SUMMER 2011
PUBLIC HEALTH AND Also… PATIENT PROTECTION • Electronic Medical Records - The Path The Future of Integrated Delivery Systems: Forward for Maryland Primary Care and Public Health Partnerships in Physicians Care Coordination • MD-Tech: Use Your The Importance of Reporting Drug Adverse Events EMR Meaningfully: Streamline the Team!
Early Breast Cancer and Modern Healthcare This Edition Approved for 2.5 CME Credits. Ovarian Cancer: Are Physicians Under-Screening Complete and Submit Journal CME Quiz at for a Silent Killer? www.mdafp.org. The Maryland familydoctor / SUMMER 2011 • 1 Place your trust in Maryland’s leading medical professional liability insurer.
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225 International Circle | Hunt Valley, Maryland 21030 | 410-785-0050 | 800-492-0193 2 • The Maryland familydoctor / SUMMER 2011 THE MARYLAND familydoctor Summer 2011 Volume 48, Number 1 contents
FEATURES
The Future of Integrated Delivery Systems: 12 Primary Care and Public Health Partnerships in Care Coordination by Andrea Mathias, M.D., MPH
The Importance of Reporting Drug Adverse Events 15 by Jasmine Chen Gatti, M.D.
Early Breast Cancer and Modern Healthcare 17 by Niharika Khanna, M.D. Ovarian Cancer: 20 Are Physicians Under-Screening for a Silent Killer? by Merrell R. Sami, M.D.
Electronic Medical Records - Cover: Historic image of a pediatric clinic waiting room. 22 The Path Forward for Maryland Physicians by Gene Ransom (EVP, MedChi)
MD-Tech: Use Your EMR Meaningfully: 24 Streamline the Team! by Matthew Hahn, M.D.
Mission Statement To support and promote Maryland family physicians in order to improve the health of departments our State’s patients, families and communities.
4 Board of Directors, Commissions and Committees 10 Executive Director Engaging and Collaborating with Health Care Partners 5 President by Esther Rae Barr, CAE Summer Time Reflections by Eugene J. Newmier, D.O. 17 Calendar
8 Editor 19 Journal CME Quiz Clinical Practice Emcompassing Public Health by Jasmine Chen Gatti, M.D. 26 Members
The Maryland familydoctor / SUMMER 2011 • 3 President Western Matthew Hahn, M.D. 301-678-7007 Eugene J. Newmier, D.O.* 410-228-1325 Kari Alperovitz-Bichell, M.D. 410-867-4700 [email protected] [email protected] [email protected] AAFP Delegates President-Elect Directors William P. Jones, M.D. 410-867-2200 Yvette Oquendo-Berruz, M.D.* 410-884-7831 Central [email protected] [email protected] Jocelyn M. Hines, M.D. 410-908-0478 Howard E. Wilson, M.D. 202-865-3200 [email protected] [email protected] 2011-2012/2013 Treasurer Christine L. Commerford, M.D.* 410-788-4800 Mozella Williams, M.D. 404-918-1278 AAFP Alt. delegates [email protected] [email protected] Adebowale G. Prest, M.D. 410-641-4200 Secretary Eastern [email protected] Kisha N. Davis, M.D.* 410-884-7831 Andrea L. Mathias, M.D. 410-632-1000 x 1004 Yvette L. Rooks, M.D. 410-328-5012 [email protected] [email protected] [email protected] Vice presidents Rosaire Verna, M.D. 410-745-6617 Immediate past president Central [email protected] Yvette L. Rooks, M.D.* 410-328-5012 Eva S. Hersh, M.D. 410-545-4481 Southern [email protected] [email protected] Patricia Czapp, M.D. 410-286-8974 Resident Director Eastern [email protected] Kevin P. Carter, M.D. (UM) 410-328-8792 Howard H. Bond, M.D. 410-256-2580 Ramona G. Siedel, M.D. 410-518-9808 [email protected] [email protected] [email protected] Student director Southern Western Meghana Desale (JHU) 408-891-4254 officers & directors & officers Trang M. Pham, M.D. 410-255-2700 Kristen Clark, M.D. 410-730-8288 [email protected] [email protected] [email protected] *Member of Executive Committee
COMMISSIONS AND COMMITTEES Executive Committee of Board of Directors Commission on Legislation & Economic Affairs Eugene J. Newmier, D.O. (President) 410-228-1325 [email protected] Vice President Southern District Yvette Oquendo-Berruz, M.D. (Pres-E) 410-884-7831 [email protected] Trang M. Pham, M.D. 410-255-2700 [email protected] Christine L. Commerford, M.D. (Treas) 410-788-4800 [email protected] Legislative Committee Kisha Davis, M.D. (Secretary) 410-884-7831 [email protected] William P. Jones, M.D.** 410-867-2200 [email protected] Yvette L. Rooks, M.D. (Immediate PPres) 410-328-5012 [email protected] Kari Alperovitz-Bichell, M.D. 410-867-4700 [email protected] Commission on Membership and Member Services Howard H. Bond, M.D. 410-256-3580 [email protected] Vice President Central District Patricia Czapp, M.D. 410-286-8974 [email protected] Howard H. Bond, M.D.** 410-256-2580 [email protected] Kevin S. Ferentz, M.D. 410-328-4282 [email protected] Natelaine E. Fripp, M.D. 410-328-4283 [email protected] Bylaws Committee Robert S. Goodwin, M.D. 410-997-5333 [email protected] Yvette Oquendo-Berruz, M.D. ** 410-884-7831 [email protected] Kenneth B. Kochmann, M.D. 410-683-3330 [email protected] (new structure as of 6/24/11) Adebowale G. Prest, M.D. 410-546-0447 [email protected] Louis Kovacs, M.D. 410-404-0889 [email protected] Finance Committee Yvette Oquendo-Berruz, M.D. 410-884-7831 [email protected] Christine L. Commerford, M.D. ** 410-788-4800 [email protected] Ben E. Oteyza, M.D. 410-838-2424 [email protected] Eva S. Hersh, M.D. 410-545-4481 [email protected] Yvette L. Rooks, M.D. 410-328-5012 [email protected] Eugene J. Newmier, D.O. 410-228-1325 [email protected] Gregory H. Taylor, M.D. 410-328-0861 [email protected] Yvette Oquendo, M.D. 410-884-7831 [email protected] Rosaire M. Verna, M.D. 410-745-6617 [email protected] Joseph W. Zebley, III, M.D. 443-524-4481 [email protected] Joseph W. Zebley, III, M.D. 443-524-4481 [email protected] Nominating Committee Vivienne A. Rose, M.D. 410-328-2550 [email protected] Yvette L. Rooks, M.D. ** 410-328-5012 [email protected] Ramona G. Seidel, M.D. 410-518-9808 [email protected] Kisha Davis, M.D. 410-884-7831 [email protected] Tracy A. Wolff, M.D., MPH 301-427-1616 [email protected] Eva S. Hersh, M.D. 410-545-4481 [email protected] Joseph W. Zebley, III, M.D. 443-524-4481 [email protected] Katina N. Moore, M.D. 443-777-6544 [email protected] Commission on Education Eugene J. Newmier, D.O. 410-228-1325 [email protected] Vice President Central District Yvette Oquendo-Berruz, M.D. 410-884-7831 [email protected] Eva S. Hersh, M.D. 410-545-4481 [email protected] Membership Committee Education Committee Charles P. Adamo, M.D. 410-573-4067 [email protected] Eva S. Hersh, M.D. ** 410-545-4481 [email protected] Yvette Oquendo-Berruz, M.D. 410-884-7831 [email protected] Kwame Akoto, M.D. 410-328-5145 [email protected] RH = Rural Health Raygan Harris-Lofton, M.D. 410-255-2700 [email protected] Matthew A. Hahn, M.D. (RH) 301-678-7007 [email protected] Tracy Jansen, M.D. 301-498-3150 [email protected] Andrea L. Mathias, M.D. (RH) (410) 632-1000 x 1004 [email protected] Eugene J. Newmier, D.O. 410-228-1325 [email protected] Eugene J. Newmier, D.O. (RH) 410-228-1325 [email protected] Shana O. Ntiri, M.D. 410-328-8792 [email protected] Adebowale G. Prest, M.D. (RH) 410-546-0447 [email protected] Adora Otiji, M.D. 410-328-4283 [email protected] Trang M. Pham, M.D. 410-255-2700 [email protected]
commissons &commissons commmittees Technology Committee Kwame Akoto, M.D. 410-328-5145 [email protected] Adebowale G. Prest, M.D. 410-546-0447 [email protected] Kristen Clark, M.D. 410-730-8288 [email protected] Vivienne A. Rose, M.D. 410-328-2550 [email protected] Matthew Hahn, M.D. 301-678-7007 [email protected] Ramona G. Seidel, M.D. 410-518-9808 [email protected] Eugene J. Newmier, D.O. 410-228-1325 [email protected] Tracy A. Wolff, M.D., MPH 301-427-1616 [email protected] Joseph W. Zebley, III, M.D. 443-524-4481 [email protected] Commission on Health Care Services and Public Health Vice President Western District Publications Committees Kari Alperovitz-Bichell, M.D. 410-867-4700 [email protected] MFD = MFD Editorial Board Richard Colgan, M.D.** (MFD) 410-328-2686 [email protected] Public Health Committee Joyce Evans, M.D. (MFD) 410-328-2273 [email protected] Niharika Khanna, M.D.** 410-328-5145 [email protected] Jasmine Chen Gatti, M.D. (MFD) 301-796-2074 [email protected] Kari Alperovitz-Bichell, M.D. 410-867-4700 [email protected] Trang M. Pham, M.D. (MFD) 410-255-2700 [email protected] Kisha Davis, M.D. 410-884-7831 [email protected] Merrell R. Sami, M.D. (MFD) 410-780-2000 [email protected] Lauren Gordon, M.D. (women’s health) 410-780-2000 [email protected] Tracy A. Wolff, M.D., MPH (MFD) 301-427-1616 [email protected] Jocelyn M. Hines, M.D. 410-908-0478 [email protected] Joseph W. Zebley, III, M.D. (MFD) 443-524-4481 [email protected] Christine A. Marino, M.D. (oncology) 443-259-3770 [email protected] EB = E-Bulletin Richard Safeer, M.D. (cardiovascular) 410-752-3010 [email protected] Jocelyn M. Hines, M.D. (EB) 410-908-0478 [email protected] Bernita C. Taylor, M.D. 410-368-8793 [email protected] Eugene J. Newmier, D.O. (EB) 410-228-1325 [email protected] Sara A. Vazer, M.D. (immunizations) 301-468-8999 [email protected] Yvette Oquendo-Berruz, M.D. (EB) 410-884-7831 [email protected] Yvette L. Rooks, M.D. (EB) 410-328-5012 [email protected] Joseph W. Zebley, III, M.D. (EB) 443-524-4481 [email protected] PRA = Public Relations & Awards Kevin S. Ferentz, M.D. ** (PRA) 410-328-4282 [email protected] Charles P. Adamo, M.D. (PRA) 410-573-4067 [email protected] Michael J. LaPenta, M.D. (PRA) 443-837-1512 [email protected] Joseph W. Zebley, III, M.D. (PRA) 443-524-4481 [email protected] **Chair
4 • The Maryland familydoctor / SUMMER 2011 president THE MARYLAND familydoctor Summer 2011 Summertime Reflections Volume 48, Number 1 Editor-in-Chief fortunate to play host to AAFP President- Richard Colgan, M.D. Elect Glen Stream, MD and used our time Edition Editor together to make him aware of issues that Jasmine Chen Gatti, M.D. are unique to Maryland. Dr. Stream will Managing Editor be inducted in September and I think he Esther Rae Barr, CAE will make an excellent advocate for Family Editorial Board Physicians nationwide. Zowie S. Barnes, M.D. I attended the Family Medicine Congres- Joyce Evans, M.D. sional Congress in early May in the Nation’s Jasmine Chen Gatti, M.D. Capital. While there, I learned about various Trang Mai Pham, M.D. Eugene J. Newmier, D.O. techniques to get one’s point across to a Merrell R. Sami, M.D. I find myself this summer reflecting legislator. From there, we put lectures into Sandra L. Swann, M.D. Tracy A. Wolff, M.D., MPH on some accomplishments that the Mary- practice by going up to Capitol Hill. I was Joseph W. Zebley, III, M.D. land Academy has achieved in the first able to meet with a representative from year as your president. It has been a very Senator Ben Cardin’s office and with Rep- Advertising Sales and Production interesting year in Family Medicine and resentative Andy Harris, who represents Publishing Concepts, Inc. I am proud of the things we’ve done on my District on the Eastern Shore. It was an ED.5 Virginia Robertson, Publisher [email protected] your behalf. I’ve had the opportunity to educational experience to do this and I left 14109 Taylor Loop Road network and meet a lot of other leaders hopeful that my message was heard. Little Rock, AR 72223 501.221.9986 One of my goals prior to taking over as MAFP For advertising information contact: Tom Kennedy president was the development of an updated 501.221.9986 or 800.561.4686 ext.104 Strategic Plan to help the Maryland Academy of [email protected] www.pcipublishing.com Family Physicians move forward as this decade of change in healthcare progresses. Publisher Maryland Academy of Family Physicians from around the country. This has given However, the two things I am most 5710 Executive Dr., Suite 104 Baltimore, MD 21228-1771 me the perspective of what Family Physi- proud of during the past year are our 410-747-1980; 410-744-6059 Fax; cians are up against in other states. The new Strategic Plan and our collaboration [email protected] annual Congress of Delegates was held with the Mid-Atlantic Business Group on last September in Denver and our Acad- Health (MABGH). One of my goals prior The Maryland Family Doctor is published four times annually and is the official publication of emy was well represented by our Dele- to taking over as MAFP president was the the Maryland Academy of Family Physicians. gates, Drs. William Jones and Howard Wil- development of an updated Strategic Plan The opinions expressed herein are those of the son, along with Alternate Delegates Drs. to help the Maryland Academy of Family writers and not an official expression of Academy policy. Likewise, publication of advertisements Adebowale Prest and Yvette Rooks. Physicians move forward as this decade of should not be viewed as endorsements of We had a very successful Mid-Winter change in healthcare progresses. those products and services by the publisher. Conference in Baltimore in February and In December, several Board members Readership: over 10,000. Copyright: All contents 2003 MAFP. All rights reserved. I congratulate the Education Committee met in Columbia for an all day retreat. Nancy Contributions and Deadlines for a job well done. Our Annual Meeting Miller from the AAFP facilitated the meeting Those interested in submitting articles for was held this past June and, as always, was and several great ideas were brought forth. publication can view the Author’s Protocol Sheet full of stimulating educational opportuni- From this retreat, several changes to the by clicking on News and Publications at www. mdafp.org or contacting the headquarters ties. During the Annual Assembly, I was continued on page 6 office. Deadline schedule for submitting articles: May 15, August 15, November 15, February 15.
The Maryland familydoctor / SUMMER 2011 • 5 Bylaws were proposed and recently favorably voted at the Annual Business Meeting. MAFP’s committee structure was streamlined and I believe that the Academy is well suited to move forward in 2012 and beyond. Last Fall, the MAFP was approached by Mr. John Miller of the MABGH to help facilitate his groups recognition of NCQA certified practices in the state of Maryland. His group represents some of the largest employers in the Mid-Atlantic region and, as such, has a lot of clout with the Insurers. The first meeting, held in January during an ice storm, recognized several practices in the state which had gone through the process of NCQA certification. Mr.
Hand • Wrist • ElboW • sHouldEr Miller asked the Academy to help in- vite our primary care colleagues to another meeting to help his group understand the challenges Primary Care Physicians have with insurers. We reached out to the Pediatricians, Inter- nists and Med-Chi to the forum held in April. It was a lively discussion that was also attended by a representative from CMS. We all felt that good dia- logue occurred and ideas exchanged. For the next meeting in the Fall, MAB- GH plans to invite the insurers to hear our concerns and issues. I am opti- mistic that, through our cooperation with the MABGH, the insurers in this state will come to understand what is threatening Primary Care in Maryland. Four days focused on family medicine. More We still have a lot of work to do in than 300 clinical and procedural CME courses. the upcoming year before I turn the Thousands of family physicians sharing reins over to President-Elect Dr. Yvette knowledge, building relationships, having fun. Oquendo-Berruz. However, I have tru- ly enjoyed the first year of my term and will continue to do whatever I can to promote Family Medicine in Maryland. Thanks to the Board for their dedica- tion and support and to the members for valuable feedback. ■ Make this your time. Register at aafp.org/assembly
6 • The Maryland familydoctor / SUMMER 2011 THE BEST CHOICE FOR BODY AND MIND
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The Maryland familydoctor / SUMMER 2011 • 7 editor
Clinical Practice Encompassing Public Health
Screening and preventative Established by Physicians measures for large for Physicians populations do impact our daily patient doctor We know how to interactions. It has been diagnose and treat established that TB your insurance & screening helps treatment: an example of how public financial needs. Jasmine Chen Gatti, M.D. health measures impacted on the personal practice Property & Liability: Others may perceive the “family of the clinician and the ✤ Medical Malpractice doctor” as the classic clinical physician patient welfare. ✤ Workers Compensation committed solely to clinical practice. ✤ Medical Office Insurance Our role as physicians encompasses so ventative measures for large popula- ✤ Employment Practices Liability much more these days. One other hat we tions do impact our daily patient doc- must wear is the duty we have as public tor interactions. It has been established ✤ Directors & Officers Liability health servants: one that is often dimin- that TB screening helps treatment: an ✤ Bonds (Fiduciary/Fidelity/Erisa) ished in the tide of healthcare reforms example of how public health measures ✤ Personal Insurance (Home, and insurance issues. Remember that impacted on the personal practice of Auto, Umbrella) public health impacts large populations the clinician and the patient welfare. In and we are the soldiers who carry out the article “The Importance of Adverse Employee Benefits: these edits: yet, simultaneously we have Event Reporting” you will see how your ✤ Medical, Dental & Vision the power to impact public health poli- reports can impact on public health is- Coverage cies that impact these large populations. sues related to drug labeling. In the ar- ✤ Group Life & Disability In this issue you will see how some of our ticle, “The Future of Integrated Systems: ✤ Section 125/Flex Spending physicians do this and how you can too. Primary Care and Public Health Partners Accounts in Care Coordination” we see the impact of family practitioners partnering direct- Find out if your ly with public health organizations. In medical practice is Dr. Khanna’s article you will see how the adequately insured. personal experience of one FP whose diagnosis questions the public health Call us today to schedule your guidelines allows her to bring more in- “no obligation” insurance and sight to the best choices for her patients. financial review. We hope you learn from the edition The front cover image of this edi- and would welcome any feedback. ■ 410-539-6642 tion, an historic photo of a pediatric 800-543-1262 clinic waiting room, merges the ori- Dr. Gatti is boarded in Family Medicine, gins of public health and clinical prac- geriatrics and palliative medicine. Her ar- tice and helps to remind us how large ticle pertinent to the theme of this edition populations are affected by public appears on p. 13. A member of the MAFP 1204 Maryland Avenue health changes implemented by the Editorial Board, she edits this, her 4th edi- Baltimore, Maryland 21201 family physician. Screening and pre- tion of The Maryland Family Doctor. www.medchiagency.com
8 • The Maryland familydoctor / SUMMER 2011 family medicine UTERINE FIBROID EMBOLIZATION
A SAFE AND EFFECTIVE ALTERNATIVE FOR FIBROIDS Uterine fi broid embolization (UFE), also known as uterine artery embolization, is a non-surgical treatment for symptomatic uterine fi broids performed by an interventional radiologist. Using a catheter and guidewire, the physician injects tiny microspheres into the vessels that feed the fi broids, blocking the blood supply, shrinking the fi broids, and relieving symptoms. Unlike myomectomy and endometrial ablation, which either address one fi broid at a time or only bleeding symptoms respectively, UFE is a global procedure that effectively After the UFE procedure addresses all fi broids and related symptoms at once. and appropriate UFE offers your patients another option: • Resolves fi broid symptoms follow-up care, your • Potential for maintaining reproductive ability fi broid patient • Doesn’t require a lengthy hospital stay or recovery time ENCOURAGING REFERRALS ENHANCES PATIENT CARE returns to you Many physicians may not be fully educated about UFE and as a result, may not be for continued care. discussing it with many patients who will fi nd it to be an attractive treatment option. To locate an experienced Interventional Radiologist (IR) in your area and to order your free supply of patient pamphlets, please call 866-275-7498.
FAMMEDPAC PUTS YOU AT THE TABLE WHEN HEALTHCARE DECISIONS ARE MADE.
SUPPORT CANDIDATES WHO SUPPORT YOU. Support FamMedPAC. FamMedPAC is the political action committee of the American Academy of Family Physicians. It is the financial vehicle through which you can support the election or reelection of candidates who share your commitment to family medicine. Now in its third year, FamMedPAC strengthens AAFP’s advocacy efforts and Contribute now at www.FamMedPAC.org. our presence in Washington. And it needs your support.
The Maryland familydoctor / SUMMER 2011 • 9 executive director
Engaging and Collaborating with Health Care Partners
Fun Facts force, pipeline, practice transition and AAFP divides its 54 chapters into small payment matters. (under 500 active), medium (500-1500 ac- 3. Maryland Health Care Commission tive) and large (over 1500 active). The (MHCC): With the stage set for health Maryland Chapter is a small, mid-sized reform in Maryland, including passage AAFP chapter with 700 active members and of the Patient Centered Medical Home two full-time employees. Our chapter has (PCMH) bill of the 2010 legislative ses- 1200 total members. AAFP’s total member- sion, MAFP works closely with MHCC to ship is now over 100,000 nationwide! recruit practices for the PCMH pilot.
Esther Rae Barr, CAE This year I was tapped, by the AAFP Chapter Affairs I HOPE YOU read (with interest) the staff, to present at a workshop entitled, “Engaging recaps in this edition on p. 27 from the Maryland Chapter’s delegates to the 2011 and Collaborating with Health Care Partners” where AAFP Annual Leadership Forum (ALF) and I shared information on the several partnerships National Conference of Special Constitu- in which MAFP is engaged as we aspire to our encies. I had the pleasure, as I have for chapter’s mission: To support and promote Maryland several years now, to be a member of the family physicians in order to improve the health of delegation to ALF where chapter elected leaders and executive staffs come togeth- our State’s patients, families and communities. er to exchange experiences and ideas. For me it’s the best networking opportunity New and Renewed Successful 4. Mid-Atlantic Business Group on Health of the year and I always bring something Primary Collaborations for MAFP (MABGH): This new, strengthening col- back to put to use at home. It’s also nice 1. Maryland Primary Care Coalition (MPCC): laboration began a couple of years ago to hear when folks report that they have this group comprised of the three pri- when I and the MABGH executive direc- learned from me: “Now that was a ‘go to mary care medical societies (MAFP, ACP tor met during a conference. Post-meet- work on Monday morning and use those of MD, MAP of MD), now expanded to ing conversations and emails ensued ideas’ kind of presentation.” (quote from include other interests, eg. The MD As- leading up to a MABGH presentation a Mid West Chapter executive colleague). sociation of Community Health Centers and request of the MAFP Board that a This year I was tapped, by the AAFP is administered under the auspices of series of meetings take place to discuss Chapter Affairs staff, to present at a MedChi. MPCC, primarily an advocacy health reform in Maryland, access to workshop entitled, “Engaging and Col- group, was established in 1998 and was care, public health initiatives, physician laborating with Health Care Partners” administered by MAFP until 2009. payment, NCQA recognition, electronic where I shared information on the several 2. The Maryland State Medical Society medical record transformation incen- partnerships in which MAFP is engaged (MedChi): MedChi took over admin- tives, etc.…. as we move forward. as we aspire to our chapter’s mission: To istration of MPCC, coinciding with the support and promote Maryland family then impending passage of the Patient MAFP and MABGH physicians in order to improve the health Portability and Affordable Care Act MABGH is an affiliated group of the Na- of our State’s patients, families and com- (PPACA), bringing focus on the need for tional Business Coalition on Health. Their munities. The workshop was well-attend- primary care providers. As Maryland members are employers. Founded in 1977, ed with good questions and lively inter- undertakes its own reform initiatives, their mantra is “Affordable Healthcare for change among the participants. Here are MAFP and MedChi have a renewed re- Employees and Their Dependants (your some highlights: lationship focusing on advocacy, work- patients).” Their interests, coinciding with
10 • The Maryland familydoctor / SUMMER 2011 Reduce your billing MAFP’s mission (stated above) are to 1) and collections headaches. improve individual healthcare experi- ences; 2) elevate health status of the population; 3) increase efficiency by reducing waste and lowering costs. Their immediate goal with MAFP is to improve their understanding of recog- nition and incentive programs and to get MAFP’s ideas on improving them. Beginning this year, a series of in- formational meetings has and con- tinues to transpire among members Annapolis Billing Services is better than Aspirin. of MABGH, MAFP, as well as represen- tatives from business, government, Annapolis Billing Services billing and account management policy-making bodies, other health- services are handled effectively and professionally, care societies and the major health returning your staffs focus to patient care and practice plans. MAFP has participated in three enhancement rather than the headaches of collections. such official exchanges which have taken place so far this year. A large, stake holders meeting is now being 621 Ridgely Avenue, Suite 404, Annapolis, MD 21401 planned for the Fall. Reports from Tel: 410-266-1588 • Fax: 410-266-6931 • www.annapolisbilling.com these sessions are available upon re- quest ([email protected]). As we move forward, I will keep members aware of any and all developments.
Conclusion MAFP is becoming more recog- nized in the environment as a thought leader with the ability to provide vital information to other groups. MAFP leadership and members, as well as the status of Family Medicine in Mary- land can only benefit by continued interaction and strengthening of ties with others.
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The Maryland familydoctor / SUMMER 2011 • 11 The Future of Integrated Delivery Systems: Primary Care and Public Health Partners in Care Coordination
sertion that coordinated care will increase There is a number of common character- quality care and save costs. Or, they may istics in care management programs that have had success in improving quality exacerbate the problem of the failing busi- and reducing costs (Table 5). ness model of primary care practice, and ultimately contribute to worsening popu- Table 5: Keys to Success lation health as well as failure of health Patient selection care reform. Person-to-person encounters Home visits Will primary care offices be able Specially trained care managers with to implement care management low case loads Andrea Mathias, M.D., MPH programs that result in Multidisciplinary terms including “The future of public health and prima- outcomes? physicians ry care are inextricably interdependent in Successful Elements for Implementation Presence of informal caregivers the face of health care reform. The success According to a recent RWJ Synthesis Use of coaching of health system reform relies heavily on Report, care coordination programs re- the availability of primary care physicians quire certain key elements to achieve the illnesses, let alone coordinate complex (PCP) and their ability to coordinate care. population health outcomes of increased social and resource needs. Over half of Yet the shortage of primary care physi- health quality and reduced overall costs. primary care physicians practice in small cians and providers grows daily. Even pa- (Table 5) Successful models of care co- or medium-sized offices and will need to tients with health insurance experience ordination feature a well-trained team of work together and with other partners to difficulty gaining access to primary care providers, including RN care managers, create successful care management teams. when they need it. The implications of social workers and other care managers, The success of health system reform re- PCP shortages for the health of a popula- situated in primary care practices and/or lies heavily on the ability of a community tion are known to increase costs of care, working closely with primary care physi- of providers to form partnerships, and ex- reduce quality and overall access to care. cians. Patients enrolled must be assessed change information to coordinate patient Hospitalizations which could have been to be at high or moderate risk of incurring care. Primary care physicians may wish to prevented by accessible and adequately- major health care costs based on multiple examine and utilize care management re- resourced primary care are rising. chronic conditions. Care manager interac- sources existing in their communities, and Meanwhile, the three primary goals of tions must occur with patients in-clinic, at may find care coordination services avail- Patient Portability and Affordable Care Act home and by telephone. able in their local health department (LHD). (PPACA) are to The primary care office is a logical site Public health departments provide 1. provide near universal insurance cov- for care management; however primary health services based on community erage and access to essential health care providers may need to consider part- health needs assessments and essential or services nerships with existing care coordination core health services. Public health depart- 2. improve quality resources to provide the necessary as- ments may provide certain health care ser- 3. reduce costs. pects of a successful program. Stresses on vices for which there is a shortage of pri- Primary care physicians brace for the primary care make it difficult to implement vate sector providers, like Mental Health, increasing overhead related to meeting all the elements of an effective care man- Addictions and Dental care. In Maryland Patient Centered Medical Home (PCMH) agement program. today, it is uncommon for health depart- criteria, as well as implementing EHR’s Reimbursement and time constraints ments to provide Primary Care or Ob/Gyn with meaningful use criteria. The cost make it difficult to manage all the medi- services outside the scope of Immuniza- savings projected in PPACA rely on the as- cal needs of patients with multiple chronic tions and Family Planning clinics. Instead,
12 • The Maryland familydoctor / SUMMER 2011 public health nurses, social workers, and case managers support clients in the coor- dination of their medical, dental or behav- ioral health care. In Maryland, many LHDs provide care coordination in a variety of settings and for certain high risk cases. While care co- ordination services vary from county to county, the LHD may be an ideal partner in finding care coordination services for certain patients. In some counties, LHD nurse case managers conduct home visits to assess high risk newborns, in an effort to reduce risk of infant mortality. In some counties, a team of RN’s, social workers and other providers work in the Adult Evaluation and Referral Service (AERS) Program to evaluate the elderly in their homes. The purpose of this program is to address social and medical needs to educate the enrollee about the Medical Deterrents to Implementation prevent nursing home placement and Assistance Program, as well as local re- Unfortunately, in most instances, care coordinate resource needs during the sources and programs. coordination or case management is not transition from an acute care facility to In some county health departments, billable to a third party payer. Funding home. Nurses also coordinate care for social workers and case managers coordi- provided under grants or Medicare waiv- patients with a variety of reportable com- nate care for clients with behavioral health er programs will not cover the scope of municable diseases such as HIV, Hepatitis needs and developmental disabilities. services or numbers of patients who will B and C, tuberculosis and others. The care These staff empower consumers to ac- need these services. Major reforms will coordination includes arranging visits cess resources and services autonomously. need to be considered regarding pay- with HIV or Infectious Disease specialists, Services include in-home visits to address ment for care coordination. Currently, drawing labs to be sent to the State Lab, basic needs of food, shelter and sanitary methods of reimbursement are being monitoring for medication adherence, housing, as well as behavioral health pro- tested with fee schedule increases or “per and arranging transportation. vider coordination. Some care coordina- member per month” payments in the Pa- Many county health departments tion programs also provide case manage- tient Centered Medical Home Pilots. Giv- host The Administrative Care Coordina- ment services to youth involved with the en the scope and intensity of successful tion Unit (ACCU). This service provides Department of Juvenile Services, have a care management programs, it remains to outreach, education, and care coordina- mental illness or substance abuse issue, be seen if these funding models will re- tion activities to the Medical Assistance and youth who need help accessing com- sult in the desired outcomes. population, as well as the uninsured and munity resources. underinsured populations. The program Finally, LHD’s may provide a variety of How will PCP’s be able to select aims to ensure that clients remain in care preventive services that address health the clients in greatest need? have access to needed health care ser- risk and health behaviors, and may be a All successful models of care coordina- vices. The Ombudsman Program accepts part of care coordination plans. Dieticians tion have relied heavily on the ability to referrals from the Compliant Resolution and health coaches teach clients how to identify clients most at risk of high cost and Unit of Medicaid. The Ombudsman at- manage certain risk factors such as To- poor clinical outcomes. Intense care coordi- tempts to resolve referred disputes, to bacco Cessation, self care for diabetes, and nation services can be focused on those cli- assist in resolving complaints, and to achieve lifestyle balance. continued on page 14
The Maryland familydoctor / SUMMER 2011 • 13 Table 3: Sample of Predictive models In the Humana Cares Program, hospitaliza- The Charlson Designed to measure the risk of 1-year mortality in tion rates decreased by 36%, ER visits de- Comorbidity Index hospitalized patients using diagnosis codes for 17 conditions creased by 22% and outpatient procedures weighted to reflect their seriousness (35). reduced by 13.6%. In order for primary care The Chronic This model looks at the classes of medications a patient is taking, and public health providers to focus care Disease Score weighs them to correspond to disease complexity and severity, coordination efforts, insurers must provide and predicts health status, mortality and hospitalization rates. It has been validated to correlate with physician ratings of lists of clients based on these proprietary disease severity and to predict mortality in the following year, algorithms, if available. hospitalization, and total health care costs after controlling for age, gender and health care visits (113, 83, 24). Integrated delivery systems: The Hierarchical The HCC model of disease severity has been adopted by the The Future Condition Centers for Medicare and Medicaid Services (CMS) to risk- Categories (HHC) adjust capitation payments under the Medicare Advantage Primary Care and Public Health pro- program. This model creates 804 diagnostic groups, which are viders will become part of an integrated further aggregated into 189 condition categories (HCCs) that system, the Accountable Care Organiza- are clinically- and cost-similar (77). tion (ACO). These systems will have the The Adjusted This system, developed at Johns Hopkins, can be used to resources and capacity to develop care Clinical Groups predict high-risk patients for inclusion in care management, (ACG) to set risk-adjusted capitation rates, and to provide a risk- management programs. In these models, adjustment tool for measuring the quality and efficiency of high-risk patients receive a seamless web medical practices. This system assigns patient to one of 32 of care management services encompass- diagnosis groups based on the duration, severity, diagnostic certainty, cause and need for specialty care services associated ing multiple transitions from hospital to with the disease. Because a particular patient is likely to have home to primary and specialty care, with diagnoses falling into more than one diagnosis group, 93 the highest-risk patients receiving the adjusted clinical groups (ACGs) were developed, and individual most intensive care management in high- patients are assigned to an ACG based on their combination of diagnosis groups plus age and gender. Individuals within risk settings. An interdisciplinary team of a given ACG have a similar pattern of morbidity and resource nurses, social workers, community health consumption over the course of a year (www.acg.jhsph.edu). educators, physicians, pharmacists and registered dieticians will approach the pa- ents to produce the greatest improvements tient’s needs. Primary care physicians in health outcomes and reduced costs. Investment in the infrastructure of care brace for the increasing A number of accurate predictive mod- management is very important, but daunt- overhead related els have been introduced to risk-stratify ing as the shortage of primary care provid- to meeting Patient populations of patients, including those ers grows, the population ages, and chronic Centered Medical with complex health care needs (see Table illness prevalence escalates. Only through 3), to determine who will best benefit from partnerships and optimal use of existing Home (PCMH) criteria, care management. Models that include di- resources will we achieve success. ■ as well as implementing agnostic and medication information are EHR’s with meaningful best at predicting future costs. Dr. Mathias is Deputy Health Officer, Wor- use criteria. The cost However, such risk assessment tools can cester County Health Department in Snow savings projected be complex, data intensive, and in some Hill. She is a member of the MAFP Board of in PPACA rely on cases, proprietary. For example, Humana Directors as Eastern District Director. the assertion that Cares and JHU Health Plans ACG use claims data to analyze members’ risk of incurring Note: references for this article are posted at coordinated care will high cost services. This data is used to de- www.mdafp.org; publications and news tab. increase quality care velop insurer-sponsored care coordination CME questions for this article appear on the and save costs. plans. The Humana Cares Care manage- Journal Quiz at www.mdafp.org; CME Quiz ment program boasts successful outcomes. tab; Summer, 2011.
14 • The Maryland familydoctor / SUMMER 2011 The Importance of Reporting Drug Adverse Events
this study deals primarily with human error What to include in the Medwatch and not harm related to intrinsic properties report and which aspects of the of drugs, it touches upon the reluctance of report are the most important? providers to report adverse events. One of The Medwatch system is the report- the reasons stated for not reporting was ing mechanism that is used by the FDA fear of punitive or legal ramifications de- to collect and monitor postmarketing spite assurance that there was anomynity in safety adverse events that are placed into submitting reports. Another reason for not the AERS database after they are submit- reporting was the lack of feedback and as- ted by physicians, manufacturers and the surance that the information they submit- general public. The website is www.fda/ Jasmine Chen Gatti, M.D. ted would be put to good use.1 gov/medwatch. Practicing physicians hold a treasure This author also proposes that other When analyzing a report, physicians trove of clinical experience that, when possible barriers or myths to why reports should know that the reviewers look for reported by physicians to the FDA, can are not submitted include the following: carefully written and comprehensive case help to protect the public health of their 1. Never taught in medical school or resi- reports. The strongest case reports tend to patients. By discovering and reporting dency how to report have elements that make the relationship adverse events, the conscientious family 2. Too much paperwork and time of adverse event to drug use “temporal” physician, can impact on labeling and drug 3. Someone else has probably done this in sequence and proximal to its use. Ad- warnings that influence prescribing prac- already ditionally, information on a dose response tices of their colleagues. More importantly, 4. One case of an adverse event makes no as the potency of the drug increases, infor- the lessons learned can potentially affect difference mation on a resolution of symptoms when many of their patients. For instance, newer 5. There are no incentives for doing this the drug is discontinued or tapered (called drugs are studied in clinical trials that have 6. In the larger scheme of all AEs that this drug “de-challenge”) or the re-appearance limited real-life use in the general popula- drug may cause, why should I report this of the adverse event when the drug is re- tion. Many drugs are approved with limited if I don’t know how frequent and severe started (called drug “re-challenge”) will experience in special populations of pedi- this AE is provide more useful information for a cau- atrics, geriatrics, and pregnant mothers and sality assessment. Other factors such as the experience in real life medical practice Definitions of Adverse Events2 the concomitant use of other drugs, other is invaluable. Multiple terminology is used to refer comorbidities or possible drug-drug inter- As clinicians, there are plenty of rea- to side effects due to drug use. Commonly actions can strengthen or weaken the like- sons we can find to justify not reporting used terms include adverse event (AE) and lihood that an adverse event is associated an adverse event associated with a drug adverse drug experience (ADE). The offi- with a drug. These elements are essential taken by our patients. But, there are more cial FDA definition (CFR 314.80(a) Code of to the report that the physician or pro- reasons that we should. As polypharmacy Federal Regulations) for ADE includes “any vider fills out. Additionally, demographics, becomes more prevalent not only in the adverse event associated with the use of a doses, date of drug use or discontinuation aging population but in all age groups, as drug in humans, whether or not considered are important. Clinical and diagnostic tests alternative and over-the-counter drugs per- drug related, including the following: in the help confirm that the adverse event is cor- meate the market, drug side effects cannot course of the use of a drug product during rectly diagnosed. be ignored. professional practice, an AE occurring from Adverse events that occur more fre- The Institute of Medicine in their report drug overdose whether accidental or inten- quently than seen during clinical trials,3 “To Err Is Human” addressed the preva- tional; an AE occurring from drug abuse; an new adverse events, rare events associ- lence of medical error and the increasing AE occurring from drug withdrawal AND any ated with newly approved drugs, or those use of event reporting systems. Though failure of expected pharmacologic action.” continued on page 16
The Maryland familydoctor / SUMMER 2011 • 15 Stand for that have serious outcomes are of Incentivizing reporting family particular interest to those who by clinicians may enhance review the reports. Serious out- reporting medicine. comes are defined as death, a life- In the UK, the Drug Safety Re- threatening ADE, a disability that search Unit (DSRU) has modules for Save time. Save money. persists or is significant, hospital- their general practitioners (GPs) for Find the support you ization or birth defect/ congenital education credits. See www.dsru. enjoyed in residency. anomaly or any important medi- org. Consideration might be given cal event4. to similar modules being devel- oped by US medical societies or Join today How to Report associations to inform providers of There are two avenues to report- their impact of Medwatch report- aafp.org/stand ing adverse events which include5: ing. Furthermore, existing columns 1. Directly to the FDA by phone, in American Family Physicians that on-line, downloading a copy of are on-line or in journals can utilize form 3500 and faxing to 1-800- columns such as “Should I Give this FDA-0178 or mailing it back. Drug: Drug News for Clinicians from 2. Directly to the drug manufac- the FDA” to further educate practi- turer or via a pharmaceutical tioners. Efforts of medical associa- Y representative6 tions to incorporate a qualified mod- Additionally, publishing in lit- ule on drug adverse event reporting erature, preferably after direct that would be eligible for CME ac- reporting to FDA or the manufac- creditation and/or be lengthened to ew York, n ew York, turer, is another means that FDA re- a module that might be used as one viewers may obtain adverse event of the components to extend recer- information. tification from 7 to 10 years may also The impact of one Medwatch be ways to incentivize reporting. ■ report can be substantial: it may af- enas, MD • n fect regulatory decisions on label- Dr. Gatti is employed by the Federal ing of a product. Often reviewers Drug Administration. She is the edi- and regulators make decisions that tor of this edition of The Maryland H a Hags dismiss case reports that do not Family Doctor. Lei L contain enough information. When cases are reported with the infor- Disclaimer: The views expressed mation we need to assess stronger in this manuscript represent the temporality and causality--without opinions of the author(s) and do the influences of concomitant med- not necessarily represent the ications or co-morbidities-- just a views or position of the Food and few cases may make the difference Drug Administration. in inclusion as an adverse event in labeling of a drug. Stronger cases Note: references for this article are when confirmed with literature ref- posted at www.mdafp.org; publica- erences, AERS database7 and dat- tions and news tab. CME questions amining8 may lead to warnings or for this article appear on the Journal contraindications in the Highlights Quiz at www.mdafp.org; CME Quiz of the label. tab; Summer, 2011.
16 • The Maryland familydoctor / SUMMER 2011 Early Breast Cancer and Modern Healthcare
in low risk women.1 For today’s 40-50 year As the investigations unfold, five dif- old woman who is always in control, not ferent pre-cancerous lesions will be found knowing that there is a cancer growing in lying unsuspectingly in both breasts. I am her breasts maybe the underpinnings of thankful that despite my “Low risk profile”, I the public outrage about the screening still received the screening that lead to ear- recommendations proffered by the United ly diagnosis. The majority of breast cancers States Preventive Services Task Force (USP- appear in women with no genetic predis- STF).1 Current USPSTF guidelines suggest position, and this fact impacts the average that no mammographic screening be of- physicians’ interpretation of breast cancer fered to women who are low risk and under screening guidelines. For me, becoming Niharika Khanna, MBBS,MD,DGO 50 years of age. first a patient, and secondly a cancer pa- Surprise diagnosis: A routine As a qualifying low risk woman, I think tient, is an experience for which I have no mammogram starts a cascade of there is no rationale for the fact that I had training. events for the author a normal mammogram at age 49 years, fol- Becoming a patient for me is a very in- Breast cancer is a very important public lowed a year later by the present abnormal teresting transition: I am a Family Physi- health problem, but I do not think it could mammogram. However, data suggests that cian with additional training in Women’s ever affect me. I barely understand the up to 20% of all screening mammograms Health and one part of my brain watches radiology technician who is saying to me, may be false negative depending on breast my transition to becoming less rational, less “You have an abnormal mammogram!” density, age, technical and other pertinent detached and more emotional. The same “Which breast,” I ask. “Both,” says my poker issues.2 Balance this information with the colleagues, saying the usual sorts of things faced radiologist later. I am very surprised! fact that aggressive cancers also occur in start to appear different. The first thing I no- Although I have felt a little unwell for the last this age group, thus making my under- tice is, that I hear what I want to hear, and 6 months, breast cancer was not on my ho- standing of the reasons for my abnormal usually that is the worst possible scenario rizon at all. Being diagnosed at age 50 with mammogram more difficult. and the worst possible outcome for what I an early multi-centric breast cancer with bi- know to be a fairly benign disease. My phy- lateral lesions comes as a complete surprise. My Personal Journey sicians are my old colleagues and people Early detection of breast cancer places I know quite well. But, when it comes to Screening Guidelines for Breast the patient and her doctors in the middle discussing my new diagnosis and potential Cancer of a no-fly zone, where evidence states that outcomes, I am crippled with anxiety and The detection of an early breast cancer the majority of early cancers have low-to- in descending order, all of the stages de- in a patient is the start of a journey in un- uncertain likelihood of progression. Howev- scribed in the Kubler-Ross model starting certainties and therapeutic dilemmas. The er, introduction of the c-word (cancer) into a with denial.3 The diagnosis process is long current public discussion on breast cancer physician-patient relationship inspires fear and involved and denial really appears to screening guidelines is an opportune time and anxiety and initiates the slide down a be a wonderful coping strategy. Further, to reflect whether a woman is better off be- slippery slope of interventions. I hear breast denial prolongs the time to final diagnosis, ing diagnosed with an early breast cancer cancer, and it comes with a chill, followed thus buying time to address the emotional for which there are aggressive therapies, by a chillier draft and there is no reason- issues surrounding multi-centric disease. Dr or, is she better off being diagnosed with a ing with me, the patient, that my cancer is Kubler-Ross described an excellent model more advanced palpable lesion associated less aggressive, less fatal; my left brain says which acknowledges the anger that inevi- with greater morbidity. Current standards there is no rationale for keeping a cancer tably follows, “why me”. I have a wonder- of care are fiscally conservative and USP- growing in my breasts. Another corner of ful life, I was at the time, a Women’s Health STF (United States Preventive Services Task my mind observes my transition to becom- scholar in a National Institutes of Health Force) recommends screening from age 50 ing a cancer patient! continued on page 18
The Maryland familydoctor / SUMMER 2011 • 17 funded program (Building Interdisciplinary The detection of an early breast cancer in a Research Careers in Women’s Health [BIRC- patient is the start of a journey in uncertainties and WH]), I work in cancer prevention and am therapeutic dilemmas. The current public discussion dabbling in chemoprevention of cervical on breast cancer screening guidelines is an pre-cancer! I now know that cancer truly knows no boundaries.. opportune time to reflect whether a woman is better off being diagnosed with an early breast cancer Early Breast Cancer Management for which there are aggressive therapies, or, is she Early breast cancers have two basic better off being diagnosed with a more advanced management strategies: conservative and non-conservative. The conservative route palpable lesion associated with greater morbidity. allows for removing the affected area, re- taining the breast and allowing for years ing the theory that non-conservative ap- tially rises. The real question is, does this of uncertainty during which innumer- proaches to early breast cancers are okay. alter my choice of therapy? able mammograms, MRI’s, biopsies are Maybe this is true in degree! As a patient, Altogether, my surgical treatment and performed. The non-conservative route I know that without my primary care phy- recovery procedures continued over a pe- allows for radical surgery for a non-life sician’s encouragement, cheerleading and riod of one year leading to time lost from threatening disease. There is no happy pain management, I would have lost my re- work, disengagement from social struc- medium. Finding a surgeon who will pres- solve to persevere with management. tures and general disruption of my life. It ent a balanced view seems at once diffi- is a fact that in today’s fast paced world cult and easy. All of them lay out the same Breast cancer terminology where early diagnosis and treatment has options and then offer the patient their debates and referral centers become a reality, several eminent centers opinion. With the increasing visibility of The recent Ductal Carcinoma In Situ around the country have developed sys- breast cancer in the lay press and the ac- (DCIS) consensus development conference tems of care that efficiently eliminate these tivism that has accompanied new devel- sponsored by the National Cancer Institute cancers. However, the duration of mental opments, it seems almost futile to go to (NCI) focused on the issue of calling a rose health recovery time for the patient has more surgeons for opinions. There are no by another name, i.e. re-naming DCIS to never changed. Thus, although in the old other opinions. All the opinions are either ductal neoplasia and other creative names.4 system of care, it may be possible for a mastectomy or conservative excisions and This name transition has already occurred surgeon to diagnose and excise all in the close follow up; with or without chemo- in lobular neoplasia and it may be too soon same week, but the patient may not pro- preventive agents and radiation. to gather enough scientific information cess the information and the procedures For a relatively healthy person to con- on the impact on patient perception and at the same pace. Breast centers introduce sider mutilating surgery for a non-life- the choice of radical surgeries. I know that a host of new specialists into the patient’s threatening condition is a difficult process. when the first pathologist told me that she life following the sentinel event: the abnor- On the one hand, the patient-physician thought I may have lobular neoplasia as mal mammogram. These breast centers fo- relationship is new. The surgeon may be well as DCIS, I was devastated. The termi- cus on efficient procedures to manage the well informed and rational, but the patient nology Neoplasia versus Carcinoma in situ disease including 23 hour turnaround times needs time to process the information at did not affect my anxiety, fear and avoid- and early discharge to home after major a snails’ pace. I dare say “there is no rush, ant response in the form of denial. When procedures such as mastectomies. Public where eagles dare”. However, the average the second expert opinion also reiterated response to the myriad needs of breast can- early breast cancer patient is beset with the same pathological diagnosis, I realized cer patients include; the development of opinions, options and most of all fear. On that clinical medicine has always been an activist groups, survivor groups, resource an average, a patient will choose radical inexact science because there are so many groups and multiple other groups to sup- surgery because it is the path of least resis- human variables. However, if two indepen- port the needs of women who are under- tance. The surgeon is happy, the oncologist dent pathologists suspect the same diag- going the uncertainties of the early breast is happy, her family is happy, thus propagat- nosis, the likelihood that it exists, exponen- cancer diagnosis and management.
18 • The Maryland familydoctor / SUMMER 2011 calendar
Significance of Early Breast Cancer Manage- ment in Patient Centered Medical Homes Health care reform proposes the development of patient centered medical homes, geared to early breast cancer, chronic disease and preventive care.5 The devel- opment of patient centered medical homes, and reorga- nization of primary care to advanced forms of healthcare delivery is central to modernizing the management of modern diseases including early breast cancers.6 Newer 2011 August 18-20 Southeastern Family Medicine Forum health care delivery models will allow teams of multiple Grand Hotel caregivers (who already know the patient) to discuss Natchez, MI unique perspectives of the same disease with the pa- tient. The physician leader in a medical home then ties September 8 Maryland Public Health Association Annual Meeting Federal, State and Local Approaches to together all the different perspectives leading to a de- Addressing Health Disparities tailed and comprehensive discussion of the nuances of Morgan State University early breast cancer decisions followed by shared decision Baltimore making with the patient. In a patient centered model of 2012 care, health education and engagement of the patient as February 25 MAFP Winter Regional Conference a participant in shared decision making would be central Hunt Valley Resort to the management of early breast cancers. Thus, when Hunt Valley developing new early breast cancer management con- June 21-23 MAFP Annual CME Assembly & Trade Show sensus guidelines, it is important to bring in the patient, Turf Valley Resort within the context of their patient centered medical Ellicott City home into the discussion. Patient centered healthcare is AAFP Scientific Assembly Schedule respectful of and responsive to individual patient pref- 2011 Sept. 14-17 Orlando 2017 Oct. 18-22 Phoenix erences, needs, and values, ensuring that patient val- 2012 Oct. 17-21 Philadelphia 2018 Sept. 26-30 Boston 7,8 ues guide all clinical decisions. Extensions of medical 2013 Sept. 25-29 San Diego 2019 Oct. 23-27 Las Vegas homes would engage surgical and medical specialists 2014 Oct. 22–26 Washington D.C. 2020 Oct. 14-18 Chicago into discussion of paradigms, ensuring a collective de- 2015 Sept. 30 - Oct. 4 Denver 2021 Sept. 29 - Oct. 3 San Francisco cision that is timely, efficient and equitable and makes 2016 Sept. 21-25 Orlando the patient a true participant in her health care. Modern medicine brings unique dilemmas that deserve modern CME Author Disclosure Statements methods of management and not the reinvention of The authors of CME articles in this publication, except for any listed be- low, disclose that neither they nor any member of their immediate families even more efficient breast centers which remain a relic have a significant financial interest in or affiliation with any commercial sup- of the old silo style medical management. Centering the porter of this educational activity and/or with the manufacturers of com- patient in health care reform remains the best manage- mercial products and/or providers of any commercial services discussed in ment of modern diseases. ■ this educational material. MAFP receives no commercial support to offset costs in the production Dr. Khanna is Associate Professor, Family and Community of The Maryland Family Doctor Publication. Medicine, University of Maryland School of Medicine in Baltimore. She is MAFP Public Health Committee Chair. Correction The correct answer to quiz question #5 (Spring, 2010 edition p. 23) is D Note: references for this article are posted at www.mdafp.org; (not C as indicated on p. 30). We regret the error. publications and news tab. CME questions for this article ap- Next Edition pear on the Journal Quiz at www.mdafp.org; CME Quiz tab; □ Focus on Women’s Health Summer, 2011. □ MD-Tech: More to Assist Maryland Family Physicians with EMR Options
The Maryland familydoctor / SUMMER 2011 • 19 Ovarian Cancer: Are Physicians Under-Screening for a Silent Killer?
for stage IV (distant metastases) is less than breast and ovarian cancers among first and 10 percent. With such survival rates, it is no second-degree relatives, one first-degree surprise that although only 25,000 women relative with bilateral breast cancer, two or (one in 3,000) receive an ovarian cancer more first or second decree relatives with diagnosis per year; 14,000 die during that ovarian cancer, one first or second-degree same year. This translates to a diagnosis relative with both breast and ovarian can- of ovarian cancer equating to death in less cers or breast cancer in a male relative. Al- than 5 years for most patients. though these screening criteria are specific Ovarian cancer can occur at any age, and evidence based, without a high index but is most common in women greater of suspicion, they are not always investigat- Merrell R. Sami, M.D. than 50 years of age. Incidence in women ed at acute visits due to vague abdominal It seems that every once in a while ovar- less than 50 is about 7 per 100,000 women. symptoms. ian cancer makes an appearance on TV It only accounts for 3% of cancers in wom- With these risk factors in mind, it is im- when someone famous is diagnosed and en, but it is the fifth most common cause portant to note that most women diag- they decide to increase awareness. Howev- of cancer death after lung, breast, colorec- nosed with ovarian cancer have no family er, it is the physician’s personal encounter tal and pancreatic cancer. We have rou- history and no known etiology. Ovarian with ovarian cancer patients that make it tine screening for 2 out of the 5 top cancer cancer is not a hard disease to diagnose, more real. In either scenario, a familiar story killers of women, colon and breast cancer. once it is suspected. Pelvic ultrasound is follows: the patient presents with vague USPSTF, based on grade A evidence, rec- 95% sensitive and 91% specific for ovarian complaints of abdominal pain, bloating, ommends against routine screening for cancer. CA 125 that is abnormal is 95% spe- and gastrointestinal and/or urinary symp- ovarian cancer. There are guidelines for cific and 78.7% sensitive. toms. The physical exam, which includes a who should be offered screening based on As family physicians who care for all genitourinary component, is usually nega- risk factors. aspects of a patient’s life, it is important tive. These initial visits may be acute visits, Risk factors associated with ovarian can- to recognize associated factors which may not necessarily with the primary care physi- cer include: delayed childbearing, early protect against ovarian cancer. These in- cian. Labs and imaging are usually not in- menarche, endometriosis, estrogen re- clude breastfeeding for 18 months or more, dicated for the initial work up of such vague placement therapy for more than five years, early menopause, multiparty (decreases symptoms given the myriads of common high fat diet, obesity, smoking, late meno- with each pregnancy), hysterectomy, tubal benign conditions that top the list of dif- pause, low parity and family history. With ligations, late menarche, low-fat diet, oral ferential diagnosis such as gastroenteritis, regard to family history, routine screening contraceptive use. Other loosely associated constipation, menstrual changes or meno- with CA 125 (Cancer Antigen 125), pelvic protective modifiable risk factors include pause. After common conditions have U/S or genetic testing is recommended for increased daily fiber, use of carotene, vita- been worked up and ruled out, months the following women: Ashkenazi Jewish min C, vitamin E, unsaturated fatty acids have passed without the true diagnosis. women with one first degree relative with and increased physical activity. Finally, a transvaginal ultrasound or CAT breast or ovarian cancer or two second-de- Ovarian cancer stems from three kinds scan is done and reveals an ovarian mass. gree relatives on the same side of the family of cells, 85-95% from epithelial cells, 5 to 8 During the de-bulking surgery that usually with breast or ovarian cancer. For all other percent from stromal cells, and 3 to 5 per- is used to treat the patient, staging is estab- women, carriers of BRCA1 or BRCA 2 genes, cent from germ cells. Epithelial cell tumors lished, with the most common stages being two first-degree relatives with breast can- are the most common because they occur III or IV. The five-year survival rate for stage cer, one of whom was diagnosed by age 50, in women above age 50. Of epithelial cells, III (peritoneal implants and/or retroperito- three or more first or second-degree rela- serous tumors are the most common with neal or inguinal lymph nodes) is 20% and tives with breast cancer, a combination of about 40% of all ovarian cancers. Stromal
20 • The Maryland familydoctor / SUMMER 2011 for appropriate early testing if there is not a As family physicians who care for all aspects of a high index of suspicion. It is important to keep in mind the vast difference in survival patient’s life, it is important to recognize associated between diagnosis at early stages and later factors which may protect against ovarian cancer. stages. This may be motivation for diligent screening for risk factors for ovarian cancer cells tumors can occur in any age and germ to 80 %. Finally as mentioned earlier, Stage that may lead to early diagnosis and im- cell tumors usually occur in patients young- III is only 20% and stage IV is less than 10% proved prognosis. ■ er than one year and in those 15-19 years of survival at 5 years from diagnosis. age. Germ cell tumors are the most highly According to the evidence, physicians Dr. Sami, resident member of the MAFP malignant. Ovarian cancer spreads locally are not under-screening for ovarian can- Editorial Board, begins her 3rd year at to opposite ovary, the uterus and then cer. Routine widespread screening has not the Franklin Square Hospital Center Fam- other peritoneal areas. Distant metastases, proven to decrease mortality and may lead ily Medicine Residency in Baltimore. She although uncommon, occur in the liver, to healthy women undergoing unneces- writes this, her 4th consecutive edition ar- lungs, pleura, adrenal glands and spleen. sary surgery and developing anxiety. How- ticle for The Maryland Family Doctor. Survival rate is determined by stage and ever, physicians may be under- suspecting histology of the tumors. Low grade tumors ovarian cancer because 14,000 women are Note: The author indicates use of the ACOG with cells of low malignancy have better dying every year. Given the vague pre- Bulletin on Ovarian Cancer Screening Rec- prognosis than high grade tumors. Stage senting symptoms, a long list of common ommendations in preparation for this article. I ovarian cancer (limited to the ovaries) has conditions among the differential diagno- CME questions for this article appear on the a 90% 5-year survival rate. Stage II (pelvic sis, and pressure for efficiency, especially Journal Quiz at www.mdafp.org; CME Quiz extension) has a five-year survival rate of 60 in acute visits, it is easy to miss the chance tab; Summer, 2011.
journal CME quiz
Articles ONLINE COMPLETION AND SUBMISSION OF MAFP JOURNAL CME QUIZZES AT WWW.MDAFP.ORG 1. The Future of Integrated Delivery Systems: The process for completion and submission of MAFP Journal CME Primary Care and Public Health Partnerships quizzes is fully automated. Read the CME articles in this edition either in Care Coordination p. 12 from this mailed version or the online version. Each “live” version is 2. Adverse Event Reporting p. 15 posted online at the Publications and News tab. If you read the articles 3. Early Breast Cancer and Modern Healthcare p. 17 online, a link on the last CME article page will take you to the CME quiz 4. Ovarian Cancer: Are Physicians Under- page. If you read the articles on your hard copy, access the quiz at the Screening for a Silent Killer? p. 20 CME Quiz tab. The Maryland Family Doctor has been reviewed and is Once on the CME Quiz page (where quizzes for each “live” edition acceptable for Prescribed credits by the American Acad- are posted), follow the directions. Upon sending, you will receive an emy of Family Physicians (AAFP). This Summer, 2011 edi- immediate confirmation that your quiz has been received by MAFP. tion (vol. 48, No. 1) is approved for 2.5 Prescribed credits. MAFP will report the credit to AAFP for posting on your member record Credit may be claimed for two years from the date of this at www.aafp.org. Those unable to complete/send the quiz using the edition (expiring July 30, 2013). AAFP Prescribed credit is automated system will be able to print the quiz for manual comple- accepted by the American Medical Association (AMA) as tion then sending to MAFP. Quiz answers for each edition are posted at equivalent to AMA PRA Category 1 credit toward the AMA www.mdafp.org; Publications and News tab. Physicians Recognition Award. Questions? Contact the MAFP office at [email protected] or 410-747-1980.
The Maryland familydoctor / SUMMER 2011 • 21 Electronic Medical Records – The Path Forward for Maryland Physicians The transition to EHRs reduced to six, with only one clinical deci- can be complicated. sion support rule required to be included. Physicians currently using To encourage physicians to meet the final paper health records will meaningful use requirements, HITECH em- ploys a series of incentives, penalties, and want to modify workflows new programs to integrate and upgrade to leverage technology. medical record technology. Successful implementation will result in the meaningful Incentives to Adopt use of an EHR system, The HITECH Act attempts to expand the Gene M. Ransom, III use of HIT by appropriating funds for imple- which in turn will help drive Physicians face significant challenges mentation through the Medicaid and Medi- better outcomes. as the federal government implements a care programs. Physicians can select one of framework for America’s health care sys- two routes to obtain incentives, participat- While medical and physician societies tem to move to the adoption of electronic ing with either the Medicaid incentive pro- around the country have applauded the health medical records. The legal founda- gram or the Medicare incentive program. A Act’s efforts to expand HIT, many are calling tion to achieve the lofty implementation physician cannot enter into both programs. for prudence in the rush to implement. The goals germinates from the Health Informa- The charts below outline the different pay- biggest challenge is that there are no com- tion Technology for Economic and Clinical ment incentives under each program. mon standards for platforms or programs. Health (HITECH) Act. The HITECH Act was Stimulus Medicare incentives, per phyician enacted as part of the stimulus bill, or the Pay-Out Year American Recovery and Reinvestment Act Starting of 2009. In Maryland, the physician com- Year 2011 2012 2013 2014 2015 2016 Totals munity and government are reacting to the 2011 $18,000 $12,000 $8,000 $4,000 $2,000 $0 $44,000 challenge and are working to achieve the 2012 $18,000 $12,000 $8,000 $4,000 $2,000 $44,000 difficult objectives of full implementation and meaningful use of electronic medical 2013 $15,000 $12,000 $8,000 $4,000 $39,000 records by 2015. 2014 $12,000 $8,000 $4,000 $24,000 The principal goal of HITECH is to pro- 2015 $0 $0 $0 mote the adoption and meaningful use of health information technology (HIT). MEDICAID INCENTIVE PROGRAM If physicians were to go out now and try to Meaningful use regulation contains the Incentives may not exceed 85 percent incorporate HIT into their practices, they rules physicians and other health care of net allowable costs (as determined would find themselves choosing from liter- entities will have to adhere to in order by HHS) for certified EHR technology, ally a hundred options. In addition, the chal- support, and training, subject to to receive payment for the adoption of caps:$25,000 in the first year lenges are exacerbated for small practices electronic health records (EHR) and avoid (six physicians or fewer). The average esti- $10,000 for the second and subsequent penalties for non-use. In the Final Rule, the years mated cost to implement HIT in a small prac- Centers for Medicare & Medicaid Services No payments for more than five years or tice is estimated to be between $50,000 and (CMS) has lowered the number of man- after 2021 (later than Medicare incentive $80,000. According to the Act, the maximum datory core requirements to 15, from the program) incentive allowed for a practice is $44,000. original 25 proposed. The number of re- Pediatricians limited to 2/3 of these Nearly 90 percent of Maryland practices are quired clinical quality measures has been amounts defined as small practices.
22 • The Maryland familydoctor / SUMMER 2011 Penalties for Failure to Adopt care community to appropriately and securely The legislation that created private incen- The HITECH Act combines the incentive share data, facilitate and integrate care, create tives also authorized the MHCC to establish payments with penalties for doctors who efficiencies, and improve outcomes.” a Management Services Organization (MSO) participate with Medicare but fail to adopt As well as creating an exchange, the state designation to offer providers access to by 2015 an EHR system that meets the mean- government realized that physicians would qualified vendors to address the challenges ingful use standard. A physician who fails to need assistance working through the myriad associated with the adoption of electronic meet that standard will face the following federal regulations and programs related to medical records. The state MSO designation cuts in their Medicare reimbursement: one adoption. The HITECH Act addressed that is a state seal of approval and will ensure that percent reduction in 2015, two percent re- concern by creating RECs. The extension the product will qualify for federal incentives duction in 2016, and three percent reduction centers for health care technology are mod- and meet the meaningful use standard. The in 2017 and thereafter. eled after the extension centers used to help state-designated MSOs will be represented MedChi expressed concern about the farmers take advantage of federal and state by hospitals, health care technology com- penalties and forwarded a resolution to the agriculture programs. In Maryland, MedChi panies, and other health care organizations. American Medical Association (AMA) calling has partnered with CRISP to assist Maryland USEFUL HIT Website resources for Maryland for that organization to press for the elimina- physicians to adopt EHRs and achieve mean- Physicians tion of or a delay in the penalties that have ingful use. CRISP and MedChi were recently www.crisphealth.org – Chesapeake Regional been established in the HITECH Act for non- selected to serve as Maryland’s REC by the Information System for our Patients (CRISP) adoption of EHR and e-prescribing within Office of the National Coordinator for Health www.medchi.org – MedChi, The Maryland the mandated timelines. The resolution Information Technology. State Medical Society passed and became AMA policy. To date, The REC will assist physicians by provid- http://mhcc.maryland.gov/ – The Maryland the AMA has not been successful in repeal- ing seminars, granting technical assistance, Health Care Commission ing the penalties and the very real threat of and fostering a cooperative and collaborative reduced reimbursements looms as the pen- environment, all of which is designed to help Conclusion alties begin to take effect in four short years. practitioners benefit the most from EHRs while Physicians face a complex array of eco- achieving meaningful use. The transition to nomic challenges, rules and regulations as Programs to Foster Adoption EHRs can be complicated. Physicians currently they move forward to adopt electronic medi- The government plan to implement using paper health records will want to modify cal records. That complexity is multiplied by electronic medical records is more com- workflows to leverage technology. Successful significant financial implications and decisions plex than providing monetary incentives. implementation will result in the meaningful that must be made when attempting to take The HITECH Act offered grants to support use of an EHR system, which in turn will help advantage of the state and federal incentives implementation through of the creation of drive better outcomes. As a partner to CRISP relating to adoption and achieving meaning- Health Information Exchanges and regional and the REC, MedChi will provide education ful use. As physicians move forward and make extension centers (RECs). Every state had and outreach to increase the number of physi- these decisions, they should do so in a delibera- the opportunity to apply for funding to cre- cians who are meaningful users.* tive, cautious manner—educating themselves ate both of these entities to encourage and before they make a major investment. ■ create an infrastructure for adoption. State Incentives and Actions The Health Information Exchange in The Maryland Health Care Commission Gene M. Ransom, III, is CEO of MedChi, The Maryland was awarded to the Chesapeake (MHCC) worked closely with MedChi and Maryland State Medical Society. You may Regional Information System for our Patients other state agencies to develop incentives contact him at MedChi at 1.800.492.1056 or (CRISP). CRISP received federal and state to encourage adoption. In 2009, the Mary- [email protected]. funding to create an exchange. The Maryland land General Assembly passed legislation Health Information Exchange’s mission is “to (Maryland House Bill 706) to require private *The MAFP Board of Directors, at its meeting on advance the health and wellness of Maryland- insurers to provide incentives for the adop- May 1, 2011 voted to partner with MedChi on its ers by deploying health information technology tion of electronic medical records. The de- Network Services Initiative (free service) to assist solutions adopted through cooperation and col- tails of those incentives will to be worked MAFP members in practice transition to EHR. More laboration. We will enable the Maryland health out through the regulatory process by 2011. information on this initiative is forthcoming.
The Maryland familydoctor / SUMMER 2011 • 23 MD Tech
Use Your EMR Meaningfully: Streamline the Team!
cal News read, “Medicare quality bonuses MU as a potential bonus. Your practice elude nearly half of reporting doctors.” should be confident that it will remain sol- What is rarely recognized is that MU also vent even if you purchase an EMR, but don’t has associated costs. Data collection to sat- receive the incentive payments. isfy the various administrative and clinical So that brings me to my original con- quality measures may be substantial for tention about earning you an additional some practices. In the Jan/Feb 2011 Fam- $200,000 through the use of health infor- ily Practice Management, a study reported mation technology. Put to good use, I be- “The major expenses related to participat- lieve that information technology should ing in a quality-reporting program includ- allow the average practice to streamline its Matthew Hahn, M.D. ed personnel time for planning, training, operations enough to cut at least one staff. What if I told you that there was a way that your EMR could dependably make you an extra $200,000 over the next 5 years, far more than the $44,000 that the federal government may pay you for its Meaning- ful Use (MU) EMR incentive? In this column, I will describe just how most practices should be able to do this. First, however, I’ll offer some food for thought regarding Meaningful Use (MU). More to the point, I think it is important that practices consider the potential costs, as well as the possible risks, of MU. Many phy- sicians are still hesitant to purchase an EMR, with excessive and unpredictable costs cited as one of the primary reasons. MU incentives, as they are being characterized, will offset EMR costs to the point that many practices that could not previously afford an registry maintenance, visit coding, data Let’s do the math...if an average employee EMR, will now be able to get in the game. gathering and entry, and modification of costs a practice a total of $40,000 per year, For some, $44,000 may not be enough. electronic systems. Costs per full-time- than streamlining by just one employee A recent study of 26 primary care practic- equivalent clinician varied widely, from should earn your practice $200,000 over es estimated “the total per-physician cost $133 to $11,100 during program implemen- five years. The average primary care prac- involved in implementing an EHR system tation phases and from $58 to $4,329 dur- tice employs between 3 and 7 employees through 60 days after launch, based on a ing maintenance phases.” per physician. Those staff typically are five-physician practice, averaged $32,409— Taken together, these issues should employed as nursing personnel, front desk or $46,659 if maintenance costs for a year make anyone who intends to pursue MU in- staff, medical records personnel, coding after launch were included.” (Health Aff centives wary. I think the best way to char- and billing staff, and other administrative March 2011 vol. 30 no. 3 481-489). Further, acterize the issue currently is that it would positions. Medicare’s record regarding quality bonus- be risky to purchase an EMR counting solely How can an EMR help streamline a typi- es has been spotty, at best. A recent head- on MU incentives to make your purchase af- cal practice? The most obvious place is in line from the May 9, 2011 American Medi- fordable. A wiser strategy might be to view medical records. With almost any EMR, the
24 • The Maryland familydoctor / SUMMER 2011 We don’t have traditional physicians began doing the coding! all the coding and at times even pick up the front desk staff or Refills consume a good deal of time telephone! The patients are often shocked traditional nursing staff. and effort. In my old paper practice, a refill to hear our voices but get over their shock We have re-imagined request began as a call to the front desk when they find that their issue is handled where a series of paper notes and multiple immediately. and re-worked all of the individuals could be involved for approval. My estimate is that HIT has enabled our usual staff positions, now Today, for an e-refill, a note comes directly practice to reduce the need for 1-2 staff per maintaining an extremely from the pharmacy into my EMR in-box, doctor (and we have two doctors). Over five streamlined model. and with a few clicks, I refill the medica- years, therefore, we are saving an estimated tion. No other staff is involved. I make one $400,000 to $800,000! Now that’s meaning- need for medical records staff is reduced. entry, and the medication list automati- ful use you can take to the bank! ■ Another place for potential savings is cod- cally updates. ing and billing. Prior to using an EMR, cod- My practice employs about 1.3 staff per Dr. Hahn is co-owner of Hahn and Nelson ing and billing was a relative mystery to me. physician. We don’t have traditional front Family Medicine in Hancock, Maryland. A But our EMR automatically links every diag- desk staff or traditional nursing staff. We MAFP Western District Director and mem- nosis to an ICD-9 code. The EMR also helps have re-imagined and re-worked all of the ber of MAFP’s new Technology Committee, us with our level of visit coding. In fact, it usual staff positions, now maintaining an he writes this, the 2nd of a series of articles became evident to us that, for the great extremely streamlined model. Our nursing which will focus on various aspects of tech- majority of patient visits, the only informa- staff works the front desk, answers most nology and practice automation to assist tion needed to create a claim was the ICD- phone calls, processes patient payments, readers in that important aspect of medical 9 code and the level of visit code. So, our and rooms the patients. The physicians do practice management.
Are you looking for a satisfying career and a life outside of work? To discuss available positions please contact Donna Maskell, EAnrejo yyoub olotohktiongt hfoer fau sllaetsistfyaitnPg actaierenetrF airnsdt.a life outside of work? To ddisocnunsas.m avaasiklaeblll@e poastiietinotnfsir sint. cVoirmginoira(, 8p0le4)a8s2e2 c-4o4n4ta9.ctW Eleeawniollra Drorawndgye, Enjoy both to the fullest at Patient First. [email protected] otri m(8e04w) i8t2h2o-n44e7o8f. oFuorr pMhyasryiclaiannds atond EFonunjdoeyd abndoltehd btyoa pthyesic ifaun,llPeatsietn taFtir sPt haastibeeennta Freirgisont.al healthcare leader in Maryland the opportunity for you to spend time with one of our physicians to AFourend eydoaun dloleodkbyinagp hfyosirc ian s, PaatiesnftyFiinrsgt h casabreeeen ar raegniodnal hliefaelt hocaurtesleidadee roinf Mwaoryrlakn?d TPoe ndenisxcypluvesarsine ianv,c paelielafaibrssleet hc paoonstdaitchioto nDwso inPnn aVat iMregnaintsiFkaie,r lspl, tldeooafnfsenera sc.moeanastcakhecltpl@ Ehlypesaaitncieoinartn fDirasotnw.codmy, and Virginia since 1981. Patient First has 30 full-service neighborhood medical centers where our or (8e0x4p) 8e2r2ie-4n4c4e9.f iWrseth wainlld ahrroawngPea thtiee notpFpiorrsttuonfiftey rfsore yaocuh top hsypseincdia tnimaen with and Virginia since 1981. Patient First has 30 full-service neighborhood medical centers where our [email protected] or (804) 822-4478. For Maryland and pFEohnuysnjidoceiaydn asbnpdor oltevhdid betypo ari mpthayresyica ifnaudn,lu lPregaetsinetn cta aFrtier sP3t 6ha5astd iabeyesennet aa cF rheirygeisoantr..alI nhefacltth,coavreer l2e0a0deprh iyns iMcianryslahnadve Poennene osxfyc olveuaprn tpiaoh,n ypasleilcacisaaenr esc eotorn. teaxcpt eDroiennncae M fiarsstkhealln, do hnonwa. mPatsikeenltl@ Fiprsatt ioefnftefirrs te.caocmh cahnods Veinrgainciar seienrcwe i1t9h8P1a. t iPeanttieFnirts tF.irsWt ehaasr e34c ufrurlel-nstelyrvliocoek ninegigfhobromrhooreodF umlleadnicdaPl acretn-Tteimrse wInhterren aolur oprh (y8s0i4c)i a8n22 a-n44 e4x9c. Wepeti owniall la crraarnegeer. the opportunity for you to spend time with apFonhudysnFidcaeimadn ialsyn pMdr oleevddidi cbeiyn p eari Pmphhayyrssyii ccaiianandns ,u PirngaetViniertng ctin aFiriaer,s 3tM 6ha5ar sdy labayensed nea aanc drhe Pygeionannr.a s lyI nhlv efaanclittah, .coavAreetr P l2ea0at0ide epnrht iyFnsi riMsctia, enryasl cahhnadve one of our physicians to experience firsthand how Patient First offers each pcahnoyds Viecinriag anin ceianr jseoienyrsc w:e i1t9h8 P1a. t iPeantti eFnirts tF.i r sWt eh aasr e3 4c ufrurlel-nstelyrv liocoek ninegig fhobr omrhooreo dF umlle adnicda Pl acretn-Tteimrse w Inhterren aolu r physician an exceptional career. apnhdys Ficaimanilsy pMroevdidicein per iPmhayrsyi caiannds u irng eVnirtg cinairae, 3M6a5r dylaaynsd e aancdh Pyenanr. s yInlv faancita, .o vAetr P 2a0t0ie pnht yFsirisctia, enas chha ve • Unique Compensation • Malpractice Insurance Coverage p•chUoynsieqcniua ean Cceaonrmjeoepyres nw: siathti oPnatient First. We are currently• lMooaklipnrga cfotirc emIonrseu Fraunllc aenCdo Pvaerrta-Tgieme Internal • Flexible Schedules • Team-Oriented Workplace •anFdle FxaibmleilyS Mchediucliense Physicians in Virginia, Marylan•dT aenadm P-OerninesnytelvdanWiao.r kAptl aPcaetient First, each • Unique Compensation • Malpractice Insurance Coverage • Personalized Benefits Packages • Career Advancement Opportunities •phPyesriscoianna leiznejodyBse: nefits Packages • Career Advancement Opportunities • Flexible Schedules • Team-Oriented Workplace • Generous Vacation & CME Allowances • UGneinqeureo uCsoVmapceantisoanti&onC ME Allowances • Malpractice Insurance Coverage • Personalized Benefits Packages • Career Advancement Opportunities • Flexible Schedules • Team-Oriented Workplace • Generous Vacation & CME Allowances • Personalized Benefits Packages • Career Advancement Opportunities • Generous Vacation & CME Allowances The Maryland familydoctor / SUMMER 2011 • 25 members
News For and About MAFP Members HIPAA Changes Members Need to Know If you haven’t already heard of it or think HIPAA-mandated upgrades. If you are not As of May 17, 2011, it is only an information technology issue, using the current version of the vender’s CMS reports that all now is a good time to learn a bit about software, you may be required to upgrade the upcoming change to the HIPAA 5010 to the newest version. Medicare contractors transaction standards. The time to change The good news is that as soon as your are ready to conduct to 5010 is now. If you wait until the end of practice management software vendor 5010 transactions and 2011, you risk not being paid or having to completes their internal testing of their have processed over pay a clearinghouse to convert your trans- systems and provides your upgrade, you actions in 2012. can begin testing with your Medicare con- 1500 claims in that tractor and/or claims clearinghouse. Most format already. What is 5010? private payers will not require individual Under HIPAA, covered entities must practices to test since claims typically pass deductible health plans and plans that will conduct electronic transactions such as through a clearinghouse but your staff be required to cover preventive services claims submission and eligibility inquiries should verify this for payers most common under ACA, verification of eligibility and in a standard electronic format. The cur- to your practice. Once you successfully benefits prior to service is more important rent standard is 4010a. As of 01/01/2012, transmit and receive test transactions, you than ever. Did you know that your staff can all transactions must be transmitted us- can switch to 5010 and have no concerns check eligibility with the payer electroni- ing an updated standard, 5010. The 5010 about compliance on 01/01/2012. You do cally in batches or by individual patient transition is also an important first step to not have to wait until 01/01/2012 to start before the patient presents to the office? preparing your practice for the 10/01/2013 conducting transactions in 5010 format. If you are not currently taking advantage change from ICD-9-CM diagnosis codes to Your staff will also need to be trained on of electronic eligibility inquiry, now is a ICD-10-CM. The 5010 format accommo- any changes to the information that must good time to consider adding this function. dates both ICD-9 and ICD-10 by including be entered into the practice management Other considerations are electronic remit- an indicator that identifies which code set system. There are a large number of chang- tance advice (some systems also include an is being transmitted. es in what data and in which order data is automatic posting to patient accounts) and As of May 17, 2011, CMS reports that all transmitted under 5010. These changes claims status inquiries. Medicare contractors are ready to conduct may require changes to your practice in- 5010 transactions and have processed over formation that goes out on claims and also Who Can Help? 1500 claims in that format already. CMS is to the patient, dependant, other insurance, Besides the support staff of your prac- also conducting periodic surveys of ven- and encounter information. Your software tice management system vendor, your dors, payers, physicians, and other provid- vendor may provide information or training Medicare Administrative Contractor (MAC) ers to track transition progress. sessions on these changes. and claims clearinghouse can provide you with information and assistance. If your What does this mean to my What Should I do to Prepare staff will be responsible for overseeing the practice? for 5010? change to 5010, please be sure they are The system that you use to electronical- If you or your staff have not already be- aware of these resources. ly submit and receive information will need gun working with your software vendor The Centers for Medicare & Medicaid to be updated and you will need to test the and any clearinghouses that receive your Services (CMS) will be providing informa- system’s ability to submit and receive 5010 electronic transmissions, it is time to do so tion directly and through the MAC’s on transactions before the compliance date of now. Now may also be the time to consider a regular basis in 2011. CMS calls include 01/01/2012. This upgrade may be included adding electronic transactions that you are question and answer time so that persons in your system maintenance/support fees not currently utilizing. With the increas- unfamiliar with the topics or with specific if your contract with the vendor includes ing number of patients who have high- concerns can get additional information.
26 • The Maryland familydoctor / SUMMER 2011 A Vibrant MAFP Delegation to AAFP’s 2011 ALF/NCSC! average cost for similar Medicare beneficia- ries in the same geographic area. Every ACO must include the participation of a group of primary care physicians able to care for at least 5000 Medicare recipients. ACO’s can also include specialists, hospitals, pharmacy benefit management organizations and any other entity that can contribute to control- ling health care costs. Demonstration proj- ects with ACO’s have shown them capable of decreasing hospital admissions by 20% and emergency department visits by 40%, although not all demonstration ACO’s were successful in doing so. Should your group (l-r) Dr. Danielle Jean (NCSC/IMG), Dr. Randy Angell (NCSC/GLBT), Dr. Eva Hersh (MAFP VP and join up with an ACO? AAFP experts advised Education Chair), Dr. Shana Ntiri (NCSC/W), Dr. Yvette Oquendo-Berruz (MAFP P-Elect), Dr. Kisha that this decision should be made only after Davis (NCSC/NP), Esther Rae Barr (Exec), Dr. Jocelyn Hines (NCSC/M). careful analysis of the profit and loss-sharing It was a pleasure to be part of Maryland’s organizations. All versions seem include at- model of the specific ACO. full 8-person delegation to the 2012 AAFP An- tention to patient education and preventive We know that health care reform will mean nual Leadership Forum (ALF) combined with health as well as the ability to measure success changes in health care payment. What type of the AAFP National Congress of Special Con- rates in various health care benchmarks. Over physician payment will work best? AAFP cur- stituencies (NCSC). Our chapter’s 5-mem- time the use of electronic medical records rently favors “blended payment”, meaning a ber NCSC delegation (one each to represent (EMR) has become recognized as an integral combination of fee for service, capitation to Women, Minorities, New Physicians, Interna- part of the PCMH, in part because EMR’s allow cover non-visit patient care services, and qual- tional Medical Gratuate and Gay/Lesbian/Bi- for accurate measurement of benchmarks in ity of care incentives. sexual/Transgender interests and issues) was a practice’s patient population. The capacity As with most state chapters, building up young, bright and friendly with a great sense and willingness to communicate by secure the workforce of family physicians is a focus of collective humor. Their post-residency ex- email with patients is also part of the PCMH of the AAFP. Tactics range from lobbying for perience ranged from 1 to 3 years. For the concept. While many chapter representatives support for expansion of family practice resi- ALF delegation, MAFP President-Elect Yvette encouraged all practices to move towards the dencies to mentoring prospective new FP’s Oquendo and me (25-year practice veterans, PCMH model of patient management, some at the medical school, college and even high long-term Board members and FP activists) cautioned that it might be wisest to wait to school levels. accompanied by our longtime chapter exec invest significant funds to create this practice ALF this year showed us how involved the Esther Barr, it was inspiring and fun to hang model until it is certain that higher reimburse- leadership of our Academy is in the vital dis- out with the next generation. ment will follow for participating practices. cussions now in progress on health care deliv- While the ALF presentations were wide- Federal health care reform, including pri- ery and payment. The 2011 ALF also reminded ranging, the top themes this year were the mary care-relevant provisions of the Afford- us how many key decisions are still in the dis- primary care medical home, federal health able Care Act such as payment reform and cussion stage at the federal level. Stay tuned! care reform including primary care-relevant Accountable Care Organizations (ACO’s), Eva S. Hersh M.D. provisions of the Affordable Care Act such as were discussed in several presentations and payment reform and Accountable Care Orga- plenary sessions. ACO’s are organizations Reflections from Maryland nizations, and building up the workforce of that agree to accept partial financial risk for Chapter 2011 NCSC Delegates Family Practice physicians. health care costs of Medicare recipients in New Physicians: The 2011 National Con- The patient-centered medical home exchange for increased payment if expendi- ference on Special Constituencies was lively (PCMH) is defined in various ways by different tures for the assigned group are less than the continued on page 28
The Maryland familydoctor / SUMMER 2011 • 27 with debate of timely issues relevant to Family calls on the AAFP to formally withdraw its rep- New Physician caucus at the 2012 NCSC. Medicine. For the 2nd consecutive year, I rep- resentative from the RUC and to create a task Please bring your issues or concerns to resented our chapter’s new physicians (NP). force to identify alternative means of valuing your NCSC delegates; we would love to hear Several resolutions came out of NP caucus primary care services. The resolution also asks from you. Each constituency has a listserv including urging the AAFP to create an online the AAFP to make this task force’s recommen- and we invite you to join the e-mail discussion procedure log similar to the current CME log dations available to CMS and other payers. All groups by signing up at http://members.aafp. to help facilitate privileging. I co-authored a who testified agreed that the RUC underval- org/discussionlist. resolution to increase business management ues primary care; however debate centered Kisha N. Davis, M.D. education and to create an online community on whether it is better to remain a part of the through AAFP Connection. system to try and change it or make a state- International Medical Graduates: My Jour- Most notably, the NP caucus put forth a ment and withdrawal (Partially taken from ney at NCSC began when I picked up my reg- resolution, which was adopted, urging the AAFP News Now- http://www.aafp.org/online/ istration packet. In my mind I was thinking, ‘I’m AAFP to withdrawal from the Relative Value en/home/publications/news/news-now/inside- going to just watch and observe.’ From the Scale Update Committee (RUC). The RUC aafp/20110511ncscruc.html). Currently the beginning of the conference, everyone kept acts as an expert panel and makes recom- RUC is comprised of representatives from 29 saying, ‘you will catch the bug, and before you mendations to CMS on the relative values of different specialties. AAFP is one of only two know it, you will get involved. I didn’t think CPT codes. However, many family physicians primary care organizations participating on I would but I was wrong! From the opening are convinced those recommendations tend the committee. session and plenary address by former U.S. to undervalue primary care services. The I was honored to be elected New Physician Surgeon General Dr. David Satcher (Physician resolution, which was introduced during the Alternate Delegate to the AAFP Congress of Leadership and Health Care for the Under- Reference Committee on Advocacy hearing, Delegates and will be the Co-Convener for the served) to the variety of breakout sessions,
28 • The Maryland familydoctor / SUMMER 2011 it was all a wonderful experience. I was not ticular interest to me: media relations, nego- leagues from across the country to discuss aware of the many processes it takes to help tiation and how to be an advocate. Over the the many issues that are confronting Family improve our practice as family physicians. I was next few days, I met so many great family docs Medicine. Serving as the Maryland Chapter so excited to immerse myself with colleagues, who are engaged in a wide variety of personal Women’s Delegate, I worked with family to be part of a process that helps shape pa- and professional activities. Since leaving resi- physicians whose practices incorporate the tient care for family physicians. There were dency, it is one of few opportunities I have had breadth of our specialty to include surgical five special constituencies and I was the Mary- to convene with so many family doctors and it obstetrics, urban adolescent care, emergency land chapter’s International Medical Graduate was inspiring to feel that connection. room and ICU coverage, academics, military (IMG) delegate. Participating in the IMG caucus After the five constituency caucuses met service, international health and more. As and being part of the resolution writing, as well and their proposed resolutions were made varied as our careers in Family Medicine may as to just be able to share concerns with other available, it was evident to me why this type be, there were several universal issues that IMGs and hear of their journeys and accom- of conference is needed. Several of the reso- we recognized as women. The Women’s plishments had an impact on me. I realize now lutions proposed by the caucuses addressed Delegation devised resolutions on optimiz- how much of a difference I can make in the issues that reminded me to think beyond ing the balance between work and personal grand scheme of things as an individual physi- the challenges that are faced in my practice life, physician re-entry into the work force, cian. This experience showed me that it is not environment. In the minority caucus, I co- and preventing the restriction of medication enough to just be a family physician and prac- authored a resolution requesting the AAFP availability. Given the current environment tice medicine. If I want to see improvements, make available both national and local re- of health care reform, particularly payment and change, I need to be involved. At first it sources to facilitate adult literacy. Another reform, our delegation also felt that it was an seemed a little overwhelming with the voting resolution that came out of the minority opportune time to bring to the forefront the process, but there was abundant support from caucus pertained to creating a mobile/elec- issue of gender pay discrepancies for family mentors. Going to NCSC showed me that I can, tronic health record for migrant patients. This physicians. This resolution and several others with my fellow physicians, effect change. resolution caused very interesting debate, written by the Women’s Delegation will be Danielle S. Jean, M.D. and during the testimony, it was clear that presented to the House of Delegates. The en- participants were broadening their ideas on ergy and passion that was generated through Minority Physicians: As a first time attend- the scope of the patient population that this the many conversations and interactions at ee to the AAFP’s 2011 National Conference of policy might impact. the NCSC was powerful. It was an energy Special Constituencies representing the Mi- Jocelyn Hines, M.D. that all of the delegates in attendance agreed nority delegation, I my goal was to find a way must be carried forward and continued here to get involved early on. I knew I was in the Women Physicians: NCSC is a revitaliz- at home in Maryland. right place with early lectures on topics of par- ing opportunity to come together with col- Shana O. Ntiri, MD, MPH
Congratulations to MAFP Members for Special Appointments, Honors, Features, Achievements! William D. Hakkarinen, M.D. of Ti- The University of Maryland Depart- Dr. Robert Michocki - monium was a featured in “Physicians ment of Family and Community Medicine’s the Community Teaching Award Reflect on Four Decades in Family Medi- Division of Medical Student Education be- Mozella Williams, M.D., Assistant Profes- cine” in the February 10, 2011 edition of stowed the following awards to the below sor and Assistant Director of Medical Student Family Practice News Digital Network named instructors at its annual Teachers Education was inducted by the 2011 graduat- (http://www.familypracticenews.com/index. Appreciation Dinner and Workshop, May ing class at the University of Maryland School php?id=2633&cHash=071010&tx_ttnews[tt_ 10, 2011 in Baltimore: of Medicine into the national scholastic honor news]=51940 or www.familypracticenews. Dr. Cyrus Hamidi - society Alpha Omega Alpha. com; search title). the Community Preceptor Teaching Award Richard Colgan, M.D., Associate Professor Francis C. Bruno, M.D. of Columbia Dr. Adaku Orisadelle - and Director of Medical Student Education authored and published “The Girl with the the Resident Teaching Award was awarded a Student Council faculty teach- Fish in Her Pocket,” a children’s book with Dr. Diana Carvajal - ing award by the 2011 graduating class at the illustrations by Alice Webb. the faculty Teaching Award University of Maryland School of Medicine.
The Maryland familydoctor / SUMMER 2011 • 29 members (continued)
AAFP/MAFP CME Requirements for Active/Supporting Members list of advertisers Active and supporting family physician they are not registrants) for the MAFP members must accrue at least 150 hours of CME requirement. AAFP Prescribed and Elective credit within 2. MAFP members who are authors of CME Medical Mutual Insurance each three-year reporting period, of which: articles published in The Maryland Family ...... 2 • At least 75 must be AAFP Prescribed cred- Doctor may claim those credits (accord- Greater Chesapeake it, of which at least six of those being ob- ing to AAFP policy, www.aafp.org) for Hand Specialists...... 9 tained from MAFP sponsored programs the AAFP and MAFP CME requirements. every three years (eg. CME conferences 3. MAFP CME credits will be waived for Washington Open MRI ������������������ 7 and journal CME) those active and supporting members • At least 25 are from live learning activities who relocate to the Maryland Chapter Med Chi Insurance Agency Inc. • Not more than 25 are from enrichment within six months of the end of their ...... 8 activities cycle of AAFP reelection. Merit Medical...... 9 • Not more than 30 are from presentation 4. Active and supporting members who or publication of an original scientific or have not met the chapter requirement Annapolis Billing Services �������� 11 socioeconomic paper pertaining to med- to report at least six chapter credits ical care within their AAFP reelection cycle may Shred-it...... 11 • Not more than 45 are from publication in receive a waiver for that cycle, to be Righttime Medical Care ��������������28 a state or national “refereed” journal made up in the subsequent AAFP Re- • Not more than 15 are from preparation election cycle, by following the process Patient First ...... 25 and presentation noted below: Members are encouraged to review the 1) Member must contact the MAFP Mid-Atlantic Dairy Association ...... 31 document AAFP Continuing Medical Educa- office submitting a request (written, tion Requirements for Members at http:// e-mail, phone call) for a one-time Cryopen ...... 32 www.aafp.org/PreBuilt/cmea_member- waiver for the chapter requirement requirements06.pdf or contact the MAFP indicating a desire to continue office to request a copy, [email protected]. membership, pledging to acquire The AAFP will send Maryland Chapter the credits during the next AAFP members, at regular intervals, correspon- reelection cycle. There is a waiver dence showing each member’s reported request administrative fee of $50. number of hours and reminding members 2) Member must make up waived of what is required. All details about the credits in the subsequent AAFP AAFP/MAFP’s CME records, reporting and reelection cycle (in addition to the information can be obtained through the required six credits). AAFP web site at www.aafp.org/cme, toll 3) If failing to acquire the required free at 800-274-2237 (ask for the CME Re- chapter hours in the subsequent cords Department) or the MAFP at 410-747- AAFP reelection cycle, MAFP will In Memory 1980, [email protected] (e-mail). not accept another waiver request The Maryland Academy of Family Physicians from member. deeply regrets the passing of its members Other Aspects of MAFP CME Policy 5. The MAFP Board of Directors will con- Allen J. Brimmer, M.D (Chevy Chase) The MAFP Board of Directors has approved sider, on individual bases, each member Barton V. Lock, M.D. (Towson) the following: failing to meet the chapter CME require- 1. MAFP members who are faculty mem- ment. The Board will determine the Katherine M. Sanzaro (Hyattsville) bers at MAFP conferences may claim course of action for each member in Memorial contributions have been made in the credits for those sessions (even if this category. ■ their names to the MAFP Foundation. ■
30 • The Maryland familydoctor / SUMMER 2011 Adding Chocolate to Milk Doesn’t Take Away Its Nine Essential Nutrients All milk contains a unique combination of nutrients important for growth and development - including three of the five “nutrients of concern” for which children have inadequate intakes. And, flavored milk accounts for less than 3.5% of added sugar intake in children ages 6-12 and less than 2% in teens. Reasons Why Flavored Milk Matters kids love the taste! Milk provides nutrients essential for good health and kids will drink more when it’s flavored. nine essential nutrients! Flavored milk contains the same nine essential nutrients as white milk - calcium, potassium, phosphorous, protein, vitamins A, D and B12, riboflavin and niacin (niacin equivalents) - and is a healthful alternative to soft drinks. helps kids achieve 3 servings! Drinking low-fat or fat-free white or flavored milk helps kids get the 3 daily servings* of milk recommended by the Dietary Guidelines for Americans. better diet quality! Children who drink flavored milk meet more of their nutrient needs; do not consume more added sugar, fat or calories; and are not heavier than non-milk drinkers. top choice in schools! Low-fat chocolate milk is the most popular milk choice in schools and kids drink less milk (and get fewer nutrients) if it’s taken away.
These health and nutrition organizations support 3-Every-Day™ of Dairy, a science-based nutrition education program encouraging Americans to consume the recommended three daily servings of nutrient-rich low-fat or fat-free milk and milk products to improve overall health.
www.nationaldairycouncil.org/childnutrition ©National Dairy Council 2010® RefeReNCes: 1. NPD Nutrient Intake Database; 2 years ending Feb. 2009. 2. Johnson RK, Frary C, Wang MQ. The nutritional consequences of flavored milk consumption by school-aged children and 8. United States Dept. of Health and Human Services, United States Dept. of Agriculture and United States Dietary Guidelines adolescents in the United States. J Am Diet Assoc. 2002;102(6):853-856. Advisory Committee, 2005 Dietary Guidelines for Americans. (6th ed. HHS publications, 2005, Washington D.C.) 3. National Dairy Council and School Nutrition Association. The School Milk Pilot Test. Beverage Marketing Corporation for 9. Greer FR, Krebs NF and the Committee on Nutrition. Optimizing bone health and calcium intakes of infants, children and National Dairy Council and School Nutrition Association. 2002. http://www.nutritionexplorations.org/sfs/schoolmilk_pilottest. adolescents. Pediatrics 2006; 117:578-585. asp (Accessed January 4, 2009). 10. Murphy MM, Douglas JS, Johnson RK, Spence LA. Drinking flavored or plain milk is positively associated with nutrient intake and 4. NICHD. For Stronger Bones….for Lifelong Health…Milk Matters! Accessed Sept 7, 2009 via http://www.nichd.nih.gov/ is not associated with adverse effects on weight status in U.S. children and adolescents. J Am Diet Assoc 2008; 108:631-639. publications/pubs/upload/strong_bones_lifelong_health_mm1.pdf 11. Johnson RK, et al. Dietary Sugars Intake and Cardiovascular Health. A Scientific Statement From the American Heart 5. HHS, Best Bones Forever. Accessed Sept 7, 2009 via http://www.bestbonesforever.gov/ Association. Circulation. 2009; 120:1011-1020. 6. Frary CD, Johnson RK, Wang MQ. Children and adolescents’ choices of foods and beverages high in added sugars are associated 12. ENVIRON International Corporation. School Milk: Fat Content Has Declined Dramatically since the Early 1990s. 2008. with intakes of key nutrients and food groups. J Adolesc Health 2004;34(1):56-63. 13. Patterson J, Saidel M. The Removal of Flavored Milk in Schools Results in a Reduction in Total Milk Purchases in All Grades, K-12. 7. American Academy of Pediatrics, Committee on School Health. Soft drinks in schools. Pediatrics 2005; 113152-154. J Am Diet Assoc. 2009; 109,(9): A97. * Daily recommenDations - 3 cups of low-fat or fat-free milk or equivalent milk products for those 9 years of age and older and 2 cups of low-fat and fat-free milk or equivalent milk products for children 2-8 years old.
The Maryland familydoctor / SUMMER 2011 • 31 MARYLAND Academy of Family Physicians Presorted Standard 5710 Executive Dr., Suite 104 U.S. Postage Paid Baltimore, MD 21228-1771 Little Rock, AR Permit No. 2437
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32 • The Maryland familydoctor / SUMMER 2011