VIRGINIA PEDIATRICS. Health Reform Is Just The Next Step On A Long Journey. Submitted by Francis Rushton, MD AAP District IV Chair INSIDE THIS ISSUE

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1 VIRGINIA PEDIATRICS A M E R I C A N A C A D E M Y O F P E D I AT R I C S V I R G I N I A C H A P T E R S U M M E R INSIDE THIS ISSUE 2 President s Message: Membership with Benefits 4 Insulin Pumps in Small Children 5 Is it Reflux or Something Else? 6 Follow-up for Childhood Cancer Survivors 8 When is Baby Fat not Baby Fat Anymore? 9 Prenatal and Postpartum Depression in Fathers 10 Caring for Adults with Congenital Heart Disease 12 Health Care Reform for Virginia s Children 14 Breastfeeding Lectureship Grant 16 Best Bones Forever! 17 Medicaid Incentive Money for your EHR 20 Navigating the EHR Maze 22 White House Obesity Initiative 24 Optimizing Asthma Care 25 Tools to Evaluate the Pediatric Patient- and Family-Centered Medical Home 25 National Center for Medical Home Implementation Launches New Web site 26 Reducing the Risk of SIDS Online Module 26 Pediatric Grand Rounds Online! 26 CPSC Warning on Drop-side Cribs 27 Dates to Remember Virginia Pediatrics is Provided as a Service to Members of the Virginia Chapter and the Virginia Pediatric Society to Promote the Profession of Pediatrics and to Further Benefit the Children We Serve. Health Reform Is Just The Next Step On A Long Journey Submitted by Francis Rushton, MD AAP District IV Chair The American Academy of Pediatrics has much to be happy about in the recent passage of health reform. Our goals of universal pediatric access to quality care coordinated through a medical home with robust preventive care benefits, and adequate reimbursement for generalist and subspecialist alike are forwarded by its passage. With the support of the AAP and its members, we ve set a new floor for pediatric reimbursement by tying Medicaid to Medicare E and M codes, providing millions more children with health care coverage and setting as the gold standard our own Bright Futures regimen for pediatric preventive care. Granted, this law is not without issues. Its size and lack of sufficient cost control are worrisome to many. Our next steps in ensuring quality within a framework of cost effectiveness will continue to be an issue for pediatricians and the Academy for some time. Although language exists in the health reform law that is designed to promote primary care, its enactment will take time and attention. Pediatric subspecialists need continued attention to ensure appropriate supply. Accountable Care Organizations are presented as major avenues of cost containment, and the details of how and when they are enacted will impact all of us. Health care systems built on primary care are cost effective, and the Academy needs to continue to support the medical home concept. Now is the time to redouble our efforts, work with the new law, our health care partners and the general public to ensure that children receive the quality health outcomes they deserve. g

2 President s Message Membership with Benefits Colleagues may wonder about the benefits of membership in the Virginia Chapter. After all, it means spending nearly $200 to join. Membership is one of the best values around, but many members are probably not aware of all the membership benefits. Fortunately the answer is easy and can be divided into four areas: Education, Leadership, Advocacy, and Networking. Each area alone is worth the small price of membership. Robert Bob Gunther, MD, MPH, FAAP President, Virginia Chapter, AAP About Virginia Pediatrics First, look at education. The Chapter offers meetings in partnership with each of the major teaching centers. These are 2-3 day meetings held at popular venues around the state. Timely CME is offered on a diverse range of topics presented in small group and seminar formats. Members receive a $100 savings on the program cost. The Chapter had three additional meetings this spring that offered members savings of $25-75 on program cost. These meetings included the Practice and Art of Pediatric Medicine (with the Pediatric Alliance), Practical Tools for Promoting and Supporting Breastfeeding and Partnering to Improve School Health (with the Virginia Department of Education and the School Nurses). Each of these programs was outstanding in terms of the participation and the presentations. In the coming year the Chapter hopes to present similar programs. 8 Virginia Pediatrics is a quarterly publication of the VA Chapter, American Academy of Pediatrics and the Virginia Pediatric Society. We welcome your opinions and ideas. Please send comments on articles, ideas for new articles, letters to the editor, suggestions for making Virginia Pediatrics more useful and address changes to: Virginia Pediatrics 2201 West Broad Street, Suite 205 Richmond, Virginia Phone: (804) Fax: (804) jdavis@ramdocs.org Jane Davis: Executive Director Amelia Barnett ( Newsletter Layout Next Issue: Fall 2010 Deadline for entries: September 6, 2010 Publication of an advertisement in Virginia Pediatrics neither constitutes nor implies a guarantee or endorsement by Virginia Pediatrics or the VA-AAP / VPS of the product or service advertised or of the claims made for the product or service by the advertiser. 2 VIRGINIA PEDIATRICS

3 Also in education the Chapter is providing options for Maintenance of Board Certification, Part 4 which basically involves a quality improvement effort within the practice. In partnership with the Medical Society of Virginia Foundation, an asthma care quality improvement program has begun. The Chapter hopes to present other opportunities for MOC, Part 4 in the coming year so stay tuned. It is easy to see the tremendous value in membership. Second, look at leadership. The Chapter offers a variety of opportunities to become a leader. These include not only specialized trainings and Chapter Board participation. Chapter members with special topic interests can develop an interest group. Examples of this are breastfeeding, obesity, and child abuse. Chapter members are sought to serve on a variety of state policy setting groups. Members with interests should contact our Executive Director, Jane Davis, to become more involved. Advocacy is the third major area. The Chapter retains a lobbyist to help navigate through our state government and coordinate with other child advocacy groups. The Chapter s voice is respected in Richmond by legislators and government officials. Legislatively, the Chapter has been a key supporter for smoke-free restaurants, car booster seats, immunization registry, and child mental health. The Chapter has partnered with other professional groups to maintain the malpractice cap, encourage appropriate scope of practice, and obtain fair payment for pediatricians. Members can jump into this at multiple levels and additional training is available. An entirely different area of advocacy is the Chapter Pediatric Council, which is a group of pediatricians who interact with various insurance providers to bring pediatric issues to the forefront. The Council has tackled a number of issues this year including immunization coding and payment, developmental screening, and making sure members are treated fairly by these organizations. The value of this group in dollars saved is significant. Members also advocate and lead through participation in a variety of groups such as Reach Out and Read (child literacy), Smart Beginnings (early child education and opportunity), School Health Advisory Boards around the state (school health), and Medical Home Plus (child with special needs advocacy and education). Networking is the final area. Networking occurs at meetings, through our quarterly Chapter newsletter, Virginia Pediatrics, and, increasingly, on line. The Member Alert s provide quick bite-size information that keeps you current. The Chapter maintains a job board for members to list employment opportunities. The Chapter offers a variety of interest groups for members. Talking with other pediatricians about how they solve practice management issues and patient care issues is invaluable. In addition, the Chapter has developed relationships with organizations to give members preferred pricing on immunizations, insurance products, and financial products. The savings from any one of these programs can easily cover the cost of membership. Chapter membership clearly has many benefits and is a great value for generalists and specialists, new or seasoned pediatricians. If you are already a member, continue your support and encourage you r colleagues to join and participate. Please take advantage of what your Chapter has to offer. Let us know what else you need from your Chapter. Contact Jane Davis, Chapter Executive Director, at jdavis@ramdocs.org for more information on any of these areas. g VIRGINIA PEDIATRICS 3

4 Insulin Pumps in Small Children Submitted by: Eric Gyuricksko, MD Division of Pediatric Endocrinology Children s Hospital of The King s Daughters Eastern Virginia Medical School Norfolk, Virginia Eric Gyuricsko, MD, pediatric endocrinologist from Eastern Virginia Medical School, Ayodeji Demuren, Ph.D., mechanical engineer from Old Dominion University, and Narou Diawara, Ph.D., statistician from Old Dominion University are collaborators on a multi-institutional translational research project. They are studying the effects of air bubbles on insulin delivery during continuous subcutaneous insulin infusion (CSII), otherwise known as insulin pump therapy. They are particularly interested in the impact of air bubbles on insulin delivery to infants and toddlers using CSII. Type 1 diabetes affects about 1 in 400 children under the age of 18 years. CSII is now commonplace, stateof-the-art, therapy for children with Type 1 diabetes. CSII delivers insulin to the person with diabetes continuously, attempting to simulate endogenous insulin secretion from the pancreas. Many years of experience with CSII has led to the use of insulin pumps in younger and younger children, even infants and toddlers. During CSII, insulin must travel from the insulin pump s reservoir, through various lengths of flexible tubing, to the patient s subcutaneous space via an infusion set. This must occur without interruption or occlusion. Young children require very small amounts of insulin to manage their diabetes. This results in a very slow rate of continuous insulin infusion (called the basal rate), often less than or equal to ml (or 0.1 units of insulin) per hour. As a consequence of this slow infusion rate, occlusion to insulin flow can, and often does, occur. Occlusion of insulin flow is a potentially dangerous, unforeseen circumstance that places the person with diabetes using CSII at imminent risk. If not detected, occlusion of insulin delivery may result in severe, sustained hyperglycemia and diabetic ketoacidosis (DKA). Anecdotal reports and a few studies have examined the causes of occlusion in CSII, concluding that insulin type may be a significant contributor. None have studied this question as it relates to infusion rates typical in infants and toddlers, where we believe the common occurrence of air bubbles within the reservoir and infusion set pose a significant interruption to insulin delivery. In addition to air bubbles, our research is studying the effects of temperature, ph level, motion, type of insulin, and type of insulin pump on the accuracy of insulin delivery via CSII. Thus far, our research has been solely laboratory based. We have developed a successful experimental setup including computerized data collection and experimental control system to ensure the consistency of experimental runs. Insulin flow is measured using sophisticated nano-flowmeters and precision balance scales. Bubble sensors are attached to each infusion line to detect and record the presence and duration of air bubbles. Initial results have confirmed the tendency of air bubbles to form in the insulin pump reservoirs and then entrain into the infusion lines themselves. These bubbles also appear to occlude insulin delivery. The duration of insulin occlusion is dependent upon the size of the air bubble. In older children, teens, and adults, these air bubbles may not be of great significance since basal rates are higher and may tend to pass more quickly. We believe the impact on the youngest children may be more significant. Our future work hopes to be truly translational by studying the impact of air bubbles on actual blood sugar control in children and develop better methods for bubble prevention/avoidance/and or early detection. g 4 VIRGINIA PEDIATRICS

5 Is It Reflux or Something Else? A Primer on Eosinophilic Esophagitis for the Pediatrician Submitted by: Lauren Willis, MD* and Kelly Maples, MD *Division of Gastroenterology and Division of Allergy and Immunology Children s Hospital of The King s Daughters and the Department of Pediatrics Eastern Virginia Medical School Norfolk, VA Background: During the past decade, Eosinophilic Esophagitis (EoE) has become increasingly recognized in children and adults. Signs and symptoms are similar to those in Gastroesophageal Reflux/Gastroesophageal Reflux Disease (GERD) but EoE has some distinctive features. The diagnosis is made by demonstrating 15 or more eosinophils/high powered field (HPF) on esophageal biopsy while excluding other disorders. Though EoE and GERD may occur in the same patient, patients with EoE typically fail to respond symptomatically and histologically to acid suppression with proton pump inhibitor therapy and ph monitoring studies are typically normal. Clinical Presentation: EoE is more common in, but not limited to, males and atopic individuals. The presentation differs somewhat depending on the age of the patient. In infants, vomiting, irritability, feeding refusal, and failure to thrive may occur. Children may present with abdominal pain, nausea/vomiting, food aversions, food impaction or dysphagia. Older children and adults have more frequent complaints of dysphagia, GERD-type symptoms, food impactions and even esophageal strictures. In general, dysphagia and food impaction are more prominent in EoE than in GERD. EoE is frequently a challenging diagnosis and delay in identification and treatment can lead to complications including recurrent food impactions, esophageal fibrosis, stricture and small caliber esophagus. More recent studies have shown that esophageal subepithelial fibrosis starts early in the disease, even in children. No increased incidence of Barrett s esophagus or esophageal adenocarcinoma has been observed. Treatment: Strict elemental formula diets and treatment with oral corticosteroids can yield symptomatic relief and histologic resolution of esophageal eosinophilia. They are, however, limited by the poor quality of life associated with an elemental diet and the well known side effects of systemic corticosteroids. Preferred treatment now consists of swallowed inhaled corticosteroids paired with an empiric elimination diet consisting of removal of milk, soy, wheat, egg, peanut, tree nut and seafood, or a less stringent selective elimination diet based on allergy skin prick and patch testing. The selective elimination diet is usually used first and is generally much easier for patients to follow. Although multiple studies have shown that the above treatment regimens successfully treat both symptoms of EoE and esophageal eosinophilia, EoE is a chronic disease and little is known about the effect of treatment on esophageal subepithelial fibrosis and related complications. There have been two case reports of resolution of esophageal subepithelial fibrosis with diet and swallowed ICS and recently a small study demonstrated reversal of lamina propria fibrosis in a subset of EoE patients following treatment with swallowed budesonide (5). However, more data is needed to establish whether the accepted treatments reliably reverse the fibrosis and therefore some of the chronic morbidity seen with EoE. Research: Basal cell hyperplasia is a common histologic feature of active EoE. At our institution, we recently completed a retrospective study of 31 children with EoE which demonstrated a statistically significant correlation between the presence of basal 8 VIRGINIA PEDIATRICS 5

6 cell hyperplasia and subepithelial fibrosis (p<0.001). The Departments of Pediatric Gastroenterology, Pathology and Allergy and Immunology at Eastern Virginia Medical School and Children s Hospital of The Kings Daughters are about to begin enrolling patients with EoE prospectively to examine whether current standard treatment of EoE can reduce subepithelial fibrosis in children with EoE. In addition, we are developing a new technique to objectively quantify the amount of subepithelial fibrosis on esophageal biopsies using image analysis. Currently only very subjective scoring systems to quantify esophageal fibrosis have been published, making comparison of biopsy specimens for research purposes difficult. Elsewhere, investigations of dietary therapy, molecular mechanisms of disease, and biological therapies are ongoing. g References and Suggested Reading: 1. Aceves SS, Newbury RO, Dohil R, J Bastian JF et al. Esophageal remodeling in pediatric eosinophilic esophagitis, J Allergy Clin Immunol 2007;119: Konikoff MR, Noel RJ, Blanchard C et al. A randomized, double blind, placebo controlled trial of fluticasone propionate for pediatric eosinophilic esophagitis, Gastroenterology 2006; 131: Maples KM, Henderson SC, Graham M, Irani AM. Treatment of eosinophilic esophagitis with inhaled budesonide in a 7-year-old boy with concomitant persistent asthma: resolution of esophageal submucosal fibrosis and eosinophilic infiltration. Ann Allergy Asthma & Immunol 2007;99: Furuta GT, Liacouras CA, Collins MH et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology 2007:133: Straumann A, Spichtin HP, Grize L et al. Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years. Gastroenterology2003:125: Late Effect Clinic; Endocrinological Follow-up for Childhood Cancer Survivors Submitted by: Kent Reifschneider, MD Pediatric Endocrinology Children s Hospital of The King s Daughters Eastern Virginia Medical School Norfolk, Virginia When seeing a childhood cancer survivor, important history includes age at diagnosis and attention to treatment exposures such as radiation to the hypothalamus, pituitary, thyroid, spine and/or gonads and chemotherapy agents. Awareness of any complications such as Graft-versus-host disease helps to focus questioning, exam and laboratory investigation. Q: What red flags can primary physicians watch for in survivors of childhood cancer in terms of normal growth and development? A: Any child that is exhibiting a lack of normal growth velocity, i.e. below 5-7 cm per year or drifting of growth curve, warrants evaluation. From a pubertal perspective, criteria consistent with delayed puberty such as males lacking testicular enlargement ( 4ml) after 14 years old and females with a lack of breast development after 13 years old would warrant evaluation for central or primary gonadal dysfunction. Additionally, recent reports indicate that survivors are 70% more likely to develop obesity and its related complications than healthy siblings. Some of this tendency to gain weight may be secondary to unappreciated endocrinopathies. It is important to appreciate that a normal growth velocity does not rule out an endocrine 8 6 VIRGINIA PEDIATRICS

7 problem. For example, radiation exposure to CNS may cause GHD and simultaneously trigger precocious puberty with the net result being a normal growth velocity. Thus, the most important thing for providers seeing survivors is to obtain information regarding treatment and known associated health risks. Q: Can chemotherapy (CTX) and radiation therapy (RTX) treatments impact fertility down the road? A: Yes, radiation (focal or total body) and chemotherapy can lead to both primary and/or central hypogonadism. Primary hypogonadism can be caused by many factors, including toxic chemotherapeutic agents such as alkylating agents (cyclophosphamide, ifosfamide) and cisplatin commonly used to treat ALL. These drugs inhibit DNA synthesis in cells with rapid mitotic activity, such as germinal cells responsible for sex hormone production and fertility, thus impacting the onset of puberty and gonadal function. Interestingly, prepubertal ovaries are more resistant to the effects of CTX and RTX on fertility and steriodogenesis. Leydig cells in prepubertal males are more radiosensitive thus at higher risk. Additionally, the most common location for ALL relapse in boys is in testicular tissue, so many have had direct testicular radiation. Central or hypogonadotropic hypogonadism can result from tumor invasion, surgical resection and/or high-dose radiation (>30Gray) therefore knowing the type of cancer and treatment helps to determine risk of central-mediated endocrinopathies. Acute effects of sex hormone deficiency include psychosocial distress, decreased stamina/fatigue and poor bone mineralization. Approximately 25 percent of mineralization occurs during puberty in the setting of adequate vitamin D, calcium and exercise, with an additional 25 percent deposition occurring during the following 10 years. Q: What situations might merit screening, and what tests should be performed? A: Annual screening to monitor growth velocity, weight and pubertal development. If the child received spinal radiation, you may need to monitor a different growth parameter such as arm span. There are other important screening questions that may help to look for potential mental and physical abnormalities rather than assuming normal consequence of therapy. For example, bone health is often impacted directly and indirectly, thus it is critical to ask about calcium, vitamin D, and daily activity/exercise in the setting of pubertal development to maximize bone health. Furthermore, all patients should undergo Tanner staging with testicular volume documentation and breast examination knowing that testicular volume may be reduced because of RTX- or CTX-induced damage. If abnormal growth velocity or delayed puberty is noted, initial screening evaluation should include TSH, Free T4, IGF-1 [somatomedin C], IGF-BP-3 with potential puberty labs plus bone age x-ray of left hand. Q: What are other issues to keep in mind? A: Recognize that endocrine disturbances have been documented in 20-50% of childhood cancer survivors with likelihood varying based on the type of cancer, total and fractional radiation exposure, type of chemotherapy, and age at treatment. The most common endocrine sequelae include growth hormone deficiency, precocious puberty and primary hypothyroidism. Many cancer survivors also have numerous psychosocial as well as medical factors that contribute to poor bone health and obesity. Optimizing calcium and vitamin D consumption (three glasses of skim milk a day or one VIACTIV chew twice daily) in the setting of pubertal hormones and daily exercise will help offset the negative effects of cancer therapies on bone health. The increased prevalence of obesity in survivors of childhood cancer has been well documented. Aside from environmental and psychological factors, hypothalamic damage via invasion, surgical resection or therapies can lead to the inability of the ventromedial hypothalamus to regulate hormonal signals involved in energy balance and satiety. Intervention is very challenging, but it is vital to focus on limiting carbohydrate and high calorie fluid consumption 8 VIRGINIA PEDIATRICS 7

8 while increasing daily activity and exercise. From a pubertal aspect, one must keep in mind that seminiferous tubules which make up the majority of testicular volume are easily damaged. Therefore, physical exam does have limitations and one must rely on risk factors, lab and radiographic imaging to determine impact. In regards to growth, IGF levels have mixed sensitivity and specificity in detecting growth hormone deficiency thus accurate measurement is the most important screening tool. g When is Baby Fat not Baby Fat Anymore? Submitted by: John Harrington, MD Division of General Academic Pediatrics Children s Hospital of The King s Daughters Eastern Virginia Medical School Norfolk, Virginia According to the National Health and Nutrition Examination Survey (NHANES) in 2007, nearly half of all American children are either overweight or obese. The General Academic Pediatric division at Children s Hospital of The King s Daughters and Eastern Virginia Medical School wanted to determine if there was a specific tipping point age at which children become overweight in a primary care pediatric practice (both urban and private) and what the trajectory of their weight gain was after this critical tipping point. In a retrospective chart review done by Vu Nguyen, we identified patients with the diagnostic codes for obese and overweight ( ) or excessive weight gain (783.1) from the medical records. Inclusion criteria were: current age between 2 and 20, a minimum of 5 visits with weight and height measurements, and a Body Mass Index (BMI) calculated kg/m2 to be at or above the 85th percentile. 260 charts were reviewed and 111 patients met inclusion criteria. Among the 111 patients in the cohort, 58% were male and 62% had private health insurance. The ethnicity composition is 46% white and 29% black. 57.5% became overweight before age 2 and 87.4% before age 5. Logistic regression models of all weight and height measurements, using the 50th and 85th percentile national growth data set as baseline, showed that children begin gaining weight beyond normal growth at 3 months of age. The rate of gain is approximately 1 excess BMI unit/year, therefore causing most children to be overweight by age 2 (R-square=0.53). This study indicates that the critical period for preventing childhood obesity in this subset of identified patients is during the first 2 years of life. This data was presented at the Pediatric Academic Society meeting in Baltimore in May Currently most of our treatments for obesity start after the problem has already spiraled out of control. Getting parents and children to change habits that have already taken hold is a monumental challenge fraught with roadblocks and disappointments. This study indicates that we may need to be discussing inappropriate weight gain early and often to stem the tide. The chunky baby is healthy cute baby is a myth that we should not necessarily perpetuate in practice; it is probably time to start considering modifications in diet earlier rather than later. g 8 VIRGINIA PEDIATRICS

9 Prenatal and Postpartum Depression in Fathers: Brief Report of a Meta-Analysis Submitted by: James F. Paulson, PhD Associate Professor and Clinical Psychologist Eastern Virginia Medical School The Children s Hospital of The King s Daughters Norfolk, VA Background: Significant depression affects between 10% and 30% of women during pregnancy and remains elevated in the year following childbirth. 1 Although a large body of research has documented the risk factors for and negative impacts of depression in mothers 2, depression in expecting and new fathers has received little attention in research and remains poorly understood. Several studies on this topic have been published in recent years, but these are plagued by inconsistent methodology and highly variable estimates limit their generality. Goodman s review of studies published prior to 2004 found postnatal paternal depression incidence to vary from 1.2% to 25.5%. 3 In Schumacher and colleagues review 4 of studies published since 2004, estimates of fathers with no clearly identified risks (e.g., maternal depression, high-risk birth, perinatal complications) varied between 0.9% to 31.5% in the postnatal and 3.8% to 32.1% in the prenatal periods. The wide range of estimates is unsurprising when the variation in timing (3 months gestation to 12 months postnatal) and measurement methods (6 different structured and semi-structured diagnostic interviews and 7 different rating scales) is considered. Underscoring the medical and psychological impact of birth-related depression in men are several studies which document negative outcomes in children. Ramchandani and colleagues, using a prospective birth cohort of 10,975 subjects in the United Kingdom, found higher rates of emotional and behavioral problems among preschool-aged children whose fathers had postpartum depression, effects that persisted even when the father s depression had remitted during late infancy. 5 A separate prospective birth cohort of 4,109 subjects in the United States found that depression in fathers at child age 9 months was associated with reduced parent-to-child reading and subsequent decrements in expressive language at age 2 years. 6 Objective: To clarify our understanding of this prenatal and postpartum depression in fathers, we conducted a meta-analysis to estimate paternal depression between conception and 1 year postpartum and to describe how timing vis-à-vis childbirth and maternal depression related to fathers experience of depression. Approach: Studies published between 1980 and 2009 that documented depression in fathers between conception and the first year postpartum were identified through MEDLINE, PsycINFO, EMBASE, reference lists, and Google Scholar. This yielded a total of 43 studies from most parts of the developed world, representing a total of 28,004 fathers during this time period. Information on rates of paternal depression, paternal-maternal depressive correlations, and several other study characteristics were extracted independently by 2 raters. Findings: Wide variation was observed in reported rates of paternal depression which was above estimated base rates for adults 7 in almost all studies. The overall meta-analytic incidence of paternal depression between conception and one year postpartum was 10.4%. Since recent national data suggest that base rates of depression are close to 5%, this suggests that prenatal and postpartum depression in fathers represents a significant public health concern. Depression rates were consistent between the first trimester of pregnancy and 12 months postpartum, except for the 3-6 month postpartum period, when a significant spike (25%) in depression rates was observed. Significantly, studies in the meta-analysis 8 VIRGINIA PEDIATRICS 9

10 that documented correlations between mothers and fathers depressive symptoms consistently showed moderate positive correlations between parents symptoms, suggesting an important link between depression in either parent and the other parent s experiences. These findings suggest several public health concerns that are important to Pediatrics. First, because of the established link between paternal depression and poor child outcomes, the need to screen for, identify, and treat depression in fathers is made much more relevant to child health. Moreover, the correlation between maternal and paternal depression suggests a specific screening rubric that may help identify and refer families with the most risk: if either parent presents with depression, screen for depression in the other. Doing so, and focusing clinical attention on both parents when possible, expands opportunities to prevent and treat parental depression and other mental health problems in the family early and effectively. g NOTE: This report is based on an article published in JAMA in May, 2010: Paulson, J. F., & Bazemore, S. D. (2010). Prenatal and postpartum depression in fathers and its association with maternal depression: a metaanalysis. JAMA, 303(19), Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR. Prevalence of depression during pregnancy: systematic review. Obstetrics and gynecology. Apr 2004;103(4): Beardslee WR, Versage EM, Gladstone TR. Children of affectively ill parents: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry. Nov 1998;37(11): Goodman JH. Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of advanced nursing. Jan 2004;45(1): Schumacher M, Zubaran C, White G. Bringing birth-related paternal depression to the fore. Women And Birth: Journal Of The Australian College Of Midwives. 2008;21(2): Ramchandani P, Stein A, Evans J, O Connor TG. Paternal depression in the postnatal period and child development: A prospective population study. The Lancet. June 25, ;365: Paulson JF, Keefe HA, Leiferman JA. Early parental depression and child language development. Journal of child psychology and psychiatry, and allied disciplines. Oct ;50(3): Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. Jun ;289(23): A Childhood Problem Grows Up: Caring for Adults with Congenital Heart Disease in Virginia Alexander Ellis, MD, M Sc, FACC, FAAP Pediatric & Adult Congenital Cardiology Children s Hospital of the King s Daughters Eastern Virginia Medical School Norfolk, Virginia Many areas within pediatrics are now seeing more of their seriously-ill or complicated patients survive (and thrive) into adulthood than ever before. From pulmonology with the cystic fibrosis population to oncology with acute lymphoblastic leukemia patients, most of these individuals diagnosed in childhood can expect to live and prosper as adults. Cardiology is no different, with legions of our patients who were born with structural heart disease now expected to survive well into adulthood and have a normal life expectancy. Nationally, it is now well accepted that there are over 1 million adults with congenital heart disease (ACHD) VIRGINIA PEDIATRICS

11 There are now more adults living with congenital heart disease than children (Figure 1), a wonderful testament to excellent past medical care but a sobering thought when considering who will provide future care. A recent study from Canada suggests that, all told, 4 in 1000 adults may be living with some form of congenital heart disease, and up to 1 in 10,000 with a severe form (Figure 2). In Virginia alone, that translates into potentially 32,000 people over the age of 18yo who have some form of congenital heart disease. These individuals have done so well thanks in large measure to advances in surgical and catheter-based techniques, ICU medicine and imaging technology as well as good general pediatric care. The challenge that currently faces this population is how best to care for them as adults. Although their problems started in childhood, these conditions may be unfamiliar to adult practitioners but yet other age-related illnesses and general adult care is not the purvey of someone trained in pediatric medicine. It is the who, what, where, and how of providing this care that we must answer, not just in cardiology but in all fields experiencing tremendous increases in adult survivors of childhood diseases. For this reason, institutions around the world have begun established programs to care for adults with congenital heart disease. Locally, we at the Children s Hospital of the King s Daughters have been growing and developing the Virginia Adult Congenital Cardiac program since Who are the patients? Anyone over the age of 18yo who is living with congenital heart disease is eligible for care in the clinic. We currently care for >275 patients in our clinic and this number is expanding rapidly. On average, our program sees 8-10 total ACHD patients per week in clinic (to include 2-3 new patients). In fact, we began caring for 55 new ACHD patients just in the first 5 months of 2010 alone. Diagnoses range from uncomplicated atrial septal defects to complex, palliated single ventricles. Our most common diagnoses include adults with palliated Tetralogy of Fallot, Transposition of the great arteries, and atrioventricular septal defects ( AV Canal ), but we also frequently see VSDs and valvar issues like pulmonary stenosis. Most have had multiple surgical and catheterization procedures and may still be faced with chronic health issues related to their congenital cardiac condition, from arrhythmias to heart failure to hematologic problems. The clinic design attempts to provide a medical home for this population and integrate their overall care with their other medical providers and services. Others may need the expertise of our collaborators within cardiology such as pacemaker or ICD management or cardiac surgical care. In addition, we collaborate closely with our colleagues in Maternal-Fetal Medicine at Eastern Virginia Medical School to help provide obstetric when our ACHD patients are pregnant. Who is on the team? The team is led by Alexander Ellis, M.D. MSc., a pediatric cardiologist who is dual-boarded in Internal Medicine and Pediatrics and spent additional time training specifically in adult congenital heart disease after fellowship. Lopa Hartke, M.D. is also a pediatric cardiologist with a Med/Peds background who sees ACHD patients from the Peninsula / Williamsburg and points west. We also work closely with Mohit Bhasin, M.D., an adult cardiologist and cardiac MRI and CT imaging specialist. In addition to these primary ACHD cardiologists, our team also consists of colleagues in congenital cardiac surgery, anesthesia, and interventional cardiac catheterization at CHKD. Furthermore, we often work with the adult services of cardiology, surgery, anesthesia, and maternal-fetal-medicine at Sentara Norfolk General and Sentara Heart Hospital, especially when inpatient procedures or hospitalizations are required for adults. State-wide, we also have similarly-trained colleagues in Charlottesville, Richmond, and Lynchburg as well as Northern Virginia / DC. ACHD medicine is a small community and, we all work together with for the benefit of our patients when situations arise. Our mission is to ensure that ACHD patients get the best medical care possible, but this does not mean that patients that come to the Virginia Adult Congenital Cardiac program become disconnected from their referring physicians. Quite to the contrary, we strive not to usurp or interrupt existing practitioner-patient relationships but to co-manage or provide consulta- 8 VIRGINIA PEDIATRICS 11

12 tive advice for these complicated patients to their adult cardiologist or primary care physician rather than taking over their care entirely. Where are they cared for? As the state s only stand-alone children s hospital, CHKD is well-suited to care for children but the door doesn t close when they turn 21yo. The Adult Congenital Cardiac program provides surgical and interventional catheter-based procedures for many of our ACHD patients in their 20 s and 30 s within CHKD facilities. For other patients who need the expertise of an adult facility, we are able to work in concert with our colleagues at Norfolk General and Sentara Heart Hospital. How are patients referred and evaluated? The Virginia Adult Congenital Cardiac program has a weekly outpatient clinic in the Children s Hospital but we are available for inpatient consultation. Non-invasive echocardiographic imaging, EKG, treadmill stresstesting, cardiopulmonary metabolic stress testing, and pacemaker interrogation are all available in our ACHD clinic with most testing performed during the patient s appointment. Cardiac MRI and CT angiography are available with Dr. Bhasin at the Advanced Imaging Center at Sentara Heart Hospital, which is connected to CHKD. To have a patient seen in the Virginia Adult Congenital Cardiac program, contact the ACHD coordinator, Meeka Randles at or Meeka. Randles@CHKD.org. Any of our physicians can be reached directly through CHKD s Doctor s Direct at g Health Care Reform for Virginia s Children Submitted by: Bryan Fine, MD, MPH Division of Pediatric Hospitalist Medicine Children s Hospital of The King s Daughters Eastern Virginia Medical School Norfolk, Virginia On March 23rd, 2010, President Barack Obama signed the Affordable Care Act. Though the main focus of this legislation is providing health insurance options for millions of uninsured adults, there is the potential for significant benefits for children. It is important to note that Medicaid and CHIP will remain intact, so the structure of public pediatric health financing will be largely unchanged. Private insurance companies will be required to expand coverage, with most changes to be phased in over the next few years. Some main bullet points on how Virginia s children will be affected: This Year (2010): 1. Parents with private insurance will be able to keep their children on their plans until they turn 27 years old. This will help with the transition to adulthood, where many college students and post-graduates lose insurance or get jobs that don t offer coverage. 2. Private insurers will not be able to refuse a child coverage for a pre-existing condition, nor will they be able to enforce a lifetime cap on expenditures. Annual caps will be phased out over the next five years. 3. All private insurers will be required to cover Bright Futures well-child care at no additional cost to the family. 4. Grants are becoming available to improve outreach for enrollment of children in Medicaid and CHIP. Estimates are that nearly 66% of children currently uninsured are eligible for public assistance. In the Future (by 2014): 1. Public insurance (ie: Medicaid and CHIP) will be expanded so that young adults with low incomes, such as transitioning foster children or those whose parents do not have private insurance through the employer market, 8 12 VIRGINIA PEDIATRICS

13 will be eligible for government coverage. 2. Establish a medical home model for chronicallyill children. 3. Private insurers will be required to cover comprehensive oral and vision benefits for children. 4. Possibly increase Medicaid and CHIP payments to primary care pediatricians and other providers, to incentivize an increased pediatric workforce. All of the above changes increase costs to both private insurers and to federal and state governments. As a result, in addition to some increased taxes, the legislation includes a personal mandate that all individuals carry health insurance. This ostensibly will get healthy individuals, with low-cost health care needs, into the risk pool and offset some of the increased expenditures. Virginia is one of several states that are challenging the constitutionality of this mandate, with resolution not likely for a couple years. Another important aspect of this legislation for pediatricians is the potential that Medicaid physician reimbursement will be increased to or near Medicare levels. In Virginia, current reimbursement is near the bottom as compared to other states. Much of this increased cost will be carried by the federal government rather than the state, an effort to prevent overburdening states with increased budget expenses. What should not be overlooked as well is how pediatricians will be affected personally, both as parents and as employees/employers. Most pediatricians likely have some form of health insurance, so their children will be able to stay on their policies until they turn 27. Depending on salary, pediatricians may face higher taxes to help pay for the increased coverage and benefits that the new legislation promises. A central dogma of Medicaid is that beneficiaries are entitled by law to needed services, but often have difficulty getting access to these services because there are too few providers willing to accept the low fees that states pay. In contrast, privately insured children have far more limited benefit packages yet payment to physicians and other pediatric providers is often very reasonable. Thinking broadly, the main goal of this legislation as it relates to children is to marry the best aspects of public health programs, such as broad benefits, with the higher payment schedules of the private insurances. g Resources: Information provided by the Virginia Child Health Policy Center. Contact: bfine@vchpc.org Help secure your future TODAY Plan ahead for long-term care Over the course of a lifetime you save and invest to achieve many goals. But have you taken into account how the future need for long-term care can impact your financial security, your quality of life, and your family s well-being? By planning ahead today, and making long-term care insurance part of your financial plan, you can help: Protect your assets from the high cost of long-term care Reduce the burden of care that often falls on family members Maintain control over where you receive care, including in your home As a member of the VA Chapter of American Academy of Pediatrics you, your employees, and your eligible family members can receive this important benefit at a 5% discount through John Hancock. INSERT PHOTO HERE Long-term care insurance is underwritten by John Hancock Life Insurance Company (U.S.A.), Boston, MA (not licensed in New York) and in New York by John Hancock Life & Health Insurance Company, Boston, MA LTC-6316A 4/09 Rev. 1/10 John Hancock Life Insurance Company (U.S.A.) (John Hancock) To learn more about long-term care solutions that fit your personal needs, please contact: Matthew D. Brotherton, CLTC at or mbrotherton@1752solutions.com. Policy Series: LTC-03, LTC-06 In ID: LTC-03 ID, LTC-06 ID, LTC-CPP2 In NY: SG-03 NY, SG-06 NY In NC: LTC-03 NC 1/08, LTC-06 NC In OK: LTC-03 OK 10/03, LTC-06 OK In PA: LTC-03FR PA, LTC-06FR PA VIRGINIA PEDIATRICS 13

14 Section on Breastfeeding Lectureship Grant VIRGINIA Submitted by: Ann L. Kellams MD & Natasha K. Sriraman MD VA-AAP Chapter Breastfeeding Coordinators Practical Tools for Promoting and Supporting Breastfeeding: Troubleshooting in a Busy Practice came about because of the Section on Breastfeeding Lectureship Grant. The VA-AAP Chapter President, Robert Gunther, MD, and Executive Director, Jane Davis, not only gave me their full support, but also put me in contact with Dr. Ann Kellams, the Chapter Breastfeeding Coordinator for Virginia, who would be my mentor for this project. And the rest is history! We were lucky enough to have additional financial support from the VA Chapter, which allowed us to expand our ideas for the conference. It was amazing to have such wonderful support from the Chapter. After speaking with Ann Kellams, we both realized that we had similar ideas and were excited to learn that we both shared the same excitement and motivation to promote breastfeeding awareness and education, especially among community pediatricians. We felt that it was important the lecture targeted those topics that community pediatricians face each day with breastfeeding mothers in their practices, many of which we were both familiar with since we had practiced as community pediatricians earlier in our careers. Also, touching upon the medical issues was not enough. To attract physicians to the conference, we realized, we had to address reimbursement issues so docs who were spending their time talking about and promoting breastfeeding to their patients, would get paid for their time. Our final agenda: Christina M. Smillie MD -Practical Latch Issues: Baby-led Breastfeeding -Coding in the Pediatric Office Frank Nice, DPA, CPHP -Medications and Breastfeeding Current Concepts -Special Medication Use During Breastfeeding Ann Kellams, MD -To Supplement or Not To Supplement Natasha K. Sriraman, MD -Jaundice in the Breastfeeding Baby: Making Sense of the Recommendations We decided to have the conference in the Tidewater area since this would be the first breastfeeding conference of this kind in this area. Of course, the location right on the Chesapeake Bay, with its amazing views was an added bonus. We were pleased with our final attendance numbers: 23 physicians, 17 nurses and 17 lactation Consultants. One way in which we made the most of our resources was by collaborating with other institutions to have one of our nationally-known speakers give Grand Rounds and noon conference at one of our academic centers and then an evening seminar at another. This enabled us to accommodate a larger honorarium, reach a larger audience and pay for travel from another state for the speaker. The finances were a bit complicated to sort out. We learned that having one site as the clearing house for everything financial would be the best way to go. Tammy Eberly, the CME Coordinator at UVA made everything run very smoothly. We lead a group called the Virginia Breastfeeding Advocates which is a list-serve of over 175 people from all disciplines: AAP, ABM, La Leche League, the State Breastfeeding Advisory Committee, the Breastfeeding Task Force, RN s, NP s, LC s, MD s and concerned citizens. At our first face-face meeting in Williamsburg, when asked what they saw as the biggest barriers to breastfeeding that we could help with, they unanimously responded: The Doctors! This information helped shape our target audience. We wanted 8 14 VIRGINIA PEDIATRICS

15 THE VIRGINIA CHAPTER AMERICAN ACADEMY OF PEDIATRICS CONGRATULATES Virginia Breastfeeding Advocates 2010 Breastfeeding Champions! Lisa Akers, State Breastfeeding Coordinator-VDH, Drs. Natasha Sriraman, co-chair of the VA-AAP Breastfeeding Committee, Robert Gunther, President Virginia Chapter and Ann Kellams, co-chair of the VA-AAP Breastfeeding Committee. These individuals provided support and guidance to make the first Breastfeeding Conference a reality! the average, busy pediatrician to look at the brochure and know instantly that they would leave this oneday CME with useful, practical information that they could go home and immediately start using in their practice. Although we provided CERPS and CEU s, we did not want to just be preaching to the choir; we wanted doctors there! John Andrako, MD Michelle Brenner, MD Lara Charette, MD Grace Conley, MD Gale Dolan,MD Scott Dubit, MD Robert Fink, MD Gauri Gulati, MD Christine Isaacs, MD Nicole Karjane, MD Ann Kellams, MD Julie Kellogg, MD Shellie Kendall, MD Samantha King, MD Wendy Klum, MD Miriam McAtee, MD Hugh McFee, MD Richmond, VA Norfolk, VA Virginia Beach, VA Richmond, VA Culpeper, VA Buena Vista, VA Norfolk, VA Richmond, VA Richmond, VA Richmond, VA Charlottesville, VA Chesapeake, VA Chesapeake, VA South Boston, VA Richmond, VA Richmond, VA Virginia Beach, VA Advertising for the conference was a challenge. We used many different methods to reach the target audience. Brochures were printed which contained registration forms. These were made available on-line. The conference was advertised primarily on-line/via the web. Brochures were also snail-mailed a brochure to the majority of the pediatricians in the Hampton Roads region. The conference information and e-brochure were also listed on the numerous web pages: American Academy of Pediatrics Section on Breastfeeding; Virginia Chapter, American Academy of Pediatrics - both on the list-serve and the VA-AAP website; University of Virginia CME Web Site; Academy of Breastfeeding Medicine list-serve; 8 Rebecca Muminovic, MD John Pierce, MD Kristin Powell, MD Andrea Rahn, MD Timothy Shope, MD Midlothian, VA Richmond, VA Richmond, VA Chesapeake, VA Chesapeake, VA J. Mark Shreve, MD Richmond, VA Charles Stein, MD Susan Werner, MD Williamsburg Pediatric, Adolescent and Sports Medicine Culpeper, VA Culpeper, VA VIRGINIA PEDIATRICS 15

16 Academy of Breastfeeding Medicine Facebook page; IBLCE Facebook page; Best for Babes Facebook page; ed to General Pediatric Directors at all five academic institutions in Virginia; ed to personal and work contacts; and invitations sent out via a Facebook page specifically created for the conference. Another way in which we marketed the conference was via our Breastfeeding Champions program. We asked all of the members of the Virginia Breastfeeding Advocates list-serve to nominate a local physician in their community who routinely goes above and beyond in their support of breastfeeding. We received 27 names from all over the state! Each came with a brief explanation about why this particular doctor was a champion for breastfeeding. All of the physicians named received a letter congratulating them and inviting them to receive their certificate at the conference. Certificates were printed, and their names were listed on the Virginia Department of Health website as well as the Virginia Chapter s website. In addition to the certificates that could be framed and hung in their offices, they also received a formal letter from the AAP Chapter President recognizing this honor. The program was very easy to implement and quite successful. We had 5 physicians come to receive their certificate in person. Future directions include expanding the scope of the conference to all aspects of newborn care and how they relate to breastfeeding. For example: jaundice, prematurity, vitamin D, skin-skin time, delivery room management, and/or becoming a breastfeeding friendly hospital or office. We plan to do the Breastfeeding Champions again next year and are considering using the newborn angle as a way to attract more participants who may feel like they do not need to spend an entire day talking about just breastfeeding. We will keep things practical and real life but make even more apparent the link between promoting and supporting breastfeeding and their other work with newborns and new parents. We would like to thank the Section on Breastfeeding for awarding the grant to make this conference possible. We received a great deal of positive feedback, and hope to make this an annual event. g Introducing Best Bones Forever! A fresh and fun bone health campaign for girls Osteoporosis is a pediatric disease with geriatric consequences. In terms of bone health, the stage is set early on: girls build close to 90% of their bone mass by age 18. Once they reach adulthood, it becomes increasingly difficult for them to make it up. Unfortunately, most adolescent girls do not get the calcium, vitamin D, and physical activity they need to grow strong, healthy bones. That s why the U.S. Department of Health and Human Services Office on Women s Health (OWH) launched Best Bones Forever!, a national bone health campaign for girls ages Best Bones Forever! Focuses on friendship and fun - and encourages girls to grow strong together, stay strong forever. The new campaign empowers girls and their BFFs (best friend forever) to build strong bones by choosing snacks and foods with calcium and vitamin D, and getting an hour of physical activity a day. Campaign materials such as journals, posters, magnets, tattoos, book covers and a Web site ( VIRGINIA PEDIATRICS

17 forever.gov) get girls excited about bone health with recipes, tips, and fun activities. Parents can get important bone health information from a brochure in both English and Spanish, and a Web site: Help make an impact by taking just a few minutes to discuss bone health with your young patients and their parents. If you are interested in ordering our free Best Bones Forever! materials, please contact Talia at owh@hagersharp.com. g Medicaid Incentive Money for Your Electronic Health Record (EHR): Meaningful Use What does that mean? Submitted by: Sandy L. Chung, MD Co-Chair, HIT Committee Delegate-At-Large, Northern Virginia In February 2009, the American Recovery and Reinvestment Act (ARRA) provided funds that will provide to eligible professionals and hospitals funding for adopting, implementing, or upgrading certified EHR technology or for meaningful use in the first year of their participation in the program and for demonstrating meaningful use during each of five subsequent years. Incentive payments may begin as soon as October 2010 to eligible hospitals. Incentive payments to other eligible providers may begin in January These funds will be given to eligible pediatricians in the form of Medicaid incentive payments. To be an eligible pediatrician, you must meet a several criteria: 1. Medicaid provider Medicaid must make up at least 20% of your patient population. This will be demonstrated by showing that in any representative continuous 90- day period during the payment year that at least 20% of visits were Medicaid patient encounters. If you have 30% or more as Medicaid, you qualify for even more funding. 2. Registration - You must register with the National Level Repository (NLR) and opt to be considered for the incentives in the Virginia Medicaid Incentive Program. Then DMAS will be notified that you are a candidate. However, there is no need to rush to register yet since the NLR is not yet functional. It is being developed by Northrop Grumman and should be available by January DMAS expects to begin reviewing applications in the first half of Adopt, Implement or Upgrade a Certified EHR In your first year of participation in the Medicaid incentive payment program you must demonstrate any of the following: adopted of EHR (such as acquired and installed), implemented EHR (such as trained staff, exchanged data) or upgraded EHR (such as expanded functionality or interoperability). The method by which you show what you ve done is being developed. 4. Certified EHR You must be using a certified EHR certified by the CMS, not just certified by other organizations such as CCHIT. The Office of the National Coordinator for Health Information Technology (ONC) has proposed interim rules for standards for EHR certification. Those should be finalized in the next few months. 5. Meaningful Use you must be meaningfully using your EHR by meeting criteria set by the Centers for Medicare & Medicaid Services (CMS). This will be further discussed below. The current rules require states to use the minimum definition of meaningful use that Medicare providers must meet. However, Virginia may request approval to implement meaningful use measures above the minimum. In determining what is meaningful use, a State must ensure that populations with unique needs, such as children, are addressed. States can also require 8 VIRGINIA PEDIATRICS 17

18 that provider report clinical quality measures as part of the meaningful use demonstration. CMS should have the final rule for minimum meaningful use criteria for Medicare very soon. How much is the incentive? If you have at least 20% Medicaid in your practice, then you are eligible to receive up to $14,167 the first year, and then $5,667 for five more years as long as you are meaningfully using a certified EHR. If you have 30% or more Medicaid in your practice, then you can receive $21,250 Medicaid Voluntary for States to implement No Medicaid fee schedule reductions Medicare CMS will implement Medicare fee schedule reductions begin in 2015 for physicians who are not meaningful users the first year, and then $8,500 for the next five years. The Medicaid program is over in Therefore, to receive the full amount of the incentive money (six years of payments), you would want to adopt an EHR by Is the Medicaid incentive program different than the Medicare program? Yes. What may be confusing to many pediatricians is the difference between the Medicaid incentive program and the Medicare program for our adult medicine colleagues. The table below from DMAS explains some of the major differences. Meaningful Use Criteria what are they? The criteria for meaningful use are not finalized yet at the time of the writing of this article. However, they should be finalized very soon. The proposed rules were released in January 2010 and were open for public comment for 90 days. The final rules will be published soon and will become effective sixty days after publication. Adopt, Implement, Upgrade option for Medicaid only Max Eligible Professional (EP) incentive $63,750 States can make adjustments to meaningful use (common base definition) Medicaid Managed Care Organization (MCO) providers must meet regular eligibility requirements Program sunsets in 2021; last year a provider may initiate program is 2016 Five Eligible Professionals, (incl physicians) ; two types of hospitals Medicare must begin with meaningful use in year 1 Max Eligible Professional incentive is $44,000 Meaningful use will be common for Medicare Medicaid Advantage physicians have special eligibility accommodations Program sunsets in 2016; fee schedule/reductions begin in 2015 Only physicians, subsection(d) and critical access hospitals. Pediatricians actually get an extra year to meet criteria since we are receiving Medicaid incentives and not Medicare. The first year, a pediatrician just has to meet the requirements that show that you are adopting, implementing or upgrading. You do not have to meet meaningful use criteria the first year. Then the second year you receive incentive payments, you will have to meet the same criteria that Medicare providers have to meet their first year. Three stages of meaningful use are planned for the next five years. The first stage focuses on data capture and sharing. The second stage will focus on advanced clinical processes. The third stage on improving outcomes. The criteria become more complex and difficult to implement (with current technology) as another stage is added. Of note, it will be more difficult to qualify for meaningful use the longer you wait to start an EHR. The reason for this is that as CMS defines the stages and makes them effective, they will expect providers to reach them sooner. For example, if you wait until 2015 to have an EMR, then you will be expected to meet Stage 3 criteria from the beginning! 8 18 VIRGINIA PEDIATRICS

19 1st Year of EHR and later Year of Payment , , , 2013, 2014, 2015 and on 2013, 2014, 2015 and on 2014, 2015 and on 2015 and on Meaningful Use Criteria Required Adopt, Implement, Upgrade Stage 1 Stage 2 Stage 3 Adopt, Implement, Upgrade Stage 1 Stage 2 Stage 3 Adopt, Implement, Upgrade Stage 1 Stage 3 Adopt, Implement, Upgrade Stage 3 Adopt, Implement, Upgrade (the first year), then Stage 3 every year after Remember, at this time, pediatricians get the first year of payment just by showing that we are meeting adopting, implementing or upgrading criteria. We do not have to meet Stage 1 criteria of meaningful use until the second year. Our Medicare counterparts must meet these criteria starting the first year of EHR. Keep in mind that the final rule or the state of Virginia can change this so keep your eyes open for announcements about whether or not this delayed requirement remains true when you apply for incentive money. How do I show that I ve adopted, implemented or upgraded an EHR? For the Medicaid incentive program, providers need to show that they have adopted, implemented or upgraded an EHR to receive the first year of payment. While the definitions of what each of these steps mean are still being defined and will be state dependent, the proposed guidelines for these definitions are as follows: Adoption you will need to show actual installation of a certified EHR (equipment purchase and installation, etc.). Just researching EHRs does not qualify. Implementation you will need to show that you have already installed a certified EHR and have begun using it. This includes training staff, entering data, and setting up data exchange agreements with your EHR and other providers such as laboratories, pharmacies, or health IT exchanges. Upgrading you will need to show that you are expanding the functionality of your certified EHR, such as adding clinical decision support, e-prescribing functionality, or other enhancements that help you to meet meaningful use criteria. What are the Stage 1 Proposed Criteria for Meaningful Use? Stage 1 Meaningful Use criteria have been proposed and will be effective starting Please visit the Chapter s website, org/chapternews/chapternews15.html to see a table outlining the 25 measures. All of these must be met to achieve meaningful use. 8 VIRGINIA PEDIATRICS 19

20 How will we report if we are meeting the meaningful use criteria? In 2011, all of the results for all objectives/measures, including clinical quality measures, would be reported by EPs and hospitals to CMS, or for Medicaid EPs and hospitals to the states, through attestation. It will be up to the states to determine if information provided is valid. In 2012, CMS proposes requiring the direct submission of clinical quality measures to the states through certified EHR technology. The hope is that by using technology to report quality data, the administrative burden of doing so will be more manageable and make it routine. The goal is to improve health care quality, efficiency and patient safety. When do I start? In order to receive the full amount of the incentive payments, you will need to start by However, as mentioned above, the meaningful use criteria become harder to meet if you wait until 2014 or later. So, one might argue that you should adopt an EHR sometime in the next three years. On the other side, if vendors change their software, new technology evolves, health information exchanges become fully developed, and the reimbursement structure changes to help pediatricians afford all of the required technologies, then it may be easier to adopt EHR five years or more from now. Unfortunately, it is never going to be easy and it will involve significant investment of time and money. Since the meaningful use criteria are still being developed and certified EHR standards are still being decided on, it is hard to know what vendor will live up to your needs. In the next year or so, those issues should be mostly worked out (at least for Stage 1) and it should be clearer as to what EHR vendors will survive the certification process. g Navigating the EHR Maze Resources for Pediatricians Submitted by: Sandy L. Chung, MD Co-Chair, HIT Committee Delegate-At-Large, Northern Virginia Many pediatricians are in the process of adopting electronic health records (EHR) or just starting to consider the purchase of one. Buying an EHR can be an overwhelming decision considering the significant monetary and time investments that must be committed. There are several resources available to Virginia pediatricians who are just beginning the process. Federal funds have been allocated to help physicians and hospitals offset the expense of adopting, implementing or upgrading EHRs in the form of incentive payments. To qualify for these incentives, pediatricians must demonstrate that at least 20% of their practice is Medicaid. Additionally, they must show that they are meaningfully using their EHR to improve the efficiency and quality of care delivered during the subsequent five years. These meaningful use criteria are still in the process of being finalized. Here are some of the resources for Virginia pediatricians: Virginia Health IT Regional Extension Center (HITREC) This organization has received federal stimulus funds to bring more than 1,000 primary care physicians onto EHR and achieve meaningful use in two years. HITREC does not provide funding to physicians, but will offer discounts for the purchase of select vendors through a group purchasing discount VIRGINIA PEDIATRICS

21 HITREC will provide technical support to practices, help them to choose and implement EHRs, and achieve meaningful use criteria to receive federal incentives. They give participating practices a single point of contact for all problems, maintenance and support issues. Virginia HITREC serves priority primary care practitioners who are licensed doctors of medicine or osteopathy in family practice, obstetrics and gynecology, general internal or pediatric medicine, as well as physician assistants and nurse practitioners in these specialties. To qualify, practitioners also must treat patients in any of the following settings: a. Individual and small group practices (less than 10 prescribing providers) that are predominantly focused on primary care b. Outpatient clinics associated with public and non-profit Critical Access Hospitals c. Community Health Centers and Rural Health Clinics d. Other settings that primarily serve uninsured, underinsured, and medically underserved populations. For more information regarding HITREC, see the following website: MSV Health IT Webinar Series - Plan your journey The Medical Society of Virginia is hosting a series of webinars to help physicians navigate the EHR purchasing process. These webinars help organizations understand the federal financial incentives, how to identify the best EHR vendor for your practice, and ways to improve bottom line performance. These webinars are being held from May until September. For more information, visit: The MSV is also holding an HIT Summit on October 21, 2010, which will feature educational seminars to help providers understand meaningful use as well as how to choose and negotiate the purchase of an EHR system. The summit will cover renegotiating vendor contracts and partnering options with local health systems. A large number of vendors will be on-site for demonstrations and information. For more details regarding the summit, visit: AAP Implementing an Electronic Health Record The AAP also offers a guide to implementing an EHR. This resource gives pediatricians an overview of EMRs, how to choose a vendor, as well as many reviews of EHRs from pediatricians who are already using them. This can be found at the following site: aap.org/ehr.aspx The Launching Your Career in Pediatrics Handbook resource, which can be found within the Practice Management Online on the AAP website, has a section on purchasing an EHR and what questions to ask. Here are some of the features of the PMS and EHR that you should investigate that are unique to pediatrics. Practice Management Software Is it capable of family billing using head of household? How are siblings linked in the system? If you update one child s address, will all the siblings be updated? Can you put alerts on the account for special situations (eg, child with special needs requires extra time for appointments)? Can you design appointment templates that can specify different types of appointments (eg, well-child appointments vs sick-child appointments)? Can you easily move appointments from one physician s schedule to another? Is it capable of running queries so that you can do studies or single out patients within certain demographics (eg, to determine your payer mix or how you are being paid for certain procedure codes)? Electronic Health Records Does it have growth charts? Does it have specialized growth charts (eg, preemie charts, Down syndrome charts)? Can you create forms (eg, school)? 8 VIRGINIA PEDIATRICS 21

22 How well does it handle immunization records? Can you add new ones (as vaccines are developed)? How does it handle reminders if a child is due for vaccines? Can it communicate with statewide immunization registries? How do you enter notes? Via templates? Can you type free text also? Can you customize the templates? How does it handle documenting a sick visit in addition to a well check? Does it have coding assistance? Does it offer electronic prescribing? Does it have a weight-based prescribing system for calculating pediatric dosing? Does it have laboratory report integration and ordering? Can you set pediatric norms for laboratories? Can you interface with local hospital laboratories and major laboratories? For how much? Can you use images or photos (eg, drawing of lesions)? Can you capture signatures (eg, for waivers)? Is there an online interface available where parents can request refills, schedule appointments, or preregister online? Are there pediatric-specific educational handouts? Can you integrate a spirometer, electrocardiogram machine, or vitals machine? Is it capable of sending charges electronically? Will it support patient self check-in? General What is your support turnaround (including after hours and weekends)? How frequent do you have upgrades? Who does those upgrades? Are upgrades included in the maintenance cost? Who performs support for your system? Is there someone local who will come onsite? Or is it done remotely? Is there a resource for users of the same specialty to network and share ideas for using the system? How long has the company been in business? What is the company s business plan? Does it give you a feeling of confidence in that it will be there for the duration of your practice? How do you store backups for patient data? Is it done locally? Is there off-site storage? What are the security features? HIPAA compliance features? As you begin the process of selecting an Electronic Health Record, take advantage of the many resources that are available to you. It is a tedious process, but if done well, can lead to a successful implementation and adoption of electronic records. g White House Obesity Initiative On February 9, 2010, President Barack Obama signed a memorandum on childhood obesity. The AAP has joined the White House, the US Department of Health and Human Services, the US Department of Education, and the US Department of Agriculture in Let s Move, a new initiative to reduce rates of overweight and obesity in our nation s children. Please visit the AAP s obesity initiatives Web site ( for information on how you can partner with families and communities to support children in healthy active living. Out of this initiative the White House Task Force has completed its report Solving the Problem of Childhood Obesity Within a Generation. This report contains many ideas and directions on how pediatricians can help with their families and communities. To see the report, visit the Chapter s website: chapternews/chapternews15.html. g 22 VIRGINIA PEDIATRICS

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24 Performance in Practice Presents Opportunities for Optimizing Asthma care The Medical Society of Virginia Foundation, with the support of the Virginia Chapter of AAP, is expanding the IMPACTTM: Improving Asthma Care and Treatment project to Pediatrics. The Pediatric IMPACT program, led by Helen Ragazzi, MD, will allow Virginia pediatricians to receive credit from the American Board of Pediatrics for the Performance in Practice component (Part 4) of the Maintenance of Certification (MOC). Tools and resources will be made available to participating clinicians to improve their ability to put the 2007 evidence based guidelines of asthma care into practice. Aims include implementing planned educational visits, appropriately classifying asthma severity, assessing asthma control and helping patients adhere to treatment protocols. Participants will be introduced to the basic principles of quality improvement, using the Model for Improvement - a powerful tool for accelerating improvement. They will coordinate an effective systematic team approach to children with asthma, modeling best practices for managing asthma and disseminating education materials and tools to other providers. This team approach to quality and performance creates a foundation for sustainable and progressive improvement over time. An extranet web portal is available to enable physicians and other members of the care team to track their progress and share resources and ideas with other team members. The following practices are participating: UVA Primary Care Center: Amy Wrentmore, MD as physician champion Virginia Pediatric Group: Noelle Bach-Halloin, MD as physician champion Fairfax Pediatrics: Saleena Dakin, MD as physician champion Pediatric Center: Liv Schneider, MD as physician champion For more information about Pediatric IMPACTTM contact Helen Ragazzi, MD at hragazzi@comcast.net. The IMPACTTM project developed by Kurt Elward, MD, MPH, was launched in May 2009 and currently involves 14 family medicine teams. This project builds on the success of the Foundation s original TO GOAL: Together Optimizing Guidelines Adherence and LifestylesTM quality improvement initiative. Established in 1986 as a nonprofit subsidiary of the Medical Society of Virginia, the MSV Foundation is a charitable partnership between the MSV and the MSV Alliance, leveraging the resources of the medical community to create a healthier Virginia. The MSV Foundation advances opportunities for physicians to participate in health improvement efforts, with emphasis on addressing the needs of the uninsured and underserved; develops avenues for physicians to leverage their capacity as volunteers; builds relationships with organizations, coalitions, or initiatives in which the involvement of the physician community would significantly enhance efforts to address specific health issues in Virginia;and supports educational programs for the physician community and the public that advance the mission and vision of the Foundation. For more information, visit www. msvfoundation.org g Botetourt Pediatrics, Carilion: Colleen Kraft, MD as physician champion 24 VIRGINIA PEDIATRICS

25 Measuring Medical Homes: Tools to Evaluate the Pediatric Patient- and Family-Centered Medical Home The purpose of this monograph is to present various tools available and in use to identify, recognize, and evaluate a practice as a pediatric medical home. Because no one tool is recognized as the de facto tool to assess pediatric practices, a review of the relative merits of existing tools will help inform purchasers, payers, providers, and patients in evaluating pediatric practices. Many of the multistakeholder and single-payer medical home demonstration projects focus on adult populations and adult outcomes. An understanding of tools to assess pediatric practices may assist such pilots in incorporating and evaluating pediatric practices in both practice transformation and payment reform. The development of this monograph was funded by the American Academy of Pediatrics National Center for Medical Home Implementation through a cooperative agreement (U43MC09134) with the US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. To view the monograph, visit the Chapter s website at: chapternews15.html. g National Center for Medical Home Implementation Launches New Web site The National Center for Medical Home Implementation has launched a new and improved web site: medicalhomeinfo.org/ The new site features a plethora of resources and information designed to help you learn more about family-centered medical home and how practices, families, communities and states are working on implementation. Informational destinations on the Web site include: Medical Homes@Work e-newsletter: Spotlights timely information and resources related to implementing medical home. How to Implement Tools/Resources: Features an extensive list of user-friendly tools and resources for implementation of medical home in the pediatric practice. Visit this section to see how you can adapt these tools to best meet the needs of your patient, client, or child. Training Resources: Houses a variety of tools and resources targeted towards pediatricians and the medical home care team that may also be of interest and/or use for families, youth, communities, and states. State Pages: Highlights information on state pediatric medical home initiatives, key contacts, partners, and related grant activities and initiatives. Quick Links: Contains links to valuable resources and information including the Building Your Medical Home toolkit ( upcoming conferences, emerging issues and marketing materials. For Families: Presents links to tools and resources aimed at assisting families including the Building Your Care Notebook, Family-to-Family Health Information Centers, tips for partnering with your physician, and Title V. National Initiatives: Consists of information that the National Center tracks on the many national medical home initiatives, including multi-payor demonstration projects and state grant initiatives that are rapidly increasing across the country. g VIRGINIA PEDIATRICS 25

26 FREE Reducing the Risk of SIDS in Child Care Online Module The recent report (2009) The Physician s Role in Reducing SIDS in Health Promotion Practice performed a study to determine physicians knowledge of SIDS. Although most all respondents (99.5%) agreed that certain measures can be taken to reduce the risks of SIDS, 30.3% incorrectly stated that the safest sleep position is something other than on the back. The new AAP Reducing the Risk of SIDS in Child Care online module was developed for child care providers. However, pediatricians can also participate in this FREE course to make sure they are up-to-date with the AAP recommendations about safe sleep. Pediatricians can also encourage parents, grandparents, relatives, child care providers, and other health care professionals to take this FREE course. Sign up for the free course at SIDSmoduleflyerINSTRUCTIONS.pdf. If you are a AAP member go to cme/sids. g Pediatric Grand Rounds Online Inova Fairfax Hospital for Children is now offering Pediatric Grand Rounds online. This is a great educational tool for physicians who cannot make it to Inova Fairfax Hospital for Children to participate in Pediatric Grand Rounds live. Participants are able to create accounts and log-in at their own convenience to view past grand rounds and obtain CME credit by successfully answering a short post-exam. Visit and try out this new educational tool today! Please contact Jessica Parker at jessica.parker@inova.org with any questions. g CPSC Warning On Drop-side Cribs The Consumer Product Safety Commission (CPSC) has issued a warning to parents and caregivers about the hazards of drop-side cribs. According to CPSC, this type of crib has a tendency to be less structurally sound than a crib with four fixed sides. In addition, drop-side hardware is more likely to break or have other problems during normal use. There have been 11 recalls involving more than seven million drop-side cribs in the last five years, due to suffocation and strangulation hazards. The agency is also aware of 32 infant and toddler suffocation and strangulation deaths and hundreds of incidents caused by or related to drop-side detachments in cribs since January In response to these incidents, CPSC is working to improve mandatory federal standards for cribs, with a new voluntary standard banning drop-side cribs from the US market. Due to this standard, many manufacturers have already stopped selling drop-side cribs. For more information about the dangers of drop-side cribs, go to the CPSC Web site at prhtml10/10225.html. g 26 VIRGINIA PEDIATRICS

27 Dates to Remember! Membership Pediatrics at the Beach 2010 July 23-25, 2010 Wyndham Oceanfront Hotel Virginia Beach, VA July 24 - Chapter Business Meeting Meeting Contact: Carole Hettema (804) ; carole.hettema@vcu.edu. Pediatrics at Williamsburg October 29 October 31, 2010 Williamsburg Lodge Williamsburg, VA October 30 - Chapter Business Meeting Meeting Contact: Rosalind Whitaker (757) ; whitakrk@chkd.com. Pediatrics for the Practitioner November 5-6, 2010 Ritz Carlton Tysons Corner More information to come - continue to check the website DO YOU KNOW A PEDIATRICIAN WHO IS NOT A MEMBER OF THE VIRGINIA CHAPTER? YOU are the most valuable link to reaching potential members. Please encourage your colleagues to become active members in the Virginia Chapter. Need an application? Visit our Web site: or call Jane Davis, Executive Director, at (804) Your active participation is vital to the Virginia Chapter! Let Morgan Stanley Smith Barney help you get started. Come for a complimentary consultation to: Evaluate your families needs and goals Review your portfolio Explore your retirement plans Prioritize your charitable giving Second Vice President Financial Planning Specialist Vice President Financial Advisor Three James Center 1051 East Cary St., Suite 200 Richmond, VA patricia.l.rice@mssb.com Unless you are otherwise advised in writing, Morgan Stanley Smith Barney is acting as a brokerdealer and not as an investment advisor Morgan Stanley Smith Barney LLC. Member SIPC. VIRGINIA PEDIATRICS 27