Wednesday, May 27, 2015

American Heart Association High Blood Pressure Leadership Twitter Chat

When: May 27, 2015 at 1pm PT/3pm CT/4pm ET

Where: Twitter – Follow #HBPLeaderChat

Audience: Primary – professional Secondary – general public

Moderator: Nancy Brown, CEO, American Heart Association

Format: HBP leaders as a panel representing Kaiser, AHA/ASA and strategic partners to discuss this important topic. Features a diverse group that represent different points on the continuum of care – doctors, researchers, program managers, nurses, health coaches, etc.

The AHA encourages other high blood pressure program or healthcare leaders from around the country to join the discussion, ask questions and share their experience in managing HBP patients & programs.

Friday, May 22, 2015

One Short Summer for ICD 10 Planning

By: Tammie Lunceford, CPC BSHA (Healthcare Advisor with Warren Averett CPAs and Advisors)

The repeal of the SGR did not include a delay in ICD 10. The medical community is now in a hurry to plan, train and budget for the ICD 9 to ICD 10 conversion which is scheduled to begin on October 1, 2015. There is no time to waste!

On February 9th, the General Accountability Office reported to the United States Senate that CMS is well prepared. End to end testing has been successful with 2,550 covered entities. Most of the tools through CMS are geared toward small or rural practices.

Since alternative payment models are evolving, implementing ICD 10 is necessary. The alternative payment models, or merit based payment models, rely on more specific coding to provide the risk adjustment details of each member to the insurance carrier. The value based modifier analyzes clinical effectiveness through PQRS reporting, and cost effectiveness through risk adjustment, to award or penalize providers.

Some physicians presume their own behavior requires little modification and they can leave it to the staff to properly code the services. Some billers believe the electronic medical record or the doctor will give them the codes to file, limiting their responsibility. Almost everyone thinks they need to understand the coding for their specialty and they don’t want to waste time with general code set training. Regardless of your belief, below are some action items:

• Choose a physician champion

• Perform a workflow analysis to devise your plan of action

• Contact vendors for readiness and preparation

• Revise paper superbills if not using electronic ones

• Train every staff member that uses diagnosis coding—not all staff need the same training

• Improve clinical documentation among all providers

• Bring coding personnel into the exam room to guide the documentation process

• Test claims with the carriers

• Work with billing staff on follow-up protocol

• Sustain revenue with a line of credit

We can find our way through this implementation if we plan appropriately. Training opportunities are available through many resources. Map a plan for your practice today, don’t delay.

Thursday, May 21, 2015

Cardiac PET-A Valuable Tool for Cardiac Diagnosis

By: Donald G. Gordon, MD, FACC with Cardiovascular Associates of the Southeast

Introduced in the 1980s, Myocardial Profusion Imaging (MPI) has had a major impact in the diagnosis of coronary artery disease. MPI is a well-established cardiac diagnostic process in which a radioactive tracer (radionuclide) is injected intravenously under the separate conditions of rest and stress. The tracer is taken up by the heart in relation to blood flow.

The most common method to accomplish MPI is called Singular Photon Emission Computerized Tomography (SPECT). As its name implies, the radioactive tracers in the myocardium emit single photons (gamma rays) that are detected by a standard nuclear camera and computer software generating scans which can be read as tomographic slices. However, in certain instances, the Positron Emission Tomography (PET) method may be more beneficial.

What is a Cardiac PET?

A Cardiac MPI PET uses a radionuclide technique combined with a low dose CT machine to produce a series of high quality images of the heart. Computer graphics can be used to create a 3-dimensional image of the heart.

Rubidium-82, the radionuclide used in PET is quite remarkable. It has a very short half-life (read minutes, not hours) and emits a positron which is a tiny bit of anti-matter that combines with an ordinary tissue electron. They annihilate each other, converting their masses to energy producing TWO highly energetic photons (gamma rays) that travel outward at 180 degrees. This geometry and energy production contributes to the high image quality.

Despite the high photon energies, the absorbed radiation dose to the patient during a PET is the lowest of all current cardiac nuclear procedures (due to the short half-life of Rb-82).

What patients might benefit from a Cardiac PET?

Patients who might benefit from a Cardiac PET include:

1. Patients in which there is a high index of suspicion for coronary artery disease but available objective evidence is inconclusive

2. Patients in which there is (or could be) a low count density with SPECT due to obesity or low cardiac output.

3. Patients in which there are attenuation problems due to significant size and/or density of breast tissue in women, or elevation to the left hemidiaphragm , as well as other possible extra cardiac attenuators such as plural effusions

Why Cardiac PET?

Cardiac MPI PET scans rarely produce "false positives" (test results indicating heart disease where none exists) or “false negatives “(“normal” test results when in fact significant coronary heart disease exists). Because of their high accuracy, Cardiac MPI PET scans are often used to confirm other tests when a false positive or false negative is suspected. This non-invasive, highly accurate diagnostic tool may benefit patients in need of cardiac imaging.

Donald G. Gordon, MD, FACC is a cardiologist at Cardiovascular Associates of the Southeast in Birmingham, Alabama. He is board certified in both cardiology and nuclear medicine.

Monday, May 18, 2015

Is the Cloud for everyone….absolutely NOT!

By: Jeremy Beck

Cloud computing continues to mature. It is big business with many companies now offering cloud based services and solutions. For example, Microsoft has invested billions in cloud based infrastructure and awareness. There are many advantages to the cloud but there are some potential disadvantages as well that need to be realized before making a transition. The Cloud can be a wonderful solution, but it can have some drawbacks as well. In this article I will detail several of both.


Almost Unlimited Storage………Storing information in the cloud gives you almost unlimited storage capacity. This avoids worrying about running out of storage space or increasing your current storage space availability when it’s needed.

• Enhanced Backup and Recovery………Since all your data is stored in the cloud, backing it up and restoring the same is easier than storing the data on a physical storage device. Furthermore, most providers are efficient enough to handle recovery of your information. This makes the entire process of backup and recovery much simpler than other traditional methods of data backup and storage.

• Automatic Software Integration……..In the cloud, software integration is relatively simple. Generally you can handpick those services and software applications that will best suit your particular needs.

• Mobility…….access from anywhere. Whether it's your development platform, office tools or custom content management systems, cloud mobility enables access from anywhere with an internet connection.

• Scalability……..This is a big benefit. You can scale your infrastructure up and down according to demand. However that flexibility does come with a cost (see list of disadvantages).

• Limited Upfront Hardware Investment…….. The cloud can limit your upfront costs for traditional hardware components like servers and data storage devices.


• Security, privacy and compliance… can be a concern in the cloud, if you manage confidential patient data. Compliance in the cloud may also be an issue, which might require deploying a private cloud to better protect sensitive data. Question: will a third party have your best interest in mind when it comes to your sensitive data? The argument that the cloud is insecure is still raging. As you are aware, there have been many data breaches involving huge companies with no shortage of IT expertise and plenty of money to invest in security. The FBI says it is over 250 days before an entity knows they have been hacked. That’s a lot of time for hackers to lay their web. This could potentially put your practice in great risk. This demands that you make absolutely sure that you choose the most reliable service provider, who will keep your information totally secure. That may be tough.

• Technical Issues………You should be aware of the fact that this technology is always prone to outages and other technical issues just like any other type of service. Even the best cloud service providers run into this kind of trouble in spite of keeping up high standards of maintenance. Besides, you will need a very good Internet connection to be logged onto the server at all times. Losing internet connectivity is never fun, and is always an inconvenience for anyone involved. You will invariably be stuck in case of network and connectivity problems.

• Compatibility…..Making sure every existing tool, software and computer is compatible with the Web based service, platform or infrastructure can be a challenge. While on-site IT may have a little more control in managing integration and compatibility, it is often "what you see is what you get" in the cloud. For example, many offices have made the switch to the cloud and then found watching training videos, listening to streaming audio, or accessing webinars to be much more difficult to manage than previously expected.

• Scalability…….this flexibility comes with a cost. The cost per hour for a cloud server can actually be greater than the average hourly cost of a server when it is amortized over its lifespan. This means that, for some companies, with certain computational workloads, it might actually make more sense to run those workloads internally rather than putting them on the cloud. In a recent situation, we encountered a practice that was debating keeping their email in the cloud versus bringing their email in-house. Ultimately they decided to move it in-house. Why? Because over a four year period they were going to save almost $15,000. These factors need to be evaluated and calculated before making any long term decisions.

• Unpredictable costs……Sure, the cloud can substantially reduce staff and hardware costs, but the price could end up being more than you budgeted. Migrating to the cloud is also a potential understated cost, and making sure your current systems that support your business are managed effectively while moving to the cloud could raise operating costs substantially.


Ultimately, a move to the cloud must be considered by companies like any other major change in technology: the benefits and drawbacks need to be weighed against each other and evaluated diligently. Just as in other Information Technology shifts, there will be situations where it makes sense and situations where it doesn't. Recognizing this doesn't weaken the cloud advocates position, but rather helps them display a maturity of thought that will be ever more important as the cloud continues to evolve. IT 4 the Planet is a provider in professional Information Technology solutions to clients in the southeast. We provide both cloud solutions and standard on premise infrastructure. Bottom line for us….we try to find the best option for the client!

Jeremy Beck is Director of Sales and Business Development at Integrated Solutions.

Thursday, May 14, 2015

How to Care for Your Body While Running

By: Dr. Christopher S. Carter

Running is often mentioned as one of the best forms of exercise. While great for losing weight and building muscle, it can actually cause more harm than good if you don’t properly care for your body.

Whether you are training for a marathon or jogging around the track, these five steps will help keep your body from enduring unnecessary stress or injury, help you increase your speed and reduce the amount of aches and pains you feel during your run.

1. Formulate a running plan based on your fitness goals and abilities.

While it’s always important to start your run with a warm-up and end with cool down, what is in between should be catered to each individual runner. Ultimately, you know your body best; listen to it! Start a running diary to chronicle how you feel before, during and after each run and to determine the progression of your running goals. Join a running group or talk to a seasoned expert to formulate a running plan based on your training level and running diary observations.

  2. Invest in an actual running shoe.

A specialty running-shoe retailer will suggest shoes based on the way you run and the make-up of your feet. Wear the shoes around the store for at least ten minutes to test them before you commit as it is up to you to determine if they are comfortable. (Note: It’s important that they fit snug to reduce the risk of blisters.) If you find a perfect shoe, invest in a few pairs because a running shoe only has a life span of about six months or 500 miles.

3. Maintain a healthy diet and continuously rehydrate.

It is important that while training you take in the proper amounts of nutrients and vitamins to maintain your energy and eliminate cramping. While you are training, eat foods that contain calcium, protein, healthy fats and complex carbohydrates. Lean meats, fruits, vegetables, whole grains and legumes are all great choices.

Hydration is particularly important before and during your run. When sweating you lose electrolytes, so drinking sports drinks are a good addition to water. You should drink based on your sweat rate. If an athlete doesn’t know their sweat rate, general fluid recommendations include 5-10 ounces of water or sports drink every 15-20 minutes.

4. Remain in constant control of your body while running.

Pay particular attention to your running form. It is important your body stay relaxed and in perfect alignment. Keep your head up, your back straight and your hips facing forward. Your arms should remain at a 90-degree angle, and your hands should stay loose. Keep your shoulders and neck relaxed while you run. Don’t bounce or take too big of strides.

5. Keep your breathing in check.

You should be breathing deeply from your belly and not your chest. Take breaths in through both your nose and breathe out through your mouth. When running with a partner, take the “talk” test. If you are unable to carry on a conversation while you are running then you may need to decrease your intensity.

Slight aches and pains are okay and even welcomed after a run, but if you start to feel severe pain, pause your training and visit with your physician about your condition. For more information about caring for your body while running regularly talk with your doctor or call Dr. Christopher Carter’s office at 205-940-4690.

Tuesday, May 12, 2015

Is It Time to Consider Surgical Weight-Loss?

by Cameron Askew, MD

Health and wellness should be the heart of every family, but often get pushed to the bottom of the priority list. Between school, work, activities, and meetings, we are left with little time to plan for healthy meals and active living. In many families, this responsibility falls on the shoulders of mom. While juggling all her other daily activities, she is supposed to stay up to date with nutrition, make healthy but delicious meals, plan activities and exercise for all, and figure out how to make it work in the budget. For many moms this is an exhausting task, and even moms who succeed in accomplishing this goal often do so at the expense of their own health. How do we stop this cycle and get the whole family healthy and happy?

The answer, while difficult to implement, is quite simple. Mom has to prioritize her health. When mom makes healthy choices the rest of the family follows. The right place to start is always dietary changes (increased protein, vegetables, healthy fats), increased activity (running, walking the dog, yoga) and behavioral modifications (no smoking, no binge eating, minimal alcohol intake). Unfortunately these changes alone are not enough for everyone and are also very hard to do long-term because of cost and time. If you have tried diets and weight-loss programs with little or no sustained success, then weight loss surgery may be the answer for you.

The hard truth is that patients with a BMI > 35 only have a 5% chance of successful sustained weight loss with diet and behavioral modification alone. Surgery is not an easy way out or a “quick-fix”, but it absolutely is a kick-start to weight-loss that is actually sustainable long-term. Laparoscopic gastric bypass, sleeve gastrectomy and adjustable gastric banding are appropriate for patients with a BMI > 35 with comorbidity, such as type II diabetes, hypertension, high cholesterol, or obstructive sleep apnea, or patients with a BMI > 40. The lap band surgery is also available for patients with a BMI > 30 with comorbidity. If you are interested in learning more about your options, please attend one of our surgical weight loss classes. Visit Brookwood’s website to register for a free, upcoming seminar at

Dr. Cameron Askew is a weight loss surgeon with Brookwood Medical Center_Cameron S. Askew MD, PC_ Bariatric and General Surgery

Monday, May 4, 2015

Atypical Gastroesophageal Reflux Disease

By: David J. Landy, MD, Birmingham Gastroenterology Associates

Atypical GERD is a subset of gastroesophageal reflux disease (GERD), and is a common problem seen by gastroenterologists in private practice. Garden variety GERD is one of the most common diagnoses that we see. The prevalence of GERD in the western world is reported to be between 10 and 20%. In a typical specialty practice, we are likely to be seeing only the tip of the iceberg when it comes to severity. With the current availability of over the counter medications, i.e. Nexium, Prilosec, Zantac, etc., many people are able to effectively treat transient esophageal reflux on their own. We suspect that there are also many people that likely have full blown GERD who we don't see and are also self medicating. Because of potential complications and issues that can arise from chronic GERD, we do recommend consultation with either a primary physician or a specialist if GERD symptoms require medications for greater than 8 weeks. Many patients who have simple GERD are cared for by their primary physicians and not sent to a gastroenterologist, unless they either become refractory or have had GERD for many years. The Atypical GERD patients can be a complicated endeavor for both the patient and the treating physician to handle.

It is important to make a distinction between what we consider GERD and what is considered "normal" esophageal reflux, which almost everyone has experienced from time to time. Physiologic (or "normal") reflux happens typically after meals, is short lived, and rarely occurs during sleep. GERD is more symptomatic frequently with inflammatory changes (esophagitis) seen as erosions/ulcers on endoscopy or pathology. About half of patients who are untreated with GERD have this kind of inflammatory response. Heartburn, or sometimes indigestion, can be typical presenting symptoms. If an individual has heartburn or any other reflux type symptom consistently more than 2 days a week, it is considered to be GERD. These symptoms of GERD respond easily to acid lowering medications, such a proton pump inhibitor (PPI), e.g., Prilosec.

Atypical GERD is not as easily treated with over the counter Prilosec or Nexium. Most of the problems associated with atypical GERD are considered complications of extraesophageal reflux. When stomach acid and/or other contents of the stomach, sometimes including bile acids, reflux past the lower esophagus and up to the area of the airway opening, we can then see complications such as asthma, posterior laryngitis (hoarseness), chronic cough, dental erosions, chronic sinusitis, recurrent pneumonitis, amongst other issues. Gastroenterologists are ready and available to help deal with these complicated problems.

About one half of patients with atypical GERD, i.e., chronic cough, noncardiac chest pain, or hoarseness, will respond to high dose proton pump inhibitors, such as Nexium. When starting a new regimen, the perceived effects can be fairly rapid, but it is typically helpful to wait at least two full months to get the maximum effect. At least some improvement should be expected over 2 weeks. A generic PPI prescribed twice daily for two months, followed by either a different generic PPI for two months, and if possible a trial of a high dose brand name PPI, such as Dexilant or Nexium will be used to treat these atypical symptoms. If there is an adequate response, the medication would be continued at that high dose for 6 months and then attempt to wean back down to a once daily regimen. The high dose regimen could be continued indefinitely if that is what is controlling the patient's symptoms.

Unfortunately, about half of patients will not respond to any manner of PPI medication. Most of those patients may have some but not adequate benefit from PPI and will live with the symptoms. In these cases, discussion of further options to diagnose or treat these refractory symptoms should occur. The evaluation and treatment become more cumbersome, expensive, risky and not as effective at this point in the process. Many times patients will learn to live with atypical GERD symptoms, which can be fortunately very mild before moving on to more complicated evaluation and treatment. Of course, we have patients with more severe symptoms who choose to be further evaluated, and we have success with many of these patients but not all of them.

Many times, the recommendation is an EGD with Bravo probe to obtain 24 hour pH data. This is usually done while the patient is off of acid lowering medication to see if acid is actually the culprit. Sometimes, reflux and associated symptoms can be secondary to bile reflux and/or reflux of stomach contents, which can be noxious to the throat, airway, and/or sinuses. This can be very important data to obtain; because if acid is NOT the culprit, it would make sense why acid lowering medications are not effective. These patients will potentially benefit from a lap Nissen's fundoplication (or similar surgical type treatment).

A fundoplication procedure is aimed at tightening the lower esophageal sphincter (LES) by wrapping part of the upper portion of the stomach around the LES in an effort to help stop stomach contents from refluxing back up into the esophagus. Getting the correct degree of tightness on the wrap is fairly subjective at the time of surgery, and patients will respond differently in many cases. If the wrap is not tight enough, it will be ineffective, but if it is too tight patients may experience difficulty swallowing (dysphagia) or can develop gas/bloat syndrome. A fundoplication procedure is sometimes indicated for atypical GERD and refractory symptoms not responsive to PPI's. However, these procedures are not commonly offered because it requires the risk of anesthesia and surgery, and patients are extremely variable as to how they respond. However, if the surgery is pursued, the Bravo 24 hour pH would be obtained, as well as an esophageal motility study to make sure that the patient doesn't have achalasia or scleroderma esophagus, which would be contraindications to the surgery. Another medical pharmaceutical option that is even less attractive is a trial of reglan. Reglan is a pro-motility drug commonly used for nausea. However, the drug has fallen out of favor, because it is not overly effective. It is a hard medication to take long term because of potential side effects notably tardive dyskinesia, which is an irreversible condition that causes tremors.

In conclusion, atypical GERD or gastroesophageal reflux with extraesophageal complications, is sometimes difficult to identify and frequently difficult to treat. It is important to recognize since it can mimic other diseases and potentially can be treated simply with the correct dose of a PPI medication.