The Maryland Medical Journal
Volume 12, Issue 2
QUALITY
What Is It &
Who Defines It?
Also InsIde:
Review of the
2011 Session of the
Maryland General Assembly
Go Paperless
and Get Paid
Register NOW for CMS Electronic
Health Record Incentives
The Centers for Medicare & Medicaid Services (CMS) is giving incentive payments to eligible
professionals, hospitals, and critical access hospitals that demonstrate meaningful use of certified
electronic health record (EHR) technology.
Incentive payments will include:
• Up to $44,000 for eligible professionals in the Medicare EHR Incentive Program
• Up to $63,750 for eligible professionals in the Medicaid EHR Incentive Program
• A base payment of $2 million for eligible hospitals and critical access hospitals,
depending on certain factors
Get started early! To maximize your Medicare EHR incentive payment you need to begin
participating in 2011 or 2012; Medicaid EHR incentive payments are also highest in the first year
of participation.
Registration for the EHR Incentive Programs is open now, so register TODAY to receive
your maximum incentive.
For more information and to register, visit:
www.cms.gov/EHRIncentivePrograms/
For additional resources and support in adopting certified EHR technology, visit the Office of
the National Coordinator for Health Information Technology (ONC):
www.HealthIT.gov
I
n
Volume 12
Issue 2
side
Features
Who Measures the Quality of Medical Care? 6
Barton J. Gershen, M.D.
U.S. Health Care: In Need of an Industrial Revolution? 8
Donald McDaniel, M.B.A., and Dan D’Orazio, M.B.A.
8
On page 8, Donald McDaniel and Dan
D’Orazio discuss why medicine needs to
take a "systems" approach to health care.
How is Quality Different from Practicing Good Medicine? 12
Thomas R. Jackson
The Role of MedChi's Quality Assurance Committee 14
Ronald Orleans, M.D.
Quality at Kaiser Permanente: Using the Population Care Model 15
Janice M. Beaverson, M.D., and Jaewon Ryu, M.D.
CMS Data Shows Gains in Key Quality Indicators through 16
Physician Quality Reporting System and ePrescribing
Incentive Program
Depa r tments
President’s Message 2
David Hexter, M.D.
Editor’s Corner 4
Bruce M. Smoller, M.D.
Word Rounds 24
Barton Gershen, M.D.
The Last Word 28
The Quality of Medicine: 18
A Senator Reflects on a Year of Living Medically
Maryland State Senator Jamin B. Raskin, Esq.
The Quality of Medicine: One Patient’s Opinion 19
Edward C. Ettin
Review of the 2011 Session of the Maryland General Assembly 20
Joseph ( Jay) A. Schwartz, Esq., and Stephen H. Johnson, Esq.
Send Him to J.C.:
Resetting Patient Expectations
PICK UP PHOTO
Gershen Pick up autumn
2006, p28
President’s Message
David Hexter, M.D.
It’s a warm spring Friday evening. Bill
monary resuscitation). But there was no
of the day, and, in many cases, at little to
is a middle-aged, overweight male who
doubt that only divine, rather than medical,
no personal cost. Such expectations beget
has just returned home after a being away
intervention could bring Bill back.
an infinite demand for healthcare services.
for a few days driving a long-haul truck.
A few weeks later, I attended to a
This is not sustainable. I submit that it is
I’ve just woken up for my second of three
106-year-old demented, mostly bedridden
we physicians who have the responsibility
emergency department night shifts in a
lady brought in by ambulance because her
to reset the expectations of our patients
row. As I arrive, I see
to be rational conthat the rack of charts
sumers of healthcare.
I submit that it is we physicians who have the
is full with 20 more in
It is something that
the waiting room, and
needs to be done at
responsibility to reset the expectations of our
two nurses have called
the most basic level—
patients...It is something that needs to be done
out sick. Our lives are
the physician-patient
at the most basic level—the physician-patient
about to intersect.
interaction. If we fail
Bill noticed a local
to lead in this regard
interaction.
carnival on his way
by providing sound
home and decided to
advice and informatake his wife and two
tion in every decision
kids out for some fun. It was bit crowded,
our patients and their caregivers make, othgranddaughter (a senior citizen herself )
but they enjoyed the rides and games. At
ers will take the lead for us. We, together
said she was not acting the same. A thorsome point after some funnel cake and a
with our patients, are not likely to be satisough evaluation did not reveal any acute
corn dog, Bill collapsed in full cardiac arrest.
fied with the results when others make the
etiology for this. I discussed the care plan
Paramedics stationed at the carnival arrived
decisions.
with her primary care physician, and we
quickly and instituted advanced cardiac life
How do we begin? When faced with
decided that she should go home and he
support. They did a robust job of trying to
patients or caregivers making demands
would check on her the next day. There
resuscitate Bill and subsequently brought
based on unrealistic or medically invalid
was no indication for admission to the
him to the hospital at around 11:30 p.m.
expectations, we need to address the underhospital. The granddaughter objected to
After another 30 minutes of futile effort,
lying beliefs and worries that motivated
this plan and demanded that grandmother
our team ended the resuscitation efforts
the request in the first place.1 We need to
be admitted. No amount of explanation
and he was declared dead.
would change her mind. I shared the feedexplain why their child does not need the
Shortly thereafter, the nurse and I met
back with her physician, and we arranged
fancy antibiotic or a test for a virus that has
with Bill’s family to deliver the bad news,
for admission. The next day, the woman
no bearing on treatment. Such explanaa job that is never easy. After I delivered
got out of bed and fell, sustaining a spiral
tions need to be carried out in a culturally
the bad news, Susan, Bill’s wife, became
femur fracture.
sensitive manner—there may be a local
very angry, told us what she thought of
Where do people develop their expectacustom or belief that is leading to the
our hospital, and demanded that Bill be
tions of what modern medicine can do?
demand. Finally, if no amount of explanatransferred. She wanted Bill transferred
Well, immortality is not on the list, yet.
tion will suffice, we need to say “no.”
to a certain hospital nearby-one with a
Most likely, it is from entertainment media.
MedChi will continue to advocate for
statue of Jesus Christ in its lobby, where
You may remember watching a popular
adequate resources to deliver the healththey could surely save him. Even after
medical drama in the 1990s, where every
care that our patients need. But we cannot
we explained that no hospital will accept
patient who underwent emergency thoadvocate for care that our patients want,
transfer of a dead patient, she would not
racotomy survived, and psychotic patients
but don’t need.
take no for an answer.
were admitted instantly to a psychiatric
So I thought about her request for a
facility with the snap of a finger. People
Reference:
moment. Despite training at that same
should develop their expectations based on
hospital, I had never seen an instance where
discussions with their physicians and other
1. Bell RA, RL Kravitz, et al.
a dead person could be brought to life. I did
healthcare providers, (not on what they see
"Patients' unmet expectations for
hear of one case of “Lazarus Syndrome”
on television dramas or in the movies).
care and the patient-physician relawhile I was there (Lazarus Syndrome is
Many people today expect to receive
tionship." Jour. Gen. Int. Med 2002
auto-resuscitation after failed cardiopulall the healthcare they want, at any time
17(11):817-24.
{
2
Vol. 12, Issue 2
Maryland Medicine
}
Quality=“Value?”
Editor’s corner
Bruce M. Smoller, M.D.
Quality: The general standard or grade
of something; a characteristic of somebody or
something; an essential identifying nature;
the highest or finest standard; a consultant’s
dream, a doctor’s nightmare.
You cannot read a medical journal, read
through a list of continuing medical education (CME) courses, read a newspaper
or listen to a “health care consultant’s”
alphabet soup laden description of his or
her activity without encountering the word
“quality” at least once, and more likely,
repeated scores of times. It is often used
in conjunction with terms such as “best
outcome” or the dreaded “pay for performance.” It encompasses the best and the
worst in our hopes for our patients, and it,
and all that it suggests, is here to stay.
Of course the concept of “quality” has
been inherent in medicine and medical training forever. We all strive, as our
forebears in earlier generations did, to
provide the best of the healing arts, skills
and science, to our patients and in the
service of better health, better quality of
life, longer life and pain free as possible.
But the word now, and ever since the
1970s, has meant something really different. It means…cost effectiveness. It
has little to do with the nobler qualities
of being a good physician. If that occurs,
so much the better, but it is not the prin-
cipal aim of quality as we know it today.
The principle aim of the those who work
in the field of quality, and which you
as practicing physicians are expected to
espouse, is saving money for the system.
It is to be matched, or so it is proposed
with the best possible outcome or the
least number of errors, but, for a number
of reasons, the term now quite explicitly
means that the physician will practice
in such a manner as to reduce costs.
Unless the consultant, or bureaucrat or
administrator is totally without scruple,
the reduction of cost is to come with
the added benefit of patient improvement. What is more, one of the guiding
principles of the “quality expert” is that
the patient improvement is to be unleavened…adherence to some abstracted rule
about outcomes will hopefully be consonant with individual patient improvement, but takes a back seat to the concept
of cost reduction if it must.
In the 1970s and 1980s the agencies
responsible for paying the majority of the
healthcare dollar began to look for ways to
cut back on the rising cost of medical care.
This increase in the bulk cost of care arose
from many sources…better, newer and more
expensive technology, increases in wages
generally across the board, expectations on
the part of the population of access to all of
these technologies, an aging population and
many more sources. The trends, however,
and the projections indicated a sharp up tic
in the slope of the spending line.
Health maintenance organizations
(HMOs) and managed care systems,
beginning in the 1970s, were the progenitors of today’s cost cutting alphabet
soup…Accountable Care Organizations
(ACOs), HMOs, Electronic Medical
Records (EMR), Pay for Performance
(P for P) and on and on. As Bennet and
Slavin write: “enter managed care.” By
attempting to reduce overutilization of
health care through utilization review,
“quality assurance” and “case management,” health maintenance organizations
“managed” care of their beneficiaries.”
They go on to say that the patients themselves began to complain, and sue the
HMOs for denial of care and eventually
these atrophied, leaving the shell to fertilize current efforts as cost cutting disguised
as “quality.” In the sense that quality
means excellence, this is misleading. The
true holy grail now is “value”… paying as
little as possible for the best possible care
and getting “good value.”
The efforts at quality control in medicine were preceded by those in industry.
Quality engineers such as John Deming
would help to make American manufacturing and services more competitive by
successfully defining “improvement” and
Editorial Statement
Editorial Offices
Montgomery County Medical Society
15855 Crabbs Branch Way
Rockville. MD 20855-0689
Phone 301.921.4300, ext. 202
Fax 301. 921.4368
sraskin@montgomerymedicine.org
Advertising
800.492.1056
Classified and Display Advertising Rates
Susan Raskin
301.921.4300, ext. 202
sraskin@montgomerymedicine.org
4
Vol. 12, Issue 2
Maryland Medicine
All opinions and statements of supposed fact
expressed by authors are their own, and not
necessarily those of Maryland Medicine or
MedChi. The Editorial Board reserves the right
to edit all contributions, as well as to reject any
material or advertisements submitted.
Copyright В© 2011. Maryland Medicine, The
Maryland Medical Journal. USPS 332080.
ISSN 1538-2656 is published quarterly by the
Medical and Chirurgical Faculty of Maryland,
1211 Cathedral Street, Baltimore, Maryland
21201, and is a membership benefit. All rights
reserved. No portion of this journal may be
reproduced, by any process or technique,
without the express written consent of the
publisher. Advertising in Maryland Medicine does
not imply approval or endorsement by MedChi
unless expressly stated.
DISCLAIMER: Some articles may contain information regarding general principles of law. They
are not intended as legal advice and cannot
be substituted for such. For advice regardig
a specific legal situation, consult an attorney
licensed in the applicable jurisdiction and with
appropriate training and/or experience in the
legal area in question.
identifying concepts such as Profound Knowledge and Systems
Analysis. He and his fellow quality engineers were successful
in differing degrees to the field of true quality improvement. It
should be noted also, that the IOM report on medical errors,
for all its flaws, singled out systems failures as the chief culprit of
hospital morbidity. Great good to patients can be achieved by
improving the quality of defective systems. Little good to patients
can be achieved by following blind calls for “quality” in the service
of saving money and dressing that up with a lot of algorithms
leading to nowhere, but fat consulting fees and government regulations set in place to satisfy the existence of a bureaucracy.
The efforts at quality control, both good and bad, are probably
here to stay in some form or other. Physicians must be not only a
part of the process, but the leading voices of sane quality control.
The problem is, this administration and others before it, both at
the federal and state level, do not trust physicians to come up with
“value.” Remember, we are not speaking here about QUALITY, even
though that is the buzzword. Instead of QUALITY, as in “I practice
good and effective medicine” you must read “VALUE.” Politicians
trust consultants who have not the slightest understanding of disease
to define that and propose the boundaries of our freedom of action
to practice medicine. This train has left the station. It is not going to
stop. We need to embrace the true meaning of quality medicine, not
its consultant- and government-driven definition, and help convey
this to the people who matter the most…our patients. Once they
understand the difference, the train will be on the right track. We
present this issue of Maryland Medicine in that spirit.
Did You Know?
The Patient Protection and
Affordable Care Act (PPACA) has
created between 47 and 159 new
commissions and boards, many of
which will monitor quality.
Maryland Medicine
Vol. 12, Issue 2
5
Who Measures the Quality of
Medical Care?
EDITOR EMERITUS
Barton J. Gershen M.D., Editor Emeritus
Within the last decade the practice of medicine has dramatically changed. Solo practitioners are rare and small group practices
are on the endangered species list. Over 50 percent of American
physicians are currently employed by hospitals or large, multispecialty groups. Payment for physician services is largely through
third party health insurers and has steadily decreased, despite the
inexorable rise in overhead expenses. The federal government has
enacted a series of laws that regulate and often restrict the activity
of many physicians. Submission of prescriptions electronically and
the implementation of electronic health records are among the
many mandates, punishable by law if physicians fail to implement
them. Recent polls by Investor’s Business Daily1 and by the Medicus
Firm indicate that between 28 percent and 46 percent of physicians
intend to leave practice when the Affordable Care Act is initiated.
Throughout this entire revolutionary period, the government continues to claim that the changes mandated will benefit
patients by significantly improving the quality of health care. In
the last issue of Maryland Medicine we discussed the ambiguity
of the term “quality,” the disparate ways in which it is measured,
and the failure to reach consensus on its meaning. Now, at last, we
have a definitive way to evaluate the quality of medical care.
In 2009 Congress passed the American Recovery and
Reinvestment Act (ARRA), often simply called the Stimulus
Bill. Unheralded in that legislation is a section authorizing the
president to appoint a board known as the Federal Coordinating
Council for Effectiveness Research. This panel consists of 15
members and is authorized to investigate and approve the best
treatment options available. The Council has been allotted 1.1
billion dollars to encourage this research, which will be distributed
among three government agencies – the Agency for Healthcare
Research and Quality (AHRQ), National Institutes of Health
(NIH), and the Center for Disease Control and Prevention
(CDC) – as well as to non-government facilities that are engaged
in effectiveness research.
The 15 members of the Coordinating Council are all federal employees selected from NIH, HHS, CDC, the Veteran’s
Administration, the Office of Management and Budget (OMB),
and the Department of Defense (DOD). Ten members are
physicians – none of whom are practicing doctors. Comparative
Effectiveness Research (CER) has been defined thus:
Comparative effectiveness research is the conduct and synthesis of
research comparing the benefits and harms of different interventions
and strategies to prevent, diagnose, treat and monitor health conditions
in “real world” settings. The purpose of this research is to improve health
outcomes by developing and disseminating evidence-based information
to patients, clinicians, and other decision-makers, responding to their
expressed needs, about which interventions are most effective for which
6
Vol. 12, Issue 2
Maryland Medicine
patients under specific circumstances. To provide this information,
comparative effectiveness research must assess a comprehensive array of
health-related outcomes for diverse patient populations and subВ­groups.
Defined interventions compared may include medications, procedures,
medical and assistive devices and technologies, diagnostic testing, behavioral change, and delivery system strategies. This research necessitates the
development, expansion, and use of a variety of data sources and methods
to assess comparative effectiveness and actively disseminate the results.
The definition above is not meant to exclude randomized trials; however, these trials would need comparator arms other than placebo and be
representative of populations seen in “real world” practice.2
It has also been defined this way:
Comparative Effectiveness ResearchВ (CER) is designed to inform
health-care decisions by providing evidence on theВ effectiveness, benefits, and harms of different treatment options. The evidence is generated from research studies that compare drugs, medical devices, tests,
surgeries, or ways to deliver health care.3
Few physicians would dispute the value of such information –
it would fulfill the very definition of “evidence-based medicine.”
However, there are several questions about the characterization
of “quality” that linger. A section of the American Recovery and
Reinvestment Act states the following:
The Secretary shall establish a payment modifier that provides for differential payment to a physician or a group of physicians…. based upon the
quality of care furnished compared to cost.4 (Emphasis mine)
In other words “quality” is being further defined as cost of treatment/number of years the patient will benefit from that treatment.
“Quality,” therefore, has a price tag associated with it. Nonetheless,
even a cost-effectiveness definition of “quality” may be acceptable
to physicians. However, three nagging questions remain: (1) How
will this comparative effectiveness research be conducted? (2) Are
Council members qualified to evaluate the best therapy on such a
plethora of illnesses? [“…given the large number of important clinical questions, it will not be possible to provide reliable empirical efficacy,
effectiveness, and cost-effectiveness data for every question to help guide
individual decision-making.”4] (Emphasis mine). (3) Is there a conflict of interest within the Council?
The ARRA legislation answers the first question by authorizing the use of meta-analyses, and randomized control trials as well
as simple observations, to ascertain the comparative effectiveness
of various treatment protocols. Response to the second question
is more difficult. There are ten physicians on the Council, none of
whom are current practicing physicians.
Thomas Valuck, M.D., has a J.D. as well as an MHSA,
and has been a senior vice-president at Strategic Partnerships
National Quality Forum. He is also a senior advisor at the
Centers for Medicare and Medicaid.
Carolyn Clancy, M.D., is the Director of the Agency for
Healthcare Research and Quality.
David Hunt, M.D., works in the office of the National
Coordinator for Health Information Technology.
Elizabeth Nabel, M.D. is Director of the National Heart, Lung
and Blood Institute at N.I.H. She is a cardiologist with extensive
clinical and research experience.
Garth N. Graham, M.D., M.P.H., is Deputy Assistant Secretary
in the Office of Minority Health. He is a cum laude graduate of Yale
University and board certified in Internal Medicine.
Rosaly Correa-de-Araujo, M.D., M.Sc., Ph.D., is Deputy
Director in the Office on Disability at HHS. She is a cardiovascular pathologist with numerous research publications.
Jesse L. Goodman, M.D., M.P.H.,В is the Acting Chief
Medical Officer of FDAВ and its Director of the Center for
Biologics Evaluation and Research. Previously Dr. Goodman was
Professor of Medicine and Chief of Infectious Diseases at the
University of Minnesota.
Joel Kupersmith, M.D., isВ Chief Research and Development
OfficerВ for the Veterans Administration. Dr. Kupersmith was
previously Professor of Medicine at the Mt. Sinai School of
Medicine and Director of Clinical Pharmacology.
Michael Kilpatrick, M.D., isВ Director of Strategic
Communications for the Military Health System,В Department of
Defense. He is a consultant in Infectious Diseases and the author
of numerous papers on tropical medicine and infectious diseases.
Ezekiel J. Emanuel, M.D., Ph.D., is theВ Special Advisor for
Health Policy in theВ Office of Management and Budget. He
is a chair of the Bioethicist at the NIH. His book,В Healthcare,
Guaranteed: A Simple, Secure Solution for America and his article “Principles of Allocation of Scarce Medical Interventions”5
explain the principles for rationing of care.
It appears that the credentials of these ten – as well as the five
non-physicians on the Council – are impeccable. Their ability
to sift through the vast scientific literature and to evaluate best
treatment modalities seems indisputable, but will undoubtedly be
incomplete given the enormous task.
Finally, the third question – that of a possible conflict of interest
– is more problematic. The federal government is painfully aware
of the burgeoning cost of medical care – currently at 17 percent of
Gross Domestic Product (GDP). Congress and the current administration are desperately seeking ways to curb those growing costs.
Linking quality of care to the cost of that care and dictating which
methods of therapy are compensable, is one effective means of limiting those costs. However, since each member of the Coordinating
Council for Comparative Effectiveness Research is a government
employee, if there are several therapeutic options, might they not
choose an option based on cost rather than usefulness? (They are,
after all, cognizant of their employer’s wishes.)
Dr. David Janda6 believes that the formula of cost of treatment/length of time the patient will benefit from that treatment will produce a ratio, which will determine whether the
government will or will not pay for that therapy. “Quality” of
health care has, therefore, been defined for us and the seeds of
health care rationing have been planted.
MedChi Alliance Report
Mano Nava, President
The 2011-2012 elected officers of the Alliance to
MedChi, the Maryland State Medical Society are:
President: Mano Nava
Alleghany County Medical Society
President Elect: Gail Johnson
Frederick County Medical Society
Vice President: Claire Jensen
Baltimore City Medical Society
Recording Secretary: Lorraine Ashker
Allegany County Medical Society
The main objective of the Alliance to MedChi during
the coming year is to continue supporting the efforts of
past president, Michele Kalish, to expand the Safe Disposal
of Medicine project. Through this worthwhile project, the
Alliance contributes to the improvement of the health and
safety of all Americans. One of the community needs that
the Safe Disposal of Medicine project hopes to address is drug
abuse, particularly among young children and teenagers.
Members will continue to distribute informational materials to physician offices, departments of health, libraries, and
various other services that support these worthwhile endeavors as well as participate in the annual Drug Take Back event.
Other projects to promote good health in communities will
continue within each of the county medical society Alliances.
These projects include supporting domestic violence shelters
and children at risk, providing booklets for children helping
them to master the skills to cope with anger, resolve conflicts
and build self-esteem, be aware of sun safety, exercise with
seniors and financial support that provides scholarships for
health-related education. The Alliance to MedChi will also
continue to work on raising membership at both the county
and state levels.
As ye sow, so shall ye reap.
Barton J. Gershen, M.D., Editor Emeritus of Maryland Medicine,
retired from medical practice in December 2003. He specialized in cardiology and internal medicine in Rockville, Maryland. For a complete list of
references contact 301.921.4300 or sraskin@montgomerymedicine.org.
References:
1. Investor’s Business Daily May 11, 2011.
2. (http://www.effectivehealthcare.ahrq.gov/index.cfm/
what-is-comparative-effectiveness-research1/).
3. Agency for Healthcare Research and Quality, U.S. Dept.
of Health and Human Services.
Maryland Medicine
Vol. 12, Issue 2
7
U.S. Health Care:
In Need of an
Industrial
Revolution?
Donald McDaniel, M.B.A., and Dan D’Orazio, M.B.A.
Health care is an industry in dire need of an industrial revolution. Many of us are familiar with the proof points: national
expenditures of $2.5 trillion growing well in multiples of the
Consumer Price Index and consuming almost 17 percent of our
economy; marginal public health indicators; a well-demonstrated
incidence of iatrogenic errors that are maiming and even killing tens of thousands of people each year. Why, in the richest
and most productive country in the world, can’t we change our
trajectory-from a cost, quality, and safety perspective?
Among other elements, surely a key assessment is that we
lack a systems approach in health care-we need to industrialize medicine-at least the substantial parts of the medical
complex that treat common illnesses and injuries and produce
repetitive services.
What would industrializing medicine mean? It would require
leaders in health care to take the lead from other industrialized
sectors that have developed a core understanding of variance in
their businesses. Some variation is acceptable-we can live with
it, but we need to understand it. Most variance is not productive, and studying the root causes of variation and how we might
address it is paramount to system improvement. At a macro level,
we also need structural change in health care. Today, providers do
not focus on managing the health status of patient populations.
Instead, providers deliver care on discrete, episodic patient needs.
While admirable, this approach is inefficient and unsustainable.
We need to move to building sustainable health organizations,
organizations built to meet the triple aim of continuous improvement in cost, quality and safety. Sustainable organizations will
redefine the value proposition and maximize the utility we gain
from a product or service per unit cost. We believe that health
care providers who commit to an industrial revolution can build
sustainable health organizations.
8
Vol. 12, Issue 2
Maryland Medicine
As mentioned, one glaringly problematic issue facing U.S.
health care today is marginal quality and safety. The data are
remarkably daunting and disheartening: at least 100,000 preventable deaths, 7,000 deaths tied to adverse events involving
prescription drugs, and millions of hospital-acquired infections
and adverse drug reactions. Today, we casually recite these statistics, as if to shrug our shoulders and say “healthcare is a part
art, part science with many variables-it’s very difficult to perfect.”
These shocking, or not shocking any more, data, are not cited
here to demean or diminish the millions of caretakers dedicated
to serving the myriad needs of their patients every day. They are,
however, meant to serve as smelling salts of sorts, to wake us up
from the ether that has lulled the health care industry into accepting the status quo. All constituents should be railing against these
staggering shortcomings. To put this in perspective, imagine if
200 fully loaded jumbo jets fell out of the sky every year and all
of the passengers were killed. Who would ever get on a plane?
In healthcare, when we kill 100,000 people a year unnecessarily,
somehow an incremental approach is acceptable. What’s more,
the scope of the problem may be much worse than we have ever
imagined. An April 2011 Health Affairs article found that adverse
events “occurred in one-third of all hospital admissions” in the
authors sample, 10 times more than previously cited.
Lessons We Can Learn
While at a recent conference with a number of executive
health care leaders, we facilitated a panel discussion about opportunities for health care improvement. The panel included the
CEO of a large multi-national with varied business interests
throughout the world. As the discussion honed in on quality in
health care, the group articulated a number of factors driving the
marginal results-industry fragmentation,
the concern that technology deployment
is overwhelmingly driving costs (even in
situations where that technology offers
dubious efficacy), a lack of quality standards or evidence-based practices, and
an almost complete lack of transparency
regarding quality, safety, and specifically,
the level of adverse events (near-misses
and “�never events”-those things that
should have never happened). Two critical
business process activities were discussed:
errors of omission and errors of commission during the various transitions of care
(exacerbated by the significant system
fragmentation and lack of information
interoperability) and the arena of medication management. After listening as
to the panel rail against the many challenges facing health care, the CEO said,
“I consider myself an industrialist, and
have been involved in many businesses in
my career-from logistics to technology to
appliances to engines-and I can identify
times in all of those businesses’ lifecycles
when they faced exactly the same kinds of
issues. We solved the problems by committing to understanding the variances
and their root causes. We took a systems
approach to solve the problem-in other
words, health care may not be as unique
as we claim it to be.” (paraphrase). He
went on to suggest that sustainability in
health care will require a standards-based
infrastructure, and those who assume a
systems approach to understanding variation in process and outcomes will be
able to resolve long-standing, seemingly intractable issues. In short, providers
need to adopt a population management
approach and develop the competencies to
manage-competencies that will leverage
various information technologies, decision
support and (remote) telemetry functionality, and advanced analytics. These will
be the bedrock of the new era of accountability in health care.
As suggested by the CEO on our
panel, there are a number of lessons
that we can learn from industries that
have prioritized quality and safety. First
and foremost, quality improvement means
product/service improvement and margin improvement. As Dr. David Nash,
the Founding Dean of the Jefferson
School of Population Health on the campus of Thomas Jefferson University in
Philadelphia, Pennsylvania, states as his
immutable rule (and students of competitive industries know already), “high qual-
ity health care costs less.” We feel these
opportunities for dramatic improvement
are best demonstrated when looking at
the tremendous safety improvement in
two industries; airlines and automobiles.
Airlines
We almost take it for granted, flight
safety that is. Save few adverse incidences
of fatal crashes, we have become accustomed to departing and arriving safely.
Those who are frequent fliers, and even
relative novices, barely pay attention to the
safety explanation of where the flotation
devices reside, or how the oxygen masks
will deploy. This is due in large part to the
airlines track records and singular focus on
safety. In the aviation industry, there is no
room for error. Miraculous landings like
the one handled by Sully Sullenberger in
the Hudson River become lore. However,
all generally have the sense that plane
crashes generally spell devastation.
There is no corollary, or better yet,
there would be no acceptance of healthcare’s iatrogenic errors in the aviation
business. Airlines have invested tremendous sums into their technology, training, and process innovations to deliver a
safe passenger experience. The data bear
this point out emphatically. The National
Transportation Safety Board reports that
from 1991 to 2009, departures increased
28 percent and flight hours have escalated by 50 percent. While flight times
and volumes are up significantly airlines
have become safer during this timeframe.
Accidents per 100,000 flight hours have
declined by 28 percent, and accidents
per 100,000 departures have fallen by
11 percent. In the recent past, commercial jet fatalities occurred once every
140 million miles flown. By 2000, safety
had improved 10-fold and commercial jet
fatalities occurred once in every 1.4 billion
miles. This improvement comes from the
direct cooperation and participation of
key stakeholders including manufacturers,
pilots' groups, civil aviation associations,
government regulatory authorities (such as
the U.S. Federal Aviation Administration
or European Joint Aviation Authorities),
and operators (Boeing)1
When accidents do occur, intense
investigations ensue, with the only goal
of understanding the cause. Efforts to
recover the black box flight recorder information, find debris, and reconstruct the
plane are conducted with painstaking
Editor
Bruce M. Smoller, M.D.
Editor Emeritus
Barton J. Gershen, M.D.
Editorial Board
Timothy D. Baker, M.D., M.P.H.
Steven Brotman, M.D., J.D.
John W. Buckley, M.D.
Tyler Cymet, D.O.
Mark G. Jameson, M.D., M.P.H.
Sallie Rixey, M.D., M. Ed.
Sandra Retzky, D.O., M.B.A.
Stephen J. Rockower, M.D.
Director of Publications
Susan G. D’Antoni
Managing Editor
Susan A. Raskin
Production
Nicole Legum Orders
MedChi, The Maryland State Medical Society
President
David A. Hexter, M.D.
President-Elect
Harbhajan S. (Harry) Ajrawat, M.D.
Immediate Past President
Murray A. Kalish, M.D., M.B.A.
Chief Executive Officer
Gene M. Ransom, III, J.D.
2010-2011 Board of Trustees
Brian H. Avin, M.D.
Tyler Cymet, D.O.
David E. Denekas, M.D.
Chinnadurai Devadason, M.D.
Reed A. Erickson, M.D., M.B.A.
Katie Fan
Jeffrey R. Kaplan, M.D.
George S. Malouf, Sr., M.D.
Ira D. Papel, M.D.
Shannon P. Pryor, M.D.
Stephen J. Rockower, M.D.
Mark S. Seigel, M.D.
Catherine Smoot-Haselnus, M.D.
Benjamin Z. Stallings, M.D.
Brian M. Thomas, M.D.
H. Russell Wright, Jr., M.D.
James J. York, M.D.
BYLAWS COUNCIL
Co-Chairs: J. Ramsay Farah, M.D. & Joseph Snyder, M.D.
LEGISLATIVE COUNCIL
Chair: James J. York, M.D.
Boards & Commission Committee
Chair: Stephen J.Rockower, M.D.
Health Insurance Committee
Chair: Gary W. Pushkin, M.D.
Public Health Committee
Chair: Brooke Buckley, M.D.
MEDICAL ECONOMICS COUNCIL
Chair: Joseph Zebley, M.D.
Information Technology Committee
Chair: George H.A. Bone, M.D.
Payor Relations Committee
Chair: Charles Samorodin, M.D.
Products and Services Committee
Chair: Vinu Ganti, M.D.
MEDICAL POLICY COUNCIL
Chair: Mollyann G. March, M.D.
Disaster Preparedness Committee
Chair: Cynthia Webb, M.D.
Disparities in Health Care Committee
Chair: Dianna Abney, M.D.
Ethics and Judicial Affairs
Chair: Regina Hampton, M.D.
Public Health Committee
Chair: Jeffrey Kaplan, M.D.
Maternal & Child Health Subcommittee
Chair: Lillian Blackmon, M.D.
Prescription & Non-Prescription Drugs with
Possible Abuse Potential Subcommittee
Chair: Marcia D. Wolf, M.D.
Quality Committee
Chair: Ronald J. Orleans, M.D.
OPERATIONS COUNCIL
Chair: Audrey Corson, M.D.
CME Review Committee
Co-Chairs: Ambadas Pathak, M.D. & Lawrence Yap, M.D.
Finance Committee
Chair: C. Devadason, M.D.
Membership Committee
Co-Chairs: Harry Ajrawat, M.D. & Shannon P. Pryor, M.D.
Performing Arts Medicine Committee
Chair: Alan J. Sweatman, M.D.
Personnel & Compensation Committee
Chair: C. Davadason, M.D.
Committee on Scientific Activities (COSA)
Chair: Steven F. Crawford, M.D.
Communications and Public Relations Council
Chair: Bruce M. Smoller, M.D.
Maryland Medicine
Vol. 12, Issue 2
9
effort. It is important to note that while the industry has a good
safety reputation as a whole, quality disparity, like in healthcare,
remains. The odds of being killed on a single airline flight on the
top 25 airlines with the best accident rates are one in 9.2 million.
Alternatively, odds of being killed on airlines with the bottom 25
accident rates are one in 840,000, more than 10 times. 2
Automobiles
There were more than 255 million vehicles in the United
States as of 20083. More cars, more drivers, more traffic, and perhaps surprisingly, many fewer motor vehicle crash deaths (Exhibit
1) over the past 35 years. As the number of miles driven increased
by 505 percent (from 1950 to 2007), the number of fatalities
increased by only 22 percent. One need not be an auto expert to
identify the reasons for these improvements: safer vehicle design
and testing, the social stigma attached to impaired driving, driver
education, law enforcement, public policy initiative, etc. Finally,
the heightened sensitivity of consumer demands about safer cars
has compelled manufacturers to truly make safety job one.
Exhibit 1
Zero Fatalities, Zero Injuries, Zero
Accident
Would any car manufacturer be so bold as to say that it will
design a car that will prevent fatalities, injuries and accidents?
Volvo has. In 2008, Volvo told the world that by 2020, it will
achieve such a feat. The auto maker synonymous with safetydriving such product innovations as crumple zones, side airbags,
and rear facing seats—now endeavors to create a system of technology to protect drivers and passengers from harm, regardless
of the climate, the environment, or the capability of the operator
of the vehicle. Volvo’s Senior Manager for Safety and Strategy
stated that “if we move forward a decade or two, you and I at that
time won’t accept situations where we would have the possibility
of getting hurt or even worse killed in a car.”4 Perhaps Volvo
is delusional. How can a car manufacturer account for primary
driver errors, inclement weather, wildlife striking cars at 55+ miles
10 Vol. 12, Issue 2
Maryland Medicine
an hour, drunk driving, tire defects, etc? Or perhaps safety is so
core to Volvo’s DNA that its unwavering commitment will drive
the once unthinkable: a zero fatality, zero injury, and zero accident
car. Volvo’s track record for safety is, after all, pretty good.
Tools of Transformation
So, what are health care providers to do, particularly physicians in
practice today? There is so much turmoil, and the traditional challenges of running a small business have been exacerbated by low
reimbursement, increased malpractice risk, and competition from
hospitals increasingly employing physicians. Above all, and without
regard to the extreme financial challenges inherent in our system,
health care is fundamentally broken, dysfunctional, and some would
say, dangerous. It is a system in need of transformation.
Despite some conventional wisdom counter, the industrialists
all understand that technology is not a strategy for improvement,
but an enabler of improvement-that the core strategy has to be
around a system composed of a series of practiced and coordinated processes. This seems to make sense when one considers
that most errors in health care occur “at the margin”, during transitions of care-which test the fragmented delivery system’s ability
to manage activities that require coordination. As Dr. Devi Shetty,
famous Indian heart surgeon and entrepreneur, suggests, what
we really need in health care is not product improvement, but
process improvement. Dr. Shetty, perhaps best known as Mother
Teresa's cardiac surgeon, offers cutting-edge medical care in India
at a fraction of what it costs in the United States, or elsewhere
in the world for that matter. His flagship heart hospital charges,
on average, about $2,000 for open-heart surgery; hospitals in the
United States are paid between $20,000 and $100,000, depending
on the complexity of the surgery. And the outcomes at his hospital are as good as or better than procedures here in the United
States. Ever-vigilant about his “system of care”, he has commented, “in health care you can't do one big thing and reduce the
price,” Dr. Shetty says. “We have to do 1,000 small things.”
We believe there to be at least three critical examples of
technologies and delivery system innovations that might be
game changers, driving true progress toward the triple-aim:
enhanced clinical decision support, interoperability, and population health management.
Much has been made of financial incentives for providers
who adopt certified electronic health records (EHR) and achieve
meaningful use. But EHR is just one tool in the shed of available
clinical decision support. Real-time decision support includes the
entire (evolving) family of remote monitoring technologies that
support patient care even when the patient is not in the physical
presence of the clinician. Remote telemetry allows providers in
distant settings to monitor the care of patients in acute settings,
and tele-health applications will allow better diffusion of expert
care in health professional shortage areas. One recent interesting example of advancing clinical decision support is Watson,
the IBM wunderkind computing powerhouse; its novelty is in
its ability to process natural language requests and queries and
respond to them accurately. As the volume of medical literature
doubles every seven years, expect even more advances in how clinicians might synthesize the information, deliver it “embedded”
in their normal workflow, and offer it semantically and contextually correct. Moving forward, clinicians will be more valued
as “choreographers”, managing the various information sources,
knowledge bases, and referral options. In this way, technology
will supplement, not supplant physicians.
Digitizing clinical data through EHR deployment is an important and necessary first step in our journey toward improvement.
Interoperability, then, is the critical next step in connecting the
health care ecosystem to allow true transparency. Interoperability
will provide the “interstate highway system”-a standards-based
information-sharing infrastructure that will allow disparate
health records systems to communicate with each other. It
will, more importantly, allow for the creation of connected care
communities-providers, patients, payers, and health services
linked together with seamless and secure clinical information
sharing and community-based workflows-that will truly unleash
the transformative potential of health information technology.
Health information exchange will also force adoption of information-sharing capabilities among various health care system
participants-;for example, e-prescribing adoption is currently at
36 percent among physician practices, when 91 percent of pharmacies can accept electronic prescriptions-these trading relationships could be much more efficient if all parties were using
latest available technologies. Efforts to build these information
exchanges will be both public and private, possibly culminating
in a “network of networks” architecture, with a vision of operating
a digital system akin to what many of us today enjoy in banking
and financial services.
Finally, because the metrics of health care are not favorable, it
is safe to assume that early, frequent discussions about payment
reform will continue, and that providers will be asked to adapt to
new financing models. One thing seems certain, accountability is
sought, and a population health management approach will take
center stage. What does this mean to you? Very simply, regardless of
specialty, you will be required to participate as a member of a health
care team, commit to evidence-based medicine standards and use of
EHR, change the way you work, proactively report on progress, and
ultimately, be at risk, financially and clinically, for the outcomes you
participate in producing. So, 10 years after hearing provider organizations of all shapes and sizes disavow capitation and managed
care, we are moving back in that direction. Accountability, transparency, and results will be front and center. Whether as a formal
member of an Accountable Care Organization, Patient-Centered
Save the Date!
Presidential Gala
Medical Home, or other entity, this new world will require a more
holistic model of health care-as sustainable health organizations
will tackle the market requirement for a reinvigorated integration
of health care delivery and financing.
Despite all of its challenges, health care has no choice but to
dramatically alter its quality and safety trajectory. Years behind
other industries, and even other countries’health care systems, US
health care needs a revolution-actually an industrial revolution.
Don McDaniel is President and CEO of Sage Growth Partners,
a healthcare strategy and applied healthcare technology firm. Mr.
McDaniel is a member of the faculty in The Johns Hopkins Carey
Business School teaching health economics and strategy. Dan D’Orazio
is the Vice President of Strategy at Sage Growth Partners and teaches
corporate strategy at The Johns Hopkins Carey Business School. For a
complete list of references contact 301.921.4300 or sraskin@montgomerymedicine.org.
References:
1. http://www.boeing.com/commercial/safety/howsafe.html
2. http://www.planecrashinfo.com/cause.htm
3. http://www.bts.gov/publications/national_transportation_statistics/html/table_01_11.html
Write to us
The Editorial Board of Maryland Medicine welcomes
your letters, comments, and opinions. Readers may
respond to the authors or the editors by e-mail at
sraskin@montgomerymedicine.org or by mail to
Editor, Maryland Medicine, c/o Montgomery County
Medical Society, 15855 Crabbs Branch Way, Rockville,
MD 20855.
Saturd ay, Octo ber 22, 2011
7:00 p.m.
Marriott Waterfront
Baltimore, Maryland
Honoring MedChi’s 164th President
Harbhajan S. Ajrawat M.D.
Featuring Performances by the Capitol Steps and Bhangra Folk Dancers
For more information, contact Catherine Johannesen at
.
.
800-492-1056
x3308 or cjohannesen@medchi.org
Maryland Medicine
Vol. 12, Issue 2
11
How is Quality
Different from
Practicing Good
Medicine?
Thomas R. Jackson
Abstract
So how is quality different from practicing good medicine? The
author makes a distinction between medical science and the healthcare
delivery system. Medical science is the best in the world and the body
of knowledge is constantly growing. However, the healthcare delivery
system does not consistently deliver the care that physicians prescribe.
It is in need of improvement. Quality improvement should be focused
on those areas of medicine where there is general agreement among
physicians. It should be used to improve the system, not judge the care
provided by individual physicians.
So how is quality different from practicing good medicine?
That was the question I was asked to discuss. Specifically I was
asked, “...why it is or is not different than practicing good medicine, why people outside the field of medicine are qualified to
define what medical quality is and isn’t, and the scientific process
used to arrive at definitions of quality….”
The gentleman who asked me to write this essay also made
statements about the quality movement being ill-defined and the
term itself being so ambiguous and diluted as to have become
almost meaningless. I agree. I have tried to refrain from the use
of the word for those very reasons.
When I first began to work in healthcare quality improvement,
the physician I worked for chose two clinical areas for focus. They
were chosen because there was wide geographical variation in the use
of these procedures-back surgery and radical prostatectomy. There
was indeed wide variation. The assumption was that physicians were
overusing theses treatments in parts of the state. They were not
medically necessary. A study group of physicians was assembled to
look at the data and the clinical indications for surgery.
It was enlightening to watch these groups of physicians as they
discussed their rationale for the decisions they made. The lessons
I learned have stayed with me for 20 years. I gained a greater
appreciation for the challenges that physicians confront on a daily
basis. I gained an appreciation of how complex those decisions
are and how much physicians struggle to make the right decision
when things are rarely black or white. The most important insight
came later in the process. The physicians who were part of these
study groups had been chosen in part for their divergent points of
12 Vol. 12, Issue 2
Maryland Medicine
view. When asked what treatment they would choose if they were
diagnosed with these diseases, they were thoughtful, and they
chose the treatment they were promoting for their patients.
They were not charlatans out to take advantage of the system and their patients. They were not out to simply make more
money. They were highly trained, experienced people, trying to
make the best decisions given the current science. The science in
these areas was grey. Honest people were coming to honest disagreements based on the science and the clinical judgment they
had developed over years of practice. I enjoyed the experience. I
also realized that areas such as these were not the best place to
try to apply improvement techniques. To be sure, there are many
areas of disagreement.
Studies over the last several years have shown that only around
20 percent of medicine is “evidence-based,” meaning based on randomized, controlled trials. This is not to say the rest of medicine
is not based on sound judgment. It is. However, this 20 percent
where there is general consensus among physicians is an area where
quality improvement can make a difference. I believe that quality
improvement should be focused on making sure the things happen
that physicians have already agreed should happen.
Where U.S. healthcare suffers is in the delivery system.
Medicine is inextricably linked to the system that has evolved
to deliver it. That system has changed very little at its core over
the past 50 years. While rising complexity has been the rule in
medicine, the healthcare system still operates much as it did in the
1940s and 50s. No wonder there are so many breakdowns in the
system. It originated in a simpler time, when there were far fewer
options, far fewer tests and far fewer treatments. The physician
often knew all there was to know about his patient, because he
was often the only physician who ever took care of his patient.
Today a patient might be dealing with a half-dozen physicians
for different issues. Those different physicians are often not even
aware that their patient is being treated be someone else. Patients
sometimes leave the hospital without their primary care physician
even knowing that they were in the hospital.
Medical science in the United States is the best in the world.
U.S. medical schools are constantly pushing the envelope,
developing new medical knowledge and creating new medical
technologies. Imaging technologies, surgical techniques, phar-
maceutical therapies are all moving so
rapidly that they would be unrecognizable
to medical professionals 50 years ago.
I was speaking to a physician recently.
He was trying to give me a sense of how
much his own field had changed. He is
an ophthalmologist. He said that when he
was originally trained, they were still called
EENTs (Eye, ear, nose and throat physicians). One person could know all that
was known about the eyes, ears, nose and
throat. As knowledge advanced, it became
impossible to know everything about all of
those systems. People began to specialize in
the nose or the eye. At this point, the man
I spoke to is a researcher and surgeon specializing in only a portion of the eye. When
I laughed, he said, “I’m serious. Knowledge
has advanced so far and is so deep, that I
would be nervous dealing with other parts
of the eye. It has changed that much.”
One of the differences between the
U.S. healthcare system and other industries is that companies in other industries
that have become successful over the last
decades have done so because they have
made quality improvement a core strategy.
Quality is not something extra. Everyone
is involved. It is also not something that
leaders can delegate.
Therein lies one of the reasons quality
in medicine and healthcare has become
ill-defined. Quality is seen as a regulatory
requirement, something extra you have to
do in addition to taking care of patients
and practicing good, solid medicine. If you
ask people in a hospital if they are involved
in quality, they’ll usually tell you “no” and
point you toward the quality department.
In some of the best companies, like
General Electric and 3M, everyone who
wishes to advance must be trained in
improvement. They must also lead an
improvement project that saves the company money by streamlining operations,
removing waste or creating a more resilient
process. The people who must take this
training and lead these projects are already
highly trained in other fields. In most cases
they are scientists and engineers. Their
companies have realized that in addition
to strong fundamental knowledge in their
fields, these professionals must also know
how to deliver that knowledge if the company is going to be successful.
This is where I start to differentiate
between “good medicine” and quality. The
science of improvement is based on the
scientific method. It includes disciplines
such as measurement, variation, causa-
Summary
country tout the Canadian and European
health systems. No doubt there is much we
can learn. But my experience was that when
people had serious illnesses, if they had the
resources they came to the states for care.
U.S. medicine is the best in the world.
Through the application of improvement
knowledge, in tandem with good medicine,
I believe we can build the best healthcare
delivery system in the world. That system will be one that is centered on the
patient. In my experience, when systems are
redesigned with the patient in mind, they
also become easier for all of the providers
involved. In the best systems, the patient
will not feel that they are moving through
a fragmented system. There will be good
communication between all of the people
who are caring for the patient. Unnecessary
variation in the system will be reduced. And
while the patient will be at the center of
the system, the patient’s physician will not
feel like someone is telling him or her how
to practice medicine. Physicians will know
that the knowledge and experience that has
taken years to gain is thoroughly appreciated
and valued by all of the stakeholders in the
healthcare system.
I said earlier that U.S. medicine is the
best in the world. I believe that. I lived in
Europe when I was young. Some in this
Thomas R. Jackson is the CEO of the
Delmarva Foundation for Medical Care. He
can be reached at 410.822.0697.
tion and the development and testing
of change. After the “good medicine”
has been determined by the physicians,
improvement can help make sure that the
delivery of that medicine is done according to the physician’s intentions.
One of the largest problems we as a
society face is that of readmissions. Twenty
to 30 percent of Medicare patients who
are hospitalized are hospitalized again
unnecessarily within 30 days. The solutions to this problem will probably not be
medical in nature.
Demonstration projects have shown that
things as simple as making sure that an
appointment with the patient’s primary care
physician is made before the patient leaves
the hospital, changes that pattern. Other
things that have worked include better methods for teaching patients and their family
members how to determine when they need
to seek medical attention after discharge, and
better communication and coordination with
other healthcare providers. Techniques as
straightforward as these have reduced readmissions by a third in pilots.
MedChi Physician’s Talents Go Beyond His
Medical Practice
In May 2011, Christopher Shih, M.D., a 38-year-old gastroenterologist
from Ellicott City, Maryland won the sixth Van Cliburn International Piano
Competition for Outstanding Amateurs.
According to National Public Radio, Dr. Shih beat 70 of the world's best nonprofessional pianists, including a lawyer from Hong Kong, a telecommunications
manager from Mexico and, in the final round, a Formula 1 race car designer from
the U.K. Dr. Shih also won the audience award and the award for the best performance of a work from the Romantic Era, which earned him another $250.
The amateur competition is based in Fort Worth, Texas and held every 4 years.
It is open to pianists age 35 and up who do not make a living by playing or teaching piano.
In the past he has won top prizes in similar contests in Boston and Paris.
He even once competed in the better-known, professional level Van Cliburn
International Piano Competition. During the week of competition he played works
by Bach, Wagner and Tchaikovsky. His prize winning piece was his final round
performance of Brahms’ Variations on a Theme by Handel. Dr. Shih is a member of
MedChi, the Maryland State Medical Society. The Maryland Medicine Editorial
Board congratulates Dr. Shih on his achievement!
The Maryland Medicine Editorial Board will be recognizing extraordinary accomplishments by MedChi members whose talents, outside of medicine, are honored.
Maryland Medicine
Vol. 12, Issue 2
13
The Role of MedChi’s
Quality Committee
Ronald Orleans, M.D.
Past
The Quality Committee of MedChi, The Maryland State
Medical Society, was initially established in 2004 at the same time
that the Medical Policy Council was formed. This occurred not
long after the General Assembly had removed MedChi from its
longstanding role in peer review of standard of care complaints
made to the Board of Physician Quality Assurance (now the Board
of Physicians). Its creation reflected a belief by MedChi leadership
that quality issues had to continue to be addressed by MedChi and
organized medicine. The first meeting of the Committee was held
on March 29, 2005. At that meeting, the mission of the Committee
was defined as follows: “The Quality Committee shall learn the needs
of community practitioners to help them improve delivery of care in their
office.” Quality was defined as “…getting the right care at the right
time in the right setting from the right practitioner consistent with current medical knowledge.”
Topics of interest for that year included tort reform, information technology alternative dispute resolution, acceptance of the
new Pay for Performance model and the Maryland Patient Safety
Center refocusing its efforts on the outpatient level of care. At the
meeting of October 25, 2005, it was suggested that the Quality
Committee function as a bridge between MedChi leadership and
its members, providing guidance to help leadership make policy
directions. However, based on the meeting minutes of 2005, no specific Committee actions or accomplishments were documented.В В В В В В В В В In 2006, topics of interest included tort reform, information
technology alternative dispute resolution or mediation, and physician education regarding Pay for Performance. Again, based on
the meeting minutes of 2006, no specific Committee actions or
accomplishments were documented.В В В В В В В В В Present
The Quality Committee did not meet in 2007 but was revived
in 2008. For the past three years, the Committee has dealt primarily with limited ad hoc items including the risk/benefit profile of
the medical marijuana legislation and the exception of specific
14 Vol. 12, Issue 2
Maryland Medicine
in-office laboratory tests from undergoing the full process of laboratory inspection and certification mandated by the federal CLIA
regulations.
Future
Given the changes occurring in medicine over the past few
years and the passage of the Patient Protection and Affordable
Care Act, will the reinstituted Quality Committee assume a new
more extensive role within the medical society?В It is clear that
the medical society, if it wants to retain a leadership role in health
care policy debate, will need to come up with a systematic method
of weighing in on quality issues with authoritative advice derived
from longstanding principles of scientific medicine.В In 2011, the
definition of medical quality has significantly changed. The definition that was used in 2005 is, in today’s world, naively simplistic.
In view of soaring healthcare expenditures, any definition of quality must now include terms such as evidence-based, value, and
health outcomes. The definition must not, in any circumstances,
be included in the same sentence with the word quantity.В No one knows what the future of medical practice will be. What
is clear is that the costs related to fee-based medicine, as practiced
today, are not sustainable. Many of the changes will not necessarily
be physician friendly but all agree that the mandate and momentum for change are here to stay. They will not go away. In order to
ease the transition, some state medical societies have formed quality
improvement organizations or foundations in order to help physicians understand, accept and most importantly, take leadership
roles in advocating and supporting quality improvement and cost
efficiency efforts within their respective states.
From my perspective, Maryland physicians need to participate
in the discussion in a more constructive, proactive manner. The
Quality Committee, with guidance from the MedChi Board,
would certainly be willing to assume this new role of promoting
medical quality in Maryland.В В В В Ronald J. Orleans, M.D., is Chair of the Quality Committee of
MedChi, The Maryland State Medical Society.
Quality at
Kaiser Permanente:
Using the Population
Care Model
Janice M. Beaverson, M.D., and Jaewon Ryu, M.D.
Abstract
The provision of high quality healthcare is facilitated by an integrated team of multi-specialty physicians who are supported by an
advanced electronic medical record. This paper shows how Kaiser
Permanente of the Mid-Atlantic States is able to provide proactive
care to members through physicians and their teams, integrated with
functional health information technology systems.
Kaiser Permanente is an integrated delivery system. Nationally,
Kaiser Permanente includes 35 owned hospitals, 454 medical
offices, and more than 15,000 physicians serving a membership
of almost 9 million members in nine U.S. states and the District
of Columbia. Kaiser Permanente’s Mid-Atlantic region is comprised of the Kaiser Foundation Health Plan of the Mid-Atlantic
States (KFHP) and the Mid-Atlantic Permanente Medical Group
(MAPMG). MAPMG is a multi-specialty physician group of
nearly 900 physicians that provides medical services to KFHP
members in Maryland, Virginia, and the District of Columbia.
Kaiser Permanente’s origins date back to the Depression era.
During World War II, the industrialist Henry J Kaiser had an
interest in keeping his large shipyard workforce healthy. Kaiser
teamed up with Dr. Sidney Garfield, who had founded the concept of prepaid healthcare years before as he provided care for the
men who built the Los Angeles Aqueduct. The concept of prepaid medical care was popular among workers and following the
war, that popularity continued and led to the formation of what
we know today as Kaiser Permanente.
The original ideals of managing the health of a population with
a focus on prevention have served as guiding principles for Kaiser
Permanente throughout its history and continues as such today.
The population care model supports a “whole person” approach to
care that focuses on proactively addressing care needs for chronic
conditions, lifestyle and behavior changes, and prevention. More
importantly, the population care model includes addressing needs
for those patients who do not actively seek medical care as well as
those who do see us in our offices.
Critical to the success of population management is the ability to
identify and satisfy evidence-based care gaps. Panel support tools,
embedded within Kaiser Permanente’s electronic medical recordthe world’s largest civilian deployment of an electronic health
record-help to identify care gaps and preventive services needed.
In our setting, not only primary care physicians are accountable for
ordering mammograms and lipid screenings, Permanente physicians in all specialties, each of whom has access to the same tools,
are alerted about and expected to order missing cancer screenings
and evidence-based lab testing needed for the successful management of patients with conditions such as cardiovascular disease or
diabetes. This concept of “proactive care” allows us to leverage our
integration and shared electronic medical record to understand
when a patient might be in the office for an optometry visit, or a
visit to a specialty, and let him or her know that we can arrange
a screening test such as mammography or pap smear or laboratory work on the same day. In addition, an online clinical library
provides access to medical journals, physician education tools, and
patient education materials for instant access.
Each year, Kaiser Permanente establishes target goals and
performance metrics for a wide variety of quality measures.
Many of the organization’s quality measures align with HEDIS
(Healthcare Effectiveness and Data Information Set)-and are
related to many significant public health issues such as cancer
screening, heart disease, smoking, asthma, and diabetes. However,
HEDIS does not define the entire scope of Kaiser Permanente’s
quality measures which extend to a variety of clinical issues such
as offering the option of palliative care to our members, working
with our hospital partners to understand and eliminate hospitalacquired conditions, and using our electronic medical record to
continued on page 17
Maryland Medicine
Vol. 12, Issue 2
15
CMS Press Release
CMS Data Show Gains in Key Quality Indicators
Through Physician Quality Reporting System and
ePrescribing Incentive Program
2009 data show increases in how many
eligible professionals successfully participate
as well as how many instances professionals report delivering evidence-based care
that can lead to better patient outcomes.
The Centers for Medicare &
Medicaid Services (CMS) issued a
report on April 20, 2011 that highlights significant trends in the growth
of two important “pay-for-reporting"
programs. The report also articulates
key areas in which physician-level
quality measures appear to show positive results in quality of care delivered
to Medicare beneficiaries.
CMS’s 2009 Physician Quality
Reporting System and ePrescribing
Experience Report states that 119,804
physicians and other eligible professionals in 12,647 practices who
satisfactorily reported data on quality
measures to Medicare received incentive payments under the Physician
Quality Reporting System totaling
more than $234 million—well above
the $36 million paid in 2007, the first
year of the program. Under the ePrescribing Incentive Program, CMS
paid $148 million to 48,354 physicians and other eligible professionals
in 2009, the first payment year for
the program. Results show that participation in the Physician Quality
Reporting System has grown at about
50 percent every year, on average,
since the program began.
Although the two pay-for-reporting
programs are open to a wide range of
health care professionals, much of the
reported data relate to care provided in
ambulatory settings, such as physician
offices. CMS Administrator Donald
16 Vol. 12, Issue 2
Maryland Medicine
Berwick, M.D., explained, “Most beneficiaries get their care in the physician office; however, this is the care
setting for which we have the least
amount of data about quality of that
care. The Physician Quality Reporting
System and the ePrescribing Incentive
Program help bridge the knowledge
gap so we can better understand the
care millions of patients receive from
physicians and other care providers
every day. The significant growth in the
Physician Quality Reporting System
shows us that the health care community shares CMS’s commitment to
improving the quality and safety of
care our beneficiaries receive.”
On average, 2009 bonus payments for satisfactory reporters in the
Physician Quality Reporting System
were $1,956 per eligible professional and $18,525 per practice. Eligible
professionals who were successful
electronic prescribers received even
more from the ePrescribing Incentive
Program in 2009: the average bonus
payment was just over $3,000 per
eligible professional and $14,501 per
practice. Physicians and other eligible professionals who satisfactorily
reported Physician Quality Reporting
System quality measures data and thus
qualified for an incentive payment for
the 2009 Physician Quality Reporting
System received their payments in the
fall of 2010.В Along with increases in participation rates and incentive payment
amounts, CMS is encouraged by data
from the Physician Quality Reporting
System that shows growing rates in how
oftenВ health care professionals report
that they are complying more often with
evidence-based care practices. These
increased reporting rates could signal a
positive trend in the quality of healthcare
Medicare beneficiaries receive from professionals who report data through the
Physician Quality Reporting System.
One of the Physician Quality Reporting
System’s main goals is to collect information about care practices that can
ultimately help improve the quality and
efficiency of care for all Americans,
especially Medicare beneficiaries.
Accordingly, the System’s measures capture evidence-based practices that are
shown to improve patient outcomes,
such as providing preventive services,
taking steps to reduce health care disparities, planning care for patients with
chronic conditions to keep them healthy
for as long as possible, and integrating
health information technology solutions
into how providers deliver care. These
measures are created by nationally recognized experts from groups such as the
American Medical Association, and are
endorsed by national quality consensus
organizations.
Based on reported data on the 55
measures that have been a part of the
System since it began in 2007, providers have improved the frequency
for which they deliver recommended
care by about 3.1 percent on average.
Similarly, of the 99 measures that were
part of the System in 2008 and 2009,
performance improved at about 10.6
percent on average. In some cases, gains
have been even more dramatic.
The measures chosen for the Physician
Quality Reporting System also provide
increased opportunities for eligible caregiving professionals from all segments of
the health delivery system to participate.
Since the program began, CMS expanded the System from
74 measures (with an eligible professional participation pool of
roughly 600,000) to 194 measures (with an eligible professional
participation pool over 1,000,000). Currently, about one in five
health care professionals who can participate do so.
“Although participation in our pay-for-reporting programs is optional now, it should be regarded as imperative
in terms of medical professionals’ shared goal of improving
quality of care and patient safety,” said Dr. Berwick. “I challenge every health care provider who has not yet participated
to begin today. We will not improve the quality of health care
in this country without knowing where we stand in delivering care and using that knowledge to continually improve
our practices. Our patients deserve nothing less.”
Dr. Berwick noted that participation in the Physician
Quality Reporting System and the ePrescribing Incentive
Program also makes good business sense for health care
providers. Both programs currently reward eligible professionals with a percentage of their estimated Part B Medicare
Physician Fee Schedule (PFS) allowed charges for covered
professional services furnished by the eligible professional
during the reporting period.
Both programs also serve as part of a broader strategy to
encourage health care providers to adopt practices that can
improve patient care. In early 2011, CMS launched incentive
programs for both Medicare and Medicaid that reward providers financially for becoming meaningful users of certain health
information technology solutions this year.В Physicians will also
see data on how well they perform against their peers on quality measures as CMS’ Physician Compare website expands to
include quality information by 2013. Also, providers who are
able to participate in the ePrescribing Incentive Program and
the Physician Quality Reporting System Program, but who
choose not to, will receive payment reductions from Medicare
beginning in 2012 and 2015, respectively for each program.
To learn more about the Physician Quality Reporting
System, including instructions on how to get started, visit the
CMS website at http://www.cms.gov/PQRS. Information
on the ePrescribing Incentive Program is available at http://
www.cms.gov/ERxIncentive/.
The full 2009 PQRS and ePrescribing Experience Report is
also available on CMS’ website at http://www.cms.gov/PQRS.
Additional 2009 program results can be found in
a CMS Fact Sheet here: http://www.cms.hhs.gov/apps/
media/fact_sheets.asp.
Quality at Kaiser...
continued from page 15
avoid medication interactions or allergies. Performance against
set targets is monitored and reported on throughout the year.
Reports can be generated down to the level of individual practitioners so physicians are able to receive timely feedback on how
well they are managing their panels to the established targets.
A common electronic medical record not only helps facilitate
population management, but is critical to the transfer of information across specialties and disciplines and supports a culture of
patient safety. For example, patients with multiple conditions may
be prescribed different medications by different specialists and it
is often up to the patient to keep track of all of the medications
prescribed. A common medical record lifts the burden from the
patient by providing a single documentation source that includes
all of the necessary information related to services and medications
received in both outpatient and many inpatient settings. A single
record also strengthens the primary care physician’s ability to manage the “whole patient” by providing a complete record.
At Kaiser Permanente, technology greatly facilitates our quality efforts, but the principles we employ-population management,
goal setting, performance monitoring, and information sharingare applicable to any provider setting and can be employed with
various levels of technology integration.
Janice Beaverson, M.D., and Jaewon Ryu, M.D., are Associate
Directors of Mid-Atlantic Permanente Medical Group.
The Best Physician Practices
Have The Best-Trained Staff.
Staying true to our motto - “Your Advocate. Your
Resource. Your Profession.” MedChi has
В®
partnered with Practice Management Institute ,
the nation's premier provider of practice
management training and credentialing for
physician practice staff, to offer professional
development classes at MedChi.
July 19, 2011
Transforming the Front Desk Staff
August 2, 9, 16, 23 & 30, 2011
Certified Medical Coder (CMC)
October 6, 2011
Collecting in a New Economy
ICD-10 Coding Implementation
November 15, 16, 17 & 18, 2011
Certified Medical Insurance Specialist (CMIS)
For more information or to register, please see our
website www.medchi.org or contact Tina McIlwrath
at
410.539.0872,
ext.
3306
or
tmcilwrath@medchi.org.
Maryland Medicine
Vol. 12, Issue 2
17
The Quality of Medicine: A Senator
Reflects on a Year of Living Medically
Senator Jamin ( Jamie) B.Raskin, Esq.
“Everyone who is born holds dual citizenship, in the kingdom of the well and in the
kingdom of the sick. Although we all prefer
to use the good passport, sooner or later each
of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”
-Susan Sontag
As I look back upon my Year of
Living Medically, certain truths stand
out in my mind.
We are not doing anyone a favor by
pretending that they do not need health
insurance and can wing it over the course
of their lifetimes. At the moment you
receive a diagnosis like mine—of colon
cancer after 47 years of perfect health—
you are so overwhelmed by fear, confusion, guilt, medical appointments, diagnostic tests, and paperwork that the last
thing you need to add to your burdens is
the inability to pay for the medical care
you need. Without insurance, even middle
class people stand one serious illness away
from financial catastrophe and seeking
out uncompensated care. Universal coverage is in the best interest not only of each
individual but of the community.
If the “individual insurance mandate” in
“Obamacare” survives its legal and political challenges and we come to more fairly
distribute health care, this achievement
will only resolve the quantity question of
how much health care society needs.
But when you are a patient, you are
focused on one case—your own—and
your main interest is not in the social
quantity of health care administered but
in the individual quality of the care you
receive.
It is both tempting and reassuring to
think that “medicine” and “quality medicine” are the same thing, but this may
not always be the case. While it is estimated that nearly 45,000 Americans die
each year because of a lack of access to
health care, it has also been reported that
18 Vol. 12, Issue 2
Maryland Medicine
200,000 Americans die because they had
access to health care that might have been
substandard.
In Maryland there is strong institutional investment in practicing quality medicine. My experience at Johns Hopkins
Hospital showed me a hospital passionately committed to achieving positive
health outcomes for patients, concerned
about patients’ emotional well-being, and
well aware of the need to maintain appropriate quality practices. I am glad that the
finest institutions are taking iatrogenic
illness seriously.
The debate over health care quality
will clearly provoke a new generation
of policy questions about which kinds
of quality industry standards should be
legislated and which are left to physicians, health care providers and courts
to sort out through the dynamics of
self-regulation, litigation, and professional
monitoring and oversight. Although the
Maryland General Assembly and public
regulatory bodies should obviously review
major issues, we are dependent in the first
instance on health care professionals to
articulate best practices and procedures.
As hospitals and physicians struggle
to define the best practices for advancing
individual health, legislators are struggling
to define the best policies for promoting
public health more broadly. One of the
strong public health measures passed in
the 2011 session was the Drunk Driving
Reduction Act, a bill I introduced to
dramatically lower drunk driving-related
accidents, injuries and casualties on our
roads. This legislation will require an estimated 4,500 new convicted drunk drivers
to have an ignition interlock breathalyzer
installed in their cars, a device that will
not permit the car to start if any alcohol is
detected on the breath of the driver.
Ultimately, of course, the imperatives of
universal coverage and health quality are
intertwined. In their book The Spirit Level,
British public health scholars Richard
Wilkinson and Kate Pickett examined
reams of cross-national data about life
expectancy and infant mortality, child wellbeing, mental illness, obesity, educational
success and drop-out rates, homicide and
suicide, crime, imprisonment, social mobility and levels of social trust.
They arrived at a striking conclusion.В While all public and social health
indicators improve dramatically for
poor countries as they increase their
gross national product and average family incomes, once countries reach a certain
level of prosperity, national wealth and
average income have very little to do with
the physical and mental well-being of the
population and the happiness of the people.
What matters once basic needs are met in
a society is not how rich the society is but
how equal it is.В One thing that makes societies sick is inequality. In the healthiest and
happiest societies, the income and wealth
gap between the rich and the poor is much
smaller than what is found in societies that
have high infant mortality, high crime and
violence, high rate of mental illness and suicide, high drop-out rates and so on.В High
inequality produces lives of social chaos.
When the authors turn their attention to
the 50 U.S. states, they document the same
pattern.В The key indicator of public health
and wellbeing is not how rich or poor a
state is, but how equal or unequal it is. The
states that have the worst public health
outcomes and the lowest levels of happiness are the most unequal states- such as
Mississippi, Texas, Louisiana, and Alabama;
the healthiest states tend to be not the richest ones, like Connecticut, New Jersey or
Maryland, alas, but the ones with the least
inequality, like Vermont, New Hampshire,
Minnesota, Utah and Wisconsin.В В В В Wilkinson and Pickett show that everyone benefits from living in a society
with “equality of conditions,” which is
what struck Tocqueville about America
when he came here in the 1830s.В continued on page 23
PERSONAL PERSPECTIVES
The Quality of Medical Care:
One Patient’s Opinion
Edward C. Ettin
In a truly rational world, the only standard by which our medical care would be
judged is by the answer to this question:
Was the patient cured and, if not, was he
or she made comfortable in order to enjoy
life as much as possible? I should add
the not unimportant subsidiary question:
Was the patient treated with dignity as
she died?
If the answers are yes, the medical care
is the best that can be and I have the sense
that U.S. medical care does extremely well
on the first question—for those of us with
insurance—and too often poorly on the
last question.
Those are rational questions and
answers. I pride myself on being a rational
person, but when I was asked to write
this article, the first question that popped
into my mind was: Does the doctor listen to me when I describe my problem?
Moreover, when I asked friends how
they would judge the quality of medical
care and rate their physician(s), the first
or second answer was always some variant of this latter question. No one said
anything about getting well. Is the key to
getting a positive review of quality medical care, therefore, some variant of Lyndon
Johnson’s principle: the most important
thing is sincerity; once you can fake that
you got it made?
On reflection, I think what my friends
and I are reacting to-this concern about
our docs’ listening to what we say-is the
effect of managed care.
I am a professional economist (please
don’t stop reading) and the dismal science has trained me to try and look at
all sides of an issue and the empirical
data if possible. I have tried to do so for
health care, but have always walked away
failing to come to grips with how best to
address the economics of medicine in the
United States. Everyone it seems is right.
The system is the best, it’s inefficient, it
leaves the poor out, insurance companies
are destroying the system, and govern-
ment doesn’t know what it’s talking about.
Nonetheless, when I look at what I believe
are irreversible fundamentals, here is what
I see:
1. Our society cannot continue to
allocate an increasing share of its
resources to medicine;
2. We are getting older, no small
thanks to medicine, and will needincreasing medical resources even
if nothing else happens;
3. Something else has happened: our
society has, I think, decided that
everyone, or at least more of us,
deserve access to doctors/hospitals
even if they can’t afford it;
4. Medical technology is opening up
new channels of diagnosis and
care; and
5. The advance of medical science is
very expensive.
These fundamentals suggest that the
economics of medicine requires tradeoffs. We are going to have to give up a
little to get a little and we have to do
that in a world of budget constraints. No
big insight here, but it implies, I think,
that one of those trade-offs means, for
sure, managed care, which itself means
that those who that can afford it will buy
themselves into limited practices and the
rest of us will have longer waits and less
face time. It also means that physicians
will earn less and work harder.
Bingo! Why doesn’t my physician listen to me? He’s too damn busy trying
to see more patients, in part because the
demand is rising, and in part to maintain
his income in a world where managed
care reduces the price he receives per
patient. This will not get better. Indeed, it
will be the conflict situation in medicine
in the years to come. It is, so to speak,
baked into the cake. Patients and doctors
are seemingly caught in gigantic forces
beyond their control. But the result is
that increasingly patients will judge the
quality of medical care, I believe, on what
doctors will increasingly have less time to
do: listen.
There is, I believe, another channel,
aside from dignity, at work here. I am
convinced that a significant part of the
healing process is the conviction of the
patient that the doctor is a special, magical person whose ability to heal requires a
sort of laying on of hands. The relationship is special-one on one: we tell the
doctor secrets we share with no one else,
we expose our naked bodies to the doctor’s view, we hang on his/her words as
he/she tells us what we must do to regain
our health, to live longer. Part of the healing process is disrupted if the doc—the
magician—is perceived as not laying on
the hands, not listening to us. This may
be irrational but I think that’s the way it is.
(Our younger son is an emergency room
doc in a middle sized southern city. Late
in the winter he called my attention to a
New York Times column entitled “Treat the
Patient, Not the CT Scan.” We exchanged
some emails about it because the title
captured its essence. In his response to one
of my emails, he replied: “This is why I
sit down when I interview a patient and
always listen to the heart and lungs, even
if they come in for a hangnail. People are
comforted by the ritual.” He gets it and
we have never been prouder of him!)
I don’t mean to imply that the patientdoctor relationship is purely magical and
that the magician should not be questioned.
Explanations of the disease, prognosis, and
options—in words I can understand—are
important to me, and I hope to most
patients. But I do, at the same time, believe
that patients and doctors are in an unequal
position and to lose sight of that and the role
that implies for each endangers the relationship. Listening, kindness, respect, touching,
and looking are understood by most doctors
to be important in the healing process.
continued on page 23
Maryland Medicine
Vol. 12, Issue 2
19
Review of the 2011
Session of the
Maryland General
Assembly
Joseph ( Jay) A. Schwartz, III, Esq., and Stephen H. Johnson, Esq.
MedChi was surprisingly successful in
implementing its agenda.
The 2011 regular session of the Maryland General Assembly
ended at midnight on Monday, April 11, after considering 2,370
bills and resolutions. MedChi reviewed 205 of those through its
Legislative Committee.
In 2011, which was the first session of the four year legislative
term, approximately one third of the representatives were new to
the General Assembly. Typically, the initial year of a term is less
productive than the second and third years. However, several significant proposals were enacted, including an increase in the sales
tax on alcohol and a proposal to provide tuition at in-state rates to
undocumented immigrants meeting certain conditions.
MedChi was surprisingly successful in implementing its agenda.
Three important MedChi initiatives were enacted into law, including two proposals pertaining to electronic health records (EHR).
HB 736/SB722 (Electronic Health Records – Incentives for Health
Care Providers) was enacted and requires carriers to pay the EHR
incentives provided by 2009 legislation in cash and directs the
Maryland Health Care Commission to determine if the program
should be extended beyond primary care practitioners. HB 784/SB
723 (Medical Records – Health Information Exchange) is aimed at
preventing the misuse of information garnered through the Health
Information Exchange (HIE) and requires the development of
regulations by the Maryland Health Care Commission (MHCC)
before any release of information can occur for non-patient care
purposes. MedChi caused this legislation to be introduced after
it became known that the Ingenix division of the United Health
Group had bought the company providing the software for the
Maryland HIE.
The third initiative of MedChi’s enacted by the General
Assembly was the repeal of the statutory provision providing for
criminal penalties to be imposed upon licensed physicians who
do not obey an order of the governor during a state of emergency.
Henceforth, physicians and other health care practitioners will be
subject to disciplinary action by their licensing board rather than
20 Vol. 12, Issue 2
Maryland Medicine
to criminal penalties for failing to comply with a governor’s order
during a declared state of emergency. This is consistent with the
nationally promulgated model legislation.
Several medical specialty groups also initiated legislative proposals.
The Maryland Society of Eye Physicians and Surgeons (MSEPS)
was successful in persuading the General Assembly to enact SB 701/
HB 888 (Health Insurance – Prescription Eye Drops – Refills) which
will require Maryland insurers to use the Medicare rule with respect
to early refill of prescription eye drops with their members as well.
The guidelines in question provide that insurers must refill prescription eye drops if the patient runs out of eye drops by the 21st day or
later of a 30 day prescription. In enacting SB 701/HB 888, MSEPS
achieved the same victory for Maryland private carrier insured
patients that the American Academy of Ophthalmology achieved
not long ago with respect to Medicare patients.
Dermatology was not as successful with respect to SB 604/
HB 1111 (Tanning Devices – Use by Minors – Prohibition). This
proposal would have changed Maryland law by forbidding
commercial tanning salons from offering ultraviolet tanning to
minors. Currently, minors may receive ultraviolet tanning with
the written permission of their parents. The House Economic
Matters Committee amended the bill to forbid children under 14
to tan but to continue to allow it with parental consent for minors
between 14 and 18. The proponents of the bill, which included
the American Academy of Dermatology as well as MedChi and
the American Cancer Society, asked the committee to kill the bill
rather than report out the weakened version.
Since 1993, the Maryland anti-self-referral laws have prevented
practices that are not exclusively composed of radiologists from
billing for certain radiology services. A decision by the Court of
Appeals in January removed all doubt as to the scope of this ban.
Consequently, SB 808/HB 782 (Health Occupations – Imaging and
Radiation Therapy Services – Accreditation) was introduced with
support from several specialties adversely affected by the current
law but opposed by radiologists.
Although neither bill emerged from committee, the regulation
of the use of radiology equipment will be studied by a MedChi
task force this summer.
MedChi successfully opposed SB 887/HB 340 (Health Care
Malpractice – Certificate and Report of Qualified Expert – Objection),
an initiative of the “Maryland Association for Justice” (formerly and
better known as the “Maryland Trial Lawyers Association”) that
would have allowed plaintiffs the option of obtaining another certificate of merit if their expert certificate (attesting that their case is
meritorious) is rejected as not meeting the requirements of the law.
Two bills proposed by the O’Malley Administration with the
purpose of bringing Maryland law into accord with federal health
system reform were enacted. SB 182/HB 166 (Maryland Health
Benefit Exchange Act of 2011) creates an insurance exchange
where individuals can secure health insurance. The federal Patient
Protection and Affordable Care Act (PPACA) requires states to
set up such entities. The bill was extensively amended to accommodate the concerns of a wide variety of stakeholders, including
the health insurance agent and broker community.
SB 183/HB 170 (Health Insurance – Conformity with Federal
Law) was also mandated by PPACA and brings Maryland rules
on such health insurance related matters as pre-existing conditions and medical loss ratio into conformance with the new
federal requirements.
HB 818 (Manufacturers of Prescribed Products – Payments to
Health Care Professionals – Prohibition) was an attempt to copy
legislation in Vermont and Massachusetts that severely restricts
pharmaceutical and medical device manufacturers from supporting doctors and various medical meetings. Although the bill when
introduced seemed to have significant support, at the hearing
significant flaws became apparent and the bill was withdrawn
shortly thereafter. As drafted, it would have effectively outlawed
1
5/26/11
5:45 PM
financialMedChi_MardiGras_Tray-HalfPgAd.pdf
support of hundreds of conferences,
health
fairs and
medical screenings. However, the issue is likely to be revisited in
2012 because Maryland health officials have indicated continued
concern with manufacturer payments.
An extensive amount of time and effort was expended in connection with SB 883/HB 1229 (Prescription Drug Monitoring
Program). This bill will establish a “Prescription Drug Monitoring
Program” in the Department of Health and Mental Hygiene. The
program is essentially a database recording data from pharmacists
and other dispensers regarding dispensing of scheduled drugs.
Although many physicians are concerned that the program will
discourage pain treatment, MedChi was successful in introducing
amendments that should work to decrease the “chilling effect” of
the database. Among the amendments proposed by MedChi that
were adopted are the following:
1. A prohibition against either prescribers or dispensers of
prescription drugs being charged a fee to support the
program.
2. A change in the membership of the Advisory Board from
being weighted towards law enforcement personnel to a
membership primarily consisting of health professionals.
3. A requirement that a Technical Advisory Committee
(TAC) composed of four physicians and one pharmacist
reviewing all requests for information and provide clinical
guidance and interpretation of the information to advise
program management in its response to law enforcement
subpoenas. The TAC will also provide clinical guidance
and interpretation of the information requested to the
party requesting a subpoena.
Maryland Medicine
Vol. 12, Issue 2
21
The initial provision of the bill exempting Health Department
freestanding ambulatory care facilities maintain a system to review
employees from penalties for improper disclosure of the informapractitioner performance as a condition of licensure. Much of what
tion has been stricken and it now provides that any person who
the bill requires is existing law in terms of peer review at hospitals.
knowingly discloses the information in violation of the law shall
This legislation came about as a result of the St. Joseph Medical
be guilty of a criminal misdemeanor.
Center cardiac surgery controversy, and is intended to ensure that
Moreover, the legislation contains a statutory admonition that
hospitals are properly reviewing utilization matters.
the data may not be used “…as the basis for imposing clinical
HB 600 (Health Care Providers–Investigations–Information
practice standards.”
Sharing Among State Agencies) allows the Health Services Cost
Several scope of practice issues arose in this session. HB 100/SB
Review Commission (HSCRC) to disclose certain identifying
560 (Health Occupations—State Board of Naturopathic Medicine) would
physician information to the Office of Health Care Quality
have licensed the practice of naturopathy in the state. At this time,
(OHCQ) (the Department of Health and Mental Hygiene
only 14 states license naturopaths. MedChi opposed this legislation
[DHMH] licensing body for hospitals and nursing facilities) and
and it was defeated in both the House and Senate committees.
any entity deemed an “ investigatory body” under the state or
Pharmacy interests introduced a number of bills. HB 1268/
federal government. In addition, the bill requires the State Board
SB 884 (Prescription Drugs – Dispensing Permits) would have
of Physicians to disclose confidential investigatory information
made it significantly more difficult for health professionals with
under certain circumstances to the DHMH Secretary, OHCQ,
prescription authority to dispense their own prescriptions to
or HSCRC. The information continues to be protected from
patients. This was defeated in committee. Other bills would
discovery in legal proceedings such as law suits.
have increased the power of pharmacists to administer vaccines.
Certain public health issues received attention from the General
Of those, only HB 986 (Administration of Vaccinations – Children)
Assembly. In addition to the alcohol tax increase mentioned prepassed, allowing pharmacists to administer influenza vaccine to
viously, the following initiatives are of particular note. SB 771/
children nine years and older passed (pharmacists are already
HB 858 (Education –Public Schools and Youth Sports Programs –
allowed to administer the vaccine to adults).
Concussions) will institute a number of measures to improve the
SB 5 (Physicians—Medical Professional Liability Insurance
safety of youthful athletes, including mandatory removal from
Coverage–Notification and Posting Requirements) would have
play of young athletes suspected of having sustained head injury.
required physicians to provide notice to patients if they did not
The Department of Education will be required to develop a promaintain malpractice insurance. The bill passed the Senate but died
gram on concussion awareness as well.
in the House Health and Government Operations Committee.
The Maryland ban on text messaging was strengthened by
HB 286 (Hospitals and Freestanding Ambulatory Care Facilities–
SB 424/HB 196 (Motor Vehicles –Use of Text Messaging Device
Practitioner
Performance Evaluation) requires
that hospitals
and PageWhile
Driving – Prohibited Acts) which includes e-mail within the
011.11 ZNC_MDMedAd_Quartpg:Layout
1 2/8/11
2:11 PM
2
definition of prohibited activity and clarifies that the prohibition
applies to writing, sending and reading messages and that the ban
applies whenever one is in the travel portion of the roadway.
Thinking of adopting an Electronic Health
SB 743/HB 778 (Family Planning Works) was enacted, extendRecord? Get free assistance from an MSO!
ing benefits for family planning services to all women with family
incomes at or below 200 percent of poverty regardless of whether
ZaneNet Connect is a Maryland Management Service Organization
they have had a child.
(MSO) that assists priority primary care providers (PPCPs) to adopt
SB 786/HB 714 (Health Newborn Screening Program – Critical
and become meaningful users of Electronic Health Record (EHR)
Congenital
Heart Disease) requires the DHMH to adopt any
systems. Our services, free to PPCPs, include the following:
federal
recommendations
that may be issued by the Secretary
вњЈ Unbiased vendor selection assistance
of Health and Human Services on the critical congenital heart
вњЈ Practice readiness workflow and technical assessment
disease screening of newborns. In addition, the bill requires the
вњЈ Project management support and onsite technical assistance
State Advisory Council on Hereditary and Congenital Disorders
✣ Assistance in attaining “Meaningful Use”
to develop recommendations on the implementation of critical
вњЈ Guidance on Medicare and Medicaid financial reimbursements
congenital heart disease screening of newborns in the state.
under the American Recovery and Reinvestment Act (ARRA)
HB 1276/SB 803 (Drunk Driving Reduction Act) requires the
вњЈ Guidance in financing the purchase of EHR systems.
Motor Vehicle Administration (MVA) to establish an interlock
program and mandates the participation of a driver as a condition
Visit our website and/or give us a call for a free consultation.
of modification of a license suspension or revocation of a license
or the issuance of a restrictive license if the driver is required to
participate by a court order; is convicted of driving while under
the influence of alcohol or under the influence of alcohol per se
and had a blood alcohol at the time of testing of 0.15 or greater; is
convicted of driving while under the influence of alcohol, under the
influence of alcohol per se, while impaired by alcohol and within
the preceding five years was convicted of any specified alcohol and/
or drug-related driving offense; or was younger than age 21 and
violated the alcohol restriction imposed on the driver’s license or
8070 Georgia Ave., Suite 407, Silver Spring, MD 20910
committed the specified alcohol-related driving offense.
301.830.7799 | www.zanenetconnect.com
22 Vol. 12, Issue 2
Maryland Medicine
The Quality of Medical Care: One Patient's Opinion...
continued from page 19
I have suggested that managed care is probably the major reason
for doctors not listening to their patients as much as patients want
them to. Tests in lieu of conversation, observation, and questions are
also significant. In effect, technology is being substituted for listening. But, apart from its “CYA” role in a world of malpractice suits,
it must also be that, in the best interest of their patients, physicians
call for tests to be sure of their diagnosis. This tendency, as irreversible as email and tech messaging substituting for the post office and
the phone, will, I submit, increasingly be turning patient perception
into reality: the trade off of managed care and technology for face
time. And if I’m right about how magical the interaction needs to
be in the treatment process, patients will only believe that the quality of medical care is declining at the same time that they are living
longer in better health. The touching old cartoon of the doctor sitting at the side of the sick little boy, deep in thought and sympathy,
captured what we, as patients, want. It forgets the reality that, up
until post-World War II, doctors were, as Lewis Thomas observed,
trained to make good diagnoses but had little capacity to cure.
One last point: one of the impacts of managed care and
changing technology, as well as a dramatic change in the culture
of medical practice (perhaps induced itself by managed care
and technology), is a significant change in the medical delivery
system. Larger size practices and the new specialty of hospitalist
have both permitted doctors to “get a life,” to share time off and
to limit, if not eliminate, hospital rounds. This seems efficient to
me, and must be a blessing to doctors, but it does reduce for each
of us that magical connection to my doctor.
Well, as I said, fundamental trends call for trade-offs and that’s
what we’re getting. We, as a society, have to allocate scarce resources.
Patients may just have to change their expectations about the quality of medical care, complain about it, and try to buy themselves out
of it if they can. But the fact is that we, the patients, will probably
continue to receive better care while still thinking it’s getting worse.
My grandchildren may think of my doctor-patient relationships
as old-fashioned and quaint, even if desirable, much as I think of
the house call of my own childhood. But as rich as our society of
the future may be, we can’t live long, healthy lives and continue to
afford the medical delivery systems of the past. I, for one, am sorry
about that. But, I understand it.
The other side of changing patients’ perceptions and realities is changing doctors’ perceptions and realities of their work/
income ratios. It used to be that a career in medicine ensured a
high income. I think that will continue, but not the same relative
income because society just can’t pay that bill and increase coverage.
Physicians will work harder, even with the new delivery systems,
and not earn as much. So many of my doctor friends tell me that
they would not advise their children to become doctors: too much
time with insurance companies and not the income and respect
they expected. I hope that’s not true. The reality is that in our
changing world not many professions or jobs are maintaining the
same relative positions as globalization and innovation do their
thing. Doctors are, like their patients, not exempt from the laws of
the dismal science—what the great economist, Schumpeter, called
“creative destruction.”
A person should do what he would do if money weren’t involved;
that’s the secret of happiness my father told me and I told our sons.
Doc, would you really want to be an investment banker?
Review of the 2011 Session of the
Maryland General Assembly...
The Quality of Medicine...A Senator Reflects
continued from page 22
As stated at the beginning, this year’s session accomplished an
unusual amount for the first year of a legislative term and creates
expectations for even greater activity in the next several years.
Joseph ( Jay) A. Schwartz, III, is one of MedChi’s lobbyists. Stephen
H. Johnson, Esq., is General Counsel, and Director of Law &
Advocacy for MedChi, The Maryland State Medical Society. Edward C. Ettin “has been a patient for three-quarters of a century, thanks to a doc or two.”
continued from page 18
The portrait of society painted by these researchers hit very close to
home for me.В As an elected official pledged to promote the common good, I am committed to advancing universal access to quality
health care, which produces better health and well-being for everyone.В Increasingly, taking care of the body politic means taking care
of the bodies and minds of the people, but that objective requires us
to constantly strengthen and renew the bonds of community.
Maryland Senator Jamie Raskin represents Silver Spring and
Takoma Park and serves on the Senate Judicial Proceedings Committee
and the Joint Committee on State-Federal Relations. He is also a
professor of constitutional law at American University where he
directs the Program on Law and Government. In May 2010 he was
diagnosed with colon cancer and has been treated at Johns Hopkins
Hospital. A year later, he says he is “feeling great—and grateful.”
Maryland Medicine
Vol. 12, Issue 2
23
Curious Eponyms
WORD ROUNDS
Barton J. Gershen M.D., Editor Emeritus
Girolamo Fabrizi of Aquapendente,
A second category of human lymphoCaligula. Her name was Julia Augusta
Italy (1533-1619) received his doctorate
cyte, also manufactured within the bone
Agrippina and she was an ambitious,
in medicine from the University of Padua.
marrow, subsequently migrates to the
controlling woman. She demanded that
His mentor was Gabriele Fallopio, of
Thymus gland where it matures. These
Claudius rename his new city after her, so
Fallopian tube fame, whom he later suclymphocytes are responsible for cellular
Oppidum Ubiorum became Colonia Claudia
ceeded as Professor of
Ara Agrippinensis –
Anatomy and Surgery.
“Agrippina’s Colony.”
In turn, Fabrizi’s
The name was almost
During his dissection of immature birds,
brightest student was
as large as the settleFabricius discovered an interesting outpouching
William Harvey, who
ment, and difficult to
described the circulause in casual converof the cloaca, which disappears as a bird ages to
tion of blood.
sation, so gradually
maturity. This sac became known as the Bursa
In the manner of
it was shortened to
of Fabricius.
that period, Fabrizi
simply the “Colonia.”
altered his name to
Over the centuries,
a Greek and Latin
as Teutonic people
form, becoming Hieronymous Fabricius.
immunity, and are known as T lymphoregained control of the city, the word for
Hieronymous is from Greek hieros:
cytes – the T representing thymus. T
“colony” became the German Kōln. Today
“sacred” and onyma: “name.” (His origlymphocytes are differentiated by various
we know that city as Cologne.
inal given name, Girolamo is Italian
groups of receptor glycoproteins present
In 1709, Giovanni Maria Farina moved
for “Jerome” and Jerome, in turn, means
on their cell surface. These protein molefrom Santa Maria Maggiore in Italy, to
“sacred one”). Fabricius is the Latinized
cules are known as CD receptors, the CD
Cologne. Once there, he altered his name
form of Fabrizi.
representing “clusters of differentiation,”
to the German Johann Maria Farina and
The man we now know as Hieronymous
and among other lymphocytic disorders
established a perfume factory, which he
Fabricius made a number of anatomical
are prominent in the diagnosis and treatnamed Farina GegenuГњber. Within a year
discoveries, designed a procedure for perment of HIV & AIDS.
Herr Farina had invented a new toiletry. By
forming tracheostomies, and established
The city of Aquapendente, birthplace
adding the scent of lemon, lime, rosemary,
several original observations in the nascent
of Fabricius, derives its name from the
lavender, etc. to a 60 percent alcohol base
field of embryology. He became the forewaterfalls found there. Aqua: Latin for
he created the finest perfume of his day. In
most surgeon of his era and, in contrast to
“water” and pendente from the Latin root
deference to his new home, he called the
most modern physicians, Fabricius retired
pendere: “to hang,” that is, “hanging water”
product Eau de Cologne, which in French
as a wealthy man. In addition to humans,
a picturesque simile for a waterfall. Pendere
means “water of Cologne.” Farina wrote to
he also performed dissections on lower
has given birth to numerous English words
his brother: "I have found a fragrance that
animals. During his dissection of immasuch as pendant [a “hanging” ornament],
reminds me of an Italian spring mornture birds, Fabricius discovered an interappendage [something “hanging onto,”
ing, of mountain daffodils and orange
esting outpouching of the cloaca, which
as an appendix] and pending [something
blossoms after the rain." Unfortunately,
disappears as a bird ages to maturity.
that is metaphorically “hanging around”].
patents were not available in Germany
This sac became known as the Bursa of
Aquapendente, located in northwestern
at that time, and many perfume factories
Fabricius. Three centuries later, the bursa
Italy, remains an active village with a
developed their own version of “Eau de
was found to produce hematopoietic cells,
population of 5500 people.
Cologne.” In today’s market, it is most
including lymphocytes that are responSome 1500 years before Fabricius, a
often sold as a man’s after shave lotion,
sible for humoral immunity. Like its avian
Germanic tribe known as the Ubii estabbut the original creation was utilized as a
predecessor, some human lymphocytes are
lished a settlement in an area that is now
perfume for women by all the royal houses
also responsible for humoral immunity. In
part of Germany. In 50 C.E. the Roman
of Europe. Of interest, Farina’s original
this case the lymphocytes are produced
emperor Claudius captured that town
factory remains operational to this day.
in the bone marrow and, in deference to
and called it Oppidum Ubiorum (“town of
Words derived from proper nouns,
Fabricius, have become known as B lymthe Ubii”). Claudius had just married his
lower-cased and utilized as names for
phocytes – the B is for bursa.
4th wife, a sister of the previous emperor
common objects, are known as eponyms
{
24 Vol. 12, Issue 2
Maryland Medicine
}
(Greek epi: “upon” plus onyma: “name,”
that is a name placed upon an object). I
have discussed eponyms in this column on
several occasions. Words such as atropine
(named for Atropos, one of the Greek
fates), priapism (named after Priapus,
the mythical son of Aphrodite), melba
toast (named after the opera singer Dame
Nellie Melba), sodomy (named for the
biblical city of Sodom) and cologne are
prime examples. Many eponyms are easily
recognizable as such, but some are hidden
and unrecognizable.
In 1784, a lieutenant in the British
Royal Artillery developed a deadly antipersonnel weapon. He devised a hollow
shell filled with iron and steel balls, black
gunpowder and a fuse. The shell was fired
from a cannon and as it arced through the
air, the interior fuse would explode breaking the outer metal casing and discharging
the lethal balls in every direction. He called
this new weapon “spherical case shot,” but
it was soon named for its inventor. His
name was Henry Shrapnel. His weapon
was not used much after WWI, but during WWII the shells from German antiaircraft cannons were designed to explode,
sending chunks of metal through the air.
Our bomber pilots also called those lethal
shards shrapnel. [The Germans referred
to them as Fliegerabwehrkanone: “aircraft
defense cannons” – or FLAK. Our pilots
also referred to them as “ack ack”– from
the World War I phonetic alphabet for
“A-A” –“antiaircraft artillery.”]
Ytterby is a Swedish village north of
Vauxholm. The village boasts a quarry that
has produced several rare earth minerals.
In 1794, Johan Gadolin, a Finnish mineralogist, examined a lump of black rock that
had been obtained from that quarry, and
discovered a new element within the rock.
He named the element yttrium after the
village and quarry in which it was found.
(Yttrium is a rare earth element whose
chemical symbol is Y and whose atomic
number is 39.) Six years later, a French
chemist named Jean Charles Galissard de
Marignac also examined samples of that
black rock and found traces of a second
element embedded within it. Marignac
named both the rock and its new element for Johan Gadolin, calling the rocky
source Gadolinite and the new element –
Gadolinium. Gadolinium, whose chemical symbol is Gd, has an atomic number of
64. It has the unique property of paramagnetism, developing magnetic properties
only in the presence of a strong external
magnetic field. This has made it uniquely
useful as a contrast agent during Magnetic
Resonance Imaging (MRI).
In 1875, French chemist Paul Emile
LeCoq de Boisbaudrin discovered an
unusual element that emitted two violet lines on spectroscopy. Since he was
a loyal Frenchman, he named the new
element Gallium for his native country.
(The Latin name for France was Gallia.
You may recall the famous line written
by Julius Caesar: “Gallia est omnis divisa
in partes tres” – all Gaul is divided into
three parts.) Gallium – chemical symbol
Ga and atomic number 31 – has been
found to possess a unique biological feature. One of its radioisotopes, Gallium67
Citrate (or nitrate), behaves like iron and
is bound to leucocytes within areas of
inflammation or rapid cell growth. This
property makes it useful as an agent in
nuclear medicine scans. Another Gallium
isotope, Gallium68, emits positrons, making it effective in PET imaging.
In 1866, a British-born amateur naturalist discovered a small fish, which has
become one of the most popular fresh
water aquarium species. The females of
this group are 1.5-2.5 inches in length
(somewhat larger than the males), and are
one of those rare fish that give birth to
live, free-swimming offspring. Somewhat
later in 1866, the British zoologist Albert
Gunther named the new genus for the
man who had discovered it – Robert John
Lechmere Guppy.
There is a river that arises in west-central Turkey and flows west to the Aegean
Sea, emptying near the ancient Ionian city
of Miletus. Its riparian course is marked
by a convoluted, serpentine channel as it
weaves its twisting way to the sea. The
modern Turks call it the BГјyГјk Menderes
River, but in ancient Greece it was named
the Meander – a word that now means
“wandering aimlessly.” The writer of this
column has occasionally been accused of
that same trait.
Finally, in this brief review of curious
eponyms, there is the story of a boy who
was born in Harer, Ethiopia in 1892. His
name was Tafari Makonnen. He grew to
manhood and was named Regent of the
country in 1916, which in the Amheric
language is Ras: “prince.” He subsequently
became the Emperor of Ethiopia, reigning
from 1930 to his death in 1974. As is often
the case, upon being crowned Emperor he
adopted a new and more regal name. Since
he was a devout Ethiopian Orthodox
Christian, he became the Emperor Haile
Selassie, which in translation means “the
power of the Trinity.” His entire royal
name was "His Imperial Majesty Haile
Selassie I, King of Kings, Lord of Lords,
Conquering Lion of the Tribe of Judah,
and Elect of God." В In the 1930s on the island of Jamaica,
there arose a new monotheistic sect
of Christians who began to worship
Haile Selassie as God incarnate – as
the Messiah. This new religious faction
named themselves Ras Tafari taking
Selassie’s pre-regnal title of Ras plus his
given birth name Tafari – they became the
Rastafarians.
Keep reading and searching – the origin of words often leads to strange and
unexpected discoveries.
Barton J. Gershen, M.D., Editor Emeritus
of Maryland Medicine, retired from medical practice in December 2003. He specialized in cardiology and internal medicine in
Rockville, Maryland.
Maryland Medicine
Vol. 12, Issue 2
25
C lassifieds
EMPLOYMENT
BETHESDA: INTERNIST: Part-time.
Join an extremely successful Internal
Medicine group practice in Bethesda,
Maryland. Seeking a part-time BC/BE
Internist to job share with an established
female physician as part of our group of
8 Internal Medicine physicians. Position is
five sessions per week and is out-patient
only. This practice is busy, growing, and
offers the potential for partnership. Please
email curriculum vitae to alt@ppa.md.
INTERNIST: Board certified Internist
for part-time position (in dynamic
Primary Care office) as preceptor for
medical residency practice. Busy community hospital outpatient practice in
Baltimore County, MD with diverse
patient population. Fully accredited, wellestablished residency program. Morning
& afternoon, 4-hour sessions, Mon-Fri
available w/flexible scheduling positions.
Hourly stipend provided. Enthusiasm for
medical education & commitment to
provide high quality care requirements
for consideration. Send inquiry & C.V. to
Joe.Fuscaldo@MedStar.net.
OCEAN CITY: Free Condo. FT, PT
or summer position at a friendly Urgent
Care/Family Practice Center. Enjoy the
beach life! NO HMO, NO ON CALL.
Luxury condo w/ pool, tennis & more.
Incl. Salary, bonus, malpractice, flex
schedules. Dr. Victor Gong, 75th St.
Medical. Ocean City, MD. 410.524.0075
(p), 410.524.0066 (f). www.75thstmedical.
com or email Vgongmd@yahoo.com.
PRIMARY CARE PHYSICIAN:
Growing practice in Silver Spring seeks
part-time physician. Friendly environment, flexible schedule, competitive salary. Contact is at office@mhcmd.com or
301.452.4062.
URGENT CARE PHYSICIANS
AND STAFF: Rockville, MD. Need
enthusiastic Physicians, PAs or NPs,
Nurse Administrator, techs, LPNs, X-ray
techs, & MAs for FT & PT positions.
Reg: BC/BE physicians in EM or FP.
IM with PEDS experience. Flex work
hours. Competitive compensation. Great
community! Paid malpractice and tail.
Send resume to Urgentcare@myphysiciansnow.com.
26
Vol. 12, Issue 2
Maryland Medicine
PRACTICE SALES,
MERGERS, ETC.
BOWIE: Practice for sale. 21-yearold practice in Bowie area. Pediatrics
& Adults (70%-30% mix). About 2500
active patients. Send inquiries to smkumarmd@comcast.net.
FREDERICK: See FOR SALE OR
LEASE below)
HARFORD COUNTY: Pain
Management practice for sale. Attractive
office space fully fitted out medical/surgical suite with new C-arm. Conveniently
located off of I-95. Send inquires to
David at Mdspaincare@aol.com.
PRIMARY CARE PRACTICE:
Potomac Physicians, P.A., a primary
care medical practice with 7 offices in
Maryland is currently looking for primary care physicians interested in moving
their existing practices under our business umbrella and into our Catonsville,
Annapolis, Whitemarsh and Laurel
offices. If interested, please contact
Carol Reynolds, M.D., Medical Director
at 410.248.2651 or at carol.reynolds@
potomacphysicians.com.
LEASE/SUBLEASE/SALE
BETHESDA: Attractive office space
for rent in physician’s practice w/private
office, exam rooms and shared waiting
room ready for use. Walking distance to
Metro, parking garage, or on street and
county garage across street. Please call
Avelene at 301.656.0220.
BETHESDA BORDER/NW DC:
Medical office sublet available. Prime
location, spacious, newly refurbished,
EMR, and ready for use. Available for fulltime or part-time. Convenient parking
located behind building. Walking distance
to Metro and Metrobus. Please call
202.237.0808 for more information.
BOWIE: New medical building, in the
heart of Bowie. Conveniently located
near the intersection of Rte. 450 and
Rte. 193. 2,300 square feet available.
Flexible terms and monthly rates. To discuss or see, call Amanda at 301.860.1200.
CAMP SPRINGS: В For sale by
owner. Two attached medical offices in
condominium at 5625 Allentown Rd. ,
Camp Springs , MD. 20746, suite # 202203. В Across from Andrews AFB. Used
for OB/GYN practice for 20 years. В 1900
sq.ft. Owner financing available. Office
equipment also for sale.В Best offer
accepted.В В Call 301.343.6018.
CHEVY CHASE: Near Friendship
Heights metro, office buildings, high-rise
residential and high end shopping. NIH
and Suburban Hospital in MD and Sibley
Hospital in D.C. Office offers 2750 sq.ft,,
6 exam rooms, kitchen, bathroom, parking. Fully accredited outpatient surgical
facility in building. Contact Elan Reisin
202.997.5007 or elanreisin@yahoo.com.
COCKEYSVILLE: Available May 2011.
2000 sq.ft., 6 exam rooms, 4 business/physician offices, one lounge, lab area, large waiting room, storage and excellent parking. Call
410.628.6100 for more information.
FALLSTON/BELAIR: Office space
for lease to health professional. Approx.
1,000 sq.ft. Well maintained in a high
growth area. Plenty of parking on Belair
Rd. Call Dr. Scharf at 410.458.9969.
FOREST HILL: Office space available
in a quiet professional building. Includes
utilities, phone, copy, fax machine, receptionist area, waiting room, and parking.
Two examination rooms and all other
necessary accommodations for an MD
(sink, closets, file areas, etc.). Part-time
availability (1-3 days a week). Please contact Dr Schmitt at 443.617.0682 or Dr.
Legum at 410.852-0582.
FREDERICK: (FOR SALE OR LEASE)
Available immediately fully fitted out
Medical Suite in a medical condominium
building. This medical suite is fitted with
5 private offices, 10 exam rooms, waiting area, lab, storage, conference room
and break room. Call Jay Nathan at
240.405.1023 or 301.471.8251.
GLEN BURNIE: Office space in
Empire Medical Building , 200 Hospital
Drive , Glen Burnie , MD 21061
(Across from BWMC) 862 sq.ft. call
410.766.5552.
GREENBELT: Brand new office, 1250
sq.ft. to share, to lease or to lease with
option to buy. Conveniently located
2 miles from Doctor's Community
Hospital. Near intersection of Beltway(I
495) and BW Parkway (I 295),on
Greenbelt Road (Rt. 193) across from
NASA. Please call Paul at 301.299.9571
or email PWang@MRIS.com.
GREENBELT: Pediatric office. 1200 sq.ft
next door to Safeway/CVS. Less than ВЅ
mile from the Beltway. Call 301.318.7259.
HUNT VALLEY: 3,793 sq.ft. medical space. Formerly used by General
Practitioner in Hunt Valley Professional
Building. 1st floor space at $17.50 psf plus
utilities and cleaning. Contact McKenzie
Commercial Real Estate Services at
410.494.4868.
RIVERDALE: Office lease or sublease.
6510 Kenilworth Ave., Riverdale, MD.
Close to Doctor’s Comm. Hospital &
P.G. Gen. Hospital. Call 301.927.6111 or
301.325.3212.
ROCKVILLE: 1,200 sq. ft. office next
to Shady Grove Hospital. Available afternoons and weekends. 301.424.1904.
SILVER SPRING/WHEATON:
Lower your overhead expenses by subleasing or sharing medical office space.
Luxurious penthouse suite with 3200
square feet, 7 treatment rooms, surgery
center, equipment and staff available.
All medical specialties welcome.В Call:
301.949.3668.
SILVER SPRING, DOCTORS
MEDICAL PARK: Georgia Ave. and
Medical Park Drive. Close to Holy Cross
Hosp., ВЅ mile north of #495. 3 building medical campus totaling 95,000 sq. ft.
with over 100 medical practitioners and
Clinical Radiology’s HQ. 2 suites 1400-
2750 sq.ft. avail. immediately. Call Steve
BerlinВ at Berlin Real Estate, 301.983.2344
or steve@berlinre.com.
WHITE MARSH: Office in modern
complex in White Marsh on Wednesdays.
1600 sq. feet. $700/mo. Utilities incl.
Ideal for specialist. Easy access from
I-695 and I-95. Call 410.812.6003 for
additional information.
OTHER
SCAN/ARCHIVE RECORDS:
Simple, efficient. Transition to EMR, EMR
alternative, or retire with office in pocket.
$1,299. Local. Go to www.PCArchiver.
com or call 410.484.4297.
CLINICAL TRIALS: We are recruiting motivated, detail-oriented physicians
as sub-investigators for diabetes-related
clinical trials. If interested, please contact
301.770.7373.
FOR SALE
ULTRASOUND MACHINE:
Ultrasound machine, ATL HDI 3000 used,
working condition $2,000.Used EXAM
TABLE $400.00. Good condition. Call
301.927.6111 or 301.325.3212.
Maryland Medicine
Vol. 12, Issue 2
27
L ast
THE
W ord
How Will the Quality of Care You Provide
Be Measured in the Future?
Unfortunately, the “future” is now on
the World Wide Web!
A thumbs-up or thumbs-down?
2.5 stars out of 4.0?
Are these effective tools to help
patients find physicians who provide
quality care?
Whether you like it or not, quality of
care is being defined by “consumers” as
the attractiveness of your reception area,
by how quickly you return a phone call,
by your mood on a daily basis, and by
the friendliness of your staff.
The following websites are just a
few of the ones which already have
quality ratings about you and your
colleagues, or at the very least, have
biographical information which may or
may not be correct. You are encouraged
to visit these sites to see what your current patients and possibly your future
patients are saying about you on the
internet!
Yelp.com
Healthgrades.com
Angieslist.com
Youtube.com
mdnationwide.org
RateMD.com
Vitals.com
Healthcare.com
Drscore.com
Ucomparehealthcare.com
Mol.net
Doctorscorecard.com
Are these ways to judge quality?
To that, we say:
A smiley or sad face?
Or by people who have never been seen by you as a patient?
28
Vol. 12, Issue 2
Maryland Medicine
Because you can’t always foresee
the unexpected along the road.
Charles and Pratt Streets: Baltimore
Reassurance. That’s the difference Medical Mutual makes in the lives of thousands
of Maryland Physicians year after year. That’s also one reason why more Physicians
choose us to be their medical professional liability insurance company. Physician
owned and directed, we’re dedicated to protecting careers, practices and professional reputations—a mission we’ve
fiercely upheld since 1975. Physicians
know that we’ll be ready if they need us
today, or somewhere down the road.
225 International Circle
Faithful to our mission since 1975
Hunt Valley, Maryland 21030
410|785-0050
800|492-0193
MedChi
The Maryland State Medical Society
1211 Cathedral St. s Baltimore, MD 21201
Address Service Requested
Presorted Standard
U.S. Postage
PAID
Permit No. 425
Southern, MD

Sample Response Letters - MMIC Group

Determining Strategic Physician Recruitment Needs Under

スリクソン ( SRIXON ) 硬式ラケット 未張り上げ レヴォ CV 3.0 SR21602

e.d. conferences

Family Medicine Billing Quick List - Alberta Health Services

Pinty`s Fill Your House Web Contest Official Rules

Older Division - Zfest Zachary Arts & Music Festival

Sildenafil And Beer (Viagra) Sildenafil And Went On To Conceive

Vehicle Check-In - Brasher`s Fresno Auto Auction

Choose your Premium Plan - secureupload.eu

University of Houston Police Department

daily activities schedule

December - Southern Arizona Community Food Bank

Continuation of coverage options - Kaiser Permanente BusinessNet

Moving Maryland Forward - Governor Martin O'Malley

2010-2011 Southern California regional guidebook - Etiwanda

Institutional Provider Manual - CareFirst