Wednesday, October 28, 2015

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.

Monday, October 26, 2015

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.


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

Wednesday, October 21, 2015

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.

Tuesday, October 20, 2015

Birmingham Heart Clinic Physicians Perform New Procedure

By: Dr. Jacob Townsend and Dr. Robert Yoe with Birmingham Heart Clinic

Physicians at Birmingham Heart Clinic are now utilizing the transcatheter aortic valve replacement (TAVR) procedure at St Vincent’s East. TAVR is a less-invasive approach to aortic valve implantation for patients considered high-risk or inoperable for traditional open-heart valve surgery.

BHC cardiologists Drs. Jacob Townsend and Robert Yoe are performing the valve replacement using the Medtronic Evolut R transcatheter heart valve. A team of cardiologists and cardiovascular surgeons perform the procedure, which treats severe aortic stenosis by using a catheter-based process to implant an artificial valve.

Aortic stenosis occurs when aortic valve does not open properly, hindering the heart from pumping blood throughout the body. If left untreated, the aortic valve creates additional work for the heart, leading to heart failure and finally death. Symptoms of aortic stenosis include chest pain, fatigue, feeling faint, passing out, and shortness of breath with activity. It is diagnosed with an exam and cardiac ultrasound. Historically, surgical aortic valve replacement has been the treatment of choice, and continues to be for most patients; however, aortic stenosis is frequently not severe until patients are in their 70s and 80s, at which point their surgical risk is often higher. In fact, up to 30 percent of patients with severe aortic stenosis are not candidates for surgical therapy, and may be best served by TAVR.

The Medtronic Evolut R is a new generation of transcatheter valve, combining an increasingly small catheter with the unique ability to be recaptured and repositioned to ensure proper placement. Its size allows nearly all patients to be treated from a femoral arterial approach with a preferred access site to reduce complications and speed recovery. It is designed to replace a patient’s diseased native aortic valve without the need for open-chest surgery and without stopping the patient’s heart, making it ideal for patients who are considered high-risk for open heart surgery.

During the procedure, the bio-prosthetic valve is guided by a catheter to the heart. After the valve is in the correct position, the catheter is retracted, allowing the newly implanted valve to self-expand and take over the function of the native aortic valve.

When symptoms develop in patients with severe aortic stenosis, there is a well-plotted decline through heart failure to death. While medical therapy has not been shown to affect this course, valve replacement offers lifesaving intervention. This has been reserved in the past to those who were reasonable surgical candidates, but can now be offered in a much less invasive manner for those at higher risk. Ongoing studies are evaluating TAVR in low and intermediate risk patients, but it is clearly the preferred option for those at high-risk for surgical complications.

For more information on the TAVR procedure being offered by Birmingham Heart Clinic, call 205-856-2284

"Halloween" The dangers of cosmetic contact lens

By: Caroline Pate, OD, FAAO with UAB Eye Care

With the Halloween season upon us, it is a good reminder to bring up the discussion on the dangers of cosmetic contact lens abuse. Today, nearly 41 million adults in the U.S. (16.7%) wear contact lenses as an option for their vision correction. There are also options available for patients who, in addition to wishing to correct their refractive error, can change the look of their eyes with cosmetic contact lenses. There are contact lenses on the market that can enhance the current color of one’s own eyes to make them brighter or more defined, make brown eyes blue, or even make your eyes look like those of a cat, zombie, or glow-in-the-dark reptile for Halloween. Decorative lenses are often sought after for theatrical purposes in order to create a special “look” or put the finishing touches on a costume. Many times, consumers do not understand the risks associated with these lenses. Contact lenses and lens care products are medical devices under regulations through the U.S. Food and Drug Administration (FDA), who oversee their safety and effectiveness. Whether correcting refractive error or not, cosmetic contact lenses fall under the same regulations and require a prescription from an eye care professional, and should never be acquired through vendors such as beauty supply stores, gas stations, flea markets, online trading sites, or pop-up Halloween stores. If a retailer is selling contact lenses without requiring a prescription from an eye care professional, then they are doing so illegally.

Although cosmetic contact lenses can seem to the consumer to serve the purpose as a fashion accessory, wearing these lenses carry the same risks associated with their wear and care as their refractive-correcting counterparts, and should be carefully monitored by an eye care provider. There is no such thing as a “one size fits all” contact lens. In a 2014 survey by the American Optometric Association, 11% of consumers without refractive correction have worn decorative contact lenses, and 53% of those individuals said they’d purchased them without a prescription. Dangers of improperly fit cosmetic lenses and consequences of poor lens hygiene include sight threatening complications such as inflammation, infection, scarring, corneal abrasions, blood vessel growth onto the cornea, decreased vision, and even blindness. These risks can be greatly minimized by receiving a proper contact lens fitting with an eye doctor including individualized education on lens care, hygiene, and replacement schedule. Anytime a patient presents with a history of contact lens wear and signs or symptoms such as pain, redness, or decreased vision, it is important that they receive prompt care for early intervention and treatment. Bacterial infections secondary to contact lens abuse can present and amplify rapidly, and lead to serious consequences if left untreated.

To safely wear cosmetic contact lenses, encourage your patients to do the following:

• Get a comprehensive eye examination and contact lens fitting from an eye care professional with proper follow up care.

  • Obtain a valid prescription which contains information including lens parameters and expiration date, even for lenses that are not correcting refractive error.

 • Never buy contact lenses without a valid prescription.

• Follow the care instructions provided for cleaning, disinfecting, and replacing the lenses.

• Never share contact lenses with anyone.

• If any pain, discomfort, redness, discharge, or decreased vision is noted, it is important to seek immediate medical attention from an optometrist or ophthalmologist.

For more information on the dangers of decorative contact lenses, visit, a website created by the American Optometric Association, the U.S. Food and Drug Administration, and Entertainment Industry Council to raise public awareness on the illegal and unsafe sales of cosmetic lenses.



Wednesday, October 14, 2015

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

Concussions…Ding dong…Not as simple as getting “your bell rung”….
Part 2 – Signs, Symptoms and Diagnosis

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

In part one of this article, we discussed the pathophysiology of head concussion, as well as the incidence of head injury in children and adolescents, emphasizing that the evaluation and treatment of concussions is not as simple as previously thought. In this article we will address the signs, symptoms and diagnosis of concussion; the complexity of the clinical picture can be a diagnostic challenge and a clinician must maintain a low threshold of suspicion for further evaluation, and be able to identify and respond immediately to life-threatening signs.

Signs, Symptoms and Diagnosis of Concussion

A thorough head injury assessment includes three diagnostic areas:

1) Characteristics of the injury itself

• the exact mechanism of the injury

• the direction of the “hit”

• type and location of the force

Even an apparently “mild” blow can cause significant injury. Rotational force can be a vital characteristic as it has been shown that angular acceleration may increase the actual risk of sustaining a concussion from 25% to 80%. It is important to ask if there was a loss of consciousness, although loss of consciousness only occurs in sports- related concussions approximately 10% of the time.

2) Symptom type and severity

Signs and symptoms of concussion are divided into four categories: somatic, cognitive, affective, and sleep. Somatic symptoms include what one would expect: headache, dizziness, vertigo, nausea/vomiting, photophobia and/or blurry vision, as well as phonophobia, a persistent, abnormal, and unwarranted fear of sound. Phonophobia is an anxiety disorder, not a hearing disorder. Cognitive symptoms include anterograde or retrograde amnesia, confusion or disorientation, loss of consciousness, and feeling “fuzzy” or “foggy”. Other cognitive manifestations include “staring into space”, focusing issues, delay in verbal or motor response, slurred or incoherent speech, and excessive sleepiness. Affective evidence of concussion includes labile emotions, irritability or fatigue, anxiety and sadness. Sleep may be affected by either sleeping too much or not enough. One of the diagnostic challenges with concussion is that it is an evolving injury in which an athlete may feel different immediately afterwards and then develop further symptomatology within 30 minutes to an hour. Monitor for signs of more serious injury or neurological deterioration during the first 24-48 hours. Red flags indicating the need for immediate evaluation and transport include loss of consciousness greater than 30 seconds, worsening headaches, repeated emesis, slurred speech, increasing confusion or disorientation, any unusual behavior; other worrisome symptoms include seizures or signs of cervical spine injury, such as weakness or numbness of the extremities, severe cervical tenderness, irritability, or loss in range of motion.

3. The risk of sustaining a concussion

The risk of diffuse cerebral edema is greater in children and adolescents which makes a second impact even more dangerous. Don’t feel pressured to allow the athlete to continue playing. Emphasize that playing with a concussion is dangerous! Monitoring should occur at least one to two hours after the immediate injury, and for at least 24 hours, as life-threatening signs can develop at any time during this time frame. Document the injury and discuss it with the child’s caregivers or parents. Specifically discuss with them signs of deterioration, when and how to seek medical treatment. This incident creates a teachable moment; time to provide coaches and parents some head injury education.

Handling an “on the field response”

Responding to an “on the field” event requires a three-step evaluation and an assertive management response:

1. The on field exam. A systematic review at the time of injury is crucial; perform the ABC’s initially, a mental status assessment, a brief neurological exam and a cervical spine status assessment.

2. Sideline evaluation. If an emergent disposition is not needed, the next step should be a sideline evaluation. At this point, conduct a more detailed exam, and obtain a past medical history, including but not limited to questions concerning whether the patient has a history of any known previous concussions. Ensure cognitive, somatic and affective symptoms are assessed. The number and duration of symptoms seems to be predictive of severity of the concussion. Evaluate the child’s orientation, memory, concentration, and balance.

A number of effective checklists and tools are available. The SCAT2 – the Sports Concussion Assessment Tool, developed by a consensus of sports medicine professionals, and recommended for athletes ages 10 years and older is commonly used 4 , 5

  3. Remove the athlete from the field. The third step is to remove the athlete from the field with no same day return to play. This is crucial. If a second hit is sustained, there is an increased chance of “second impact syndrome” which in its extreme form, can result in permanent brain damage or even death.

Whether diagnosis of concussion occurs in the office, ED or on the sideline, the exam should focus on cognition, neurologic exam, balance and any deteriorating neurological function. Neuroimaging studies should be reserved for suspicion of intracranial hemorrhage, skull fractures or other structural injury and be based on neurological exam, symptom assessment, and mechanism of injury. Practices vary, and currently there is no clear cut evidence on when to perform neuroimaging studies. Hospital admission should be considered if repeat serial exams may be required due to signs of intracranial injury or fluctuating or deteriorating symptoms are occurring. When dealing with children, if there is any question of inadequate supervision or follow up, then hospital observation may be warranted. 6

In summary, the clinical picture of concussions can be an evolving and fluid process. Clinical judgement plays a critical role in diagnosis and medical decision making for further evaluation. The importance of educating those caring for the child or adolescent cannot be overemphasized as deterioration can occur in the first 24 hours after the initial injury. 

In Article (3) we will discuss concussion complications, treatment options, and recommendations for follow up care.

Published October 2015


3 Consensus statement on Concussion in Sport – the 4th international conference on concussion in sport held in Zurich, November 2012. Journal of Science and Medicine in Sport 16(2013) 178-189
4 Consensus statement on Concussion in Sport – the 4th international conference on concussion in sport held in Zurich, November 2012. Journal of Science and Medicine in Sport 16(2013) 178-189

Tuesday, October 13, 2015

Intelligent Giving

By: J. Samuel Fitch, CFP® with Bridgeworth, LLC

I have always been impressed and inspired by how charitable people are in the South. There is no limit to the number of organizations that are truly making a difference in our communities.

If you are planning to make a relatively substantial contribution to a charity, such as a church or synagogue, university, hospital, or other qualified charitable organization, you should consider donating appreciated stock or mutual fund shares instead of cash. You can receive meaningful tax benefits from the donation and the organization will be excited to receive the gift.

As an example, assume Ben and Jerry each inherited shares of General Motors stock 20 years ago worth $25,000 with a $5,000 tax cost basis.

Ben decides to sell his stock so he can give cash to a local charity. This creates capital gains tax of $4,000 (assuming a 20% capital gains rate) so he gives the remaining $21,000 to the charity. Assuming he is in a 25% tax bracket for Federal and State, Ben realizes a tax savings of $5,250 as a charitable tax deduction.

Jerry, on the other hand, decides to donate his actual shares of General Motors to his alma mater. He receives the full benefit of the value of the stock at $25,000, does not pay any capital gains tax and realizes a tax savings of $6,250 since he is also in a 25% marginal tax bracket. Obviously, a much better result for both the university and Jerry.

The key facts to know are:

• You will be eligible to receive an income tax charitable deduction for the full market value of the shares at the time of the gift.

• If the security has been held for at least one year, you will avoid paying capital gains tax.

• The organization you are donating to must have an investment account that can accept the securities “in-kind”.

• The gift must be made by December 31st to qualify for the current tax year.

• The gift of appreciated shares is fully deductible up to 30% of your adjusted gross income (high income donors may be subject to a partial phase out).

This tax planning technique is derived from the general rule that the deduction for a donation of property to charity is equal to the fair market value of the donated property. Where the donated property has an unrealized long-term capital gain, the donor does not have to recognize the gain on the donated property. These rules allow for the "doubling up," so to speak, of tax benefits: a charitable deduction, plus avoiding tax on the appreciation in value of the donated property.

The tax aspects of charitable giving can be complex so please consult with your tax professional before making any gifts. However, executed properly, gifting appreciated shares is a great way to support the causes that are most important to you while also reducing your tax burden.

*Charitable Contributions of Stock, Roy Lewis, The Motley Fool

*Charitable Donations: The Basics of Giving, by Rande Spiegelman

This commentary is provided for information purposes only and does not pertain to any security product or service and is not an offer or solicitation of an offer to buy or sell any product or service. Any opinions expressed are based on our interpretation of the data available to us at the time of the original publication of the report. These opinions are subject to change at any time without notice. Bridgeworth, LLC does not undertake to advise you of any changes in the views expressed herein. Unless otherwise stated, all information and opinions contained in this publication were obtained from sources believed to be accurate and reliable as of the date published or indicated and may be superseded by subsequent market events or other reasons.

Risks include, but are not limited to, liquidity, credit quality, fluctuating prices and uncertainties of dividends, rates of return, and yield. Past performance does not guarantee future results. Investors should consult their Financial and/or Tax Advisor before making any investment decision.

BTN #1-405505.0715.

Thursday, October 8, 2015

Increasing Profitability by Establishing Staff Accountability

By: Hal ‘Buzz’ Coons III, CPA, Pearce, Bevill, Leesburg, Moore P.C  

When I conduct my initial discovery meeting with a new client, the first questions that I ask are “Do you know what your staff does on a daily basis?” and “Is there a system of accountability and measurement?” The answers I get range from “I have no idea what my staff does” to “I do not interact with my staff at all.”

It’s important to identify the deficiencies that exist in your practice with respect to human resources and how to correct them. This is one problematic area where profit leaks may exist.

Employee Accountability

Enforcing employee accountability in the workplace can be a challenging task. Physician business owners are experts at exercising proper bedside manner and often find themselves in a position of having to deliver life changing information to their patients. However, put them in a position that requires enforcing accountability with their staff and they often prefer to do nothing and simply hope for the best. Unfortunately, taking this position costs practices a significant amount of wasted time and money.

The warning signs are numerous and often common among offices. They consist of patient complaints, high employee turnover, frequent absenteeism, office staff conflict, getting to work late, texting, stealing time and ultimately, interruptions in your day due to poor office and front desk management. All of these items will cause profit leaks, impact your office’s net income and productivity, and they could cause a 10% to 15% decline in net profits. For the physician-owner this particular type of profit leak is more difficult to measure in terms of dollars which is often the reason the problem is not addressed properly.

Addressing the Issue at Hand

The first step is to acknowledge the problem exists. Next, identify a measurable area for improvement and assign a dollar amount to the profit leak you want to address. One example would be employee texting in the office.

Example- if you have eight employees and each employee spends 15 minutes a day texting, it would add up to two hours per day of unproductive time. Do the math and now you are looking at 10 hours per week or 520 hours per year. Now take it a step further and calculate this number using your average wage rate. For this purpose let’s use $18 an hour. What seems like harmless texting (only 15 minutes a day) is costing the practice over $9,000 a year.

Of course this is a simplified example, but you can apply this methodology to other profit leaks that involve human resources, such as patient insurance benefit verifications or pre-certifications, proper patient demographic intake and the cost of employee turnover and retraining. Then, you will realize that there are significant costs to not maintaining a proper system of human resource internal controls.

What Changes Need to Be Made

The task of implementing change in an effort to establish employee accountability begins with managing expectations and then communicating to your employees not only what you expect from them in terms of productivity, but also what they can expect from you as their employer. If you are not able to communicate your expectations, then it is your responsibility to share the blame if poor employee performance exists in your practice.

You need to incorporate job descriptions and written job functions for each position into your practice. Job descriptions will provide an employee with an outline of what the duties of his or her position encompasses. More importantly, written job functions will give your employees the information they require on how to complete tasks.

Create a ‘how to’ folder on your computer system that employees can reference when necessary. Anytime a job function comes up that initiates a question, take the time to have the solution documented and saved on your server. The initial time required to have the solution written up will save you countless hours and will improve productivity in the future.

Establish a Measurement System

Measurement is the key to establishing a successful system of management and helps facilitate employee accountability. The question often asked is what to measure? This can range from the obvious, such as average wait time for a patient to be seen and patient satisfaction surveys to accurately capturing current patient demographics and benefit verification information, as previously mentioned.

After your system of measurement is established, develop achievable goals for your employees to accomplish. Your team should develop an understanding that the work they do is important to the profitability of the practice. It is important that you communicate results to your employees and the relevance of a job well done. Achieving and surpassing measureable goals should be rewarded with some form of incentive. Alternatively, lack of accountability and poor performance should be met with consequences such as stagnant wages, demotion, reduced responsibility, and if necessary, dismissal.

To record and monitor employee performance, develop written performance reports to review with your employees bi-annually, or annually at a minimum. It is your opportunity to communicate your measurement of their achievements and manage expectations for the future.

A Recipe for Success

Creating a system of employee accountability is paramount to a successful office culture and environment. Maintaining a system of open dialogue and communication with your staff will improve the profitability of your practice. The physician business owner needs to embrace the changes required to improve practice profitability wherever it is achievable.

Hal ‘Buzz’ Coons, III, CPA is a partner with Pearce, Bevill, Leesburg, Moore P.C an accounting and consulting firm located in Birmingham, Alabama. Buzz is also President of the National CPA Healthcare Advisors Association, a nationwide network of CPA firms devoted to serving the healthcare industry. Buzz can reached at  

Monday, October 5, 2015

Concussions…Ding ding…Not as simple as getting “your bell rung” anymore?

By Ann L. Contrucci, M.D.

Concussions – what to do? In “the good ol’ days”, children or adolescents with concussions or “getting your bell rung” were back in the game very quickly, often within minutes. Follow up or objective neuropsychological testing was also rarely performed. As more and more research is done, diagnostic and treatment options including follow up of head trauma has become more involved. This issue confronts primary care and ER doctors on a daily basis making care for patients with concussions confusing and complex. To complicate things further, giving the proper amount of time needed to care for the patient can also be taxing on an already stressed staff.

This article is the first in a three-part series dealing with the pathophysiology and statistics of this common injury. The second article will focus on the clinical picture and diagnosis, and the last on treatments, complications and follow up recommendations. The series will spotlight concussions in children and adolescents as they exhibit certain unique characteristics.

Some of the statistics surrounding concussions in children and adolescents illustrate that this type of injury is extremely prevalent within this age group. During the 2008-2009 school year, 400,000 concussions occurred in high school athletes nationwide. From 1997-2007, ED visits for concussions doubled within the 8-13 year old age group and almost tripled for older children. A 2011 study of high schools with one or more athletic trainers on staff found that concussions were responsible for almost 15% of all reported sports injuries. Traumatic brain injuries in kids are associated with sports and recreational activities 21% of the time. Female high school athletes suffer more concussions than males: 40% more in soccer, and 240% more in basketball. Additionally, once a high school athlete has sustained a concussion, he or she is three times more likely to have another in the same season.

The definition of concussion is, interestingly enough, not universally accepted. A conglomeration of sports medicine groups define it as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Notably, this definition designates concussions as a functional injury, not a structural injury. This is why imaging studies do not show any abnormalities. The neurometabolic cascade involved occurs after some kind of traumatic force triggers neuronal dysfunction. In turn, this results in axonal dysfunction. Besides the aforementioned trauma-induced disruption of brain function, concussion characteristics must include at least one of the following as well as a Glasgow Coma Score of 13-15: an alteration in mental status at the time of injury, amnesia less than 24-hours before or after the event, loss of consciousness, or focal neurological deficits that may be transient.

With a still developing brain children and adolescents are even more susceptible to concussions. Why? The tissue is unable to recover as quickly as adult tissue because it is more vulnerable to neurochemical and metabolic changes. The axons themselves are not as myelinated or insulated as the adult brain, increasing the likelihood of injury. Secondly, younger athletes’ muscles are less developed and therefore insufficient at absorbing traumatic forces, i.e. cervical and shoulder musculature is not as able to withstand the shock of a blow to the head. Not using the proper technique in defending against a hit in sports also increases their risk.

No two concussions are alike, even with similar mechanisms of injury. Sometimes a mild traumatic brain injury can have long lasting impact and complications including sleep disturbances, cognitive impairments, and more. A recent trend has moved away from the traditional “grading” system used in diagnosing and treating concussions and towards an individualized assessment of symptoms to determine best course of treatment and follow up. This will be covered in detail in the second part of this series. Stay tuned!

Ann L. Contrucci, M.D., Director, Risk and Patient Safety at MagMutual Patient Safety Institute. Dr. Contrucci continues to practice pediatrics in a tertiary care children’s Emergency Department as well as in primary care offices.