MD360ºIn

dici

aor

Post

age H

ere

US

Post

age

PAID

718

Tean

eck

Road

• Te

anec

k, N

J 076

66

Medical Executive Committee Officers and Positions President: Dr. Thomas BirchVice President: Dr. Ronald WhiteSecretary: Dr. John PooleTreasurer: Dr. Randy TartacoffMedical Chiefs Representative: Dr. Benjamin RosenbluthSurgical Chiefs Representative: Dr. Harris StermanMember At Large: Dr. Patricia BurkeMember At Large: Dr. Giuseppe Condemi

Medical Staff Department Directors and Division ChiefsDept. of Anesthesia: Dr. Alan GwertzmanDept. of Emergency Medicine: Dr. Richard Schwab and Dr. Randy Tartacoff (co-directors)Dept. of Family Practice: Dr. Ohan KaratoprakDept. of Interventional Radiology: Dr. John RundbackDept. of Medicine: Dr. Michael Denker Allergy: Dr. Patrick Perin Cardiology: Dr. Stephen Angeli Dermatology: Dr. Jeffrey Rapaport Endocrinology: Dr. Mark Wiesen Gastroenterology: Dr. Michael Schmidt Infectious Disease: Dr. Mihran Seferian Internal Medicine: Dr. Lewis Attas Nephrology: Dr. Louis Jan Neurology: Dr. David Van Slooten Oncology: Dr. Yadyra Rivera Psychiatry: Dr. Sharad Wagle Pulmonary Medicine: Dr. Stuart Silberstein Radiation Oncology: Dr. Benjamin Rosenbluth Rehabilitative Medicine: Dr. Michael Denker (Interim) Rheumatology: Dr. Ralph MarcusDept. of Obstetrics & Gynecology: Dr. Christopher EnglertDept. of Pathology: Dr. Drew OlsenDept. of Pediatrics: Dr. Harry BanschickDept. of Radiology: Dr. Jacqueline BrunettiDept. of Surgery: Dr. Joseph Manno Dentistry: Dr. Stephen Haber General Surgery: Dr. Joseph Manno Neurosurgery: Dr. Roy Vingan Ophthalmology: Dr. Joseph Manno (Interim) Orthopedics: Dr. Raphael Longobardi Otolaryngology: Dr. Asmat Quraishi Podiatry: Dr. Ritchard Rosen Plastic Surgery: Dr. Harris Sterman Thoracic Surgery: Dr. Ignatios Zairis Urology: Dr. Vincent Lanteri Vascular Surgery: Dr. Kenneth Fried

News from and for Holy Name Medical Center’s

Medical Staff

Also available online at:www.holyname.org/md360

Second Quarter 2012

Accountable Care Organization Holy Name has submitted our non-binding letter of intent to CMS that details our intent to start an Accountable Care Organization (Holy Name Medical Center/Physician Accountable Care Organization). We will submit our full application, with the assistance of QualCare, at the end of August. This ACO will be a risk-sharing partnership between the Medical Center and members of our Medical Staff. Our goal is to partner with members of the medical staff who are interested in learning from this “risk sharing experiment.” In order to be accepted by CMS, we will have to partner with enough physicians for a minimum of 5,000 covered Medicare lives; but ideally, we will get enough physicians on board to have 10,000 lives. We will be having a series of town hall meetings to discuss further details of the ACO and answer any questions that members of the Medical Staff may have. Briefly, in this model, all providers, physicians and hospital, will be paid traditional fee for service; however, at the end of each year, if less money is spent on the ACO’s covered lives than predicted, the savings will be shared between Medicare and the providers. The ACO will be governed by a Board of Directors consisting of physicians and Medical Center representatives, and the Board of Directors will develop an Operating

Experimental Payment Models

Adam Jarrett, MD, MS, is Executive Vice President/Chief Medical Officer at Holy Name Medical Center. He can be reached at 201-833-7273.

There are two initiatives for me to write about in this summer season. One is the Holy Name Accountable Care Organization and the other is the Information Technology Task Force (ITTF). For many months, we have all been reading about and discussing the reasons why ACOs may succeed or fail as part of the solution to the problems with health care. I think that it is important to recognize that the ACO program is only one of 10 or more demonstration projects developed by the Centers for Medicare and Medicaid Services (CMS). These demonstration projects are experiments in economic and industrial engineering. One previous example is the hospital DRG reimbursement methodology that began as an experiment, initially in New Jersey. If these experiments succeed, they are likely to become public policy and, if they fail, they may be scrapped or modified with or without retesting. It is the responsibility of our political leaders and CMS to develop solutions to our problems. Because of the dire but seemingly reliable economic forecast for health care, demonstration projects have bipartisan support and will survive any effect of the impending Supreme Court decision on other provisions of the Affordable Care Act. Government

programs and public employment now pay for 50% of healthcare expenses in the United States. More than ever, “She who pays the piper calls the tune.” With the current ACO project, we can gain experience accepting and managing financial risk for coordinated care of patients with Medicare and for care of our hospital employees. We will get paid according to the same fee-for-service schedule and assume no financial risk. Physicians will join the Medical Center in analyzing utilization data provided in a timely fashion by CMS. QualCare, the insurer owned by New Jersey hospitals, will be contracted by Holy Name to handle the application and regulatory process. The Hospital-Physician ACO will be eligible to receive bonus payments if Medicare expenditures (including outpatient, hospital and inpatient rehabilitation, but not pharmaceuticals) are less than 98% of a case mix adjusted average of our own historical controls. This concept, as currently structured, may succeed or fail, but our choice is clear: Gain expertise, grow and create the future or sit on our hands watching others follow the exploratory path. You can only sign up for one ACO, as currently structured. We need to have a minimum of 5,000 covered lives but a healthier mix would be 10,000. We are

Season for Change looking for every primary care physician with or without a subspecialty to sign on. Pure specialists are welcome and also suffer no downside risk. The real question is: “Can we work well together to improve the efficiency of our work?” If the answer isn’t “YES!” then please review your retirement plans because change is coming quickly and this ACO experiment is just a tiny introduction. Please call or e-mail Melanie Augello, Manager, Medical Affairs at 201-833-7220 (augello@holyname.org) with your interest. Our deadline is July 31.

* * *• Did you know… If a computer is running more than one WebHIS program and a doc has not logged out of his/her screen operating behind yours, that you could be dictating into that physician’s voice recognition, corrupting your note and the other doctor’s voice profile?

— Continued on page 2

Agreement that details exactly how the potential savings are divided. During the first three years of this model, if more money is spent than predicted by CMS, there will be no penalty to the ACO. Because there is no real risk in this model, our primary motivation for involvement is learning from the experience of working with our physicians in a risk-sharing model. However, it is likely that, in the future, there will be downside risk—therefore, please seriously consider partnering with HNMC on this ACO experiment so that together, we can learn how to manage care in this new risk-sharing environment. Episode of Care Model We are also seriously contemplating partnering with members of our medical staff in an “episode of care” experimental model. This model looks at episodes of care that begin at the time of hospitalization for select DRGs, and last for 90 days after discharge from the hospital. Starting from the time of admission and for 90 days after discharge, all medical costs (with the exception of medications) are included in these episodes of care. In this model, all providers are again paid traditional fee for service; however, if there are savings on these episodes of care, after CMS takes its percentage, the savings are divided between the providers. One significant difference in this model is that if our costs are greater than expected for

these episodes of care, HNMC will have to pay that money back to CMS. However, physicians will not be at risk for additional costs. We will also be looking for physicians to partner with us on this “episode of care” model so keep an eye out for meetings to learn more.

It is extremely important that Holy Name gains experience in assuming risk. The economic realities are such that risk-sharing models are inevitable and although these specific experimental models may not be the final model, some form of risk-sharing is coming. Please consider working with HNMC on these experimental programs, which have been designed by CMS to not put physicians at risk. It is only a matter of time when physicians will be “forced” by CMS and other payors to take on risk. It seems likely that we are in the last years of traditional fee for service medicine, so now is the time to get the experience we need to thrive in this new world. Please contact me if you would like to discuss further and be on the lookout for specific meetings about participation in these models.

MESSAgE frOM thE PrESiDEnt Of thE MEDiCAl StAff

MESSAgE frOM thE ChiEf MEDiCAl OffiCEr

Thomas Birch, MD, is an infectious disease specialist and President of the Medical Staff at Holy Name Medical Center. He can be reached at 201-833-7274.

2

Season for ChangeContinued from page 1

• What do you do when the floor cleaner is passing by?

• Can we get that monster text box out from in front of all of the clinical data so that we can slice and dice the information to actually understand what is going on with the patient while attempting to reliably document care?

I was privately cursing these and other issues until more than a dozen other doctors approached me and said: “You are president of the medical staff. You have to do something about this situation with Dragon.” As a result, the Medical Executive Committee created the Information Technology Task Force, ITTF. We are looking for a dozen or more doctors who use the system frequently to commit to a small number of meetings with Mike Skvarenina, Deb Ross, Adam Jarrett and Mike Maron to optimize the user experience of WebHIS as we move into CPOE. A new version of Dragon is coming this month and we must begin CPOE by October 31 to meet meaningful use requirements.

We have a system that is more user-friendly than most and more under our control than any. We can take it to the next level with a robust collaboration in a more prospective way than ad hoc tips and comments in the course of rounds. The goal is to take our experience from the Microsoft experience to the Apple experience. You know what to do. Contact Melanie at 201-833-7220 (augello@holyname.org)!

Bedside Shift Reporting for Quality, Safety and Satisfaction Knowing that communication errors account for more than 70 percent of the sentinel events that occur in a hospital, and with quality care and patient safety our foremost goals, the nursing staff at Holy Name Medical Center embarked on a quest to initiate change in the way information is transferred by caregivers to other caregivers, and by caregivers to patients. After researching best practice throughout the country, our nurses crafted a customized Bedside Shift Reporting structure that not only meets the needs of our nurses and patients, but delights them. Instituted earlier this year on all units during all shifts, Bedside Shift Reporting is all about interaction at the patient’s bedside at a time when communication breakdowns are most likely to occur. After up to 12 hours with the same nurse, patients worry that a shift change will bring a “new” nurse who won’t know the particulars of his or her case. For oncoming nurses, an accurate debriefing about the events of the last several hours is essential to the ability to care thoroughly and appropriately for the patient during the next shift. Bedside Shift Reporting addresses these concerns, empowering patients to take part in their own care and reassuring them that all members of the nursing team understand the plan of care and are in agreement. Similarly, direct observation of patients in the presence of another caregiver promotes nurse-to-nurse accountability, elevating the quality of care and decreasing the

Sheryl Slonim, DNP, RN-BC, NEA-BC, is Executive Vice President of Patient Care Services and Chief Nursing Officer at Holy Name Medical Center. She can be reached at 201-833-3131.

potential for error. Here’s how it works: The off-going nurse notifies the patient that the shift is about to change and s/he will be transferring responsibility of her/his patients to another nurse. The nurse then checks pain levels, administers the appropriate medications and attends to other needs, such as position change and toileting. When the oncoming nurse arrives, the bedside report is given to the colleague in the presence of the patient, providing a valuable opportunity for questions, comments and corrections. In the interests of sensitivity and the need to convey a completely accurate picture of the patient’s status, the off-going and oncoming nurses will discuss matters such as a new diagnosis, test results, and issues surrounding difficult behavior or non-compliance, prior to entering the patient room. The way in which we document bedside shift report information will also undergo a significant transformation. Formerly, the bedside report was recorded in handwritten notes, leading to irregularities in format and content. In several weeks, we will institute a standardized Electronic Bedside Report Sheet. Having been trialed successfully on two units, the sheet will provide hospital-wide consistency in how the bedside report is given and taken, with a head-to-toe assessment utilizing the SBAR (situation, background, action, response) format. Physicians can feel confident that the right information is being communicated about and to their patients in an appropriate manner

and that we are visualizing the patient in real time, witnessing the patient’s status and any changes, as we give and take the report. We expect that Bedside Shift Reporting will have a measurable effect on your patients’ level of satisfaction, by generating a sense of cohesiveness between them and their caregivers. We hope your patients will feel more secure, knowing that all members of their healthcare team are on the same page, and that we care enough to give the patient voice to their needs and concerns. A bonus benefit of Bedside Shift Reporting is that it satisfies several of the Joint Commission’s National Patient Safety Goals, including:• Improving the effectiveness of communication among caregivers• Implementing a standardized approach

to ‘hand off’ communications, including an opportunity to ask and respond to questions• Encouraging the patient’s active involvement in their own care as a patient safety strategy

Your feedback about our new bedside reporting strategy is welcome. Please don’t hesitate to contact me.

rEPOrt frOM thE ChiEf nurSing OffiCEr

Benefits of Bedside RepoRting…• Improves effectiveness of communication among caregivers.• Allows caregivers the opportunity to ask and respond to questions during change of shift reports.• Promotes accountability between shifts with direct observation by both incoming and off-going RNs.• Enables the nurses to visualize the patient and get a baseline assessment for comparison.• Alerts us to inconsistencies between information provided and actual patient status.• Fosters nurse-patient interaction.• Promotes patient involvement in care.• Increases patient satisfaction.• Decreases patient anxiety.• Allows the patient to witness a safe professional transfer of responsibilities.• Reassures the patient that the nursing staff works as a team and that everyone knows the plan of care.• Maximizes efficiencies of care.

Is Our Goose Cooked? Happy 4th of July! A day to remember our independence, or what there is left of it. The last week of June rattled the heads of many with the monumental decision of the Supreme Court and Chief Justice Roberts to uphold the Affordable Care Act (ACA). But did it? Having read his opinion, it is evident that Roberts strained to accommodate the mandate by relabeling it as a tax, as the instrument to collect and enforce it is the IRS and its agents. While the Obama administration tried to compel us to believe that the mandate was legal under the Commerce Clause, Roberts, in essence, stated that one cannot regulate commerce that does not exist, that the Commerce Clause is “not a general license to regulate an individual from cradle to grave” by mandating health coverage for all. In addition, the “individual mandate forces individuals into a commerce precisely because they elect to refrain from commercial activity.” So why then, if deemed unconstitutional in and of itself as a mandate, did Roberts bend over backwards to ensure that the ACA was sustained, if only as a tax? Was it about his legacy on the Supreme Court, was it pressure from the liberal media who taunted him as a partisan hack up to the very second of his pronouncement? Now it appears that Roberts has earned “darling” status from the media, if only for the time being. Multiple times in his opinion, Roberts asserts that the courts do not make the laws, the duly elected representatives do, and it is the obligation of the Court solely to decide on the constitutionality of a particular law. But again, did Roberts do that? In my opinion, no; he minced words and devised nuances for interpreting the mandate as a tax. If it were to remain as a mandate, it would be unconstitutional. While the liberal media

and Obama claim victory, their success rings hollow, especially now, as Obama’s legacy is that of a President who has created the largest single tax in our history. But the question remains as to whether or not care is actually going to be given to the uninsured through the ACA. Roberts, in his opinion, has struck down as unconstitutional the expansion of Medicaid, which was to have absorbed all the new “non-elderly” individuals to be covered. At present, the states, through their established Medicaid programs, cover “four particular categories of the needy: the disabled, the blind, the elderly, and needy families with dependents.” Under the ACA, states would be forced to expand their program to include non-elderly individuals with incomes 133% of the poverty level, or risk losing what federal funding they receive at present for their established Medicaid programs. The Court described this as coercion of the state by the federal government and as disregard for the individual states’ rights; therefore, the Court has ruled the Medicaid expansion as unconstitutional and has allowed the states to opt out, as it were, from participating in the ACA, while preserving their funding for their present Medicaid program. In addition, “Congress mandated that the newly eligible persons receive a level of coverage that is less comprehensive than the traditional Medicaid benefit.” Indeed, New Jersey is second only to New York in its provision of benefits to Medicaid recipients at present. Therefore, and allegedly, Governor Christie has previously vetoed the State Assembly’s decision to initiate exploration of health care exchanges in New Jersey, thus ahead of the game, as it were, and without waste of resources or revenues. It can only be assumed that the other 25 states participating in the suit will opt out as well. Therefore, the ACA appears

to have little to stand on other than being found to be constitutional in part as a tax, and unconstitutional as an instrument to provide health care for the uninsured. Again, a hollow victory for Obama, a sort of secondhand lion without teeth. But really, was that the only thing that happened last week of note? On the same day as the Supreme Court’s decision, Congress voted, in a non-partisan way, to hold Attorney General Eric Holder in contempt of Congress for the “Fast and Furious” debacle. Liberals argue that the contempt charge is nothing but partisan pre-election politics as Holder has turned over more than 7,000 documents to Representative Darrell Issa. My question is what is in the other 90,000 or so documents and how does executive privilege pertain in this case? Although people claim that Bush did it too, there were GPS chips to follow that lot of guns, whereas there were not any in Holder’s lot, plus, and perhaps more importantly, no U.S. or Mexican citizens were killed prior to “Fast and Furious.” Executive privilege is primarily extended for issues of national security. How is this issue national security except to expose collusion and wrongdoing by Holder? And to top off “That Was the Week That Was,” Saturday, June 30th was the last day one could legally obtain foie gras in the state of California! Even as the cities of Stockton and Mammoth Lakes have declared and cascaded into bankruptcy, the state legislature in California has decided that it is inhumane to make duck and goose liver pâté. Phew! Now that’s critical.

Patricia Burke, MD, PhD, is an ophthalmologist on staff at Holy Name Medical Center, Member-at-Large of the Medical Executive Committee and Past-President of the Medical Staff.

COMMEntAry

One of the important aspects of urinary tract infection (UTI) management is differentiating between colonization, which is the benign presence of bacteria in the urinary tract, and infection. This differentiation is crucial since one condition requires antibiotic usage and the other doesn’t. Bear in mind, that this dilemma is common due to fact that UTI is the most common nosocomial infection. Bacteriuria, the growth of bacteria in the urine, is quite common, especially in the elderly population, and usually doesn’t require further intervention. The final outcome of this condition depends on the balance between the bacterial virulence and a whole host of related factors in the patient. Among those, are the health of the immune system systemically and locally, as well as bladder/kidney issues. Anatomical abnormalities, obstruction, stones and other conditions may play a role. The bacteria also has a better chance of overwhelming the host’s response if they have or acquired the capacity to stick to the uroepithelium better and longer. Once infection is established, the patient could then experience a range of symptoms, depending on the extent and the level of such infection. If it is limited to the lower urinary tract, symptoms of cystitis are experienced. These include burning, frequency and urgency of urination. Hematuria may or may not be present. If the upper tract is involved, the condition is more serious, and symptoms of pyelonephritis are experienced. Fever, chills, back and flank pain are few of those.

The treatment of these infections also varies. Generally, the quinolones and the sulfonamides are quite effective. The duration of treatment depends on the level and extent of involvement. The emergence of resistance to these antimicrobials, however, is catching up quickly and that sometimes requires the use of unconventional agents. Consider the advice of an infectious disease specialist if resistant strains are encountered. Finally, prevention of these potentially serious infections could be as easily achievable as removing an unnecessary Foley catheter. And ultimately, our patients would be the beneficiaries of this disciplined and educated approach.

Mihran Seferian, MD, is Chief of Infectious Disease at Holy Name Medical Center. His private practice is located at 200 Grand Ave., Suite 102, Englewood, NJ 07631. He can be reached at 201-503-0660.

urinary tract infections

Human beings are judging machines. We immediately judge the appearance of other people. Our first impressions are often indelible. Science reveals that the first thing we notice about another person is their face and, more specifically, their mouth and smile. An attractive person with a good smile is judged (rightly or wrongly) to be more trustworthy, smarter and more competent. For those patients who are not happy with their smile, modern dentistry has the answer in dental bonding. Dental bonding is performed directly in the mouth using tooth colored resins, meticulously layered onto the front of each tooth that appears in the smile. The process is done often with no injections and little to no drilling. Chipped and broken teeth, as well as stained and misaligned teeth can easily be treated. Even large gaps between teeth can be corrected. Dental bonding is often used to perfect the smile after braces or Invisalign® treatment. Results are amazing and life-changing. Some patients actually cry with gratitude upon seeing their new smile. Patients report that they have more confidence, and experience an improved social life. Certainly it’s a major ego boost when you know you have the nicest smile in the room! Dental bonding is extremely affordable. All of the upper teeth that show in the smile can be bonded for little more than the cost

of a single crown, porcelain laminate or Lumineers®. The process only requires one or two dental visits to complete, and dental bonding is easily repairable. Bonding does require extra training of the dental practitioner. The dental professional must understand color science, esthetics, proper proportions and proper application of dental materials. All the traditional impediments that stop patients from improving their smile, such as pain, finances, and fear of dentistry have really been eliminated with this treatment. Today, everyone can truly enjoy the benefits of a beautiful smile!

Alvin C. Jacobs, DDS, is a dentist on staff at Holy Name Medical Center. His private practice is located at 1625 Anderson Ave., Fort Lee, New Jersey 07024. He can be reached at 201-944-1331.

Change your Smile, Change your life…Through Cosmetic Dental Bonding

Before After

Before After

Bonding used to fill gaps between teeth.

Bonding used to straighten appearance and whiten teeth.

3

Vitamin D is a fat soluble vitamin essential for normal calcium homeostasis that recently has been recognized for its role in preventing many diseases. Vitamin D receptors are present in most tissues of the body and approximately 2,000 genes are affected by or regulated by vitamin D. Activated D has been shown to inhibit prostate cell proliferation, although once cancer is present in cells, this beneficial effect appears to be blocked by the abnormal cellular mechanisms that exist in the cancer cell. Vitamin status is assessed by measuring serum 25 hydroxy vitamin D. Optimal serum levels range from 30 – 60 ng/ml. A deficiency of < 20 ng/ml has been linked to increased risk for colon, prostate, breast, renal, and possibly, pancreatic cancers. Vitamin D can be derived naturally from exposure to sunlight, as well as from a variety of food sources or with supplementation. Vitamin D that is made in the skin lasts two times longer than orally-ingested vitamin D, however most

people who live in latitudes north of Atlanta, Georgia are deficient if relying on sunlight as their source. In northern climates, exposure to sunlight is ineffective in the winter months, due to the angle of the sun and UVB levels. In the summer months or in southern climates, exposure for five to 15 minutes with arms and legs bared, two or three times per week from 10 a.m. to noon is adequate for vitamin D synthesis in the skin. African Americans will need five to 10 times this amount of sun exposure, due to the effects of melanin. Additionally, higher SPF sunscreen can decrease production by more than 90%. It is not possible for the body to make too much vitamin D; excesses are altered into other metabolites. It is thought that there may be a link between lesser amounts of sun exposure in children and an increased risk of cancer in later life, adding another reason for children to be active outdoors, as opposed to playing video games.

Jacqueline Brunetti, MD, is Medical Director of the Department of Radiology at Holy Name Medical Center.

Vitamin D: We Evolved in Sunlight…So Let the Sunshine InVitamin D in the Dietfood sources of vitamin d include: Cod liver oil 1,360 IU/1 ouncePink canned salmon 530 IU/3 ozSardines 231 IU/3ozTuna, canned 200 IU/3 ozCow’s milk, fortified 100 IU/8 ozOrange juice, fortified 100 IU/ 8 ozFortified breakfast cereals 40-50 IU/1 cupEgg 20 IU/1 oz

NOTES:• Farmed salmon has no vitamin D content and is, in fact, inflammatory due to the grain feed and should be avoided.• For those who are vegetarians, a vegetarian source of D2 can be found in many supplements.

Vitamin D Supplementation Vitamin D supplementation comes as both D2 and D3. Although some data

How risky is foreign travel? People tend to exaggerate dangers such as terrorism or the potential for the transmission of Ebola virus and disregard or minimize more common perils such as motor vehicle accidents and malaria. Health risks vary according to destination, itinerary and the medical history of the traveler. All individuals traveling frequently or planning an extended trip abroad should have a pre-travel evaluation, preferably at a travel clinic.

health and international travel

Lalita Wagle, MD, is an internist and Medical Director of Occupational Health at Holy Name Medical Center. She can be reached at 201-833-3001.

suggests that D3 is preferable, other studies show no difference. The National Osteoporosis Foundation recommends supplementation from a reputable source at levels of 400 – 800 IU/day for adults younger than 50 years, and 800 – 1,000 IU/day for adults older than 50. The safe upper limit set by the Institute of Medicine is 4,000 IU/day; however, more is given to correct deficiencies. For a deficiency <20 ng/ml, dosing may be as high as 50,000 IU D2 per week for eight weeks, which may be repeated if serum levels are still low, under the supervision of a physician. For levels between 20 – 30 ng/ml, dosage is D2 or D3 2,000 IU/day for 12 weeks, after which serum levels are rechecked.

Most travel-related diseases can be prevented. Listed below are some of the diseases that can be prevented by vaccination:• Hepatitis• Meningitis• Yellow fever• Typhoid• Rabies Chemoprophylaxis combined with protective measures against mosquito bites can prevent virtually all cases of malaria, as well as other insect-transmitted diseases. Sexually transmitted diseases, including HIV, can be avoided with

behavior modification. Although your own doctor may be able to administer some routine immunizations, most physicians’ offices do not stock specialized vaccines, such as those for typhoid, rabies or meningitis, and they are not authorized to stock or administer yellow fever vaccine or issue the International Certificate of Vaccination. Occupational Health Services at Holy Name Medical Center offers services for the express purpose of traveling abroad, including completion of your immunization record.

We can also provide advice and administer vaccinations for shingles, pneumococcus and influenza. In addition, it is recommended that grandparents-to-be obtain immunization for Tdap, as pertussis is increasing morbidity in very young children.

4

Do i really need to go with an electronic health record system? If you plan to be practicing medicine for five years or more, the electronic health record (EHR) is the way of the future and it’s imperative that you get with the program. If you’re wondering whether you should start now or later, consider this: Establishing Meaningful Use with an EHR is not a concept that will go away. You can start now and earn a total of $44,000 to offset the cost of implementation. Or, you can start later and receive lower incentive payments. If you wait too long, you will implement the EHR at entirely your own expense.

What is the timeframe for incentive payments? (Medicare) Establish an EHR system and prove Meaningful Use for 90 days this calendar year, and you will be reimbursed $18,000 for 2012. The last 90 days of 2012 are October 3 through December 31. That means that, to qualify for EHR incentive reimbursement, you need to get your system up and running now, and prove Meaningful Use no later than those last 90 days of 2012. The 90 days of Meaningful Use can’t be “carried over” from one calendar year to the next, i.e., November through January. They must be accomplished during the

calendar year. You may choose to not start the process until 2013, but your total overall incentive payment will be $5,000 less. If you wait until 2014, you will be entitled to a total of only $24,000, which is $20,000 less than if you start in 2012. There is discussion about disincentives or penalties for physicians who do not adopt the EHR and achieve Meaningful Use by 2015. Plans for these will be finalized by the fall of 2012, but we are anticipating a disincentive of 1%, 2% and 3% per year less in Medicare payments for doctors without Meaningful-Use EHRs.

how do i achieve Meaningful use? In order to achieve Stage 1 Meaningful Use, physicians must attain success in 15 required Core Measures. A few of these measures are: using computerized provider order entry (CPOE) for medical orders for at least 30 percent of patients taking at least one medication (#1/15), transmitting more than 40 percent of prescriptions electronically using certified EHR technology (#4/15), maintaining an active medication allergy list for more than 80 percent of patients (#6/15), and recording demographics – preferred language, gender, race, ethnicity, DOB – for more than 50 percent of patients (#7/15). There are 10 Menu Measures, of which physicians are required to achieve five. A couple of these are: enabling the

going Electronic? It Can’t Happen Too Soon

Ron Manke is the North Jersey Regional Director at NJ-HITEC. He can be reached at his office, 973-642-4055; cell number, 201-632-5990; and manke@njhitec.org. Visit www.njhitec.org.

functionality for drug formulary checks and having access to least one drug formulary (#1/10), and incorporating more than 40 percent of clinical lab test results in the EHR as structured data (#2/10). There are also Clinical Quality Measures (CQMs), which are required. However, doctors cannot fail these measures, as they will register automatically when you see the patient. To achieve Meaningful Use, each physician will need to submit numerators and denominators for each of the measures. No personal health information, diagnoses or billing information is shared. Meaningful Use attestation is simply submitting these numbers as proof that you are structuring your practice accordingly.

how can Ehr data benefit my practice? The EHR enables a multitude of efficiencies that can impact your bottom line and enhance the way you practice medicine day-to-day. Having the kind of data that an electronic health record system supplies can benefit your practice in ways you may have never conceived, by affording opportunities for quality improvement, reducing disparities between patient groups, research and outreach. For example, the EHR can help you manage patient populations with chronic illnesses. By identifying trends in appointments and behavior, and ascertaining

whether patients’ chronic illnesses are improving, you can drive appointments, versus waiting for patients to call. You can run reports by diagnosis, age or any criteria you wish, such as: patients with a BMI greater than 30 who are taking blood pressure meds and haven’t been to the office in the last 12 months; patients with an A1c greater than 8.0 who haven’t been back in three months; patients who have been taking Lipitor® for longer than 90 days and need to get current blood values. An EHR provides a system of checks and balances to help avoid errors. A patient photo and demographics confirm the patient’s identity and medical issues. Those fundamental things you always recorded on paper – vitals, smoking status, drug-to-drug interactions, allergies and so forth—you’ll simply be doing in an electronic format that provides you with a valuable database.

The possibilities are endless. Please contact NJ-HITEC soon. We will help you select, adopt, implement and achieve Meaningful Use of an accredited electronic health record system.

Peggy Cottrell, MS, CGC, is a Certified Genetic Counselor in the Regional Cancer Center at Holy Name Medical Center. She can be reached at 201-541-6303 or m-cottrell@holyname.org.

Breast cancer is one of the most frequently diagnosed cancers in women. Many patients with the disease have heard of hereditary breast cancer and may be concerned about their risk of ovarian cancer. Often, unaffected family members are frightened to see a mother or sister struggle with cancer and are concerned that they are at an increased risk of developing the same condition. What is the best way to answer your patient’s questions about hereditary cancer risk? A consultation with Holy Name’s cancer genetic counselor, Peggy Cottrell, can help. Many patients believe that all cancers are hereditary; however, only about 5 - 10% of breast and ovarian cancers are considered to be inherited. There are two genes, BRCA1 and BRCA2, that are implicated in many hereditary breast cancer families.

the national Comprehensive Cancer network (nCCn) has criteria for further genetic risk evaluation for hereditary breast and ovarian cancer, including:• Early-age-onset breast cancer at age 50 or younger• Triple negative breast cancer• Two breast primaries in a single individual• Breast cancer at any age and • A close blood relative with breast cancer at or under age 50 •A close blood relative with epithelial ovarian cancer • Two close blood relatives with breast or pancreatic cancer at any age • Ashkenazi Jewish ancestry (there is an increased risk for mutations in this population)• Ovarian, fallopian tube or primary peritoneal cancer at any age• Male breast cancer at any age

An unaffected individual who has a family history of early onset breast cancer, ovarian

cancer, male breast cancer, or a known mutation in a breast cancer susceptibility gene may also be a good candidate for genetic counseling.

Patients who come for a cancer genetics consultation will receive a personalized risk assessment. The first step is a detailed personal and family medical history, including a three-generation pedigree. The patient is given a statistical likelihood of finding an inherited mutation if s/he elects to have testing. The genetics of cancer and inheritance patterns are reviewed with the patient, and we discuss the risks, benefits and limitations of testing. We review the implications for results and options for mutation carriers as part of the informed consent for testing. Not every patient who comes in for genetic counseling is a good candidate for testing. After a full risk assessment, it may be determined that another relative, often someone affected with cancer, may be the best person in the family to have genetic testing. Sometimes we can reassure patients that it appears unlikely that the cancer in the family is hereditary. It is almost always best to start genetic testing in a family with the person who has been diagnosed with cancer. At first glance this seems counterintuitive: Isn’t it the person who hasn’t had cancer yet at the greatest risk? There are several reasons why we prefer to first test the person affected with cancer. The first is that many people diagnosed with cancer who undergo genetic testing will have negative results. However, their negative result does not mean their cancer is not hereditary. There are many undiscovered genetic risk factors for breast cancer. Negative results do not mean that the cancer is not hereditary, but only that we did not find a mutation in BRCA1 or BRCA2. Comprehensive Bracanalysis®,

Does My Patient need genetic testing for Breast Cancer?offered by Myriad Genetic Laboratories, finds most, but not all BRCA1 and BRCA2 mutations that are present. Second, if we test the affected patient, and s/he does not have a mutation, additional genetic testing is usually unnecessary for other family members. A patient unaffected with cancer who receives a negative genetic testing result does not really have informative results, as we haven’t identified a hereditary cause for the cancer in the family. Third, once a mutation is identified in a family member, other members of the family are then able to have single site mutation analysis. This test looks for the mutation present in this family at a significantly reduced cost. Once a mutation is identified in a family, a negative result becomes much more informative. Finally, the patient who has breast cancer and tests positively for a mutation in BRCA1 or BRCA2, is not only at risk to develop a second breast cancer but is also at risk to develop ovarian cancer. Any individual with a mutation in BRCA1 or BRCA2 may consider additional strategies to reduce the risk of cancer. These may include enhanced screening, chemoprevention, and risk-reducing surgery. All of these options are reviewed as part of the consultation, and patients can get help in deciding what options make the most sense in their situation. Evaluation of the family tree is probably the most critical part of the consultation. The implications of results often depend on the interpretation of the pedigree. In addition to documenting the cases of cancer in the family, it is important to find out the age of onset. Cancer occurring at a young age may be an important clue. One relative with breast cancer under age 40 is a more important clue than several relatives with breast cancer in their sixties or seventies.

It is also important to document the gender and age of unaffected relatives, as well. A patient with breast cancer at a young age and no family history of cancer is at a greater likelihood to have an inherited mutation if her family is small or is dominated by male relatives. If there are many unaffected female relatives in the pedigree, the likelihood of a hereditary cause is reduced. There is a misconception that risk of breast cancer is only inherited from the maternal side of the family. In asking about family history of breast cancer, it is important to include questions about paternal aunts and cousins. Women with hereditary breast cancer are just as likely to have inherited their mutation from the father’s side of the family as the mother’s side. Finally, there are rare known hereditary causes of breast cancer outside of BRCA1 or BRCA2. There may be other clues in the family tree to help determine if testing for these other genes might be helpful. According to the NCCN guidelines, a combination of breast cancer with one or more of the following is an indication for referral to genetics: thyroid cancer, sarcoma, adrenocortical carcinoma, endometrial cancer, pancreatic cancer, brain tumor, diffuse gastric cancer, dermatologic manifestations and/or macrocephaly, or leukemia/lymphoma on the same side of the family (especially if early onset).

ApplauseMark S. Goldfarb, MD, FACS, an ophthalmologist on staff at Holy Name Medical Center, has received the American Medical Association Physician Recognition Award (PRA) with Commendation for his dedication to lifelong learning and improving patient care through participation in continuing medical education. The PRA with commendation recognizes the exemplary commitment of those physicians who go beyond the minimum AMA PRA credits required to obtain the standard PRA. Based on three years of continuing medical education, the award is considered the most prestigious recognition of its kind. Dr. Goldfarb is also a member of Holy Name’s ICCR, the Medical Center’s institutional review board, which evaluates all clinical research projects at HNMC. He is Associate Clinical Professor of Ophthalmology at Mt. Sinai School of Medicine in New York City. Dr. Goldfarb is an EyeCare of America Volunteer, and Ophthalmology Consultant to the Bergen Volunteer Medical Initiative. In June, he received letters of recognition from both organizations. Dr. Goldfarb specializes in cataract surgery and lens implants, which he performs at Holy Name Medical Center. His private practice office is located at 130 Kinderkamack Rd., Suite 205, River Edge, NJ. He can be reached at 201-488-2020. He resides in Oradell, NJ.

Mark S. Goldfarb, MD, FACS

Service AnniversariesThe Holy Name family extends its congratulations and gratitude to the following members of the medical staff for their association with our Medical Center. This list recognizes anniversaries during May and June 2012.

35 YearsJack Levi, dds, General Dentistry

30 YearsAlan felsen, Md, Internal MedicineRobert Harris, Md, Internal Medicineedward Hedlund, Md, Internal MedicineAsmat Quaraishi, Md, Otolaryngology

25 Yearsselwyn e. Levine, Md, Internal MedicineJohn R. scheuch, Md, UrologyRonald White, Md, General Surgery

20 Years Anna Lavotshkin, Md, Internal MedicineRoy d. Vingan, Md, Neurosurgery

15 YearsChang W. Lee, Md, Internal Medicineesther Hershenbaum, Md, Dermatology

10 YearsMark Berman, Md, OrthopedicsChristopher d. Brown, Md, OphthalmologyMark s. sapienza, Md, Internal Medicine

5 YearsRoel galope, do, RadiologyJames park, Md, RadiologyMichael d’souza, Md, Anesthesiashanthi shenoi, Md, Pediatricsgregory taylor, Md, Neurology

Yoon Han, dpMsurgery/podiatry

Medical school: Temple University School of Podiatric MedicineResidency: New York Hospital of Queens, Podiatrypractice: 15 Engle St., Suite 202, Englewood, NJ 07631phone: 201-227-0700

emad Hashemi, Mdobstetrics/gynecology

Medical school: St. George’s University School of MedicineResidency: Newark Beth Israel Medical Center, Ob/Gynfellowship: Athena Women’s Medical Group, Urogynecology & Pelvicpractice: 120 Irvington Ave., South Orange, NJ 07079phone: 973-275-0025

odessa Hoinkis, Mdfamily practice

Medical school: University of EssenResidency: JFK Medical Center, Family Medicinepractice: 680 Kinderkamack Rd., Suite 205, Oradell, NJ 07649phone: 201-262-0608

Ruth Holliday, doRadiology (teleradiologist)

Medical school: Nova Southeastern University, College of Osteopathic Medicineinternship: Scott & White Memorial Hospital, Internal MedicineResidency: Baptist Medical Center, Radiologypractice: 695 Dutchess Tnpk., Poughkeepsie, NY 12603phone: 888-647-5979

Kiran Joshi, Mdobstetrics/gynecology

Medical school: Seth G. L. Medical Collegeinternship: Mount Sinai Medical Center, SurgeryResidency: Detroit Medical Center, Ob/Gynpractice: 301 Beech St., Hackensack, NJ 07601phone: 201-880-7641

Roohi Kamal, Mdobstetrics/gynecology

Medical school: King Edward Medical Collegeinternship: New York Hospital of Queens, Internal MedicineResidency: Lincoln Medical Center, Ob/Gynpractice: 331 Summit Ave., Hackensack, NJ 07601phone: 201-457-2300

Chhaya Makhjia, MdMedicine/internal Medicine - Hospitalist

Medical school: Byramjee Jeejeebhoy Medical Collegeinternship: Mountainside Hospital, Internal MedicineResidency: Mountainside Hospital, Internal Medicinepractice: 718 Teaneck Rd., Teaneck, NJ 07666phone: 201-530-7931

david Milikow, MdRadiology (teleradiologist)

Medical school: New York University School of Medicineinternship: Montefiore Medical Center, Internal MedicineResidency: Long Island Jewish Medical Center, Radiologyfellowship: Montefiore Medical Center, Radiology Abdominal Imagingpractice: 695 Dutchess Tnpk., Suite 105, Poughkeepsie, NY 12603phone: 888-647-5979

Mykola Mohuchy, MdRadiology (teleradiologist)

Medical school: St. George’s Universityinternship: Jersey Shore Medical Center, Internal MedicineResidency: Jacobi Hospital, Radiologyfellowship: Beth Israel Medical Center, Abdominal Imagingpractice: 695 Dutchess Tnpk., Suite 105, Poughkeepsie, NY 12603phone: 888-647-5979

Kenneth nalaboff, MdRadiology (teleradiologist)

Medical school: Tel-Aviv Universityinternship: Schneider Children’s Hospital, PediatricsResidency: North Shore University Hospital, Radiologyfellowship: Thomas Jefferson University Hospital, Radiology/Muscoloskeletalpractice: 695 Dutchess Tnpk., Suite 105, Poughkeepsie, NY 12603phone: 888-647-5979

olga Rakhlin, MdMedicine/psychiatry

Medical school: Nizhni Novgorod Medical State Academyinternship: Richmond University Medical Center, PsychiatryResidency: St. Vincent’s Hospital & Medical Center, Geriatric Psychiatrypractice: 610 Valley Health Plaza, Paramus, NJ 07652phone: 201-265-8200

pattyann Romanik, npMedicine/internal Medicine

school: Felician College, MSNpractice: 140 Grand Ave., Englewood, NJ 07631phone: 201-569-9010

Lauren schwartz, Mdsurgery/neurosurgery

Medical school: Temple University School of Medicineinternship: Cleveland Clinic, SurgeryResidency: Cleveland Clinic, Neurosurgeryfellowship: St. Christopher’s Hospital for Children, Pediatric Neurosurgeryfellowship: Institute for Neurology & Neurosurgery, Pediatric NeurosurgeryResidency: Albert Einstein College of Medicine, Neurosurgerypractice: 131 Madison Ave., Suite 140, Morristown, NJ 07960phone: 973-326-9000

Michael seidner, Mdobstetrics/gynecology

Medical school: Autonomos University of Guadalajarainternship: Hackensack University Medical Center, 5th PathwayResidency: NY Infirmary Beekman Downtown Hospital, Ob/Gynpractice: 385 Prospect Ave., 3rd Fl., Hackensack, NJ 07601phone: 201-488-1700

Joseph Vella, Mdpathology

Medical school: University of Medicine & DentistryResidency: University of Rochester Medical Center, Pathologypractice: 70 Hatfield Ln., Suite 205, Goshen, NY 10924phone: 845-294-4339

Yael Vidal, MdMedicine/internal Medicine

Medical school: Technion-Israel Institute of TechnologyResidency: Beth Israel Medical Center, Medicinepractice: 180 Engle St., Englewood, NJ 07631phone: 201-567-2050

Mark Weinstock, dpMsurgery/podiatry

Medical school: New York College of Podiatric MedicineResidency: New York College of Podiatric Medicine affiliated hospitals, Podiatrypractice: 240 W. Passaic St., Suite 4, Maywood, NJ 07607phone: 201-880-6000

5

Welcome new Appointments

suhel Ahmed, MdMedicine/internal Medicine

Medical school: Ross University School of MedicineResidency: University of Medicine & Dentistry of NJ, Internal Medicinepractice: 52 1st Street, Hackensack, NJ 07601phone: 201-342-0066

iyad Baker, Mdfamily practice

Medical school: American University of Antigua, College of MedicineResidency: St. Joseph Hospital and Medical Center, PediatricsResidency: Hoboken University Medical Center, Family Medicinepractice: 200 Main St., Ridgefield Park, NJ 07660phone: 201-870-6099

omar Baker, Mdpediatrics

Medical school: George Washington University, School of MedicineResidency: New York University Medical Center, Pediatricspractice: 714 10th St., Secaucus, NJ 07094phone: 201-863-3346

sarah Bornstein, npMedicine

school: Fairleigh Dickinson Universitypractice: 550 Kinderkamack Rd., Suite 201, Oradell, NJ 07649phone: 201-967-7130

Ramin Cocozielloobstetrics/gynecology

Medical school: University of Medicine & Dentistryinternship: Maimonides Medical Center, Ob/GynResidency: Maimonides Medical Center, Ob/Gynpractice: 12-15 Broadway, Suite E, Fair Lawn, NJ 07410phone: 201-794-0910

susan Cocoziello, Mdobstetrics/gynecology

Medical school: Pahlavi University, School of Medicineinternship: St. Elizabeth Hospital, RotatingResidency: Women’s Medical College, Ob/GynResidency: Beth Israel Medical Center, Ob/Gynfellowship: New York Medical College, Infertilitypractice: 1 Broadway, Elmwood Park, NJ 07407phone: 201-794-7717

Macarthur drake, MdRadiology (teleradiologist)

Medical school: Wright State University School of Medicineinternship: Summa Health System, Internal MedicineResidency: Mount Sinai Medical Center, Radiologyfellowship: Jackson Memorial Hospital, Neuroradiologypractice: 695 Dutchess Tnpk., Suite 105, Poughkeepsie, NY 12603phone: 888-647-5979

Arifa faiz, MdRadiology

Medical school: Fatima Jinnah Medical College for Womeninternship: Mount Vernon Hospital, Internal MedicineResidency: Cook County Hospital, RadiologyResidency: St. Luke’s-Roosevelt Hospital, Radiologyfellowship: Beth Israel Medical Center, Abdominal and Breast Imagingpractice: HNMC Breast Imaging Center, 718 Teaneck Rd., Teaneck, NJ 07666phone: 201-833-7100

taya glotzer, MdMedicine/Cardiology

Medical school: New York University School of Medicineinternship: Mount Sinai Medical Center, Internal MedicineResidency: Bellevue Hospital, RadiologyResidency: Bellevue Hospital, Internal Medicinefellowship: Bellevue Hospital, Cardiology/Electrophysiologypractice: 20 Prospect Ave., Suite 701, Hackensack, NJ 07601phone: 201-996-2997

Appointments to the Medical Staff for April, May and June 2012.

Rebecca Rigolosi, ANP-BC, is an Adult Nurse Practitioner and CDMP Team Leader at Holy Name Medical Center. She can be reached at 201-833-3734.

The Clinical Documentation Management Program at Holy Name Medical Center recognizes a CDMP Physician of the Month, based on data reflecting practitioner response rate to clarification, documentation of that response, interaction with the Clinical Documentation Specialist Team, and support of the CDMP program.

CDMP Spotlight

Hrach Kasaryan, doCardiology

Raymond Villongco, Md internal Medicine

Alex Vitievsky, Mdnephrology

MAY June JuLY

6

New Oral Anticoagulants The recent proliferation of oral anticoagulants and antiplatelet agents has healthcare professionals questioning how to choose among them. The newest anticoagulants, dabigatran (Pradaxa) and rivaroxaban (Xarelto), have been added to Holy Name Medical Center’s formulary. With the addition of these agents, it is necessary to review their indications, dosing, cautionary notes, adverse events and reversal. See charts below.

Pharmacy & Therapeutics newsletter now appears in MD360

Dabigatran (Pradaxa)description• Direct thrombin inhibitor

indications for use at HnMC• Reduction of stroke & systemic embolism in atrial fibrillation

dosing• CrCl greater than 30 mL/min: 150 mg orally twice daily • CrCl 15-30 mL/min: 75 mg orally twice daily• CrCl less than 15 mL/min or on dialysis: Caution – no recommendations can be made

ConVeRsion to/fRoM otHeR AntiCoAguLAnts:

Converting fRoM warfarin to dabigatran

Converting to warfarin from dabigatran• Since dabigatran can contribute to an elevated INR, the INR will better reflect warfarin’s effect after dabigatran has been stopped for at least 2 days, but starting time of warfarin is also dependent on CrCl

Converting fRoM parenteral anticoagulation to dabigatran

Converting to parenteral anticoagulation from dabigatran

• Discontinue warfarin and initiate dabigatran when patient’s INR is less than 2

• CrCl greater than 50 mL/min: start warfarin 3 days before discontinuing dabigatran• CrCl 31-50 mL/min: start warfarin 2 days before discontinuing dabigatran• CrCl 15-30 mL/min: start warfarin 1 day before discontinuing dabigatran• CrCl less than 15 mL/min: caution; no recommendations can be made

• Discontinue parenteral anticoagulation – start dabigatran 0 to 2 hours before the next dose of the parenteral anticoagulant was to be administered (e.g. enoxaparin)• Discontinue parenteral anticoagulation – start dabigatran at the time of discontinuation of a continuously administered parenteral anticoagulant (e.g. intravenous unfractionated heparin)

• CrCl 30 mL/min or greater: wait 12 hrs after the last dose of dabigatran before initiating treatment with a parenteral anticoagulant• CrCl less than 30 mL/min: wait 24 hrs after the last dose of dabigatran before initiating treatment with a parenteral anticoagulant

Adverse eventsBleeding: Major 3% Minor 16%

Cautionary notes (not all-encompassing)• Capsules should be swallowed WHOLE. Do NOT break, chew, or open capsules for administration. NOT for administration via NG/PEG tube, etc. + Open capsules increase biovailability ~ 75%• NOT to be given concurrently with prophylactic or therapeutic parenteral anticoagulation (e.g. heparin, enoxaparin, or fondaparinux). + patients should be on either parenteral anticoagulation or oral anticoagulation with dabigatran, not BotH.• There is no evidence or support for traditional bridge therapy with warfarin. • No black box warning for spinal hematoma but caution should be used, as risk for spinal hematomas have been identified.

Reversal of bleed/overdose

• no KnoWn speCifiC Antidote

• TRY:

+ Activated charcoal – within 2 hours of administration

+ Dialysis – 2-3 hour session may remove ~ 60%

+ Supportive measures - Compression, surgical hemostasis/intervention, fluid replacement, blood products/ components (fresh frozen plasma, red blood cell transfusion) + Last resort – consider situation and COST - Recombinant factor VIIa - Activated prothrombin complex concentrate (FEIBA)

rivaroxaban (Xarelto)description• Selective factor Xa inhibitor

indications for use at HnMC• Reduction of stroke & systemic embolism in nonvalvular atrial fibrillation • DVT and/or PE prophylaxis/prevention (NOT treatment) after elective total hip or knee replacement surgery

dosing• Thromboembolism prevention in A fib + CrCl greater than 50 mL/min: 20 mg orally once daily + CrCl 15-50 mL/min: 15 mg orally once daily + CrCl less than 15 mL/min or on dialysis: Avoid use

ConVeRsion to/fRoM otHeR AntiCoAguLAnts:

Converting fRoM warfarin to rivaroxaban

Converting to warfarin from rivaroxaban• Since rivaroxaban affects INR, initial INR measurements after intiating warfarin may be unreliable

Converting fRoM parenteral anticoagulation to rivaroxaban

Converting to parenteral anti-coagulation from rivaroxaban

• Discontinue warfarin and initiate rivaroxaban when patient’s INR is less than 3

• Initiate warfarin and a parenteral anticoagulant 24 hours after discontinuation of rivaroxaban

• Discontinue parenteral anticoagulation – start rivaroxaban 0 to 2 hours before the next dose of the parenteral anticoagulant was to have been administered (e.g. enoxaparin)• Discontinue parenteral anticoagulation – start rivaroxaban at the time of discontinuation of a continuously administered parenteral anticoagulant (e.g. intravenous unfractionated heparin)

• Initiate parenteral anticoagulation 24 hours after discontinuation of rivaroxaban

postoperative dVt/pe prophylaxis• Initiate after hemostasis established (~ 6-10 hrs post-operatively)• CrCl greater than 50 mL/min: 10 mg orally once daily • CrCl 30-50 mL/min: Caution – no recommendations can be made• CrCl less than 30 mL/min or on dialysis: Avoid use

Adverse eventsBleeding: Major (nonvalvular atrial fibrillation, 5.6%; hip/knee replacement, 0.3% ), Minor (hip/knee replacement, 5.8%)

Cautionary notes (not all-encompassing)• Avoid use in moderate to severe hepatic impairment and any hepatic disease associated with coagulopathy.• Discontinue in patients who develop acute renal failure.• Doses ≥ 15 mg/day should be given with food.• NOT to be given concurrently with prophylactic or therapeutic parenteral anticoagulation (e.g. heparin, enoxaparin, or fondaparinux). + patients should only be on either parenteral anticoagulation or oral anticoagulation with rivaroxaban, not BotH.• Rivaroxaban increases the risk of epidural or spinal hematoma. + Avoid removal of epidural catheter for at least 18 hours after last rivaroxaban dose. + Avoid rivaroxaban administration for at least 6 hours following epidural catheter removal. + If traumatic puncture occurs, avoid rivaroxaban administration for at least 24 hours.

Reversal of bleed/overdose• no KnoWn speCifiC Antidote• TRY: + Activated charcoal – within 2 hours of administration + Supportive measures - Compression, surgical hemostasis/intervention, fluid replacement, blood products/ components (fresh frozen plasma, red blood cell transfusion) + Last resort – consider situation and COST - Recombinant factor VIIa - Activated prothrombin complex concentrate (FEIBA) - Prothrombin complex concentrate (Beriplex P/N)

things to remember when prescribing anticoagulants at hnMC:• Does your patient already have an active order for an anticoagulant?• Indication• Dosing / Renal-Hepatic Function • Appropriateness of bridge therapy• Risk vs. benefit for concomitant antiplatelet therapy• Adverse events• Is patient on an epidural or have a spinal catheter?

due to the complexity of these agents, patients need to be assessed individually. this class will be updating and changing rapidly, as new agents are approved. Look for the direct factor Xa inhibitor apixaban (eliquis) with fdA approval expected in 2012. other agents in the pipeline include edoxaban (Lixiana in europe) and betrixaban.

to B e n e f i t

V i l l a M a r i e C l a i r e

7

A Shortage of Everything Except Errors: Harm Associated With Drug ShortagesAdapted from ISMP Medication Safety Alert, April 19, 2012, Volume 17, Issue 8

In the November 3, 2011 newsletter, the Institute for Safe Medication Practices (ISMP) asked nationwide hospital pharmacy staff to let ISMP know if the drug shortage problem in the US has continued to result in harmful outcomes for hospitalized patients. At that time, an Associated Press article had just reported 15 deaths that were linked directly to drug shortages. In response to our request for information, nearly a hundred practitioners took our short survey and strengthened our belief that the ongoing drug shortage crisis is extracting a significant toll on patient safety. Survey respondents provided a bleak picture of certain and suspected patient harm that has resulted during the past year (March 2011 to March 2012) due to crucial drug shortages. The medications most commonly involved in the reported adverse events include: chemotherapy (27%), particularly Doxorubicin (Adriamycin); opioid analgesics (17%), mostly fentanyl (i.e. Duragesic) and

morphine (i.e. Duramorph); electrolytes (7%); antibiotics (5%); phentolamine (4%); and phytonadione (Vitamin K) (4%). The types of harm reported by respondents included prolonged duration or progression of a disease, transient and permanent injuries, and death. Table 1 provides examples of the types of harm reported. Predominantly, problems associated with a drug shortage that resulted in harm fell into four categories:

1. Alternative medication provided, but it was not the drug of choice, which led to inadequate treatment (35%)

2. An error with an alternative drug or form/strength of a drug used as a substitution for the drug in short s supply (27%)

3. An omission of vital medication leading to non-treatment of the patient (27%)

4. An error when a hospital pharmacy attempted to compound a product or drug strength no longer available (6%).

ISMP in cooperation with the American Society of Health-System Pharmacists (ASHP), the US Food and Drug Administration, and many other partner organizations (e.g., American Hospital Association, American Society of Clinical Oncology, American Society of Anesthesiologists) will continue its efforts to articulate the scope of this problem, and develop a plan to reduce the occurrence of drug shortages and better manage them when they occur.

As stated in previous publications, Holy name Medical Center is not immune to drug shortages. drug shortages significantly impact our patients every day. the pharmacy continues to alert the medical staff about critical drug shortages via WebHis. in addition, shortages that affect specific practices are notified via the division chair.

• prolonged duration or progression of disease• Behavioral/mental status changes• Inability to work• Medication overdoses• Respiratory depression and excessive sedation• Treatment with rescue agents• Debilitating and life-threatening side effects from alternative drug (e.g., ileus, gastrointestinal toxicity, mucositis, malabsorption, seizures)• Prolonged hospitalization/critical care therapy• Infections and cross contamination• Severe hypotension and hypertension• Severe electrolyte and acid/base imbalances• Repeated surgical procedures• Transient and permanent neurological harm• Permanent vascular and integumentary harm• Untreated pain

• Death

Mark your Calender...

Annual Founders Ball

Saturday, OctOber 27, 2012

the WaldOrf = aStOrianew York, nY

fOr infOrmatiOn cOntact:201-833-7143

email: mcgarry@hOlyname.Org

table 1: examples of types of Harm

Is it Parkinson’s disease?Find out with DaTscan™

DaTscan™ is the first FDA-approved radiopharmaceutical imaging agent to help physicians evaluate suspected Parkinson’s disease.

Used in conjunction with SPECT imaging technology, DaTscan™ perceives the physiologic changes in the brain that are associated with Parkinson’s and is able to differentiate between Parkinson’s and illnesses with similar symptoms.

• Make a definitive diagnosis.

• Provide the right intervention earlier.

• Decrease patient anxiety associated with uncertainty.

Holy Name Medical Center is a Certified DaTscan™ Provider

DaTscanTM Normal DaTscanTM Abnormal

For more information or to refer your patient please call

201-833-3675.

Saturday, September 22, 20127:00 pm

ridgeWOOd cOuntry club

96 west Midland aVenue

ParaMus, nJ 07652

for More inforMation ContaCt:

201-833-3105

Annual MS Awards Dinner

thurSday, nOvember 29, 2012

the paliSadiumCliffside Park, nJ

Honoring CHris CiMino

wnBC Meteorologist

fOr infOrmatiOn cOntact:201-833-3000 ext. 3899

Published by Holy Name Medical Center’s Pharmacy Department. If you have any questions or concerns regarding the content of the Pharmacy & Therapeutics Newsletter, call the Pharmacy at 201-833-3055 or ext. 3773. References are available upon request.

September 15

Second Quarter 2012 Adam Jarrett, MD, MS, Executive Vice President/Chief Medical Officer Thomas Birch, MD, President of the Medical Staff Jane F. Ellis, Vice President of Marketing, Public Relations and Community Healtheditor: Barbara Franzese Cron, Director, Marketing Communications

Please e-mail all comments and contributions to: editor MD360@holyname.org or call Jane Ellis, 201-833-3129 or Barbara Cron, 201-530-7904.

MD360º is published by Holy Name Medical Center’s Department of Marketing/ Public Relations and is intended for use by the medical staff of Holy Name Medical Center.

Magnet Recognition From the American Nurses Credentialing Center. Places

us among the top 5% of hospitals nationwide for

excellence in patient care.

Beacon Award From the American

Association of Critical Care Nurses for exceptional acute

and critical care nursing.

Joint Commission Top Performer in Key Quality

MeasuresFor Excellence in Heart Attack, Pneumonia and Surgical Care

J.D. Power and AssociatesDistinguished Hospital

Awards For Emergency, Inpatient, Outpatient and Maternity

Service Excellence.

Accredited Chest Pain Center

From the Society of Chest Pain Centers for our ability to

diagnose chest pain and acute coronary symptoms.

Primary Stroke Care Center Certification

From The Joint Commission, the nation’s leading

health care evaluation and accreditation organization.

HealthGrades® Specialty Excellence Award for

Stroke Care™

Ranked in the top 10% of hospitals nationally for stroke

services.

HealthGrades®

Distinguished Hospital Awards for Clinical

Excellence™ Among the top 5% of hospitals in the nation

for clinical excellence.

Modern Healthcare magazine

Ranked fourth in the nation on the “100 Best Places to Work in Healthcare” list.

NJBIZ magazine Cited Holy Name among the

“Best Places to Work in New Jersey.”

Data Advantage, LLC Awarded for quality,

affordability, efficiency, patient safety and

overall experience.

Printed on Neenah Environment—a

100% post- consumer waste recycled paper.

18th Annual holy name golf tournament

A toast for hopeA wine-tasting event benefiting HNMC’s Hispanic Outreach Program