Florida Vein Care & Cosmetic Center EndoVenous Laser Treatment (EVLT) – A Minimally Invasive Option for Vein Disease

MARCH 2020 • COVERING THE I-4 CORRIDOR

FLORIDA MD - MARCH 2020 1

contents MARCH 2020COVERING THE I-4 CORRIDOR

DEPARTMENTS 2 FROM THE PUBLISHER

3 DERMATOLOGY

7 MARKETING YOUR PRACTICE

8 HEALTHCARE LAW

10 CANCER

12 PHARMACY UPDATE

4 COVER STORY

Since 1999, EndoVenous Laser Treatment (EVLT) has become the therapy of choice for patients with painful and painless varicose veins. Now the standard of care and FDA approved, EVLT is minimally invasive, done in the doctor’s office in under an hour, requires no general anesthesia or stitches and provides immediate relief from symptoms. Patients return to normal activities right away. “Over the past 20 years, the demand for EVLT has skyrocketed 200 percent,” says Richard Bragg, M.D., medical director for Florida Vein Care and Cosmetic Center in Lake Mary, Florida. “The procedure has really directed patients away from stripping and ligation done in the hospital.”

According to the American College of Phlebology (ACP), more than 80 million Americans suffer from some form of venous disorders. Phlebology is the field of medicine that treats vein disease such as spider and varicose veins. Varicose veins occur when the one-way valves in the veins don’t function efficiently and the veins become visibly distended with blood. The condition can cause pain, heaviness and/or throbbing in the legs and are often a cosmetic embarrassment for the patient. Nearly 40% of women and 25% of men suffer from varicose veins. Heredity is the primary contributing factor for varicose veins. Other predisposing factors include multiple pregnancies, aging, leg injury and occupations that require standing for many hours. Spider veins are small, thread-like clusters of red, purple, and blue veins that are usually considered an aesthetic annoyance. They most commonly appear on the thighs, calves and ankles.

ON THE COVER: Richard Bragg, MD, medical director for Florida Vein Care and

Cosmetic Center in Lake Mary, Florida.

11 ACOS, MEDICAL MARIJUANA, AND THE PROHIBITION HANGOVER

FLORIDA MD - MARCH 20202

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FROM THE PUBLISHER

Publisher: Donald RauhoferPhotographer: Donald Rauhofer / Florida MDContributing Writers: John “Lucky” Meisenheimer, M.D, Jennifer Thompson, Julie Tyk, JD, Michael Patterson NHA, OTR/L, CEAS, Juan Lopez, Pharm D, John Meisenheimer, VII, John AndersenArt Director/Designer: Ana EspinosaFlorida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information. Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762.Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2018, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

I am pleased to bring you another issue of Florida MD. Sometimes a patient may have the opportunity to participate in a clinical trial. Sometimes a patient may need specialized treatment that is not available in Central Florida. And sometimes there’s no money for that patient to get

to those places. Fortunately there is Angel Flight Southeast to get those patients where they need to go. I asked them to tell us about their organization and how you, as physicians, can help. Please join me in supporting this truly wonderful organization.

Best regards,

Donald B. RauhoferPublisher

ANGELS ON EARTH HELP PATIENTS GET TO LIFESAVING MEDICAL TREATMENTEveryone knows angels have wings! But did you know in Florida and many parts of the nation they have engines

and tails with dedicated volunteers who donate lifesaving services every day? Leesburg, Fla.-based Angel Flight Southeast is a network of approximately 650 pilots who volunteer their time, personal airplanes and fuel to help passengers get to far-from-home medical care. A member of the national Air Charity Network, Angel Flight Southeast has been flying passengers since 1993.

Almost all of its passengers are chronic-needs patients who require multiple, sometimes 25-50 treatments. Passengers may be participating in clinical trials, may require post-transplant medical attention or are getting specialized treatment that is not available near home. Each passenger is vetted to confirm medical and financial need and is often referred to Angel Flight Southeast by medical personnel and social workers.

Angel Flight Southeast “Care Traffic Controllers” arrange flights 24 hours a day, 365 days a year. In the event of a transplant procedure, the Care Traffic Controllers have precious minutes to reach out to its list of volunteer pilots who have agreed to be prepared on a moment’s notice to fly a patient to receive his or her potentially lifesaving organ.

The organization is completely funded through donations by individuals and organizations. A typical Angel Flight Southeast pilot donates $400 to $500 in services-per-trip. In fact, Angel Flight Southeast has earned the Independent Charities of America Seal of Approval as a good steward of the funds it generates from the public. Each $1 donated generates more than $10 worth of contributed services by Angel Flight Southeast.

The charity always seeks prospective passengers, volunteer pilots and donations. For additional information, please visit https://www.angelflightse.org or call 1-888-744.8263.

Check out our newly redesigned website at www.floridamd.com!

FLORIDA MD - MARCH 2020 3

DERMATOLOGY

Things That May Look Malignant But Are Not

The rate of the number of skin biopsies performed each year nationally has increased by about 6% a year for the last ten years or so. Part of this increase appears to be due to physician extenders biopsying more lesions. The good news is that although there may be more unnecessary biopsies, we have also had an increase in early detection of melanoma in situ, so overall, we are still saving lives. The difficulty is that there are many benign lesions to the untrained eye that look suspicious for skin cancer. Often, for a trained dermatologist, it is simple to tell benign from malignant lesions. Still, in some cases, it is far more problematic, and a biopsy is needed to make sure you are not missing something important.

In my practice, I never tell a patient, we will “closely watch” something suspicious to see if it looks worse in 6 months. I have had patients on their visits with me point out lesions that their health care provider is “following” as it appeared a little suspicious to them. If it is questionable, then it needs to be biopsied, period, now, not in 6 months when it has had a chance to grow. You only follow lesions that don’t look suspicious. If I am at all suspicious, and of course, being a dermatologist, I have the advantage of intuitive expertise, I will biopsy, and I like other dermatologists have a high rate of success in finding the spots that do need biopsying.

There are times that I will biopsy a spot just because I have an inkling of a thought that there might be something going on; this is the intuitive expertise kicking in again. Sometimes I biopsy lesions because it is a CTA (Cover Thy Ass) moment. Although I know deep in my heart that the spot is benign, it sure looks funky, and I want to make sure I have not made a mistake. Better

to biopsy and prove yourself wrong than trying to explain to the jury why not biopsying the malignancy that appeared benign, was the correct choice, good luck with that challenge.

What about a growth that looks completely benign, but you are mistaken? If I feel that there is nothing clinically wrong with a lesion, I will explain to the patient, “if it should change or become symptomatic, then come back in for a recheck, do not wait for your six or twelve months follow up.” If you don’t give the patients this bit of sage advice, then you will invariably see the following scenario happen.” A patient calls three years after his last exam. “Doc, I had a spot you said was okay, but it started growing about a week after I saw you. I didn’t do anything as you said it was okay. It’s now about the size of a golf ball, do you think I need to come in, it’s been three years now and still growing, what do you think?”

Benign appearing lesions that, in reality, have gone to the dark side will eventually evolve. The patient will be the first to notice this happening, and they need to know you take changes seriously, even if it occurs days or weeks after their exam. Return checks on sudden changes in benign-appearing growths are your security net for wolves hiding under sheepskins.

Lucky Meisenheimer, M.D. is a board-certified derma-tologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic - Dermatology and Mohs Surgery. John Meisenheimer, VII is a medical student at USF.

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII

ALL PHOTOS: JOHN MEISENHEIMER, VII

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Abscess – not an ulcerated squamous cell carcinoma.

Pyogenic Granuloma – not Metastatic carcinoma.

Hidrocystoma - not Merkel cell carcinoma.

Herpes – not Basal cell carcinoma.

Chondrodermatitis - not Squamous cell carcinoma

FLORIDA MD - MARCH 20204

COVER STORY

Florida Vein Care and Cosmetic Center EndoVenous Laser Treatment (EVLT) – A Minimally Invasive Option for Vein DiseaseBy Margaret M. Sloane, RN, BSN

Since 1999, EndoVenous Laser Treatment (EVLT) has become the therapy of choice for patients with painful and painless varicose veins. Now the standard of care and FDA approved, EVLT is minimally invasive, done in the doctor’s office in under an hour, requires no general anesthesia or stitches and provides immediate relief from symptoms. Patients return to normal activities right away. “Over the past 20 years, the demand for EVLT has skyrocketed 200 percent,” says Richard Bragg, M.D., medical director for Florida Vein Care and Cosmetic Center in Lake Mary, Florida. “The procedure has really directed patients away from stripping and ligation done in the hospital.”

According to the American College of Phlebology (ACP), more than 80 million Americans suffer from some form of venous disorders. Phlebology is the field of medicine that treats

This varicosed anterior thigh circumflex vein was removed by a phlebectomy using 3mm incisions. No sutures are required, and the after picture is 4 weeks post-op.

vein disease such as spider and varicose veins. Varicose veins occur when the one-way valves in the veins don’t function efficiently and the veins become visibly distended with blood. The condition can cause pain, heaviness and/or throbbing in the legs and are often a cosmetic embarrassment for the patient. Nearly 40% of women and 25% of men suffer from varicose veins. Heredity is the primary contributing factor for varicose veins. Other predisposing factors include multiple pregnancies, aging, leg injury and occupations that require standing for many hours. Spider veins are small, thread-like clusters of red, purple, and blue veins that are usually considered an aesthetic annoyance. They most commonly appear on the thighs, calves and ankles.

Patients who come to Florida Vein Care and Cosmetic Center seeking relief for these conditions can expect Dr. Bragg and his

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FLORIDA MD - MARCH 2020 5

COVER STORY

healthcare team to provide a comprehensive three step process that includes consultation, treatment and follow up.

Consultation - The consultation phase consists of a careful medical history evaluation followed by an initial vascular exam known as a “Doppler,” a quick, painless, non-invasive test to determine the extent of the problem. During this time, Dr. Bragg enjoys getting to know his patients, answering questions, and exploring the many options available to treat varicose and spider veins. In some cases, additional diagnostic testing using an ultrasound is required in order to create an effective treatment plan. These painless diagnostics are conveniently performed by Dr. Bragg in the office.

Treatment - Florida Vein Care and Cosmetic Center offers a personalized treatment plan that includes safe, effective, state of the art procedures for varicose and spider veins. Dr. Bragg notes that he has seen an annual growth of 40% in his office over the past seven years and EVLT accounts for a large portion of that growth. EVLT has the same if not better results than vein stripping and ligation, once considered the gold standard for treatment of varicose veins. Clinical studies indicate that EVLT has a 95% initial success rate and excellent long term outcomes. Candidates for EVLT usually fall between the ages of 20-60 and must be able to walk immediately following the procedure.

Typically, EVLT uses laser energy to target a faulty valve at the saphenous femoral junction located in the groin. The saphenous vein runs up the inside of the leg. A small laser fiber is inserted at the knee and advanced up the leg to the groin using non-invasive ultrasound for accurate placement. As the laser is withdrawn, pulses of light cause the vein to heat up, collapse, and then seal itself. During the process, local anesthetic is delivered inside the vein so the patient doesn’t feel the heat. When the laser tip is withdrawn back to the knee, the

Immediately after endovenous laser treatment, patients walk for 20 minutes in the office on the treadmill. A post-op dressing and compression stocking is worn for 1 week after treatment.

All patients are screened with the bi-directional doppler to rule out saphenopopliteal junction incompetence prior to any treatment.

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FLORIDA MD - MARCH 20206

COVER STORY

physician removes it from the vein, applies a small piece of tape along with a Sigvaris graduated compression stocking. The patient is asked to get up and begin walking in the office to check for bleeding and reduce the risk of clots. “With EVLT, there is reduced risk of anesthesia, reduced risk of infection, reduced cost and instead of a one inch scar as is the case with vein stripping, the patient has a tiny three millimeter incision at the knee,” remarks Dr. Bragg. “Female patients say they can finally wear skirts without being embarrassed and teachers are amazed that their legs feel fine at the end of a long day on their feet.” Dr. Bragg has done over 1500 EVLT procedures since 2002.

After nearly every EVLT procedure, Dr. Bragg points out that it is usually necessary to have an ambulatory phlebectomy on the remaining bulging veins. “This is a micro-surgical removal of surface varicose veins using a small vein hook,” says Dr. Bragg. “Phlebectomy is also done in the center under local anesthesia through tiny incisions that require no stitches and leave nearly imperceptible scars.” After the vein has been removed, a bandage and stocking is worn for one week.

Sclerotherapy is used in treatment for spider and varicose veins and has been developed and refined by experts since its introduction in Europe nearly a century ago. It’s become popular in the United States in the past decade. Once diseased veins are identified, a sterile solution of “sclerosing” material is injected microscopically into the vein altering the walls of the vein causing them to collapse and dissolve. The simple procedure is safe and virtually painless and essentially improves the circulation in the legs by diverting blood flow into nearby healthy veins. Treatment does not prevent the development of more spider veins, but the removal of existing spider veins can dramatically improve the appearance of the area. Often, two or more sessions are required to achieve optimum results.

For tiny veins on the legs, face or chest, a laser procedure using a high energy light source can be used. The laser light passes through the skin without damaging it and selectively targets the spider vein. The light is absorbed by the red blood cells in the vein. The resulting heat causes the walls of the vein to seal together and disappear. Laser light treatment may be used in conjunction with sclerotherapy.

When considering treatment options, Dr. Bragg ensures that his patients understand the risk and limitations and that patients have realistic expectations for outcomes.

Follow-Up - Follow-up is an important component of Dr. Bragg’s care management plan. Unlike with vein stripping and ligation which requires bed rest and limited activities, patients who undergo non-surgical treatments are expected to get moving. “We want our patients to walk 30-40 minutes a day for up to three weeks to facilitate resolution of the treated veins,” says Dr. Bragg. A Sigvaris support stocking should be worn for one week after the treatment and patients must schedule a brief follow-up

580 Rinehart Road, Suite 110 • Lake Mary, FL 327467009 Dr. Phillips Blvd., Suite 240 • Orlando, FL 32819

10902 Dylan Loren Circle • Orlando, FL 32825

407.805.8989 Office • 407.805.8833 Faxwww.floridaveincare.com

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appointment to evaluate the results of the procedure.The consultation, the in-office diagnostic ultrasound, and the

procedure is covered by most insurance plans.Laser treatment holds great promise in the field of phlebology,

says Dr. Bragg. Today, EVLT can be used on the greater saphenous vein, short saphenous vein and perforator veins. These three areas cause most varicose veins seen in the legs.

Dr. Bragg received his pre-medical Bachelor’s degree from Louisiana State University in 1988. After graduating from Louisiana State University Medical School in 1992, he was selected for internship and residency at Florida Hospital’s Family Practice residency program. He remains board certified in family practice medicine. Dr. Bragg is an instructor with the National Procedures Institute and teaches physicians who come to him from around the world injection sclerotherapy, ambulatory phlebectomy and EVLT techniques. An active member of the American College of Phlebology, he volunteers many hours a year to educate physicians, nurses, and lay people about venous disease.

Dr. Bragg’s main office is located at 580 Rinehart Road in Lake Mary, Florida. His other locations are at 7009 Dr. Phillips Blvd. and at 10902 Dylan Loren Circle in Orlando.

For more information log on to www.floridaveincare.com or to schedule an appointment, call the office at (407) 805-8989.

Dr. Bragg sees all patients in consultation. He explains venous anatomy, pathology and treatment options.

4 | REPRINTED FROM CENTRAL FLORIDA M.D. NEWS MAY 2007

and then seal itself. During the process, local anesthetic is delivered inside the vein so the patient doesn’t feel the heat. When the laser tip is withdrawn back to the knee, the physician removes it from the vein, applies a small piece of tape along with a Sigvaris graduated compression stocking. The patient is asked to get up and begin walking in the office to check for bleeding and reduce the risk of clots. “With EVLT, there is reduced risk of anesthesia, reduced risk of infection, reduced cost and instead of a one inch scar as is the case with vein stripping, the patient has a tiny three millimeter incision at the knee,” remarks Dr. Bragg. “Female patients say they can finally wear skirts without being embarrassed and teachers are amazed that their legs feel fine at the end of a long day on their feet.” Dr. Bragg has done over 1500 EVLT procedures since 2002.

After nearly every EVLT procedure, Dr. Bragg points out that it is usually necessary to have an ambulatory phlebectomy on the remaining bulging veins. “This is a micro-surgical removal of surface varicose veins using a small vein hook,” says Dr. Bragg. “Phlebectomy is also done in the center under local anesthesia through tiny incisions that require no stitches and leave nearly imperceptible scars.” After the vein has been removed, a bandage and stocking is worn for one week.

Sclerotherapy is used in treatment for spider and varicose veins and has been developed and refined by experts since its introduction in Europe nearly a century ago. It’s become popular in the United States in the past decade. Once diseased veins are identified, a sterile solution of “sclerosing” material is injected microscopically into the vein altering the walls of the vein causing them to collapse and dissolve. The simple procedure is safe and virtually painless and essentially improves the circulation in the legs by diverting blood flow into nearby healthy veins. Treatment does not prevent the development of more spider veins, but the removal of existing spider veins can dramatically improve the appearance of the area. Often, two or more sessions are required to achieve optimum results.

For tiny veins on the legs, face or chest, a laser procedure using a high energy light source can be used. The laser light passes through the skin without damaging it and selectively targets the spider vein. The light is absorbed by the red blood cells in the vein. The resulting heat causes the walls of the vein to seal together and disappear. Laser light treatment may be used in conjunction with sclerotherapy.

When considering treatment options, Dr. Bragg ensures that his patients understand the risk and limitations and that patients have realistic expectations for outcomes.

Follow-Up - Follow-up is an important component of Dr. Bragg’s care management plan. Unlike with vein stripping and ligation which requires bed rest and limited activities, patients who undergo non-surgical treatments are expected to get moving. “We want our patients to walk 30-40 minutes a day for up to three weeks to facilitate resolution of the treated veins,” says Dr. Bragg. A Sigvaris support stocking should be worn for one week after the treatment and patients must schedule a brief follow-up appointment to evaluate the results of the procedure.

The consultation, the in-office diagnostic ultrasound, and the procedure is covered by most insurance plans.

Laser treatment holds great promise in the field of phlebology, says Dr. Bragg. Today, EVLT can be used on the greater saphenous vein, short saphenous vein and perforator veins. These three areas cause most varicose veins seen in the legs.

Dr. Bragg received his pre-medical Bachelor’s degree from Louisiana State University in 1988. After graduating from Louisiana State University Medical School in 1992, he was selected for internship and residency at Florida Hospital’s Family Practice residency program. He remains board certified in family practice medicine. Dr. Bragg is an instructor with the National Procedures Institute and teaches physicians who come to him from around the world injection sclerotherapy, ambulatory phlebectomy and EVLT techniques. An active member of the American College of Phlebology, he volunteers many hours a year to educate physicians, nurses, and lay people about venous disease.

Dr. Bragg’s main office is located at 580 Rinehart Road in Lake Mary, Florida. His second office is at 7009 Dr. Phillips Blvd. in Orlando. For more information log on to www.floridaveincare.com or to schedule an appointment, call the office at (407) 805-8989.

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Dr. Bragg sees all patients in consultation. He explains venous anatomy, pathology and treatment options.

580 Rinehart Road,Suite 110

Lake Mary, FL 32746407.805.8989 Office407.805.8833 Fax

www.floridaveincare.com

7009 Dr. Phillips Blvd.,Suite 240

Orlando, FL 32819407.352.9877 Office407.351.0755 Fax

PROOF

FLORIDA MD - MARCH 2020 7

MARKETING YOUR PRACTICE

Top 10 Strategies, Tools, and Trends to Grow Your Practice in 2020 (Part III)

Healthcare professionals recognize that an array of factors influ-ence patient health, safety, and satisfaction. One of the most often overlooked yet influential variables is employee satisfaction and engagement. Robust employee engagement is linked to significant improvements in patient care and satisfaction. Moreover, adopt-ing state-of-the-art technology can also bring the patient experi-ence to a whole new level.

This month, we wrap up our deep dive into the top 10 strategic tools you can use to grow your practice in 2020.

8. EMPLOYEE ENGAGEMENT AND TRAININGEmployee engagement is the new marketing. And the numbers

back it up: when you improve employee engagement, patient satisfaction increases. Furthermore, healthcare organizations that deliver a “superior” customer experience achieve, on average, 50% higher net margins than organizations that provide “average” cus-tomer service.

That means your entire staff needs to recognize and understand the critical role they play in providing excellent customer service to your patients. And that can only come through employee en-gagement and training.

An engaged employee is a happy employee. And when your staff is content, it has a trickle-down effect to your patients who have a better overall experience. The employment market is extremely competitive, so it’s critical to make sure you have the best people in place and keep them there. And the best way to keep them is to engage them and make sure they have the proper training.

9. WEBSITE CHATYour patients increasingly expect medical websites to include

some chatbot capability, as do other product and service sites. A chatbot is very similar to a “Live Chat” button on any customer service website. But, the conversation occurs with AI instead of a human being.

The added value AI brings is its ability to deliver personalized content without the need for a live person to respond. Also, inter-actions can be recorded and securely stored in a HIPAA-compli-ant fashion.

A chatbot driven by AI can address common questions from existing and prospective patients on behalf of your practice 24/7. Bots represent a sure-fire way to make patients happy by giving them the specific information they are looking for right away. They also help free up significant phone and email time from your front-line employees.

Don’t think all-out AI is feasible for you right now? If not, you can set something up during business hours where someone in your call center is responsible for the chatbox and directs queries as needed. After closing, the chat icon will still be visible on your website but will respond to any messages saying, “Sorry, no one is

at the office right now, but we’ll get back to you as soon as we can during regular office hours.”

10. RESOURCE LIBRARIESIn 2020, from a content standpoint, less will be more. Your focus

should be on special projects, and one way to do it is through a resource library. Instead of posting content pieces twice a month and dealing with all the extra work that goes with it, you can build up resources that current and potential patients can use.

One orthopaedic practice we work with created a library of physical therapy exercises on their website. That way, their post-surgery patients can check the library when doing the exercises at home in case they don’t remember the movements.

Another plastic surgeon we work with is creating pre- and post-operative care videos. Following, for example, rhinoplasty surgery, patients are shown how to tape and care for their noses immediately after surgery. It’s a free resource that is emailed to patients with a link and is designed to educate and engage them. Stay tuned for next month’s installment where we break down what owned media is and how it can help you grab more attention in rented online spaces like Facebook and Instagram.

Jennifer Thompson is the President of Insight Marketing Group and Insight Training Solutions and can be reached at 321.228.9686 or jennifer@insightmg.com.

By Jennifer Thompson

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FLORIDA MD - MARCH 20208

HEALTHCARE LAW

Understanding Exculpatory ClausesAn exculpatory clause purports to deny an injured party the

right to recover damages from a person negligently causing his injury. Cain v. Banka, 932 So. 2d 575 (Fla. 5th DCA 2006). They are disfavored in the law because they relieve one party of the obligation to use due care and shift the risk of injury to the party who is probably least equipped to take the necessary precautions to avoid injury and bear the risk of loss. Applegate v. Cable Water Ski, L.C., 974 So. 2d 1112, 1114 (Fla. 5th DCA 2008). Such clauses are strictly construed against the party seeking to be relieved of liability. Sunny Isles Marina, Inc. v. Adulami, 706 So. 2d 920 (Fla. 3d DCA 1998). Thus, exculpatory clauses are enforceable, only where, and to the extent, that the intention to be relieved from liability is made clear and unequivocal. Tatman v. Space Coast Kennel Club, Inc., 27 So. 3d 108, 110 (Fla. 5th DCA 2009). The wording must be so clear and understandable that “an ordinary and knowledgeable person will know what he is contracting away.” Id. (quoting Gayon v. Bally’s Total Fitness Corp., 802 So. 2d 420 (Fla. 3d DCA 2001).

The seminal Florida case on exculpatory clauses is the Florida Supreme Court case of Sanislo v. Give Kids The World, Inc., 157 So. 3d 256 (Fla. 2015). Give Kids the World, Inc. (“GKTW”) provided free vacations to seriously ill children and their families. When applying for the vacation, the Sanislos executed a “wish request” form that contained a waiver of liability, also known as an exculpatory clause. When the parents arrived at the resort village they again signed a liability release form, also an exculpatory clause. The language of the exculpatory clause is reprinted below for reference:

I/we hereby release Give Kids the World, Inc. and all of its agents, officers, directors, servants, and employees from any liability whatsoever in connection with the preparation, execution, and fulfillment of said wish, on behalf of ourselves, the above named wish child and all other participants. The scope of this release shall include, but not be limited to, damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs and physical injury of any kind....

I/we further agree to hold harmless and to release Give Kids the World, Inc. from and against any and all claims and causes of action of every kind arising from any and all physical or emotional injuries and/or damages which may happen to me/us....

Sanislo at 258-259.

While participating in a horse-drawn wagon ride, a rear pneumatic lift designed to allow those in wheelchairs to participate failed, and Ms. Sanislo was injured. The Sanislos brought suit and GKTW filed a motion for summary judgment arguing that the signed releases precluded an action for negligence. The Sanislos filed a motion for partial summary judgment against GKTW’s affirmative defense of release. The trial court granted the Sanislo’s motion and denied GKTW’s motion. The jury found for the Sanislos and GKTW appealed. Id.

The Fifth District reversed, finding the lower court erred in denying GKTW’s motion for summary judgment because the release signed by the Sanislos was unambiguous and did not contravene public policy. It ruled the exculpatory clause barred the negligence action despite the lack of a specific reference to “negligence” or “negligent acts” in the exculpatory clause.

The Fifth District reasoned that exculpatory clauses are ef-fective if the wording of the exculpatory clause is clear and un-derstandable so that an ordinary and knowledgeable person would know what he or she is contracting away, and that the court had previously rejected “‘the need for express language referring to release of the defendant for “negligence” or “negligent acts” in order to render a release effective to bar a negligence action.’ ” On the public policy argument, the Court said the relative bargain-ing power of the parties should not be considered because it was outside of the public utility or public function context and the Sanislos were not required to request a vacation with GKTW or go on the vacation. Id.

In affirming the Fifth District’s decision, the Supreme Court wrote that the conflict for the Court’s resolution was “whether an exculpatory clause is ambiguous and thus ineffective to bar a negligence action due to the absence of express language releas-ing a party from its own negligence or negligent acts.” Id. at 260.

The Florida Supreme Court wrote:

.... we are reluctant to hold that all exculpatory clauses that are devoid of the terms “negligence” or “negligent acts” are ineffective to bar a negligence action despite otherwise clear and unambigu-ous language indicating an intent to be relieved from liability in such circumstances. Application of such a bright-line and rigid rule would tend to not effectuate the intent of the parties and render such contracts otherwise meaningless.

Id. at 270.

The Court found that the GKTW liability release form re-leased GKTW and all of its agents, officers, directors, servants and employees from “any liability whatsoever in connection with the preparation, execution and fulfillment of said wish…” The release then provided that the scope of the agreement included “damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs and physical injury of any kind . . . .” The Court found that the release clearly conveyed that GKTW would be released from any liability, including negli-gence, for damages, losses, or injuries due to transportation, food, lodging, entertainment and photographs. Id.

The determination of whether an exculpatory clause is en-forceable will be determined by the Judge, as the enforceability of a pre-injury release is a question of law. The enforceability there-

By Julie A. Tyk, JD

FLORIDA MD - MARCH 2020 9

HEALTHCARE LAW

fore, will depend on the Judge assigned to the matter. Physicians should not assume that because a patient signed a liability release form the patient does not have a viable cause of action. Physicians should consult with an experienced attorney who can examine the facts of the case and help you determine the best path forward. The Health Care Practice Group at Pearson Doyle Mohre and Pastis, LLP is com-mitted to assisting Clients in navigating and defending medical malpractice claims. For more information and assistance, please contact David Doyle and Julie Tyk at Pearson Doyle Mohre & Pastis, LLP.

Julie A. Tyk, JD, is a Partner with Pearson Doyle Mohre & Pastis, LLP. Julie concentrates her practice in medical

practice defense litigation, insurance defense litigation and health care law. She has represented physicians, hospitals,

ambulatory surgical centers, nurses and other health care providers across the state of Florida. She may be contacted by

calling (407) 951-8523; jtyk@pdmplaw.com.

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FLORIDA MD - MARCH 202010

CANCER

Orlando Health Brings First Robotic Bronchoscopy to the SoutheastBy Staff Writer

Imagine a bronchoscopy plat-form that enables you to make faster and less invasive lung cancer diagnoses on a larger patient pop-ulation. Imagine no further.

Orlando Health UF Health Cancer Center now offers this new enhanced technology. It is the first facility in the Southeast to use the FDA-approved Monarch™ Plat-form robotic bronchoscopy system developed by Auris Health.

SURGICAL BENEFITSThe reach and precision of ro-

botic bronchoscopy delivers a minimally invasive approach to lung cancer testing that reduces risks of a deflated lung or other potential side effects, while potentially improving outcomes. “With the Monarch, we have the ability to see and access parts of the lungs that were previously out of reach,” says Dr. Mark Vollenweider, section chief for pulmonary medicine at Orlando Health.

HOW IT WORKSThe Monarch Platform has a telescoping design to more easily

navigate the periphery of the lung, providing more access and a better view of small, hard-to-reach lung nodules otherwise deemed unreachable with previous minimally in-vasive procedures.

A robotic hand controller, much like a video game controller, allows the specialist to insert a flexible endoscope through the patient’s mouth and steer it on the most direct path to the nodule with greater precision and control.

A combination of 3-D modeling of the patient’s lung anatomy, real-time video and electromagnetic

navigation similar to a car’s GPS provide 360-degree visibility all the way to the nodule. Once the endoscope reaches the nodule, the tissue sample can be collected for testing.

AN EARLIER DIAGNOSISPerformed as an outpatient procedure, the process takes from 30

minutes to 90 minutes. Thoracic and pulmonary interventionists already have completed numerous robotic bronchoscopies at the cancer center’s downtown Orlando campus.

“Lung cancer often goes unnoticed in its early stages, so there is an unmet need to diagnose this disease much earlier in our patients,” says Dr. Vollenweider. “The Mon-arch helps us speed up diagnosis and has the poten-tial to improve survival rates.”

For more information about lung cancer di-agnostic testing with the Monarch Platform, contact the Rod Taylor Thoracic Care Center at (407) 648-5384.

Mark Vollenweider, MD, MPH, is an inten-sivist trained in interventional pulmonology at Orlando Health. He works with Orlando Health UF Health Cancer Center to provide complete medical care for all thoracic patients. He is using several innovative technologies to diagnose and treat benign and malignant air-way and pulmonary lesions and specializes in electromagnetic navigational bronchoscopy, airway tumor ablation, balloon dilation, tracheostomy revision and multiple pleural procedures. He is board certified in internal medicine, critical care medicine and pulmo-nary medicine.

Mark Vollenweider, MD

FLORIDA MD - MARCH 2020 11

ACOs, or Accountable Care Organizations, are a growing influ-ence on healthcare today. Their power over decision making will continue to increase for the goals of streamlining healthcare costs, improving communication between all healthcare settings (Medi-cal practices, hospitals, surgical centers, nursing homes, home health care, outpatient providers, etc.), and improving the quality of healthcare.

If you have been in healthcare long enough, you know the only constant is change. ACOs are just the beginning. Bundled pay-ments for services across multiple providers are here. In 2019, Nursing Homes and Home Health started dealing with outcome-based payments, rather than service-based payments.

With all this change in reimbursement, some providers will get left behind. Those who are not willing to change, or do not want to change, will not make it. They will hold on, put their head in the sand, and keep “milking” the current system telling their employees to do “more with less” and expect the same financial returns.

One of these areas of change, which is already happening, is Medical Marijuana (MMJ) in Florida. Unless you have been living under a rock, it’s been legal now for almost 5 years. We currently have surpassed 310,000 active MMJ patients in Florida and that number will continue to increase at 5,000 patients per week in-definitely. Now the question, “Why should I care if patients use MMJ? I don’t have anything to do with MMJ in my ACO, so it doesn’t affect me.” Your patients are already using MMJ, they are just not telling you! By capturing the data from these patients, you will begin to see how MMJ is saving your company lots of money indirectly now and will save millions more by using the data to bet-ter patient outcomes.

Right now, I know of ZERO healthcare providers in Florida tracking MMJ data. If you want to be ahead of all your competi-tion, start doing the following:1) Start asking your patients about MMJ use. Medical Marijuana

has been proven to decrease prescription drug use each month. (https://www.cboutlook.com/bradford2016.pdf ). It has been proven to decrease depression, increase appetite, kill cancer cells, cure colitis, improve Alzheimer’s symptoms, decrease chronic pain, decrease the effects of a stroke, and the list goes on, and on, and on. (https://www.businessinsider.com/health-benefits-of-medical-marijuana-2014-4#animal-studies-suggest-that-marijuana-may-protect-the-brain-after-a-stroke-18)

2) Track the data. Start “connecting the dots”. All these positive ef-fects will help your patients and your bottom line ONLY if you know what is happening. Why are they using MMJ? Is it pro-viding them with benefits in their health? What other benefits are they finding by using MMJ? Are they less depressed or anx-ious so they can exercise more? Do they now have the ability to eat better so they can put on weight and decrease potential skin tears and wounds? (which are tremendously expensive to treat). Have they been able to stop taking costly prescription medica-

ACOs, Medical Marijuana, and the Prohibition Hangover By Michael Patterson, NHA, OTR/L, CEAS

tions and have better outcomes and less side effects? At first your patients may not trust you enough to tell you. (the current FL MMJ law does not protect patients from losing their job if they use MMJ). However, over time if you continue to show that your ACO or company is looking to learn how MMJ will help their condition and it will help you provide better care, they will slowly warm up and an-swer the questions truthfully.

3) Educate your ACO on the findings of your data- once you start collecting enough data on MMJ, you will begin to extrapolate results. For example, you may find that your patients who are using MMJ for chronic pain are less likely to get addicted to opiates (which means the ACO will have to pay for less drug dependency treatment over time). Or, your patients using MMJ for colitis or IBS don’t need expensive prescription meds for their condition anymore (which will save your ACO millions of dol-lars). Or, your Alzheimer’s patients are not getting worse, actual-ly better, and are less likely to fall and break a hip requiring costly surgery, hospital stay, nursing home care, and home health.

In the new age of blockchain, super computing power, and data analytics, a wise man once told me, “Whomever has the data wins.” Regardless of your opinion of MMJ, this new legal medicine is a treasure-trove of data that can begin to lower costs, improve out-comes, and put more money in your pocket (without having to recommend the medicine). The “prohibition hangover” is alive and well. The “prohibition hangover” is the inability to come to grips with Medical Marijuana being legal and refusing to learn anything about it. If you have not noticed, our neighbors to the north (Can-ada), have legalized cannabis across the entire country. Currently, over 40 countries in the world have legalized Medical Marijuana and that list continues to grow every month. (Germany has legal-ized MMJ and it is paid for through the national healthcare system). The use of MMJ in Florida and globally will only increase over time. Savvy healthcare operators will use the data of this new legal medi-cine to jump ahead of the competition because whomever gets rid of their prohibition hangover last, will lose.

Michael Patterson NHA, OTR/L, CEAS is CEO of US Cannabis Pharmaceutical Research and Development LLC. (uscprd.com). Mr. Patterson is a healthcare executive with over 25 years experience in: Cannabis-Hemp investment, Law, Regulation, Compliance, Operations, and Management, Skilled Nursing, Pharmacy, Laboratory, Assisted Living, Home Healthcare, and Healthcare Analytics. Michael is a subject matter expert in the Global Cannabis and Hemp In-dustry with Gerson Lehrman Group (glg.it) and Guidepoint. Mr. Patterson is an editorial board member of the American Journal of Medical Cannabis, licensed Nursing Home Admini- strator, and licensed Occupational Therapist in 4 states.

FLORIDA MD - MARCH 202012

COVER STORYPHARMACY UPDATE

How Pharmacists Can Help During the Coronavirus Outbreak

Patients should be reassured that actions have been taken by state and federal officials to empower pharmacists and utilize pharmacy services for the benefit and protection of the public health.

EMERGENCY ORDER – MAINTENANCE MEDICATION FOR CHRONIC CONDITIONS

On Monday, March 9, 2020, Governor Ron DeSantis declared a State of Emergency for the state of Florida in response to the recent outbreak of the Coronavirus Disease 2019 (COVID-19). Under the State of Emergency, a pharmacist may dispense up to a 30-day supply of maintenance medication for a chronic condi-tion provided that the medication is essential to the maintenance of life or to the continuation of therapy in a chronic condition; or in the pharmacist’s professional judgment, the interruption of therapy might reasonably produce undesirable health conse-quences or may cause physical or mental discomfort. Pharma-cists are required to create a written order and notify the patients’ prescriber of the emergency dispensing within a reasonable time. This emergency order does not extend to medications listed as Schedule II controlled substances.

HAND SANITIZER SHORTAGEConsumers and health care professionals have experienced dif-

ficulties obtaining alcohol-based hand sanitizers. The Food and Drug Administration (FDA) has received a number of queries concerning compounding of alcohol-based hand sanitizers due to shortages. On March 14, 2020 the FDA announced it will take no enforcement action against pharmacists who prepare alcohol-based hand sanitizers during the current public health emergency. The FDA has issued guidance to communicate its policy and re-quirements for the temporary compounding of certain alcohol-based hand sanitizer products by pharmacists in State-licensed pharmacies, Federal facilities, or registered outsourcing facilities. Compounding pharmacists are trained and well qualified to pre-pare hand sanitizer products. This action empowers compound-ers to serve their communities in this time of shortage.

The FDA has confirmed with the Alliance for Pharmacy Com-pounding (APC) that a patient-specific prescription is not re-quired while this temporary guidance is in effect.

DELIVERY SERVICESAs patients are looking for ways to “flatten the curve” through

social distancing, pharmacy delivery and curbside pick-up are be-coming popular services offered to further this effort. Ask your pharmacy provider if your medication order can be delivered di-rectly to your home via delivery or shipping services.

Pharmacists are a readily accessible health care resource and are only a phone call away. If you have questions about your medication therapy, options available to you in case of a drug

by Juan Lopez, PharmD, FIACP

shortage, or what you can be doing for immune support, please give the pharmacy a call.

REFERENCES:1. Florida Board of Pharmacy. Gov. Desantis Declares A State Of Emergency In FL

In Response To COVID-19. [online] Floridaspharmacy.gov. Available at: https://floridaspharmacy.gov/latest-news/gov-desantis-declares-state-of-emergency-in-flori-da-in-response-to-covid-19/ [Accessed 19 March 2020].

2. Florida Statutes - 465.0275 Emergency prescription refill [online] Avail-able at: http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400-0499/0465/Sections/0465.0275.html [Accessed 19 March 2020].

3. Alliance for Pharmacy Compounding (APC). APC ALERT: FDA allows com-pounders to prepare hand sanitizers during emergency [electronic communication] March 14, 2020.

4. Alliance for Pharmacy Compounding (APC). APC ALERT: More on hand sani-tizers -- and telling your story [electronic communication] March 16, 2020.

5. Policy for Temporary Compounding of Certain Alcohol-Based Hand Sanitizer Products During the Public Health Emergency Immediately in Effect Guidance for Industry. U.S. Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research (CDER). March 2020.

Juan Lopez, PharmD, FIACP, is a personalized medi-cine pharmacist with Pharmacy Specialists Compounding Pharmacy in Altamonte Springs, FL. For more information, please call 407-260-7002, or email us at Info@MakeRx.com.

2019 Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market.

Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD.

It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

JANUARY – Digestive Disorders Diabetes

FEBRUARY – Cardiology Heart Disease & Stroke

MARCH – Orthopaedics Men’s Health APRIL – Surgery Scoliosis

MAY – Women’s Health Advances in Cosmetic Surgery

JUNE – Allergies Pulmonary & Sleep Disorders

JULY – Neurology / Neuroscience Advances in Rehabilitation

AUGUST – Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICU’s Autism

OCTOBER – Cancer Dermatology

NOVEMBER – Urology Geriatric Medicine / Glaucoma

DECEMBER – Pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information.

EDITORIALCALENDAR

FLORIDA MD - MARCH 2020 13

2019 Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market.

Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD.

It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

JANUARY – Digestive Disorders Diabetes

FEBRUARY – Cardiology Heart Disease & Stroke

MARCH – Orthopaedics Men’s Health APRIL – Surgery Scoliosis

MAY – Women’s Health Advances in Cosmetic Surgery

JUNE – Allergies Pulmonary & Sleep Disorders

JULY – Neurology / Neuroscience Advances in Rehabilitation

AUGUST – Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICU’s Autism

OCTOBER – Cancer Dermatology

NOVEMBER – Urology Geriatric Medicine / Glaucoma

DECEMBER – Pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information.

EDITORIALCALENDAR

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Happy Doctors’ DayWe thank our doctors for all that they do to help us feel whole.

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