Intensive Feeding Program

By: Dr. Michelle Mastin is a clinical psychologist and head of the new Intensive Feeding Program at Children’s of Alabama.


A new Intensive Feeding Program at Children’s of Alabama helps infants, toddlers and adolescents overcome problems feeding and drinking often associated with developmental delays or serious illness. It is the first and only program of its kind in Alabama and one of only a handful of similar programs in the U.S.


The program incorporates pediatric subspecialists, technologies and behavioral psychology into a unique and effective system for teaching both parents and children how to deal with these difficult issues. The program at Children’s is designed in a similar fashion to the one developed at Helen DeVos Children’s Hospital in Grand Rapids, Mich.


The program at Children’s of Alabama is the behavioral psychology component of the new Aerodigestive Program, which encompasses a larger mission of managing complex airway, feeding or nutritional issues. Program specialists evaluate children, develop treatment plans and provide care for a wide variety of conditions using proven, behavior modification techniques coupled with the insight and interventions of speech and language pathologists and occupational therapists.


About half of the program’s patients are expected to be feeding-tube dependent, and in many cases the team will work to normalize the child’s eating and drinking abilities. The Intensive Feeding Program is also capable of dealing with:

• Food refusal

• Oral aversion

• Inability to consume adequate volumes of food and liquid

• Transitioning to age-appropriate textures, consistencies or utensils

• Recurrent vomiting

• Restricted eating patterns


Patients should be referred to the program at Children’s after going through previous attempts to improve their feeding and drinking behaviors. The program is set up to handle tougher, more persistent cases that require multi-disciplined interventions and are often associated with conditions such as gastric esophageal reflux disease, failure to thrive, dysphagia, gastrointestinal problems, developmental disorders, including those on the autism spectrum and behavioral difficulties.


This is an intensive, outpatient program lasting six to eight weeks, five days a week, from 8 a.m. until 5 p.m. Generally, experts will spend about four weeks feeding a child all meals during the week in order to approach identified goals. Care is provided in a room equipped for unobtrusive observation by parents, other caregivers or health professionals.


After that, parents or caregivers will be provided with a small earphone and sent into the treatment room to take over the feeding and drinking interventions. Initially they will be working with their child with the help of therapists. As the caregivers progress and the child demonstrates consistent success, therapists will transition to the observation rooms where they can continue to coach caregivers. It is an effective way to improve the interaction between parents and children at mealtimes.


The results are often impressive. For example, the program at Children’s had its first graduate of the day treatment program in November 2014. This patient was born with significant complex medical challenges, including significant prematurity (born at 22 weeks gestation). The patient came into the program 100 percent dependent upon a feeding tube for nutrition, but was discharged 8 weeks later without the need for G-tube feedings.


Similar programs have been studied and found to be effective. This is a precisely targeted therapy that often succeeds in improving the quality of life for both the child and family. Children’s program is currently evaluating patients weekly and is currently admitting two patients at a time into day treatment. The goal is to expand the program to be able to treat three patients at a time in the second year of the program and four patients at a time in the third year. Referrals forms for evaluation can be found on the Children’s website at www.childrensal.org or by calling 205-638-7590.

Fuse - The Newest and Most Advanced Technology in Colonoscopes

by Kenneth M. Sigman, M.D. Birmingham Gastroenterology Assoc., PC Chief of Gastroenterology - Trinity Medical Center


Colonoscopy has proven its worth over the past 40 or more years. It is clearly the best test for screening for colon cancer and detecting and removing pre-cancerous polyps. Multiple longitudinal studies have confirmed that removing these polyps significantly reduces the incidence of colon cancer. Colonoscopes, and their imaging qualities, have improved remarkably over that time to the current high definition images showing very fine detail of the colonic mucosa. Despite these technologic improvements, a significant percentage of lesions are not seen and are missed - even in the best and most careful examiner’s hands - because haustral folds and turns or flexures create blind spots for these lesions.


A newly designed colonoscope has been developed to improve the field of view and remove some of these blind spots. The standard forward viewing colonoscope (FVC) has one lens with a field of view of 140-170 degrees. The new Fuse colonoscope, full spectrum endoscopy (FSE) produced by the Endochoice company, has three lenses that provide a 330 degree field of view allowing an image of significantly more of the colonic surface, reducing blind spots. This should translate into more complete exams detecting more pre-cancerous polyps (adenomas) as well as smaller, cancerous lesions that may be missed by the FVC. Studies comparing the two types of colonoscopes have shown a significantly lower adenoma miss rate for FSE when compared to FVC. A recent multicenter randomized study, published in the Lancet, showed an adenoma miss rate of 41% for standard FVC vs 7% for FSE. Although more data is needed, these early results are very promising.


The Fuse FSE has been in commercial production for about a year. Several institutions in the US have adopted this technology. Trinity Medical Center in Birmingham is the only hospital in the state of Alabama to offer this advanced method of colonoscopy.


The gastroenterologists of Birmingham Gastroenterology Associates, in association with Trinity Medical Center, continue to be on the forefront of technological advances in GI medicine and offer the most advanced care for their patients. Patients can be scheduled for FSE colonoscopy or any other GI testing by contacting Trinity Medical Center GI Lab or Birmingham Gastroenterology offices.

The Silent but Blinding Disease…

By: Shilpa Register, OD, MS, PhD, FAAO, FNAP Associate Professor UAB School of Optometry

UAB Eye Care is the clinical operation for the UAB School of Optometry, an integral part of the UAB Medical Center. Here, UAB optometrists and ophthalmologists who specialize in eye disease provide comprehensive care to the Birmingham and surrounding area. Our goal is to promote healthy habits and prevent the loss of vision from sight threatening eye diseases such as glaucoma. As part of this goal, we wanted to take a few minutes of your time to inform you of the symptoms and treatment for glaucoma since January is National Glaucoma Awareness month.


Glaucoma affects over 2.2 million people, but only 50% of them are aware that they have glaucoma. If left untreated, glaucoma will lead to blindness making it the 2nd leading cause of blindness in the world. We want this to change!


Glaucoma comes in many forms but most are marked with high eye pressures and subsequent damage to the optic nerve and vision loss. Because there is no pain, irritation, redness, or other noticeable symptom, it is extremely important that all adults obtain comprehensive eye exams from their optometrist on an annual basis. Most people do not notice any vision changes until a substantial portion of their vision has been lost. Any vision loss cannot be regained. The American Optometric Association recommends the following schedule for preventative dilated eye exams:


Table 1

Patient Age                     Risk-Free                                      At-Risk

Birth to 24 months          At 6 months of age                         At 6 months of age or as
                                                                                                recommended

2-5 years                         At 3 years of age                             At 3 years of age or as
                                                                                                recommended

6-18 years                       Before 1st grade and                       Annually or as
                                        every 2 years thereafter                   recommended
                                   

18-40 years                     Every 2 years                                   Every 1-2 years or as
                                                                                                 recommended

41-60 years                     Every 2 years                                   Every 1-2 years or as
                                                                                                 recommended

61 or older                       Annually                                          Annually or as recommended


Glaucoma is a silent disease that affects people of all ages with older adults being at the highest risk. Those individuals who are at-risk for certain types of glaucoma include older individuals, African Americans, Asians, and Latinos. Those patients with a positive family history of glaucoma are at higher risk for glaucoma. Most people do not know that diseases that affect your body also increase their risk of glaucoma including the presence of diabetes, poor perfusion or the presence of vasospasms. During the annual eye exam, optometrists can identify additional ocular risk factors such as high or asymmetric intraocular pressures, optic nerve enlargement, optic nerve asymmetry, high myopia, thin central corneal thickness, and visual field defects that could be indicative of glaucoma.


Optometrists will perform necessary tests to diagnose and monitor glaucoma. He or she may prescribe eye drops or recommend surgical intervention to stabilize the eye pressures and reduce further ocular damage.



What can you do to help your patients? 

• Follow the AOA guidelines and recommend comprehensive dilated eye exams. 
• Recommend that any patients with diabetes, poor perfusion, or vasospasm obtain a comprehensive dilated eye exam. 
• Encourage your glaucoma patients to follow the treatment and follow up recommendations.

To contact UAB Eye Care for referrals and/or consultations, please call (205) 975-2020. We accept most vision and medical insurance plans.

Baptist Health System Signs Letter of Intent with Tenet Healthcare

Baptist Health System today announced that it has signed an exclusive, non-binding Letter of Intent (LOI) with a subsidiary of Tenet Healthcare Corporation, the parent company of Brookwood Medical Center, to form a new, jointly-owned company that will include all Baptist Health System hospitals, Brookwood Medical Center, and their related businesses. The parties have initiated an exploratory period of due diligence, which is intended to result in a definitive agreement. 

The new company would unite Baptist Health System’s four hospitals -- Citizens Baptist Medical Center, Princeton Baptist Medical Center, Shelby Baptist Medical Center and Walker Baptist Medical Center -- with Tenet’s Brookwood Medical Center. Together, the new system would have more than 1,700 licensed beds and include 77 primary and specialty care clinics, approximately 7,300 employees and approximately 1,500 affiliated physicians.

The partnership would build upon the strengths of both Baptist Health System and Brookwood Medical Center, and give the expanded healthcare network access to a sustainable source of capital and the possibility of significant investments in new equipment, facility upgrades and strategic initiatives in the future, creating meaningful opportunities for innovations in care delivery.

“We are excited to engage in an exclusive dialogue about developing a joint venture with Tenet Healthcare,” said Keith Parrott, CEO of Baptist Health System. “A primary reason to enter into a partnership with Tenet is its track record partnering with and growing faith-based institutions and allowing them to continue operating with a faith-based mission and focus. At the same time, Tenet can offer resources such as sustainable access to capital, a strong history of operating well-run hospitals and access to its existing purchasing contracts. This potential partnership represents an opportunity to strengthen our collective efforts and enhance healthcare across central Alabama while preserving and honoring the Baptist name, maintaining our Christian values, and supporting our faith-based approach to healthcare.” 

“Tenet sees great benefit in a partnership with Baptist Health System’s dedicated group of health professionals,” said Garry Gause, chief executive officer, Southern Region at Tenet Healthcare. “This proposed partnership offers the opportunity to improve healthcare delivery to communities throughout central Alabama while preserving the remarkable legacies of Baptist Health System and Brookwood Medical Center. The new organization will enable our institutions to better navigate the changing landscape of healthcare today, and to meet the growing demands for quality care in Alabama tomorrow.” 

Once a final definitive agreement is reached, the new joint venture could be formed as early as next spring. The parties do not plan to provide additional details until such time as a definitive agreement is reached. 

Bariatric Surgery – How one decision can change your life

By: Sue Bunnell, RN and manager of the Comprehensive Bariatric Center at Princeton Baptist Medical Center


As a former weight loss patient, I know first-hand the impact that excess weight can have on a person’s life. Eleven years ago, I found myself at 293 pounds and made a decision that has truly changed my life. I decided to take action and find out more about bariatric surgery.


I remember when my oldest son was a Cub Scout – all I wanted was to be active in his life and participate in the fun scheduled outings. Because of my weight, however, my capacity was greatly limited and both my son and I missed out on the trips.


According to the Centers of Disease Control (CDC), obesity affects approximately 78 million Americans – with Alabama’s obesity rate at 32.4 percent. In addition, the disease is linked to more than 40 other life-threatening conditions, including type 2 diabetes, heart disease, stroke, osteoarthritis and even cancer.


If you are one of the millions who are overweight, I know where you are and I know what you are facing. Looking back, I remember the fear of losing my life and happiness to the disease and also the fear of taking the first step to freedom.


The Comprehensive Bariatric Center at Princeton Baptist Medical Center is dedicated to delivering personalized, cutting-edge services to improve the health and quality of life for our patients. Everything from our individualized program to the design of our facility was created with patient experience in mind.


Recently, our Center was designated as an Optum™ Center of Excellence, indicating that the Center meets or exceeds nationally recognized standards of care. Since opening nearly two years ago, our team of specialist have focused on providing the highest quality bariatric program in the Southeast.


When you visit our Center for the first time, you will notice something different. It’s the size-appropriate chairs that are placed from the valet parking to the patient rooms, the wider halls, the bimonthly support group, the lifelong free follow-up care, the gym that can accommodate 450 pounds and is wheel-chair accessible and the large auditorium for our training and weekly educational classes that truly sets us apart from any other facility in the region.


Our board-certified surgeons are specialized in minimally invasive surgeries, including Roux-en-Y Gastric Bypass (RYGB); Adjustable Gastric Band (AGB); and Gastric Sleeve (GS). In addition to surgical options, we also offer a medical weight-management program, educational sessions, nutritional and exercise counseling, support groups, cooking classes and recovery programs.


If you are struggling with your weight like I was 11 years ago, I would encourage you to schedule a tour or a seminar to find out more about how our services can help you. It has made all the difference in my life – I’m now 145 pounds healthier – and that’s something I am proud to share.



For more information, please visit our website: http://princetonbariatrics.com/  

Eye Care for the Underserved

By: Katherine A. Clore, O.D., Associate Professor UAB School of Optometry

As a Doctor of Optometry and Associate Professor at the University of Alabama at Birmingham School of Optometry, I find many rewards in my profession. From providing primary patient care and preparing future optometrists for a professional career, to research and community service, all aspects of the profession are exceptionally satisfying. However, recently the School of Optometry provided a community outreach program named "Gift of Sight," which gave me a special sense of fulfillment.


The first-time program is a mobile extension of UABSO's Eye Care Clinic whose goal is to provide eye care to those who might not otherwise be able to afford comprehensive eye exams. A comprehensive dilated eye exam can reveal ocular diseases as well as ocular manifestations of systemic diseases. If other care is needed, patients are referred for appropriate treatment throughout the health care community.


According to BB Jefferson, Clinic Coordinator at UAB's School of Optometry Community Eye Care, over 200 patients were seen for complete dilated eye exams. In addition, they were offered donated gift items such as hats, gloves, socks, scarves and blankets. The interns were excited about helping others as well as being able to diagnose and treat various conditions! A quote from one of those who helped helped, with tears running down her face said “I haven’t had a Christmas like this since I was a little girl.” It is always gratifying to treat a patient and have a successful outcome, but it is especially rewarding with patients who likely would not have the opportunity to receive treatment otherwise.


A 2011 study of over 11,000 adults by the CDC found that almost 40% who were considered to have moderate to severe visual impairment said they had skipped seeking care in the past year because of cost or lack of insurance.


In a study conducted in 2007 by the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, they concluded that approximately 5 million high-risk adults in the United States could not afford eyeglasses when needed; being female, having low income, not having insurance, and having vision or eye problems were each associated with such inability.


The "Gift of Sight" to these people is especially precious and The UAB School of Optometry is proud to provide services to those who might not have access otherwise through its year-round Community Eye Care program.


Community Eye Care is an outreach program from UAB Eye Care to the community. Vision screenings are provided at many area schools during the fall. There are also vision screenings at many senior centers and health fairs. Comprehensive eye care is provided at several health department clinics in Jefferson County, such as Bessemer (Bessemer Health Center), North Birmingham (Northern Health Center) and Ensley (Western Health Center). The Community Eye Care Service also provides comprehensive vision services for the adult clients at United Cerebral Palsy of Birmingham (LincPoint).


Community Eye Care also partners with various campus entities to provide services in underserved populations in the Black Belt and for the homeless in the Greater Birmingham area. As collaborators with the Friends of the Congressional Glaucoma Caucus Foundation, mutual goals of disease identification and patient education are met as well.


In describing the program, Dr. Felton Perry, Director of Community Eye Care, is quoted as saying, "It's our way of giving back... We owe it to the community."


The need for vision care is great and Community Eye Care is always exploring other opportunities to serve the community, either through screenings, examinations or education.



If you have an opportunity that you would like to explore with Community Eye Care, contact UAB Eye Care at (205) 975-2020, and leave your contact information with the operator. Someone in the Community Eye Care Service will return your call.

A LOOK AT LEG VEIN PROBLEMS AND TREATMENTS

By: Dr. Robert E. Foster _ Director, BHC Vein Center

The Birmingham Heart Clinic Vein Center diagnoses and treats venous disease with minimally invasive procedures, resulting in less pain and quicker recovery for patients. Our goal is to quickly return patients back to a functional, painless lifestyle.



What is venous disease? About 40 million Americans suffer needlessly from venous disease which occurs in approximately 25 percent of women and 15 percent of men. Unfortunately, only 3 percent of those with venous disease have sought or received treatment that could distinctly improve their lifestyle. Venous disease occurs when diseased or abnormal veins cause blood to flow backwards in the veins of the leg. This causes stretching of the veins as well as leg swelling, pain and ultimately leg wound formation.


What are spider and varicose veins? One of the most common visible signs of venous disease is spider veins which appear as small, purplish or blue clusters of veins on the leg. Varicose veins are larger bluish veins which may be painful due to engorgement when standing or sitting. Spider veins typically do not cause discomfort but if they do become painful, it is important to meet with a physician who is qualified in the diagnosis and treatment of venous disease. Although spider and varicose veins may be unsightly, many patients do not realize that these are outward signs of an underlying serious condition in the deeper vein system which, if not treated, may lead to increased risk for blood clots, swelling, skin color changes and ulceration.


What are the symptoms of venous disease? Venous disease may not present itself until leg pain or skin problems emerge. Venous disease symptoms may include the following:

• Swelling or heaviness in the legs (especially in the evening)

• Leg pain or cramping

• Visible varicose or spider veins

• Discoloration of the skin

• Dry and weeping eczema

• Leg ulcers

• Restless legs


What if venous disease is left untreated? Venous disease can progressively worsen over time due to pressure created by the backflow of blood in the legs. This may lead to additional spider and varicose veins, and in some cases, it may lead to swelling and venous ulcers in the lower calf and ankle. If left untreated, venous disease can markedly affect quality of life by reducing the patient’s ability to sleep, walk or sit/stand for long periods of time due to severe symptoms of the legs. Even if only spider veins are present, you should consult a vein specialist to determine the problem so that it can be treated.


What venous services are offered at the BHC Vein Center?

• Consultation with a vein specialist. Our vein team consists of vein specialists certified by the American Board of Venous and Lymphatic Medicine. They will evaluate you closely to assess the diagnostic and treatment procedures that are the best for your specialized needs.

• Radiofrequency ablation. This minimally-invasive procedure is performed in the office using radiofrequency energy to apply heat to the vein through a thin catheter. This essentially “welds” the vein closed to prevent its ability to reflux.

• Endovascular laser therapy. This is similar to ablation in that a thin catheter is inserted into the vein, but instead it uses a laser fiber to heat the vein wall.

• Sclerotherapy. This is an effective treatment for both spider and varicose veins. A medication (sclerosant) is injected into the affected vein causing it to shrink. Most patients require a series of treatments.

• Phlebectomy. This procedure involves the removal of large visible varicose veins through small punctures in the skin.



If you think you may have venous disease, call the BHC Vein Clinic for a consultation at 205-856-2284 or visit www.birminghamheart.com

It’s the Holidays, Can we Talk?

By: Craig Greer, Director of Special Programs at Comfort Care Home Health and Hospice


The holidays are upon us. It’s a time for family and friends, sharing memories and bonding in the midst of celebrations and gifts. But the greatest gift loved ones can provide and receive is peace of mind. How can we provide another with peace of mind - by talking about life and healthcare choices.


Stephen Covey, author of Seven Habits for Highly Effective People talks about beginning with the end in mind. For each of us, our lives will eventually end in death. Not a happy thought, but a true fact that we cannot deny. Somehow we avoid discussing this reality until there is a crisis.


As a chaplain, I have held hands with family members and heard the same sad theme time and time again. “I know what I would want, but I don’t know what mom would want,” as they agonize over difficult decisions about ventilators, feeding tubes, palliative care or hospice. No matter the decision in these situations, there is no peace of mind.


The time to talk about end-of-life care options is when we are healthy. To do so after a diagnosis is more difficult because of the fear and anxiety. This doesn’t mean it is easy to have this conversation, but it is easier after topic has been introduced and there has been talk about the types of care a loved one prefers. Certainly we may change our minds when a diagnosis occurs, but the fact that there has been discussion makes it easier to revisit our decisions and modify as necessary.


Important decisions for those 19 years old or older can be achieved by pondering the following questions: Who would speak for you if you could not speak for yourself? What types of care would you want to receive if there was less than a five percent chance of meaningful recovery? What does meaningful recovery mean to you? It is critical to have this discussion with your healthcare proxy, so he/she will understand the responsibility involved.


The next phase is discussing options if you have a chronic or debilitating disease. It is important to fully comprehend the diagnosis and how the disease might progress over time. For example Congestive Heart Failure and pulmonary diseases typically don’t improve - these conditions worsen over time and often require frequent hospitalizations. Likewise cancer treatments can cause many side effects that may be intolerable. At what point is it enough? How would you want to live your life? Where would you want to receive care? There are options and you do have choices.


There is no right or wrong answer. It is crucial for all of us to reflect on our values and beliefs in order to come up with a plan and we should talk with all of our loved ones in order to make our wishes known. How can loved ones honor healthcare decisions when they don’t know what those decisions are?


We think of this primarily as a legal issue, but it is also a conversation issue. We must have the talk with our loved ones and then put our wishes down in writing as a last step.


For the past two years Comfort Care Hospice has worked to promote this conversation in our communities for people of all ages. There are many great grass-roots programs to help people navigate this difficult topic. For a list of resources visit our website http://comfortcarehospice.com/advance-care-planning/.



If you would like more information about our community events or to have someone to talk to your group, please contact cgreer@comfortcarehospice.org

LSVT LOUD (Lee Silverman Voice Therapy)

By: Sonya L. Pearson, PT, DPT  _ LSVT BIG Certified Clinician at HealthSouth Lakeshore Outpatient Therapy


LSVT BIG is an evidenced based neurorehabilitation treatment program originally designed to treat the motor impairments related to Parkinson's Disease and evolved from the efficacious speech treatment LSVT LOUD (Lee Silverman Voice Therapy).

The primary manifestations of Parkinson's Disease include bradykinesia (slowness of movement) and hypokinesia (decreased amplitude or range of movement). Individuals with Parkinson's Disease often report that they move slower, have greater difficulty getting dressed, write smaller and are often asked to 'speak up', all of which can be attributed to the effects of bradykinesia and hypokinesia.


The basic principles of LSVT BIG are directly aimed at increasing the amplitude of movement during everyday activities. The four basic principles of LSVT BIG include high effort, progressive movements, continuous activity and motivation. The delivery and administration of this innovative Physical and Occupational therapy is a hallmark feature of LSVT BIG. The program schedule includes 16 individual therapy sessions, delivered four days a week over the course of four consecutive weeks.

During a typical one hour LSVT BIG session participants will perform highly repetitious exercises, which include whole body movements, functional component tasks and BIG walking trials. In addition to the high frequency of delivery participants perform LSVT BIG carryover exercises and homework practice one to two times a day while away from therapy during the course of their treatment. This high level of intensity and frequency assists in increasing the amplitude and speed of movement in their everyday lives.

Participants may experience the following improvements:
Faster walking with bigger steps
Improved balance
Increased trunk rotation
Improved confidence
Restored Hope


Although LSVT BIG was originally designed to treat motor impairments related to Parkinson's Disease, it has since been successfully used to treat other neurological diseases and injuries including: Stroke, Brain Injury and Multiple Sclerosis.



For more information on LSVT BIG, please contact HealthSouth Lakeshore Outpatient Therapy at 205-868-2290.

Saving Lives: One Person At A Time

Bibb Allen, Jr., MD FACR Diagnostic Radiologist Trinity Medical Center


About 450 Americans die every day from lung cancer. Lung cancer kills more of us than any other type of cancer – 160,000 people every year – more than breast, colorectal, prostate and pancreas cancers combined! But we know that if we can catch lung cancer in its earliest stages, it can be cured. The problem has always been how to find it early because for the vast majority, by the time lung cancer causes symptoms, it is already in an advanced stage and much more difficult to treat.


Well that’s about to change. We now have a tool that will actually save lives in lung cancer patients by detecting the disease in its earliest stages. Recent scientific studies show we can lower the overall mortality of lung cancer by 20% through early detection of the disease in high-risk individuals. Tobacco use continues to be the highest risk factor for lung cancer, and by targeting this group of individuals for early detection, we can save 50 lives a day. A study sponsored by the National Cancer Institute and the National Institutes of Health conclusively demonstrates that screening for lung cancer in high-risk individuals with low dose computed tomography would save lives – ten to twenty thousand lives – each and every year. Early detection through screening high-risk patients will save more lives than the decades of work we have spent on new ways of treating lung cancer.


Who should be screened? Current or former smokers who smoked a pack of cigarettes per day for 30 years or more are considered at high risk for lung cancer. Our veterans, rescue workers, firefighters and construction workers are unfortunately over-represented in this group and make up a significant portion of our population in Alabama. Even former smokers who have quit smoking in the last 15 years remain at risk and should be screened as well. So beginning at 55, these individuals should be screened for cancer every year until they are 80. This is the recommendation of the United States Preventative Services Task Force and because of this recommendation insurance carriers are required by the Affordable Care Act to provide coverage and we expect this to happen beginning in 2015 or even sooner.


How does screening work? Lung cancer screening is easy. We use standard computed tomography (CT) equipment, and the CT scan takes less than 10 seconds to perform – no medicines, no needles. Although the CT scan uses x-rays to look at the lungs, the examination is considered very safe. We use the lowest possible amount of radiation for satisfactory examination, and it is an amount similar to that used for a routine screening mammogram. Considering the overwhelming benefits, risk of radiation exposure should not deter high-risk patients from being screened.


How good is screening? When an early lung cancer is detected, patients have a 93% chance of being cured, and while that’s exciting news, no test, including CT screening for lung cancer is perfect. Sometimes patients can have a cancer or other medical condition that will not be detected by the screening examination. Sometimes, the screening examination detects an abnormality that could be cancer but is not. In order to make sure these findings are not cancer, patients may need to have some follow-up tests that will only be performed after consultation with he patient. Most times this may be short interval follow-up CT scan to make sure a likely benign finding is not changing. Sometimes, more invasive procedures are required to determine a diagnosis including bronchoscopy and/or biopsy. Finally, in 5 to 10% of cases the screening CT examination may detect abnormalities in areas of the body adjacent to the lungs including the kidneys, adrenal glands, liver or thyroid. These findings may not be serious, but sometimes need to be examined further.


Overall, about 1 out of 4 lung screening exams will find something in the lung that may require additional imaging or evaluation, and most times these findings are lung nodules. Lung nodules* are very small collections of tissue in the lung that are quite common, and almost always – 97% of the time – they are not cancer. Most are small areas of scarring from past infections. But less commonly, lung nodules are cancer. If a small lung nodule is found to be cancer, the cancer can be cured in the vast majority of cases. But to distinguish the large number of noncancerous nodules from the few nodules that are in fact cancer, we may need to get more images before the next yearly screening exam usually in about six months. If the nodule has suspicious features (for example, it is large, has an odd shape or grows over time), patients are referred to a specialist for further testing.


At Trinity Medical Center, we have put together a Lung Cancer Screening Program that is dedicated to saving lives of people with lung cancer in Alabama. Our program is a multi-specialty effort between radiology, pulmonary medicine, medical and radiation oncology, thoracic surgery and primary care. We offer all of our enrollees a smoking cessation counseling to help them stop smoking. Our equipment specifications and protocols exceed all of the minimum standards for lung cancer screening, and our personnel are trained and highly qualified to perform and interpret the examinations. We have a structured reporting system that ensures appropriate and standardized management and multi-specialty follow-up of nodules and other abnormalities detected in the examination.


As a radiologist, who for years has seen mostly advanced lung cancers, it is an exciting time to finally be able to help the people of our state by offering a way to make a dent in mortality from our country’s largest cancer killer. My hope is that the folks in our state will take advantage of this opportunity to beat lung cancer.



*For more information on Lung Nodules see September 2014 blog by Dr. Karl Schroeder, Pulmonologist.

Objectivity in Communication

By Jane Mock, Risk Management Specialist NORCAL Group


There is no doubt that physicians have a lot on their plates. Regular challenges include providing quality care to each patient within a fully booked schedule; keeping up with medical record documentation; learning new systems; maintaining current awareness of regulations and laws; and navigating reimbursement issues. In addition, physicians spend a great deal of time educating patients and managing expectations for treatment, yet they still encounter the non-compliant, demanding or dissatisfied patient.

These circumstances can create a charged environment. Add into the mix a disagreement with a colleague, an unanticipated outcome in patient care, or a notice of a lawsuit, and the environment gets even hotter. Many providers have rushed to confess their shortcomings or criticize a colleague’s care (which can appear to be self-serving), only to learn later that the outcome was unrelated to the care given or, in the case of criticizing a colleague, that there were additional factors that influenced treatment choices. In the tense environment after an adverse outcome, providers may say things to patients or document opinions in the chart that are not objective and do not serve to promote patient care.


Sometimes a subsequent treating physician (knowingly or unknowingly) acts as a trigger for the filing of a lawsuit when he or she makes a remark to the patient that is critical of a prior physician’s care. In addition to a physician verbalizing his or her subjective opinion to the patient, similar comments expressed in the medical record do not meet the patient’s clinical needs. Some physicians have actually found themselves pulled into the litigation process when they make remarks to a patient about another provider’s care, only to learn that there is an active suit in progress. The following scenario shows how disparaging remarks can help a plaintiff’s case that is already underway.


A surgeon performed an angioplasty and stenting on a 55 year-old male patient who had suffered an acute myocardial infarction. One week later, the patient experienced a pulmonary embolism and a chest infection. He also developed an aortic aneurysm. He was then treated at a clinic over a two-week period. The physicians at the clinic were able to resolve the chest infection with a drain, but did not address the aortic aneurysm. Following the patient’s clinic stay, he returned to the surgeon, who performed a second procedure to address the aortic aneurysm. Because the patient had enjoyed a good rapport with the physicians at the clinic, he decided to see them for follow-up care. During one of these visits, his primary treating physician told him that he was “lucky to be alive” because the surgeon clearly did not perform the first procedure properly. The physician documented this conversation in the medical record. Unbeknownst to the physician, the patient and his family had recently filed a claim against the surgeon, alleging negligence resulting in his poor post-surgical course and need for additional surgery.


In addition to speaking negatively about another provider’s care and documenting those comments, this physician—who did not know that the patient was entering into litigation with the surgeon—was soon subpoenaed for deposition by the patient’s attorney.


A physician’s ability to respond appropriately to patient care situations involving other providers is crucial. Expressing oneself objectively in both written and oral communication is key to promoting continued patient care and, if applicable, defense of a malpractice claim.


Risk Management Recommendations

Communicating with the Patient

• Contact your professional liability carrier’s risk management department for assistance with communicating with patients.
• If the patient asks you to comment on the treatment or role of other healthcare providers, only comment on your own care and interaction with the patient.
• When conveying to the patient and family what is known about an unanticipated outcome, avoid speculation and blaming anyone.
• If a patient asks a specific question about an unanticipated outcome, and the cause is not yet known, an honest answer might be, “I don’t know” or “I don’t know yet.”

Communicating with a Colleague

• Access your clinical quality committee or medical director/medical staff leadership, as appropriate, for assistance with handling concerns regarding clinical patient care provided or with patient inquiries regarding a physician’s care provided.
• Review the patient’s record, previous studies, etc., to prepare for the discussion. The better prepared you are with the facts, the more likely you are to maintain a cool head; conversely, plunging into a conversation with little information and a lot of emotion pulls attention away from proper patient care and management of the event.
• Find a quiet place to have a discussion; this demonstrates respect for the work environment and also protects patient confidentiality.
• Discuss disagreements about care objectively; ask for clarification.

Documenting in the Medical Record

• Document in a timely fashion.
• Focus your chart documentation on your care of the patient.
• Document discrepancies using objective language.
• If addressing the contents of comparison reports, prepare a formal, written report for all studies that includes review of previous reports and, if indicated, comparison of previous images when possible. State if previous reports and images are not available and any attempts to obtain them.

• DO NOT:

o Blame or disparage other providers or the patient in the chart
o Offer personal (other than medical) opinions o Speculate on causes of poor outcomes
o Make observations, notes or entries unrelated to patient care
o Make derogatory statements or use language that blames another healthcare provider (e.g., “error,” “mistake in judgment”)
o Engage in professional disputes in the chart
o Include references to incident reports, legal actions, and attorney or risk management activities in the medical record (These should be maintained in a separate, confidential file.)

In the Event of a Claim or a Potential Claim

• Never alter the medical record in any way.
• If you are involved in an adverse or unanticipated outcome, contact your professional liability carrier’s claims department to report the medical incident. An experienced claims professional can guide you through the process of how to communicate with your carrier and defense attorney, as well as how to document appropriately.

Does Your Banker Make House Calls?

By: Maggie Tanner – Vice President of Private Banking, HeritageBank of the South; Wife of (non-traditional) 3rd year Medical Student at UASOM


Would you compare your banking relationship to a trip to the Emergency Room or a House Call with your Internist at a concierge practice? The ER banking experience is one in which a major event is transpiring and financing is needed by close of business yesterday. It’s bloody, chaotic and high stakes. Regular office hours are over, so you are stuck. You have no idea what banker will be “on call”, which location you should direct the ambulance to, and if the institution still goes by the same name. Will they take your form of payment? You find yourself in a painful, frantic scramble of paperwork, waiting and frustration. When you finally hear your name called, you have to explain your situation and your history. Your records with your other specialists will have to be faxed on Monday. You quickly realize that this is not the experience you were seeking, things will fall through the cracks and your opportunity may be lost.


On the flip side, you have the cell phone number of your Internist. You are contemplating a major financial decision. She knows you were on call last night and all day, so your concierge banker arranges to meet you at home. She brings your file with her. Comprehensive care is the standard because she knows your attorney, your CPA, and your financial planner by name. She is already up to speed on your records. You spend the next couple hours in a strategy session with tangible, customized solutions, perfect for your unique situation. The ideas fit within the framework of your comprehensive financial plan, other specialists are in the loop, and your stress level is low. The opportunity is captured and objectives are maintained.


Unfortunately for many busy physicians, they don’t have their banker’s cell phone number and their banker doesn’t know their name. They treat their banking relationship like an uninsured trip to an emergency room chosen at random. With a good Private Banker, it is possible to have a banking experience that much more closely resembles concierge medicine where house calls are the norm. All aspects of a banking relationship, commercial and personal, are handled with one single point of contact who is engaged with other professional partners for cohesive, comprehensive financial care. In many cases, physicians and their practices are so closely intertwined that the banker needs to know all financial aspects of both.


When choosing a banker, look for a Private Banker who is accessible, flexible, creative and proactive. Choose one who seeks to deliver comprehensive care on an ongoing basis. Choose to have the concierge experience with house calls.

Sleepy Heads

By: Kelli Tapley M.D. _ Physician at Birmingham Pediatric Associates


While we encourage our adolescent patients to get enough sleep, we are aware that few are actually getting the recommended 8.5-9.5 hours each night. Results from a National Sleep Foundation poll showed that as many as 59% of 6th-8th-graders and 87% of high school students in U.S. get less than the recommended amount of sleep on school nights and the average amount of school-night sleep obtained by high school seniors is fewer than 7 hours. However, 71% of parents believed that their teen was getting sufficient sleep.


For the first time the American Academy of Pediatrics has weighed in on the topic of adolescent sleep. In August the AAP issued a policy statement on school start times, urging middle schools and high schools to “begin classes no earlier than 8:30 am”, citing research showing the “average teenager in today's society has difficulty falling asleep before 11 p.m. and is best suited to wake up at 8 a.m. or later.”


But why is it happening and why weigh in now? Is it simply that they have too much to do before going to sleep (i.e. homework and after school activities)? Or is it due to electronic devices (i.e. iphone, ipad, TV) in their bedrooms?


Yes, to all of the above but there’s more going on here. Hormonal changes in adolescents result in a delay in the secretion of nocturnal melatonin causing a decrease in “sleep drive.” Additionally, there is potential link between screen time and disruption of circadian rhythm. Caffeine also plays a role in shorter sleep duration, increased wake time after sleep onset and increased daytime sleepiness.


The effects of sleep insufficiency are long lasting and potentially fatal. Restricted sleep has been found to increase risk of car crashes, delinquent behavior, depression, and difficulty maintaining focus and attention, and obesity.


While there are schools in the US that currently delay starting their day until after 0830, most do not. The Center for Applied Research and Educational Improvement, citing a study done in Minnesota in which school districts delayed start times for 9-12 grades until 0830, reported higher GPAs, significant increase in attendance rates as well as graduation rates, statistically less depression, as well as fewer school counselor visits for emotional problems and psycho somatic complaints. Not to be understated, 92% of their parents reported they were “easier to live with.”


The problem won’t be resolved simply by delayed school start times. The AAP also suggests Pediatricians make sleep part of their well-child care visits with adolescents by educating parents and young people on how much sleep they need on a regular basis and that extra sleep on weekends and caffeine use are not substitutes for regular sufficient sleep. Parents should set bedtimes and enforce a “media curfew.”



  For more information on the UM study http://www.cehd.umn.edu/carei/sleepresources.html

What Do the Recent Election Mean For Healthcare

By: Bill Cockrell with Cockrell and Associates, LLC


The fact that the Senate will now be under Republican leadership means there are a lot of thoughts about what will happen with the Affordable Care Act (ACA or “Obamacare”). This includes questions ranging from Medicaid enrollment to incentives (federal and by payer) to the elimination of the entire program all together. While there a good and bad parts of the program, there are many parts to the bigger picture. Here are some thoughts on that.


Overall – While the ACA is viewed to be a major thorn in the sides of providers, and many individuals, here are just a few elements to consider.


The House and Senate are both now in the hands of Republicans but that does not give them the freedom to do what they want. The President still has veto power and the Republicans did not receive enough seats, unless some Democrats cross over, to eliminate the program altogether.

Many people, millions, did receive healthcare coverage they did not have before. Rather they were without insurance because of individual cost, the lack of employer support or other reasons, they did see benefits which will be hard to take away.

The role of mandates, subsidies and taxes on certain healthcare items are those where the most change will occur.

Medicaid expansion, in most states, has too much steam to change, again, because of coverage being expanded to more individuals. What Alabama will do remains to be seen but don’t be surprised to see some expansion here at some point.

Bottom line, expect some fine tuning, some of it significant, but don’t expect the ACA to go away.


Meaningful Use and EHR Incentives – These were not part of the ACA. They had their beginnings before the ACA and were not part of it. Again, some fine tuning will occur along with additional delays (this will not require congressional legislation), but this will remain part of our healthcare environment.

Payers – With little of these individual program’s (Medicare Advantage plans, etc.) elements driven by government regulations, the process of restricted networks and individual incentive plans, will continue. From the Alabama BCBS Value Based Program and other incentive plans introduced by other providers, to Medicare’s, and other provider’s annual risk assessments as part of their Medicare Advantage plans. Expect further expansion. These are in place to control costs and will continue.

Medical Homes, ACO’s, and other special programs – Again, not driven by the ACA, these programs will continue to expand. There is evidence to support their value although the market itself (financial issues) may restrict the growth of ACO’s. Indeed, an SGR fix (see below) may hasten them.

Alabama Medicaid and Regional Care Organizations (RCO’s) in Alabama are coming and, with success seen in Oregon, one of the models the Alabama ACO’s are based on, they will occur. What potential Medicaid expansion and the difficulties in managing the many elements involved, this will be something providers.

The SGR fix – The Sustainable Growth Rate program for Medicare predates many of the above programs and will not be impacted by any changes in their programs. Last year proposed fix, driven by a combined Republican / Democrat (rare as it is) agreement, pushed more to reducing annual fee adjustments to increasing the role of Alternative Payment Models. This pushes more on the Pay for Performance program models (Medical Homes, shared savings, episode of care reimbursement, etc.) and we can expect more of this. A bright side will be combining many of the existing programs (PQRS, ePrescibe, etc.) into a consolidated model. This fix will occur, again with some possible modifications, with the question being whether or not a lame duck Congress finish what they started, or will it be delayed again until after the new Congress steps in.

ICD-10 – Expect this to finally occur in 2015. There have been many delays but a lot of money has been spent by system vendors and providers to prepare for this. The detail provided by enhanced coding plays well in many of the above programs.

Hepatitis C 101 - What you need to know

By: Rishi K. Agarwal, MD with Birmingham Gastroenterology Associates


What is hepatitis? Hepatitis is a general term for inflammation of the liver, which can occur from a number of different sources including toxins, medications, heavy alcohol use, and viruses. Hepatitis C (HCV) is the most common viral hepatitis in the US with an estimated 3.2 million individuals with chronic HCV. There are an estimated 17,000 new cases of HCV per year.


 Hepatitis C is classically known as a chronic disease, though there is a phase of acute HCV which occurs during the first 6 months of exposure. In the vast majority of cases this acute phase will lead to chronic hepatitis C. Why is the chronicity of this disease so important? It is because until recently, hepatitis C was considered a lifelong illness, and one of the leading causes of cirrhosis and liver cancer. Different patient populations are considered to be at high risk for hepatitis C. Those are namely current or former injection drug users, recipients of blood transfusions or solid organ transplants prior to 1992, chronic hemodialysis patients, persons with known exposure to HCV (healthcare works after needle sticks with HCV-positive blood), persons with HIV, and children born to HCV-positive mothers. Hepatitis C can be transmitted sexually but the risk is significantly lower compared to those listed above.


Given how common hepatitis C is in our population, the next obvious question is: "what symptoms should we be looking for?" That is a bit more challenging since approximately 70-80% of patients with acute hepatitis C, and a large percentage of patients with chronic hepatitis C, do not have any symptoms. For acute hepatitis C, some patients may have mild to severe symptoms including fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, joint pain, and jaundice. For chronic hepatitis C, the majority of patients will not have symptoms until they begin to have liver damage, even in the setting of normal liver function tests. With this being said, asymptomatic patients can still spread the virus to other individuals.


Chronic hepatitis C is a serious disease than can lead to long-term health problems. Of every 100 people infected with hepatitis C, 75-85 people will develop chronic hepatitis C. Of those, 60-70 people will go on to develop chronic liver disease, 5-20 will go on to develop cirrhosis over a 20-30 year period, and 1-5 people will die from cirrhosis or liver cancer. With this data, approximately 15,000 people die every year from hepatitis C related liver disease.


Because HCV infection is frequently asymptomatic, screening patients who may have an increased likelihood of being infected with HCV is an important step toward improving the detection and ultimately the treatment of infected individuals. Screening for HCV generally focuses on testing those who have an individual risk factor for exposure, who have evidence of liver disease, and who belong to certain demographic groups that have a high-prevalence of infection-including individuals born in the United States between 1945 and 1965. Several organizations have provided guidelines for who should be tested/screened for HCV infection.


Screening is performed initially via a hepatitis C antibody test. A positive antibody test is followed by an RNA test. If positive, it is important to discern the genotype, as treatment regimens are tailored to the genotype the patient has. It is important to avoid alcohol if diagnosed with hepatitis C, as alcohol and hepatitis C can have a synergistic effect on disease progression. Vaccinations are very important as well, thus patients should be vaccinated against hepatitis A and B, as well as against the flu (once a year), pneumonia (at least once), diphtheria and tetanus (once every 10 years) and pertussis (once during adulthood).


Treatment for hepatitis C has come a long way from where we started. Approximately 20% of patients with hepatitis C will spontaneously clear the virus; however the remaining 80% of patients will be looking for treatment options. In the early days, our options were limited, typically committing patients to 2-drug (and even 3-drug) therapy from anywhere between 6 and 12 months with the primary medications being interferon and ribavirin. In some cases, we were only able to offer successful treatment ~50% of the time. These medications were noted to have multiple side effects ranging from anemia, to fatigue, to depression, which decreased compliance. Over the last few years great strides have been made in the treatment of hepatitis C, to the point that depending on the genotype, we can potentially offer non-interferon treatment regimens (i.e. an all-oral regimen) and have a near 90% chance of clearing the virus – thus providing not only treatment but a cure.


In summary, hepatitis C is a global health problem that can progress to cirrhosis and end stage liver disease in a substantial proportion of patients. Screening can play a major role in identifying patients and ultimately treating them with ever-evolving and improving therapies.

OA? NO WAY!

By: Dr. Ryan Cordry, DO, MBA Orthopaedic Surgery at Medical West


For just about everyone, our body is our main mode of transportation. Whether if you are physically active exercising several times a week, if you walk to work, or just going back and forth from the kitchen to the couch - it takes your body moving to get there. And that involves all those bones inside rotating around, rubbing on each other, and stabilizing your body. Your joints are where all this happens.


I want to bring to your attention a common disorder called osteoarthritis (OA). It develops from aging and prolonged or extreme activity on a joint. It typically appears in the hips, knees, shoulders, and spine - all places that bear weight and stress.


First, know that OA is a normal occurrence of aging, and the symptoms usually begin showing up around middle age. And if you are 70 years old or older - I would be pretty positive that you are showing at least some symptoms of OA. Also people who have a family history, are obese, or have suffered trauma also see increased risk of OA.


What are symptoms of OA?

1) Pain in the joints. Especially after exercise or when putting weight/pressure on the joint.

2) Stiffness in your joints, and they have become difficult to move. Perhaps you could begin noticing rubbing, cracking, or scraping sounds when you move the joint.

3) "Morning Stiffness" - for almost 30 minutes after you wake up, all those joints are stiff and you have difficulty or pain getting around. After some activity, it goes away. (You've 'warmed up' the joint.)

4) Joint pain wakes you up at night. While OA is a normal occurrence as we age, it is possible to both expedite the onset of OA and to reduce the effects of OA. And you guessed it - it has a lot to do with your lifestyle choices.


Offsetting OA:

1) I mentioned above about how your body is your main mode of transportation. Some of us have bigger bodies than others. And some of us have bodies that are too big for our personal frames. Preventing obesity will help prevent osteoarthritis. Which makes sense, right? The less inactive weight you carry around with you is still pressing down on those joints. The ratio goes at 1 lb of body weight = 5 lbs on the hip/knee joints.

2) Exercising. Some light impact exercises such as cycling, swimming, elliptical machines, and walking can decrease stress on your joints. (Remember, at its core, it's the joint stress that causes OA.)

3) You can control the symptoms of OA by keeping the arthritic joint mobile and strengthen the muscle around it. Give that hurting joint a little bit of help - it will probably reward you with less pain. For OA treatment, it's best to discuss with your personal doctor. They can help you best get a plan that works you individually.


OA Treatments Include:

1) Ice/heat the afflicted area

2) Compression

3) Just resting the joint

4) Changing your activities (do a different exercise, stop going down to the paint and banging around during your church league basketball game…)

5) Braces can assist with joint relief and provide stability

6) Medications can be prescribed

7) Physical therapy

8) Injections

9) Surgery. Joint replacement is an option for severe cases.


For just about all of us, OA is something we are going to have to deal with at some point. But do what you can in order to lessen the effects of it. Staying healthy, avoiding excess weight, and making smart decisions when it comes to your activities can help you live a more pain-free life.


Take Care, Dr. Cordry

HIPAA Compliance: Never a Final Word

By: Susan Pretnar, President, KeySys Health, LLC


How is it possible that when new guidance is issued from CMS around the Meaningful Use core objective to conduct a security risk analysis, the message ends up muddled? On Oct 6, 2014, CMS issued a new FAQ on their web site to respond to a question that states:

How can a provider meet the “Protect Electronic Health Information” core objective in the       Electronic Health Records (EHR) Incentive Programs?

The first sentence of the response seems clear enough (emphasis added):

To meet the “Protect Electronic Health Information” core objective for Stage 1, eligible professionals (EP), eligible hospitals or critical access hospitals (CAH) must conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1) and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process.


However, the next paragraph is truly a puzzler:

In Stage 2, in addition to meeting the same security risk analysis requirements as Stage 1, EPs and hospitals will also need to address the encryption and security of data stored in the certified EHR technology (CEHRT).


One has to wonder how the ‘certified’ EHR technology got certified in the first place if it had weaknesses in how it handled encryption and security of the data stored in its databases. Or, why isn’t your ‘uncertified’ PACs system, unencrypted emails and text messages, of greater concern than software that was supposed to be ‘certified’? Why does CMS single out only the EHR systems, when the HIPAA Security Rule does not? But, I digress.


Further down the FAQ comes the following statement, which in my limited experience, has been taken to heart by those who are actually conducting the audits of HIPAA compliance and Meaningful Use attestations:

This meaningful use objective complements, but does not impose new or expanded requirements on the HIPAA Security Rule.


What does this mean? If you are complying with 45 CFR 164.308(a)(1) you have done a comprehensive job of assessing or reviewing the policies and procedures that constitute your ‘risk management process’, analyzing any gaps in your program against the HIPAA requirements in 45 CFR, and you’ve established a risk remediation plan that assures you are closing known vulnerabilities.

CMS concedes that ‘Once the risk analysis is completed, providers must take any additional “reasonable and appropriate” steps to reduce identified risks to reasonable and appropriate levels.’ This statement is the crux of what is required of CEs and their Business Associates.

If CMS is not imposing new or expanded requirements on the HIPAA Security Rule, then it must accept that a new ‘risk analysis’ need not be conducted in every year of attestation as long as the ongoing risk management process includes review of policies, procedures and plans, not just annually, but whenever significant changes are made to technology, facilities or staff that impact ePHI in particular.

If you have attested to Meaningful Use and accepted incentive payments, but you have not implemented a security risk management process, or, you have never conducted a security risk assessment and have no documented plan to remediate gaps in your security posture, perhaps it is time to secure expert legal advise.

The risk of audit is not the compelling reason to implement a risk management program, however, any more than averting a lawsuit is the sole purpose of conducting clinical risk reviews. The business of healthcare requires ‘doing no harm’, by keeping patients safe, including their protected health information. The financial and reputational impact of failing either task can be significant.

For various reasons, a large number of healthcare entities and their business associates feel no compunction about shelving efforts to identify their risks and securely manage their data and information systems. It’s as if that effort, unlike their other business activities, can be suspended without impact.

Carotid Stenosis and Stroke - "Once upon a time".

By: Gary S Roubin MD PhD with Cardiovascular Associates, a Brookwood Medical Partner.


There are many “once upon a time” stories in medicine! The extraordinary development of science and technology in cardiovascular medicine has dramatically changed the way life-threatening diseases are treated. We rightly call the recommendations and treatment guidelines, based on rigorous scientific studies and expert consensus opinion, “ Best Practice”. And they are constantly changing! “Once upon a time” – 2 to 3 decades ago, rigorous studies showed that a surgical operation to remove blockages in the neck arteries feeding blood to the brain was effective in preventing stroke.


Then some 20 years ago pioneering work at the University of Alabama at Birmingham provided physicians with a considerably less invasive method of treating the blockages, a procedure that became known as carotid stenting. In 2010 the Federal National Institute of Neurological Diseases and Stroke (NINDS) completed a major 2500 patient, prospective multicenter study comparing Surgery and Stenting. This trial confirmed that these two procedures were equally safe and effective in preventing stroke from carotid stenosis - albeit stenting is done without an operation.


But time and medical science march on! And over the last 20 years we have also seen incredible advances in the medications used to treat this condition. Cholesterol lowering drugs that stabilize the blockages, antiplatelet drugs that prevent blood clot in the blockages and blood pressure medicines that all effectively reduce the risk of stroke. We have also made great strides in reducing tobacco use, managing diabetes, and improving our diet and exercise patterns all of which are known to reduce stroke.


So now physicians have not 2 but 3 options to manage carotid disease in patients with significant blockage but who are quite asymptomatic. (Patients who have specific neurologic symptoms are still best treated with surgery or stenting). Some experts in the field are convinced that surgery and stenting are unnecessary, potentially harmful and unnecessarily costly. Other experts fervently disagree! An expert panel at the NINDS has examined all the available evidence and concluded that given the advances in medicine, stenting and surgery this important question needs to be resolved in a rigorous scientific study. They have commissioned the CREST2 Trial that will begin enrolling patients in the coming months.


All patients in this study will receive the best medical therapy available including advice on medication compliance and risk factor management. Depending on a variety of now well-established factors that determine if a patient is best suited for stenting or surgery; half of the group will be treated with either one of these therapies in addition to the medication program. All treatment strategies will carry a very low risk of a stroke occurring and accordingly patients will be followed with stringent care for a minimum of 4 years. Patients in Alabama are fortunate to have centers participating in this important trial and access to physicians with vast experience in treating carotid disease.





Gary S Roubin MD PhD practices cardiovascular medicine with Cardiovascular Associates, a Brookwood Medical Partner. He is recognized as an international expert in the procedure of carotid stenting and is the lead stenting investigator in the NINDS CREST2 trial. Visit cvapc.com for more information or call (205) 510-5000 to refer a patient.

Fighting the Flu!

by Tracy Jacobs, MD with Family Medicine Trinity Medical Clinics – Chelsea


Once again it is flu season in Alabama. To avoid being one of the 1 million people hospitalized annually for this potentially deadly virus, protect yourself with one of the following options:

1. The seasonal flu vaccination. This is the typical yearly "flu shot" that one can get at most pharmacies, primary care and urgent care offices. It can protect against 3 or 4 strains of the flu. If you have had a life-threatening reaction to a flu shot in the past, have had Guillain-Barre Syndrome, or have an egg allergy, talk to your doctor before getting a flu shot. This is approved for everyone 6 months of age and older.

2. The nasal spray vaccination. This is approved for children aged two to adults aged 49. This is a weakened live virus vaccine and those on long term aspirin, allergic to eggs or pregnant females should avoid the nasal spray. Patients with a history of Guillain-Barre Syndrome or immunosuppressed patients should talk to their doctor before getting the nasal vaccine. Children, ages 2 to 4, who have recently taken influenza antiviral medications or have a history of wheezing or asthma, should avoid the nasal vaccination. Despite all of the warnings, there are recent data to suggest that in children ages 2 to 8, the nasal vaccine prevented 50% more cases of the flu than the flu shot. Children, who get immunized against the flu for the first time, will need two doses of either method (nasal spray or shot) at least 28 days apart.

3. Recombinant flu vaccination. This shot is for people, ages 18 to 49, who have had a severe allergic reaction to eggs. This injection is usually administered by a physician with experience in severe allergic conditions. There are fewer doses of this vaccination and the cost is significantly more, so discuss this option with your physician.

4. High dose flu vaccination. This is specifically designed to protect people ages 65 and older who may have a weaker immune system. By giving the individual four times the dose a more robust response is expected. The high dose vaccination has been shown to be 24.2% more effective as compared to the regular flu vaccine. As with all flu vaccines, this is not recommended for those who have had a severe reaction to flu vaccine in the past.

5. Intradermal vaccination. This shot uses a much smaller needle and is injected into the skin instead of muscle. This is indicated for those individuals ages 18 to 64 and has the same precautions as the regular flu vaccination.


The flu vaccine cannot cause the flu! However, one can get a headache, mild body ache and malaise after being vaccinated. This usually lasts only a day or two and is much less severe than the flu. If you feel like you may have the flu, call your doctor’s office. In the meantime, stay hydrated, use acetaminophen or ibuprofen as needed for fevers, and get plenty of rest. Good hand hygiene and wearing a mask if symptoms appear will help prevent spreading the flu to your family and coworkers.

What is low vision rehabilitation?

By: Lynne Stevens, O.D., F.A.A.O. Low Vision Optometrist at the UAB Center for Low Vision Rehabilitation


Most of us have family members or know someone who is affected by macular degeneration, glaucoma, or another type of sight-threatening condition. We are lucky to have wonderful optometrists and ophthalmologists here in Birmingham that can treat and manage a wide range of eye conditions. However, having a diagnosis and proper medical treatment often should not be the end of the management of the patient. Even with the best treatments many still have functional difficulties with everyday life activities such as reading, watching television, and driving.


Low vision rehabilitation is not exclusive to only individuals with reduced visual acuities. It also includes those with visual field loss, such as in someone who is 20/20 but has a field cut secondary to a stroke. So there is no criteria to be classified as having low vision. Low vision rehabilitation is for anyone having functional difficulties related to their vision.


There is a vast array of magnifiers and adaptive devices that are available to help patients with their functional difficulties. They range from basic handheld magnifiers to electronic types of magnifiers. Optometrists specialized in low vision rehabilitation can evaluate and prescribe the appropriate amount of magnification and types of devices based on the patient’s goals for rehabilitation. Often times simple modifications to lighting, computer settings, or activities of daily living can make a big impact on one’s daily functioning. Low vision certified occupational therapists can train patients how to implement these modifications and magnifiers into their lives.


There are also resources available throughout the community which can benefit someone with low vision. There are audiobooks, free directory assistance, and cell phone data exemption plans just as a few examples. Alabama Department of Rehabilitation Services offers programs and services to those with disabilities within their homes, schools, workplace, and communities.


Low vision rehabilitation can be instrumental in helping someone see better to manage their diabetes or other medications, which in essence, could help prevent further vision loss. It can also help someone cope with and adapt to their vision loss. If you, a patient, or someone you know is frustrated with their vision despite the receiving the optimal medical treatments consider low vision rehabilitation.

#UABeyecare

The HIPAA Risk Assessment

By: Phyllis Drummond, Risk Management Specialist NORCAL Mutual Meaningful use.


The Affordable Care Act. Laws and regulations continue to mount as clinical and administrative mandates multiply. Most recently, the Department of Health and Human Services (DHHS) unveiled additional requirements to existing HIPAA Privacy and Security Rules. Within this regulatory environment, it is important that providers are able to create and follow processes for investigation of possible breaches, and that they develop a breach notification policy.


In order to facilitate compliance with the HIPAA Security Rule, the DHHS has supplied education and assessment resources for covered entities. These can be found in various locations, including the DHHS website: http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/securityruleguidance.html (accessed 3/4/14)

Guidance on preparing for, and conducting a risk assessment can be found at: http://www.healthit.gov/providers-professionals/security-risk-assessment


The HIPAA Privacy Risk Assessment

In the broadest sense, the risk assessment is an evaluation of the potential risks associated with how an organization collects, manages, uses and discloses its protected health information (PHI). Gap analysis refers to evaluating the organization's information-handling practices in light of the requirements of HIPAA, as well as identifying gaps between current and required practices . Covered entities are required by the HIPAA Security Rule to complete a risk assessment and to create a HIPAA Security Rule Risk Management Program based on their findings.


Conducting an analysis helps covered entities identify potential weaknesses in their privacy and security practices that can subject them to breaches in patient confidentiality or invasions of privacy. Gaps in systems and processes can lead to unintended release of PHI, loss of vital data, or inappropriate alteration of data. Finding these gaps and addressing them will help mitigate liability risk for patient confidentiality breaches, as well as assure that the organization is maintaining compliance with HIPAA and HITECH regulations. Avoidance of increasing fines associated with many breaches is also top of mind when addressing gaps.


Covered entities may choose to conduct their own risk assessment. They know their systems and processes best and usually have the in-house expertise and experience to conduct such an assessment. One individual, such as the Compliance Officer, the Chief Information Officer (CIO), or the Information Technology (IT) Director, can do this. A team approach, often found to be more comprehensive, may include the organization's Risk Manager. It may also include department heads such as directors of Health Information Management, Pharmacy and Lab Services, Clinic or Practice Manager, and/or other key personnel whose responsibilities include managing patient information.

Covered entities may wish to hire a professional with expertise in laws and regulations pertaining to privacy and security practices. This will ensure an objective point of view and will add insight not readily available within a covered entity. Many consultants and vendors can be found with a simple online search. The covered entity might conduct a HIPAA-specific analysis, primarily to meet the analysis requirements, or may wish to take a broader approach and also assess the organization's vulnerability and system weaknesses not addressed by HIPAA requirements.


According to the American Health Information Management Association (AHIMA), some of the goals for an information management assessment (HIPAA and broader) may include: 

• Identify all areas of noncompliance with HIPAA requirements (technical, procedural, training, administrative, etc.—This is known as gap analysis) 
• Evaluate weaknesses that have led to past breaches of confidentiality, as documented through claims, lawsuits, occurrence or incident reports, and patient and family complaints or concerns 
• Identify computerized and paper-based health information system vulnerabilities beyond the scope of HIPAA; e.g. licensing violations, cultural factors predisposing the system to problems, etc.
• Establish an up-to-date inventory of all hardware and software resources 
• Map the internal and external flow of protected health information

More information may be found at the AHIMA website: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok2_001416.hcsp?dDocName=bok2_001416 , (accessed 3/4/14)


AHIMA recommends evaluating various approaches to the privacy and security risk assessment, and determining what is likely to work best in your organization. Numerous web-based resources are provided in the article referenced above. These resources include sample checklists and tools for conducting an internal privacy risk assessment.

The Department of Health and Human Services website offers a 7-part series on HIPAA Security, beginning with a primer on HIPAA security for covered entities. The series includes detailed information on administrative, physical and technical safeguards. It also stipulates requirements for organizational policies and procedures related to privacy and security, as well as an entire chapter on the basics of risk analysis and risk management. These resources can be found at: http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/securityruleguidance.html

A variety of sample assessment tools can also be found at the following resources:

• ECRI Healthcare Risk Control: https://www.ecri.org/hrc

• HealthIT.gov: http://www.healthit.gov/providers-professionals/security-risk-assessment-tool

How Can NORCAL Mutual support your practice’s ability to manage risk in the areas of privacy and security?


We can offer advice to policyholders on practices or policies that may impact the security of their patients' protected health information.


In the event of a possible breach, NORCAL Mutual can provide assistance on how best to handle the situation, as well as information regarding the prevention of future breaches.


Cyber Liability: Reminder

NORCAL Mutual provides cyber liability coverage. For details on this coverage, contact NORCAL Mutual or your agent/broker. To discuss risk management concerns regarding privacy and/or security, call our Risk Management department at 855.882.3412 To report a potential breach, call our Claims department at 844.4NORCAL

To discuss risk management concerns regarding privacy and/or security, call our Risk Management department at 855.882.3412

To report a potential breach, call our Claims department at 844.4NORCAL  

Copyright 2014 NORCAL Mutual Insurance Company. All rights reserved. This material is intended for reproduction in the publications of NORCAL-approved producers and sponsoring medical societies that have been granted prior written permission. No part of this publication may be otherwise reproduced, edited or modified without the prior written permission of NORCAL. For permission requests, contact: Jo Townson at (855)882-3412, ext. 2270.

 

The information contained in this document is intended as risk management advice. It does not constitute a legal opinion, nor is it a substitute for legal advice. Legal inquiries about topics covered in this document should be directed to an attorney. Recommendations contained in this document are not intended to determine the standard of care, but are provided as risk management advice. Recommendations presented should not be considered inclusive of all appropriate risk management strategies or exclusive of other strategies reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the individual physician/healthcare provider in light of the individual circumstances presented by the patient.