2013_fall_ramifications EHR
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This document summarizes an article about advance care planning and end-of-life care. It discusses how the Richmond Academy of Medicine is taking a leadership role in promoting advance care planning across various healthcare systems in the region. They held an educational conference where they received support to continue their work. Their next step is to launch an Advance Care Initiative based on the Respecting Choices model to help patients articulate their end-of-life care preferences. The initiative will require funding and resources to implement clinical changes and a community marketing campaign.
![w w w . r a m d o c s . o r g 3
This story demonstrates both
the generational difference in how
technology is viewed and how
technology has changed education
forever.
Medicine has not been immune to
these technological changes but was
slower to embrace them.
Five years ago when the economy
tanked, the Obama administration
and Congress passed a stimulus
package to help the U.S. economy
recover. In that package was money
to encourage the wide adoption of
electronic health records (EHR) by
American medicine. There was also
a financial penalty for those who
refused to make this change.
Medicine has responded as our
government hoped we would and
EHRs are now everywhere. They are
in the hospitals in which we practice
and most of us now use them in our
offices every day.
This issue of Ramifications
addresses the impact of these new
record-keeping methods on the
practice of medicine. How they are
impacting what we do to care for
patients is ongoing and evolving
and will continue to do so into the
foreseeable future.
The process of creating an elec-
tronic health record is very different
from the process of hand-writing a
note or dictating one. As you click
through lists of symptoms in a history
and findings on a physical exam, and
import lab and X-ray results, the note
is created. At the end, though, what
is often missing is the thought process
of the doctor as he or she comes to a
diagnosis and treatment plan.
The notes often appear cookie-
cutter and filled with data which are
sometimes repeated over and over
again in the computer chart. The note
that is created is legible and easy to
read, and filled with lots of data and
information. This can allow a greater
level of billing, but it can make it
harder for other caregivers to see the
thought process of the clinician who
cared for the patient.
Who would have known how
important that typing class I took in
10th grade would be in 21st century
medicine? I find myself free texting
regularly in the hospital and in my
office system to document my thought
process about patients. When I read
other doctors’ notes, that is the
part I look for. It is where the real
information lies. Ironically, it is often
harder to find now than it used to be
when we were writing our notes by
hand or dictating them.
In the office setting, the EHR
can change the interaction we have
with our patients, and not always
for the better. As we talk to patients,
instead of looking them in the eye or
touching them, we are often looking
at and touching the computer as we
are entering data. This can detract
from our human contact with
patients. There are ways around this,
having a scribe or doing the record as
homework outside of the exam room,
but this is not always feasible in a
busy practice.
One of the interesting things about
EHRs is how many of them there are.
For those who practice in a single
hospital system, only one is needed.
For example, the inpatient and
outpatient components of a patient
record in Connect Care, which is
the Bon Secours system, talk to each
other and are one record. However,
for those of us who work in a private
practice and have our own system
and also use the hospital system for
inpatient care, the transition is not
seamless and can be difficult.
The same thing applies to the
interaction with referring practices
that send us letters and notes. In
both of these situations, instead of
having patient labs and path reports
and notes appear in an in-box on a
computer which we can then read and
deal with, these records appear as piles
of paper on our office fax machine.
Our office staff then brings them to
our attention so we can do what needs
to be done to care for our patients.
The end result is more paper, not less.
Making the different systems
talk to each other seamlessly can be
done but it is expensive. I think this
will occur as we move forward and,
hopefully, we will all have less paper
to deal with in the future. I know
we are not there yet. It has always
seemed to me that if our government
was going to essentially drive us all to
use EHRs, it would have chosen one
EHR system for the entire country,
sort of like the one radar system
we have for air traffic controllers. I
think the political issues to make this
happen were insurmountable.
One of the great hopes is to use
data mined from EHRs to improve
our health. Some of those same
computer-savvy high school students
who altered the first laptops given
out by Henrico County now have
computer engineering degrees from
prestigious schools and are working
for consulting firms inside the Beltway
trying to figure out how to do that.
The paranoid among us think the
government will use this information
to control us. There is a big difference
between health records and email
and phone conversations, and these
conspiracy theorists may be right.
It is interesting how many fine
Richmond physicians have chosen
2013 as the year to retire. There are
many reasons we hang up our white
coats and put away our stethoscopes
and scalpels, but I have heard it said
in the lunchroom by some of these
retiring docs that the EHR is one of
the things that is making them pull the
trigger and stop practicing medicine.
Some of these physicians never learned
to type and I can’t imagine working
in this new world without that skill.
Others really did not like the changes
and are choosing to move on.
Going forward, the challenge for
all of us is to do what my son and his
friends did when they got their first
laptops. We have to “make it [the
EHR] our own.” I suspect it will be
the generation being trained now that
will do that. EHRs will be all they
know. Hopefully, the human touch
will remain in medicine as this change
moves forward. The machines cannot
be allowed to win. R
Dr. Wornom practices at
Richmond Plastic Surgeons and
is a past president of RAM. He
can be reached at wornom@
richmondplasticsurgeons.com.
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“Health record,” continued from page 1
Source: Health Information
Technology in the United States 2013,
Robert Wood Johnson Foundation
The number of U.S.
hospitals that have
implemented systems
that meet federal
Meaningful Use
Stage 1 criteria, up
from 4.4 percent in 2010.
42%](https://image.slidesharecdn.com/3e166a64-200c-497e-8cd7-f3373e595958-150917013652-lva1-app6892/85/2013_fall_ramifications-EHR-3-320.jpg)
![6 FA L L 2 0 1 3
Technology and social distancing
—the EMRB Y R I C H A R D P. W E N Z E L , M D , M S C .
he sea change in re-
cording the history
and physical examina-
tion as a result of the
electronic medical record (EMR) is
remarkable. Those of us witnesses
to the before and after eras recall the
desperate search for the bundled-up
old records, the time-consuming and
frustrating attempts to decipher the
unique handwriting of prior clini-
cians, the long queues in front of the
radiology film room seeking to review
earlier images. Technology has solved
key problems for patient care.
But something has been lost
with the useful technology. In the
pre-EMR era, the team room was a
workweek and the business focus on
patient throughput. Together these
forces have transformed the team
rooms’ banter to hundreds of syn-
copated sounds of keyboard strikes.
There is a sense of urgency felt but not
stated—the need to record so much
into the chart as quickly as possible—
for the clock is ticking.
In a thoughtful essay published
in the Annals of Internal Medicine
in 2010, Mike Edmond noted that
attending on the wards is “much less
fun and exhausting, [with] limited
[time for] levity, banter and humor. I
feel guilty if I ask the residents ques-
tions about themselves or what they
did over the weekend as they type
(and they are always typing), because
I’m distracting them and using pre-
cious time.”
Physician and author Abraham
Verghese wrote about the issue in
“Culture Shock—patient as icon, icon
as patient,” a 2008 article in The
New England Journal of Medicine.
Concerned that the time of engage-
ment of house staff and patient is
shrinking, he noted, “Patients are
handily discussed in the [call room]
bunker while the real patients keep
the beds warm and ensure that the
folders bearing their names stay alive
on the computer.” Like Edmond,
Verghese is alarmed by the erosion
of bedside skills of the modern house
staff. “…the bedside is hallowed
T
…the interpersonal distancing created by
the new technology has conspired with
the residents’ 80-hour workweek and the
business focus on patient throughput.
buzz of verbal exchanges, as senior
clinicians traded ideas with the house
staff, reviewed the assessments and
plans, engaged the students, and
together rounded at the bedsides—
spending time to illustrate important
physical findings.
In contrast, the team room today
Richard P.Wenzel, MD, MSc.
is relatively quiet, each member now
facing a computer screen along the
wall as a lonely typist. All eyes gaze
at the periphery of the room, none
at the center, none at each other,
observing the unspoken expressions
of the others. As a result we don’t
know each other personally as well as
we used to—the aspirations, worries,
insecurities or confidence levels of
students and house staff.
To be fair, the interpersonal distanc-
ing created by the new technology has
conspired with the residents’ 80-hour](https://image.slidesharecdn.com/3e166a64-200c-497e-8cd7-f3373e595958-150917013652-lva1-app6892/85/2013_fall_ramifications-EHR-6-320.jpg)
![8 FA L L 2 0 1 3
t first glance, storing
patient data in “the
cloud” sounded intrigu-
ing to the IT experts
at Virginia Eye Institute. Maybe it
would help save money to back up
their new electronic medical records
system. It makes sense to look for
savings, given that the costs for EHRs
can be considerable—estimates range
from $5,000 to more than $50,000
per provider. And that doesn’t include
hiring consultants to work through
the many details of customizing,
installing, and ensuring quality con-
trols. Ka-ching! Throw in hardware
upgrades, lost productivity and the
cost of extra staffing, and the total
price tag can easily top $1 million.
“So I can see why smaller practices
go with the cloud” to store data, said
Eric Hays, vice president of opera-
tions at VEI.
But at VEI—a practice with 38
providers who need customized
records-keeping at 11 locations—
Hays spotted a big problem with
any business plan that would put his
patients’ medical records in the hands
of third-party servers.
“Then your [electronic medical re-
cords] supplier is keeping your data,
Caveat Emptor: Rules of the
Electronic Road
B Y C H I P J O N E S
A
and if they were to go under, you’d
have to make sure the contract has
language that you’d get ownership of
the data,” Hays said. “That’s why we
like to have it internalized,” by using
an offsite data center—Peak 10—
which offers special security measures
(such as fingerprint access), electrical
backups, and other data recovery
components.
“I know the model is moving to the
cloud, but in terms of a security issue,
it’s nice to have control,” Hays said.
Yet another practice administrator, Kit
Young at Richmond Plastic Surgeons,
takes a slightly sunnier view. “Two
years ago I may not have considered
the cloud, but in today’s market, there
are many good options worth consid-
ering during the evaluation process.”
Decisions, decisions…. Interviews
with practice managers and doctors
show how wide open—and some-
times confusing—this new technology
terrain can be. They shared different
approaches to how they customize
records for physicians and nurses,
working in billing and communica-
tions features along the way. And,
depending on their Medicare and
Medicaid populations, they expressed
varying degrees of interest in meeting
Understand what you need the system to
do and what data you need to collect.
Eric Hays keeps a steady focus on electronic health records at theVirginia Eye Institute.
the federal government’s Meaningful
Use standards.
But while their needs and ap-
proaches differed, from pediatricians
to plastic surgeons to OB/GYN offices,
there was agreement to never forget
the old adage, caveat emptor, or “let
the buyer beware.”
“When we first got quotes for IT,
they were based on the minimum
standards from the vendor,” recalled
Leslie Bachmann, practice manager at
the Skin Surgery Center of Virginia.
She soon discovered those “stan-
dards” were “the minimum to run
their software and nothing else.” It
will cost more once “you calculate all
of your needs.”
These practice managers, and
one physician interviewed, said
it’s important to determine all of
the features needed and then have
the software vendor provide solid
price quotes. “Practices have other
programs, outside of their patient
medical records, that are required to
KitYoung](https://image.slidesharecdn.com/3e166a64-200c-497e-8cd7-f3373e595958-150917013652-lva1-app6892/85/2013_fall_ramifications-EHR-8-320.jpg)
![w w w . r a m d o c s . o r g 9
run their day-to-day operations.” Her
advice: “Work with your IT vendor
to evaluate the cost of running all
programs” if you want a true cost of
upgrading your office.
Understand what you need the sys-
tem to do and what data you need to
collect. Are you going to participate
in Meaningful Use, the Patient-Cen-
tered Medical Home, an Accountable
Care Organization (ACO), and the
Physician Quality Reporting System
(PQRS)? If so, what PQRS measures
would you like to collect data on?
Not all vendors have this built in.
How hard is it to retrieve data—and
can you report out of the system, or
do you need additional features (at a
cost) to do so?
Bottom line, said Young: “Make
sure you have all you want listed in the
final agreement before signing.”
In the case of the Skin Surgery
Center, which specializes in Mohs
surgery, Bachmann and practice
founder Dr. Christine Rausch wanted
to make sure they purchased a system
that guaranteed the best experience
for patients and practitioners.
They spent hours researching, meet-
ing with vendors, talking with other
physicians and other practice manag-
ers, and paying visits to medical prac-
tices to see their systems. They also ex-
ercised self-discipline not to be driven
by the government’s deadlines for
Meaningful Use. But because they have
a number of Medicare patients and a
deadline approaching, Dr. Rausch said
in late summer, “We finally decided we
had to get it done.”
While Rausch’s practice is smaller
than VEI, she tackled many of the
same data storage and transmis-
sion issues. They also opted for an
in-house data storage system, Rausch
said, “because then if you change
EMRs you don’t have to worry about
[access] to your own data. The down-
side is there’s more maintenance and
cost, and it’s not as accessible when
you’re out of the office.”
After they finally settled on a
customized system for dermatologists,
they faced the next big decision point:
How to get it up and running?
Super users
Young, administrator and direc-
tor of information technology at
Richmond Plastic Surgeons, gave this
advice for preparing for the “go live”
date for practices still transitioning to
EMRs: “You can begin by having your
patient forms ask the same questions
in the same format that you’ll be ask-
ing in the electronic record.”
With the Meaningful Use require-
ments—such as obtaining patients’
ethnicities— getting everyone on the
same page as early as possible is even
more essential, said Young, who has
supervised the installation of records
systems at several practices. “That’s
something I’ll do two to three months
out while working to build the sys-
tem” to ensure the staff and practitio-
ners “become accustomed to asking
the question in the form that’s being
asked” in the electronic record.
Three months ahead of the “go
live” date at Pediatric Associates of
Richmond, “We pre-scanned a lot of
charts,” said office manager Jo DiPer-
na. This helped speed up the adoption
of the electronic records, and for legal
reasons, it’s crucial to keep consistent
records on paper and in digital charts.
Once this paper-to-digital work
is done, it’s time to do something no
EMR vendor can do for you: organize
staff training and implementation.
“Think about the work flow of
your office, and how it ties in,” said
Nicole Midulla, front desk supervi-
sor at Pediatric Associates. So, for
Leslie Bachmann (l), practice manager of the Skin Surgery Center ofVirginia, helped Dr. Christine
Rausch find the right system.
“Electronic road,” continued on page 10](https://image.slidesharecdn.com/3e166a64-200c-497e-8cd7-f3373e595958-150917013652-lva1-app6892/85/2013_fall_ramifications-EHR-9-320.jpg)
![14 FA L L 2 0 1 3
s Virginia Cardiovascu-
lar Specialists was begin-
ning to make its mark
in Richmond in the late
1970s, its co-founder traveled to Eu-
rope to study with the renowned phy-
sician Andreas Gruentzig, a pioneer
of balloon angioplasty techniques.
“Bill [Dr. William Holland]
stayed with him for several weeks
and learned how to do it,” recalled
Dr. Gan Dunnington, a cardiolo-
gist who’s been with the practice for
decades.
Holland brought the skills back
to Richmond, trained his colleagues
and over the years improved care and
treatment for countless patients. That
spirit of cooperation continues today.
A commitment to learning the
latest techniques—and sharing that
information—remains a cornerstone
of VCS. “We’ve shared knowledge
and stayed ahead of the curve,” said
Dunnington.
As the largest independent cardiol-
ogy practice in Central Virginia, VCS
is committed to being at the forefront
tals. All VCS physicians are board-cer-
tified, and many also have additional
subspecialty training in cardiovascular
intervention, carotid stenting, CT
angiography, electrophysiology and
peripheral vascular disease.
The practice was founded in 1977
by Holland and Dr. Eric Kemp. Dr.
John Fitzgerald joined soon after,
followed by Dunnington. From
there, the group has added many new
physicians and absorbed several other
practices over the years. Pulmonary
medicine went out, vascular came in.
As the practice grew in size and
in scope, it also became more so-
phisticated. “When we started out,
Drs. Kemp, Fitzgerald, Holland and
I would meet out in the parking lot
around 11 o’clock and that was it,”
recalled Dunnington.
As VCS has grown, it’s gotten a lit-
tle more difficult to meet in the park-
ing lot between patients. A highly
organized system of governance has
replaced those get-togethers, with a
pod system and regular physician and
shareholder meetings. But VCS enjoys
its status as an independent practice
and tries to allow its physicians to
have a fair amount of independence
too, said Thomas.
In all, VCS boasts about 200
employees, making it one of the larg-
est independent cardiology practices
in the commonwealth. Its size has
allowed VCS to hire well-qualified
administration and staff, in addition
to its cardiologists.
“We focus on hiring the best staff
that will support our physicians and
ensure their efficiency. These physi-
cians have been really good about
investing in their infrastructure,” said
Executive Director Ann Honeycutt,
who joined VCS after a career at
Bon Secours. “We have the ability to
run things well, improve the patient
experience, and from a business office
standpoint, keep [practice] viable.
That’s essential, because, sadly, get-
ting paid for the work doctors do has
gotten very complex.”
That attention to detail is some-
thing the physicians appreciate, said
Joyner. He also appreciates how ad-
ministrators and practice leaders are
proactive in issues that could influ-
ence the field of medicine.
“We are able to recognize some of
these things that end up affecting all
cardiologists,” he said.
By staying in tune with local and
national politics and the American
College of Cardiology, VCS can flag
issues that it feels it should act on.
“We’ve got a lot of leverage as a large
group to do that,” said Joyner.
Thomas agrees. “Part of our job in
this as good practitioners of cardiol-
ogy is to ensure that we have a voice
in some of the legislative [venues] or
organizations that regulate our work.”
Case in point: In the late 1990s,
the group was part of a successful
lobby to change laws to allow nuclear
medicine to be performed in medi-
VCS: Taking care of Virginia’s
hearts since 1977B Y L I S A C R U T C H F I E L D
A
of clinical breakthroughs, improv-
ing outcomes for patients and saving
lives. “We’ve done a lot of firsts in
the state,” said Dr. Shelton Thomas,
the group’s president.
Some of those firsts over VCS’
three decades include:
• Coronary stents
• Coronary vein graph
• Carotid stenting
• CRT device ICD
• Hybrid maze
• First robotic atrial fibrillation
ablation
• Stand-alone permanent pacemakers
• CT heart scan and calcium screen/
score
• Coronary angioplasty
• Ventricular tachycardia ablation
using the Impella left ventricular
assist device
“We feed off each other. One guy
can take the lead and spread the ex-
pertise around the practice,” said Dr.
Charles Joyner, who has been with
VCS for a decade.
At VCS, 38 cardiologists practice in
seven offices and at many area hospi-
SheltonThomas, MD Gan Dunnington, MD
Dr. Charles Joyner andVCS use high-tech equipment to diagnose and treat various heart conditions.
Charles Joyner, MD](https://image.slidesharecdn.com/3e166a64-200c-497e-8cd7-f3373e595958-150917013652-lva1-app6892/85/2013_fall_ramifications-EHR-14-320.jpg)
![w w w . r a m d o c s . o r g 15
cal offices. “We went to the General
Assembly every day and eventually
convinced legislators to change the
law,” said Thomas. “That has been a
benefit for our patients.”
Though they keep a close eye on
the big picture of medicine, VCS
physicians stress that they haven’t lost
touch with the basic needs of patients,
referring physicians and hospitals.
“We try to focus on doing a
great job of forming relationships
with patients, physicians and being
omnipresent in hospital and office,
days and nights and weekends. That’s
what traditionally brings in patients,”
said Joyner.
The ability to be a one-stop shop
for all matters cardiac helps, too, and
VCS offers a variety of screening and
treatment options on site. It’s the only
private area practice to maintain a
computed tomography angiography
(CTA) scanner and accredited
cardiac CT.
“We’re very proactive about figur-
ing out what we need to do and still
do good work,” said Joyner. “It’s a
recipe we understand very well.
“There are some fundamentals
that never change. Patients have
choices and you have to treat them
well. Referring physicians like re-
sponsiveness. They like competency.
They like getting their questions
answered and getting people seen in a
reasonable time frame.”
Though it works closely with area
hospital systems, VCS isn’t ready to
be part of them.
“For us, it’s always been important
to remain independent,” said Thom-
as. “There’s a tendency to align with
hospitals and we looked at that . . .
no one group can support us, no one
healthcare system can handle us, nor
do we want that.
“Despite the challenges of being an
independent practice and the uncer-
tainty in health care, our allegiance is
to our patients. It’s always been that
way.”
VCS physicians say they’re look-
ing forward to more “firsts” as they
continue to care for patients.
“What excites me clinically about
cardiology today is prevention,” said
Dr. William Coble. “We’ve seen a
decline in deaths from cardiovascular
disease with the advent of improved
medicine and stenting, and our ability
to intervene in heart attacks within
that critical 90-minute window.
“So we’ve decreased mortality. But
the problem with that is that in-
creased morbidity is still there. People
are living longer with heart disease.
We’re seeing more [atrial fibrillation],
Bell Creek Medical Park ~ Boulders VI ~ Forest Medical Plaza
Harbourside* ~ Waterside* ~ InteCardia ~ St. Mary’s ~ Tappahannock
Darryn L. Appleton, MD
Michael J. Ball, MD, FACC
Robert M. Bennett, MD, FACC
Michael J. Bunda, MD, FACC
Carolyn A. Burns, MD, FACC
Martin D. Caplan, MD, FACC
Dean E. Caven, MD, FACC
William L. Coble, Jr., MD, FACC
Steven W. Cross, MD, FACC
Aalya H. Crowl, MD, FACC
John M. DiGrazia, MD, FACC
Gan H. Dunnington, MD, FACC
Michael B. Erwin, MD, FACC
Charles G. Evans, Jr., MD, FACC
John E. Fitzgerald, MD, FACC
James B. Garnett, MD, FACC
David M. Gilligan, MD, FACC
Timothy W. Hagemann, MD, FACC
Jiho J. Han, MD, FACC
Brian K. Holdaway, MD, FACC
C. Foster Jennings, Jr., MD, FACC
Charles A. Joyner, MD, FACC
Ashwani Kumar, MD, FACC
Ramesh N. Kundur, MD, FACC
Bradford J. Matthews, MD, FACC
C. Mark Newton, MD, FACC
Reza K. Omarzai, MD, FACC
John R. Onufer, MD, FACC, FHRS
Charles W. Phillips, MD, FACC
Peter S. Ro, MD, FACC
Sameer Rohatgi, MD, FACC
Daniel A. Schneider, MD
Saumil R. Shah, MD
Robert E. Sperry, MD, FACC
Shelton W. Thomas, MD, FACC
S. Craig Vranian, MD, FACC
Yvonne J. Weaver, MD, FACC
Charles M. Zacharias, Jr., MD, FACC
VCS has worked to improve the heart-health
of Virginians for more than 35 years. From prevention
and testing to cardiac and vascular interventions,
we offer the finest cardiovascular care from some of
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ImprovingVirginia’s
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MSVIA_HelpYou_ad_RAM2013.indd 1 4/4/2013 10:20:58 AM
Dr. Gan Dunnington has
seen a lot of changes over
the years, butVCS’top
priority has always been
its patients.
“VCS,” continued on page 16
arrhythmias and more heart failure.
I think the true challenge is keeping
these people living longer and staying
out of the hospital.”
VCS has a wealth of new
techniques and tools to improve a
patient’s chances of survival and](https://image.slidesharecdn.com/3e166a64-200c-497e-8cd7-f3373e595958-150917013652-lva1-app6892/85/2013_fall_ramifications-EHR-15-320.jpg)
2013_fall_ramifications EHR
- 1. A vision of tomorrow: Honoring patient choiceB Y R I C H A R D A . S Z U C S , M D tarting a conversation about end-of-life care can be dif- ficult, whether we are physi- cians, patients, family mem- bers, religious and community leaders or other professionals. It is, however, imperative that these conversations take place. And, once they occur, it is equally critical that caregivers honor patients’ choices. When no conversa- tion occurs, families and caregivers are left making decisions that may not reflect what a patient desires. The Richmond Academy of Medicine champions advance care planning, hospice and palliative care. Within the last two years, we have developed a core group of healthcare professionals, including hospice and palliative care specialists from Bon S FALL 2013 n VOLUME 19 n NO. 4 WWW.RAMDOCS.ORG We want you to take it home and make it your own: The age of the electronic health record B Y I S A A C L . W O R N O M I I I , M D FA C S RR A M I F I C A T I O N S Technology and social distancing 8 6 Whither EHRs? 4 As a physician, any discussion of electronic records should start with two words:“audit trail.”Here’s why: According to the July 2013 issue of the Virginia Medical Law Report, lawyers across the commonwealth are busily adapting to the brave new digital world of patient information. It begins with language itself, one Norfolk lawyer told the publication. “There’s a whole new lexicon, a new language we have to speak.” Lawyers also are learning to dig things up in new ways as they perform discovery in malpractice cases, giving up the“stray facts and telling details”they used to find in various folders and log books in hospitals and doctors’offices. Now lawyers must obtain screen shots of pull-down menus and tabs for extra details in the electronic record. Another personal injury lawyer called medical records“the skeleton on which my case is based.” Do you have any“skeletons” lurking in your data closets? For good housekeeping tips, check out this www.fierceemr.com report (Oct. 2, 2013), “EHRs Won’t Decrease Malpractice Risks, Premiums.” Though electronic records may help to improve patient care, the report cautions providers not to“expect such systems to lower their malpractice premiums, as EHRs can create new problems and make it harder to defend against such claims.” Some potential problem areas: l Disabled clinical decision support alerts that, if used, could have caught a problem. l Auto complete functions that fill in data incorrectly. l Sharing of passwords, so that the physicians look like they’re viewing the chart when they actually are not doing so. l Sloppy documentation, such as incorrectly entered data. EHRs also create audit trails, according to the report. And guess who likes audit trails? Not just the IRS! Chip Jones is RAM’s communications and marketing director. Rules of E-road EHRs and malpractice B Y C H I P J O N E S Secours, HCA and VCU, to advise us regarding how we, working with others, can promote and encourage advance care planning (ACP) in this community. The core group agreed that adopting a uniform approach to ACP across the healthcare mar- ketplace was essential for increasing awareness and engagement. In late May 2013, the Acad- emy sponsored a community-wide educational conference where 100 healthcare professionals from the health systems and the wider com- munity came together to learn about best advance care planning practices. There was unanimous support among the participants that the Richmond Academy of Medicine assume a lead- ership role as catalyst, convener and organizer of a community-wide effort on advance care planning. Everyone agrees that advance care planning is a lifelong process, best begun before a crisis develops. We shared the outcomes of the conference with health systems, Secretary of Health and Human Resources Bill Hazel, Senator Mark Warner, and the Virginia Center for Health Innovation. We were encour- aged to continue to do the work that brought the healthcare community “Health record,” continued on page 3 hen my son Chris was a rising junior at Douglas Freeman High School, we went together to an assembly to get the new laptop that Henrico schools gave to every rising high school student. Dr. Pruden, the excellent principal of Freeman at the time, stood in front of us and told the students that he wanted them to take those computers home and in the two weeks before school started, “make them their own.” Well that is just what Chris and his computer-savvy friends did. By the time school started, those little laptops had 10 times as much RAM and more new programs on them than you could shake a stick at. That did not last. The county figured out what had happened and collected the laptops and returned them to their original configuration and made lots of rules to keep it from happening again. The students who made the changes became the go-to people for computer problems at the school. W “Vision,” continued on page 2 Richard A. Szucs, MD, is a radiologist with Commonwealth Radiology, P.C., and president of the Board of Trustees of the Richmond Academy of Medicine.
- 2. 2 FA L L 2 0 1 3 P R E S I D E N T Richard A. Szucs, MD V I C E P R E S I D E N T Peter A. Zedler, MD T R E A S U R E R L. Randolph Chisholm, MD S E C R E TA R Y Joseph S. Galeski III, MD E X E C U T I V E D I R E C T O R Deborah Love E D I T O R Isaac L. Wornom III, MD C O M M U N I C AT I O N S A N D M A R K E T I N G D I R E C T O R Chip Jones cjones@ramdocs.org (804) 622-8136 A D V E R T I S I N G D I R E C T O R Lara Knowles lknowles@ramdocs.org (804) 643-6631 A R T D I R E C T O R Jeanne Minnix Graphic Design, Inc. minnix1@verizon.net (804) 405-6433 R A M M I S S I O N The Richmond Academy of Medicine strives to be the patient’s advocate, the physician’s ally, and the community’s partner. O N T H E W E B www.ramdocs.org Published quarterly by the Richmond Academy of Medicine 2201 West Broad Street, Suite 205 Richmond, Virginia 23220 (804) 643-6631 Fax (804) 788-9987 Non-member subscriptions are available for $20/year. The opinions expressed in this publications are personal and do not constitute RAM policy. © Richmond Academy of Medicine Letters to the editor and editorial contributions are encouraged, subject to editorial review. Write or email Communications and Marketing Director Chip Jones at cjones@ramdocs.org. R A M I F I C A T I O N S FA L L 2 0 1 3 V O L U M E 1 9 n N O . 4 RR A M I F I C A T I O N S “Vision,” continued from page 1 together, speaking in one voice, in sup- port of honoring a patient’s choice. Now we are ready to take the next logical step to support system change, advocacy and education around advance care planning throughout Central Virginia. The Academy desires, as convener and coordinator, to launch an Advance Care Initiative built upon the proven concepts of Respecting Choices®. Respecting Choices is a program started more than 20 years ago in LaCrosse, Wisconsin, to help patients articulate their choices about end-of-life care and put in place systems to ensure that patients’ choices are known and respected. Their experience has shown that this results in improved quality of life and improved patient and family satisfaction with end-of-life care. Their methods have been widely recognized and replicated at many other sites regionally, nationally, and internationally. Respecting Choices is also the platform behind Virginia’s markers for success of this work. Once clinical implementation is un- derway, we will launch a major grass- roots effort to reach citizens through a marketing campaign. Community stakeholders, including religious, civic, legal, and business organizations, will be invited to join in our efforts. No doubt, all of this requires significant resources. In the spirit of co- operation and leadership, the Academy has committed $100,000 in startup funds provided all health systems join. Health systems were asked to contrib- ute $40,000 a year for two years. We will keep you informed of our conversations and efforts. It has been an honor to serve as your President for the past two years. I believe that this initiative is the most important thing I have had the privilege to lead. I believe it will result in a significant improvement in the quality of end-of-life care in our community. Because I believe this so strongly, I intend to remain involved with the project. I invite you to join us as we move forward. R here once was a story from CNN Health about a hospital director in Africa who told of a patient dying of malaria in a room with hundreds of bottles of medicine that could save the man’s life, but no intravenous lines with which to administer it. A simple item, such as an intrave- nous line, could mean life or death for an individual in the developing world. Unfortunately, this is all too often what happens around the world. But it doesn’t have to happen that way. So what can be done? A small group of students in Richmond is working to make a big difference. Thousands of boxes of medical supplies—items such as sterile surgical kits, respirator masks, gloves, syringes, crutches, exam tables, and gauze bandages—are hand-packed on a weekly basis by dedicated members of United2Heal, a humanitarian aid organization at Virginia Common- wealth University. We, as students, do everything we can to ensure that these supplies are useful, well within the expiration date, and appropriate to ship over- seas. After we collect and organize our donated medical supplies, we then determine the logistics of ship- ping these supplies. With the help of VCU physicians and faculty, and advisors at the Rich- mond-based World Pediatric Project, over the past two semesters we have been able to ship approximately $1.5 million worth of medical supplies to Syria and Egypt. What difference are we making? Our most recent shipment to the United2Heal: Your supplies can help! B Y A L B A R A E L S H A E R Children’s Cancer Hospital in Egypt made it possible to extend the hospi- tal’s operations by providing 500 new beds. Fellow VCU sophomore Karima Abutaleb and I have had the oppor- tunity to visit the hospital in Egypt to evaluate the shipment’s impact and receive feedback on how to improve future shipments. If we can do all this with the help of key partners in the U.S., imagine how many more people we could serve if others got involved? Help us help others by donating excess medical supplies, surgical kits and even simple items such as examination gloves. We also could use more volunteers to help sort the supplies. Please visit our web- site, www.united2heal.org, to see our past events, to contact us, or to make a donation. T The motto of Unted2Heal is: “In the war against health disparities, we realize that many battles must be fought in the political arena. But we want to be on the front lines of saving lives.” R Albara Elshaer is a sophomore at VCU. He can be reached at elshaeran@vcu.edu or by calling (571) 723-3004. Since 2010, the number of U.S. hospitals having a basic electronic health record (EHR) has tripled. Source: Health Information Technology in the United States 2013, Robert Wood Johnson Foundation Boy in Syria happy to see gift along with helping hand of U2H. VCU medical students load supplies bound for Syria. POST pilot projects. Recently, we invited Central Virginia health systems to join us. We cannot do this work alone, but with their support and guidance we can be a collaborative partner for a community-wide initiative. Health systems joining us would agree to a common emphasis on improving the conversation between patient and provider, not only in word but also in action. Such a commitment requires a collaborative partner to invest in technology that adequately stores and retrieves advance care planning documents; to invest in the training of professionals and laypersons; and to devote the organizational resources needed to implement new programs and services. To guide the work of this initia- tive, collaborative partners will appoint two or more professionals to a community steering committee that will oversee the project. The steering committee will articulate the goals and objectives, select pilot sites, and define achievable and measurable
- 3. w w w . r a m d o c s . o r g 3 This story demonstrates both the generational difference in how technology is viewed and how technology has changed education forever. Medicine has not been immune to these technological changes but was slower to embrace them. Five years ago when the economy tanked, the Obama administration and Congress passed a stimulus package to help the U.S. economy recover. In that package was money to encourage the wide adoption of electronic health records (EHR) by American medicine. There was also a financial penalty for those who refused to make this change. Medicine has responded as our government hoped we would and EHRs are now everywhere. They are in the hospitals in which we practice and most of us now use them in our offices every day. This issue of Ramifications addresses the impact of these new record-keeping methods on the practice of medicine. How they are impacting what we do to care for patients is ongoing and evolving and will continue to do so into the foreseeable future. The process of creating an elec- tronic health record is very different from the process of hand-writing a note or dictating one. As you click through lists of symptoms in a history and findings on a physical exam, and import lab and X-ray results, the note is created. At the end, though, what is often missing is the thought process of the doctor as he or she comes to a diagnosis and treatment plan. The notes often appear cookie- cutter and filled with data which are sometimes repeated over and over again in the computer chart. The note that is created is legible and easy to read, and filled with lots of data and information. This can allow a greater level of billing, but it can make it harder for other caregivers to see the thought process of the clinician who cared for the patient. Who would have known how important that typing class I took in 10th grade would be in 21st century medicine? I find myself free texting regularly in the hospital and in my office system to document my thought process about patients. When I read other doctors’ notes, that is the part I look for. It is where the real information lies. Ironically, it is often harder to find now than it used to be when we were writing our notes by hand or dictating them. In the office setting, the EHR can change the interaction we have with our patients, and not always for the better. As we talk to patients, instead of looking them in the eye or touching them, we are often looking at and touching the computer as we are entering data. This can detract from our human contact with patients. There are ways around this, having a scribe or doing the record as homework outside of the exam room, but this is not always feasible in a busy practice. One of the interesting things about EHRs is how many of them there are. For those who practice in a single hospital system, only one is needed. For example, the inpatient and outpatient components of a patient record in Connect Care, which is the Bon Secours system, talk to each other and are one record. However, for those of us who work in a private practice and have our own system and also use the hospital system for inpatient care, the transition is not seamless and can be difficult. The same thing applies to the interaction with referring practices that send us letters and notes. In both of these situations, instead of having patient labs and path reports and notes appear in an in-box on a computer which we can then read and deal with, these records appear as piles of paper on our office fax machine. Our office staff then brings them to our attention so we can do what needs to be done to care for our patients. The end result is more paper, not less. Making the different systems talk to each other seamlessly can be done but it is expensive. I think this will occur as we move forward and, hopefully, we will all have less paper to deal with in the future. I know we are not there yet. It has always seemed to me that if our government was going to essentially drive us all to use EHRs, it would have chosen one EHR system for the entire country, sort of like the one radar system we have for air traffic controllers. I think the political issues to make this happen were insurmountable. One of the great hopes is to use data mined from EHRs to improve our health. Some of those same computer-savvy high school students who altered the first laptops given out by Henrico County now have computer engineering degrees from prestigious schools and are working for consulting firms inside the Beltway trying to figure out how to do that. The paranoid among us think the government will use this information to control us. There is a big difference between health records and email and phone conversations, and these conspiracy theorists may be right. It is interesting how many fine Richmond physicians have chosen 2013 as the year to retire. There are many reasons we hang up our white coats and put away our stethoscopes and scalpels, but I have heard it said in the lunchroom by some of these retiring docs that the EHR is one of the things that is making them pull the trigger and stop practicing medicine. Some of these physicians never learned to type and I can’t imagine working in this new world without that skill. Others really did not like the changes and are choosing to move on. Going forward, the challenge for all of us is to do what my son and his friends did when they got their first laptops. We have to “make it [the EHR] our own.” I suspect it will be the generation being trained now that will do that. EHRs will be all they know. Hopefully, the human touch will remain in medicine as this change moves forward. The machines cannot be allowed to win. R Dr. Wornom practices at Richmond Plastic Surgeons and is a past president of RAM. He can be reached at wornom@ richmondplasticsurgeons.com. We operate on the philosophy that your website is the central hub of your marketing efforts— using other media to drive traffic to your site. We improve your online presence and ROI by offering these services: • Branding & Logo Design • Internet Marketing • Website Design • Mobile Websites • Print Marketing • Referral Marketing Impression-Marketing.com Call 804.464.1230 for your complimentary consultation RAM Ad 4.875 x 7.75 12/31/12 3:37 PM Page 1 “Health record,” continued from page 1 Source: Health Information Technology in the United States 2013, Robert Wood Johnson Foundation The number of U.S. hospitals that have implemented systems that meet federal Meaningful Use Stage 1 criteria, up from 4.4 percent in 2010. 42%
- 4. 4 FA L L 2 0 1 3 In 2004, President George W. Bush issued a bold proclamation that most Americans should have electronic health records by 2014. It was recognized at the time that information technology adoption in health care lagged far behind that of other industries, most notably that of banking. Despite the lack of adop- tion, however, health IT was viewed as necessary—if not sufficient—to drive transformation toward im- proved quality, safety, efficiency and effectiveness. With just a couple of months left before we reach 2014, it’s an appropriate time to review where we’ve been; where we are; and specu- late on where we’re going. Where we’ve been While good data on EHR adop- tion in 2004 is scarce, it is generally believed to have been less than 25 per- cent, with some estimates as low as 5 percent. Locally, practices with EHRs were the exception rather than the rule. Virginia Urology was one of the early adopters, building its own EHR platform in 1992 that even included the ability to import clinical results. Electronic health records: where we’ve been…maybe where we’re goingB Y M I C H A E L M AT T H E W S Many looked to this practice for experience and inspiration for the work that lay ahead in EHR adoption. At the time, most practices had electronic bill- ing and practice management systems, albeit with varying levels of capability and satisfaction. Hospitals were usually an amalgamation of patient accounting systems and “unintegrated” lab, phar- macy, OR, and radiology systems. The concepts of “health information ex- change” and “personal health records” were new and not widely accepted. While e-prescribing was being pursued by a few pioneers, the Surescripts phar- macy gateway was years away from becoming a definitive platform for eRX transactions. Physicians sometimes ask why the U.S. didn’t move to a single solution EHR, thereby improving compat- ibility between doctors’ offices. Given the lack of EHR adoption and use in 2004, that proposition could have been considered. In fact, the closest we came to such a scenario was when Medicare offered free access to VistA, the EHR utilized by the Department of Veterans Affairs. It was then that I first heard the phrase “free is not cheap enough.” While the VistA software was open-source (and thereby, free), implementation costs and customiza- tion ran well over $10,000. Physicians began taking a serious look at how an EHR would work best in their practice and most concluded that “one size does not fit all.” So it was that the possibility of a single EHR faded as fast as the prospects of a single payer system. All was not lost on the compatibility front, though, as the focus shifted from a single EHR system to adoption of industry- accepted interoperability standards. While still a work-in-progress, these standards became an increasingly important aspect of health IT over the past 10 years. Where we are So much has changed in the healthcare world in the past 10 years, driven in part by significant incentives provided by CMS for “meaningful use.” By 2011, 54 percent of physicians had adopted an EHR. Almost three-fourths of physi- cians who have adopted an EHR system report that their system meets “meaningful use” criteria. Eighty-five percent of physicians report being somewhat (47 percent) or very (38 percent) satisfied with their system. Three-fourths of physicians report that their EHR system has resulted in enhanced patient care. And nearly one-half of physicians currently with- out an EHR plan to have one in place within the next year. (Statistics from NCHS Data Brief No. 98, July 2012) The increase in EHR adoption is impressive and should be considered an overwhelming success. Perhaps the lofty goal of universal adoption of EHRs by 2014 was ambitious to the point of being unrealistic. I recall a conversation I had with the national coordinator for health information technology shortly after the passage of HITECH when I observed, “It has taken 30 years to get to 30 percent adoption…we can’t possibly get another 70 percent in three years!” He seemed surprised and dismayed by my comment. Being a “glass half full” kind of guy, I still think what has occurred in health IT has been extraordinary, and a deep and broad foundation has been laid for the future. Where we’re going I tip my hat to all of you who have suffered through the blood, sweat and tears (and costs!) of EHR implemen- tation over the past few years. There’s more to be done, though, and I offer a Michael Matthews Three-fourths of physicians report that their EHR system has resulted in enhanced patient care.
- 5. w w w . r a m d o c s . o r g 5 few areas to keep in mind as we look to the future: l Interoperability: Let’s make sure we haven’t unintentionally cre- ated even more isolated data silos through EHR deployment. l Patient engagement: Patients are increasingly demanding not only access to their clinical informa- tion online, but also the ability to conduct business online (schedule appointments, etc.). l Mobile devices: Home-based monitoring is ready to explode, but are you ready, willing and able to integrate information from these devices into your EHR? l Registries and analytics: Most use of EHR systems has been focused on care for individual patients, but increasingly will be leveraged for population health. l Value-based purchasing and clini- cal outcomes: Pure fee-for-service payment methodologies will soon be a thing of the past, while EHR systems will be used to demonstrate best-in-class clinical outcomes in a variety of innovative pay-for- performance initiatives. Morgan Stanley Smith Barney LLC, its affiliates and Morgan Stanley Financial Advisors do not provide tax or legal advice. Individuals should consult their tax advisor for matters involving taxation and tax planning and their attorney for matters involving trust and estate planning and other legal matters. Certified Financial Planner Board of Standards Inc. owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNER™ and federally registered CFP (with flame design) in the U.S. © 2013 Morgan Stanley Smith Barney LLC. Member SIPC. GP11-01363P-N09/11 7679847 MAR004 09/13 The Downtown Group at Morgan Stanley Brandon C. Taylor Portfolio Manager First Vice President Financial Advisor Patricia L. Rice, CFP® Financial Planning Specialist Vice President Financial Advisor 901 E. Byrd Street, Suite 2000 Richmond, VA 23219 804-780-3378 brandon.taylor@ms.com patricia.l.rice@ms.com www.morganstanleyfa.com/downtowngroup MECH JOB INFORMATION PROJ. NO.: 7679847 JOB NAME: Retail Chin Downtown Group Ad SPECIFICATIONS TRIM SIZE: 10” × 7.75” FINISHED SIZE: 10” × 7.75” BLEED: 0.125 BINDERY: NA NOTES You know how to make money. We know how to help you keep it. With wealth comes great responsibility. Every dollar should be cared for, nurtured and preserved. In other words, your wealth must be managed. As Financial Advisors, we have the experience and resources to assist in managing the many facets of your financial world—from investments and risk management to estate planning. By working together, we can create a detailed wealth plan to help protect and grow your wealth. Front Row: Kelly A. Leyfert, Registered Associate; Patricia Rice, CFP®; Tammy A. Maitland, Senior Registered Associate; Back Row: Kirsten A. Martin, Client Service Associate; Brandon Taylor; Gabriel Hoffman, Financial Advisor Associate I’ve been in the business for 35 years, and I can’t remember a time of such change, turbulence and uncertain- ty. I also can’t remember a time of such promise…promise that will in part be realized through health information technology. I strongly believe EHRs and health information exchange will be accepted as a standard-of-care, and not as optional or discretionary. We have much more work to do to ensure that health IT is as efficient for the physician as it is effective. Having a “day job” of working on health IT and population health is a luxury most of you don’t have… you have to accomplish all this while actually caring for patients! You’re to be commended for the changes you’ve undertaken in an industry that doesn’t change easily. It’s been a privilege to work alongside you. And if this is all just too stressful to embrace, perhaps we should simply follow the wisdom of Albert Einstein: “I never think about the future—it comes soon enough.” R Michael Matthews is CEO of MedVirginia. He can be reached at mmatthews@medvirginia.net or (804) 359-4500, ext. 4225. Thank you for your amazing support! These practices made generous gifts that took Access Now to new heights during 36 hours of the 2013 Amazing Raise fundraising event! Leading the way for other donors, their support helped us raise more than $16,000! ACCESS NOW THANKS YOU! ADVANCED ORTHOPAEDIC CENTERS COMMONWEALTH DERMATOLOGY, PC COMMONWEALTH RADIOLOGY, PC DERMATOLOGY ASSOCIATES OF VIRGINIA, PC ORTHOVIRGINIA PULMONARY ASSOCIATES OF RICHMOND, INC. VIRGINIA CANCER INSTITUTE, INC. VIRGINIA CARDIOVASCULAR SPECIALISTS VIRGINIA ENT VIRGINIA EYE INSTITUTE VIRGINIA UROLOGY
- 6. 6 FA L L 2 0 1 3 Technology and social distancing —the EMRB Y R I C H A R D P. W E N Z E L , M D , M S C . he sea change in re- cording the history and physical examina- tion as a result of the electronic medical record (EMR) is remarkable. Those of us witnesses to the before and after eras recall the desperate search for the bundled-up old records, the time-consuming and frustrating attempts to decipher the unique handwriting of prior clini- cians, the long queues in front of the radiology film room seeking to review earlier images. Technology has solved key problems for patient care. But something has been lost with the useful technology. In the pre-EMR era, the team room was a workweek and the business focus on patient throughput. Together these forces have transformed the team rooms’ banter to hundreds of syn- copated sounds of keyboard strikes. There is a sense of urgency felt but not stated—the need to record so much into the chart as quickly as possible— for the clock is ticking. In a thoughtful essay published in the Annals of Internal Medicine in 2010, Mike Edmond noted that attending on the wards is “much less fun and exhausting, [with] limited [time for] levity, banter and humor. I feel guilty if I ask the residents ques- tions about themselves or what they did over the weekend as they type (and they are always typing), because I’m distracting them and using pre- cious time.” Physician and author Abraham Verghese wrote about the issue in “Culture Shock—patient as icon, icon as patient,” a 2008 article in The New England Journal of Medicine. Concerned that the time of engage- ment of house staff and patient is shrinking, he noted, “Patients are handily discussed in the [call room] bunker while the real patients keep the beds warm and ensure that the folders bearing their names stay alive on the computer.” Like Edmond, Verghese is alarmed by the erosion of bedside skills of the modern house staff. “…the bedside is hallowed T …the interpersonal distancing created by the new technology has conspired with the residents’ 80-hour workweek and the business focus on patient throughput. buzz of verbal exchanges, as senior clinicians traded ideas with the house staff, reviewed the assessments and plans, engaged the students, and together rounded at the bedsides— spending time to illustrate important physical findings. In contrast, the team room today Richard P.Wenzel, MD, MSc. is relatively quiet, each member now facing a computer screen along the wall as a lonely typist. All eyes gaze at the periphery of the room, none at the center, none at each other, observing the unspoken expressions of the others. As a result we don’t know each other personally as well as we used to—the aspirations, worries, insecurities or confidence levels of students and house staff. To be fair, the interpersonal distanc- ing created by the new technology has conspired with the residents’ 80-hour
- 7. w w w . r a m d o c s . o r g 7 ground, the place where fellow hu- man beings allow us the privilege of looking at, touching, and listening to their bodies. Our skills and discern- ment must be worthy of such trust.” What’s amazing in comparing the old and new eras is the stunning increase in length of the daily notes. Some recorders copy and paste the latest laboratory data, radiology findings, special test results such as a cardiac echo; they often paste the notes verbatim from the consultants. Lastly, they list the examination they did and all pending tests. Up to this point, the new report is heavy with data but light on real information— what are now brief are the Assess- ment and Plan sections. I cannot help but notice how little I learn about the thinking of today’s clinician, what she really concludes are the key issues, and the summary evidence to support those; the steps to clarify the lingering questions remain unclear. To be sure, the pre- EMR days had considerably less in- formation totally, but often contained the reflective thoughts of clinicians, clearly outlined. It required time to think about the assessment and plan, but we thought that was the idea. In many corners of the hospital, think- ing time has been replaced with typ- ing activity. All of this is to say that there are trade-offs with technologi- cal advances. The repository for highly use- ful, legible and efficiently acquired information is a welcome effect of the electronic medical record. In my opinion what has been lost is the nar- rative describing both the inductive (pattern recognition) and deductive (logical) thinking of the bedside clini- cian. In the EMR era, one has to call the recording physician to know the underlying—often unstated—assump- tions and the current reflective ideas. Surely I don’t want to return to the days of the pre-EMR but only recapture those associated features that made life at the hospital more valuable. All technology separates people: patients from their families, patients from their physicians, physi- cians from each other. The current struggle, then, is to acknowledge that fact, make continual efforts to recon- nect, and to restore the direct com- munication useful for next steps such as patient management. In the future, what may help will be discarding the redundant informa- tion that is crowding the chart and currently discouraging a full read- ing of the clinical notes; shortening the follow-up recordings to essential bedside and laboratory findings, and focusing on the critical thinking. Right now the loss of this reflection— the active engagement of expertise, experience and thoughtful pursuit of truth—is an unfortunate adverse ef- fect of technology. When I was in graduate school for my MSc. degree from the Lon- don School of Hygiene and Tropical Medicine, I was introduced to the English ritual of teatime—30 minutes in the morning and 30 minutes in the afternoon. Initially I had the mis- guided thought that this is incredibly wasteful, a loss of productivity time, and one leading to inefficiency. What I learned quickly was that more than 80 percent of the faculty and all of us students showed up in one room for every teatime; and the vast exchange of information, mentoring, sharing of scientific and clinical ideas that occurred in those 30-minute periods was something never seen in the U.S. Of course the U.S. culture is differ- ent; we don’t get RVUs or reimburse- ment for that time; we feel tremen- dous pressure to keep going (typing). Yet more direct face-to-face talking with other clinicians, house staff and students would likely be more efficient. Importantly, it would add quality to our lives, quality lost with the advent of technology. I am reminded of the words of author and philosopher Robert Pirsig from his iconic book “Zen and the Art of Motorcycle Maintenance”: “We’re in such a hurry most of the time we never get much chance to talk. The result is a kind of endless day-to-day shallowness, a monotony that leaves a person wondering years later where all the time went.” With every distancing technology, including the EMR, we lose some part of our humanity—the connection between patient and physician, teacher and student, physician and colleague. We are marginalizing bedside teaching on the wards and the true exchange of information. With all the useful advance of technology we risk the loss of our key values. The challenge now is not to be a victim of technology but to seek ways to remold it to enhance the quality of life. R Dr.Wenzel is Professor and Former Chair of the VCU Department of Internal Medicine. He is the author of a medical thriller, “Labyrinth of Terror.” The Kay Janney InvesTmenT Group of Janney Montgomery Scott LLC InvesTInG for Income In a Low InTeresT raTe envIronmenT Askyourself…WhatamIhopingtoaccomplishwithmyinvestmentstrategy?AmIcompletelysatisfiedwithmycurrentinvestments? As an investor, you have many different strategic options. The Kay Janney Investment Group of Janney Montgomery Scott can help: • Provide downside protection. • Diversify your portfolio. • Potentially, produce additional income. How we Can Help You. Setting goals is an important part of life and financial planning. Without some planning, the odds of achieving the retirement lifestyle you hope for can drop significantly. We deliver with integrity, drive for results, and exceed expectations. We provide a spectrum of advice and solutions to fit your unique needs and goals. Your financial success is our priority, and our services can help you retire with the lifestyle that you deserve. ContaCt us todaY. We welcome the opportunity to speak with you about your investment and retirement planning strategies. Contact us today, and get started on the road to achieving your long–term financial goals. RobeRt F. KaY, sR. Senior Vice President/Investments pHilip H. JanneY Vice President/Investments tHe KaY JanneY investment GRoup of Janney Montgomery Scott LLC 804.595.9450 • 877.526.6397 www.kayjanneyinvestmentgroup.com THE KAY JANNEY INVESTMENT GROUP OF JANNEY MONTGOMERY SCOTT LLC, 1021 E. CARY STREET, SUITE 1000, RICHMOND, VA 23219 WWW.KAYJANNEYINVESTMENTGROUP.COM • MEMBER: NYSE, FINRA, SIPC Investing involves risk that should be considered prior to making any investment decision. Janney FAs are available to discuss these risk factors with you. Connect with us: B_Janney_Half Page Ad_2013-04_final_rev.indd 1 4/30/2013 4:40:18 PM
- 8. 8 FA L L 2 0 1 3 t first glance, storing patient data in “the cloud” sounded intrigu- ing to the IT experts at Virginia Eye Institute. Maybe it would help save money to back up their new electronic medical records system. It makes sense to look for savings, given that the costs for EHRs can be considerable—estimates range from $5,000 to more than $50,000 per provider. And that doesn’t include hiring consultants to work through the many details of customizing, installing, and ensuring quality con- trols. Ka-ching! Throw in hardware upgrades, lost productivity and the cost of extra staffing, and the total price tag can easily top $1 million. “So I can see why smaller practices go with the cloud” to store data, said Eric Hays, vice president of opera- tions at VEI. But at VEI—a practice with 38 providers who need customized records-keeping at 11 locations— Hays spotted a big problem with any business plan that would put his patients’ medical records in the hands of third-party servers. “Then your [electronic medical re- cords] supplier is keeping your data, Caveat Emptor: Rules of the Electronic Road B Y C H I P J O N E S A and if they were to go under, you’d have to make sure the contract has language that you’d get ownership of the data,” Hays said. “That’s why we like to have it internalized,” by using an offsite data center—Peak 10— which offers special security measures (such as fingerprint access), electrical backups, and other data recovery components. “I know the model is moving to the cloud, but in terms of a security issue, it’s nice to have control,” Hays said. Yet another practice administrator, Kit Young at Richmond Plastic Surgeons, takes a slightly sunnier view. “Two years ago I may not have considered the cloud, but in today’s market, there are many good options worth consid- ering during the evaluation process.” Decisions, decisions…. Interviews with practice managers and doctors show how wide open—and some- times confusing—this new technology terrain can be. They shared different approaches to how they customize records for physicians and nurses, working in billing and communica- tions features along the way. And, depending on their Medicare and Medicaid populations, they expressed varying degrees of interest in meeting Understand what you need the system to do and what data you need to collect. Eric Hays keeps a steady focus on electronic health records at theVirginia Eye Institute. the federal government’s Meaningful Use standards. But while their needs and ap- proaches differed, from pediatricians to plastic surgeons to OB/GYN offices, there was agreement to never forget the old adage, caveat emptor, or “let the buyer beware.” “When we first got quotes for IT, they were based on the minimum standards from the vendor,” recalled Leslie Bachmann, practice manager at the Skin Surgery Center of Virginia. She soon discovered those “stan- dards” were “the minimum to run their software and nothing else.” It will cost more once “you calculate all of your needs.” These practice managers, and one physician interviewed, said it’s important to determine all of the features needed and then have the software vendor provide solid price quotes. “Practices have other programs, outside of their patient medical records, that are required to KitYoung
- 9. w w w . r a m d o c s . o r g 9 run their day-to-day operations.” Her advice: “Work with your IT vendor to evaluate the cost of running all programs” if you want a true cost of upgrading your office. Understand what you need the sys- tem to do and what data you need to collect. Are you going to participate in Meaningful Use, the Patient-Cen- tered Medical Home, an Accountable Care Organization (ACO), and the Physician Quality Reporting System (PQRS)? If so, what PQRS measures would you like to collect data on? Not all vendors have this built in. How hard is it to retrieve data—and can you report out of the system, or do you need additional features (at a cost) to do so? Bottom line, said Young: “Make sure you have all you want listed in the final agreement before signing.” In the case of the Skin Surgery Center, which specializes in Mohs surgery, Bachmann and practice founder Dr. Christine Rausch wanted to make sure they purchased a system that guaranteed the best experience for patients and practitioners. They spent hours researching, meet- ing with vendors, talking with other physicians and other practice manag- ers, and paying visits to medical prac- tices to see their systems. They also ex- ercised self-discipline not to be driven by the government’s deadlines for Meaningful Use. But because they have a number of Medicare patients and a deadline approaching, Dr. Rausch said in late summer, “We finally decided we had to get it done.” While Rausch’s practice is smaller than VEI, she tackled many of the same data storage and transmis- sion issues. They also opted for an in-house data storage system, Rausch said, “because then if you change EMRs you don’t have to worry about [access] to your own data. The down- side is there’s more maintenance and cost, and it’s not as accessible when you’re out of the office.” After they finally settled on a customized system for dermatologists, they faced the next big decision point: How to get it up and running? Super users Young, administrator and direc- tor of information technology at Richmond Plastic Surgeons, gave this advice for preparing for the “go live” date for practices still transitioning to EMRs: “You can begin by having your patient forms ask the same questions in the same format that you’ll be ask- ing in the electronic record.” With the Meaningful Use require- ments—such as obtaining patients’ ethnicities— getting everyone on the same page as early as possible is even more essential, said Young, who has supervised the installation of records systems at several practices. “That’s something I’ll do two to three months out while working to build the sys- tem” to ensure the staff and practitio- ners “become accustomed to asking the question in the form that’s being asked” in the electronic record. Three months ahead of the “go live” date at Pediatric Associates of Richmond, “We pre-scanned a lot of charts,” said office manager Jo DiPer- na. This helped speed up the adoption of the electronic records, and for legal reasons, it’s crucial to keep consistent records on paper and in digital charts. Once this paper-to-digital work is done, it’s time to do something no EMR vendor can do for you: organize staff training and implementation. “Think about the work flow of your office, and how it ties in,” said Nicole Midulla, front desk supervi- sor at Pediatric Associates. So, for Leslie Bachmann (l), practice manager of the Skin Surgery Center ofVirginia, helped Dr. Christine Rausch find the right system. “Electronic road,” continued on page 10
- 10. 10 FA L L 2 0 1 3 “Electronic road,” continued from page 9 BSGN-1543 Ramifications Ad-Neuro 4.85x14.628_FIN_OL.pdf 1 6/26/13 2:46 PM example, when nurses and other office staff needed training in how to enter procedure codes, Midulla took screen shots of each new code in order to show everyone how it would look in the new system. Before going “live,” Midulla asked her staff to come in over the weekend for a dry run, with each person enter- ing 25 appointments into the EMR system. “It gave them time to ask questions without tying up the phone lines,” DiPerna said. At Virginia Ear, Nose and Throat, CEO Susan Shackelford said, “From my perspective, the best thing you can do is spend however much time it takes you to do the customization up front” for your system. And no matter how much you prepare to launch it, “When you go live, you must have ‘super users’ there because you can not think of all the things that are going to happen in real life.” Doctors also need time for training and hand-holding before the systems are active. A doughnut or two also doesn’t hurt. “Physicians in medical school and in residencies are taught what their styles or routine is in an exam,” said Young, “and an elec- tronic health record really changes the dynamic.” Electronic records should be con- figured to meet the treatment styles of physicians, who probably will show varying degrees of comfort at first. This isn’t simply a generational issue, Young observed. “I’ve had young physicians who are just as frustrated” by digitization as older ones. At VEI, Hays said, “90 percent of our doctors’ questions are about the speed of the system.” Using large- screen desktop computers—mandatory in the visually-driven world of eye care—it was important to invest to make sure the software runs as quickly as possible. Even then, he said, “We still had issues.” In this age of digital doctoring, new problems are bound to arise when electronic records become as much of a staple of practice as a stethoscope. Which is why, said Hays, “We hired a corporate trainer. Because eventually the support we were expecting from the vendor goes away.” VEI’s trainer puts on regular “lunch and learn” sessions, and the practice also started a help desk to answer questions about everyday glitches (printers that don’t work, glitches in data fields, and so on). According to Young, many soft- ware systems have testing at the end of training modules. “Sometimes soft- ware is a version or two ahead of the training,” she said. “I found this was true with a few different office-based systems, so I would develop my own how-to cheat sheets.” Over time, Young said, “I have often found that many clinicians learn by doing: see one, teach one, do one.” During training, she creates a “test patient” and works with the physician to enter information on the sample patient to practice “moving through the system.” She cautioned, “Just make sure you are able to designate in the system that this is a test patient, and the data does not result in final quality or meaning- ful use reports.” EMRs and patient safety Like any major shift in workplace flow and medical practice, the plusses and minuses seem to balance out. But when it comes to improving patient safety, the switch to electronic health records is a definite plus. “We’ve been able to mine our data and that extra information actually im- proves our patient safety,” said Brenda Burgess, practice manager of Virginia Women’s Center. Her practice “mines” the data weekly, “so if there’s some- thing missing in a record, we identify it in real time, and address it.” This data-mining capacity didn’t come with the practice’s original EMR software. “We had to take the technol- ogy to the next level,” she said. And given the improved safety features they’ve built-in, Burgess said the ef- fort—and the cost—was worth it. R Chip Jones is RAM’s communications and marketing director. Susan Shackelford, CEO of Virginia Ear, Nose and Throat, used to spend half of her time on IT-related problems. Now it’s down to about 10 percent.
- 11. w w w . r a m d o c s . o r g 11 Urology • Gynecology • Urogynecology • Physicial Therapy Please join us in welcoming Francie James, MD and Meghana Gowda, MD to Virginia Urology and to the medical community of central Virginia. Virginia Urology Women’s Health is a division of Virginia Urology. Appointments can be made by calling 804-288-0339. Dr. James obtained her medical degree from the Medical University of South Carolina in 2007. She completed her general surgery internship and urologic residency at Eastern Virginia Medical School. Following residency Dr. James completed a one year fellowship in genitourinary reconstructive surgery at Eastern Virginia Medical School. Her clinical interests include general urology, reconstructive surgery, male and female urinary incontinence, and urethral stricture disease. Dr. James grew up in South Carolina and attended Tulane University in New Orleans for her undergraduate studies. She and her husband Ennis now reside in Richmond with their young daughter. She will be seeing patients in our Stony Point and Reynolds Crossing locations. Dr. Gowda joins Virginia Urology as our first urogynecologist and one of the few in the region to have completed an accredited, 3-year combined fellowship program in Female Pelvic Medicine & Reconstructive Surgery. Dr. Gowda has been trained in clinical & surgical options for women with pelvic floor disorders and brings this expertise to the Urogynecology practice of Virginia Urology. Dr. Gowda was awarded her undergraduate and medical degrees from Virginia Commonwealth University. Following her time in Richmond, she completed her residency training in Obstetrics and Gynecology at New York University and Bellevue Hospital. Dr. Gowda then completed her fellowship in Female Pelvic Medicine & Reconstructive Surgery at Vanderbilt University in Nashville,Tennessee. Her clinical interests include female incontinence, pelvic organ prolapse, minimally invasive techniques, and complicated childbirth injuries. She will be seeing patients in our St. Francis, Stony Point and Reynolds Crossing locations. C M Y CM MY CY CMY K Rich Academy of Med - half pg.pdf 1 10/4/13 12:28 PM RAM events DATE MEETING/LOCATION/TIME January 14, 2014 Presidential Inauguration of Peter A. Zedler, MD Tuesday University of Richmond’s Jepson Alumni Center 5:30 p.m. cocktails, 6:15 p.m. dinner 7:00 p.m. presentation January 22, 2014 RAM White Coat Day #1 – Lobby Day at the Wednesday General Assembly Hilton Garden Inn, 501 E. Broad Street Richmond, VA 23219 8:00 a.m. – 12:30 p.m. February 18, 2014 RAM White Coat Day #2 – Lobby Day at the Tuesday General Assembly Hilton Garden Inn, 501 E. Broad Street Richmond, VA 23219 8:00 a.m. – 12:30 p.m. DATE MEETING/LOCATION/TIME March 11, 2014 General Membership Meeting Tuesday B. Rick Mayes, Ph.D-Keynote Speaker Associate Professor of Political Science Co-coordinator, Healthcare and Society Program University of Richmond’s Jepson Alumni Center 5:30 p.m. cocktails, 6:15 p.m. dinner, 7:00 p.m. presentation May 13, 2014 General Membership Meeting Tuesday Barry Duval, President and CEO Virginia Chamber of Commerce Country Club of Virginia 6031 St. Andrews Lane Richmond, VA 23226 5:30 p.m. cocktails, 6:15 p.m. dinner, 7:00 p.m. presentation Should you have questions about any of our upcoming meetings, please call the Academy at 804-643-6631. Drs. Melissa Nelson and Andy Vorenberg at April Member Social at Arcadia. Dr. Shaun Spadafora and son Jacob at RAM Family Night at Children’s Museum of Richmond.
- 12. 12 FA L L 2 0 1 3 E-mailing and texting are efficient, convenient, and direct methods to communicate in the dental and health care world, but they can be fraught with inadvertent security breaches. When e-mailing or texting replaces direct consultations and communi- cation with dental colleagues, the dental provider must take steps to en- sure the e-mails and texts are secure. Without appropriate safeguards, e-mailing and texting can lead to violations of the Health Insurance Portability and Accountability Act (HIPAA). Health care providers are smart- phone “super-users.” According to Make certain electronic communications ensure patient privacy B Y J U L I E S O N G , M P H , PAT I E N T S A F E T Y / R I S K M A N A G E M E N T A C C O U N T E X E C U T I V E , T H E D O C T O R S C O M PA N Y Manhattan Research, over 81 percent of health care providers use a smart- phone to communicate and access health information. The attractions are obvious: Texting and e-mailing reduce time waiting for colleagues to call back and may expedite health care by allowing necessary patient data to be sent and received quickly. Safeguard against HIPAA violations The very convenience that makes electronic communications so invit- ing may create privacy and security violations if messages containing pro- tected health information (PHI) are not properly safeguarded. Electronic messages among physician colleagues should be encrypted and exchanged in a closed, secure network. However, according to a member survey conducted by the College of Healthcare Information Man- agement Executives, 57.6 percent of those surveyed did not use en- cryption software. The underlying reasons for poor compliance with encryption could be due to lack of technical knowledge or to avoid the inconvenience of sending a message to someone who may not be able to unencrypt it. With penalties starting at $50,000 per HIPAA violation, safeguard- ing electronic messages should be of utmost priority. In addition to encrypting the messages, consider installing autolock and remote wip- ing programs on smartphones and computers. Autolock will lock the device when it is not in use, and requires a password to unlock it. This feature needs to be activated in the settings of the smartphone by activat- With penalties starting at $50,000 per HIPAA violation, safeguarding electronic messages should be of utmost priority.
- 13. w w w . r a m d o c s . o r g 13 ing the “screen lock” feature so that the phone will automatically lock after the phone has been inactive for a designated period of time. Remote wiping programs can erase data, texts, and e-mail remotely should the phone be compromised. Depending on the type of smartphone, there are different remote wiping applications that either come with the phone or can be downloaded. Both types of safeguards provide additional protec- tion if a device is lost or stolen. Ensure accuracy to avoid liability concerns A cavalier attitude when compos- ing an electronic message can pose a legal risk. The informal nature of some messages may at times lead to using shorthand, which can increase miscommunication. Additionally, de- leted messages are never fully deleted, as metadata (the “data behind the data”) is also producible in a law- suit. It’s important to ensure accu- racy—particularly with consultations, personal health information, or any other important text communication. Finally, electronic messages can- not substitute for a dialogue with a colleague concerning a patient. If there is a critical matter or any doubt about the communication, pick up the phone. Use available safeguards In some cases, an electronic record vendor may offer a secure e-mail network option to clients. If this is the case, be certain that the e-mail re- cipient is also utilizing encryption in response to your messages. Be aware that some vendor contracts attempt to shift liability risks resulting from faulty software design or decision support data onto the provider. The contract may also give rights to the vendor to utilize patient or provider data. Take Steps to Protect Your Practice Consider the following steps to safeguard your practice: • Enable encryption on your elec- tronic devices. • Have a texting policy that outlines the acceptable types of text com- munication and situations when a phone call is warranted. • Report to the practice’s privacy of- ficer any incidents of lost devices or data breaches. • Install autolock and remote wiping programs to prevent lost devices from becoming data breaches. • Know your recipient, and double- check the “send” field to prevent sending confidential information to the wrong person. • Ensure the metadata retention policy of the device is consistent with the record retention policy, and/or in accordance with a legal preservation order. • Ensure that your system has a secure method to verify provider authorization. • When conducting your HIPAA risk analysis, include text message content and capability. R As the nation’s largest physician-owned medical malpractice insurer, our insights into the practice of internal medicine have helped earn us the exclusive endorsement of the Richmond Academy of Medicine and have made us the first choice for RAM members. When your reputation and livelihood are on the line, only one carrier can give you the assurance that today’s challenging practice environment demands—The Doctors Company. To learn more, call 866.990.3001 or visit www.thedoctors.com. does your medical malpractice insurer know which drugs lead to lawsuits in internal medicine? the doctors company does. 20% coumadin 18% opioids 7% gentamicin 5% kenalog 5% prednisone drugs most frequently involved in medication-related malpractice claims against internists Source: The Doctors Company Exclusively endorsed by 4179_VA_Ramifications_Fall2013_flat_f.indd 1 10/2/13 11:08 AM The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appro- priateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered. ©2013 The Doctors Company (www.thedoctors.com). That’s the percent of 114 countries around the world reporting most patient data is still collected on paper. Only 45 percent of high income countries reported some level of adoption of electronic records. Source: World Health Organization, 2009 survey 90%
- 14. 14 FA L L 2 0 1 3 s Virginia Cardiovascu- lar Specialists was begin- ning to make its mark in Richmond in the late 1970s, its co-founder traveled to Eu- rope to study with the renowned phy- sician Andreas Gruentzig, a pioneer of balloon angioplasty techniques. “Bill [Dr. William Holland] stayed with him for several weeks and learned how to do it,” recalled Dr. Gan Dunnington, a cardiolo- gist who’s been with the practice for decades. Holland brought the skills back to Richmond, trained his colleagues and over the years improved care and treatment for countless patients. That spirit of cooperation continues today. A commitment to learning the latest techniques—and sharing that information—remains a cornerstone of VCS. “We’ve shared knowledge and stayed ahead of the curve,” said Dunnington. As the largest independent cardiol- ogy practice in Central Virginia, VCS is committed to being at the forefront tals. All VCS physicians are board-cer- tified, and many also have additional subspecialty training in cardiovascular intervention, carotid stenting, CT angiography, electrophysiology and peripheral vascular disease. The practice was founded in 1977 by Holland and Dr. Eric Kemp. Dr. John Fitzgerald joined soon after, followed by Dunnington. From there, the group has added many new physicians and absorbed several other practices over the years. Pulmonary medicine went out, vascular came in. As the practice grew in size and in scope, it also became more so- phisticated. “When we started out, Drs. Kemp, Fitzgerald, Holland and I would meet out in the parking lot around 11 o’clock and that was it,” recalled Dunnington. As VCS has grown, it’s gotten a lit- tle more difficult to meet in the park- ing lot between patients. A highly organized system of governance has replaced those get-togethers, with a pod system and regular physician and shareholder meetings. But VCS enjoys its status as an independent practice and tries to allow its physicians to have a fair amount of independence too, said Thomas. In all, VCS boasts about 200 employees, making it one of the larg- est independent cardiology practices in the commonwealth. Its size has allowed VCS to hire well-qualified administration and staff, in addition to its cardiologists. “We focus on hiring the best staff that will support our physicians and ensure their efficiency. These physi- cians have been really good about investing in their infrastructure,” said Executive Director Ann Honeycutt, who joined VCS after a career at Bon Secours. “We have the ability to run things well, improve the patient experience, and from a business office standpoint, keep [practice] viable. That’s essential, because, sadly, get- ting paid for the work doctors do has gotten very complex.” That attention to detail is some- thing the physicians appreciate, said Joyner. He also appreciates how ad- ministrators and practice leaders are proactive in issues that could influ- ence the field of medicine. “We are able to recognize some of these things that end up affecting all cardiologists,” he said. By staying in tune with local and national politics and the American College of Cardiology, VCS can flag issues that it feels it should act on. “We’ve got a lot of leverage as a large group to do that,” said Joyner. Thomas agrees. “Part of our job in this as good practitioners of cardiol- ogy is to ensure that we have a voice in some of the legislative [venues] or organizations that regulate our work.” Case in point: In the late 1990s, the group was part of a successful lobby to change laws to allow nuclear medicine to be performed in medi- VCS: Taking care of Virginia’s hearts since 1977B Y L I S A C R U T C H F I E L D A of clinical breakthroughs, improv- ing outcomes for patients and saving lives. “We’ve done a lot of firsts in the state,” said Dr. Shelton Thomas, the group’s president. Some of those firsts over VCS’ three decades include: • Coronary stents • Coronary vein graph • Carotid stenting • CRT device ICD • Hybrid maze • First robotic atrial fibrillation ablation • Stand-alone permanent pacemakers • CT heart scan and calcium screen/ score • Coronary angioplasty • Ventricular tachycardia ablation using the Impella left ventricular assist device “We feed off each other. One guy can take the lead and spread the ex- pertise around the practice,” said Dr. Charles Joyner, who has been with VCS for a decade. At VCS, 38 cardiologists practice in seven offices and at many area hospi- SheltonThomas, MD Gan Dunnington, MD Dr. Charles Joyner andVCS use high-tech equipment to diagnose and treat various heart conditions. Charles Joyner, MD
- 15. w w w . r a m d o c s . o r g 15 cal offices. “We went to the General Assembly every day and eventually convinced legislators to change the law,” said Thomas. “That has been a benefit for our patients.” Though they keep a close eye on the big picture of medicine, VCS physicians stress that they haven’t lost touch with the basic needs of patients, referring physicians and hospitals. “We try to focus on doing a great job of forming relationships with patients, physicians and being omnipresent in hospital and office, days and nights and weekends. That’s what traditionally brings in patients,” said Joyner. The ability to be a one-stop shop for all matters cardiac helps, too, and VCS offers a variety of screening and treatment options on site. It’s the only private area practice to maintain a computed tomography angiography (CTA) scanner and accredited cardiac CT. “We’re very proactive about figur- ing out what we need to do and still do good work,” said Joyner. “It’s a recipe we understand very well. “There are some fundamentals that never change. Patients have choices and you have to treat them well. Referring physicians like re- sponsiveness. They like competency. They like getting their questions answered and getting people seen in a reasonable time frame.” Though it works closely with area hospital systems, VCS isn’t ready to be part of them. “For us, it’s always been important to remain independent,” said Thom- as. “There’s a tendency to align with hospitals and we looked at that . . . no one group can support us, no one healthcare system can handle us, nor do we want that. “Despite the challenges of being an independent practice and the uncer- tainty in health care, our allegiance is to our patients. It’s always been that way.” VCS physicians say they’re look- ing forward to more “firsts” as they continue to care for patients. “What excites me clinically about cardiology today is prevention,” said Dr. William Coble. “We’ve seen a decline in deaths from cardiovascular disease with the advent of improved medicine and stenting, and our ability to intervene in heart attacks within that critical 90-minute window. “So we’ve decreased mortality. But the problem with that is that in- creased morbidity is still there. People are living longer with heart disease. We’re seeing more [atrial fibrillation], Bell Creek Medical Park ~ Boulders VI ~ Forest Medical Plaza Harbourside* ~ Waterside* ~ InteCardia ~ St. Mary’s ~ Tappahannock Darryn L. Appleton, MD Michael J. Ball, MD, FACC Robert M. Bennett, MD, FACC Michael J. Bunda, MD, FACC Carolyn A. Burns, MD, FACC Martin D. Caplan, MD, FACC Dean E. Caven, MD, FACC William L. Coble, Jr., MD, FACC Steven W. Cross, MD, FACC Aalya H. Crowl, MD, FACC John M. DiGrazia, MD, FACC Gan H. Dunnington, MD, FACC Michael B. Erwin, MD, FACC Charles G. Evans, Jr., MD, FACC John E. Fitzgerald, MD, FACC James B. Garnett, MD, FACC David M. Gilligan, MD, FACC Timothy W. Hagemann, MD, FACC Jiho J. Han, MD, FACC Brian K. Holdaway, MD, FACC C. Foster Jennings, Jr., MD, FACC Charles A. Joyner, MD, FACC Ashwani Kumar, MD, FACC Ramesh N. Kundur, MD, FACC Bradford J. Matthews, MD, FACC C. Mark Newton, MD, FACC Reza K. Omarzai, MD, FACC John R. Onufer, MD, FACC, FHRS Charles W. Phillips, MD, FACC Peter S. Ro, MD, FACC Sameer Rohatgi, MD, FACC Daniel A. Schneider, MD Saumil R. Shah, MD Robert E. Sperry, MD, FACC Shelton W. Thomas, MD, FACC S. Craig Vranian, MD, FACC Yvonne J. Weaver, MD, FACC Charles M. Zacharias, Jr., MD, FACC VCS has worked to improve the heart-health of Virginians for more than 35 years. From prevention and testing to cardiac and vascular interventions, we offer the finest cardiovascular care from some of the most respected physicians in the state. ImprovingVirginia’s Cardiac Health Since1977 V C S P HYS I C I A N S (804) 288-4827 • www.vacardio.com *New Locations Who better to help you with your practice’s insurance needs than an agency that was created by physicians? We understand your challenges like no other agency because we are governed by a board of physicians and practice administrators. To experience our personal services, call us at 877 | 226-9357 or, to request a quote visit www.msvia.org/RequestQuote. Who better to help you? MSVIA_HelpYou_ad_RAM2013.indd 1 4/4/2013 10:20:58 AM Dr. Gan Dunnington has seen a lot of changes over the years, butVCS’top priority has always been its patients. “VCS,” continued on page 16 arrhythmias and more heart failure. I think the true challenge is keeping these people living longer and staying out of the hospital.” VCS has a wealth of new techniques and tools to improve a patient’s chances of survival and
- 16. 16 FA L L 2 0 1 3 RichmondAcademyofMedicine 2201WestBroadStreet,Suite205 Richmond,Virginia23220 RRAMIFICATIONS quality of life, including: • New vascular technologies to help restore blood flow and avoid am- putations • Transcatheter aortic valve replace- ment (TAVR) • Lower levels of radiation exposure in scanners • New therapies such as hybrid ablation for arrhythmias and atrial fibrillation VCS is also on the forefront of developing new ideas by participat- ing in research studies. The practice employs two full-time research nurses and is looking to expand its program. There’s also increased interest in remotely monitoring patients to pre- vent readmissions, either with telem- etry or the use of physician extenders. “I feel like we’ve come full circle,” said Coble. “In a sense, we’re making house calls again, using technology.” “It’s very satisfying to fix people,” said Dunnington. “And it’s also very interesting to note that even after 35 years, we haven’t seen everything.” R Lisa Crutchfield is a Richmond-based freelance writer. “VCS,” continued from page 15 Let’soutsmartcancer. You’ve dedicated your life to the health of your patients. So when cancer comes into the picture, you want to refer them to the best team to help them fight. You’ll find that team at Virginia Cancer Institute. Our group includes four of Richmond Magazine’s five “Top Docs” for Oncology, and every physician here is committed to bringing the world’s latest advancements in cancer treatment to Central Virginia. We’re also focused on helping your patients live as full a life as possible while they’re battling cancer. Because we know that’s what you’d want for them, too. Call us or visit vacancer.com to learn more about the latest cancer treatments from the independent practitioners at Virginia Cancer Institute. SOUTHSIDE The Thomas Johns Cancer Hospital Phone (804) 330-7990 St. Francis Medical Center Phone (804) 378-0394 Sharon A. Goble, M.D. Pablo M. Gonzalez, M.D. Lawrence M. Lewkow, M.D. James T. May, III, M.D., F.A.C.P. Attique Samdani, M.D. Gisa Schunn, M.D. Will R. Voelzke, M.D. HANOVER Bell Creek Square Medical Office Park Phone (804) 559-2489 M. Kelly Hagan, M.D., F.A.C.P. Maurice C. Schwarz, M.D. S. McDonald Wade, III, M.D. WEST END Reynolds Crossing Phone (804) 287-3000 Joseph P. Evers, M.D. Elke K. Friedman, M.D. James L. Khatcheressian, M.D. Joshua J. McFarlane, M.D. R. Brian Mitchell, M.D. David F. Trent, Ph.D., M.D. May R I C H M O N D M A G A Z I N E TOP DOCS 2013 + WadeMcFarlane Mitchell Samdani Schunn Schwarz Trent Voelzke Evers Friedman Goble Gonzalez Hagan Khatcheressian Lewkow An in-office CT scanner saves patients a trip to the hospital.