A vision of tomorrow: Honoring patient choice BY RICHARD A. SZUCS, MD RRAMIFICATIONS

Richard A. Szucs, MD, is a radiologist with Commonwealth Radiology, P.C., and president FALL 2013 n VOLUME 19 n NO. 4 WWW.RAMDOCS.ORG of the Board of Trustees of the Richmond Academy of Medicine.

EHRs and tarting a conversation about end-of-life care can be dif- malpractice ficult, whether we are physi- BY CHIP JONES cians, patients, family mem- Secours, HCA and VCU, to advise the participants that the Richmond bers,S religious and community leaders us regarding how we, working with Academy of Medicine assume a lead- or other professionals. It is, however, others, can promote and encourage ership role as catalyst, convener and imperative that these conversations advance care planning (ACP) in this organizer of a community-wide effort take place. And, once they occur, it is community. The core group agreed on advance care planning. Everyone equally critical that caregivers honor that adopting a uniform approach agrees that advance care planning is a patients’ choices. When no conversa- to ACP across the healthcare mar- lifelong process, best begun before a tion occurs, families and caregivers ketplace was essential for increasing crisis develops. are left making decisions that may awareness and engagement. We shared the outcomes of the As a physician, any discussion of not reflect what a patient desires. In late May 2013, the Acad- conference with health systems, electronic records should start with two The Richmond Academy of emy sponsored a community-wide Secretary of Health and Human words: “audit trail.” Here’s why: Medicine champions advance care educational conference where 100 Resources Bill Hazel, Senator Mark According to the July 2013 issue of the Virginia Medical Law Report, lawyers planning, hospice and palliative care. healthcare professionals from the Warner, and the Virginia Center for across the commonwealth are busily Within the last two years, we have health systems and the wider com- Health Innovation. We were encour- adapting to the brave new digital world of developed a core group of healthcare munity came together to learn about aged to continue to do the work that patient information. professionals, including hospice and best advance care planning practices. brought the healthcare community It begins with language itself, one palliative care specialists from Bon There was unanimous support among “Vision,” continued on page 2 Norfolk lawyer told the publication. “There’s a whole new lexicon, a new language we have to speak.” Lawyers also are learning to dig things We want you to take it home and make it your own: up in new ways as they perform discovery in malpractice cases, giving up the “stray facts and telling details” they used to The age of the electronic find in various folders and log books in hospitals and doctors’ offices. Now lawyers must obtain screen health record shots of pull-down menus and tabs for extra details in the electronic record. BY ISAAC L. WORNOM III, MD FACS Another personal injury lawyer called medical records “the skeleton on which hen my son Chris was a rising junior at my case is based.” Douglas Freeman High School, we went Do you have any “skeletons” together to an assembly to get the new lurking in your data closets? For good laptop that Henrico schools gave to every housekeeping tips, check out this W rising high school student. www.fierceemr.com report (Oct. 2, 2013), “EHRs Won’t Decrease Malpractice Risks, Dr. Pruden, the excellent principal of Freeman at the time, Premiums.” stood in front of us and told the students that he wanted Though electronic records may help to them to take those computers home and in the two weeks improve patient care, the report cautions before school started, “make them their own.” providers not to “expect such systems Well that is just what Chris and his computer-savvy to lower their malpractice premiums, as friends did. By the time school started, those little laptops EHRs can create new problems and make had 10 times as much RAM and more new programs on it harder to defend against such claims.” them than you could shake a stick at. That did not last. The Some potential problem areas: l Disabled clinical decision support county figured out what had happened and collected the alerts that, if used, could have caught a laptops and returned them to their original configuration problem. and made lots of rules to keep it from happening again. The l Auto complete functions that fill in students who made the changes became the go-to people for data incorrectly. computer problems at the school. l Sharing of passwords, so that the physicians look like they’re viewing “Health record,” continued on page 3 the chart when they actually are not doing so. l Sloppy documentation, such as incorrectly entered data. 4 6 8 EHRs also create audit trails, according Whither EHRs? Technology Rules of E-road to the report. And guess who likes audit and social trails? Not just the IRS! distancing Chip Jones is RAM’s communications and marketing director. 2 FALL 2013

“Vision,” continued from page 1 POST pilot projects. markers for success of this work. Recently, we invited Central Once clinical implementation is un- together, speaking in one voice, in sup- Virginia health systems to join us. derway, we will launch a major grass- RRAMIFICATIONS port of honoring a patient’s choice. We cannot do this work alone, but roots effort to reach citizens through RAMIFICATIONS FALL 2013 Now we are ready to take the next with their support and guidance we a marketing campaign. Community VOLUME 19 n N O . 4 logical step to support system change, can be a collaborative partner for a stakeholders, including religious, civic, advocacy and education around community-wide initiative. Health legal, and business organizations, will advance care planning throughout systems joining us would agree to a be invited to join in our efforts. PRESIDENT Central Virginia. The Academy common emphasis on improving the No doubt, all of this requires Richard A. Szucs, MD desires, as convener and coordinator, conversation between patient and significant resources. In the spirit of co- VICE PRESIDENT to launch an Advance Care Initiative provider, not only in word but also in operation and leadership, the Academy Peter A. Zedler, MD built upon the proven concepts of action. Such a commitment requires has committed $100,000 in startup

TREASURER Respecting Choices®. Respecting a collaborative partner to invest in funds provided all health systems join. L. Randolph Chisholm, MD Choices is a program started more technology that adequately stores Health systems were asked to contrib- than 20 years ago in LaCrosse, and retrieves advance care planning ute $40,000 a year for two years. SECRETARY Joseph S. Galeski III, MD Wisconsin, to help patients articulate documents; to invest in the training We will keep you informed of our their choices about end-of-life care of professionals and laypersons; and conversations and efforts. EXECUTIVE DIRECTOR Deborah Love and put in place systems to ensure to devote the organizational resources It has been an honor to serve that patients’ choices are known needed to implement new programs as your President for the past two EDITOR and respected. Their experience has and services. years. I believe that this initiative is Isaac L. Wornom III, MD shown that this results in improved To guide the work of this initia- the most important thing I have had COMMUNICATIONS AND quality of life and improved patient tive, collaborative partners will the privilege to lead. I believe it will MARKETING DIRECTOR and family satisfaction with end-of-life appoint two or more professionals to result in a significant improvement in Chip Jones [email protected] care. Their methods have been widely a community steering committee that the quality of end-of-life care in our (804) 622-8136 recognized and replicated at many will oversee the project. The steering community. Because I believe this so other sites regionally, nationally, and committee will articulate the goals strongly, I intend to remain involved ADVERTISING DIRECTOR Lara Knowles internationally. Respecting Choices and objectives, select pilot sites, and with the project. I invite you to join [email protected] is also the platform behind Virginia’s define achievable and measurable us as we move forward. R (804) 643-6631

ART DIRECTOR Jeanne Minnix Graphic Design, Inc. [email protected] Children’s Cancer Hospital in Egypt (804) 405-6433 made it possible to extend the hospi- United2Heal: Your tal’s operations by providing 500 new RAM MISSION The Richmond Academy of Medicine beds. Fellow VCU sophomore Karima strives to be the patient’s advocate, Abutaleb and I have had the oppor- the physician’s ally, and the supplies can help! community’s partner. tunity to visit the hospital in Egypt to BY ALBARA ELSHAER evaluate the shipment’s impact and ON THE WEB receive feedback on how to improve www.ramdocs.org future shipments. Published quarterly by the If we can do all this with the help Richmond Academy of Medicine 2201 West Broad Street, Suite 205 of key partners in the U.S., imagine Richmond, Virginia 23220 how many more people we could (804) 643-6631 serve if others got involved? Help us Fax (804) 788-9987 help others by donating excess medical Non-member subscriptions are supplies, surgical kits and even simple available for $20/year. The opinions expressed in this items such as examination gloves. We publications are personal and do not also could use more volunteers to help constitute RAM policy. © Richmond Academy of Medicine sort the supplies. Please visit our web- site, www.united2heal.org, to see our Letters to the editor and editorial past events, to contact us, or to make contributions are encouraged, subject to editorial review. Write or email a donation. Communications and Marketing Director Chip Jones at [email protected].

VCU medical students load supplies bound for Syria.

here once was a story gauze bandages—are hand-packed on Since 2010, the number from CNN Health about a weekly basis by dedicated members a hospital director in of United2Heal, a humanitarian aid of U.S. hospitals having Africa who told of a organization at Virginia Common- a basic electronic health T wealth University. patient dying of malaria in a room record (EHR) has tripled. with hundreds of bottles of medicine We, as students, do everything we that could save the man’s life, but can to ensure that these supplies are no intravenous lines with which to useful, well within the expiration administer it. date, and appropriate to ship over- A simple item, such as an intrave- seas. After we collect and organize Boy in Syria happy to see gift along with nous line, could mean life or death for our donated medical supplies, we helping hand of U2H. an individual in the developing world. then determine the logistics of ship- The motto of Unted2Heal is: “In Unfortunately, this is all too often ping these supplies. the war against health disparities, what happens around the world. But With the help of VCU physicians we realize that many battles must be it doesn’t have to happen that way. and faculty, and advisors at the Rich- fought in the political arena. But we So what can be done? mond-based World Pediatric Project, want to be on the front lines of saving A small group of students in over the past two semesters we have lives.” R Richmond is working to make a big been able to ship approximately $1.5 Source: Health Information Technology difference. Thousands of boxes of million worth of medical supplies to Albara Elshaer is a sophomore in the United States 2013, Robert Wood medical supplies—items such as sterile Syria and Egypt. at VCU. He can be reached at Johnson Foundation surgical kits, respirator masks, gloves, What difference are we making? [email protected] or by calling syringes, crutches, exam tables, and Our most recent shipment to the (571) 723-3004. www.ramdocs.org 3

“Health record,” continued from page 1 2013 as the year to retire. There are many reasons we hang up our white This story demonstrates both coats and put away our stethoscopes % the generational difference in how and scalpels, but I have heard it said technology is viewed and how in the lunchroom by some of these technology has changed education 42 retiring docs that the EHR is one of forever. the things that is making them pull the Medicine has not been immune to trigger and stop practicing medicine. these technological changes but was Some of these physicians never learned slower to embrace them. to type and I can’t imagine working Five years ago when the economy in this new world without that skill. tanked, the Obama administration from our human contact with Others really did not like the changes and Congress passed a stimulus patients. There are ways around this, and are choosing to move on. package to help the U.S. economy having a scribe or doing the record as Going forward, the challenge for recover. In that package was money homework outside of the exam room, all of us is to do what my son and his to encourage the wide adoption of but this is not always feasible in a friends did when they got their first electronic health records (EHR) by busy practice. laptops. We have to “make it [the The number of U.S. American medicine. There was also One of the interesting things about EHR] our own.” I suspect it will be a financial penalty for those who EHRs is how many of them there are. the generation being trained now that hospitals that have refused to make this change. For those who practice in a single will do that. EHRs will be all they implemented systems Medicine has responded as our hospital system, only one is needed. know. Hopefully, the human touch that meet federal government hoped we would and For example, the inpatient and will remain in medicine as this change Meaningful Use EHRs are now everywhere. They are outpatient components of a patient moves forward. The machines cannot Stage 1 criteria, up in the hospitals in which we practice record in Connect Care, which is be allowed to win. R from 4.4 percent in 2010. and most of us now use them in our the Bon Secours system, talk to each offices every day. other and are one record. However, This issue of Ramifications for those of us who work in a private Source: Health Information addresses the impact of these new practice and have our own system Technology in the United States 2013, Robert Wood Johnson Foundation record-keeping methods on the and also use the hospital system for practice of medicine. How they are inpatient care, the transition is not Dr. Wornom practices at impacting what we do to care for seamless and can be difficult. Richmond Plastic Surgeons and patients is ongoing and evolving The same thing applies to the is a past president of RAM. He and will continue to do so into the interaction with referring practices can be reached at wornom@ foreseeable future. that send us letters and notes. In richmondplasticsurgeons.com.RAM Ad 4.875 x 7.75 12/31/12 3:37 PM Page 1 The process of creating an elec- both of these situations, instead of tronic health record is very different having patient labs and path reports from the process of hand-writing a and notes appear in an in-box on a note or dictating one. As you click computer which we can then read and through lists of symptoms in a history deal with, these records appear as piles and findings on a physical exam, and of paper on our office fax machine. import lab and X-ray results, the note Our office staff then brings them to is created. At the end, though, what our attention so we can do what needs is often missing is the thought process to be done to care for our patients. of the doctor as he or she comes to a The end result is more paper, not less. diagnosis and treatment plan. Making the different systems The notes often appear cookie- talk to each other seamlessly can be cutter and filled with data which are done but it is expensive. I think this sometimes repeated over and over will occur as we move forward and, again in the computer chart. The note hopefully, we will all have less paper that is created is legible and easy to to deal with in the future. I know read, and filled with lots of data and we are not there yet. It has always information. This can allow a greater seemed to me that if our government level of billing, but it can make it was going to essentially drive us all to harder for other caregivers to see the use EHRs, it would have chosen one thought process of the clinician who EHR system for the entire country, cared for the patient. sort of like the one radar system Who would have known how we have for air traffic controllers. I important that typing class I took in think the political issues to make this We operate on the philosophy that your website is 10th grade would be in 21st century happen were insurmountable. the central hub of your marketing efforts — using medicine? I find myself free texting One of the great hopes is to use other media to drive traffic to your site. We improve regularly in the hospital and in my data mined from EHRs to improve your online presence and ROI by offering these services: office system to document my thought our health. Some of those same process about patients. When I read computer-savvy high school students • Branding & Logo Design • Mobile Websites other doctors’ notes, that is the who altered the first laptops given • Internet Marketing part I look for. It is where the real out by Henrico County now have • Print Marketing information lies. Ironically, it is often computer engineering degrees from • Website Design • Referral Marketing harder to find now than it used to be prestigious schools and are working when we were writing our notes by for consulting firms inside the Beltway Call 804.464.1230 for your complimentary consultation hand or dictating them. trying to figure out how to do that. In the office setting, the EHR The paranoid among us think the can change the interaction we have government will use this information with our patients, and not always to control us. There is a big difference for the better. As we talk to patients, between health records and email Impression-Marketing.com instead of looking them in the eye or and phone conversations, and these touching them, we are often looking conspiracy theorists may be right. at and touching the computer as we It is interesting how many fine are entering data. This can detract Richmond physicians have chosen 4 FALL 2013

Electronic health records: where we’ve been…maybe where we’re going BY MICHAEL MATTHEWS

heard the phrase “free is not cheap enough.” While the VistA software was open-source (and thereby, free), implementation costs and customiza- tion ran well over $10,000. Physicians began taking a serious look at how an EHR would work best in their practice and most concluded that “one size does not fit all.” So it was that the possibility of a single EHR faded as fast as the prospects of a single payer system. All was not lost on the compatibility front, though, as the focus shifted from a single EHR system to adoption of industry- accepted interoperability standards. While still a work-in-progress, these standards became an increasingly important aspect of health IT over the past 10 years.

Where we are So much has changed in the healthcare world in the past 10 years, driven in part by significant incentives provided by CMS for “meaningful use.” By 2011, 54 percent of physicians had adopted an EHR. Almost three-fourths of physi- cians who have adopted an EHR system report that their system meets “meaningful use” criteria. Eighty-five In 2004, President George W. Bush Many looked to this practice for percent of physicians report being issued a bold proclamation that most experience and inspiration for the work somewhat (47 percent) or very (38 Americans should have electronic that lay ahead in EHR adoption. At the percent) satisfied with their system. health records by 2014. time, most practices had electronic bill- Three-fourths of physicians report It was recognized at the time that ing and practice management systems, that their EHR system has resulted information technology adoption in albeit with varying levels of capability in enhanced patient care. And nearly health care lagged far behind that of and satisfaction. Hospitals were usually one-half of physicians currently with- other industries, most notably that of an amalgamation of patient accounting out an EHR plan to have one in place banking. Despite the lack of adop- systems and “unintegrated” lab, phar- within the next year. (Statistics from tion, however, health IT was viewed macy, OR, and radiology systems. The NCHS Data Brief No. 98, July 2012)

Michael Matthews as necessary—if not sufficient—to concepts of “health information ex- The increase in EHR adoption is drive transformation toward im- change” and “personal health records” impressive and should be considered proved quality, safety, efficiency and were new and not widely accepted. an overwhelming success. Perhaps effectiveness. With just a couple of While e-prescribing was being pursued the lofty goal of universal adoption months left before we reach 2014, it’s by a few pioneers, the Surescripts phar- of EHRs by 2014 was ambitious an appropriate time to review where macy gateway was years away from to the point of being unrealistic. we’ve been; where we are; and specu- becoming a definitive platform for eRX I recall a conversation I had with late on where we’re going. transactions. the national coordinator for health information technology shortly after the passage of HITECH when I Three-fourths of physicians report that observed, “It has taken 30 years to get to 30 percent adoption…we can’t their EHR system has resulted in enhanced possibly get another 70 percent in three years!” He seemed surprised patient care. and dismayed by my comment. Being a “glass half full” kind of guy, I still Where we’ve been Physicians sometimes ask why the think what has occurred in health IT While good data on EHR adop- U.S. didn’t move to a single solution has been extraordinary, and a deep tion in 2004 is scarce, it is generally EHR, thereby improving compat- and broad foundation has been laid believed to have been less than 25 per- ibility between doctors’ offices. Given for the future. cent, with some estimates as low as 5 the lack of EHR adoption and use percent. Locally, practices with EHRs in 2004, that proposition could have Where we’re going were the exception rather than the been considered. In fact, the closest I tip my hat to all of you who have rule. Virginia Urology was one of the we came to such a scenario was when suffered through the blood, sweat and early adopters, building its own EHR Medicare offered free access to VistA, tears (and costs!) of EHR implemen- platform in 1992 that even included the EHR utilized by the Department of tation over the past few years. There’s the ability to import clinical results. Veterans Affairs. It was then that I first more to be done, though, and I offer a www.ramdocs.org 5

few areas to keep in mind as we look I’ve been in the business for 35 Thank you for your to the future: years, and I can’t remember a time of such change, turbulence and uncertain- amazing support! l Interoperability: Let’s make sure we haven’t unintentionally cre- ty. I also can’t remember a time of such ated even more isolated data silos promise…promise that will in part be through EHR deployment. realized through health information technology. I strongly believe EHRs l Patient engagement: Patients are increasingly demanding not only and health information exchange will access to their clinical informa- be accepted as a standard-of-care, and These practices made generous gifts that took Access Now to new tion online, but also the ability to not as optional or discretionary. We heights during 36 hours of the 2013 Amazing Raise fundraising conduct business online (schedule have much more work to do to ensure event! Leading the way for other donors, their support helped us appointments, etc.). that health IT is as efficient for the physician as it is effective. raise more than $16,000! l Mobile devices: Home-based Having a “day job” of working monitoring is ready to explode, but on health IT and population health ACCESS NOW THANKS YOU! are you ready, willing and able to is a luxury most of you don’t have… integrate information from these you have to accomplish all this while ADVANCED ORTHOPAEDIC CENTERS devices into your EHR? COMMONWEALTH DERMATOLOGY, PC actually caring for patients! You’re to l Registries and analytics: Most use COMMONWEALTH RADIOLOGY, PC be commended for the changes you’ve of EHR systems has been focused DERMATOLOGY ASSOCIATES OF VIRGINIA, PC undertaken in an industry that doesn’t on care for individual patients, but ORTHOVIRGINIA change easily. It’s been a privilege to increasingly will be leveraged for PULMONARY ASSOCIATES OF RICHMOND, INC. work alongside you. population health. VIRGINIA CANCER INSTITUTE, INC. And if this is all just too stressful to l Value-based purchasing and clini- VIRGINIA CARDIOVASCULAR SPECIALISTS embrace, perhaps we should simply cal outcomes: Pure fee-for-service VIRGINIA ENT follow the wisdom of Albert Einstein: payment methodologies will soon VIRGINIA EYE INSTITUTE “I never think about the future—it be a thing of the past, while EHR VIRGINIA UROLOGY systems will be used to demonstrate comes soon enough.” R best-in-class clinical outcomes in a variety of innovative pay-for- Michael Matthews is CEO of performance initiatives. MedVirginia. He can be reached at [email protected] or (804) 359-4500, ext. 4225.

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Technology and social distancing —the EMR BY RICHARD P. WENZEL, MD, MSC.

he sea change in re- workweek and the business focus on cording the history patient throughput. Together these and physical examina- forces have transformed the team tion as a result of the rooms’ banter to hundreds of syn- T copated sounds of keyboard strikes. electronic medical record (EMR) is remarkable. Those of us witnesses There is a sense of urgency felt but not to the before and after eras recall the stated—the need to record so much desperate search for the bundled-up into the chart as quickly as possible— old records, the time-consuming and for the clock is ticking. frustrating attempts to decipher the In a thoughtful essay published

unique handwriting of prior clini- Richard P. Wenzel, MD, MSc. in the Annals of Internal Medicine cians, the long queues in front of the in 2010, Mike Edmond noted that radiology film room seeking to review is relatively quiet, each member now attending on the wards is “much less earlier images. Technology has solved facing a computer screen along the fun and exhausting, [with] limited key problems for patient care. wall as a lonely typist. All eyes gaze [time for] levity, banter and humor. I But something has been lost at the periphery of the room, none feel guilty if I ask the residents ques- with the useful technology. In the at the center, none at each other, tions about themselves or what they pre-EMR era, the team room was a observing the unspoken expressions did over the weekend as they type (and they are always typing), because I’m distracting them and using pre- …the interpersonal distancing created by cious time.” Physician and author Abraham the new technology has conspired with Verghese wrote about the issue in “Culture Shock—patient as icon, icon the residents’ 80-hour workweek and the as patient,” a 2008 article in The New England Journal of Medicine. Concerned that the time of engage- business focus on patient throughput. ment of house staff and patient is shrinking, he noted, “Patients are buzz of verbal exchanges, as senior of the others. As a result we don’t handily discussed in the [call room] clinicians traded ideas with the house know each other personally as well as bunker while the real patients keep staff, reviewed the assessments and we used to—the aspirations, worries, the beds warm and ensure that the plans, engaged the students, and insecurities or confidence levels of folders bearing their names stay alive together rounded at the bedsides— students and house staff. on the computer.” Like Edmond, spending time to illustrate important To be fair, the interpersonal distanc- Verghese is alarmed by the erosion physical findings. ing created by the new technology has of bedside skills of the modern house In contrast, the team room today conspired with the residents’ 80-hour staff. “…the bedside is hallowed www.ramdocs.org 7

ground, the place where fellow hu- ing activity. All of this is to say that bedside and laboratory findings, and the advent of technology. man beings allow us the privilege of there are trade-offs with technologi- focusing on the critical thinking. I am reminded of the words of looking at, touching, and listening to cal advances. Right now the loss of this reflection— author and philosopher Robert Pirsig their bodies. Our skills and discern- The repository for highly use- the active engagement of expertise, from his iconic book “Zen and the ment must be worthy of such trust.” ful, legible and efficiently acquired experience and thoughtful pursuit of Art of Motorcycle Maintenance”: What’s amazing in comparing information is a welcome effect of truth—is an unfortunate adverse ef- “We’re in such a hurry most of the the old and new eras is the stunning the electronic medical record. In my fect of technology. time we never get much chance to increase in length of the daily notes. opinion what has been lost is the nar- When I was in graduate school talk. The result is a kind of endless Some recorders copy and paste the rative describing both the inductive for my MSc. degree from the Lon- day-to-day shallowness, a monotony latest laboratory data, radiology (pattern recognition) and deductive don School of Hygiene and Tropical that leaves a person wondering years findings, special test results such as (logical) thinking of the bedside clini- Medicine, I was introduced to the later where all the time went.” a cardiac echo; they often paste the cian. In the EMR era, one has to call English ritual of teatime—30 minutes With every distancing technology, notes verbatim from the consultants. the recording physician to know the in the morning and 30 minutes in the including the EMR, we lose some Lastly, they list the examination they underlying—often unstated—assump- afternoon. Initially I had the mis- part of our humanity—the connection did and all pending tests. Up to this tions and the current reflective ideas. guided thought that this is incredibly between patient and physician, teacher point, the new report is heavy with Surely I don’t want to return to wasteful, a loss of productivity time, and student, physician and colleague. data but light on real information— the days of the pre-EMR but only and one leading to inefficiency. What We are marginalizing bedside teaching what are now brief are the Assess- recapture those associated features I learned quickly was that more than on the wards and the true exchange ment and Plan sections. that made life at the hospital more 80 percent of the faculty and all of us of information. With all the useful I cannot help but notice how little valuable. All technology separates students showed up in one room for advance of technology we risk the loss I learn about the thinking of today’s people: patients from their families, every teatime; and the vast exchange of our key values. The challenge now clinician, what she really concludes patients from their physicians, physi- of information, mentoring, sharing is not to be a victim of technology but are the key issues, and the summary cians from each other. The current of scientific and clinical ideas that to seek ways to remold it to enhance evidence to support those; the steps struggle, then, is to acknowledge that occurred in those 30-minute periods the quality of life. R to clarify the lingering questions fact, make continual efforts to recon- was something never seen in the U.S. remain unclear. To be sure, the pre- nect, and to restore the direct com- Of course the U.S. culture is differ- Dr.Wenzel is Professor and Former EMR days had considerably less in- munication useful for next steps such ent; we don’t get RVUs or reimburse- Chair of the VCU Department of formation totally, but often contained as patient management. ment for that time; we feel tremen- Internal Medicine. He is the author the reflective thoughts of clinicians, In the future, what may help will dous pressure to keep going (typing). of a medical thriller, “Labyrinth of clearly outlined. It required time to be discarding the redundant informa- Yet more direct face-to-face talking Terror.” think about the assessment and plan, tion that is crowding the chart and with other clinicians, house staff but we thought that was the idea. In currently discouraging a full read- and students would likely be more many corners of the hospital, think- ing of the clinical notes; shortening efficient. Importantly, it would add ing time has been replaced with typ- the follow-up recordings to essential quality to our lives, quality lost with

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Caveat Emptor: Rules of the Electronic Road BY CHIP JONES

Eric Hays keeps a steady focus on electronic health records at the Virginia Eye Institute.

t first glance, storing and if they were to go under, you’d patient data in “the have to make sure the contract has cloud” sounded intrigu- language that you’d get ownership of ing to the IT experts the data,” Hays said. “That’s why we Aat Virginia Eye Institute. Maybe it like to have it internalized,” by using would help save money to back up an offsite data center—Peak 10— their new electronic medical records which offers special security measures system. It makes sense to look for (such as fingerprint access), electrical savings, given that the costs for EHRs backups, and other data recovery can be considerable—estimates range components. from $5,000 to more than $50,000 “I know the model is moving to the per provider. And that doesn’t include cloud, but in terms of a security issue, Kit Young hiring consultants to work through it’s nice to have control,” Hays said. the many details of customizing, Yet another practice administrator, Kit the federal government’s Meaningful Use standards. But while their needs and ap- Understand what you need the system to proaches differed, from pediatricians to plastic surgeons to OB/GYN offices, do and what data you need to collect. there was agreement to never forget the old adage, caveat emptor, or “let the buyer beware.” installing, and ensuring quality con- Young at Richmond Plastic Surgeons, “When we first got quotes for IT, trols. Ka-ching! Throw in hardware takes a slightly sunnier view. “Two they were based on the minimum upgrades, lost productivity and the years ago I may not have considered standards from the vendor,” recalled cost of extra staffing, and the total the cloud, but in today’s market, there Leslie Bachmann, practice manager at price tag can easily top $1 million. are many good options worth consid- the Skin Surgery Center of Virginia. “So I can see why smaller practices ering during the evaluation process.” She soon discovered those “stan- go with the cloud” to store data, said Decisions, decisions…. Interviews dards” were “the minimum to run Eric Hays, vice president of opera- with practice managers and doctors their software and nothing else.” It tions at VEI. show how wide open—and some- will cost more once “you calculate all But at VEI—a practice with 38 times confusing—this new technology of your needs.” providers who need customized terrain can be. They shared different These practice managers, and records-keeping at 11 locations— approaches to how they customize one physician interviewed, said Hays spotted a big problem with records for physicians and nurses, it’s important to determine all of any business plan that would put his working in billing and communica- the features needed and then have patients’ medical records in the hands tions features along the way. And, the software vendor provide solid of third-party servers. depending on their Medicare and price quotes. “Practices have other “Then your [electronic medical re- Medicaid populations, they expressed programs, outside of their patient cords] supplier is keeping your data, varying degrees of interest in meeting medical records, that are required to www.ramdocs.org 9

run their day-to-day operations.” Her ercised self-discipline not to be driven advice: “Work with your IT vendor by the government’s deadlines for to evaluate the cost of running all Meaningful Use. But because they have programs” if you want a true cost of a number of Medicare patients and a upgrading your office. deadline approaching, Dr. Rausch said Understand what you need the sys- in late summer, “We finally decided we tem to do and what data you need to had to get it done.” collect. Are you going to participate While Rausch’s practice is smaller in Meaningful Use, the Patient-Cen- than VEI, she tackled many of the tered Medical Home, an Accountable same data storage and transmis- Care Organization (ACO), and the sion issues. They also opted for an Physician Quality Reporting System in-house data storage system, Rausch (PQRS)? If so, what PQRS measures said, “because then if you change would you like to collect data on? EMRs you don’t have to worry about Not all vendors have this built in. [access] to your own data. The down- How hard is it to retrieve data—and side is there’s more maintenance and can you report out of the system, or cost, and it’s not as accessible when do you need additional features (at a you’re out of the office.” Leslie Bachmann (l), practice manager of the Skin Surgery Center of Virginia, helped Dr. Christine Rausch find the right system. cost) to do so? After they finally settled on a Bottom line, said Young: “Make customized system for dermatologists, ments—such as obtaining patients’ charts,” said office manager Jo DiPer- sure you have all you want listed in the they faced the next big decision point: ethnicities— getting everyone on the na. This helped speed up the adoption final agreement before signing.” How to get it up and running? same page as early as possible is even of the electronic records, and for legal In the case of the Skin Surgery more essential, said Young, who has reasons, it’s crucial to keep consistent Center, which specializes in Mohs Super users supervised the installation of records records on paper and in digital charts. surgery, Bachmann and practice Young, administrator and direc- systems at several practices. “That’s Once this paper-to-digital work founder Dr. Christine Rausch wanted tor of information technology at something I’ll do two to three months is done, it’s time to do something no to make sure they purchased a system Richmond Plastic Surgeons, gave this out while working to build the sys- EMR vendor can do for you: organize that guaranteed the best experience advice for preparing for the “go live” tem” to ensure the staff and practitio- staff training and implementation. for patients and practitioners. date for practices still transitioning to ners “become accustomed to asking “Think about the work flow of They spent hours researching, meet- EMRs: “You can begin by having your the question in the form that’s being your office, and how it ties in,” said ing with vendors, talking with other patient forms ask the same questions asked” in the electronic record. Nicole Midulla, front desk supervi- physicians and other practice manag- in the same format that you’ll be ask- Three months ahead of the “go sor at Pediatric Associates. So, for ers, and paying visits to medical prac- ing in the electronic record.” live” date at Pediatric Associates of tices to see their systems. They also ex- With the Meaningful Use require- Richmond, “We pre-scanned a lot of “Electronic road,” continued on page 10 10 FALL 2013

BSGN-1543 Ramifications Ad-Neuro 4.85x14.628_FIN_OL.pdf 1 6/26/13 2:46 PM

Susan Shackelford, CEO of Virginia Ear, Nose and Throat, used to spend half of her time on IT-related problems. Now it’s down to about 10 percent.

“Electronic road,” continued from page 9 the vendor goes away.” VEI’s trainer puts on regular “lunch example, when nurses and other office and learn” sessions, and the practice staff needed training in how to enter also started a help desk to answer procedure codes, Midulla took screen questions about everyday glitches shots of each new code in order to (printers that don’t work, glitches in show everyone how it would look in data fields, and so on). the new system. According to Young, many soft- Before going “live,” Midulla asked ware systems have testing at the end of her staff to come in over the weekend training modules. “Sometimes soft- for a dry run, with each person enter- ware is a version or two ahead of the ing 25 appointments into the EMR training,” she said. “I found this was system. “It gave them time to ask true with a few different office-based questions without tying up the phone systems, so I would develop my own lines,” DiPerna said. how-to cheat sheets.” At Virginia Ear, Nose and Throat, Over time, Young said, “I have CEO Susan Shackelford said, “From often found that many clinicians my perspective, the best thing you learn by doing: see one, teach one, can do is spend however much time it do one.” During training, she creates takes you to do the customization up a “test patient” and works with the front” for your system. And no matter physician to enter information on the how much you prepare to launch it, sample patient to practice “moving “When you go live, you must have through the system.” ‘super users’ there because you can not She cautioned, “Just make sure you think of all the things that are going to are able to designate in the system that happen in real life.” this is a test patient, and the data does Doctors also need time for training not result in final quality or meaning- and hand-holding before the systems ful use reports.” are active. A doughnut or two also doesn’t hurt. “Physicians in medical EMRs and patient safety school and in residencies are taught Like any major shift in workplace what their styles or routine is in an flow and medical practice, the plusses exam,” said Young, “and an elec- and minuses seem to balance out. But tronic health record really changes when it comes to improving patient the dynamic.” safety, the switch to electronic health Electronic records should be con- records is a definite plus. figured to meet the treatment styles of “We’ve been able to mine our data physicians, who probably will show and that extra information actually im- varying degrees of comfort at first. proves our patient safety,” said Brenda This isn’t simply a generational issue, Burgess, practice manager of Virginia Young observed. “I’ve had young Women’s Center. Her practice “mines” physicians who are just as frustrated” the data weekly, “so if there’s some- by digitization as older ones. thing missing in a record, we identify it At VEI, Hays said, “90 percent of in real time, and address it.” our doctors’ questions are about the This data-mining capacity didn’t speed of the system.” Using large- come with the practice’s original EMR screen desktop computers—mandatory software. “We had to take the technol- in the visually-driven world of eye ogy to the next level,” she said. And care—it was important to invest to given the improved safety features make sure the software runs as quickly they’ve built-in, Burgess said the ef- as possible. Even then, he said, “We fort—and the cost—was worth it. R still had issues.” In this age of digital doctoring, new problems are bound to arise when electronic records become as much of a staple of practice as a stethoscope. Which is why, said Hays, “We hired a Chip Jones is RAM’s communications corporate trainer. Because eventually and marketing director. the support we were expecting from www.ramdocs.org 11

RAM events Should you have questions about any of our upcoming meetings, please call the Academy at 804-643-6631.

DATE MEETING/LOCATION/TIME DATE MEETING/LOCATION/TIME

January 14, 2014 Presidential Inauguration of Peter A. Zedler, MD March 11, 2014 General Membership Meeting Tuesday University of Richmond’s Jepson Alumni Center Tuesday B. Rick Mayes, Ph.D-Keynote Speaker 5:30 p.m. cocktails, 6:15 p.m. dinner Associate Professor of Political Science 7:00 p.m. presentation Co-coordinator, Healthcare and Society Program University of Richmond’s Jepson Alumni Center January 22, 2014 RAM White Coat Day #1 – Lobby Day at the 5:30 p.m. cocktails, 6:15 p.m. dinner, Wednesday General Assembly 7:00 p.m. presentation Hilton Garden Inn, 501 E. Broad Street Richmond, VA 23219 May 13, 2014 General Membership Meeting 8:00 a.m. – 12:30 p.m. Tuesday Barry Duval, President and CEO Virginia Chamber of Commerce February 18, 2014 RAM White Coat Day #2 – Lobby Day at the Country Club of Virginia Tuesday General Assembly 6031 St. Andrews Lane Richmond, VA 23226 Hilton Garden Inn, 501 E. Broad Street 5:30 p.m. cocktails, 6:15 p.m. dinner, Richmond, VA 23219 7:00 p.m. presentation 8:00 a.m. – 12:30 p.m.

Drs. Melissa Dr. Shaun Spadafora Nelson and Andy and son Jacob at Vorenberg at April RAM Family Night at Member Social at Children’s Museum Rich Academy of Med - half pg.pdf 1 10/4/13 12:28 PM Arcadia. of Richmond.

Please join us in welcoming Francie James, MD and Meghana Gowda, MD to Virginia Urology and to the medical community of central Virginia.

Dr. James obtained her medical degree from the Medical Dr. Gowda joins Virginia Urology as our rst urogynecologist and University of South Carolina in 2007. She completed her one of the few in the region to have completed an general surgery internship and urologic residency at accredited, 3-year combined fellowship program in Female Eastern Virginia Medical School. Pelvic Medicine & Reconstructive Surgery. Dr. Gowda has been trained in clinical & surgical options for women with Following residency Dr. James completed a one year pelvic oor disorders and brings this expertise to the fellowship in genitourinary reconstructive surgery Urogynecology practice of Virginia Urology. at Eastern Virginia Medical School. Her clinical interests include general urology, reconstructive Dr. Gowda was awarded her undergraduate and C surgery, male and female urinary incontinence, medical degrees from Virginia Commonwealth M and urethral stricture disease. University. Following her time in Richmond, she Y completed her residency training in Obstetrics CM Dr. James grew up in South Carolina and and Gynecology at New York University and MY attended Tulane University in New Orleans Bellevue Hospital. Dr. Gowda then completed CY for her undergraduate studies. She and her her fellowship in Female Pelvic Medicine & CMY husband Ennis now reside in Richmond with Reconstructive Surgery at Vanderbilt K their young daughter. University in Nashville, Tennessee. Her clinical interests include female incontinence, pelvic She will be seeing patients in our Stony organ prolapse, minimally invasive techniques, Point and Reynolds Crossing locations. and complicated childbirth injuries.

She will be seeing patients in our St. Francis, Stony Point and Reynolds Crossing locations. Virginia Urology Women’s Health is a division of Virginia Urology. Appointments can be made by calling 804-288-0339.

Urology • Gynecology • Urogynecology • Physicial Therapy 12 FALL 2013

Make certain electronic communications ensure patient privacy

BY JULIE SONG, MPH, PATIENT SAFETY/RISK MANAGEMENT ACCOUNT EXECUTIVE, THE DOCTORS COMPANY

E-mailing and texting are efficient, Manhattan Research, over 81 percent messages among physician colleagues convenient, and direct methods to of health care providers use a smart- should be encrypted and exchanged in communicate in the dental and health phone to communicate and access a closed, secure network. care world, but they can be fraught health information. The attractions However, according to a member with inadvertent security breaches. are obvious: Texting and e-mailing survey conducted by the College When e-mailing or texting replaces reduce time waiting for colleagues of Healthcare Information Man- direct consultations and communi- to call back and may expedite health agement Executives, 57.6 percent cation with dental colleagues, the care by allowing necessary patient of those surveyed did not use en- dental provider must take steps to en- data to be sent and received quickly. cryption software. The underlying sure the e-mails and texts are secure. reasons for poor compliance with encryption could be due to lack of technical knowledge or to avoid the inconvenience of sending a message With penalties starting at $50,000 per to someone who may not be able to unencrypt it. HIPAA violation, safeguarding electronic With penalties starting at $50,000 per HIPAA violation, safeguard- messages should be of utmost priority. ing electronic messages should be of utmost priority. In addition to encrypting the messages, consider Without appropriate safeguards, Safeguard against HIPAA violations installing autolock and remote wip- e-mailing and texting can lead to The very convenience that makes ing programs on smartphones and violations of the Health Insurance electronic communications so invit- computers. Autolock will lock the Portability and Accountability Act ing may create privacy and security device when it is not in use, and (HIPAA). violations if messages containing pro- requires a password to unlock it. This Health care providers are smart- tected health information (PHI) are feature needs to be activated in the phone “super-users.” According to not properly safeguarded. Electronic settings of the smartphone by activat- www.ramdocs.org 13

ing the “screen lock” feature so that is a critical matter or any doubt about the acceptable types of text com- the phone will automatically lock the communication, pick up the phone. munication and situations when a after the phone has been inactive for phone call is warranted. a designated period of time. Remote % Use available safeguards • Report to the practice’s privacy of- wiping programs can erase data, In some cases, an electronic record ficer any incidents of lost devices or texts, and e-mail remotely should the vendor may offer a secure e-mail data breaches. 90 phone be compromised. Depending network option to clients. If this is • Install autolock and remote wiping on the type of smartphone, there are the case, be certain that the e-mail re- programs to prevent lost devices different remote wiping applications cipient is also utilizing encryption in from becoming data breaches. that either come with the phone or response to your messages. Be aware • Know your recipient, and double- can be downloaded. Both types of that some vendor contracts attempt check the “send” field to prevent safeguards provide additional protec- to shift liability risks resulting from sending confidential information to tion if a device is lost or stolen. faulty software design or decision the wrong person. support data onto the provider. The • Ensure the metadata retention Ensure accuracy to avoid liability contract may also give rights to the policy of the device is consistent concerns vendor to utilize patient or provider with the record retention policy, A cavalier attitude when compos- data. and/or in accordance with a legal ing an electronic message can pose preservation order. a legal risk. The informal nature of Take Steps to Protect Your Practice • Ensure that your system has a That’s the percent of some messages may at times lead to Consider the following steps to secure method to verify provider 114 countries around using shorthand, which can increase safeguard your practice: authorization. the world reporting miscommunication. Additionally, de- • Enable encryption on your elec- • When conducting your HIPAA most patient data is leted messages are never fully deleted, tronic devices. risk analysis, include text message as metadata (the “data behind the • Have a texting policy that outlines content and capability. R still collected on paper. data”) is also producible in a law- Only 45 percent of suit. It’s important to ensure accu- high income countries racy—particularly with consultations, The guidelines suggested here are not rules, do not constitute legal advice, and reported some level of personal health information, or any do not ensure a successful outcome. The ultimate decision regarding the appro- adoption of electronic other important text communication. priateness of any treatment must be made by each health care provider in light records. Finally, electronic messages can- of all circumstances prevailing in the individual situation and in accordance with not substitute for a dialogue with a the laws of the jurisdiction in which the care is rendered. Source: World Health Organization, colleague concerning a patient. If there ©2013 The Doctors Company (www.thedoctors.com). 2009 survey

does your medical As the nation’s largest malpractice insurer know physician-owned medical which drugs lead to lawsuits malpractice insurer, our in internal medicine? insights into the practice of internal medicine the doctors have helped earn us the company does. exclusive endorsement of the Richmond Academy of Medicine and have made us the first choice for RAM members. When your 20% 18% 7% 5% 5% reputation and livelihood are coumadin opioids gentamicin kenalog prednisone on the line, only one carrier can give you the assurance drugs most frequently involved in medication-related malpractice claims against internists Source: The Doctors Company that today’s challenging practice environment demands—The Doctors Exclusively endorsed by Company. To learn more, call 866.990.3001 or visit www.thedoctors.com.

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tals. All VCS physicians are board-cer- VCS: Taking care of Virginia’s tified, and many also have additional subspecialty training in cardiovascular intervention, carotid stenting, CT hearts since 1977 angiography, electrophysiology and BY LISA CRUTCHFIELD peripheral vascular disease. The practice was founded in 1977 by Holland and Dr. Eric Kemp. Dr. John Fitzgerald joined soon after, followed by Dunnington. From there, the group has added many new physicians and absorbed several other practices over the years. Pulmonary medicine went out, vascular came in. As the practice grew in size and in scope, it also became more so- phisticated. “When we started out, Drs. Kemp, Fitzgerald, Holland and I would meet out in the parking lot around 11 o’clock and that was it,” recalled Dunnington. As VCS has grown, it’s gotten a lit- tle more difficult to meet in the park- ing lot between patients. A highly organized system of governance has replaced those get-togethers, with a pod system and regular physician and shareholder meetings. But VCS enjoys its status as an independent practice and tries to allow its physicians to have a fair amount of independence too, said Thomas. In all, VCS boasts about 200 employees, making it one of the larg- Dr. Charles Joyner and VCS use high-tech equipment to diagnose and treat various heart conditions. est independent cardiology practices in the commonwealth. Its size has s Virginia Cardiovascu- of clinical breakthroughs, improv- allowed VCS to hire well-qualified lar Specialists was begin- ing outcomes for patients and saving administration and staff, in addition ning to make its mark lives. “We’ve done a lot of firsts in to its cardiologists. in Richmond in the late the state,” said Dr. Shelton Thomas, “We focus on hiring the best staff A1970s, its co-founder traveled to Eu- the group’s president. that will support our physicians and rope to study with the renowned phy- Some of those firsts over VCS’ ensure their efficiency. These physi- sician Andreas Gruentzig, a pioneer three decades include: cians have been really good about of balloon angioplasty techniques. • Coronary stents investing in their infrastructure,” said “Bill [Dr. William Holland] • Coronary vein graph Executive Director Ann Honeycutt, stayed with him for several weeks • Carotid stenting who joined VCS after a career at and learned how to do it,” recalled • CRT device ICD Bon Secours. “We have the ability to Dr. Gan Dunnington, a cardiolo- • Hybrid maze run things well, improve the patient gist who’s been with the practice for • First robotic atrial fibrillation experience, and from a business office decades. ablation standpoint, keep [practice] viable. Holland brought the skills back • Stand-alone permanent pacemakers That’s essential, because, sadly, get- to Richmond, trained his colleagues • CT heart scan and calcium screen/ ting paid for the work doctors do has and over the years improved care and score gotten very complex.” treatment for countless patients. That • Coronary angioplasty That attention to detail is some- spirit of cooperation continues today. • Ventricular tachycardia ablation thing the physicians appreciate, said A commitment to learning the using the Impella left ventricular Joyner. He also appreciates how ad- latest techniques—and sharing that assist device ministrators and practice leaders are information—remains a cornerstone “We feed off each other. One guy proactive in issues that could influ- of VCS. “We’ve shared knowledge can take the lead and spread the ex- ence the field of medicine. and stayed ahead of the curve,” said pertise around the practice,” said Dr. “We are able to recognize some of Dunnington. Charles Joyner, who has been with these things that end up affecting all As the largest independent cardiol- VCS for a decade. cardiologists,” he said. ogy practice in Central Virginia, VCS At VCS, 38 cardiologists practice in By staying in tune with local and is committed to being at the forefront seven offices and at many area hospi- national politics and the American College of Cardiology, VCS can flag issues that it feels it should act on. “We’ve got a lot of leverage as a large group to do that,” said Joyner. Thomas agrees. “Part of our job in this as good practitioners of cardiol- ogy is to ensure that we have a voice in some of the legislative [venues] or organizations that regulate our work.” Case in point: In the late 1990s, the group was part of a successful lobby to change laws to allow nuclear Shelton Thomas, MD Gan Dunnington, MD Charles Joyner, MD medicine to be performed in medi- www.ramdocs.org 15

cal offices. “We went to the General They like getting their questions Assembly every day and eventually answered and getting people seen in a convinced legislators to change the reasonable time frame.” law,” said Thomas. “That has been a Though it works closely with area benefit for our patients.” hospital systems, VCS isn’t ready to Though they keep a close eye on be part of them. the big picture of medicine, VCS “For us, it’s always been important physicians stress that they haven’t lost to remain independent,” said Thom- touch with the basic needs of patients, as. “There’s a tendency to align with referring physicians and hospitals. hospitals and we looked at that . . . “We try to focus on doing a no one group can support us, no one great job of forming relationships healthcare system can handle us, nor with patients, physicians and being do we want that. omnipresent in hospital and office, “Despite the challenges of being an days and nights and weekends. That’s independent practice and the uncer- what traditionally brings in patients,” tainty in health care, our allegiance is said Joyner. to our patients. It’s always been that The ability to be a one-stop shop way.” for all matters cardiac helps, too, and VCS physicians say they’re look- VCS offers a variety of screening and ing forward to more “firsts” as they treatment options on site. It’s the only continue to care for patients. private area practice to maintain a “What excites me clinically about computed tomography angiography cardiology today is prevention,” said (CTA) scanner and accredited Dr. William Coble. “We’ve seen a cardiac CT. decline in deaths from cardiovascular “We’re very proactive about figur- disease with the advent of improved ing out what we need to do and still medicine and stenting, and our ability arrhythmias and more heart failure. Dr. Gan Dunnington has do good work,” said Joyner. “It’s a to intervene in heart attacks within I think the true challenge is keeping seen a lot of changes over the years, but VCS’ top recipe we understand very well. that critical 90-minute window. these people living longer and staying priority has always been “There are some fundamentals “So we’ve decreased mortality. But out of the hospital.” its patients. that never change. Patients have the problem with that is that in- VCS has a wealth of new choices and you have to treat them creased morbidity is still there. People techniques and tools to improve a well. Referring physicians like re- are living longer with heart disease. patient’s chances of survival and sponsiveness. They like competency. We’re seeing more [atrial fibrillation], “VCS,” continued on page 16

Improving Virginia’s Cardiac Health Since 1977 VCS has worked to improve the heart-health of Virginians for more than 35 years. From prevention and testing to cardiac and vascular interventions, we offer the finest cardiovascular care from some of the most respected physicians in the state.

VCS PHYSICIANS

Darryn L. Appleton, MD Brian K. Holdaway, MD, FACC Michael J. Ball, MD, FACC C. Foster Jennings, Jr., MD, FACC Robert M. Bennett, MD, FACC Charles A. Joyner, MD, FACC Michael J. Bunda, MD, FACC Ashwani Kumar, MD, FACC Who better to help you? Carolyn A. Burns, MD, FACC Ramesh N. Kundur, MD, FACC Martin D. Caplan, MD, FACC Bradford J. Matthews, MD, FACC Dean E. Caven, MD, FACC C. Mark Newton, MD, FACC Who better to help you with your practice’s insurance needs William L. Coble, Jr., MD, FACC Reza K. Omarzai, MD, FACC than an agency that was created by physicians? We understand Steven W. Cross, MD, FACC John R. Onufer, MD, FACC, FHRS Aalya H. Crowl, MD, FACC Charles W. Phillips, MD, FACC your challenges like no other agency because we are governed John M. DiGrazia, MD, FACC Peter S. Ro, MD, FACC by a board of physicians and practice administrators. Gan H. Dunnington, MD, FACC Sameer Rohatgi, MD, FACC Michael B. Erwin, MD, FACC Daniel A. Schneider, MD Charles G. Evans, Jr., MD, FACC Saumil R. Shah, MD John E. Fitzgerald, MD, FACC Robert E. Sperry, MD, FACC To experience our personal services, call us at 877 | 226-9357 James B. Garnett, MD, FACC Shelton W. Thomas, MD, FACC or, to request a quote visit www.msvia.org/RequestQuote. David M. Gilligan, MD, FACC S. Craig Vranian, MD, FACC Timothy W. Hagemann, MD, FACC Yvonne J. Weaver, MD, FACC Jiho J. Han, MD, FACC Charles M. Zacharias, Jr., MD, FACC

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MSVIA_HelpYou_ad_RAM2013.indd 1 4/4/2013 10:20:58 AM 16 FALL 2013

“VCS,” continued from page 15 remotely monitoring patients to pre- vent readmissions, either with telem- quality of life, including: etry or the use of physician extenders. • New vascular technologies to help “I feel like we’ve come full circle,” restore blood flow and avoid am- said Coble. “In a sense, we’re making putations house calls again, using technology.” • Transcatheter aortic valve replace- “It’s very satisfying to fix people,” ment (TAVR) said Dunnington. “And it’s also very • Lower levels of radiation exposure interesting to note that even after 35 in scanners years, we haven’t seen everything.” R • New therapies such as hybrid ablation for arrhythmias and atrial fibrillation VCS is also on the forefront of developing new ideas by participat- ing in research studies. The practice Lisa Crutchfield is a Richmond-based employs two full-time research nurses freelance writer. and is looking to expand its program. An in-office CT scanner saves patients a trip to the hospital. There’s also increased interest in

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2201 West Broad Street, Suite 205 Suite Street, Broad West 2201 RAMIFICATIONS Richmond Academy of Medicine of Academy Richmond