Thursday, August 28, 2014

The Best of Times or Worst of Times…Depends on the practice

By: Curtis Woods, COO with Integrated Solutions, a division of IT 4 the Planet

It is the best of times and the worst of times in medical information technologies. Both the potential benefits and potential risks are great. The outcome is up to the individual medical practice. In July, The editor of Healthcare IT News was “optimistic about the promise of health information.” Yet, on August 4, the publication reported that only 1 percent of eligible providers had met Stage 2 goals of ‘meaningful use’ of the HITECH Act, which “seeks to improve American health care delivery and patient care through an unprecedented investment in Health IT (HIT).”

Even for the other 99 percent that have not fully implemented Electronic Health Records, the data of a healthcare practice is an investment that can reap benefits or wreak havoc. Outside of the painful consequences of data breaches, when computerized systems fail or records become unavailable, it can cripple the daily operation of a practice. The problem strikes close to home. Recently, an Alabama medical clinic experienced a catastrophic failure of their server due to electrical storms. Even with on-site backups, the data was corrupted and unrecoverable, at a cost that could have been minimized and recovered with the right preventive medicine. In Alabama and Tennessee, 16 HIPAA regulated facilities have made the “Wall of Shame” for electronic data loss, published by the U.S. Department of Health and Human Services. For these practices and others that make news headlines, it is the “worst of times.” But, there are steps that can not only protect practices, but also improve quality of care and revenues, making the best of the technologies and resources available.

In a recent technical audit conducted for a large medical clinic, it was discovered that the outsourced IT vendor had not backed up off-site records that could have resulted in a catastrophic loss. As this case illustrates, there is value in an independent IT audit to assess risks, just like a regular medical checkup. Here are just a few items that should be on the checkup list:

Encryption: Data for portable computers and storage devices should be encrypted. Verify with your IT service provider that off-site backups are encrypted, too.

Backup Off-Site Daily: Backup critical data to an off-site provider each night to allow for recovery of data that is accidentally deleted or corrupted.

Laptops and Portable Devices: Mobile devices require additional measures and protocols, and are not suited for Cloud backup solutions as a primary backup.

Contracted Providers: Not all contracted providers have the medical background to ensure their HIPAA compliance. A recent breach involved the contracted transcriptionist company, which was immediately fired, but the damages and fines had already occurred. Even the IT service provider should have medical experience. Many IT providers use public cloud storage companies, which increases the risk of a breach and improperly protected information.

There are necessary steps and best practices to minimize risks of fines, data breaches, and data recovery costs. But, information technologies are more than just a “necessary evil.” Beyond protecting a healthcare practice, good information technologies and management solutions can be an investment in improving and growing the practice. Whether it is the “best of times or worst of times” depends on the practice.

Tuesday, August 12, 2014

Celiac Disease and Gluten: More Than Just a Fad


By: Charles A. Dasher, Jr., MD with
Birmingham Gastroenterology Assoc.

Gastrointestinal illness often has a marked impact on quality of life, and celiac disease (CD) in its more severe form is a great example of this. In its milder form you may not have any symptoms at all, but malabsorption of nutrients may be occurring. For example, impaired iron and vitamin absorption can occur and lead to anemia or altered clotting of the blood. However, most people with celiac disease come to clinical attention because of bothersome symptoms like diarrhea, weight loss, and crampy abdominal discomfort. CD can occur in people of any age and it affects both genders.

CD occurs when the immune system inappropriately responds to ingested gluten and leads to damage to the lining of the small intestine. It is not clear what causes CD, but it likely involves both environmental and genetic factors. In fact, in cases where the diagnosis may be uncertain, a simple blood test to look for a certain genetic component can be helpful. When that genetic make-up is absent, it essentially excludes the possibility of CD in that patient. Furthermore, CD is much more common in certain areas of the world than others-supporting both environmental and genetic predisposition as important in the development of the disease. Gluten-free diets (GFD) have become popular, trendy diets that many Americans try, but those with true CD understand that a GFD is more than just a fad. CD usually responds well to a GFD, but strict compliance is a must. Even small amounts of gluten that make their way into the diet can wreak havoc on a previously well controlled patient with the disease.

CD can be difficult to diagnose because the signs and symptoms are similar to other conditions. Fortunately, testing is available that can easily distinguish untreated CD from other conditions. Simple blood tests to evaluate for certain antibodies that become elevated in people with CD is often the first test ordered, and there should be a low threshold for ordering it in the right clinical scenario. Over 95% of those with CD will have elevated levels of these antibodies, while it is exceedingly uncommon for the levels to be elevated in those without the disease. If the blood test is positive or the diagnosis remains uncertain, a biopsy of the small intestine is usually required to confirm the diagnosis. The biopsy is easily collected via an upper endoscopy. In patients with CD, the lining of the small intestine may have some typical appearances; however, a normal appearing lining does not exclude CD. Biopsies must be taken for microscopic examination to look for the characteristic findings. Normally, the lining of the small intestine has distinct finger-like projections called villi that allow the intestine to absorb nutrients. In CD, small intestine biopsies characteristically show flattening of the villi, among other changes. Fortunately, once gluten is removed from the diet, the villi resume a normal growth pattern and most patients begin to feel better within two weeks after eliminating gluten from the diet.

Complications from CD can occur, but the risk is substantially lowered by long-term compliance with a GFD. When individuals fail to respond to a GFD, a search for other co-existent conditions should take place, including small intestinal bacterial overgrowth, microscopic colitis, and irritable bowel syndrome. Usually, inadvertent ingestion of gluten is to blame for failure to respond to a GFD. Thus, early consultation with an experienced dietician is an invaluable tool to minimize the chance of this happening. Certain types of lymphoma have been associated with celiac disease, but the risk is low and minimized further by long-term compliance with a GFD.

As mentioned before, the treatment of CD is removing ALL gluten from the diet. Steroids may be needed in the rare cases of refractory celiac disease, but long-term side effects from steroids are often worse than complications from incompletely treated CD. Steroids should never be used as first line therapy for CD. Although changing a diet may seem better than taking medications, following a GFD is challenging and requires major lifestyle adjustments. On the positive side, most patients with CD have complete resolution of their symptoms with strict GFD. There aren’t many medical conditions that have such good outcomes from dietary modification alone, and many are glad to learn they don’t need another medication added to their daily regimen!

General Tips to Remember about CD:

• If signs and symptoms of CD are present, testing should be done

• Avoid gluten-containing foods such as wheat, barley, malt, brewer’s yeast, and oats (unless pure and uncontaminated foods with gluten-free label)

• Naturally gluten-free foods include rice, corn, potato, soy, many beans. However, watch out for gluten contamination of these foods when purchased processed or prepared

• Early involvement of an experienced dietician is an important part of CD management

Monday, August 11, 2014

Closing the Gaps In HIPAA Compliance: Corrective Action Needs a Plan

 By: Susan Pretnar, President at Keysys Health

In previous posts, I mentioned that simply accomplishing a one-time assessment and analyzing your risks at a single point in time does not a risk management program make. By developing a plan of action to correct the gaps identified in your risk assessment, you stand a greater chance of actually implementing required policies, procedures and plans that resolve the ‘holes’ in your risk management program. Revising and maintaining a documented risk remediation plan is a basic tenet of an ongoing risk management program, as well as a requirement of HIPAA.

A risk remediation plan is a roadmap for getting unresolved privacy and security requirements implemented in your practice or company, and another step toward HIPAA compliance. Just like the abundance of assessment techniques, there are myriad ways to develop a plan of action. But, it is important to have your plan documented. Don’t ignore the need to plan a budget for some of the changes that will be needed, especially if there are technology weaknesses that should be addressed. It is highly recommended that you use some basic project management techniques to keep your plan moving forward: document agendas and minutes, schedule routine status meetings, create an issues log, assign a specific project manager for each remediation project.

Develop a remediation plan by identifying the highest rated risks from your assessment. If your assessment instrument did not provide some type of rating system to allow you to prioritize your risks (gaps) it will be necessary to devise a system to do so, regardless of how simplified. The HHS/OCR web site provides a discussion of how to think about vulnerabilities, threats and risks:

The goal is to identify the privacy or security gaps that pose the greatest threat to your company and attempt to resolve them first. For instance, if your clinicians are using mobile devices to acquire PHI, and you have no policy or procedures to assure secure access to PHI data using mobile technologies like smartphones and tablets, that weakness will pose a very high priority gap for your organization.

The basic elements of any plan require that you identify the actions needed to accomplish project tasks, ie. define and document a policy, develop and document procedures, develop an implementation schedule, develop and deliver a training plan, etc.. The remediation plan should indicate the specific individual who is assigned responsibility for each task, and include an estimate of the time it will take to accomplish the task, so that progress can be measured. Regardless of size, most companies must also budget for projects like IT system penetration testing or vulnerability scans.

Plans of action are only temporarily static. Technology changes rapidly, practices expand or relocate, and hundreds of other changes impact the scope of risks to your practice. For this reason, the HIPAA Rule requires routine reexamination of your organization, which invariably leads to a revision of your risk remediation plan. Your risk remediation plan is one of the cogs in the wheel of an ongoing risk management program.

Tuesday, August 5, 2014


By Cheryl Pierce, OT, CLT-LANA with HealthSouth Lakeshore

Lymphedema is an abnormal accumulation of fluid in the interstitial tissue space that is caused by a number of reasons. Primary lymphedema is a condition that people are born with that develops either at birth or can show up later in life. Secondary lymphedema is caused by a disruption in the lymphatic system, commonly due to cancer, resulting in an extremity or area of the body to swell.

Lymphedema is treated through CDT (Complete Decongestive Therapy), which includes a number of treatment approaches such as lymphedema massage, known as manual lymphatic drainage (MLD), multi-layered compression bandaging, skin care and exercise. A patient will participate in CDT for 2-3 weeks to obtain edema reduction, and then be fit in an appropriate compression garment for daytime and possibly a nighttime garment as well. It is very important that the lymphedema patient also learns how to do self-massage and self-bandaging so that the patient can continue the CDT protocol long-term.

Lymphedema is a condition that can progressively worsen left untreated and cause other medical concerns such as infection, skin issues and orthopedic problems due to the weight of an extremity. It is important that a person with lymphedema seek treatment with a therapist that is a Certified Lymphedema Therapist and ideally LANA(Lymphology Association of North America) certified as well to ensure the most up-to-date treatment and knowledge for their lymphedema condition.

Be Careful What You Read

By: Dr.Gregory Bourgeois with Shelby Dermatology

There has been a lot of buzz regarding sunscreen shared in social media with an obviously mixed message. As a dermatologist, I recommend sun protection habits beyond sunscreen including hats, sunglasses, sun protective clothing, avoidance of peak hours during summer, and seeking shade when possible. I do this because we know that UV exposure adds up over the years and can lead to skin cancers such as basal cell carcinoma, squamous cell carcinoma, and, to some extent, melanoma. Chronic sun exposure also leads to photoaging – the wrinkles and dark brown spots and skin texture changes that patients often seek help to correct.

The following articles were shared with me by friends and colleagues. I’d like to examine them individually.

Spray sunscreens are a novel idea for sunscreen application. They make sense: it takes a ton of time to apply sunscreen so just spray it on. Many companies have come out with their version, and many consumers are buying them for their convenience. But, to be truthful, we really don’t know how well these work in the hands of the typical consumer. Many dermatologists are leery of their use because they feel that patients will not spray enough sunscreen on their skin to get the actual sun protection labeled, so they recommend spraying on hands first then applying. Also, perhaps the aerosol spraying of chemicals is harmful when inhaled, particularly the nanoparticles mentioned in the article. For now these have not been studied enough, so avoid use on children and stay tuned.

The article in the Daily Mail UK shows a glaring headline that sunscreen may NOT prevent skin cancer. Read on and you’ll find that they are speaking of melanoma in particular (why didn’t they just say ‘melanoma’ in the headline? A bit misleading to use the blanket generalization of ‘skin cancer’). They do summarize a recent article in the journal Nature that studied the use of sunscreen in preventing development of melanoma in mice that have the BRAF mutation, a mutation found in many melanomas. These sunscreen-protected mutant mice developed melanoma after exposure to ultraviolet radiation (albeit development of melanoma occurred at a smaller percentage and later than those BRAF mutant mice exposed to ultraviolet radiation that did not have any sunscreen protection). Although it has been studied many times with various results, there is still no solid evidence that melanoma is prevented by regular sunscreen use. It makes sense intuitively since many melanomas occur in patients with chronic sun exposure and history of blistering sunburns, but perhaps it is only risk reduction of melanoma with regular use of sunscreen. I think this Nature article drives home the point that sunscreen is only part of the protection strategy (remember the hats, the clothing, the sunglasses, the shade, avoiding peak hours).

The last article on opens with this line “…women who avoid sunbathing during the summer are twice as likely to die as those who sunbathe every day.” This bold statement should have anyone at least questioning the validity of it. They quote a study from the Melanoma in Southern Sweden cohort published recently in the Journal of Internal Medicine. The cohort was composed of light-skinned Caucasian females in an area of the world with low UV due to latitude. This environmental geography is where a chronic low Vitamin D level could be an issue in leading to all-cause mortality. But one can’t deduce from this Swedish study the further accusations found in this article:

The link between melanoma and sun exposure (dermatology’s dogma) is unproven. There’s no conclusive evidence that sunburns lead to cancer. There is no real proof that sunscreens protect against melanoma. There’s no proof that increased exposure to the sun increases the risk of melanoma.

For a great rebuttal see

The bottom line is that sunscreen works but is not perfect. It should be used as part of a strategy for skin cancer prevention, along with the aforementioned apparel, seeking shade, and avoiding peak sun hours. As always, visit a dermatologist to screen for skin cancer or to evaluate any suspicious appearing skin lesions.

Monday, August 4, 2014

What’s in my lung?

by: Karl Schroeder MD
Pulmonary/Critical Care Physician Pulmonary Associates of the Southeast PC

After the discovery of a pulmonary nodule, the first question a patient asks is, ‘what is a pulmonary nodule?’ This is actually a hard question to answer. The simple answer is a nodule is a lump of tissue in the lung that is less than 3 cm seen on a radiographic study. If it is larger than 3 cm, then it is classified as a lung mass. This usually leads to their next question, ‘what caused it?’. This question is actually much harder to answer and probably the most frustrating to both the physician and the patient.

A pulmonary nodule can represent many things with most of them being benign. These include cancer (both metastic lesions and primary lung cancer), granulomas, harmartomas, and chondromas, among others.

All of these reasons are important but most of these are benign lesions. It is very important to rule out cancer from any source as the cause of the nodule. Lung cancer, like breast, colon, and other types of cancer, is very important to diagnosis at its earliest stage possible. Lung cancer remains the leading cause of death by cancer in both men and women. This is because the overwhelming majority of lung cancer cases are discovered as either stage 3 or stage 4. When discovered at these stages, they are usually not respectable and carry a low survival rate. Stage 3 and 4 has survival rate of 15% at 5 years where as stage 1 and 2 has a 92% survival rate at 5 years. Unfortunately, pulmonary nodules are usually asymptomatic or produce common symptoms like cough, chest congestion. It is not till it becomes much larger that it produces symptoms that prompt investigation like hemoptysis, weight loss and chest pain.

Therefore, the strategy to monitor these small lumps of tissue is to catch them at the earliest stage IF THEY ARE CANCER. Most of these nodules are benign. There are some common strategies used to monitor the nodules. The most common is to get repeated CT scans to monitor for changes in size. These CT scans are usually at 3-6 month intervals. If the nodules grow, then the nodule should either be biopsied or resected. Unfortunately, over that same timeframe, some of these nodules will grow significantly or even metastasis to a distant site. These events can change the diagnosis from a potentially curable disease to a disease that can only be managed.

Because of this, new techniques and technology is being developed to biopsy these nodules even at a small size. Electromagnetic Navigational Bronchoscopy (ENB) is one of these techniques. ENB allows physicians to biopsy lung nodules at small sizes (greater than 6 mm). This allows patients and physicians to know what actually caused the nodule. Most nodules less than 10mm will not show up on PET scan imaging. ENB has increased the yield of trans bronchial biopsy from 20-30% to 70-90%. If non-diagnostic, then the nodules should still be monitored with serial CT scans.

Most recently, there is a study that tried to identify nodules early-- even before they become symptomatic. These studies focused on screening people who smoked for a significant amount of time (30 pack years), are between the ages of 55-74, and they quit smoking less than 15 years prior. The study showed that by screening these people with a yearly CT scan, the mortality from lung cancer could be decreased. Unfortunately, most insurance companies are not paying for screening lung CTs.

With this in mind, there are some facilities in the United States that are utilizing nodule clinics, lung cancer screening programs, and ENB to significantly increase the number of stage 1 and 2 lung cancer in the populations they access. Trinity Hospital and Pulmonary Associates of Southeast are working together to implement this type of program in Birmingham to help affect an earlier stage which lung cancer is diagnosed.