleagues are also adding imaging tests to their diagnostic arsenal. Instead of relying

III clinical trials and is designed to control the inflammation response without prompting the accompanying immunosuppression. In particular, the drug impacts alpha4beta7 integrin, the antibody that plays an active role in controlling intestinal inflammation. So far, clinical trial results have shown Vedolizumab blocks the inflammatory marker on white blood cells, stopping any inflammatory cells from moving into the intestinal wall.

‘‘Our society has become so sterile that people aren’t exposed to pathogens. So, at least in Western societies, we’ve seen a rise in allergies.”

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A s Chief Medical Officer of the American Lung Association, it is my re-sponsibility to make sure

everyone understands the serious-ness of the influenza virus. Everyone 6 months of age and older is recom-mended by the Centers for Disease Control and Prevention (CDC) for annual influenza immunization; we all need to do our part and get ourselves vaccinated as soon as the vaccine becomes available locally.

It is particularly important for those in the health care field to be vaccinated against this serious virus. We can spread the disease to patients in our care. From physicians, nurses and pharmacists to other office and hospital staff, we all need to set an example and be vaccinated annually. Influenza is a serious respiratory illness that is easily spread, and its

complications lead to approximately 226,000 hospitalizations and thou-sands of deaths each year. Combined with pneumonia, influenza is the eighth leading cause of death in the nation.

Immunization rates fall far short of public health goals each year, especially with health care provid-ers. In fact, a recent report from the CDC found that only 63.5 percent of health care workers were vaccinated during the 2010-2011 influenza sea-son; health officials are aiming for a 90 percent vaccination rate according to Healthy People 2020 goals.

These low immunization rates highlight the need to raise aware-ness among health care providers about the importance of getting vaccinated against influenza to help protect themselves, their patients and their loved ones. Although everyday

preventative actions such as washing hands frequently and avoiding close contact with sick people can help you stay healthy, an influenza vaccination is the best protection available.

The American Lung Association has been raising awareness about the seriousness of influenza and encouraging influenza immuniza-tion through its “Faces of Influenza” campaign. This educational initiative helps Americans put a “face” on this serious disease and recognize annual influenza vaccination as an impor-tant preventative measure.

The CDC recommends annual im-munization for everyone 6 months of age and older; however, groups at a higher-risk for developing influenza-related complications include adults 50 years of age and older, children 6 months to 18 years of age, pregnant women, anyone with chronic health

The seriousness of influenza

Why health care workers need to get vaccinated

By Norman H. Edelman, M.D.

feature

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The flu is a serious disease, and it can have scary consequences. According to a report from the CDC, there were 115 cases of

influenza-associated pediatric deaths in the U.S. during the 2010-11 flu season. Among those who died from influenza, less than a quarter were vaccinated. As a mother, this really hits home and em-phasizes the need to improve vaccina-tion coverage among all children.

While children are hit hard by the flu, vaccination is recommended for everyone 6 months of age and older. To help increase vaccination rates, the American Lung Association’s Faces of Influenza campaign has worked for the past six years to show all Americans that they are among the many “faces” of influenza.

This year, I am spearheading this initiative along with my mother, Carole Yamaguchi, to boost influenza immuniza-tion rates among family members of all generations. Mothers often are the pri-mary health care decision-makers, and

it’s important we ensure our children, husbands, parents and whole family get a flu shot every year.

We all are at risk of contracting and spreading this serious disease. The com-plications from the virus can be fatal. As part of the Faces of Influenza campaign I’ve heard the stories of families that have lost children due to complications from the virus, as a mother their stories had a significant impact on me.

Everyone should get vaccinated as soon as vaccine is available, but even if you don’t get vaccinated at the start of the flu season, immunization later in the season can still be beneficial because flu activity often doesn’t peak until winter or early spring. In fact, as long as influenza viruses are in circulation, it’s a good idea to get vaccinated.

Get vaccinated! It’s safe and is the best way to help prevent influenza and its complications. Talk to your health care provider about your best options for influenza immunization, and put vacci-nations on your family’s “to-do” list now.

conditions, such as asthma, chronic obstructive pulmo-nary disease (COPD), heart disease and diabetes and residents of long-term care facilities. Vaccination is es-pecially important for those who come into close con-tact with high-risk groups such as household contacts, caregivers and health care providers.

It is important to know that vaccination is safe and effective, and the best way to prevent influenza. With 166-173 million doses an-ticipated for this flu season, there is an ample supply of vaccinee. People can get their shots in doctors’ of-fices, public health clinics, pharmacies and even places of work. The CDC report found 98.1 percent of health care workers got vaccinated when it was required by their employer, and a nearly 70 percent vaccination rate when vaccination was of-fered free of charge on-site at workplaces.

The American Lung As-sociation encourages places of employment to keep these practices in mind this flu season to help increase rates of vaccination among healthcare professionals, and to serve as role models by going and getting immu-nized.

Together, we can continue to spread the word and edu-cate others on the impor-tance of vaccination. For more information on the flu and vaccination, visit www.facesofinfluenza.org.

Influenza immunization important to keep the whole family healthy

By Kristi Yamaguchi

Kristi Yamaguchi (right) and her mother, Carole, are putting a “face” on immunizing for the ful season

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28| NOVEMBER 2011

feature

When dealing with the prevention and man-agement of chronic illnesses, physicians

tend to face certain dilemmas. When should treatment start? Can treatment stop? Are we treating the diagnosis without affecting the quality of life? What about the long term costs? These questions are made more dif-ficult when the disease is most often without symptoms. One condition which brings all of these issues to light is bone loss.

The management of bone loss (osteopenia and osteoporosis) has received a great deal of attention over the past three decades. With the significant aging of the population, the consequences of prolonged bone loss have become more apparent as public health issues. Senile hip frac-tures, despite adequate surgical and

medical care, continue to be the cause of significant morbidity and mortality. Vertebral and peripheral fractures also impact upon life quality. Today, tech-nological advances allow for both the screening and treatment of bone loss before symp-toms such as fractures occur.

The question is: who do we treat and how do we treat? I believe that one of these answers has become simpler, the other more complex.

Who Needs TreatmentBefore the days of DXA (Dual-en-

ergy X-ray absorptiometry) scanning, there was no commonly utilized gen-eral population screening tool available for bone loss assessment. As DXA scanning data became available, treat-ment protocols were suggested. How-

ever, no absolute standards evolved. Some common practices were to treat anyone with osteopenia at a T-score of less than -2.0 or anyone with a T-score less than -1.8 with “risk factors.” Oth-ers would wait until osteoporosis was diagnosed, either by a T-score of -2.5 or by clinical grounds (i.e., low impact fracture). Still other clinicians would treat any and all osteopenia or even suggest therapy for prophylaxis in the absence of any documented disease.

The WHO (World Health Orga-nization) has made my decisions on the initiation of prescriptive therapy

Bone loss & preventable fractures How we can manage

osteopenia and osteoporosis while we wait for a “magic bullet” to be found

By Jim Rupp, M.D. FACOG

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easier. With the introduction of FRAX (fracture risk assessment tool) there exists a standard for therapy which incorporates basic individual statistics (height, weight, race, age), personal history, family history and DXA scan results. Incorporation of the DXA data into the FRAX tool produces the probability of developing a low impact fracture over the following 10 years. The suggested thresholds for initiation of therapy are a hip fracture probabil-ity of 3 percent or greater or an overall fracture probability of 20 percent or greater. Presently, for the majority of the population, I will initiate therapy when one of two thresholds has been met: either the FRAX risk (3 percent or 20 percent) is present or the patient has osteoporosis by either clinical or DXA scan parameters. As with all protocols, there will be exceptions. Examples of situations which might trigger prescriptive therapy use despite a low FRAX risk in the absence of osteoporosis could be prolonged sys-temic corticosteroid use or the use of some chemotherapies.

Any ordering clinician can generate a FRAX report by collecting the ap-propriate personal data and plugging in the DXA results. The FRAX tool is available online and many clinicians do take advantage of it after receiving a DXA scan report. The most ideal situation for most clinicians is to have the DXA scanning service provide the FRAX results along with the DXA scan report. In any event, I have found that the FRAX tool has simplified my deci-sions on the initiation of prescriptive therapy for bone loss.

Treatment OptionsThe stickier question has become

how to treat. Treatment options range from diet and exercise to vitamins to

a range of prescriptive medications. The reality most clinicians face is that, in the absence of contraindica-tions, diet, exercise, Calcium and Vitamin D use will be suggested to most all adults. Debates rage on con-cerning appropriate dosages, but in most clinical settings, 1200 mgs. to 1500 mgs. of Calcium along with 800 IU of Vitamin D are adequate.

Systemic Estrogen and Raloxifin (Evista) can be useful as primary agents, usually utilized for less severe situations. The RANK Ligand inhibi-tor Denosumab (Prolia) is a newer agent and is limited in its indica-tion to postmenopausal women with osteoporosis and risk factors. The parathyroid hormone Teripara-tide (Forteo) is very effective but is limited to two years of lifetime use and is generally not a first line agent except in the more severe cases. The lion’s share of the drug market for bone loss therapy is commanded by the Bisphosphonates.

Alendronate (Fosamax), Risedro-nate (Actonel, Atelvia) Ibandronate (Boniva) and Zolendronate (Reclast) constitute the usually prescribed Bisphosphonates. As a group, the Bisphosphonates can be very help-ful in improving DXA scan results and, more importantly, in decreasing fracture risks. However, as seems to be with all things medical, there are potential down sides.

One “black mark” associated with Bisphosphonate use is its association with osteonecrosis of the jaw. Osteo-necrosis of the jaw occurs spontane-ously in the general population at a very low rate. It has also been noted in individuals who use Bisphospho-nates. However, osteonecrosis of the jaw is only associated with Bisphos-phonate use, in any significant numbers, when there is high dose

intravenous Bisphosphonate use in individuals receiving chemotherapy. The risk increases significantly when there is dental work being done at the same time. In this group, the risk of developing osteonecrosis of the jaw can be as high as one to 12 percent. With individuals using the usually prescribed doses of Bisphos-phonates for bone loss, the risk of developing osteonecrosis of the jaw is in the range of 1/100,000.

The more recent issue with Bisphosphonate use has been the incidence of atypical femur fractures. The concern is that with prolonged Bisphosphonate use, the bone turnover is slowed to the point that the bone becomes brittle and thus can “snap” under low impact in an atypical pattern. This complication is noted at a rate of 1/1000 in long-term (greater than five consecutive years) Bisphosphonate users. How-ever, the comparative reality is that, in persons avoiding Bisphosphonate use, there will likely be 200 clinical fractures occurring for every one atypical femur fracture prevented.

To prevent these fractures, pa-tients should discontinue the use of Bisphosponate for a year or two after prolonged use. Even after discon-tinuation, the medication will prob-ably continue to offer some fracture protection due to its long half life. Additionally, if some bone turnover begins, perhaps the bone turnover will allow newer, healthier matrix to be laid down.

Things have certainly changed since my young Ob/Gyn days when it was either prophylaxis, estrogen or nothing. Hopefully, the “magic bullet” for osteoporosis therapy will arrive from the pipeline. Until then, it’s all about scanning, lifestyle, diet and medication.

 

30| NOVEMBER 2011

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the arts

ART as THERAPY

How art helps with healingby Deborah Kohn Brenner

MEDMONTHLY.COM |33

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Art and illness have been an inseparable part of my life. I was married to an amazing artist who died

of cancer when I was 38-years-old. I am also a self-taught artist and I have been painting full-time for over 20 years. As part of my therapy during this period of time, I started to paint joyous, colorful, musical flowers in honor of my late husband Howard. He always had an amazing sense of wonder and poetry in his work, and being creative for me is life giving and what I was born to do.

Several years after his death I remarried. My husband, Paul, is a gy-necological oncologist and psycholo-gist who works at a cancer center in San Diego. I have never forgotten how much art and art therapy helped me recover and heal the torn fabric of my life and I believed my art might help others too. I asked the center if I could paint a few pieces for their walls. The feedback from the staff and patients was very heartfelt and rewarding. It was as if my past con-nected to the patients’ present experi-ence.

I tried to paint the interconnected-ness of all life through my musical gardens, as well as incorporate the energy that surrounds them. I also included art that would move pa-tients into infinity through dreamlike water landscapes. In these paintings, I would blend acrylic and oil paints with the subtlety of ink. The effect is to take the viewer into a meditative, peaceful state in the tradition honed by Japanese masters.

My abstract compositions, com-prised of shapes, drips, veils and colors, are a signature style of mine and featured in medical offices, hotels, lobbies and corporate offices. Each structure represents the relationship between form, color, balance and space. These large-scale paintings have often been referred to as “fine art that is currently the most representa-tive of contemporary living in the 21st century.” These paintings are big, yet unassuming. In essence, I try to take the complex and make it simple.

My art is displayed in galleries and collections throughout the world. I paint every day and hope that my art meets others in the same sacred place.

ART as THERAPY Above: Deborah Kohn Brenner taught herself to paint when mourning the death of

her first husband to cancer. Left: Her over-sized pieces, like Pink Tulips, pictured here, use color and flowers. Brenner hopes they will bring others peace and healing.

34 | NOVEMBER 2011

I never liked vegetables. I was one of those adults who never outgrew their childhood distaste for all things green. At mealtime, I turned

to meat: flavorful and filling - savory, salty, tasty meat. I chose meat for lunch, meat for dinner, and some-times meat for breakfast, too, with a side of dairy each time for good measure. Why not? I needed protein and Calcium. It never occurred to me that meat and dairy may be respon-sible for my chronic daily fatigue (and subsequent coffee addiction), or for my slow, steady weight gain with each year of my 20s. It may also have contributed to my heartburn after meals. After almost 30 years of being

a carnivore, and a western medical education which fully supported my eating habits, I watched a documen-tary that turned everything I thought I knew about nutrition and chronic disease on its head. The film, “Forks Over Knives” featured a Cornell University professor of nutrition, Dr. T. Colin Campbell, and a Cleveland Clinic Cardiac Surgeon, Dr. Caldwell Esselstyn, who both claimed that the tsunami of chronic diseases sweeping the West could not only be stopped, but reversed by simply subscribing to a whole grain, plant-based diet.

Meat and dairy, the doctors as-

sert, are not our exclusive sources of protein. In fact, the amount of protein found in a serving of meat may be significantly more than we need in one meal, leading to a form of “poi-soning,” which occurs when we ingest too much of any vitamin, mineral or nutrient. The American diet can be described as excessive. The majority of America’s poor does not starve, but instead are easy targets for industries selling inexpensive processed “fast” foods. If we look instead to legumes and grains for all the essential amino acids we need to build protein, we may bring our dietary protein back

What’s the relationship between diet and chronic disease?

How greens & grains can change your life

By Shirin Peters, M.D.

healthy living

PHO

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MEDMONTHLY.COM |35

into balance. By further eliminating processed foods, which are extremely high in calories for a given unit vol-ume of food, we can reign in the fat, carbohydrates and total calories in our diet. By making the right choices at the grocery store, we can safely curb our diet of excess, and eliminate obesity, diabetes and hypercholester-olemia.

Abstaining from MeatCompelled by some of the argu-

ments in the film, I picked up a copy of “The China Study,” published in January 2005 by Dr. Campbell. It detailed an epidemiologic study conducted over 20 years by Cornell University, Oxford University and The Chinese Academy of Preventa-tive Medicine. Dr. Campbell, who was born and raised on a cattle farm, be-gan his career in nutritional research by trying to prove hypotheses about the benefits of protein in meat and dairy. Frustrated with his early find-ings, he took a new approach by de-signing and conducting several stud-ies about the potential harmful effects of animal-based protein. One such study found a relationship between peanut contaminant Aflatoxin AF and the high prevalence of liver cancer in the children of affluent families. The affluent children developed cancer far more frequently when exposed to Aflatoxin and had a much higher percentage of protein in their diet.

Spurred by further findings that the milk protein casein promotes tumor development and growth in rats, Dr. Campbell became involved in “The China Study.” The

associated with significantly better health. The strength of “The China Study” was in the huge population of China included in the study which is largely genetically homogenous - at least as compared to most other countries in the world - but which has a diet that varies significantly by region. Although Dr. Campbell acknowledges “we have no data to show that 100 percent plant based eating is better than 95 percent,” he

advocates for total abstinence from meat and dairy because he believes they are unnecessary for good health, and that our tastes change when we eliminate these foods thus breaking

study’s conclusions were radical: that high consumption of animal based foods were associated with a high prevalence of chronic disease, while a predominantly plant-based diet was

our widespread addiction to animal-based fats and flavors.

Inspired by the preliminary find-ings of “The China Study,” Dr. Es-selstyn began a 12 year clinical trial involving only patients with known advanced coronary artery disease demonstrated on angiography. Five of the 17 patients in the study were given

If we look to legumes and grains for all the essential amino acids needed to build protein, we may bring out dietary protein back into balance.”‘‘

36| NOVEMBER 2011

a life expectancy of one year at the beginning of the 12-year period. Of the 17 patients who adhered to a plant-based diet, all 17 demonstrated a sig-nificant decrease in serum cholesterol levels, no further cardiac events and a widening of the coronary arteries on angiography, indicating a reversal of disease. These findings were a shock to the medical community who are yet to find a pharmaceutical with the power to undo damage to coronary arteries.

No Full Consenus Not all are believers, however. A

recent Harvard study performed and published in the U.S. in May 2010 found no increased risk of heart disease among meat eaters in general. The study also found that eating only one serving of bacon, sausage or deli meat a day is associated with a 42 percent increased risk of heart disease and a 19 percent increased risk of diabetes. Still meat itself has not been linked to chronic disease in any major study in the U.S. Many argue that while meat and dairy industry insid-

ers may well have circulated a biased perspective on our need for animal products, for personal gain, Dr. Campbell himself has every reason to present a biased perspective on nutrition. After a lifetime of research dedicated to proving a single point — that animal products in our diet cause chronic disease and cancer — he has yet to prove it definitively. Because there are certainly a multitude of factors that cause disease and many confounding variables, we may never have a clear answer.

Dr. Campbell’s critics point out that his demonstration of casein caus-ing cancer in rats should not be used to make a blanket accusation about all animal protein. What powdered, isolated casein does to rats may tell us very little about what milk does to humans and nothing that can be gen-eralized to animal protein. However, no further studies were done before his overarching proclamation in “The China Study” that animal based foods increase tumor development, while nutrients from plant based foods decrease tumor development. Critics also attack Dr. Esselstyn’s study on diet and heart disease for including a small number of subjects. Both the doctors do seem to jump from limited data to emphatic, life-changing advice on nutrition.

Finding the MiddleAs for “The China Study” itself,

some claim it tells only half the story. The nutritional benefits of animal proteins are totally ignored, and Dr. Campbell is cautious not to generalize from casein to plant proteins, but he has no issue in generalizing from ca-sein to animal protein. He ignores the well-described role of wheat gluten in autoimmune disease, but emphasizes the role of milk protein.

Although doctors Campbell and Esselstyn seem to select and interpret evidence with the intention of making

a case for a whole grain, plant-based diet, they do present basic science and clinical data which is quite over-whelming. We may not yet have all the answers, but all evidence seems to support the idea that a diet devoid of animal products and processed refined items will help any person to feel healthier, manage their weight and consequently stave off weight-related diseases such as hypertension, diabetes and coronary artery disease. The possibility that a whole grains, plant-based diet may also stunt the development and growth of cancer may simply be a bonus.

On the Internet, patient testimo-nials are abundant in support of the dietary advice of these medical pioneers, and I am happy to add one more. Since adopting a whole grains, plant-based diet, I have more energy and a healthier digestive system. As a primary care provider, I cannot ignore an intervention with no side effects that can outperform any combina-tion of medications designed to treat chronic disease. My patients deserve to know that a specific change in their diet may be an effective treatment. Since the answers are not simple and will likely never be, it follows that neither can the recommenda-tions. Perhaps, as our mothers taught us, moderation is the key. But then maybe the question is: “what is mod-eration?” Certainly it is not processed meat and a side of dairy for breakfast, lunch and dinner.

My conclusions? Eat fewer pro-cessed foods and fewer animal prod-ucts. Eat more greens and grains. Eat to feel healthy and be healthy. That is what I teach my patients to do. I don’t believe it is an all-or-nothing situa-tion, and it may be difficult for some to transition to a meat, dairy and oil-free lifestyle. I encourage any patient suffering from a chronic ailment, and certainly any physician, to try it. You never know, you may just love it.

GREAT GRAINS

GREAT GREENS

That’s great!Amaranth, Barley, Buck-wheat, Cous cous, Millet, Oats, Quinoa, Rice, and Wheat

Spinach, Collards, Kale, Rapini, Mustard Greens, Swiss Chard, Bok Choy and Turnip Greens

the kitchen

A nutritious way to indulge!

By Ashley Acornley, R.D., L.D.N

Fall is officially here, and apples are one of the most delicious seasonal ingredients to enjoy this season! The best way to enjoy desserts is in moderation, incorporating healthy and fresh ingredients into your recipes. This homemade apple crisp includes fresh tart apples, apple juice, lemon juice, oats, cinnamon

and dried cranberries. Not only is this a great way to treat your sweet tooth, but there is plenty of Vitamin C and fiber to enjoy in this dish!

Total Preparation Time: 1 hour 25 min

Serves: 10

Topping:

1 cup all purpose flour

1 tsp. cinnamon1 ½ sticks unsalted butter (I use Best Life Buttery

Spread for added nutritional benefits)

1 cup rolled oats¼ cup packed light brown sugar

1 tbsp. granulated sugar (artificial sweetener

like Splenda works well too)

½ tsp. salt

Filling:

8 medium Granny Smith apples, peeled,

cored and cut into ½ inch wedges

¼ cup sugar2 tbsp. fresh lemon juice

1 cup dried cranberries

½ cup unsweetened apple juice

4 tbsp. unsalted butter, melted

Preparation:

1. Prepare the topping:

Preheat the oven to 350 degrees Fahr-enheit. In a medium

bowl, whisk the flour

with the cinnamon.

Cut the butter with a

pastry blender or your

fingers until the mix-

ture resembles a coarse meal. Stir in the oats, brown

and granulated sugars, and salt.

2. Prepare the filling: In a large bowl, toss the apples with

the sugar and lemon juice. Add the dried cranberries,

apple juice and melted butter. Toss again. Spread the filling

in a 9x13 inch baking dish.

3. Sprinkle the topping over the apples evenly. Bake in the

upper third of the oven for about 55 minutes, until the top-

ping is golden brown and the filling is bubbling. Let the crisp

cool slightly, and serve with unsweetened whipped cream.

HOMEMADE APPLE CRISP

WITH CRANBERRIES

MEDMONTHLY.COM |37

AlabamaP.O. Box 946 Montgomery, AL 36101 334-242-4116http://www.albme.org/

Alaska550 West 7th Ave., Suite 1500Anchorage, AK 99501907-269-8163http://www.commerce.state.ak.us/occ/pmed.htm

Arizona9545 E. Doubletree Ranch Rd. Scottsdale, AZ 85258480-551-2700http://www.azmd.gov

Arkansas1401 West Capitol Ave., Suite 340Little Rock, AR 72201501-296-1802http://www.armedicalboard.org/

California2005 Evergreen St., Suite 1200Sacramento, CA 95815916-263-2382 http://www.mbc.ca.gov/

Colorado1560 Broadway, Suite 1350Denver, CO 80202303-894-7690http://www.dora.state.co.us/medical/

Connecticut401 Capitol Ave. Hartford, CT 06134860-509-8000http://www.ct.gov/dph/site/default.asp

DelawareDivision of Professional Regulation Cannon Building 861 Silver Lake Blvd., Suite 203 Dover, DE 19904 302-744-4500http://dpr.delaware.gov/

District of Columbia899 North Capitol St., NE Washington, DC 20002  202-442-5955http://www.dchealth.dc.gov/doh

Florida2585 Merchants Row Blvd.Tallahassee, FL 32399850-245-4444http://www.doh.state.fl.us/

Georgia2 Peachtree Street NW, 36th Floor Atlanta, GA 30303 404-656-3913http://medicalboard.georgia.gov/portal/site/GCMB/

HawaiiDCCA-PVL P.O. Box 3469 Honolulu, HI 96801808-587-3295http://hawaii.gov/dcca/pvl/boards/medical/

IdahoIdaho Board of Medicine P.O. Box 83720 Boise, Idaho 83720208-327-7000http://bit.ly/orPmFU

Illinois 320 West Washington St. Springfield, IL 62786217-785 -0820http://www.idfpr.com/

Indiana402 W. Washington St. #W072Indianapolis, IN 46204317-233-0800http://www.in.gov/pla/

Iowa400 SW 8th St., Suite C Des Moines, IA  50309 515-281-6641http://medicalboard.iowa.gov/

Kansas800 SW Jackson, Lower Level, Suite ATopeka, KS 66612785-296-7413http://www.ksbha.org/

Kentucky310 Whittington Pkwy., Suite 1B Louisville, KY  40222502-429-7150http://kbml.ky.gov/default.htm

LouisianaLSBMEP.O. Box 30250 New Orleans, LA 70190504-568-6820http://www.lsbme.la.gov/

Maine161 Capitol Street  137 State House Station Augusta, ME 04333 207-287-3601http://www.docboard.org/me/me_home.htm

Maryland4201 Patterson Ave.Baltimore, MD 21215(410)764-4777http://www.mbp.state.md.us/

Massachusetts200 Harvard Mill Sq., Suite 330 Wakefield, MA 01880 781-876-8200http://www.mass.gov

MichiganBureau of Health Professions P.O. Box 30670 Lansing, MI 48909517-335-0918http://www.michigan.gov/lara

MinnesotaUniversity Park Plaza  2829 University Ave. SE, Suite 500  Minneapolis, MN 55414 612-617-2130 http://bit.ly/pAFXGq

Mississippi1867 Crane Ridge Drive, Suite 200-B Jackson, MS 39216601-987-3079http://www.msbml.state.ms.us/

MissouriMissouri Division of Professional Registration 3605 Missouri Blvd. P.O. Box 1335 Jefferson City, MO  65102 573-751-0293 http://pr.mo.gov/

U.S. MEDICAL BOARDS

Montana301 S. Park Ave. #430Helena, MT 59601406-841-2300http://bit.ly/obJm7J p

NebraskaNebraska Department of Health and Human ServicesP.O. Box 95026Lincoln, NE 68509402-471-3121http://www.hhs.state.ne.us/

NevadaBoard of Medical ExaminersP.O. Box 7238Reno, NV 89510 775-688-2559  http://www.medboard.nv.gov/

New HampshireNew Hampshire State Board of Medicine 2 Industrial Park Dr. #8 Concord, NH 03301 603-271-1203http://www.nh.gov/medicine/

New JerseyP. O. Box 360Trenton, NJ 08625 609-292-7837http://www.state.nj.us/lps/ca/bme/index.html

New Mexico2055 S. Pacheco St. Building 400 Santa Fe, NM 87505 505-476-7220http://www.nmmb.state.nm.us/

New YorkOffice of the ProfessionsState Education Building, 2nd FloorAlbany, NY 12234518-474-3817http://www.op.nysed.gov/

North CarolinaP.O. Box 20007Raleigh, NC 27619919-326-1100http://www.ncmedboard.org/

North Dakota418 E. Broadway Ave., Suite 12Bismarck, ND 58501701-328-6500http://www.ndbomex.com/

Ohio30 E. Broad St., 3rd FloorColumbus, OH 43215614-466-3934http://med.ohio.gov/

OklahomaP.O. Box 18256 Oklahoma City, OK 73154405-962-1400http://www.okmedicalboard.org/

Oregon1500 SW 1st Ave., Suite 620Portland, OR 97201971-673-2700http://www.oregon.gov/OMB/

Pennsylvania P.O. Box 2649  Harrisburg, PA 17105  717-787-8503 http://bit.ly/havKVj

Rhode Island3 Capitol HillProvidence, RI 02908401-222-5960http://www.health.ri.gov/partners/boards/medicallicensureanddiscipline/

South CarolinaP.O. Box 11289Columbia, SC 29211803-896-4500http://www.llr.state.sc.us/pol/medical/

South Dakota101 N. Main Ave. Suite 301Sioux Falls, SD 57104605-367-7781http://www.sdbmoe.gov/

Tennessee425 5th Ave. NorthCordell Hull Bldg. 3rd FloorNashville, TN 37243615-741-3111http://health.state.tn.us/

TexasP.O. Box 2018Austin, TX 78768512-305-7010http://www.tmb.state.tx.us/agency/contact.php

UtahP.O. Box 146741 Salt Lake City, UT 84114801-530-6628http://www.dopl.utah.gov/

VermontP.O. Box 70Burlington, VT 05402802-657-4220http://healthvermont.gov/hc/med_board/bmp.aspx

VirginiaVirginia Dept. of Health ProfessionsPerimeter Center9960 Maryland Dr., Suite 300Henrico, VA 23233804)-367-4400http://www.dhp.virginia.gov/About/contact.htm

WashingtonPublic Health Systems DevelopmentWashington State Department of Health101 Israel Rd. SE, MS 47890Tumwater, WA 98501360-236-4085http://www.doh.wa.gov/PHIP/default.htm

West Virginia101 Dee Dr., Suite 103Charleston, WV 25311304-558-2921http://www.wvbom.wv.gov/

WisconsinP.O. Box 8935Madison, WI 53708877-617-1565http://drl.wi.gov/section.asp?linkid=6&locid=0

Wyoming320 W. 25th St., Suite 200Cheyenne, WY 82002307-778-7053http://wyomedboard.state.wy.us/

medical resource guide

1-800-Urgent-Care6881 Maple Creek BlvdSuite 100West Bloomfield, MI 48322-4559248-819-6838

www.ringringllc.com

Find Urgent CarePO Box 15130Scottsdale, AZ 85267602-370-0303

www.findurgentcare.com

MedMedia9PO Box 98313Raleigh, NC 27624919-747-9031

www.medmedia9.com

Advanced Physician Billing, LLCPO Box 730Fishers, IN 46038866-459-4579

www.advancedphysicianbillingllc.com

Ajishra Technology Support3562 Habersham at Northlake, Bldg JTucker, GA 30084866-473-0011

www.ajishra.com

Applied Medical Services4220 NC Hwy 55, Suite 130BDurham, NC 27713919-477-5152

www.ams-nc.com

Axiom Business Solutions4704 E. Trindle Rd.Mechanicsburg, PA 17050866-517-0466

www.axiom-biz.com

Frost Arnett480 James Robertson ParkwayNashville, TN 37219800-264-7156

www.frostarnett.com

Horizon Billing Specialists4635 44th St., Suite C150Kentwood, MI 49512800-378-9991

www.horizonbilling.com

Manage My Practice103 Carpenter Brook Dr.Cary, NC 27519919-234-4880

www.managemypractice.com

myEMRchoice.com24 Cherry LaneDoylestown, PA 18901888-348-1170

www.myemrchoice.com

Urgent Care America17595 S. Tamiami TrailFort Meyers, FL 33908239-415-3222

www.urgentcareamerica.com

Medical Practice Listings8317 Six Forks Rd. Ste #205Raleigh, NC 27624919-848-4202

www.medicalpracticelistings.com

Laboratory Management Resources3729 Greene’s crossingGreensboro, NC 27410336-288-9823

www.managemypractice.com

ADVERTISING

BILLING & COLLECTION

CONSULTING SERVICES,PRACTICE MANAGEMENT

Biomet 3i4555 Riverside Dr.Palm Beach Gardens, FL 33410800-342-5454

www.biomet3i.com

Dental Management Club4924 Balboa Blvd #460Encino, CA 91316

www.dentalmanagementclub.com

The Dental Box Company, Inc.PO Box 101430Pittsburgh, PA 15237412-364-8712

www.thedentalbox.com

Dentistry’s Business Secrets9016 Phoenix ParkwayO’Fallon, MO 63368636-561-5445

www.dentrysbusinesssecrets.com

Modern Dental Marketing Practices504 N. Oak St. #6Roanoke, TX 76262940-395-5115

www.moderndentalmarketing.com

Mediserv6451 Brentwood Stair Rd.Ft. Worth, TX 76112800-378-4134

www.mediservltd.com

Practice Velocity1673 Belvidere RoadBelvidere, IL 61008888-357-4209

www.practicevelocity.com

Sweans Technologies501 Silverside Rd.Wilmington, DE 19809302-351-3690

www.medisweans.com

VIP BillingPO Box 1350Forney, TX 75126214-499-3440

www.vipbilling.com

NextGen200 Welsh Rd.Horsham, PA 19044215-657-7010

www.nextgen.com

Synapse Medical Management18436 Hawthorne Blvd. #201Torrance, CA 90504310-895-7143

www.synapsemgmt.com

COMPUTER, SOFTWARE

CDWG300 N. Milwaukee AveVernon Hills, IL 60061866-782-4239

Instant Medical History4840 Forest Drive #349Columbia, SC 29206803-796-7980

www.medicalhistory.com

DENTAL

40| NOVEMBER 2011

ABELSoft1207 Delaware Ave. #433Buffalo, NY 14209800-267-2235

www.abelmedicalsoftware.com

Acentec, Inc17815 Sky Park Circle , Suite JIrvine, CA 92614949-474-7774

www.acentec.com

AdvanceMD 10011 S. Centennial PkwySandy, UT 84070800-825-0224

www.amdsoftware.com

CollaborateMD201 E. Pine St. #1310Orlando, FL 32801888-348-8457

www.collaboratemd.com

DocuTAP4701 W. Research Dr. #102Sioux Falls, SD 57107-1312877-697-4696

www.docutap.com

Integritas, Inc.2600 Garden Rd. #112Monterey, CA 93940800-458-2486

www.integritas.com

ELECTRONIC MED. RECORDS

LOCUM TENENS

INSURANCE, MED. LIABILITY

Medical Protective5814 Reed Rd.Fort Wayne, In 46835800-463-3776

MGIS, Inc.1849 W. North TempleSalt Lake City, UT 84116800-969-6447

www.mgis.com

Professional Medical Insurance Services16800 Greenspoint Park DriveHouston, TX 77060877-583-5510

www.promedins.com

Wood Insurance Group4835 East Cactus Rd. #440Scottsdale, AZ 85254-3544602-230-8200

www.woodinsurancegroup.com

MEDICAL EQUIPEMENT

Arup Laboratories500 Chipeta WaySalt Lake City, UT 84108800-242-2787

www.aruplab.com

Clinical Reference Laboratory8433 Quivira Rd.Lenexa, KS 66215800-445-6917

www.crlcorp.com

Peters Medical Research507 N. Lindsay St. 2nd FloorHigh Point, NC 27262

www.Petersmedicalresearch.com

medical resource guide

MEDICAL RESEARCH

MEDMONTHLY.COM |41

MEDICAL ART

MEDICAL PRACTICE SALES

PRACTICE VALUATIONS

Physician SolutionsPO Box 98313Raleigh, NC 27624919-845-0054

www.physiciansolutions.com

Abaxis3240 Whipple RoadUnion City, CA 94587800-822-2947

www.piccoloxpress.com

ALLPRO Imaging1295 Walt Whitman RoadMelville, NY 11747888-862-4050

www.allproimaging.com

Biosite, Inc9975 Summers Ridge RoadSan Diego, CA 92121858-805-8378

www.biosite.com

Brymill Cryogenic Systems105 Windermere Ave.Ellington, CT 06029860-875-2460

www.brymill.com

Cryopen800 Shoreline, #900Corpus Christi, TX 78401888-246-3928

www.cryopen.com

Deborah Brenner877 Island Ave #315San Diego, CA 92101619-818-4714

www.deborahbrenner.com

Martha Petty316 Burlage CircleChapel Hill, NC 27514919-933-4920

www.marthapetty.com

Carolina Liquid Chemistries, Inc.391 Technology WayWinston Salem, NC 27101336-722-8910

www.carolinachemistries.com

Dicom Solutions548 WaldIrvine, CA 92618800-377-2617

www.dicomsolutions.com

Radical Radiology524 Huffman Rd.Birmingham, AL 35215866-324-9700

www.radicalradiology.com

Roche Diagnostics9115 Hague Rd.PO Box 50457Indianapolis, IN 46250-0457317-521-2000

www.roche-diagnostics.us

BizScorePO Box 99488Raleigh, NC 27624919-846-4747

www.bizscorevaluation.com

Medical Practice Listings8317 Six Forks Rd. Ste #205Raleigh, NC 27624919-848-4202

www.medicalpracticelistings.com

Our secret weapon against smoking?

Each other.I first lit up a cigarette when I was 9. I started smoking at 16 and smoked for 15years. When I wanted to quit, I found out the average person takes 3-4 efforts toquit because nicotine is so powerful. I learned that if you pick it up again, it’spart of a process. It’s not that you failed, that’s just how it works. When I finallyquit, I had more weapons to help me — my pills, my support and my nursepractitioner to talk to. Now we have Tobacco Free Nurses to help, too.

— Maria, RN

Support for the Initiative was provided by a grant from the Robert Wood Johnson Foundation in Princeton, New Jersey, to the School of Nursing, University of California, Los Angeles in partnership with American Association of Colleges of Nursing, American Nurses Foundation / American Nurses Association, and National Coalition of Ethnic Minority Nurse Associations.

Toll Free: 877-203-4144 | www.tobaccofreenurses.org

Tobacco Free Nurses is a one-stop shop for all nurses, especially nurses who want to help their patients

quit smoking and nurses who want to quit themselves. We are nurses who want to benefit nurses and

patients, and promote a tobacco free society. Please visit our website or call for further information. Phot

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MEDMONTHLY.COM |45

North Carolina North Carolina (cont.)Occupation Health Care Practice located in Greensboro, N.C. has an immediate opening for a primary care phy-sician. This is 40 hours per week opportunity with a base salary of $135,000 plus incentives, professional liability in-surance and an excellent CME, vacation and sick leave package. Send copies of your CV, NC medical license, DEA certificate and NPI certificate with number to Physi-cian Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolutions@gmail.com Family Practice physician opportunity in Raleigh, N.C. This is a locum’s position with three to four shifts per week requirement that will last for several months. You must be BC/BE and comfortable treating patients from 1 year of age to geriatrics. You will be surrounded by an exceptional, experienced staff with beautiful offices and accommodations. No call or hospital rounds. Send copies of your CV, N.C. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolutions@gmail.com Methadone Treatment Center located near Charlotte, N.C. has an opening for an experienced physician. You must be comfortable in the evaluation and treat-ment within the guidelines of a highly regulated envi-ronment. Practice operating hours are 6 a.m. till 3 p.m. Monday through Friday. Send copies of your CV, N.C. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate con-sideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physicianso-lutions@gmail.com

Family Practice physician is needed to cover several shifts per week in Rocky Mount, N.C. This high profile practice treats pediatrics, women’s health and primary care patients of all ages. If you are available for 30 plus hours per week for the remainder of the year, this could be the perfect opportunity. Send copies of your CV, N.C. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate con-sideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolu-tions@gmail.com

Cardiology practice located in High Point, N.C. has an opening for a Board Certified Cardiovascular physician. This established and beautiful facility offers the ideal

setting for an enhanced lifestyle. There is no hospital call or invasive procedures. Look into joining this three physician facility and live the good live in one of North Carolina’s most beautiful cities. Send copies of your CV, N.C. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate con-sideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolu-tions@gmail.com

Board Certified Internal Medicine Physician position is available in the Greensboro, N.C. area. This is an out-patient opportunity within a large established prac-tice. The employment package contains salary plus incentives. Please send a copy of your current CV, N.C. medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to: Physician Solutions, P.O. Box 98313, Raleigh, NC 27624. Email: physiciansolutions@gmail.com or phone with any questions, PH: (919) 845-0054.

Locum Tenens opportunity for Primary Care MD in the Triad Area, N.C. This is a 40-hour per week on-going as-signment in a fast pace established practice. You must be comfortable treating pediatrics to geriatrics. We pay top wage, provide professional liability insurance, lodging when necessary, mileage and exceptional opportunities. Please send a copy of your current CV, North Carolina medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to: Physician Solu-tions, P.O. Box 98313, Raleigh, NC 27624. E-mail: physi-ciansolutions@gmail.com or phone with any questions, PH: (919) 845-0054.

Internal Medicine practice located in High Point, N.C., has two full time positions available. This well-estab-lished practice treats private pay as well as Medicare/Medicaid patients. There is no call or rounds associated with this opportunity. If you consider yourself a well-rounded IM physician and enjoy a team environment, this could be your job. You would be required to live in or around High Point and if relocating is required, a moving package will be extended as part of your salary and incentive package. BC/BE MD should forward your CV, and copy of your N.C. medical license to physician-solutions@gmail.com View this and other exceptional physician opportunities at www.physiciansolutions.com or call (919) 845-0054 to discuss your availability and options.

Physicians needed Physicians needed

To place a classified ad, call 919.747.9031

classified listings

Classified

Our secret weapon against smoking?

Each other.I first lit up a cigarette when I was 9. I started smoking at 16 and smoked for 15years. When I wanted to quit, I found out the average person takes 3-4 efforts toquit because nicotine is so powerful. I learned that if you pick it up again, it’spart of a process. It’s not that you failed, that’s just how it works. When I finallyquit, I had more weapons to help me — my pills, my support and my nursepractitioner to talk to. Now we have Tobacco Free Nurses to help, too.

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Support for the Initiative was provided by a grant from the Robert Wood Johnson Foundation in Princeton, New Jersey, to the School of Nursing, University of California, Los Angeles in partnership with American Association of Colleges of Nursing, American Nurses Foundation / American Nurses Association, and National Coalition of Ethnic Minority Nurse Associations.

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Hospice Practice wanted in Raleigh/Durham area of North Carolina.

Medical Practice Listings has a qualified physician buyer that is ready to purchase. If you are considering your Hospice practice options, contact us for a confidential discussion regarding your practice.

Hospice Practice Wanted

To find out more information call 919-848-4202 or e-mail medlistings@gmail.com

www.medicalpracticelistings.com

Wanted:

To view our national listings visitwww.medicalpracticelistings.com

Hospice Practice in Dallas, TX

We have a qualified buyer that is looking for an established Hospice practice in the Dallas,Texas area. To review your Hospice practice options confidentially, contact

Medical Practice Listings at 919-848-4202 or e-mail us at

medlistings@gmail.com.

Urgent Care Practice wanted in North Carolina.

Qualified physician is seeking to purchase an established Urgent Care within 100 miles of Raleigh, North Carolina. If you are considering retiring, relocations or closing your practice for personal reasons, contact us for a confidential discussion regarding your Urgent Care. You will receive cash at closing and not be required to carry a note.

Wanted:Urgent Care Practice

Call 919-848-4202 or e-mail medlistings@gmail.comwww.medicalpracticelistings.com

Medical Practice ListingsBuying and selling made easy

MedSpa Located in North Carolina

We have recently listed a MedSpa in N.C.

This established practice has staff MDs, PAs and Nurses to assist patients. Some of the procedures performed include: Botox, Dysport, Restylane, Perian, Juvederm, Radiesse, IPL Photoreju Venation, Fractional Laser Resurfacing as well as customized facials. There are too many procedures to mention in this very upscale practice. The qualified buyer will be impressed with the $900,000 gross revenue. This is a new listing, and we are in the valuation process.

Contact Medical Practice Listings today to discuss the practice details.

N.C. MedSpa For Sale

For more information call Medical Practice Listings at919-848-4202 or e-mail medlistings@gmail.com.

www.medicalpracticelistings.com

Urgent Care opportunities throughout Virginia. We have contracts with numerous facilities and eight to 14-hour shifts are available. If you have experience treating patients from Pediatrics to Geriatrics, we welcome your in-quires. Send copies of your CV, Va. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolutions@gmail.com Pediatric Locums Physician needed in Harrisonburg, Dan-ville and Lynchburg, Va. These locum positions require 30 to 40 hours per week, on-going. If you are seeking a beautiful climate and flexibility with your schedule, please consider one of these opportunities. Send copies of your CV, Va. medical license, DEA certificate and NPI certifi-cate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolu-tions@gmail.com

Virginia

Physicians needed Practice sales

North CarolinaImpressive Internal Medicine Practice in Durham, N.C.: The City of Medicine. Over 20 years serving the commu-nity, this practice is now listed for sale. There are four well equipped exam rooms, new computer equipment and a solid patient following. The owner is retiring and willing to continue with the new owner for a few months to assist with a smooth transition. Contact Medical Practice List-ings at (919) 848-4202 for more information. View addition-al listings at: www.medicalpracticelistings.com

Modern Vein Care Practice located in the mountains of N.C. Booking seven to 10 procedures per day, you will find this impressive vein practice attractive in many ways. Housed in the same practice building with an Internal Medicine, you will enjoy the referrals from this as well as other primary care and specialties in the community. We have this practice listed for $295,000 which includes charts, equipment and good will. Contact Medical Practice List-ings at (919) 848-4202 for more information. View addition-al listings at: www.medicalpracticelistings.com

Family Practice located in Hickory, N.C. Well established and a solid 40 to 55 patients split between an M.D. and physician assistant. Experienced staff and outstanding medical equipment. Gross revenues average $1,500,000 with strong profits. Monthly practice rent is only $3,000 and the utilities are very reasonable. The practice with all equipment, charts and good will are priced at $625,000. Contact Medical Practice Listings for additional informa-tion. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail: medlistings@gmail.com

Locum Tenens Primary Care Physicians Needed If you would like the flexibility and exceptional pay associated with locums, we have immediate opportunities in family, urgent care, pediatric, occupational health and county health departments in North Carolina and Virginia. Call today to discuss your options and see why Physician Solu-tions has been the premier physician staffing company on the Eastern seaboard. Call 919-845-0054 or review our corporate capabilities at www.physiciansolutions.com

North Carolina (cont.)

MEDICAL PRACTICE LISTINGSAre you looking to sell or buy a practice? We can help you!

View national practice listings by visiting our website or contact us for a confidential discussion regarding your practice options. We are always ready to assist you.

919.848.4202medlistings@gmail.com | medicalpracticelistings.com

in-house practice experts and attorney

To place a classified ad, call 919.747.9031

Classified

48| NOVEMBER 2011

Practice for sale

North Carolina (cont.)

South CarolinaLucrative E.N.T. practice with room for growth, located three miles from the beach. Physician’s assistant, audiolo-gist, esthetician and well-trained staff. Electronic medi-cal records, mirror imaging system, established patient and referral base, hearing aids and balance testing, esthetic services and Candela laser. All aspects of otolar-yngology, busy skin cancer practice, established referral base for reconstructive eyelid surgery, Botox and facial fillers. All new surgical equipment, image-guidance sinus surgery, balloon sinuplasty, nerve monitor for ear/parotid/thyroid surgery. Room for establishing allergy, cosmet-ics, laryngology and trans-nasal esophagoscopy. All the organization is done; walk into a ready-made practice as your own boss and make the changes you want, when

Internal Medicine Practice located just outside Fayette-ville, N.C. is now being offered. The owning physician is re-tiring and is willing to continue working for the new owner for a month or two assisting with a smooth transaction. The practice treats patients four and a half days per week with no call or hospital rounds. The schedule accommo-dates 35 patients per day. You will be hard pressed to find a more beautiful practice that is modern, tastefully decorated and well appointed with vibrant art work. The practice, patient charts, equipment and good will is being offered for $415,000 while the free standing building is be-ing offered for $635,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail: medlistings@gmail.com

Primary Care practice specializing in women’s care. The owning female physician is willing to continue with the practice for a reasonable time to assist with smooth own-ership transfer. The patient load is 35 to 40 patients per day, however that could double with a second provider. Exceptional cash flow and profitable practice that will surprise even the most optimistic practice seeker. This is a remarkable opportunity to purchase a well-established woman’s practice. Spacious practice with several well-appointed exam rooms, well-appointed throughout. New computers and medical management software add to this modern front desk environment. This practice is being offered for $435,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail: medlistings@gmail.com

you want. Physician will to stay on for smooth transition. Hospital support is also an option for up to a year. The listing price is $395,000 for the practice, charts, equip-ment and good will. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail: medlistings@gmail.com

Practice for sale

South Carolina (cont.)

Wanted:Classified ads for

Med Monthly!Call our Advertising Departmenttoday to find out about all the

advertising opportunities available with Med Monthly.

919.747.9031Visit us online anytime at

medmonthly.com

To place a classified ad, call 919.747.9031

Practice wanted

Pediatric Practice wanted in Raleigh, N.C.Medical Practice Listings has a qualified buyer for a Pe-diatric Practice in Raleigh, Cary or surrounding area. If you are retiring, relocating or considering your options as a pediatric practice owner, contact us and review your options. Medical Practice Listings is the leading seller of practices in the U.S. When you list with us, your practice receives exceptional national, regional and local expo-sure. Contact us today at (919) 848-4202.

North Carolina

Classified

Primary Care practice specializing in Women’s careRaleigh, North Carolina

The owning female physician is willing to continue with the practice for a reasonable time to assist with smooth owner-ship transfer.  The patient load is 35 to 40 patients per day, however, that could double with a second provider.  Excep-tional cash flow and profitable practice that will surprise even the most optimistic practice seeker.  This is a remarkable opportunity to purchase a well-established woman’s practice.  Spacious practice with several well-appointed exam rooms, tactful and well appointed throughout.  New computers and medical management software add to this modern front desk environment.   

List price: $435,000.

Practice for Sale in Raleigh, NC

Call Medical Practice Listings at (919) 848-4202 for details and view our other listings at

www.medicalpracticelistings.com

North Carolina Family Practice located about 30 minutes from Lake Norman has everything going for it.

Gross revenues in 2010 were 1.5 million, and there is even more upside. The retiring physician is willing to continue to practice for several months while the new owner gets established.

Excellent medical equipment, staff and hospital near-by, you will be hard pressed to find a family prac-tice turning out these numbers.

Listing price is $625,000.

Medical Practice Listings For more information call

(919) 848-4202. To view other practice listings visit medicalpracticelistings.com

EXCELLENT FAMILY PRACTICE FOR SALE

MEDMONTHLY.COM |49

OCCUPATIONAL HEALTH CARE PRACTICE FOR SALEGreensboro, North Carolina

Well-established practice serving the Greensboro and High Point areas for over 15 years. Five exam rooms fully equipped, plus digital X-Ray. Extensive corporate accounts as well as walk-in traffic. Lab equipment includes CBC. The owning MD is retiring, creating an excellent opportunity for a MD to take over an existing patient base and treat 25 plus patients per day from day one. The practice space is 2,375 sq. feet. This is an exceptionally opportunity. Leased equipment includes: X-Ray $835 per month, copier $127 per month, and CBC $200 per month. Call Medical Practice Listings at (919) 848-4202 for more information.

PRACTICE FOR SALE

Asking price: $385,000

To view more listings visit us online at medicalpracticelistings.com Please direct all correspondence to mdstaffingforsale@gmail.com.Only serious, qualified inquirers.

One of the oldest Locums companies Large client list Dozens of MDs under contract Executive office setting Modern computers and equipment Revenue over a million per year Owner retiring List price is over $2 million

MD STAFFING AGENCY FOR SALE

Great opportunity for anyone who wants to purchase an established business.

Buying Bene�tsAccurate practice pricingDetailed reports and �nancialsLargest selection of health care facilitiesWork one-on-one with an experienced team of quali�ed professionals

medicalpracticelistings.comA Philip Driver Company

Maintain con�dentialityProfessional representationNational and regional marketingMaximize your practice valueBizScore Valuation assessment

Listing Bene�ts

Medical Practice Listings

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Buying or selling? We can help!

Scan this QR code with your smartphone to learn more

Plastic Surgery practice for sale with lucrative E.N.T. specialty

Myrtle Beach, South Carolina

Practice for sale with room for growth and located only three miles from the beach. Physician’s assistant, audiologist, esthetician and well-trained staff. Electronic medical records, Mirror imaging system, established patient and referral base, hearing aids and balance test-ing, esthetic services and Candela laser. All aspects of Otolaryngol-ogy, busy skin cancer practice, established referral base for reconstruc-tive eyelid surgery, Botox and facial fillers. All new surgical equipment, image-guidance sinus surgery, balloon sinuplasty, nerve monitor for ear/parotid/thyroid surgery. Room for establishing Allergy, Cosmet-ics, Laryngology & Trans-nasal Esophagoscopy. All the organization is done, walk into a ready made practice as your own boss and make the changes you want, when you want. Physician will to stay on for smooth transition. Hospital support also an option for up to a year. The listing price is $395,000.

For more information call Medical Practice Listing at (919) 848-4202. To view our other listings, visit medicalpracticelistings.com.

Practice at the beach

MEDMONTHLY.COM |51

Established North Carolina Primary Care practice only 15 minutes from Fayetteville, 30 minutes from Pinehurst, 1 hour from Ra-leigh, 15 minutes from Lumberton and about an hour from Wilm-ington. The population within 1 hour of this beautiful practice is over one million. The owning physician is retiring and the new owner will benefit from his exceptional health care, loyal patient following, professional decorating, beautiful and modern free standing medical building with experienced staff. The gross revenue for 2010 is $856,000, and the practice is very profitable. We have this practice listed for $415,000. Call today for more details and information regarding the medical building. Our Services:• Primary Health• Well Child Health Exams• Sport Physical• Adult Health Exams• Women’s Health Exams• Management of Contraception• DOT Health Exam• Treatment & Management of Medical Conditions• Counseling on Prevention of Preventable Diseases• Counseling on Mental Health• Minor surgical Procedures

Exceptional North Carolina Primary Care Practice for Sale

For more information call Medical Practice Listing at (919) 848-4202. To view our other listings, visit medicalpracticelistings.com.

Pediatrics Practice wanted in N.C.Considering your options regarding your Pediatric Prac-tice? We can help. Medical Practice Listings has a well qualified buyer for a Pediatric Practice anywhere in central North Carolina.

Contact us today to discuss your options confidentially.

Pediatrics Practice Wanted

Medical Practice ListingsCall 919-848-4202 or e-mail medlistings@gmail.com

www.medicalpracticelistings.com

Med MonthlyMed Monthly is the premier health care

magazine for medical professionals.

By placing an ad in Med Monthly you’ll reach: family medicine, internal

medicine, physician assistants and more!

Call us today to place your classified!

919.747.9031

Also available online 24/7medmonthly.com

best places to see fall foliagethe top

52 | NOVEMBER 2011

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EASTERN SIERRAS, CALIF. Start in Coleville and

head up to Lundy Lake, where you can take a short hike up to Lundy Canyon Falls, which plum-mets hundreds of feet.

Timing is essential in these nine autumn road trips across the U.S. The U.S. Forest Services has a Fall Foliage Hotline (800) 354-4595, which offers region by region info and pre-dictions of foliage peaks.

Compiled by Will O’Neil

BLUE RIDGE PARKWAY, N.C. A popular destination on this 469 mile drive is Mount Mitchell State Park, the highest peak in the Eastern U.S.

N.Y. STATE HIGHWAY 9N This New England drive winds through the Eastern Adiron-

dacks near Lake Champlain. History buff? Stop by Saratogao battlefield and Fort Ticonderoga during your cruise.

SKYLINE DRIVE, SHENANDOAH NA-TIONAL PARK, VA.

Ride horseback at Skyland Resort through breathtaking trails, and don’t forget to stop at Luray Cav-erns near Charlottesville.

MOOSEHEAD LAKE REGION, MAINEA popular stop is the Attean Overlook. This tourist stop has a great view of the Moose River Valley and in the far distance the Canadian border.

COLORADO Breckenridge offers great ATV tours in some of the Rockies highest peaks. If a mountain bike is more your speed, Grand Junction has a 25 mile public bike ride.

DENALI HIGHWAY IN SOUTH-CENTRAL ALASKA From Maclaren Summit you can see the always snow cov-

ered Alaska Range and Mt. Denali, the highest peak in North America.

ENCHANTED CIRCLE SCENIC BYWAY, N.M. Some of the best south-western foliage can be found near Taos up to Eagle Nest. Dine at the Old Blinking Light Restaurant, known for its Tex-Mex Red Chile.

7 ARKANSAS STATE HIGH-WAY NO. 7 Head out from

Hot Springs through the Ozark National Forest to Jasper, a hub for fall hiking, biking and horseback riding.

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GROW YOUR PRACTICELet MedMedia9 expert designers create a website

for your practce. Need more? We can also create print collateral to help your practice grow.

IMAGINE THAT!MEDMEDIA9.COM | 919-747-9031Scan this QR code with your smartphone to learn more.