Join Children’s in Celebrating Heart Month

By: Dr. Robert J. Dabal, chief of pediatric cardiac surgery and an associate professor of surgery in the Division of Cardiothoracic Surgery at the University of Alabama at Birmingham (UAB).

Every year surgeons at the Pediatric and Congenital Heart Center of Alabama at Children’s of Alabama perform hundreds of cardiopulmonary surgeries. If a child in Alabama needs one of these life-saving procedures, they will likely get it at Children’s.

Our expertise in treating congenital heart disease (CHD) in children can be traced back to Dr. John W. Kirklin, a legendary heart surgery pioneer, clinician and scientist who came to UAB from the Mayo Clinic in 1966 and died in 2004. In recent years, we have moved into state-of-the-art facilities at Children’s where we perform most of our procedures.

These days, we take a team approach to treating patients. In the past, doctors would work more or less independently, for instance, with patients moving from cardiologists, to surgeons, to ICU. Now, everybody is involved in every aspect of care. When patients enter the hospital, a team of doctors and nurses provide a continuum of care from admission to discharge and beyond. For example, a child coming in for open heart surgery will have a minimum of three doctors taking care of him or her at all times.

We spend much time and effort sharing data with a nationwide collaborative, run by the Society of Thoracic Surgeons, of congenital heart surgery programs. Every time we perform an operation, we enter all the information in a database that allows us to compare time in hospital, time in ICU, time on ventilators and other variables. We are proud of our outcomes. Last year, our surgical mortality rate was 2.6 percent, which is lower than the national average of 3.2 percent. That’s great for us and great for the children here.

A third of our patients are under 30 days old, and those tend to need the most complicated operations. Therefore, they spend the most time in the hospital. Another third of our children are between about 30 days old and 2 years old. And the final third of patients are toddlers through adults. Our program also has a component for adults who have congenital heart disease, and most of those operations are performed at UAB by Dr. James K. Kirklin. Because of the outstanding success of the current surgeries, we expect that portion of our program to expand as generations of pediatric patients grow older and require follow up care.

A significant percentage of surgical patients need to be followed for a lifetime. Recently, Dr. Kirklin saw a 39-year-old patient who had surgery as a baby. The patient had been followed by a pediatric cardiologist until she was 13 and then released from care. It turns out that her pulmonary valve had been removed, and needed to be replaced. It shows that many if not most patients need lifelong follow up. The more complicated an operation is early in life, the more likely that follow up is needed late in life.

We also work cooperatively with interventional cardiology on hybrid procedures. Our new facility at Children’s includes a large cardiac catheterization lab that can double as an operating room, a hybrid room.. It has equipment for both specialties. While the cost of building and equipping this one room in the hospital was extremely high, it allows complicated operations to be performed in a more stream-lined fashion. Recently, I opened a child’s chest, performed a surgical repair and then put a catheter into an artery so a cardiologist could put a stent in a blood vessel. Then I removed the IV. The hybrid room made it easier on me, easier on the cardiologist and easier on the staff. But most importantly, the hybrid room made the operation easier on the patient.

As the field has evolved, results have improved, and now, there’s more emphasis on outcomes other than mortality. In the next decade we will be looking more closely to what happens to patients after the immediate post-op period. We want to see problems that arise in 6 months, 12 months or 5 years. That will help ensure that we are doing everything possible to protect the brain and other critical organs. Our goal is to provide patients a lifetime of good health, with hopes to restore a normal life expectancy.

Dr. Robert J. Dabal is the chief of pediatric cardiac surgery and an associate professor of surgery in the Division of Cardiothoracic Surgery at the University of Alabama at Birmingham (UAB). His areas of expertise include neonatal and pediatric cardiac surgery. Dr. Dabal graduated from Duke University School of Medicine and completed his cardiac training at the University of Washington Medical Center. He completed fellowships in congenital heart surgery at Denver Children’s Hospital and Children’s Hospital Boston.

A Fantastic Endoscopic Voyage

By: Christopher P. Shaver, MD, Birmingham Gastroenterology


The Fantastic Voyage was a 1966 science fiction film about a team of scientists miniaturized and injected into the body of a world-renowned scientist dying of a brain aneurysm. Their mission was to pilot their mini-submarine to the depths of his brain to perform life-saving neurosurgery.

At Birmingham Gastroenterology Associates, we have the endoscopic technology to perform our own fantastic voyages. This voyage involves the endoscopic surveillance of the entire length of the small intestine. The human small intestine spans an average length of twenty-two feet. Due to its lengthy anatomy and relative inaccessibility, the direct inspection of this very important segment of the digestive tract was difficult. Consequently, a good look at the interior of the small intestinal tract was reserved for risky, low yield, and last resort operations.

The advent of the wireless video capsule changed all of that. The pill camera is an ingestible, wireless video camera that puts your Go Pro to shame. During its eight-hour battery life, its takes no less than 50,000 images. The images are uploaded into a sophisticated workstation producing a high definition video of the entire small intestine. The procedure is painless and the pill camera is disposable. A physician makes expert recommendations regarding future diagnostics and therapy based on the findings.

We utilize video capsule endoscopy primarily for the evaluation of two common conditions: undetectable gastrointestinal bleeding and unexplained, chronic diarrhea.

GI bleeding, often associated with chronic anemia, is frequently encountered in our patients. Though its source is usually easily identified, five percent of gastrointestinal bleeding events occur beyond the reach of conventional endoscopy. In this era of powerful blood thinning medications used to treat various cardiovascular and hematologic diseases, both overt and obscure GI bleeding events are quite common. Fortunately, we have a powerful diagnostic tool to shine a light on the depths of the gut previously beyond our reach.

Diarrhea is common symptom that significantly restricts the quality of life of many of our patients. Though routinely diagnosed and treated in a routine and uncomplicated fashion, its cause is occasionally elusive and the symptoms sometimes refractory. In situations where small intestinal inflammation is suspected, video capsule imaging is very helpful in inspecting the small intestinal lining for signs of damage.

Indications for wireless capsule endoscopy are expanding into the realms of celiac disease, hereditary polyposis syndromes, and malabsorption. Though not widely available, other novel uses for wireless capsule technology include Barrett esophagus screening and non-invasive colonic inspection. The wireless Smartpill is also available which assesses intestinal motility based on pressure, ph and temperature readings.

Well, the Fantastic Voyage ended well. Despite many close calls and the attempted sabotage of the mission, the brave medical pioneers successfully completed their mission by saving the scientist and returning home safely. The good news for our patients is that fantastic voyages in gastroenterology are no longer science fiction.

"Diabetes can do WHAT to my penis?"

By: Brian Christine M.D. with Urology Centers of Alabama


Diabetes.... now, why would a urology blog start off with "Diabetes"? The fact is that diabetes mellitus is one of the primary causes of Erectile Dysfunction (ED), and, since my practice is limited to male sexual dysfunction and male urinary incontinence, diabetes is a great way to start off this blog.

Not only is diabetes a major contributor to ED it is also a contributor to Peyronie's Disease. ED, which is the inability of a man to attain an erection that is rigid enough or long lasting enough to engage in satisfactory sexual intimacy, and Peyronie's Disease, which is curvature of the penis with an erection, are two of the disease processes that I see daily in my men's sexual health practice. Because of the damaging effect diabetes has on the arteries in the penis and the fibrosis of penile tissue caused by diabetes, diabetic men are at high risk for ED and Peyronie's Disease, and not uncommonly men with diabetes have both Peyronie's and ED.

Though ED is more widely discussed and known about by both patients and physicians, Peyronie's Disease can be, and often is, just as devastating to the patient and the person who loves them. The curvature of the penis in Peyronie's Disease can be so severe that penetration is impossible or extremely painful for the man's partner.

The encouraging news is that we have excellent treatments for both ED and Peyronie's Disease. I would ask my Primary Care colleagues to specifically query their diabetic patients about ED and Peyronie's, and if your patient has either or both refer them to a urologist. Personally, I am readily available to see your patients and to handle their sexual health care from the most basic treatments to more complex, surgical interventions. I promise you, your patients will be thankful and appreciative.

Atrial Fibrillation

By: Anil Rajendra, MD, Cardiac Electrophysiologist with Alabama Cardiovascular Group    

Background

Atrial fibrillation (afib) is the most common arrhythmia and affects over 2.5 million Americans. It is an irregular, unorganized heart rhythm originating in the top chambers of the heart (atria). When people are in afib, there are electrical signals originating from numerous locations in the atria, causing the atria to fibrillate or “quiver” rather than contracting normally. Many, but not all, the electrical signals in the atria are passed to the lower chambers of the heart (ventricles), often causing the heart rate to be rapid and irregular.

While afib is not a fatal arrhythmia, it does carry an increased risk of other issues, of which the most concerning may be strokes. Patients with afib have a 5 times increased risk of stroke. To minimize this risk, patients are placed on anticoagulation (blood thinners) to prevent blood clots from forming in the heart.

In addition, as mentioned previously, patients tend to have fast heart rates while they are in afib. If the heart continues to beat fast for an extended period of time, then the heart muscle may weaken and lead to heart failure. Patients with heart failure often complain of swelling in their legs or abdomen and difficulty breathing, particularly with activity or when lying flat.

The exact cause of afib is unknown. We don’t know yet why one patient develops afib and another does not. However, there are many risk factors for the development of afib, including high blood pressure, sleep apnea, diabetes, heart failure, among many others. If you have these medical problems, it is important to see your doctor regularly to ensure they are being adequately treated.


Types of atrial fibrillation

Afib is categorized based on the duration of the arrhythmia, i.e. how long patients remain in afib:

Paroxysmal afib -- intermittent episodes of afib. Episodes start and stop spontaneously and can last from seconds to days. Aside from these episodes of afib, the patient is in a normal rhythm.

Persistent afib – long episodes of afib that last over a week. These episodes of afib usually do not stop on their own. Patients will need medications to terminate the episode and restore normal rhythm, or they will need to have a cardioversion, which is an electrical shock to the heart to restore a normal rhythm.

Long-standing persistent afib – extremely long duration of afib that has lasted for over 1 year at least. These patients will almost always require advance therapies to restore a normal rhythm. However, despite these advanced therapies, patients are at high risk for recurrence of afib.

Permanent afib – afib is the permanent rhythm. The patients are always in afib and no attempts are made to restore a normal rhythm.


Symptoms

There is a wide spectrum of symptoms that patients experience when in afib. Some patients are asymptomatic, meaning they cannot tell at all when they are in afib. For patients who do have symptoms, these symptoms can include palpitations (feeling heart racing or irregular), shortness of breath, fatigue, weakness, dizziness, poor activity tolerance, among others.


Treatment of atrial fibrillation

For patients that do not have any symptoms related to their afib, then it is not necessary to try to prevent them from having episodes of afib. Instead, it is ok to let them remain in afib and to control the heart rate. As mentioned previously, it is important to ensure the heart rate is controlled to avoid possibly developing heart failure. For patients who are symptomatic from their afib, then it is important to try to prevent them from having afib to avoid those symptoms. Medications called anti-arrhythmic drugs can be used to try to keep patients in a normal rhythm. There are a number of different anti-arrhythmic drugs and sometimes patients will have to try several different ones before finding one that works well.

For patients that do not tolerate medications well or for whom the medications are not working well, an afib ablation is a very good option. This is a procedure where the origin of the abnormal electrical impulses that start afib are targeted with a catheter. The heart muscle is either “cauterized” (radiofrequency ablation) or frozen (cryoablation).


Prevention of Stroke

As aforementioned, patients with afib are at a much higher risk of stroke. Oral anticoagulation (blood thinners) are used to minimize that risk. There are several blood thinners available on the market, including warfarin (Coumadin), dabigatran (Pradaxa), rivoraxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). Blood thinners will increase one’s risk of bleeding, so patients on blood thinners need to be monitored by their physician closely.

For some patients, the risk of bleeding is too high, and they cannot take blood thinners for a long period of time. In those patients with high risk of bleeding, there is a device called the Watchman device that is available. The Watchman device is implanted inside the heart in the area where most of the blood clots form and will permanently seal off this area of the heart. Patients with a successfully implanted Watchman device, will be able to stop their blood thinner several weeks after the implant procedure.


Conclusion

Atrial fibrillation is a complex arrhythmia that can cause many different symptoms. If you think that you may have an irregular heart rhythm, it is important see your doctor to investigate whether you have afib. Although afib is a complex arrhythmia, it can be very well treated.

Pandaemonium and The Glucose and Gonadotropin Mystery

By: Matt Smith, MD with Alabama Pain Physicians, Comprehensive Pain Care


Several years ago, some of my colleagues and I were the attending physicians of an inpatient rehabilitation unit. It was a great experience. We had all become good friends and we had many similar interests. Among these common interests was that well before becoming attendings we had each become fascinated by the exercise and nutrition world. I was the beneficiary of a hand-me-down squat rack and for the year or so that we worked together, we would literally exercise this interest by meeting after work in my garage four times a week and practice the "slow lifts".

The “slow lifts” are some of the typical exercises done with a barbell. These include such basic movements as squatting and standing back up (the “squat”), picking something off the floor (the “deadlift”), and lifting something overhead (the “press”). For as simple and for as fundamental as these lifts were, we had never done them in earnest before and we were amazed at how the systematic practice of such basic movements yielded relatively profound results.

Our enthusiasm for our personal gains had the happy double benefit of not only helping us reap the rewards of stronger and leaner physiognomies, but it also coincided with our professional responsibilities. We were, after all, the medical doctors in charge of helping some very sick and debilitated people also get stronger, better physiognomies.

It was around this same time that a tremendous paradigm shift was just starting to break through the medical literature in regard to the medical scourge of our generation: the metabolic syndrome. And the relationships between obesity, visceral adipose tissue, systemic inflammation, sex hormones, muscle mass, and pain, and what this had to do with the metabolic syndrome, were just graduating from the nascent phase in becoming well understood. And all of these aspects of the metabolic syndrome were problems that nearly every one of our patients faced. Even before one of our patients had their incident that brought them into inpatient rehab - stroke, massive myocardial infarction, above the knee amputation, or some other horrid problem, our patients typically had nearly every manifestation of this syndrome. In fact, the reason that our patients experienced their MIs, AKAs, and whatnot in the first place were usually a direct result of this selfsame syndrome.

Thus we discovered what by that time was already in the literature for a few years, but which we had never been taught in our formal training. This is that in both males and in females there is a direct correlation between the metabolic syndrome and hypogonadism. In fact, not just a correlation but a multifactorial and complicated process of causation. Furthermore, as time went on, this new paradigm led us to learn that these complex processes extend far beyond mere glucose control, but also link such seemingly disparate things as wound healing, rehabilitation potential, all-cause mortality, pre-menstrual depressive disorder, traumatic brain injury, post-traumatic stress disorder, opioid induced hypogonadism, and chronic pain.

This nuance of the metabolic syndrome and hypogonadism made a particular impact on us when it led us to reconsider the treatment of one of my patients. This unfortunate gentleman was suffering immensely from an above the knee amputation because of severe peripheral vascular disease, ostensibly from poorly controlled diabetes mellitus. He was on metformin and supplemental insulin and nonetheless continued to have persistent markedly elevated blood glucose. Moreover, rather than healing, his surgical wound only got worse. With his poor glucose control, he was losing muscle and becoming rapidly cachectic. Numerous surgical revisions were doing little to slow the progression of a wound that would simply not heal. Instead of getting better with inpatient rehab, he was getting worse. In fact, his condition was so precarious that what had started out as a hopeful rehabilitation potential turned out to be negative rehabilitation potential.

But, remembering some of the research that we had just started delving into, and how testosterone is intimately tied to both glucose regulation and healing, we decided to check his free and total testosterone. He pretty much did not have any.

We then checked his leutinizing hormone. Leutinizing hormone is the hormone secreted from the anterior, or front, of the pituitary gland and responsible for telling the testes to make testosterone. This was virtually zero too.

Thus we immediately started a testosterone supplementation regimen (and of course consulted Endocrinology).

Upon starting testosterone, we noticed within two days a marked improvement in his uncontrolled blood glucose levels. In fact, the improvement was so marked that within a week we had to halve his metformin and decrease his supplemental insulin substantially.

What is more, seemingly overnight his wound started healing. This wound, which was refractory to numerous surgeries and the care of very talented wound specialists, was now healing rapidly on its own. He then re-started his engagement in rehabilitation. He gained strength rapidly. His mood of course vastly improved. He was eventually discharged and, as far as I know, did relatively well thereafter. In the process of all of this workup and treatment, one of the conundrums shared by both us and Endocrinology was why his leutinizing hormone was so low (and we would also discover follicular stimulating hormone and sex hormone binding globulin).

What we would come to understand is that our patient suffered from a phenomenon now called “Male Obesity-Associated Secondary Hypogonadism”, or MOASH for short. MOASH is not one particular disease, but something of a brief glimpse into the fascinating and pervasive interrelatedness between the phenomena of insulin resistance, generalized inflammation, and sex hormone dysfunction. What is even more interesting is how this is related to other, seemingly disparate phenomena, such as chronic pain, opioid use, PTSD, and traumatic brain injury.

To give an adequate description of the complicated web of causality that leads to MOASH and its variants is beyond the scope of this brief article. What is more, we do not totally understand exactly how it works and it is likely that it varies from person to person. Yet, one thing that appears to be a common denominator in most of its manifestations is one of the most dreaded phenomenon in medicine: the positive feedback loop.

Most of the human body works by way of a “negative feedback loop”. Take the normal secretion of the sex hormone testosterone. In the hypothalamus, the hormone gonadotropin releasing hormone (GnRH) is released in a pulsatile fashion. GnRH travels down to the front of the pituitary gland to cause the release of another hormone, “leutenizing hormone” (LH). In men, LH then travels down to the testes to cause certain cells to release testosterone. Once testosterone reaches a certain level in the blood, it tells the hypothalamus and pituitary to stop making GnRH and LH, thus regulating itself. When things are working well, testosterone negates its own production. Hence negative feedback loop.

Imagine why having a positive feedback loop would therefore be bad. What if testosterone did not negate its own production, but spurred it on? In short order, far too much testosterone would be made.

Of course the prototype of the positive feedback loop is cancer. All control is loss and bad things can happen very quickly.

What we witnessed with my patient and many patients thereafter was a positive feedback loop. We now know that low testosterone leads to insulin resistance. Yet insulin resistance also leads to low testosterone. This happens by a confluence of factors. Obesity causes a rise in insulin resistance. It can also cause a decrease in testosterone by converting it into estrogen by the enzyme aromatase, which is expressed heavily in fat cells. Estrogen can cause a dysregulation in GnRH, causing a decrease in testosterone. Low testosterone by itself can lead to poor skeletal muscle development, central adiposity, changes in a hormone called gastric-inhibitory peptide (GIP), and mitochondrial dysfunction. All of these cause worsening of energy metabolism and worse insulin resistance. Further, insulin resistance is part and parcel with a systemic inflammatory state that affects everything (this is why obese people are more likely to get wear and tear arthritis in their hands - they have more inflammation all over). This increased inflammation with insulin resistance leads to a perpetual "sympathetic" or fight or flight response by the body. In fact, the metabolic syndrome is called by some a "sympathetic disease". Part of the fight or flight response is a release of the hormone cortisol from the adrenal cortex. Hypercortisolemia, or having too much cortisol in the blood, is part and parcel with the metabolic syndrome.

And the interactions between cortisol, testosterone, and the metabolism in general make another positive feedback loop. Recall what cortisol does. It makes the liver secrete glucose. It causes fat deposition in unusual places, such as the insensitively-named "buffalo hump". It does all of the things that you do not want done if you already have the metabolic syndrome. Metabolic syndrome thus causes hypercortisolemia. And hypercortisolemia worsens metabolic syndrome.

Thus, low testosterone can lead to poor skeletal muscle development, central adiposity, changes in GIP, and mitochondrial dysfunction. All of these can lead to the metabolic syndrome. In turn, the metabolic syndrome causes a decrease in the hypothalamic and pituitary mediated creation of testosterone by way of hypercortisolemia and gonadotropin dissociation. Metabolic syndrome also makes tissues resistant to testosterone by the effects of cortisol on fat cells and it reduces the amount of existing testosterone by converting it to estrogen with aromatase.

Now, let’s take a step back and consider anxiety disorder, traumatic brain injury, and PtSD. Recall that the metabolic syndrome is a sympathetic disease. It is a fight or flight disorder. But anxiety disorder is also a problem with fight or flight. And so is PTSD. And in many ways so is TBI. Thus it is no wonder that all of these disorders are also now strongly associated with a dysregulation of the sex hormone pathway.

Of course another now well recognized example of this positive feedback loop is with chronic opioid use. Opioids are now well known to dysregulate GnRH firing, causing a further dysregulation of testosterone, and perpetuating again this cycle of inflammation, anxiety, and vicious downward cycle affecting nearly every organ system. This frequently causes the patient to experience worse pain, seeking more opioids, and perpetuating this cycle even further. 

In these ways it seems now clearer that there is a common underlying web of pathologies underlying the metabolic syndrome, pain, chronic systemic inflammation, obesity, anxiety, PTSD, TBI, and hypogonadism. There is something systemic going on. Each patient’s manifestation may be different but there are also many, many commonalities.

According to John Milton in Paradise Lost, Pandaemonium is where all (pan) of the demons (daemonium) are. Thus pandaemonium is an apt demonym in describing the metabolic syndrome and its relationship to so many of the things we see as clinicians. For it involves the whole metabolism. There is not one singular abnormality nor just one aberrant aspect of normal physiology. With the metabolic syndrome, we have all of the metabolic daemons in one place. Seemingly everyone is a player. The sex hormones, the stress hormones, muscle, fat, neurological tissue, reproductive tissue, and likely many other hormones and pretty much every other tissue. This is important because it has not just physical manifestations, but devastating psychological consequences, particularly in regard to depression, cognition, and the experience of pain.


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Matthew Thomas Smith, MD is a physician at Alabama Pain Physicians, located at 2868 Acton Road, Vestavia Hills, AL 35243. For more information visit http://www.bamapain.com

Alabama Pain Physicians, Comprehensive Pain Care.

From Measuring “Clicks” to Measuring Performance

By: Elizabeth N. Pitman, CHPC ( Beth ) with Waller Lansden Dortch & Davis, LLP


“For the times they are a-changin’” says Bob Dylan, and his advice, “then you better start swimmin’ or you’ll sink like a stone,” could easily apply to providers floating in CMS’s ebb and flow of reimbursement/incentive/penalty structures. Just when providers have become accustomed to the technology and workflows necessary for navigating the Meaningful Use EHR incentive program and other required CMS provider reporting, CMS announces change. In mid-January Andy Slavitt, CMS administrator, announced what sounded like the demise of the Meaningful Use Incentive Program only to clarify his statement the following week in the January 19th CMS blog with his co-administrator, Karen DeSalvo.

The CMS Administrators pointed out that Meaningful Use would continue into the unforeseeable future as a component of the composite provider performance score enacted in the new Medicare Merit-based Incentive Payment System (MIPS) under the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA), stating “While MACRA also continues to require that physicians be measured on their meaningful use of certified EHR technology for purposes of determining their Medicare payments, it provides a significant opportunity to transition the Medicare EHR Incentive Program for physicians towards the reality of where we want to go next.”

Adele Allison (Director of Provider Innovation Strategies at Birmingham’s DST Health Solutions), a subject matter expert and national speaker on federal legislation and policymaking related to HIT, healthcare reform, and provider reimbursement models, agrees that Meaningful Use is here to stay: “Today, the majority of providers are used to reimbursement under a fee schedule. However, MACRA rapidly moves Medicare down the payment reform causeway and heralds the onset of acceptable new forms of reimbursement designed to draw a hardline on cost containment. This new payment era will result in differential payment based on quality and efficiency data; and, adoption and use of health IT - Meaningful Use - will be one of those measures. As of 2019, MACRA makes Meaningful Use permanent under MIPS as a component of a weighted performance measure for Medicare reimbursement. Other payers will follow this lead. Simply stated, meaningful use is now tied to provider long-term economic success.”

MIPS represents a shift from performance measurements based on the frequency of technology use to outcomes-based measurements demonstrated through use of technology in producing better patient outcomes, cost savings and a healthier patient population. Under MIPS, beginning in 2019, CMS will sunset the applicable payment adjustments under the CMS programs and replace adjustments with the MIPS 100 point weighted performance scale: clinical quality performance, 30%; resource utilization, 30%; meaningful use, 25%; and clinical practice improvement, 15%. MIPS is intended to be budget neutral, differentiating the poor performers from the best performers. The top 25% have the ability to receive a 10% performance bonus while the lower 25% will see like-minded reductions in reimbursements. The exact scoring standards are yet to be defined. Slavitt and DeSalvo said to expect regulations in spring 2016 guided by four principles: (1) rewarding providers based on patient outcomes achieved through technology, (2) flexibility in customizing HIT which fits the provider’s needs, (3) promoting technological innovation and (4) prioritizing interoperability. MACRA also establishes incentive payments for providers participating in Alternative Payment Models (APMs) such as bundled payments and accountable care organizations (ACOs) and we can expect that the quality measures will be comparable to those in MIPS.

So what does that mean for now? From 2016-2018, providers will continue to measure Meaningful Use, and other CMS quality measurement programs, under the current set of standards. Providers will have the opportunity to contribute to the structure of MIPS and time to prepare for MIPS. This transition phase should also enable HIT vendors and developers to shift their focus to technological innovation that meets the principles under MIPS as opposed to the checklist functionality under Meaningful Use compliance.

CMS’s Dec. 18, 2015 draft “Quality Measurement Development Plan” (MDP) lays out a strategy for meeting the 4-pronged scoring of MIPS through alignment of the CMS quality measurement programs of Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM) and the Meaningful Use incentive program. The MDP is open for public comment through March 2016, the final MDP is expected to be published in May 2016 and CMS expects to release the Final Rule for MIPS no later than November 1, 2016.

At present, MIPS applies solely to physician and non-physician providers. While CMS states that there will be a correlating program for hospitals, it has not yet been announced.

The Death of the Office Note

By: Rebecca Hanif with Jackson Thornton Healthcare


The electronic health record and all of the associated incentive programs have taken the life and soul out of the provider note. Oh how I long for the days of dictation - even the hand scribbled illegible note is more preferable than a “point and click” EHR note. I used to struggle to assign a level five to any note, but these days, with templates carefully designed to mimic the Centers for Medicare and Medicaid Services (CMS) Evaluation and Management (E/M) guidelines, a provider can achieve all of the bullet points necessary for a level five visit in five minutes or less. Ironically, level five visits are estimated to take between 40 and 60 minutes in the office depending on whether or not the patient is established or new. How did we get to this point, you might ask?

Example 1:

CC: Urinary Tract Infection
Duration: 1 week
Quality: Burning Associated Signs & Symptoms: Abdominal Pain
Severity: On a scale of 1 – 10, the patient’s pain is a level 4.

Review of Systems:
Constitutional: Positive for Fever
Eyes: Negative for blurring
ENT: Negative for hearing problems, sinus infections, and sore throat
Cardio: Positive for varicose veins
Respiratory: Positive for cough
GI: Positive for abdominal pain
GU: Positive for UTI
Musculoskeletal: Negative for join pain
All others reviewed and negative except otherwise noted in the HPI.

Current Medications:
Lasix 20mg Twice Daily 11/12/2013
Coumadin 5mg Once Daily 11/12/2013

Family History: Cancer, Mother
Social History
Former smoker

Here’s a so-called “complete” history for this fictitious patient, easily derived from pointing and clicking.  Now, let’s look at the dictated version below.

Example 2:

Ms. Rebecca is a 67 year old Asian female who called this morning, and asked to be seen for a UTI. She complains of a burning sensation since this past Monday. She also has lower abdominal pain. Her daughter was her caregiver, and sadly, she was killed in a car-crash over Christmas break. Her niece hired a live-in caregiver to assist her with activities of daily living.

The dictated history is more problem focused. It is far from complete. However, it’s not filled with useless information like the history in the first example. The note is personalized and reflects a conversation the Provider had with the patient.


As much as I prefer Example 2 over Example 1, as an auditor, I can no longer review the notes simply for accuracy of E/M code selection. These days, I’m looking for tobacco use, family history, allergies, immunizations, specific diagnosis codes, whether a provider prescribes name-brand or prescription drugs, whether or not the patient has any chronic illnesses, and anything else that will help the Provider survive the Merit-Based-Payment System. In addition to combing over Medicare patient files for quality initiatives, I am also becoming well versed in the commercial insurance versions of these quality programs for all of the other patients.

Auditing for levels of service and correct diagnosis code selection, while still important, barely scratches the surface of what I review with Providers after an audit. My problem is no longer lack of documentation - it is 10 pages of templated, cut and pasted, impersonal information for each patient that may be upcoded because the EHR counts bullets and assigns codes based on the number of bullets selected. I cringe when I can count bullet points for the psychiatry, neurology, and cardiovascular portion of an exam on a patient with a urinary tract infection. The practice of cloning medical records thrives in the Electronic Health Record. Is it possible for 10 notes for 10 different patients to have the same comprehensive exam down to the “Inspection and Palpitation of Digits and Nails?” 

The rebel in me cheers for joy when the Provider bucks the system and practices medicine without concern for checking boxes, and vows to focus on the patient in order to provide “real” quality-care. Yet the sensible side of me nags and nags about Provider reimbursement, the quality of care measured by diagnosis codes, the efficiency of the practice measured by the cost per patient, and eventually my sensible side wins the argument. I find myself saying things like, “Have any of your patients sent you an electronic message yet? Have you sent any of them an electronic message? Have you been giving those tobacco handouts to your patients? I know your patients want their prescriptions hand-written, but you need to e-prescribe or you won’t pass Meaningful Use.”

The Bottom Line

Providers are not trying to game the system by clicking every button available on the template; they are trying to cover their bases with payors. I have become an auditor of code selection, quality, cost, severity of illness, and efficiency. The notes are longer, they tell me all about the patient’s tobacco use, they address the patient’s chronic illnesses in alphabetical order, and yes, every patient’s extraocular movements are intact. They are also littered with template errors and misinformation. Consequently, the US health system continues to rank last among eleven countries on measures of access, equity, quality, efficiency, and healthy lives, though the advent of the EHR promised improved quality of data, decreased costs, and efficiency. 1

America, it looks like we have our work cut out for us.

1 http://www.commonwealthfund.org/publications/press-releases/2014/jun/us-health-system-ranks-last


About the Author

Rebecca Hanif, an AHIMA Approved ICD-10-CM/PCS Trainer, has worked in the healthcare industry for seven years. At Jackson Thornton Healthcare, she assists multiple physician practices with process improvement on the Physician Quality Reporting System, Meaningful Use, and Coding Compliance. She is committed to improving operational practices, patient-centered care, and the utilization of healthcare informatics by integrating commercial and government quality reporting programs into every day practice.

Preventing Injury in the Winter Months

By: Christopher Carter, MD with Brookwood Care Network


Many of us enjoy winter activities like skiing, snowboarding, sledding, ice-skating and hockey. These sports are thrilling and fun for all ages, but high speeds and slippery surfaces can lead to serious injuries, including concussions. The following are some injury prevention tips to keep you safe while having fun in the cold.


1. Always wear a properly fitted helmet and replace it after a serious fall. When wearing a hat or cap to keep your head warm, make sure your helmet still fits securely on your head. It's also very important to replace your helmet after a serious crash. Some helmets are built to only withstand a single impact, while others can withstand more than one — depending on the severity. The snow may seem soft, but trees, ice, and other people aren't.

2. Have fun, but know your limitations. I will never forget my first time skiing. I thought I was athletic enough to hit the slopes without any formal training. Needless to say, I spent the majority of the day on my back. It was a very humbling, cold, and wet experience. Take it from me - if it's your first time on the slopes, take lessons from an expert. Learn the fundamentals, start slowly, and be patient. Know your limitations and make sure children do as well. Young children should never play on snow or ice without close supervision.


3. Be familiar with your surroundings and stay alert.

• Be sure to scope out the trail, sledding hill, or skating rink before you take off at full speed.

• Be aware of blind spots, turns, and sudden drops or knolls.

• Try to avoid crowded areas, as you could also be injured when someone else does something irresponsible.

• Try to stay near the center of the trail or hill to avoid obstacles.

• Never ski or sled through, or close to trees.

• Stay alert and never wear headphones so you can hear what's going on around you.


4. Be aware of the warning signs of concussion. If you or someone you are with does take a hard spill, be sure you recognize the warning signs of a traumatic brain injury. Signs and symptoms of a mild brain injury, or concussion, can show up right after the injury, or they may not appear until days or even weeks afterward. Concussion symptoms can include:

• Headaches

• Weakness

• Numbness

• Decreased coordination or balance

• Confusion

• Slurred speech

• Nausea

• Vomiting

Sometimes people complain of “just not feeling like themselves.” If you or a loved one notices any of these symptoms, you should seek medical attention right away. And if the person loses consciousness, call 911 or seek emergency medical help as soon as possible. Finally, if you have a concussion, give yourself time to heal. Experiencing a second injury before the first one heals could have long-term consequences.


Enjoy yourselves this winter, but make sure to stay safe. If you or someone you know suffers a concussion, or has an injury whether winter-related or not, Dr. Carter can be reached at 205-352-1175.


Christopher Carter, MD practices family medicine with an emphasis on sports medicine and non-surgical orthopedics with the Brookwood Care Network.

It’s Not Too Late to Participate in Meaningful Use or PQRS

By: Tammie Lunceford, CPC with Warren Averett LLC


Many healthcare entities have finalized 2015 financially but there could be loose ends physicians or hospitals have not addressed. It is very difficult to stay abreast of the guidelines for Meaningful Use because they are constantly changing. Many struggled in 2014 to meet Meaningful Use Stage 2 even when the participation period was shortened to 90 days. The participation period for 2015 was originally set for 90 days. In October of 2015 flexibility options were released but it was after October 1st making it difficult to meet the last 90 day attestation period. During the last week of 2015, President Obama signed the Meaningful Use Hardship Bill which broadens to options to file for hardship. The Centers for Medicare and Medicaid Services released the instructions and the application to file a hardship last week. The deadline to file a hardship is March 15, 2016, if approved you will avoid a 3% adjustment to Medicare reimbursement in 2017. Some will be able to attest to Meaningful Use Stage 1 or Stage 2 with the flexibility rule, you should attest if you were able to update your dashboard and meet the measures.


The Physician Quality Reporting System has been in effect since 2007, first it was an incentive program but the incentive ended in 2014. This is a very important year because PQRS is a component of the value based modifier, 2015 is the look back period for 2017. If a physician is not participating in PQRS, they will incur a 2% adjustment to Medicare but also a possible 4 % adjustment to Medicare based on the value based modifier. The value based modifier weighs cost efficiency against clinical effectiveness and clinical effectiveness is measured through PQRS. Many administrators think it is too late but there is still time to contact an outside vendor to walk you through successful participation using your 2015 data. Many of the specialty organizations also have resources to assist members in successful participation. February 29, 2016 is the last day to submit CQMs for PQRS and EHR incentive program, those reporting through registry or QCDR have until March 31, 2016.


Do not delay in reviewing your options to participate in these programs, we are now seeing a combined adjustment potential close to 10 % if you cannot show success with either program. The lack of success with Meaningful Use has caused many to believe it has ended. Meaningful Use is expected to morph into the Merit Based Incentive Program in 2018, until then we must stay abreast of changes and try to participate especially if your Medicare payer mix is significant. Check with your vendor for assistance or reach out to a consultant soon.