Pediatrician Fall 2012
Back to the Future For private-practice pediatricians, “The times they are a-changin’,” notes Maryland pediatrician Dan Levy. R egardless of the demands he faces in daily practice, pediatrician Dan Levy takes a thoughtful, upbeat approach in caring for his patients.
wings Mills, Md., pedia- he was asked earlier this year to do a What evolved out of that era of the trician Dan Levy recalls presentation at Johns Hopkins’ annual simple doctor-patient relationship, driving by a park a few sum- Pediatric Trends conference on Sept. starting in the mid-1960s, were groups Omers ago not too far from 20, it was only natural that he’d select like the American Academy of Pediatrics his favorite summer vacation spot, Lake “Imagining the Future of Pediatric and guidelines for preventive care and George in upstate New York. The sign at Medicine” as his topic, but in the wellness, which led to Bright Futures, the entrance – “The Abraham Jacobi and context of what physicians like Abraham the gold standard of pediatric care Carl Schurz Memorial Park” – stopped Jacobi brought to pediatrics. today. In the 1990s came managed him in his tracks. “We have to start thinking about the care and initiatives to make health care “I did a double take and pulled the changing dynamics and demographics of more efficient and affordable. What it car over,” says Levy, a self-described pediatric practice, and we have to adapt meant for a lot of pediatricians, Levy medical history buff who knew well the to that and understand the realities,” added, was less control of care and more story of Abraham Jacobi, the so-called Levy said. “But we can’t talk about the work for the same or less amount of father of pediatrics who established one future until we talk about where we compensation. An expansion of pediatric of the first children’s clinics and pediatric came from.” sub-specialists – and a decline in pediatric departments in this country. “I found Jacobi and some of his contempor- primary care – followed, along with the town historian, who took me into aries, Levy explained, initiated and higher expectations among consumers. the town hall, a back room and a whole developed concepts like prevention, “This put more pressure on the system file on Jacobi.” wellness and primary care for children because there’s more demand for the Rummaging through the archive, in this country. The initial concept of services we can provide but there just Levy reflected on his own 35 years as prevention was well-baby clinics and aren’t enough of us to provide that a pediatrician and changes in pediatric care rendered in pediatric offices, Levy service,” Levy said. “Fewer and fewer medicine during that time – like explained. “The expectation,” Levy said, people are interested in going into managed care, the Affordable Care Act, “was you’d walk into the office and the primary care.” and the retail medicine craze. So when doctor would sit and talk with you.” continued on page 5
In Clinic Radiology In Practice In the Community 2 3 4 6 Director’s Column In Clinic
George Dover, m.d. Director, Johns Hopkins Children’s Center Given Professor of Pediatrics Looking back, moving ahead I n Bloomberg Children’s Center’s upgraded echocardiography suite, equipped with advanced telemedicine technology, pediatric cardiologists W. Reid As I’m pretty sure you’ve heard by now, we’ve Thompson, left, and Phil Spevak review images. moved into a marvelous new building, The Charlotte R. Bloomberg Children’s Center. As we look ahead at how pediatric medicine might change in our new home, we thought Screening for Critical it might be constructive to look back to our origins, which surprisingly were in a tiny two- story building known as the “Bath House.” Congenital Heart Disease Apparently, in 1896 baths were considered therapeutic. ritical congenital heart disease and an echocardiogram is done to check At the time we had no full-time pediatric (CCHD) – heart conditions like for CCHD. Studies have shown that the faculty, training or research program. But with pulmonary atresia associated combined use of pulse oximetry and a the opening in 1912 of the Harriet Lane Home with hypoxia that require physical exam along with focused prenatal came the first full-time academic department C interventions like surgery or catheterization echocardiography identifies 80 percent of in pediatrics in this country. The melding of soon after birth – has been responsible for infants with CCHD. pediatric research and training with patient more deaths in the first year of life than Through simulations and actual screens, care followed and Hopkins became known for any other birth defect. Fortunately, around Hopkins staff in obstetrics, neonatology pioneering pediatric treatments. By the late half of CCHD patients are diagnosed by and pediatric cardiology prepared for 1950s the Harriet Lane Home was outmoded ultrasound prenatally – and of those missed the statewide screening kickoff Sept. 1. and drawings were drafted for the Children’s about 60 percent by symptoms on physical At Johns Hopkins Hospital and Johns Medical & Surgical Center (CMSC), where exam soon after birth – and appropriately Hopkins Bayview Medical Center the pediatric academic medicine would thrive over treated. But some 280 infants born with test is administered in term infants by a the next half century. The CMSC eventually CCHD in the United States each year are pediatric nurse practitioner or nurse in outlived its space, too, and in 1998 we began undetected and discharged from nurseries, the nursery. Neonatologist Christopher planning a new building – Bloomberg Chil- notes Hopkins Children’s Center pediatric Golden explains that physiologic changes dren’s Center – with a new challenge: How cardiologist Phil Spevak, placing them in the neonatal heart in the first 24 hours would we sustain the innovation that sus- at greatest risk of deteriorating before after birth may give false positive or false tained the Harriet Lane Home and CMSC? diagnosis. negative readings; hence, screening is done Interestingly, in a parallel way, pediatrician “They may get metabolic acidosis, poor after one day of life. If the infant fails the Dan Levy in this issue looks back at pioneers perfusion and, potentially, brain and first screen, a second and, if necessary, in pediatrics like Abraham Jacobi and his em- kidney failure,” Spevak says. “It’s not the third screen is done, each an hour apart. If phasis on primary care, prevention and well- controlled prenatal presentation where all three tests are abnormal or borderline, ness – and shares how such early hallmarks of you’re stabilized in the neonatal intensive an echocardiogram is ordered. pediatric medicine are being stressed in new care unit (NICU) and have elective Spevak stresses that pediatric cardiology models of care today. Similarly, neonatolo- management.” staff have added resources, including gist and informatics expert Chris Lehmann However, a new non-invasive screening advanced telemedicine technology, to opens a wide window to our future with elec- test recommended by the Department handle the anticipated increase in calls tronic health records in this era of dynamics of Health and Human Services and from both Johns Hopkins and other like the Affordable Care Act. The take-home mandated by the state of Maryland aims Maryland hospitals requesting echo reminder is that regardless of whether our to significantly reduce the number of readings: “We have the ability to receive space is a state-of-the-art children’s hospital missed diagnoses among those born with the calls, interpret the test, and get the with a rich history or a demanding pediatric CCHD. The test, called pulse oximetry, results out quickly.” n practice, we all bring ideas to the table. Col- involves placing a small sensor on both laboration and innovation continue to be es- the baby’s hand and foot to measure the For more information on CCHD screen- sential as we strive to provide the very best amount of oxygen in the blood. If no ing, visit the Centers for Disease Control care possible for children. n other reason for low oxygen saturation is and Prevention at www.cdc.gov/ncbddd/ found, pediatric cardiology is consulted pediatricgenetics/pulse.html 2 | PEDIATRICIAN FALL 2012 Radiology
Imaging for Kids Only
t wasn’t too long ago, Children’s Center areas for inpatients and Pediatric Radiology Director Thierry outpatients that reduce Huisman notes, that a 4-year-old would their risk of infection. Ifind himself in a radiology waiting room Also, Children’s Center sitting next to a 85-year-old man, or a healthy radiologists are using child next to a sick child. That’s because the newest imaging pediatric radiologists shared space with equipment optimized their adult counterparts where they treated for low-dose radiation, both inpatient and outpatients. Also, their reducing exposure to offices and the imaging suites they used were children. dispersed throughout the hospital. In a sense, Family-friendly the division had no home. initiatives include glass- No more. Now housed on the fourth enclosed alcoves in the floor of the new Charlotte R. Bloomberg radiology suites to allow I n the new CT suite for children only, (from left to right) Children’s Center, pediatric radiologists – young patients to have pediatric radiologists Melissa Spevak, Thierry Huisman for the first time – have their own space. visual contact with their and Aylin Tekes. “It’s much more convenient for parents parents while undergoing and children to go to one place in a imaging. Also, dedicated “quiet rooms,” the studies and ED physicians. “This pediatric setting,” says Huisman. “They do designed to have a calming, soothing effect will greatly improve the quality of not have to walk into a hospital for adults.” on young children awaiting imaging, is interpretation of imaging studies,” says Another plus, Huisman notes, is helping them avoid general anesthesia. Huisman, “which should make a big pediatric radiology’s proximity to the Huisman notes that over a recent two- difference in service.” pediatric intensive care unit (PICU), month period, 13 children scheduled for Huisman also notes that thanks to pediatric operating rooms, and pre-op and an imaging study under general anesthesia Johns Hopkins leadership’s support, he has post-op care units, all of which are also on were able to complete their studies without been able to grow his division from three the fourth floor of Bloomberg Children’s it thanks to the quiet rooms and the pediatric radiologists four years ago to more Center. That translates into safer transport support of the recently recruited full-time than six today. That means quicker referrals of pediatric patients and a more rapid Child Life specialist in pediatric radiology. and more accurate imaging studies. response from radiologists. Having a radiologic reading room in “The acquisition of new faculty will mean Imaging is safer and more family the Pediatric Emergency Department, much better end results,” says Huisman. friendly in the new suite, too, notes another first, allows greater interaction “And it should be a much more enjoyable Huisman, pointing to separate waiting between pediatric radiologists conducting experience for patients and their families.” n
Research Briefs
Abnormal Carotids in Children with Out-Of-Tune Protein Leads to Kidney Disease Heart Muscle Failure
A federally funded study led by researchers at Johns Hopkins A new Johns Hopkins study has unraveled the changes in a key cardiac Children’s Center has found that children with mild to moderate protein that can lead to heart muscle malfunction and precipitate heart kidney disease have abnormal narrowing of the thick neck arter- failure. Troponin I, found exclusively in heart muscle, is already used as ies, a condition known as carotid atherosclerosis, usually seen the gold-standard marker in blood tests to diagnose heart attacks, but the in older adults with a long history of elevated cholesterol and new findings reveal why and how the same protein is also altered in heart untreated hypertension. The findings – published online ahead of failure. Scientists have known for a while that several heart proteins – tro- print on Sept. 13 in the Clinical Journal of the American Society of ponin I is one of them – get “out of tune” in patients with heart failure, Nephrology – are particularly striking, the researchers say, because but up until now, the precise origin of the “bad notes” remained unclear. they point to serious blood vessel damage much earlier in the The discovery, published online ahead of print on Sept. 12 in the journal disease process than previously thought. As a result, they add, Circulation, can pave the way to new – and badly needed – diagnostic tools even children with early-stage kidney disease should be moni- and therapies for heart failure, believed to affect more than 6 million tored aggressively and treated promptly for both hypertension adults in the United States, the researchers say. and high cholesterol to reduce the risk for serious complications down the road. For more on these findings and others from Johns Hopkins Children's Center, go to www.hopkinschildrens.org and see “Latest News.”
3 | PEDIATRICIAN FALL 2012 In Practice
The Future Role of Technolog y Medical informatics expert makes the case for greater participation by pediatricians in health information technology.
o, just why is it that described a collaborative effort only 25 percent of in which pediatricians and the pediatricians report AAP provide IT vendors with Susing an electronic evidence-based best practices health record (EHR), compared guidelines like Bright Futures, with 43 percent of adult which the IT vendors, in turn, providers? develop for real-time digital That was among the questions access via the Internet, mobile pediatric neonatologist Chris devices and clinical information Lehmann posed at Johns systems. The AAP is already Hopkins annual Pediatrics for the in the business of distributing Practitioner conference Sept. 21. knowledge of how to do child And as a member of the Board of health in the best possible way, Directors of the American Medical Lehmann said, so a natural next Informatics Association, Director step would be integrating that of the American Academy of knowledge, including Bright Pediatrics (AAP) Child Health Futures guidelines, into EHRs. Informatics Center, and editor “With Bright Futures there’re of Applied Clinical Informatics, so many actionable key items perhaps there’s no better figure you should be doing on visits, in pediatrics than Lehmann which makes it hard for people to address such questions. His to remember everything. Going answer? back and pulling up those forms Most EHRs, Lehmann and doing it on paper is a real explained, are not well designed pain,” Lehmann said. “Wouldn’t for the practice of pediatrics, it be nice to integrate that which require certain features directly into your EHR?” like weight-based dosing, With considerations like immunizations and growth costs, interoperability of systems charts, not to mention and training, Lehmann noted, developmental issues that tend High-tech informatics specialist Chris Lehmann. implementation will be tricky. to be more variable in children But help is available, he added, and adolescents: “With adults pointing to resources like the you can generally do the same showed no patient-safety benefit. Pediatricians, however, are not Child Health Informatics baseline functional assessment, But by building a customized taking full advantage of HIT, nor Center, or CHIC, which serves but the 16-year-old has different medical logic module, Lehmann optimizing long-term health and as the AAP home for health developmental issues, and said, Hopkins Children’s Center financial returns on investments information technology, and the EHRs are not well designed to improved compliance with alerts of health information technol- Council on Clinical Information incorporate these issues into the significantly. ogy, noted Lehmann. Now is the Technology, or COCIT. Such documentation process.” “All of a sudden the alerts time to get involved, he added, resources can help pediatricians Nonetheless, EHRs and other became meaningful and acted pointing to new state and federal identify the EHR that might be forms of health information on,” Lehmann said. “They were programs, prompted by the Af- best suited for their particular technology, or HIT, can be truly things that you should care fordable Care Act, that will rely practice. Also, “Buddy Lists” beneficial, said Lehmann, citing about as a provider.” on pediatricians having an EHR. assist pediatricians in finding a recent initiative designed In another quality improve- “And if you don’t have a colleague who has already to improve compliance with ment initiative designed to in- an EHR, you’ll be left out,” implemented an EHR. drug-drug interaction alerts in crease immunization rates at Lehmann said, noting that “These resources can Hopkins Children’s Center’s Hopkins’ Harriet Lane primary practices that implement certified help you do the best job at EHR. One internal review care clinic, charge nurses were EHR technology, depending on implementation,” Lehmann said, showed that house staff had paged whenever a patient due their Medicaid panel, will have “as well as help you get money been ignoring 97 percent of such for a shot showed up on the da- the potential to receive between from the federal government.” n alerts because they appeared tabase when arriving for an ap- $44K and $62K per physician. irrelevant and lengthy. Indeed, pointment. Immunization rates So, how will HIT and EHRs For more information, go to: two months of surveillance skyrocketed. on the horizon work? Lehmann www.aap.org/CHIC
PEDIATRICIAN FALL 2012 | 4 In Clinic Sickle Cell and Asthma
he question of how many children with sickle cell disease (SCD) also have asthma is unknown, notes Hopkins Children’s Center pedi- T Christy Sadream- atric pulmonary fellow eli. But the answer is important, she adds, because SCD patients who also have asthma tend to have more frequent acute chest syn- Screening a sickle cell patient for asthma, pediatric hematologist John J. Strouse drome episodes, painful crises, hospitaliza- and pediatric pulmonologist Christy Sadreameli. tions and higher mortality than those who do not have asthma. two disorders, Sadreameli says, and hopefully hesitant to give oral steroids to the sickle “Sickle cell patients with asthma may die at lead to more effective asthma treatments. cell patient having an asthma attack, but if a younger age,” Sadreameli says, “and we are “There’s not a whole lot in the it’s bad enough you have to give it,” says trying to understand how to prevent this.” literature on this subject and no one really Sadreameli. “That’s all the more reason to Better detection will mean earlier understands whether sickle cell disease keep the asthma under control so oral steroids treatment and improved asthma outcomes, patients’ risk of higher morbidity and are needed less frequently.” says Sadreameli, which is why she and mortality is modifiable with good asthma The asthma should continue to be treated pediatric hematologist John J. Strouse care,” Sadreameli says. “Does treating by the pediatric pulmonologist, and the sickle launched a pilot one-year asthma screening the asthma help you have less pain than cell disease by the pediatric hematologist, but program at Hopkins Children’s Center’s in someone with untreated asthma? We don’t there needs to be more coordination of care September, Sickle Cell Awareness Month. know.” by the two specialists, stresses Sadreameli. The Thanks to a grant from the Thomas Wilson Another unresolved issue is the impact of sickle cell patient with asthma should be seen Foundation for a portable spirometer and tapering down a common asthma medication – by a pulmonologist at least every six months, other expenses, Sadreameli and Strouse fast-acting systemic steroids – to stop severe she adds, and have pulmonary function are conducting the screenings in Hopkins asthma attacks. Sadreameli cites a rebound testing yearly. n Children’s hematology clinic. The screenings, effect of acute pain and complications for which include a pulmonary function test some sickle cell patients when steroids are For more information, call 410-614-0050. and a questionnaire, should also enhance withdrawn. For appointments with Pediatric Pulmonol- understanding of the relationship between the “Sometimes doctors are a little more ogy, call 410-955-2035.
Back to the Future continued from page 1 the Future” picture in which pediatric primary coordinate the care, too.” care is redesigned with greater emphasis on Other issues include the Affordable Care Such dynamics, Levy explained, have some of the hallmarks of its past – prevention Act, where Levy sees improved compensation contributed to the fractionalization of health and wellness and the collaborative medical for improved quality of care, and the further care and the phenomena of retail care and home model in which the child’s family, development of electronic health records, or minute clinics, as though medicine had school and community are incorporated into EHRs (see page 4). Epigenetics and how the become a fast-food service. With increased his care. More and more, Levy explained, patient’s environment and experience impact availability of information via media and the future pediatricians will be focused on the expression of the genome will also influence Internet, many families have been willing concerns of children with special health-care pediatric care. Virtually stirring this pot, participants. But what these families fail to needs, with conditions ranging from attention Levy can’t contain his optimism. realize, Levy said, is that when their child deficit disorder to multiple handicaps. “With all this stuff I’m dealing with in comes in for a sick visit, more often than not Consequently, care will be both individualized my office now with EHRs and thinking there’re other issues regarding the health of and coordinated with the primary care how we’re going to redesign care for kids, that child. pediatrician the hub for all care. I’m really excited,” Levy said. “This is an “It’s not likely that someone in a walk-in “It can’t be one size fits all anymore, opportunity for pediatricians to speak out center is going to sit there and think and the pediatrician really has to tailor care with an increasingly larger voice to promote thoughtfully about all the other issues that in terms of time, the needs of the family, primary care but also how to interact could be causing that sore throat,” Levy said. and the supportive care they need,” Levy smoothly with our subspecialty colleagues, “But if we can’t convince people that the best said. “If we redesign care to deal with these our academic colleagues, and our colleagues place to bring their child for anything is the new realities, it’s likely the pediatrician’s in the community. That’s what this new doctor who knows them best, then it’s our time is going to be spent more usefully, model is all about – it’s much more inclusive fault. We have to change the system.” using more of our knowledge base and and much more thoughtful than the way How? Levy painted somewhat of a “Back to our ability not only to care for kids but to we’ve been providing care.” n
5 | PEDIATRICIAN FALL 2012 In the Community
Bringing Children can now have laparoscopic inguinal hernia repair at GBMC, Less-Invasive reports pediatric Surgery surgeon Jeffrey Lukish. to GBMC
ohns Hopkins general pediatric surgeon Jeffrey Lukish is not shy about discussing the increasing number painful incision in the groin.” Jof inguinal hernia cases he sees at But such innovative community hospitals, including Anne minimally invasive procedures Arundel Medical Center (AAMC), Howard have historically been County General Hospital (HCGH) and performed only at academic Greater Baltimore Medical Center (GBMC). medical centers like Johns He doesn’t question the care these children Hopkins. No more, says receive in undergoing the traditional open Lukish, who in a randomized repair of this bulge in the abdominal wall, controlled trial with pediatric rate is the same but with less pain,” Lukish in which surgeons make an incision over the surgeon Fizan Abdullah is now offering says. “But we really don’t know. This will be groin, divide the skin and underlying muscle children the minimally invasive hernia repair the first study to give us an answer.” to access and tie off the hernia sac. But at GBMC. Half of the children in the trial “This is a great opportunity,” adds he’d like to see them have the option of the of 151 patients under age 3 will undergo Abdullah, “for parents in the community minimally invasive inguinal hernia repair, in the open surgery and half the laparoscopic to get a laparoscopic inguinal hernia repair which three small incisions are made instead procedure to compare outcomes. Both the without having to travel to Johns Hopkins in of the single large and painful cut. open and laparascopic approach require East Baltimore.” “In the open surgery, you have to general anesthesia, and both are same-day Abdullah and Lukish plan to open up cut through the muscles of the groin, outpatient procedures. Retrospective studies the trial to patients at AAMC and HCGH, mobilize an area that has some very delicate have measured end points like cosmetic too. Says Lukish, “We’re trying to partner structures, the testes and vessels that carry results, pain medication use and return with these outstanding community hospitals sperm,” Lukish says. “Now in this less- to physical activity, but until now there and bring innovation to the table out there invasive approach, we’re able to thread a has been no randomized controlled trial because it’s the right thing to do.” n 2.9 millimeter telescope through the belly evaluating the two approaches. button, project the image of these inguinal “We know the recurrence rate and For more information, call 410-955-1983. hernias on a digital screen, which allows us post-op complications in open repair, and in For referrals and patient appointments at to close the hernia defect without making a laparoscopic repair we think the recurrence GBMC, call 443-849-6201.
Non-Profit Org Pediatrician U.S. Postage PAID Pediatrician is produced quarterly by the Johns Hopkins Children’s Center Office of Communications and Public Affairs. Baltimore, MD Medical Editors: Cozumel Pruette, M.D., Kenneth Schuberth, M.D., Permit No. 1608 Lauren Cohee, M.D., Stacy Cooper, M.D. Director: Kim Martin Editor: Gary Logan Science Writer: Ekaterina Pesheva Designer: Lori Kirkpatrick Photographers: Keith Weller Distribution: Naomi Ball Web site: www.hopkinschildrens.org © 2012 Johns Hopkins University and The Johns Hopkins Health System Corporation To reach Hopkins Children’s Physician to Physician To refer or check on the condition of a patient, or to consult with a Hopkins physician, call 410-955-9444 or 1-800-765-5447 24 hours a day, 7 days a week
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