Staying Sober During the Holidays

By: Terry and Sherry Pouncey, with ARCpoint Labs of Birmingham at Greystone


The holidays can be one of the most difficult times during the year to stay sober. For some, it’s the excess of food and drink and merriment. Attending parties and being surrounded by people eating and drinking to their heart’s content can make staying sober difficult, as no one wants to be left out of the party. And of course, there’s the stress of planning for the holidays, cooking the food, hosting a family gathering, and being forced to spend time with those family members that you may normally try to avoid. All that stress can make it tempting to use just one little drink to relax. Unfortunately, that one little drink tends to turn into two, and then three, and even more. These tips will help you stay strong and stay sober this holiday season.

Plan Non-Alcoholic Drinks Ahead of Time

If attending a holiday meal or other holiday party where most of the other adults will be drinking alcohol, make sure to bring your own non-alcoholic alternative beverage. Rather than just drinking water, consider bringing something that you enjoy drinking, whether that’s Diet Coke, non-alcoholic apple cider, or juice. Bring some sparkling grape juice for a more festive drink that you can even slip into a wine glass to feel more included in the holiday toast. Being prepared with a tasty alternative will give you something to sip on while others are downing glass after glass of wine.

Connect with a Support Group

As the holidays approach, it may be a good idea to connect with a sober support group, if you don’t already have one. Before entering any kind of high-risk situation, like a holiday party, attending a support meeting or talking with a sponsor or mentor will help give the support and resolve you’ll need to help you stay sober.

Recruit a Sober Buddy

Invite a sober friend to attend the Thanksgiving meal or holiday party with you, or ask a close family member to help you by remaining sober with you. Having someone by your side who you can trust to remain sober with you can be an enormous help. It’s much less tempting to drink if a friend is not drinking and that friend can also keep an eye on you to help keep you from slipping up.


ARCpoint Labs provides drug and alcohol testing to promote a sober and healthy workplace. Find the nearest ARCpoint Labslocation today.

Can Esophageal Cancer Be Prevented?

By: Brian A. Brunson, M.D., Gastroenterology Associates of North-Central Alabama, P.C.


Esophageal adenocarcinoma, or cancer of the lower portion of the esophagus, is one of fastest growing cancers in our country over the last several decades, with the number of new diagnoses growing six-fold from 1975-2001. It carries a poor prognosis, with a 17% five year survival once diagnosed. A condition known as Barrett’s Esophagus (BE) is the primary risk factor for the development of esophageal adenocarcinoma. Up to 1.3% of the general population is affected by BE, although this number is higher in patients seen in a typical gastroenterology practice (up to 5-10%). Barrett’s esophagus is thought to result from prolonged acid exposure in the esophagus, leading to replacement of the normal lining (squamous epithelium) with a specialized lining called intestinal metaplasia. Gastroesophageal reflux disease (GERD), therefore, is the primary disorder that puts a person at risk for BE. It’s most common symptom is heartburn which affects up to 10% of the population on a daily basis and up to 44% of the population on a monthly basis.

While there are no definitive recommendations for screening, most gastroenterologists will perform an upper endoscopy, or EGD, in patients over age 50 who have a history of GERD. This allows direct visualization of the lining of the esophagus and biopsies if there is suspicion for Barrett’s. Multiple studies have suggested that the risk is highest in males over the age of 55 who are overweight or obese. It is not clear, though, if we should screen patients with acid reflux who don’t meet those criteria, although this is still routinely done. Once Barrett’s Esophagus is confirmed by a pathologist, the gastroenterologist is then faced with the decision on how often to repeat the endoscopy to assess for progression towards cancer.

The progression of Barrett’s esophagus to cancer occurs in a stepwise fashion. Reflux of acid, bile, or other intestinal contents into the esophagus results in injury to the esophageal lining. This then leads to inflammation and, in some cases, transformation (metaplasia) into a specialized intestinal lining. In some patients, this will continue to progress to dysplasia, which is a change in the cells of the lining that is much more likely to lead to cancer. Many factors determine which patients develop this higher risk change, including ongoing inflammation and genetics. Treatment of the acid reflux with a class of medicines called proton pump inhibitors (PPIs) does decrease the risk of progression to cancer, but does not completely eliminate it. Therefore, once BE is diagnosed, patients are placed in a standardized protocol for follow up endoscopies and biopsies. After the initial diagnosis, a repeat endoscopy with biopsies is typically performed one year later. If no dysplasia is found at that time, then a surveillance exam is performed every 3 years. Unfortunately, studies have not shown surveillance to be very good at preventing cancer formation, particularly in patients who have dysplasia which is much more likely to turn into cancer.

Surgically removing the esophagus previously was the only true preventative option in patients at high risk for cancer. This surgery carries significant risks and typically requires a prolonged recovery and long-term dietary modifications. Thankfully new techniques to actually treat and eliminate Barrett’s Esophagus have been developed over the last decade. Initial therapies using a laser or a technique called photodynamic therapy brought mixed results and a high risk of complications such as stricture formation.

Newer therapies developed and tested over the last five years include radiofrequency ablation (or RFA) and cryotherapy ablation. Ablation is a technique where tissue is heated or frozen until it is no longer alive. RFA (or the “Halo” procedure) has become the most widely utilized technique in our country and can be performed by gastroenterologists or surgeons with a special interest and training in this field. This procedure is performed during a standard upper GI endoscopy. Special balloon catheters can be used to treat or “ablate” large circumferential segments of Barrett’s tissue. Smaller focal areas can be treated with a catheter with electrodes mounted onto the tip of the endoscope. Clinical trials have shown that RFA completely eliminates the dysplastic or pre-cancerous tissue in greater than 90% of patients at average followup of 2.5 to 3 years. A followup study showed this response persisted out to 5 years in 92% of patients. Depending on the length of the Barrett’s segment, it usually takes at least 2-3 treatment sessions to completely eliminate the abnormal area.

RFA is now recommended by all the major endoscopy and gastroenterology societies for the treatment of all patients with Barrett’s and high grade dysplasia, and in patients with low grade dysplasia confirmed by 2 expert pathologists. Some patients with long segments of Barrett’s tissue without dysplasia may also be candidates, especially young patients (under age 40) or those with a family history of esophageal cancer. The risks of the procedure are very low; less than 1% cumulative risk of developing esophageal strictures and less than 1/1000 risk of perforating the esophagus during the procedure.

In summary, heartburn and gastroesophageal reflux can put you at risk for Barrett’s Esophagus and esophageal cancer. Therefore it is recommended that all patients with symptoms of reflux be evaluated by a gastroenterologist to assess the risk of Barrett’s and need for endoscopy. New low risk, non-invasive and highly effective therapies have been developed to treat and eliminate the pre-cancerous Barrett’s tissue and prevent progression to esophageal cancer.

A Dose of Our Own Medicine – Exercise During the Holidays

By: Ricardo E. Colberg, M.D., Andrews Sports Medicine and Orthopaedic Center


As healthcare professionals, all of us know the importance of a healthy diet, staying physically active and getting a restful night’s sleep. On a daily basis, we treat many patients with chronic medical conditions that are a direct result of a sedentary lifestyle.

Even though we continually remind our patients about the need to make better lifestyle choices, we too are human and struggle with the same temptations. With the holidays, cooler months, and shorter days, the need to practice what we preach increases exponentially; otherwise, we become patients too. The American Heart Association recommends that we perform 30 minutes of exercise, five times a week, all year long. If you are having a hard time getting motivated to exercise during the winter months, here are your MUST READ reasons and recommendations.


“Why Should I Work Out?”

1. It is Easier to Keep Weight Off Than to Try Losing It

With the colder weather, our basal metabolic rate decreases, which means our bodies build fat easier. Staying physically active during the colder months keeps our metabolic rate elevated, allowing us to enjoy our holiday feasts without the guilt of packing on a few pounds. Considering that it takes one week to lose one pound of excess weight, it is easier to keep weight off than to gain weight during the winter and try losing it in the summer.

2. We are More Productive When We Work Out

With the colder mornings and later sunrise, we are all tempted to hit the snooze button more often. However, studies have shown that exercising in the morning increases your energy level and productivity throughout the whole day. There is also better compliance with the exercise program since it is the first activity of your day, so you are less likely to skip exercising due to running late with other commitments.

3. “Feel Good” Hormones are Produced When We Exercise

With the long, dark, and cold days of winter, we are more susceptible to seasonal affective disorder and depression. Staying physically active is a great way to produce endorphins, which are the "feel good" hormones in our bodies. This goes a long ways in keeping us energized throughout the day making those dark days of winter more enjoyable. Most importantly, it keeps us emotionally stable.

4. Exercise Stimulates the Production of Joint Fluid

Our joints tend to get stiffer during the winter due to the colder temperature causing peripheral vasoconstriction. Exercise stimulates increased blood flow to our extremities, which promotes the production of healthy joint fluid and helps preserve the joint’s full-range-of-motion. In the long run, this leads to decreasing the risk of developing osteoarthritis, specifically of the hips and knees.

5. Staying Active in the Winter Decreases Injuries in the Summer

Exercising during the winter keeps our bodies in shape, maintains our strength and flexibility, and keeps us ready for spring time. This decreases the risk of injuries when the warmer weather comes and we are more inclined to go outside and participate in sports and recreational activities.


“How Can I Stay Compliant?”

1. Schedule Workouts

Rather than leaving your workout up to chance, you can be proactive and schedule dedicated time to exercise, ideally in the morning.

2. Recruit an Accountability/Training Partner

While it may be hard to motivate yourself to get going on cold mornings, it is easier if you are not alone. Find a workout partner to stay motivated. You will be less likely to press the snooze button if there is someone else you are leaving hanging.

3. Exercise at Home and at Work

If you can't go to the gym during the holiday season, you can still get a great workout at home. There are many workout videos that you can play on your TV or tablet that do not require special equipment. In addition, make an effort to park at work farther from the building and to take the stairs more often. This forces you to exert your body more frequently during the day in order to maintain a higher basal metabolic rate.



Ricardo E. Colberg, M.D. is a sports medicine & non-surgical orthopaedic physician at the Birmingham & Pelham offices of Andrews Sports Medicine and Orthopaedic Center. Dr. Colberg has a special interest in treating acute and chronic musculoskeletal injuries, including bone, joint, ligament, muscle and tendon injuries. He performs various treatment modalities in the clinic that assist the patient in their recovery from the injury, among them diagnostic musculoskeletal sonography, ultrasound-guided injections, and platelet-rich plasma therapy. For more information, contact Andrews Sports Medicine and Orthopaedic Center at 205.939.3699 or visit AndrewsSportsMedicine.com

Access is Key in Patient Engagement

By: Tammie Lunceford, Healthcare Consultant at Warren Averett LLC.

Patient satisfaction is an ever growing aspect of medical service in the last few years. Physicians are acutely aware of competition in many forms; urgent care, Uber medicine, and telemedicine to mention a few. Even in rural areas, physicians complain that their patients will not call to schedule with them when they are sick because it is simply too easy to go the urgent care, close by. Recent radio advertisements reveal a telemedicine product designed to treat twenty common ailments without leaving home. Even if you need to see a healthcare provider face to face, Uber medicine will send someone to your home with the personal touch of the 1950’s. Busy patients simply want to receive treatment fast and spend their time on other aspects of life. Basically, patients want healthcare to be as easy as picking up their dry cleaning.

What does this mean for physicians in private practice? It means we can’t stop the way medicine is changing so we must make adjustments to keep the patient relationship strong. Unless you are a specialist known for your expertise, you may have to revise your schedule to accommodate immediate access. Consider a mid-level provider to accommodate walk-in or patients who call to be seen. Train your staff to meet the patient’s needs and to monitor no shows. How many patients who booked appointments today, also no showed today? If they could be seen more conveniently elsewhere, they went elsewhere! Another way to meet the needs of the patient is to stagger staff and providers during lunch so patients can be seen on their lunch hour. You can stagger the physician and the mid-level for early and late access. Be sure to market your changes so patients will know you are available.

I recently reviewed physician schedules to find new patients could only be seen during one appointment slot a day, one specific time of the day. We must adopt open access scheduling to meet the needs of busy professionals, working moms, etc. The only decision should be the number of patients your office can accommodate each day, then let the schedule fill. Your referring physicians will appreciate your flexibility. Your patients will recommend you to their friends.

Another Head on the Hydra Metabolic Syndrome and Low Back Pain

By: Matthew Smith M.D. with Alabama Pain Physicians

“Modernity’s double punishment is to both make us age prematurely and live longer.” - Nassim Nicholas Taleb, The Bed of Procrustes


The developed world is facing an insidious healthcare epidemic. Via a confluence of medical breakthroughs, primarily in neonatology and infectious disease, we have benefitted from a jump in life expectancy since the early 1900s. Yet, these advances have been deceptive. Our success in addressing some of the most immediately preventable causes of death have masked the fact that morbidity has been gradually increasing over the last century and a half, with a rapid increase over the last twenty years. Today, the average elderly male spends 7.7 years in increasing medical dependency before death and the average female over 10 years. Moreover, there is a steadily increasing progression of morbidity prior to these years of dependency.

The main reason why our society has been getting progressively sicker despite our medical advances is because of the widespread development of a constellation of interrelated diseases known as the metabolic syndrome. The metabolic syndrome is classically defined as a disease whose primary manifestations are a dysregulation of glucose and insulin metabolism, dyslipidemia, hypertension, and suboptimal excesses of visceral adipose tissue. It is well known that the metabolic syndrome is strongly associated with, and causative of, many instances of gout, polycystic ovary syndrome, myocardial infarction, stroke, and dementia. To borrow from Greek mythology, its disparate manifestations are like a many-headed hydra, with each head representing a different “disease” but with each head attached to the same body of pathology.

Yet this hydra has at least one more head. And while this head is less well known than the others, it is no less important. It is common knowledge that the metabolic syndrome causes gout, diabetes, and heart disease. It is less well known that the metabolic syndrome is also the cause of many cases of osteoarthritis, or the type of arthritis more traditionally thought to be only from “wear and tear.” The metabolic syndrome appears to not just cause arthritis in the weight bearing joints, where bad mechanics can play a role, but in the hands, elbows, and every other non-weight bearing joint of the appendicular skeleton. And there are now numerous studies showing that osteoarthritis of the spine (also known as spondylosis) is also often caused by the metabolic syndrome.

This new understanding of how a vast amount of arthritis and pain are caused is a game changer. We now know that the pain and debility associated with osteoarthritis has at least as much to do with physiology as it does with mechanics. Perhaps the most salient physiology linking the metabolic syndrome to arthritis involves the visceral adipose tissue (VAT). VAT is the “white” adipose tissue that is in the viscera, as opposed to the white adipose tissue under the skin. The main purpose of VAT was previously thought to be just to store extra fat. We now know that our previous understanding was not just incomplete but misleading. VAT is actually an important endocrine organ that has the capacity to produce inflammation and cause profound destructive systemic effects. VAT is one of the primary generators of such pro-inflammatory cytokines as interleuken-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha). VAT leads to a decrease in the anti-inflammatory cytokines IL-10 and adiponectin as well. It also causes an increase in phospholipase A2. Regarding the latter, note that corticosteroids, still one of the mainstays for injection therapy for numerous arthritides, works by inhibiting phospholipase A2. VAT is thus akin to the anti-corticosteroid injection. But this is not the end of the ways that the metabolic syndrome destroys joints and causes pain. The vascular diseases associated with the metabolic syndrome, including small vessel occlusion and venous stasis, predisposes individuals to subchondral bone ischemia and poor nutrient and gas exchange in the joint cartilage.

The problem of the metabolic syndrome from too much visceral adipose tissue is compounded by a general lack of muscle, or sarcopenia, that is also becoming ever more prevalent in our patient populations. Robust skeletal muscle mass is an excellent insulin sensitizer and acts as a “glucose sink”, stabilizing the metabolic abnormalities that are part and parcel with the metabolic syndrome. Skeletal muscle also acts on the periosteum on a cellular level, establishing a normalization of metabolic function and improving bone density, chondrocyte health, and other factors implicit to bone and joint health. A lack of adequate skeletal muscle is therefore not just bad mechanically, but it worsens the destructive potential of the metabolic syndrome physiologically. Thus we now know of many ways in which the metabolic syndrome wrecks havoc on bones, joints, and their surrounding tissue. Above are a few of these ways and this is by no means an exhaustive list.

The physiological causes of osteoarthritic pain from the metabolic syndrome are important as they explain why so many more people are now experiencing arthritic pain, particularly of the low back. Back pain has been with us since time immemorial. Even Otzi, the tattooed mummy unearthed in the Alps and thought to have lived about 6,500 years ago, had some spondylosis. Spondylosis is nothing new and, like wrinkles of the skin, seems to usually be a normal part of the aging process. And, like spondylosis, some degree of back pain has been with humans since the very beginning of our species. Back pain has classically been the second most common reason to visit the doctor, just after upper respiratory tract infections. Yet, while spondylosis and back pain are part of the human condition, the prevalence and severity of back pain has been increasing tremendously in recent years, in lockstep with the tremendous increases with the other manifestations of the metabolic syndrome.

In order to appreciate the magnitude of the problem, it is helpful to look at some of the numbers. Low back pain has a direct cost in the United States of 70 billion dollars annually, with an indirect cost of up to $130 billion. Nearly 150 million workdays in the United States are lost every year because of low back pain. The worldwide incidence of back pain is 5% a year, with recurrence in one year ranging from 24-80%, depending on which study is favored. And the problem continues to get worse. European studies have shown a quadrupling of low back pain workdays lost over the late twentieth century with similar trends in the United States.

And consider this in correlation with the astronomical rise in obesity over the last two decades. According to the CDC, in both 1994 and 2010, Alabama was the second most obese state in the union. Yet, if you took the percentage of Alabamians who were obese in 1994 and transferred them to 2010, Alabama would be the leanest state in the union. And things have only worsened over the last five years.

These findings are important for three reasons. The first reason is that it shows that arthritic pain is an incredibly important disease whose etiology now looks to be vastly more complicated than previously appreciated. The second reason is it shows that in many ways the Pain Physician is treating manifestations of the same pathology as Cardiologists, Endocrinologists, Nephrologists, and General Practitioners. The third reason is that it gives us guidance as to the optimal treatment of our patient’s chief complaints.

Since the primary way by which the metabolic syndrome leads to pain and osteoarthritis is physiological, this opens up opportunities to treat some of these conditions pharmacologically and interventionally. As mentioned earlier, this is already done somewhat with treatments such as corticosteroid injection therapy. Visceral adipose tissue produces phospholipase A2, which leads to the production of pro-inflammatory cytokines. Corticosteroids inhibit phospholipase A2. Likewise, the metabolic syndrome is associated with an increase in TNF-alpha. There is some preliminary evidence that TNF-alpha inhibitors may help with osteoarthritic pain. While TNF-alpha inhibitors have classically been associated with the treatment of autoimmune pathologies, it thus makes sense why these could work with the much more common osteoarthritides. Leptin, adiponectin, and other cytokines may also be targets for pharmacological intervention. Furthermore, as the metabolic syndrome is associated with a variety of hormonal and neurohormonal issues (hypogonadism, etc), we may be able to leverage our better understanding of this pathology to address these as well.

While pharmacological advances and procedural interventions are exciting, the most obvious guidance that this new knowledge gives us is the importance of addressing the root cause of the metabolic syndrome in general. The most important take away is that there is simply no substitute to a healthy lifestyle, including the diet and activity necessary to ensure that our patients are appropriately lean and well conditioned. Of course, the problem is this requires a tremendous amount of patient buy in. And it can be really difficult to get this buy in. But not all hope is lost. Smoking used to be vastly more prevalent than it is today. Yet due to a change in societal norms, including the advice of doctors, tobacco use has decreased dramatically. Hopefully, with enough time and perseverance, we can change the lifestyle factors that are the root cause of the metabolic syndrome and the increasing incidences of arthritic pain as well. In the meantime, perhaps we can also utilize our new and fuller understanding of the ultimate cause of many types of pain to design better interventions for those for whom lifestyle changes are not enough.


Further Reading:

Conaghan PG, Vanharanta H, Dieppe PA. Is progressive osteoarthritis an atheromatous vascular disease? Ann Rheum Dis, 2005, 64: 1539–1541.

Gandhi R, Woo KM, Zywiel MG, Rampersaud YR. Metabolic Syndrome Increases the Prevalence of Spine Osteoarthritis. Orthopaedic Surgery, 2014, 6: 23-27.

Goodson NJ, Smith BH, Hocking LJ, McGilchrist MM, Dominiczak AF, Morris A, Porteous DJ, Goebel A. Cardiovascular risk factors associated with the metabolic syndrome are more prevalent in people reporting chronic pain: Results from a cross-sectional general population study. Pain, 2013, http://dx.doi.org/10.1016/j.pain.2013.04.043

Alam I, Lewis K, Stephens JW, Baxter JN. Obesity, metabolic syndrome, and sleep apnoea: all pro-inflammatory states. Obesity Reviews, 2007, 8: 119-127.

Katz JD, Agrawal S, Velasquez M. Getting to the heart of the matter: osteoarthritis takes its place as part of the metabolic syndrome. Current Opinion in Rheumatology, 2010, 22:512-519.

The National Practitioner Data Bank: What Every Healthcare Practitioner Needs to Know

By: Kelli Robinson, Kelli is a member of the Health Care Law Consulting Group at Sirote & Permutt, P.C. She also serves as a hearing officer for the Board of Dental Examiners of Alabama.


Most healthcare practitioners have heard of the National Practitioner Data Bank (NPDB), but many are unfamiliar with exactly what it is, how it operates, and what implications it might have on a healthcare practitioner’s career. The NPDB acts as a national clearinghouse for information relating to the professional competence of healthcare practitioners, and it is administered by the Health Resources and Services Administration (HRSA), a division of the United States Department of Health and Human Services (HHS).

The information reported to the NPDB is intended to be used in combination with information from other sources in making determinations on employment, affiliation, clinical privileges, certification, licensure, or other decisions. Hence, if the name of a physician or dentist, or other healthcare practitioner, is found in the NPDB, it could affect the ability of that healthcare practitioner to obtain privileges with a hospital or a state license.

On April 6, 2015, the HRSA released a revised NPDB Guidebook - the first update in more than ten years. An electronic copy of the 2015 NPDB Guidebook can be found on the NPDB web site (www.npdb.hrsa.gov).

Queries

The 2015 NPDB Guidebook contains detailed information about what entities and individuals must or may query the NPDB, including information about the type of information available to the specific entities or individuals and how the specific entities and individuals are permitted to use the information they obtain from the NPDB.

Following are two examples of federally-mandated queries of the NPDB:

• Hospitals are required to query the NPDB when a physician, dentist, or other healthcare practitioner applies for medical staff appointment (courtesy or otherwise) or for clinical privileges at the hospital, including temporary privileges.

• Every two years, hospitals are required to query the NPDB on all physicians, dentists, and other healthcare practitioners who are on its medical staff (courtesy or otherwise) or who hold clinical privileges at the hospital.


Other healthcare entities may query the NPDB when they have or may be entering into employment or affiliation relationships with healthcare practitioners; when healthcare practitioners apply for clinical privileges or medical staff appointments; and/or when they are engaging in professional review activity.

Entities like health plans and state licensing and certification agencies also may query the NPDB when they are determining the fitness of individuals to provide healthcare services; when they are protecting the health and safety of individuals receiving healthcare through programs they administer; and/or when they are protecting the fiscal integrity of programs they administer.

Practice Pointer: A healthcare practitioner may self-query the NPDB at any time by submitting a request through the NPDB web site (www.npdb.hrsa.gov) and paying a small fee (currently $5.00). Healthcare practitioners should regularly request a NPDB self-query to ensure all information in the data bank is correct. If any inaccurate information is discovered, promptly follow the steps below to correct or dispute the NPDB report.

Reports

NPDB reporting requirements by entity are set forth in detail in the 2015 NPDB Guidebook. Below is a summary of the information required to be reported to the NPDB:

• Medical malpractice payments resulting from a written claim or judgment;

• Certain adverse licensure actions related to professional competence or conduct;

• Certain adverse clinical privileges actions related to professional competence or conduct;

• Certain adverse professional society membership actions related to professional competence or conduct;

• DEA controlled substances registration actions;

• Exclusions from participation in Medicare, Medicaid, and other Federal health care programs;

• Negative actions or findings by peer review organizations;

• Negative actions or findings by private accreditation organizations;

• Exclusions from participation in State health care programs;

• Health care-related civil judgments in Federal or State court;

• Health care-related Federal or State criminal convictions;

• Federal licensure and certification actions; and

• Other adjudicated actions or decisions.

Information reported to the NPDB is maintained permanently unless it is corrected or voided from the system.

Practice Pointer: Healthcare practitioners at risk of being reported to the NPDB should immediately consult with experienced legal counsel to assess whether there are opportunities to avoid a report to the NPDB. Even when a NPDB report must be made by a reporting entity, legal counsel can help mitigate the adverse consequences of a report by negotiating the wording of the report, as well as classification codes and basis of action codes.

Subject Statements and the Dispute Process

When the NPDB processes a report, the NPDB notifies the subject of the report. The notification provides instructions for obtaining an official copy of the report from the NPDB web site.

The subject of a report submitted to the NPDB should review the report for accuracy, including the description of the reported event. If any information in the report is inaccurate, the subject of a report can request that the reporting entity file a correction. The NPDB is prohibited by law from modifying any submitted information, even if the healthcare practitioner who is the subject of the information can prove its inaccuracy.

If a reporting entity refuses to change the report it submitted to the NPDB, the affected healthcare practitioner may initiate a dispute to the NPDB and/or add a statement to the NPDB report, which any subsequent requestor would receive. The dispute process allows a healthcare practitioner to protest the factual accuracy of the report or whether the report was submitted in compliance with the NPDB reporting requirements. A healthcare practitioner, however, is prohibited from disputing the underlying reasons for the reports, such as the merits of a medical malpractice claim or the appropriateness of, or basis of, other types of reports.

Practice Pointer: A healthcare practitioner should seek the assistance of experienced legal counsel before determining the best way to respond to an inaccurate NPDB report, including contacting the reporting entity directly, drafting a subject statement for inclusion with the NPDB report, and/or navigating the NPDB dispute resolution process.

Conclusion

Reports to the National Practitioner Data Bank can have a significant impact on a healthcare practitioner’s future. Therefore, it is important for healthcare practitioners to understand how the National Practitioner Data Bank operates, as well as the healthcare practitioner’s rights with respect to the information reported, how information is reported, who is allowed access, and what can be done to ensure the accuracy of the information in the National Practitioner Data Bank. Finally, healthcare practitioners must be aware of which types of adverse actions will be reported to the National Practitioner Data Bank and should take care to mitigate any potential future impact.

Children’s of Alabama Pediatric Spondyloarthritis Clinic

By: Matthew Stoll, M.D., Ph.D., MSCS, treats pediatric rheumatology patients at Children’s of Alabama. Dr. Stoll is also an associate professor in the University of Alabama at Birmingham Department of Pediatrics, Division of Pediatric Rheumatology.

The Pediatric Spondyloarthritis Clinic at Children’s of Alabama is devoted to the clinical care and research of children diagnosed with juvenile spondyloarthritis. The clinic was established in March 2014. Today, more than 150 children are being treated for spondyloarthritis at Children’s.

According the Arthritis Foundation, nearly 300,000 children — from infants to teenagers — in the United States have some form of arthritis. Juvenile idiopathic arthritis (JIA) is the most common type of arthritis in children, in which the immune system mistakenly attacks the body’s tissues, causing inflammation in joints and potentially other areas of the body.

Spondyloarthritis is one of six types of JIA. It involves inflammation and tenderness in areas where the ligaments and tendons attach to the bones, accompanied by pain and swelling in the joints. In some cases, spondyloarthritis primarily affects the spine. Some forms can affect the peripheral joints, primarily — but not exclusively — those in the legs. Typical symptoms are low back pain and stiffness, joint swelling and pain in areas such as the Achilles tendon.

In addition, some patients with spondlyoarthritis may experience inflammation in parts of the body other than the joints. My research has focused specifically on the links between inflammation in the gut and in the joints of children and adults with spondlyoarthritis.

Children who are referred to the weekly Pediatric Spondyloarthritis Clinic benefit from the continuity of care from a team of doctors with targeted clinical expertise in this area. While there are few effective therapeutic options in the management of spondlyoarthritis, current treatment regimens include conventional therapeutic drugs, as well as newer biologic therapies.

While the exact cause of juvenile idiopathic arthritis, including spondlyoarthritis, remains unknown, clinic patients can participate in our ongoing research that will help advance understanding of pediatric spondyloarthritis.

The Pediatric Spondyloarthritis Clinic also provides screening and treatment specifically for temporomandibular joint arthritis (TMJ), a joint frequently ignored in children with JIA as a whole.


To refer a patient, please contact the Pediatric Rheumatology Clinic at 205-638-9438.



The Division of Pediatric Rheumatology at the University of Alabama at Birmingham (UAB) and Children's of Alabama was created in 2007 in response to a great need for pediatric rheumatic care in the state of Alabama, the largest state population without a pediatric rheumatologist at the time. A partnership between UAB, Children’s, the local chapter of the Arthritis Foundation and the greater Birmingham community helped to establish new clinic space, the creation of an endowed chair in Pediatric Rheumatology and ongoing support for the growth of the division.

Perinatal Care Certification at Brookwood

By: Nathan Ross, MD, OB/GYN at Brookwood Medical Center


This month Brookwood Medical Center was excited and honored to be the first hospital in Alabama and the sixth hospital nationwide to receive the Joint Commission Perinatal Certification. As Alabama’s first women’s hospital, Brookwood has continued to push the envelope in providing high quality medical care to both mothers and their newborn infants.

The Joint Commission has recently initiated a program that recognizes hospitals that are committed to achieving integrated, coordinated and patient-centered care for mothers and their newborns. Brookwood saw this as an opportunity to demonstrate the quality work that has been ongoing for years. Members from multiple departments including obstetrics, neonatology, pediatrics, anesthesiology, and our nursing staff worked together to prepare for the onsite review which occurred in October.

Some of the key requirements included:

• Integrated, coordinated patient-centered care that starts with prenatal and continues through postpartum care
• Early identification of high-risk pregnancies and births
• Management of mothers’ and newborns’ risks at a level corresponding to the program’s capabilities
• Available patient education and information about perinatal care services

As one of Alabama’s busiest maternity hospitals, Brookwood feels that this is yet another way to help demonstrate the commitment to quality maternal and neonatal medical care. The team approach that we were able to demonstrate to the Joint Commission was self-evident and the quality of the services and programs was able to shine as well. Our commitment to improve care in the areas of elective inductions, cesarean section rates, and breast feeding rates were at the forefront of the review process. Not to be lost in the maze of numbers and statistics, we were able to share personal stories of success and triumph as well.

Brookwood looks forward to sharing with other hospitals the ways in which we were able to excel and we look forward to providing quality maternal and neonatal care far into the future of an ever changing world of medicine.



Dr. Nathan Ross is a board-certified OB/GYN at Brookwood Medical Center. Learn more about Brookwood women’s services at iChooseB.com .

Thumb Carpometacarpal Joint Osteoarthritis

By: Julian Carlo, MD, surgeon at The Brookwood Orthopedic Sports Medicine Institute

The thumb is an essential part of our anatomy and one of humans’ most important anatomic features. The thumb plays a vital role in most hand functions through a combination of flexibility and strength. The carpometacarpal (CMC) joint of the thumb is integral in providing the thumb the flexibility to position itself in space. The joint’s complex saddle-like morphology allows it to abduct, oppose, and rotate the thumb into numerous positions necessary for the hand to deftly interact with the world and its objects. The large thenar muscles can apply forces delicate enough for a precision pinch or strong enough for a power grip. Given its importance, it should be no surprise that without the thumb, the hand loses about 50% of its function.

Although the CMC joint seems elegantly designed, the freedom of mobility and tremendous demands placed on the thumb can predispose it to developing osteoarthritis. The biomechanical design of the thumb concentrates forces on the CMC joint by a factor of 12 times the original applied force. In addition, the laxity essential for allowing wide range of motion often translates into instability, which can increase joint contact forces and accelerate cartilage wear. As a result, the thumb CMC joint is one of the joints most susceptible to osteoarthritis. Up to one in four post-menopausal women may be affected.

Most patients present with complaints of activity-related pain, aching, or burning at the base of the thumb that results in functional disability. Activities that are particularly painful include a forceful pinch (such as when holding dishes, turning a key, or pulling up a pair of pants), the positioning of the joint at extremes of motion (such as reaching across to the small finger), and a forceful grip (such as opening a jar). On exam, reproduction of symptoms by palpation at the CMC joint or an axial “grind” test are suggestive of the diagnosis. Radiographs show findings typical of arthritis, including joint space narrowing, sclerosis, erosion, loose bodies, and osteophytes.

When I see patients with this condition, I feel it is important to lay out the goals of care: reduction of pain and improvement of function. Patients should embark on a trial of nonoperative treatment because many people can improve without surgery. Activity modification, use of assistive devices, and splinting the thumb CMC joint are a good place to start. Nonsteroidal anti-inflammatories or acetaminophen can also help improve symptoms. Injecting the CMC joint with corticosteroid or a hyaluronidase can also provide relief that may help delay or eliminate the need for surgical treatments.

When should a patient be referred to a hand surgeon? It is appropriate for primary care physicians or other healthcare providers to diagnose and initiate care for this common condition as described above. Patients can be referred if they are failing nonoperative management and surgery is anticipated. Referral can also be initiated at any time in treatment, if the diagnosis is uncertain, or if more specialized treatment such as a CMC joint injection is desired.

When nonoperative management has failed to adequately improve the overall condition, it is reasonable to consider surgery. Many patients are unaware that a surgery can help their condition. There are a number of outpatient surgical procedures that reliably improve pain and function. The most common surgeries include excision of the trapezium with or without a reconstruction of ligaments that stabilize the thumb. In young patients a fusion of the joint may be indicated. Other procedures that preserve the trapezium or replace the joint have been devised. The surgeon will decide which operation is best for a patient’s particular presentation. Postoperatively patients require a short period of immobilization and most benefit from hand therapy to regain motion and strength. Improvement in pain, strength, and function can reliably be achieved, and there is generally a high satisfaction rate after surgery.


Julian Carlo, MD is an orthopedic hand and upper extremity surgeon at The Brookwood Orthopedic Sports Medicine Institute. For questions, appointments, or referrals call (205) 877-BONE (2663).

Update on Prostate Cancer Diagnosis from Urology Centers of Alabama

By: Dr. Thomas Holley, Urology Centers of Alabama


Prostate cancer continues to be a major public health problem in American men particularly those in Alabama. The death rate in Alabama from prostate cancer is too high. One of the particularly disturbing problems has been the lack of early diagnosis in African American men. Since 2007 we have supported a major effort to bring early detection opportunities to the underserved men of our state.

Recent statistics from the Alabama Department of Public Health have shown that the disparity in early stage at diagnosis between black and white men has been eliminated. We are encouraged that the death rate from prostate cancer continues to decline nationwide as well as in Alabama. Of particular interest the death rate among black men in Alabama has declined at an even faster rate.

The physicians of Urology Centers of Alabama are very concerned that the US Preventive Task Force has recommended against prostate cancer screenings. As a result of their recommendations the incidence of prostate cancer has declined over the past few years. Prostate cancer has not gone away it is just not being diagnosed at the same rate. Our fear is that many of the men who were not diagnosed early will be seen in a few years with late stage prostate cancer. This could have been prevented. The physicians at Urology Centers of Alabama continue to be strong advocates of prostate cancer screening as well as innovations to make screening more effective (see notes below).

Some of the challenges in prostate cancer diagnosis and management involves potential over diagnosis and over treatment. One of the areas of importance is trying to determine which men who have had a negative prostate biopsy should have a repeat biopsy. In an attempt to answer that question Urology Centers of Alabama joined with several national and internationally respected prostate cancer centers to study this problem.

The group found that using a methylation intensity-based algorithm performed on the negative biopsy specimens could help predict which men harbored high grade prostate cancer and thus needed to be rebiopsied.

The implication of this methodology could be far reaching by avoiding unnecessary biopsies and in men with positive biopsies segregating likely under graded men from active surveillance candidates.



Urology Centers of Alabama remains committed to excellences in prostate cancer care.

IT, Millenials, and PRM – The Future is Now

By: Susan (Zeisler) Pretnar

President at KeySys Health LLC

You may be thinking ‘Please…spare me another acronym!’. Most practices are already struggling with identifying, securing and maximizing the information technologies (IT) they’ve installed. Needing IT to manage patient relationships seems to complicate what is thought to be a comfortable, face-to-face space between the patient and the caregiver: doctor, nurse or other traditional clinician. So, what do Millenials have to do with patient relationship management (PRM)? They’re the tsunami coming our way. The future health care delivery model is quickly morphing, in no small way due to the digital natives among us.

The IT part of the healthcare story is no longer very clear, especially because of the proliferation of mobile devices and myriad data communication alternatives. The younger the caregiver and the deeper we get into the meaningful use of electronic medical records, the softer the protest at having been dragged into that world. A few are actually starting to see benefits, while others still feel hindrances.

IT has an impact on:

• Revenue

• Market share

• Patient acquisition and retention

• Employee satisfaction

• Loyalty

• Brand image

• Profit margins

• Cost reduction

• Organizational efficiency/productivity


All of these things contribute to the practice and to patient relationships. If you are not aware of the potential impact of IT on the items in this list, you probably are not convinced that investing further in IT is a valuable ‘spend’ for your practice. Finding the long term ROI in IT expenditures for operations makes selecting the right ICD10 code seem simple. Until recently, healthcare had few of the characteristics of a ‘market’, including the influence of its users. It appears that a true healthcare market, foisted on us by the totally connected Millenials, may finally emerge. It would be one with standard benchmarks and recognizable comparatives. So, why does this seem to be happening now?

A finger can be pointed at the Millenials in our midst. As a group, they will become the largest demographic in the next 10 years. That means Millenials will represent the majority of the patients in your practice (estimated to be 75%), save for the average geriatric specialist. They have faith in technologies and services that can bypass the traditional doctor or hospital delivery systems. The shear size of their generation means that they will have an impact.

Millenials have already influenced many other industries, as a direct result of their swift adoption of digital gadgets. I say swift because truly the smartphone started it all, and was introduced a mere 8 years ago. Can you name a proven clinical practice or procedure that has been embraced by all of healthcare in less than 8 years? Even for non-Millenials, smartphones, tablets and wearable electronics are ubiquitous in everyday life.

Millenials are disrupting healthcare delivery systems just as they impacted traditional paper media, financial services, and brick and mortar sales of goods and services. They are comfortable getting their healthcare information from Google – and they believe it. Aren’t we all getting just like them? We also want same day appointments, online scheduling and bill payment, electronic access to our medical records and the option to text or email our providers. And, we all assume someone else is handling privacy and security matters.

Providers say that it is not their fault that patients aren’t ‘engaged’, but we may soon be crying that Millenials are pushing us too fast to accept bi-directional communication with them. They believe that their patient generated health data (ugh - PGHD!) is valuable information to share, not just on Facebook, but also with their doctor. They already self-monitor with Fitbits or one of the 40,000 health related apps they can download to multiple mobile devices. This group is questioning the traditions of healthcare: where it is delivered and by whom.

I bought a smartphone in order to communicate with my grandchildren (text only of course), and to enable me to access business emails from literally anywhere in the world. We’re pushed privately and professionally to adopt the latest technologies. Secure IT belongs in any strategy around patient relationship management. Perhaps it is beyond time for healthcare to accept the meaningful use of technology, instead of quibble over the meaningful use of electronic medical records. As has been eloquently stated by others ‘if we are going to live in interesting times, there is no reason not to embrace them’.

Are Your Text Messages HIPAA Compliant?

By Jeremy Beck,

Director of Sales and Business Development at Integrated Solutions

 

Most clinic administrators have lost sleep wondering if their doctor’s texts are HIPAA Compliant. Is it okay for the doctor to receive and send sensitive patient data over their phone? What if they lose their phone?

So, are your doctor’s text messages secure and compliant? The answer under the HIPAA guidelines is yes as long as “administrative, physical and technical safeguards exist that ensure the confidentiality, integrity and security of electronically stored or transmitted private health information.” This statement might be even more confusing to you so let’s look below at somethings that might make this a bit clearer.

WHY ARE TEXT MESSAGES NOT SECURE?

- You Use SMS For Your Phone or Tablet

o First, you likely use SMS for your phone or a tablet. SMS stands for Simple Message Service and is the underlying protocol that all text messages use. The primary transmission methods (protocols) used for SMS are not encrypted

- Text Messaging is, By Default, Not Secure

o Text messaging by default is not sent or received in a secure manner although some cellular providers provide additional security methods. In other words, the messages can be intercepted and read as plain text.

WHAT CAN YOU DO ABOUT IT?

- Create Solid Clinic Rules

o In order to safeguard against PHI data loss on these devices and to safeguard messages sent and received via text messaging, clinics need to have policies in place stating guidelines for what is acceptable use on portable devices and what to do in case of a breach.

- Encrypt it

o The clinic should protect the transmission of data by encrypting it. There are many good products on the market that will provide secure text messaging as well as the ability to delete the data from a portable device should it become lost or stolen. Encrypting mobile devices like Apple, Android and Windows can be accomplished by using a 3rd party application such as Wickr, Gliph, MeOnCloud or WhisperSystems. These applications can help for SMS encryption and can help to ensure that patient data is protected.

- Erase the phone

o Your doctors and staff might not like this response but applications need to be in place so that smartphones and tablet data can be remotely deleted. If the phone or tablet is lost or in question you can delete the data remotely.

Marketing and the Medical Practice

By Bill Cockrell,

President - Cockrell, Egeland and Associates, LLC

Thirty plus years ago, when I first got into medical practice management, I was the practice administrator for a small primary care group. Right before he left, the previous administrator had purchased a business card sized listing in the yellow pages (yes, once people really used the paper version). It simply listed the practice, the physicians, the address and phone number – that’s it. When I started, I was told one of my first jobs was to write a letter of “apology” to the Medical Society for using “advertising” to attract patients. It’s commonplace now but, at that time, no professionals (doctors, accountants, and even attorneys) talked about themselves in ways that could be construed as marketing. Yes, things have indeed changed.

Today, it’s hard for physicians to market themselves on television because all the good slots are taken up by attorneys. Kidding of course but, the reality is that medical marketing does occur, even if a physician doesn’t lift a hand. It’s through insurance carrier provider network listings, hospitals pushing their physician networks and other organizations with something to gain. On top of the normal channels, anything that appears on social media, whether it deals with a practice or not (for example, waiting too long to see the doctor, poor bedside manner or even big game hunting), is a form of marketing, positive or negative. Finally, go on any major insurance provider’s website, including Medicare, and plenty of information on patient satisfaction, quality and cost, among others, are easy to find.

So, does it matter if a practice markets itself? Yes. Absolutely yes. As stated, there’s a lot of information out there. However, explanations on what the information means, is lacking and, often, clear only to those who put it together for their needs. On the CMS (Medicare) Physician Compare website, it states “CMS has continually worked to make the site function better, improve the information available, and provide useful information about physicians and other health care professionals who take part in Medicare. This ongoing effort, along with the addition of quality measures on the site, helps Physician Compare serve its two-fold purpose:

Provide information to help consumers make informed decisions about their health care and create clear incentives for physicians to perform well.”

Consumer information includes what “CMS indicated that the first measures available for public reporting on Physician Compare would be the 2012 PQRS GPRO measures collected via the GPRO Web Interface for groups of 25 or more eligible professionals.”

This will not be limited to larger groups of course but, despite the intentions of CMS, when it’s hard for us to understand what PQRS measures mean, what happens when that information gets in the hands of a consumer who has only a government explanation to help them understand it. Now, what do we do? We educate (market). By being proactive in showing our own data, patient satisfaction or any sound quality data we help the patient understand what the information represents and how to use it. That’s called productive marketing through education. We can even use provider data and explain what it means. And, on top of the information, we can use the same information to target populations groups based on demographics or referring physicians based on the type patients they care for.

If a provider / practice wants to thrive, what about gathering the information that’s out there already, verifying or adding to it through their own data and presenting it in an educational format to patients and providers is a real option. We’re not talking about contact information or cost. We’re talking about our own results and information. We’re not bad mouthing others, we’re truly educating. Of course, we’re going to benefit from the marketing element but, if a provider really does provide high quality care, in a cost efficient manner, it seems the provider, the payer and, most importantly, the patient, wins. That’s a pretty good outcome. The proliferation of data to the patient is happening whether we like it or not. Isn’t it better to manage the process rather than have it manage you?

The marketing prescription:

Gather your own, provable data

Learn what else is available about you

Repackage it in an understandable format

Identify the targets to get the information to

Deliver the message.


That’s marketing – no apology needed.

Doctors and Hospitals Face Cuts in Budget Deal signed into law on Monday

Michael Staley

                                                                   Brandon Schirg

By:  Brandon Schirg, Michael Staley

This blog was originally posted at Waller Healthcare Blog on 10/29/15 and modified on 11/3/15 for this publication.


On Monday, President Obama signed a two-year, $80 billion budget deal that raises the national debt limit as needed through March 2017 and pushes off the possibility of a government shutdown until after a new Congress and President have been elected.

Of particular concern to hospitals and other providers, the legislation will impact Medicare payments to hospitals by codifying the Centers for Medicare & Medicaid Services (CMS) definition of provider-based (PBD) off-campus hospital outpatient departments (HOPDs) as those locations that are not on the main campus of a hospital and are located more 250 yards from the main campus and limiting reimbursement to new off-campus HOPDs in the future.

The big winners seem to be hospitals with existing PBD HOPDs since they will be grandfathered in under the higher existing reimbursement model. They have the government to thank for giving them what many will call an unfair competitive advantage and the government to thank for new uncertainties surrounding their future growth and expansion. MEDPAC’s recommendations released earlier this year recommended not grandfathering in existing PBD HOPDs.

The biggest losers may be hospitals with PBD HOPDs currently incomplete that were under development or construction at the time the law was signed. The loosely worded law could ultimately be interpreted by CMS to eliminate their eligibility to receive reimbursements at the HOPD rate starting in 2017. The costs for those projects have already been incurred and communities and patients (especially in rural areas) will likely soon be asking lawmakers to help them prevent the government from picking winners and losers through an arbitrary deadline by striking the grandfathering clause.

Requirements for new off-campus HOPD locations to enter into new provider agreements leave the industry with many unanswered questions related to the following:

• Will the Medicare hospital conditions of participation apply to these locations?

• If outpatient surgical locations are required to enter into new provider agreements, will it be the provider agreement that is typically signed by ambulatory surgery centers (ASCs)? If so, does that mean the ASC conditions for coverage apply to the location, as well?

• If the outpatient location is treated as a physician clinic, what CMS coverage rules will apply to that location?

• If new provider agreements are required, will hospitals end up with multiple provider numbers?

• If new provider numbers are issued for the outpatient locations, will CMS allow larger healthcare companies to have the reimbursement payments that are paid to those new numbers deposited in a central bank account? Currently, CMS will allow this approach with amounts that are paid to Medicare Part A numbers but refuses to take that same approach with Medicare Part B numbers.

• How will the Medicare successor liability provisions apply to these new provider agreements?

• How will the effective date be determined for these new locations? For example, if an outpatient surgery department is treated as a new ASC, the location typically has to pass a CMS/accreditation survey before it can participate in Medicare. Would that apply here?

• Does Congress agree with CMS’s position that the 250-foot requirement for on-campus status is measured from the front door of the facility?


The legislation is likely to impact hospitals' physician-alignment strategies and reduce incentives for hospitals to buy physician practices and other ancillary service lines which many hospitals and health systems have done to expand networks and meet the Affordable Care Act's push for coordinated care.

The Federation of American Hospitals’ spokesman said the change in payment method to HOPDs is reasonable, thinking the current payment method was flawed and being exploited.

The American Hospital Association, meanwhile, said the proposed cut in funding to HOPDs is an untested idea which "may endanger patient access to care, especially among patients who are sicker, the poor, minorities and seniors who often receive care in hospital outpatient departments. Moreover, rural communities will be most adversely impacted, as hospitals will no longer be able to help physicians in these communities continue to provide access to their patients."

President Barack Obama stated, “Evidence suggests that in recent years, billing of many ambulatory services has been shifting from physicians’ offices to the usually higher paid hospital outpatient department setting, increasing Medicare spending and beneficiary cost-sharing.”

It is important for lawmakers in the U.S. House and Senate to hear directly from industry-related constituents as the new law is implemented at the agency level.



Staley is senior policy adviser at Waller (wallerlaw.com). He served as chief of staff for former Rep. Spencer Bachus (R-Ala.) from 2007 to 2014 and now works as a federal and state contract lobbyist, splitting time between Alabama and Washington, D.C.

How Your IT Equipment Saps Your Productivity

 

By Thomas Kane, CEO  Keep IT Simple 


One of the most common issues our clients ask about is productivity and speed of their IT set-up. Their questions include:

• Why is my EHR running so slow?
• My computer has gotten so slow recently. Can you fix it?
• The internet seems so slow and it didn’t used to. What happened?
• Can I just upgrade or repair this computer instead of buying a new one?

Questions like this usually result in a conversation about hardware, meaning any IT device in your office (e.g., computers, servers, routers, wireless access points, monitors, keyboards, mice, etc.).

When it comes to hardware, the stage is rapidly shifting. Especially right now, technology is progressing much faster than we have ever experienced. Just in the last several weeks, you have been hearing about Windows 10, tablets, 2-in-1s, convertibles, and more. This rapid progress is welcome, however, it often leaves people confused. So here are answers to some of the most common questions we get asked about IT hardware.


“I paid to upgrade our speed, but the internet is still slow. What’s wrong?”

Often, slow internet speeds have everything to do with your provider. Here’s some hard-and-fast rules about things beyond your reach that affect speed:

• Cable internet is faster than DSL
• Suburban and urban areas offer faster speeds than rural areas
• Old cabling provided by your internet provider, both inside and outside the office, has trouble           carrying fast connections.

Most of these can be resolved with a few phone calls to your provider — or by simply changing providers.
However, you could still be bottle-necking the speed that you are paying for with your equipment. If your router is several years old, chances are very likely that it can’t match the speed of your modem. This results in your internet speed remaining the same even though you just upgraded your plan.

An older router may also send incorrect wireless signals to your new iPad or laptop, which will cause dead spots in the office. Upgrading your router can also drastically improve your ability to connect, as well as the speed after you’re connected, especially when using cloud-based software, where a fast, reliable connection is required.

You don’t need the most expensive router on the market, but you do need one capable of handling the internet speeds that you pay for.


“Can I just repair this computer instead of buying a new one?”

When a computer is damaged or broken, either by weather (lightning strikes, power surges, etc.) or by physical damage (spilled coffee, being dropped, etc.), the question will arise, “Can I just repair this one?” And sometimes, the answer is, yes, as long as the hard drive is fine and the computer is under warranty or the parts are available. Unfortunately, most of the time, the best use of your dime is to purchase a new one.

 A computer’s lifespan is about five to six years. After that, either the computer will start to malfunction, or programs, apps, or websites will require more than your computer has to give.

When discussing this with our clients, we always weigh the cost of the repair to how much lifespan that repair adds to the computer. If it will cost $400 to repair, but will still be slow and need to be replaced next year, it’s a poor investment. Spend the additional money to replace it, and you get another good five to six years of life.

If you are pushing the 10 to 15-year mark on your equipment — like we’ve seen tons of times — you may not have any problems until your software company issues a shiny, new update with all of the features you have been waiting years for. Now your hardware is too old to handle it.

This puts you in a tight spot. You really need this program update, but do you have the $10,000 to $30,000 or more needed to upgrade your entire office hardware? This is why hiring an IT company well versed in spotting outdated equipment can guide you in gradually replacing equipment, so you don’t face any surprises.

“How do I choose new equipment in a Windows 10 world?”


Purchasing new equipment creates another pickle right now. We are smack in the middle of a Windows 7, 8, and 10 world on office computers available for purchase.

The EHR and practice management (PM) software you are using is likely still stuck in a Windows 7-only world (Windows 8, if you’re lucky). So when your front desk computer dies, and you get that email from a big box store advertising a brand new laptop for $200, you buy it. The problem is, most of the new computers now come with Windows 10. And this could be a huge problem. Some EHR and PM software will not even install on Windows 10. So you take the computer back and get another one with Windows 8. Now your EHR works, but your PM can’t be installed because it requires Windows 7. In that case, you may need to make a special order to get a new computer with that old of an operating system installed.

So before purchasing new, upgraded hardware, know all of the requirements enforced by all the different software you use. And that list of software doesn’t just stop with your EHR and PM. You also must know the version of Microsoft Office, Quickbooks, task or to-do list software, time clock, etc. Then for each of them, you must ask if you have the disk from which to installed it? If not, do you have the activation key for granting a new download? Can the key be reactivated? What about that program for printing holiday card envelopes? What type of wireless is required for that new iPad Pro?

New hardware is an investment. Do your research, hire the help you need to get it right, and spend a little extra money where it matters. Then you can see your office productivity fly through the roof.

Concussions…Ding dong…Not as simple as getting “your bell rung”

Part 3 – treatment, complications, and follow up

By: Ann L. Contrucci, MD, Director, Risk and Patient Safety, MagMutual Patient Safety Institute  

This article will discuss the treatment, recovery process, and complications that can arise from a concussion, as well as follow-up - a crucial step in the overall recovery process for adolescents and children who have sustained concussions.

Risk factors can complicate and prolong the recovery process from a concussion. The risk of cumulative effects from a history of multiple concussions is real, especially if they occur over a shortened period of time. This is why we emphasize taking a detailed neurological history that includes a personal or family history of migraines, depression, mood disorders, anxiety, learning disabilities and ADHD. Any of these morbidities can prolong a patient’s recovery time. As always, signs of deteriorating neurologic function should be promptly evaluated and treated.

The management of concussions

As a part of your initial evaluation, include a general discussion of the steps involved in concussion recovery with the patient and family, and the importance of patient/family compliance with your recommendations, such as the need for the patient to avoid physical and cognitive exertion, especially in the acute stages of recovery. Highlight the fact that some symptoms may not be noticed for several days after injury and that they must monitor the patient for those types of changes and notify you or the attending physician immediately.

The good news is that most patients recover fully without sequelae. The bad news is that the management can become quite complex and cumbersome. Individualize patient management and monitor the patient’s physical and cognitive activities closely. Typically, if symptoms resolve within 7-14 days, treatment and follow up may be done in the primary care office setting. If seen initially in the ED, that treating physician should ensure proper follow up either through the PCP or with a concussion specialist. ED physicians should not allow return to play the same day and should not give a date to return to play when discharging a concussion patient.

All evaluating/treating physicians should refer the child or adolescent to a concussion specialist if symptoms persist after 10-14 days, if they worsen, if there is a history of multiple concussions or if other risk factors exist that could prolong recovery. At that point, neuropsychological testing may be considered to validate persistent subjective symptoms, especially symptoms related to reaction time, executive functioning, etc. However, neuropsychological testing should not be used exclusively to diagnose, treat, or make return to play decisions.

What about returning to school?

Often parents and patients will ask these questions as soon as the injury occurs. A recovery plan must be individualized to the particular patient. Memory, concentration, and focusing issues can and do occur. This is why “cognitive rest” is crucial, especially in early management and recovery – examples include avoiding computer work, watching TV, texting, video games, and even reading. Teachers can be a vital set of “extra eyes” upon a concussed student’s return to school by watching out for the following: difficulty concentrating or remembering new information, taking longer to complete tasks, complaining of increased headache or fatigue while doing school work, or poorer academic performance than baseline. Accommodations may be required temporarily as the child or teen transitions back, including a shortened school day or taking rest breaks during class or during the day as well as allowing for more time to complete work and providing the student with accommodations in testing situations.

What about returning to play?

The physician should make an unpressured decision as to when a child may return to play, not the family or coach. The challenge is to individualize each patient’s plan, based on his or her symptoms. A good rule of thumb is the younger the athlete, the more conservative the treatment. As we mentioned in Part 2 of this article, children’s brains are still developing and the neurometabolic cascade of injury is very different than in the adult’s brain.

There is a 5-step process of increasing activity that may take days, weeks or months. Symptoms and cognitive function should be evaluated during each increase in activity level. This is best done in a team approach as it requires a fair amount of follow up. The 5-step process reintroducing activity is as follows:

1. Step 1: Start with light aerobic exercise, which is defined as increasing heart rate for 5-10 minutes such as with an exercise bike or light walking. However, Step 1 should not occur until at “baseline” and there are no physical or cognitive symptoms for a minimum of 24 hrs.
2. Step 2: Next introduce some moderate exercise and limited body and head movement but for a time that is less than the “typical routine.” Examples include moderate jogging, biking, or weight lifting.
3. Step 3: Gradually move closer to a “typical routine” with some non-contact exercise, which includes running, regular weight lifting routine and sports specific drills.
4. Step 4: The athlete is allowed back to practice.
5. Step 5: Return to competition.

If symptoms return at any of these steps, rest for minimum of 24 hours and return to previous step. There will most likely be resistance from patients and families at this point. Reiterate that the rest period will help them return sooner than if they “try to push through”.

Post concussive syndrome occurs when symptoms continue for several weeks to months after injury. It occurs in approximately 5-8% of patients with a history of previous concussions. Students may be eligible for a “504 plan” in school which is a plan to accommodate those with a disability (temporary or permanent) that affects academic performance.

Can we prevent concussion injuries?

Realistically, can concussions be prevented? Planning during the pre-season can be important so all team members understand the roles they play – who will be responsible for the field response, the emergency assessment of the athlete, the observation on the sideline and deciding about disposition. This can be difficult as there is not always an actual trainer available on the sidelines especially for the younger children. These tips will help:

• Know where trauma centers are in the area.
• Educate coaches and athletes on concussions.
• Consider conducting baseline assessments during the pre-season especially in contact sports.
• Ensure the league or school has a concussion plan in place – numerous resources are available.
• Use common sense regarding appropriate techniques of play, following the rules, conducting good sportsmanship, and correctly wearing protective equipment Keep in mind that helmets themselves are not “concussion proof” – they are there to prevent catastrophic injuries only.

In conclusion, remember children and teenagers have different brains and should be treated differently than adults. Reach out for help when needed. Concussions can create long-lasting complications and should be taken seriously. Numerous resources are available for clinicians including checklists for symptoms and guidelines for return to play and school. The CDC has a specific toolkit which includes CME credit. The AAP and American Academy of Neurology have guidelines as well. The good news is that concussions can be successfully treated to full recovery with the end result being a team of happy physicians, parents, coaches, children and teenagers.

[1] www.cdc.gov/concussion/headsup

TrueBeam™ Offers Next-Level Cancer Care

By: Clinton Holladay, M.D., radiation oncologist, Baptist Health System


As the technological landscape for cancer care and radiotherapy treatment evolves, we will continue to see trends focused toward increased precision of radiation treatment with emphasis on personalized care and patient experience.

Of the newest technologies on the market, one such treatment method that is making a big splash by delivering innovation and highly personalized cancer care is a high-precision radiotherapy system that sends a beam of radiation to the tumor while preserving the healthy surrounding tissue. Our patients are already seeing the benefit of the fast and accurate treatments due to its shorter duration and calmer delivery environment, which includes soothing music.

The TrueBeam™ Radiotherapy System from Varian Medical Systems can treat cancer anywhere in the body, including the lungs, breast, prostate, head and neck, delivering a more powerful cancer treatment using intuitive visual cues to exhibit advanced imaging and motion management technologies.

Additionally, this technology maintains accuracy with its respiratory gating option for synchronizing beam delivery with a tumor in motion. For radiation oncologists, the innovative sophistication of this system can help us provide an enhanced patient experience, allowing for treatment with fewer factions in greater doses, cutting a typical 30-minute treatment down to five minutes or less for some tumor sites. Less time on the table ultimately improves our patients’ comfort and less interruption into their daily lives.

Every piece of technology and advancement brought into our hospital is done for the patient. The ability to offer them the best in cancer care is what we strive for, and this latest system helps us achieve just that.



Princeton Baptist Medical Center introduced TrueBeam™ Radiotherapy System from Varian Medical Systems to its cancer service offerings in July 2015. Physicians at Princeton’s Cancer Center are utilizing TrueBeam™, in addition to other leading edge cancer technologies, to deliver a personalized, innovative approach to the quality care and comprehensive patient experience they deliver.


To learn more about cancer care at Princeton, please call (205) 783-3243 or visit http://baptisthealthalabama.org/Cancer.

Technology Makes It Easier… To Unknowingly Put Your Data at Risk

By: Ryan McGinty President / CEO at OCERIS, Inc.


The “always connected” evolution of modern technology has made a deluge of appealing, instantly accessible productivity services and apps. Almost all flaunt being secure - the problem is, healthcare professionals are not included in the “everyone” these services are referencing. Protected Health Information (PHI), as defined by HIPAA, has very specific requirements, and most of these services are not HIPAA compliant out of the box. As an EHR/Practice Management vendor, we have seen first-hand how many people don’t understand how these services work behind the scenes, and whether or not they are appropriate for use in healthcare.


What Types of Services Are We Talking About?

Everyone hopefully knows by now that normal, unencrypted email is not secure and shouldn’t be used to transmit PHI. But there are many other services that also claim to be “secure”, but should not be used for PHI. Some examples (by far not a complete list):

• Cloud storage (Google Drive, OneDrive, DropBox, iCloud)

• Note taking (EverNote)

• Online backup programs (Carbonite)

• Communication (Skype, iMessage, WhatsApp)


The Confusion: “Secure” vs “HIPAA Secure”

One of the primary issues is the use of the word “secure”. Most services are labeled as “secure”. What that means is that the service encrypts the data as it is transmitted and that you have to login to it to access the information. It technically is secure – but only from the outside world. HIPAA goes further and requires that data be protected at a much higher level. There are essentially two ways that a service can be used in a HIPAA compliant manner:

1) Use a HIPAA compliant version of the product – This option is available for many services, but is rarely free. Examples include Office 365 and Google Apps – but not just the “regular” versions. You have to choose the versions that are specifically labeled as HIPAA compliant. An indicator you are on the right track is the service offering a Business Associate Agreement (BAA), which is a HIPAA requirement for entities that house PHI data that is technically viewable by their own employees. HIPAA compliant versions of services also have audit tools for comprehensive logging of access to data and other tools to assist in maintain compliance.

2) For data storage services (like cloud storage), you CAN store PHI but ONLY if it is encrypted with a HIPAA compliant encryption routine and only you, or others in your organization, can access the data. For example, you could store a file with PHI on your free cloud storage account as long as the file is encrypted with AES256 – a type of strong encryption that is considered strong enough to protect data sufficiently. If you do not have a BAA with the service, it is your responsibility to ensure the data is encrypted strongly enough that employees of such a service cannot view the data.


Some Real-World Examples

Now that we’ve defined the problem, let’s go over some example situations where PHI is not adequately protected. Many of these are things people do every day and don’t realize that they are putting data at risk. Again, for “regular” businesses, this wouldn’t be a problem – but it is in healthcare when dealing with PHI:


You save an unencrypted Word document containing PHI to your free Google Drive account to work on at home.

Not only is the storage of that PHI in an unencrypted form on the free (non-HIPAA compliant) version of the service a problem, but also the fact that it might auto synchronize to other devices, such as laptops, phones, and more. If those devices aren’t encrypted, they now contain unencrypted PHI and the data is at risk if a device is lost or stolen.


You take a picture of a hospital note with your iPhone which is set to auto upload your pictures to iCloud.

Most people don’t even think about this scenario. They set their phone to auto upload their pictures because most phones are used in the dual role of personal and business. You want vacation photos backed up, but you don’t want PHI to be sent since the storage service is not HIPAA compliant.


You record notes about a patient in EverNote.

In order to make your notes available everywhere, these popular note programs sync to a central server owned by the note company. As with other services, unless you subscribe to a specific HIPAA compliant version, PHI is not properly protected.

You use your online calendar to store PHI.

The convenience of a centralized calendar is inarguable and might seem like a great way to track upcoming surgeries with patient details. But, unless the calendar is part of a HIPAA complaint offering (such as Office 365), then the it should not be used to store PHI.

You backed up all your medical data with the free version of a cloud backup program.

If the backup program isn’t HIPAA compliant, or if it does not allow you to specify an encryption key (usually accompanied by a large warning that if you lose the key, no one will be able to recover your data), then your data is not properly protected.

How Do You Gain Control of Your Data?

As you can probably see, there are a multitude of ways that your data can be outside of a HIPAA protected zone and you wouldn’t even realize it. So what is a non-technical person supposed to do to gain control of this both at a personal and organizational level? Enterprise operations have entire IT departments devoted to managing this type of thing, but small to mid-size offices are on their own to make sure everyone in the organization stays compliant – a sizable task given the proliferation of easy, accessible services and the Bring Your Own Device (BYOD) movement.

Educate Everyone That Has Access to PHI

It is imperative that everyone who works with PHI understand the importance of keeping it protected – and to understand how current technology works. The main cause of data being at risk is simply because people not knowing the difference between the “secure” and “HIPAA secure”. Do not take anything for granted when developing education – ensure everyone knows they should never take pictures of PHI with their cellphones, never post PHI on a social media site (even in a private message), and never, ever email PHI.

Ban Certain Apps and Services

Prohibit co-workers from using services that are not HIPAA compliant. This is a “better safe than sorry” measure. If you aren’t sure co-workers will know when it is appropriate to use a non-HIPAA compliant service, then don’t take a chance – keep them from being able to accidentally put data at risk. For the ultimate protection, have an IT consultant help you lock down devices to prevent anyone being able to access or install non-compliant programs.

Secure and Encrypt Devices That Are Taken Offsite or Easily Stolen

Most devices, including laptops, tablets, and even phones, now have the ability for full-device encryption. These technologies make it virtually impossible for a stolen device to have its data accessed by anyone without a passcode or key. Make sure the device also has a password or passcode to unlock or log into it. Finally, if the device offers a locator service and/or a “remote wipe” capability, make sure to enable it. Most are not enabled by default, so verify it is setup – after it is lost or stolen, it is too late.

Provide a HIPAA Compliant Option

While not free, signing up for a HIPAA compliant version of a service gives co-workers an option they know is acceptable on which to store PHI. Having an “approved” option means they are less likely to go looking for a readily available “unapproved” solution.


It Is Time to Change How You Look at Technology

Up until the last few years, it was fairly easy to keep data inside a protected network. Smartphones, tablets, file sharing services, and social media have vastly decreased the complexity required to share information, but blurred the lines of what is “secure” enough to use to store or share PHI. Take control of your data now – look at the organization as a whole, including all employees and all services used. The healthcare industry doesn’t have the luxury of using every new piece of technology that becomes available without some close scrutiny. Ongoing compliance requires the diligent research of products and services prior to their introduction to your organization to ensure it meets the requirements of our industry – and the PHI your organization is responsible for stays protected.