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On Rounds Dr. Jack Dabbs at 81: “Medicine Has Been Good to Me” On a recent weekday morning, a lot more people than usual were passing through the offices of Dr. Jack Dabbs, an ENT whose building is on Lomb Avenue near Princeton Baptist Medical Center ... page 3
UAB Lab Studies Chronic Fatigue Syndrome Institute of Medicine Announces New Name for CFS In California, patients wait up to five years for initial appointments at a Stanford clinic that caters to chronic fatigue syndrome. “That’s how little supply there is for the demand,” says Jarred Younger, PhD, head of the new Neuroinflammation, Pain and Fatigue Lab at UAB. “No specialty has taken it on.” ... page 4
INFORMATION TECHNOLOGY
Preventing Breaches with Hardware Firewalls By Jane Ehrhardt
On the Health and Human Services website, a section posts every healthcare organization since 2009 whose patient data covering 500 or more individuals has been breached. Each page of this “Wall of Shame” lists 100 organizations. As of June 15, the list runs 1,249 pages long. Breaches can result in hefty costs. Penalties can range from $100 to $50,000 per violation or record, meaning even a small practice of 300 patients could pay out a minimum of $30,000 in fines. Avoiding a data breach begins with a hardware firewall, say information technology experts. Not to be confused with software loaded onto individual workstations as firewalls, “a hardware firewall is your own private security firm that protects all your internet traffic entrance and exit
doors,” says Curtis Woods with Integrated Solutions in Birmingham. The hardware device connects between a practice’s internal server and their internet connection, serving as a gatekeeper. “It monitors traffic going in and out to make sure it’s not compromised,” says Aaron Woods, also with Integrated Solutions. “It inspects every piece of traffic to make sure it’s allowed through.” Too many healthcare practices, however, never use the entire protective abilities of their firewall. “Everybody understands you need some sort of protection from the internet. And that’s a firewall,” says Russ Dorsey with Kassouf & Co. “But what it should really do is help you control what your users are able to do.” Recent publicized security breaches, from Target to the fed(CONTINUED ON PAGE 6)
Mendelsohn Performs Nation’s First Vessix™ Renal Denervation for Hypertension By Laura Freeman
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Farrell Mendelsohn, MD
When two good ideas cross paths by chance, sometimes something wonderful happens. When Farrell Mendelsohn MD, an interventional cardiologist with Cardiology PC at Princeton Baptist Medical Center, was at a medical conference in Las Vegas, he happened to meet Raymond Cohen, who is CEO of Minnow Medical, a small biotech company that had developed a balloon catheter device designed for leg procedures. As Cohen described his balloon catheter, it occurred to Mendelsohn that it might be adapted to another purpose, an idea that Mendelsohn had been contemplating for some time. “Years ago, before the development of hypertension medications, the only thing medical science could offer patients with lethal levels of hypertension was surgery to cut the sympathetic nerves in the kidneys,” Mendelsohn says. “No one (CONTINUED ON PAGE 16)
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HEALTHCARE SPOTLIGHT
Dr. Jack Dabbs at 81: “Medicine Has Been Good to Me” By daLe Short
On a recent weekday morning, a lot more people than usual were passing through the offices of Dr. Jack Dabbs, an ENT whose building is on Lomb Avenue near Princeton Baptist Medical Center. They weren’t all patients, but mostly a stream of well-wishers - friends and former co-workers bringing cakes, cookies, and wrapped gifts, and having their photographs taken with him for their scrapbooks. It’s not every day that a physician retires after practicing for 54 years. It’s been a long and winding road for Dabbs since he was born in the small town of Hueytown near the Warrior River, and where he spent much of his boyhood around the area’s fishing camps. “My granddaddy was in the timber business,” he says, “and I followed him everywhere he went. He’d cut timber, and I’d go stay in the woods with him. He built a slab shack, with a little stove and some cots, and we’d stay all week. “Of course I was exposed to a lot of colorful language from the timber cutters, and by the time I was five or six years old I had a very extensive vocabulary,” he says with a laugh. A little more than a decade later he would go to Vanderbilt University on a football scholarship. He played middle linebacker, “and a little bit of tackle. I would be way too little to play nowadays, and my speed was a problem as far as being an outside linebacker. But we had a pretty good ball team. We beat Auburn in the Gator Bowl.” Apparently not all Auburn students held a grudge after the loss, because Dabbs married a young woman attending the university and then they both transferred to the University of Alabama in Tuscaloosa. After completing their studies the couple would eventually have two daughters and a son; both daughters are doctors, and their son is an electrical engineer. After a time as chief resident at UAB’s medical school, Dabbs and two partners
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Jack Dabbs, MD
moved into a brand-new office building in a high-traffic area, and the practice flourished. When he wasn’t practicing
medicine, he raised quarter-horses, Arabians, and cattle. Along the way, he’s also done a great deal of surgery at Princeton - sometimes 12 to 15 cases a week - before retiring from surgery a few years ago because of spinal stenosis. His philosophy of surgery, he says, is “Never do anything you don’t have to do.” His most challenging cases over the years have been patients with cancer of the larynx who required total laryngectomies. “It’s the kind of surgery you dread,” he says, “not just for cosmetic reasons but also because it’s disabling and makes life hard for people afterward. “Fortunately there are fewer of those cases today, and that’s a very good thing. Part of the decrease is because of so much better treatments with radiation, and part of it is because fewer people are smoking. I’d say more than 99 percent of cancers of the larynx are a result of smoking or of working in an atmosphere where there are caustic chemicals. Most cases of laryngeal cancer occur in people age 60 or above, but I’ve seen a few over the years in men in their late 30s who were welders,
working in enclosed areas.” One of the biggest changes in medicine since he began his career is the revolution in diagnostic imagery. “All these new developments are a great aid in finding out what’s wrong with people,” Dabbs says. “Plus, there’s bypass surgery, stents, and so on. Cardiovascular care is so much better than it used to be. Overall, the technology of medicine has increased markedly.” The downside of changes over the years, he says, is the new financial basis under which physicians practice: “For instance, co-pays are so high that people don’t go to the doctor unless they absolutely have to, because they can’t afford it.” Why keep practicing so long past the standard retirement age of 65? “I’ve enjoyed medicine,” he says. “I’ve never had any real problems. We were fortunate to have good nurses working for us. I’m a firm believer in treating your patients right. I’ve enjoyed my patients, and a lot of them have come over this week to say goodbye. “Overall, my health has been good. I never smoked or drank. And when I was growing up, we didn’t know what drugs were. But I’ve also been fortunate. Medicine’s been very good to me. It’s like I’ve led a charmed life.”
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UAB Lab Studies Chronic Fatigue Syndrome Institute of Medicine Announces New Name for CFS By Jane Ehrhardt
In California, patients wait up to five years for initial appointments at a Stanford clinic that caters to chronic fatigue syndrome. “That’s how little supply there is for the demand,” says Jarred Younger, PhD, head of the new Neuroinflammation, Pain and Fatigue Lab at UAB. “No specialty has taken it on.” This lack of a medical specialty for chronic fatigue syndrome, also called myalgic encephalomyelitis (ME/CFS), results from the cause of the disease remaining unknown. At the Stanford clinics, led by Jose Montoya, MD, the theory runs to a viral infection. “They think it may be hiding in the brain, and it’s not constantly active,” Younger says. “When it flairs up, so do the symptoms.” Younger also thinks the cause may lie in the brain, but from a different source. “We believe there is a low level of inflammation in the brain,” he says. When the immune cells exclusive to the brain, called microglial, activate to fight trauma or disease, they secrete an array of chemicals. “And they all make you feel tired,” Younger says. “We think the microglial are tricked into thinking there’s a problem all the time, so they constantly produce the chemicals that make ME/CFS patients feel profoundly fatigued.”
Jarred Younger, PhD, (right) and postdoctoral fellow, Joanne Lin, PhD, discuss testing new ways to study how areas of the brain talk to each other.
In March, research identified a new potential trigger for the inflammation. Leptin, a master hormone in the body that controls hunger, also interacts with the microglial in the brain. “They found people with chronic fatigue have a high level of leptin on their bad days, and on those bad days, the leptin in women is three times higher than in men.” Women are also four times more likely to have ME/CFS than men. “This could lead to potential treatments,” Younger says. But the road may
lead more toward correcting the patients’ intolerance to leptin rather than to directly diminishing leptin levels. In people with an intolerance, the body keeps producing more and more leptin. “You can see how horrible this is, because all the while the brain is getting more inflamed,” Younger says. Curing the intolerance would shut down the leptin overload and eliminate the inflammation. For now, with the cause of chronic fatigue syndrome remaining a mystery,
treatments tend to lean toward alleviating symptoms. Patients often find themselves on antidepressants and stimulants, like Ritalin. The treatment at the Stanford clinic focuses on complex antivirals. “It’s worked for a lot of people,” Younger says, hence the backlog of patients. Without an FDAapproved treatment, though, most of the one-million ME/CFS patients in the U.S. run through innumerable treatments. “It’s one of the most frustrating things to deal with as a physician, and physicians don’t like not being able to help. It’s why ME/CFS patients get shuffled around, because there is no one place to send them for help,” Younger says. He adds that the condition is not that uncommon, striking more often in the United States than multiple sclerosis, lupus, and many forms of cancer. Diagnosing the disease is equally frustrating. The name oversimplifies the condition and no test or unique set of symptoms separates ME/CFS from a whole host of other diseases. “There’s no biomarker,” Younger says. “What’s missing is a brain scan or a blood test. We’re working on that.” ME/CFS patients often get misdiagnosed by physicians as hypochondriacs or simply depressed. “The debilitating chronic fatigue means you can’t do the things you want to do which creates an emotional toll,” Younger says. “So unlike depres(CONTINUED ON PAGE 6)
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The Home Advantage Brookwood’s New Locally-Based Hospitalist Group Brings a Win/Win Strategy By Laura Freeman
In his eight years with Brookwood Medical Center along with his work as chairman of Anesthesia Services of Birmingham PC, Matt Sherrer, MD, has seen the value of teamwork. Shared experiences over time build professional relationships and continuity, helping medical teams work together more seamlessly to enhance quality of care. That’s one reason Matt Sherrer, MD Sherrer has been encouraging the development of locally based collaborative groups in other specialties. The first such endeavor launched this month is Brookwood’s new hospitalist group. “Hospitalists have made tremendous contributions to the quality of inpatient care,” Sherrer said. “What is changing in this new healthcare environment is how these positions are staffed. In many hospitals, national companies have won contracts to provide hospitalists. When that happens, those already working there either become employees of the national company or have to seek another position. We think a local solution is better than a transient solution for just about everyone. That’s why we decided to build our own group. “Local hospitalists are likely to be here because they want to be here, not because they were transferred. If they want to be here, they are more likely to be thinking long term. That gives them the time to build professional relationships and learn the nuances of the local culture to enhance rapport with patients. This continuity also avoids the disruptions that come when new people have to learn a new environment.” From the hospitalist’s point of view, there are also advantages in working for a local group. Stirling Shirah, MD, is chairman of the new hospitalist group at Brookwood Medical Center. “Working with a local group is attractive to hospitalists who think of this area as home,” Shirah said. “We can do our jobs without the stress of wondering whether we might be transferred Stirling across the country on Shirah, MD short notice, and what that would mean to a spouse’s job and our children’s school and friends. We can build a life and a career here.” The Brookwood Medical Center hospitalist team begins with nine physicians who will be working throughout the hospital. “We have 24-hour coverage, with two groups of four alternating in two-week daytime shifts, and a nocturnist on duty through the night,” Shirah said. Sherrer said the group has been welcomed with a great deal of enthusiasm from
other members of the Brookwood health care team. “Our primary care physicians like knowing that even when they are taking care of other patients or have to be elsewhere, there’s always a doctor nearby, keeping close watch if their patient needs immediate attention,” Sherrer said. “The response from surgeons has also been positive. Having a hospitalist monitor the patient’s condition before and after procedures frees surgeons to focus on surgery. The hospitalist is checking blood sugar, blood pressure and other vital signs to make sure the patient is in the best possible condition going into surgery, and then follows the healing process afterward. That can mean better outcomes for patients—and a record of better reported outcomes, which reflects well on everyone.” Another advantage of a locally based hospitalist group is local decision making, which facilitates fine tuning of working procedures to better meet the specific needs of the hospitals. One of the first goals Brookwood hospitalists are working toward is expediting the transition of new patients from the emergency room to their room in the hospital. “We work very closely with emergency department physicians and staff to get patients who need to be admitted into their rooms faster. Then we make sure they are seen by a physician promptly,” Shirah said. The sooner patients are evaluatedand the labs and consults they may need determined, the sooner a treatment plan can be developed to get them on the road to recovery. Moving patients to their rooms faster also frees up ER space. Hospitals avoid losing patients to diversion, ER waiting times are shorter, and incoming patients can be treated at the nearest hospital rather than having to go farther for care. Sherrer is also looking into determining whether there is interest among emergency physicians and/or other intensivists in forming a locally based collaborative group similar to the new hospitalist group. This would allow a similar degree of local autonomy in issues related to their work. As an example of how local decision making allows agility in implementing advances in treatment, Sherrer can point to his group’s multimodal anesthesia program. “You can’t simply hammer patients with narcotics without creating problems like respiratory distress. A broader approach with smaller doses works better. That’s why our group has made multimodal anesthesia a priority. We combine multiple medications, procedures and treatments to not only deal with acute pain, but to also help patients feel better the next day, the next month and the next year,” Sherrer said. “We might combine analgesics and antiinflammatories with regional blocks before surgery so patients are in better condition post op. Treating acute pain early and effectively with a multimodal approach is the first step in preventing chronic pain later.”
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Preventing Breaches with Hardware Firewalls, continued from page 1 eral government, were not firewall penetrations. “They were people getting malware on their computers by going to websites they were not supposed to go to or opening emails they were not supposed to open,” Dorsey says. Russ Dorsey Malware - most of which derives from the Eastern Bloc and Africa - becomes active by downloading needed programming from its home website. “The firewall stops that process by blocking its access to websites outside the U.S.,” Dorsey says. “So bad email can still come through, but if your firewall is set up as a malware filter, it can prevent bad email from turning into a disaster.” Firewalls can also block employees from accessing sites that may be prone to malware or simply time-wasters, such as
Facebook and EBay. “That can increase productivity,” Dorsey says. “The office then builds a culture where the internet is not a playground anymore.” Not all firewalls come with a content filtering capability. However, a separate piece can be purchased to enhance existing devices. Healthcare organizations can also use firewalls to establish secure connections with third-party vendors. These virtual private networks (VPN) allow for HIPAA-compliant transmission of protected healthcare information (PHI), such as x-rays and lab results. “It’s like talking through the internet over a secure tunnel,” Aaron Woods says. Setting up a VPN on a firewall will require configuration by an IT provider. IT professionals can also configure firewalls for a practice’s intranet servers to block external access. “Internet traf-
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fic is routed through ports. Web traffic goes through port 80,” says Alan Callahan with Dataperk. “If you didn’t have a firewall, someone could access your server from the outside going through port 80. But if you’re blocking that port, they cannot gain access.” Firewalls cost anywhere from $750 to $25,000 for massive office environments with many needs. For a typical clinic of two to five physicians and 30 staff, the cost runs about $1,500. Along with the purchase price, the devices require an annual subscription fee by the manufacturer for service and software upgrades. “That annual fee generally runs about 20 percent of the Curtis Woods purchase price,” Curtis Woods says.
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When choosing a new firewall, practices should ensure it can handle the amount of data being transferred to avoid slowing their internet traffic. “Especially in these days of high-speed internet connections,” says Jason Williams with VentureNet. “A lot of firewalls can’t handle the data speed.” The average healthcare practice likely runs at least 10,000 to 20,000 connections. Generally after about five years, manufacturers stop supporting a model or releasing firmware updates for it. “It can also tell you when it’s failing,” Williams says. “Set the log to send an email if it detects issues. If you get errors, forward them to your IT person and let them look at it.” Firewalls are only the first line of defense, warn IT experts. “You can’t lock a firewall down too tight or good stuff won’t come through and the user will never see it,” Curtis Woods says. “You still need good anti-virus software at your servers and desktops.” Dorsey says devices and software take your security only so far. Regularly training employees in security protocols should be required. “The best firewall cannot protect you against bad practices by users.”
UAB, continued from page 4 sion, you’re not fatigued because you’re depressed, but you’re depressed because you’re fatigued.” One symptom does stand out in its severity. “There are things that are pretty unique about ME/CFS,” Younger says “The main one is why they changed the name.” In February, The Institute of Medicine proposed the new name of systemic exertion intolerance disease (SEID). They believe the term better reflects the core symptom of sustained lethargy days after minimal cognitive or physical exertion. They also included new diagnostic criteria. “Six months of profound, unexplained fatigue, post-exertional malaise, and unrefreshing sleep,” Younger says. Patients must also exhibit cognitive problems or an inability to stand upright for more than a short period. A pitfall for physicians is prematurely diagnosing for SEID. “My biggest concern is that physicians would stop doing tests too early for potential causes of the fatigue, because so many diseases have to be ruled out,” Younger says. For instance, Lyme’s disease causes severe fatigue and the telltale rash does not always appear. “You can treat that with specific antibiotics. But if you miss it, that patient could be sick for years,” Younger says. Younger and his team will be conducting studies on the causes and hopefully treatments for SEID and similar diseases, such as fibromyalgia. To view information about their studies, follow the links at www. psy.uab.edu/younger. If physicians have patients who wish to participate in any of Younger’s research, they should send information to youngerlab@uab.edu or call 205-975-5907.
Birmingham Medical News
JULY 2015 • 7
Measuring the Impact of Interprofessional Education Do Lessons Learned Translate from the Classroom to the Clinical Setting? By CINDY SANDERS
IPE … or interprofessional education … has become a popular buzzword among educators preparing the next generation of providers. An interprofessional, team-based curriculum has been lauded as the best way to prepare healthcare professionals to work collaboratively in a value-based system where efficiency and quality are rewarded. But does it work? Do the lessons learned in the classroom effectively translate into the clinical setting? And does this model of delivery actu-
ally have an impact on patient outcomes and the healthcare system itself? Those were some of the questions posed by the Institute of Medicine’s Global Forum on Innovation in Health Professions Education. In late April, a six-member committee, chaired by Malcolm Cox, MD, published their findings in the IOM report “Measuring the Impact Dr. Malcolm Cox of Interprofessional Edu-
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cation on Collaborative Practice and Patient Outcomes.” The short answer to a long list of questions is that while the empirical evidence suggests this is a desirable way to train future providers, there simply isn’t enough scientific research to validate that opinion. Asking the Question Cox, who is an adjunct professor of Medicine at the University of Pennsylvania Perelman School of Medicine and the former Chief Academic Affiliations Offi-
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cer of the U.S. Department of Veterans Affairs, noted IPE became a common topic of discussion and debate among members of the Global Forum. “One of the things that came up early on was that health professions education was ‘faith-based’ when it came to outcomes … that is we believed, without much data, that interprofessional education would be helpful, if not essential, to producing the kind of clinical workforce that the U.S. and world need in the future,” he said. Cox noted a common sentiment among many educators is ‘the era of the Lone Ranger’ is over. He added, “I think that’s true … no one doubts that. Moreover, no one doubts that the U.S. health system is rapidly moving in that direction.” And in fact, Cox pointed out, data exists showing teams can provide safer, more effective, efficient care … but that isn’t the same as proving the best route to get there. “How do we prepare health professionals to hit the ground running when they reach the clinical workforce so they are ready to work in teams rather than as individuals?” he asked. “What we discovered is that while teams are known to be effective, how to create great teams is unclear,” Cox continued. No ‘I’ in Team “The leaders of healthcare systems are not pleased with the graduates we are sending them,” Cox stated. While these new professionals might be well versed in disease recognition and the medical sciences, they aren’t well trained in working together, noted the physician-educator, who previously served as dean for Medical Education at Harvard Medical School Even when professionals from multiple disciplines are grouped together, Cox said it’s often more a matter proximity than actual teamwork. “Team leadership should be expertise- and situation-based rather than hierarchically based,” he pointed out. “Physicians are still giving orders and nurses are taking orders, which is fine if the physician has the most knowledge on a subject, but there are times when the nurse or physical therapist or pharmacist should lead. The most effective team is where the expertise of professionals overlap so that the whole is greater than the sum of the parts.” While a lot of emphasis is placed on leadership, Cox said the concept of ‘followership’ is equally important. “Physicians are great leaders but poor followers … I’m allowed to say this because I’m one of them,” he added with a chuckle. In his experience, he added, “The only way you can really learn to work together as a team … is to work together as a team.” (CONTINUED ON PAGE 12)
AL MEDICAID REGIONAL CARE ORGANIZATIONS
Regional Care Organizations on Track to Take Over Medicaid By Jane Ehrhardt
In January, Alabama Medicaid named eleven organizations as probationary Regional Care Organizations (RCOs). By October of next year, the plan is for these nonprofit RCOs to manage the care of just over 600,000 qualifying Medicaid patients in the state. Under the emerging revision, Medicaid broke the state into five regions with the possibility of multiple RCOs overseeing each region. Right now, two RCOs have been approved for every region, with one region, Region A in northern Alabama, having three. Medicaid believes all of the probationary RCOs could meet the remaining criteria and become active by the fall of 2016. “Our mission is to be sure changes in Medicaid lead to better quality care while shifting the risk of managing the monies to the RCOs,” says Robin Rawls, communications director with Alabama Medicaid Agency. Robin Rawls Most of the RCOs reflect a partnership between hospitals
and other healthcare businesses from the region. For instance in Region B, which includes Birmingham, the RCO called Alabama Care Plan is comprised of UAB Health Systems, St Vincent’s Health System, and Triton Health Systems, which is the parent company of Viva Health, an insurance carrier for employers statewide. Companies, organizations and investors are not restricted to participating in only one RCO. Both Viva Health and UAB Hospital are also part of an RCO in Region D, which includes the Montgomery area. Each RCO can also apply to cover more than one region. Alabama Healthcare Advantage, composed of McKesson/ Med3000, WellDyne Rx, and individual investors, has been granted probationary status in all five regions. Viva Health partners in two RCOs along with overseeing the administration of a third. “Taking on a whole state is a big task, but we felt comfortable working with three regions. That was our sweet spot,” says Anna Velasco, Director of Strategy for Viva. Overseeing multiple regions creates advantages for the RCOs in eliminating redundant set-up and administrative tasks. “Building infrastructure costs the same
whether you’re in one or five regions, so there are economies of scale,” Velasco says. Patients will also benefit from their RCO managing multiple regions, especially those Anna Velasco patients living on regional borders. “You might live in a region where the nearest city is in another region. And that’s where you would likely need to see a specialist,” Rawls says. Ensuring access to enough Medicaid physicians across their region is the next step to qualify as an active RCO. This criterion could present problems for the RCOs. “The state overall has shortages in certain specialties,” Velasco says. “That makes the shortage more acute for RCOs, because not all providers take Medicaid.” But the RCO arrangement may help solve the specialist shortage by enticing previously reluctant providers to participate in Medicaid. “The services provided by RCOs can help make it easier to work with the Medicaid population,” Velasco says. Those services help patients overcome obstacles to consistent care which can be frustrating to providers, such as finding
transportation to the pharmacy, calling with reminders about appointments, and visiting in the hospital to ensure patients being released understand their medications. Medicaid providers under RCOs could also see more secure revenue. Right now, physicians accepting Medicaid run the risk of reimbursements being cut midyear if monies run short. “Physicians don’t like that uncertainty. But the RCOs will have a guaranteed fixed payment, which means we can offer the same security to the providers,” Velasco says. “And there’s the possibility of physicians seeing additional financial rewards for achieving quality measures.” As a stepping-stone to taking over the care of Medicaid patients, six of the RCOs have been deemed Health Homes this year. “It’s a program that will hopefully create savings for the state while allowing RCOs to get experience with the most difficult Medicaid patients — the ones identified by the state with chronic healthcare needs — before we’re at risk for paying the claims,” Velasco says. Started April 1, Viva Health’s RCO began Health Home services for 67,000 (CONTINUED ON PAGE 18)
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AL MEDICAID REGIONAL CARE ORGANIZATIONS
Summary of Alabama’s Medicaid Care Management Programs By: Richard J. Brockman and Angie Cameron
Alabama recently passed into law two separate bills to develop at-risk provider-driven Medicaid care management programs. The first bill, passed in 2013, created the Regional Care Organization (RCO) system. See Alabama Code § 22-6150 et seq. This legislation was developed upon the recommendation of the Medicaid Study Commission, which was created by the Governor who appointed members representing a range of providers, insurers, consumer advocacy groups, and state government officials. Under the RCO legislation, the state is to be divided into not less than five or more than eight regions. Each region is required to have a sufficient Medicaid population to support at least two RCOs, although there is no requirement that there be more than one RCO in a given region. By rule, the Alabama Medicaid Agency (Medicaid) established five regions. The legislation contemplates that providers in each region would convene to form and fund the RCOs. To the extent practical, the regions were designed to accommodate historical
referral patterns, while having sufficient targeted Medicaid populations to support two RCOs. Currently there are 11 probationary RCOs. Three probationary RCOs are in the north region, and two probationary RCOs are in each of the other four regions. Although the legislation provides that all Medicaid beneficiaries would be assigned to a RCO, it also permits Medicaid to carve-out classes of beneficiaries. The RCO legislation further provides that long term care (LTC) services would be studied and continue to be administered under the current Medicaid system through October 1, 2016, the date the RCOs are to be operational. “Long term care services” is defined in the RCO statute as “…Medicaid funded nursing facility services, home and community based support services, and such other long-term care services as Medicaid may determine by rule….” The RCO legislation definition includes intermediate care facilities for the developmentally disabled (ICF-DDs). The second bill, passed on May 28, 2015, created the Integrated Care Network (ICN) system. The ICN legislation authorizes a provider-driven program for the Medicaid LTC population that would
function similar to the RCOs. This bill was written based on the recommendations made by the Medicaid LTC Study Task Force commissioned in the RCO legislation. Similar to the Medicaid Study Commission, the LTC Study Task Force consisted of representatives from an array of providers, consumer groups and government officials. The task force received reports from various of its members, as well as persons and groups outside its membership. The ICN legislation contemplates that providers would convene to form and fund the ICNs and that Medicaid would assign LTC beneficiaries to the ICNs. In addition to care managing Medicaid beneficiaries and their benefits, the legislation permits ICNs to coordinate with other provider programs. The ICN program is to be operational no later than October 1, 2018. This bill further provides that until the ICN program is operational, LTC services would continue to be administered by Medicaid under its current program. The RCO and ICN entities will each receive an actuarially determined monthly per member-per month (PMPM) payment from Medicaid and in return (i) case
manage assigned Medicaid beneficiaries and (ii) process claims and pay providers for Medicaid covered goods and services provided to its assigned Medicaid beneficiaries. RCOs and ICNs are deemed to be “at-risk” entities because, in accepting the actuarially determined PMPM payment, each (a) assumes all responsibility for care managing, claims processing, and paying Medicaid covered claims for its assigned Medicaid beneficiaries, and (b) must make up any short-falls. Medicaid has applied to the Centers for Medicare and Medicaid Services, Department of Health and Human Services (CMS) for a section 1115 waiver for the RCOs. (States may apply to CMS for waivers from certain federal Medicaid state plan requirements. These waiver applications refer to specific sections of the federal Medicaid statute.) It is contemplated that the ICN program will either be added to that section 1115 waiver application or there will be a separate section 1115 waiver filing, as well as a filing to apply for a section 1915 waiver for the home care portions of the ICN program. Under the RCO and ICN programs, (CONTINUED ON PAGE 18)
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Measuring the Impact, continued from page 8
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IPE & Outcomes Cox said the committee studied the available research and literature for both the intermediate and final outcomes of IPE. The intermediate outcomes side of the equation is tied to learning outcomes and whether or not students understood, gained knowledge and developed new skills. “There’s pretty good information that interprofessional education begins to promote collaborative behavior within students,” he said. “But,” he continued, “we haven’t taken it to the final endpoint, which is do those learning outcomes lead to enhanced patient health and health system outcomes?” Cox said, “The conclusion was there is no data that links the learning outcomes to health and system outcomes … that’s where the gap is.” While this committee was focused specifically on measuring IPE, Cox said he personally believes that all health education innovations should be held to the same evidence-based standard. “We keep changing the way we educate, and there’s little solid data that any of these changes lead to measurable changes in health or system outcomes,” he said. “Belief is one thing, but data is another.”
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ommendations on how to move forward to produce more data to assess the real world outcomes of IPE on patients, populations and healthcare systems. The committee highlighted four areas that should be addressed in order to truly evaluate the impact of IPE on collaborative practice – 1) more closely align the education and healthcare delivery systems, 2) develop a conceptual framework for measuring the impact of IPE (see graphic), 3) strengthen the evidence base for linking IPE to health and system outcomes, and 4) better link IPE with changes in collaborative behavior. Furthermore, the committee made two recommendations: Interprofessional stakeholders, funders and policymakers should commit resources to a coordinated series of well-designed studies of the association between interprofessional education and collaborative behavior, including teamwork and performance in practice. These studies should be focused on developing broad consensus on how to measure interprofessional collaboration effectively across a range of learning environments, patient populations and practice settings. Health professions educators and academic and health system leaders should adopt a mixed-methods research approach for evaluating the impact of IPE on health and system outcomes. When possible, such studies should include an economic analysis and be carried out by teams of experts that include educational evaluators, health services researchers, and economists, along with educators and others engaged in IPE. Cox said the first recommendation is focused on collaborative learning outcomes. The second, which he said is “the real crème de la crème” of the report, looks at linking IPE to health and system outcomes by using ‘mixed methods’ … incorporating both qualitative and quantitative research designs. “We need to know the how and why, as well as the what,” he stated, adding that without the qualitative piece, it’s difficult to generalize the quantitative results and apply findings to the larger population.
Baptist Health System and Tenet Create New Healthcare Network Baptist Health System and Tenet Healthcare Corporation have signed a definitive agreement to create a joint venture that will operate a healthcare network serving Birmingham and central Alabama. The new network will include all Baptist Health System hospitals, Tenet’s Brookwood Medical Center and each organization’s related businesses. Under the joint venture arrangement, Tenet will be the majority partner and will manage the network’s operations. The new company will unite Baptist Health System’s four hospitals – Citizens Baptist Medical Center, Princeton Baptist Medical Center, Shelby Baptist Medical Center and Walker Baptist Medical Center – with Brookwood Medical Center. Together, the new system will have more than 1,700 licensed beds; 77 outpatient and physician office facilities, including clinics delivering primary and specialty care; approximately 7,300 employees; and approximately 1,500 affiliated physicians. “We are excited about joining with Tenet to provide high-quality healthcare to communities across central Alabama,” said Keith Parrott, CEO of Baptist Health System. “Together, we will continue to improve health care delivery to communities throughout central Alabama while preserving each hospital’s remarkable legacies,” said Garry Gause, CEO of Tenet southern region. Parrott will become CEO of the joint venture, which will be overseen by a board composed of five representatives from Baptist and five representatives from Tenet. The transaction, which is subject to customary closing conditions and regulatory approvals, is expected to be finalized in the third quarter of 2015.
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Rolling Out the President’s Precision Medicine Initiative NIH’s Collins, Sen. Alexander Discuss Next Steps in Nashville By CINDY SANDERS
During a National Institutes of Health Precision Medicine workshop held in Nashville at the end of May, NIH Director Francis Collins, MD, PhD, and Sen. Lamar Alexander (R-Tenn.) discussed the steps necessary to roll out a national effort to deliver highly personalized care. The Precision Medicine Initiative (PMI) has near-term goals focused on diagnosing and treating cancer and longerterm goals that look to expand the scope to the full continuum of health and disease. In announcing the initiative earlier this year, President Barack Obama highlighted the impact of ivacaftor – a new class of drug to target the underlying cause of cystic fibrosis that is now approved for patients with 10 different mutations to the CF transmembrane conductance regulator (CFTR) gene. For those with one or more of the mutations, ivacaftor has demonstrated improvement of CFTR function and has significantly extended quality and quantity of life. Collins, a physician-geneticist who is known for his landmark discoveries in disease genes and his leadership in mapping the human genome, said the plan is to launch a million-person (or more) PMI research cohort in the next few months. “We do expect by the fall to begin the process of implementing what we are designing right now,” Collins said. He spoke from Vanderbilt University where he was onsite for a two-day PMI workshop focused on digital health data and research cohort design. In order to deliver individually tailored approaches to prevention and risk assessment, health maintenance, diagnosis and treatment, Collins said it was critical to build a large evidence base encompassing gender, race, ethnic, age and geographic variances. By sharing genomic information from participants, along with important clinical data from electronic health records and lifestyle and environmental information from mobile health devices and applications, researchers hope to better understand how genomic variations, in concert with other factors, impact the development and progression of disease. Some participants will have their entire genome mapped, which has become much more cost effective over the past decade. Collins, who was director of the National Human Genome Research Institute when human DNA sequencing was completed in April 2003, noted that first map cost about $400 million. Today, the price is about $2,000. Collins said the hope is that individuals already enrolled in several large research cohorts like those with Kaiser Permanente, Mayo Clinic, Geisinger and the Veterans Administration might give permission to roll their data into this national effort. In addition to ‘stitching together’ some of the
existing cohorts, Collins noted, “We will also have to find ways to fill gaps and invite highly motivated people who want to take part to come join.” The goal is for patients at a family practitioner’s office in a small town to be able to participate as easily as those at major academic centers or large health systems. However, Collins stressed, having an electronic health record would be crucial to participation. Even with EHRs, Collins admitted interoperability and data sharing could be an issue. Alexander, who has been a vocal critic of the current EHR program, said
problems ranging from excessive documentation to disrupted workflow to interoperability issues have electronic health records “in a ditch, nationally.” Alexander, who is the Senate health committee chair, and Patty Murray (DWash.) recently announced a bipartisan work group to pinpoint ways to improve EHRs. “The goal of this working group is to identify the five or six things we can do to help make the failed promise of electronic health records something that physicians and providers look forward to instead of something they endure,” Alexander said in announcing the new committee at the end
of April. That work, he noted in Nashville, would be critical to the success of personalized medicine. While there is a long road from the $215 million included in the president’s proposed fiscal 2016 budget for PMI and congressional approval, Alexander did say this was an area where bipartisan support exists. ”Precision medicine – tailoring treatments and cures to individuals – has the potential to affect and improve the life of every American,” he said. Another concern addressed by Alexander and Collins was the impact … in terms (CONTINUED ON PAGE 18)
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INFORMATION TECHNOLOGY
Transitioning to a New EHR By Jane Ehrhardt
“I don’t know that sales people are really mentioning this problem upfront,” says Ryan McGinty with Oceris, makers of FlexMedical electronic health record (EHR) system. “But each time a practice transitions to a new EHR, a complete data conversion is almost never possible.” That means for physicians to maintain access to the last ten years of treatment history for adult patients, as recommended by the Alabama Board of Medical Examiners, the old EHR must Carrie Gulledge (left) and Vicki Green view EHR data. be kept going along with the new one, and possibly paper charts as ally, EHRs will successfully transfer only a well. “So they may be paying for two EHR patient’s basic demographics like name, adsubscriptions each month for years,” Mcdress, birthday, and social security number. Ginty says. He knows of one practice that’s However, those certified to meet Meanon its third EHR in 18 months. ingful Use requirements for 2014 have exSeventy percent of Oceris sales are to panded exportation abilities. “But it’s data offices that want to replace a current EHR. that the government agreed upon as a core The remaining 30 percent are installing data set—the patient’s demographic info, EHRs for the first time. “But not because current medications, current problems, imthey haven’t used an EHR before. It’s bemunizations—basically a snapshot of the cause they’re a new office,” he says, adding now,” McGinty says. “It’s not a complete that he rarely sees anyone transitioning from history. So for past problems or past medicapaper to EHR anymore. tions, you still have to pull up the old system.” Finding out that only a small part of Data is stored in each EHR so differpatient data will automatically transfer to ently that a complete transfer becomes very the new system tends to be a shock. Gener-
complicated and unreliable. The custom coding needed to transfer all data from one EHR to another would cost anywhere from $10,000 to $25,000. In addition, EHR companies often charge upwards of $10,000 to export their own client’s patient data beyond the required core data and also to import that extra data from another EHR. Most practices opt to electronically transfer only the basic demographics. Then they manually enter the rest of the data as they need it. “This way they get a clean slate,” McGinty says. “And they can set up the information in the new EHR the way they want it.” “You don’t want a situation where it’s garbage in, garbage out,” says Carrie Gulledge with MediSYS. When practices began using their initial EHR, staff likely documented the same data using different phrasings or in different places. “It’s not that the data was incorrect. It’s just not organized in the manner they wanted to see it,” she says. Manually entering the data into their new EHR allows staff to sort and display their patient data more consistently and to take advantage of the new EHRs en-
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hanced capabilities. “One of best things to keep in mind is that you won’t be slowed down like you were when you went from paper to EHR,” Gulledge says. “Because of the experience with EHRs already, the big learning curve doesn’t exist. You don’t have to overcome all those big hurdles.” McGinty adds that manually entering the data from the old to the new system versus a digital transfer has another advantage. “You don’t have to transition all your doctors at once. You can stagger it,” he says. “Have two or three doctors a week start on the new system.” “A good recommendation when transitioning is to not get so focused on what you could do on the old system,” Gulledge says. “Every EHR offers new efficiencies and options. So go into this process with an open mind. Don’t get hung up on how something was done in the old system, because the new one may do it better.” To make the most of the new EHR, physicians should identify what they liked and didn’t like about their old system. Then ask the new EHR’s trainer to replicate those positives and offer solutions to the negatives. “Be upfront with the implementation specialist. What you liked in the old one may just be housed in a different area of the new EHR,” Gulledge says. “Don’t assume that just because your old EHR couldn’t do something you want, the new one can’t either.”
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really understood how it worked, but it did. However, it was difficult to find the right place to cut, and too often nerves controlling the bladder, bowel and sexual organs were damaged. With the advent of hypertension medications, the surgery was no longer done. “I often see patients with hypertension that is difficult to control, even with multiple medications. Compliance isn’t always easy. There are side effects. Sometimes, even with the best efforts, some patients are still at risk for stroke and damage to their heart and other organs. “Since we can do so much with RV ablation in the heart, it had occurred to me that a similar approach might give us more precision in ablation of the sympathetic nerves in the kidney that affect blood pressure. I had begun searching the literature to identify the location of the nerves that influence blood pressure and found that very little work had been done in that area. So mapping those nerves became a research project. One of our residents and a pathologist at Princeton did five cadaver studies to trace them. We compiled the data and had a good sense of where the nerves lay along the renal artery and how deeply energy would have to penetrate to be effective. “As Cohen and I talked, he mentioned that he had met with several advisors looking for suggestions of other applications for his technology and asked what I thought. I told him to send me the details about his design and I’d get back to him. “After studying the design, I called him and asked whether he had considered using it for renal nerve ablation to treat hypertension. He agreed it could probably be used in the renal artery, but said ‘no one knows where the nerves are.’ I told him, ‘I do. It’s in a study I haven’t published yet.’ He didn’t say anything for about ten seconds, then said ‘Get on a plane and bring your data.’” Mendelsohn flew to California and met with Cohen at Minnow Medical. “We pulled out a white board and started drawing, plotting where on the balloon we’d need to place electrodes to have them in the optimal position,” Mendelsohn says. “We also added temperature controls. The question was whether we could get the energy deep enough to be effective. Using a prototype and tweaking it in about 100 animal studies, we found that the answer was yes.” The next step was human trials in Europe. The Rothschild group in Paris was the lead investor of a venture capital group that funded the trials. They suggested changing the name of the company, since Minnow Medical had an X-rated connotation in French. “So, as Vessix Vascular, they began the European trial of 150 patients,” Mendelsohn says. “They responded so well, we saw blood pressure numbers improving in the neighborhood of 30 mm. We were delighted and the company received certification to market the device in Europe. It was going to take a much larger company with more resources to commercialize the device in the U.S., gather data, and get it through the process of FDA approval. About 16
months after Rothchild made its investment, the company sold for several times that amount to Boston Scientific. “Eight to ten lead investigators across the country will be involved in the randomized REDUCE-HTN: REINFORCE trial of the device. Since I was there from the beginning, and my partners at Cardiology PC and research staff have been very involved, they knew we could get up and running quickly, so they chose us to perform the first US procedure. Our team mobilized quickly. They have been remarkable. One of my partners, Michael Wilensky M.D, referred the first patient. It isn’t just me. It’s our entire team working together. “It’s a thrill for me to see this device through from that whiteboard drawing to the first patients. We’ve done four procedures now. Since it’s a randomized trial, we won’t be able to release data until all 100 procedures have been completed and all the patients are seen for their eight-week followup. However, I’ve very optimistic that we will see results comparable to the response we saw in Europe. “If so, FDA approval should follow, and it shouldn’t take long to train cardiologists who are accustomed to doing other catheter procedures. One thing that is especially nice about the design is how userfriendly it is. Once the catheter is positioned in the renal artery just before the branch, you simply inflate the balloon and the electrodes should be in the right position. Turn it on for 30 seconds, then go to the other kidney. A procedure that takes half an hour or less could change a patient’s life forever.” Why selective denervation of the renal sympathetic nerves works is still not well understood. It may be related to feedback to the brain related to fluid retention and stimulation of hormones. However, this new, more precise approach to an old strategy could dramatically change how persistent hypertension is treated in the near future. Since their chance meeting at a medical conference and working together to develop the device, Mendelsohn and Cohen have become good friends. “Raymond is a wonderful guy, and he has a soft heart,” Mendelsohn said. “One of the doctors who helped us with the European trial was from Australia. He had a patient who was only 12 and despite all medications his blood pressure was still over 250. Since the device we’re testing is sized for adults, he called Raymond to see if anything could be done. Raymond and his engineer went in the lab and built a smaller version and shipped it off to Australia. They probably saved the child’s life.”
Sniffling & Wheezing Across the U.S.
Memphis Tops List of 2015 Asthma Capitals; Southern Cities Swap Rankings By JULIE PARKER
After jockeying for position in the top five most challenging cities to live in the United States with asthma, Memphis holds the leading spot for 2015, according to the newly released annual Asthma Capitals report by the Asthma and Allergy Foundation of America (AAFA). Poor air quality, inadequate public smoking bans, high reliance on asthma medications and voluminous emergency room visits for asthma were among the significant factors why the Bluff City – alternately known as Home of the Blues and Birthplace of Rock ‘n’ Roll, and perhaps more tellingly of health issues, the Barbecued Pork Capital of the World – climbed to the uncoveted spot atop the annual list, after moving from No. 3 in 2013 and No. 2 in 2014. Rounding out the top five Asthma Capitals for 2015: Richmond, Va., which held the top perch last year; Philadelphia, Pa.; Detroit, Mich.; and Oklahoma City, Okla. “Each year for our report, we look at the largest cities across the country and measure the things that people with asthma care about the most,” said Mike Tringale, senior vice president of external affairs and principal investigator for the
report. “Obviously, we look at pollen, pollution, and ozone because nature affects adults and kids with asthma. But we also look at poverty, uninsured rates and city smoking bans because public policies matter, too.”
Community Blueprint
The annual report, Tringale pointed out, provides communities with a blueprint for change, along with data on 13 critical factors relating to asthma prevalence, environmental conditions and healthcare usage. Teva Respiratory (TEVA) and QVAR Inhalation Aerosol sponsored the report, an independent AAFA research project. “Communities can work to make progress of many of these factors,” said Tringale. The most noticeable ranking change for Medical News markets: Knoxville, Tenn., which tumbled from No. 41 to No. 7, after making progress from the 2013 list (No. 10). “The Allergy Capitals can help to inform a pollen sufferer about geographical areas that may provide and worsen their seasonal symptoms, which impacts their quality of life,” said allergist Cliff Bassett, MD, AAFA ambassador and medical director of Allergy & Asthma Care of NY. Similarly, the information holds true for families traveling to Asthma Capitals, perhaps altering the time of year to visit for the least impact on asthma sufferers.
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Bassett also pointed to AAFA’s spring allergy capitals. The worst metro area: Jackson, Miss., based on higher-than-average pollen and medication use. “It’s important that allergy sufferers take heed,” he said. “A new study by AAFA revealed that spring is when most allergy patients experience their worst
seasonal allergy symptoms, and patients report that they’re not fully satisfied with over-the-counter (OTC) options they find on drug store shelves.” Rounding out the top five spring allergy capitals for 2015, respectively: Louisville, Ky.; Oklahoma City, Okla.; Memphis, Tenn.; and Knoxville, Tenn.
Congressional Response
With an estimated $50 billion national price tag for treating asthma annually, Congress is considering important legislation to reduce America’s asthma burden. The Family Asthma Act of 2015 (S 1064), introduced again this year by Sen. Kirsten Gillibrand (D-NY), would strengthen research, promote public education and develop improved recommendations for asthma treatment and management. If enacted, the Centers for Disease Control and Prevention (CDC) would expand asthma tracking to provide researchers with much-needed data on disease prevalence, severity and treatment in the United States. The CDC could also develop recommendations regarding the federal government’s role in response to asthma by providing steps for reducing asthma’s prevalence, cost and mortality rates; and ideas for further research, treatments and intervention. Gillibrand also introduced legislation to enable schools to enact better asthma management plans. The School Asthma Management Plans Act (S 1065) could greatly improve the way schools provide care and treatment for students with asthma. In the U.S., an estimated 7 million children under the age of 18 have asthma, a leading cause for school absenteeism. The act directs grant-receiving schools to develop asthma management plans that identify all students with an asthma diagnosis, provide asthma educa-
tion for all school staff, and develop protocols and training to support symptom management. Schools could also use grant funds to acquire asthma inhalers, spacers, air purifiers, and related supplies.
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Medicaid patients in the Birmingham area. They now perform the same support functions as they will as a Medicaid RCO. The program was piloted around the state several years ago and offers Medicaid providers greater incentives for participating. The state paid providers a flat rate of 50 cents per month for every Medicaid patient. But if the patient is under chronic care and enrolls with Health Home, they get an additional $8 per patient per month. In addition, the provider receives all the support of an outside organization helping to keep the patient compliant and responsive. “Those providers able to engage with Home Health have been happy about it, and they’re calling us with issues,” Velasco says. “If they’re not able to get a Medicaid patient in to see a certain specialist, they’re now turning to us to get in. It’s
very labor intensive for a Medicaid provider. We’re trying to be their provider.” Over the next year, the RCOs must pass through rigorous approval levels to demonstrate they can handle all aspects of managing Medicaid patient care. The next step falls on October 1 when they must show they have recruited an adequate number of providers to geographically cover their entire region. “They will also have to prove they have the fiscal ability and resources to operate as an RCO, so our recipients suffer no loss in care,” Rawls says. Medicaid thinks Regional Care Organizations have a strong place in the state’s healthcare future. “RCOs have the ability to do things that the state is not able to do,” Rawls says. “They can be innovative, and we’re looking for opportunities for innovation.”
Summary, continued from page 10
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Regional Care, continued from page 9
Alabama providers (with consumer input through non-at-risk board membership) are given the unique opportunity to develop and apply innovative and creative methods for case managing assigned Medicaid beneficiaries through collaborating provider networks. Establishing the RCOs and ICNs will require significant investment by the provider community. While these are difficult undertakings, Alabama’s Governor and Legislature have deemed that this course has the potential to not only create tangible Medicaid program savings by requiring the RCOs and ICNs to promote care collaboration among providers, thereby bending the growth curve, but also, through this system of care collaboration, develop better access to needed medical treatment and better quality of care and life for its citizens who are Medicaid beneficiaries. It is anticipated that these provider collaborating networks will reach into other payor classes, such as Medicare, to inno-
vate better care coordination throughout the care continuum and permitting these benefits to have wider application. To view a longer, more in-depth version of this article, go to http://birminghammedicalnews.blogspot.com/2015/06/ summary-of-alabamas-at-risk-provider. html Or go to www.birminghammedicalnews.com and click on “blog” on the gold horizontal bar across the top. Once you are in the blog, go to June and scroll down for this. Richard Brockman is Counsel with Burr & Forman LLP. He is also the current President of the Alabama Nursing Home Association. Richard served on the Governor’s Medicaid Study Commission during the development of the RCO legislation and worked with the Medicaid LTC Task Force in the development of the ICN legislation. Angie Cameron is a Partner with Burr & Forman LLP practicing in the firm’s healthcare group.
Rolling Out, continued from page 13 of time and cost … of creating new therapies tailored to smaller numbers of people. “I’m working with Sen. Patty Murray, the committee’s top Democrat, to examine how we can get safe, cutting-edge drugs, medical devices, and treatments from the discovery process through the regulatory process into medicine cabinets and into doctors’ offices more quickly,” Alexander said. He added work groups currently are looking at ways to lower costs and shorten timeframes while maintaining safety. “We hope to have that legislation ready by the first of next year,” Alexander said. Collins noted precision medicine might actually help get more drugs on the market. “The era of blockbusters may no longer be one that is going to apply as we understand more and more differences between people,” he said. “But look at it the other way,” he continued, “The failure rate in developing a new therapeutic is about 99 percent.” Collins noted after spending an average of 14 years from idea through human trials, most therapeutics don’t wind up approved. “That’s
why the cost of the whole pharmaceutical industry is so high … because you have to pay for all those failures,” Collins said. “What precision medicine gives you is an opportunity, first of all, to pick the right target because we really understand at a much more detailed level what is happening with diabetes or cancer or heart disease.” He added researchers not only start with more evidence before embarking on developing new therapeutic agents, but they also have the ability to pick groups that fit the target profile. A drug crafted to impact a specific mutated gene would not be tested in patients without that genomic profile. “”That means you can run a clinical trial that is much smaller, and therefore much cheaper … and you also will have a much higher likelihood of success.” Collins pointed out such a drug used in a broad trial, as is often the case now, might look like a massive failure because it only worked 10 percent of the time. However, he added, if only tested in the 10 percent of patients that fit the target profile, that ‘failure’ suddenly becomes a roaring success.
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“Compliance with HIPAA and HITECH is not about whether your IT is working, but if your patient data is at risk. It’s kind of an invisible issue,” says Blake Perry with Keep IT Simple. “Unless you know what you’re looking for, you could be non-compliant.” Breaches from violating HIPAA protocols Blake Perry have cost healthcare entities hundreds of thousands, and even millions of dollars in penalties. And now hackers are finding medical data ten times more valuable than credit card data. According to Reuters, the cyber criminals use provider and patient numbers to buy and then resell medical equipment or drugs and file false claims with insurers. Many medical offices are strewn with unintentional HIPAA violations. “An office sent me a photo of their monitor to help with an IT problem,” says Thomas Kane with Keep IT Simple. “It showed all the sticky notes around the monitor that listed passwords. They had just unintentionally given me access to everything.” Thomas Kane
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Unsupported Software A more hidden violation of HIPAA lies in unsupported software. The most recent will occur this year on July 14th when Microsoft will no longer support their highly popular Windows Server 2003 software. After that date, Microsoft will no longer issue security patches to protect against new viruses or malware. “Which means all the hackers of the world are waiting for that day when they can go in and find those open gateways into servers running that software,” says William Sester with TekLinks. William Remote Access Sester Anytime patient information is shared outside the practice or accessed from outside the practice, HIPAA has requirements. To create secure remote access, practices need to require a different user name and password to access patient health information (PHI) when offsite, employ 128-bit AES encryption, allow passwords to be changed immediately, and activate an automatic log-off of the connection after a short period of inactivity. “Audit the usage log, too, so you can review when people log on,” Kane says. Logs reviewed at one practice revealed that the husband of a front-desk employee
signed in from their home every few days. Her remote access was cut. Even on cloud-based data, the same vulnerabilities exist. “You can cut your exposure by setting it so nobody but the physicians have access after seven pm or only certain usernames have access from certain IP addresses,” Perry says. Lazy Passwords “A lot of times administrators overlook the importance of passwords,” Sester says. Even laziness in devising passwords can be a violation. HIPAA requires that passwords contain eight to nine characters and include uppercase and lowercase letters along with non-alphabet characters, like exclamation points. “Avoid common phrases and current crazes too,” he adds. Following those guidelines, a computer could take years to find a correct password on a system. “Don’t use the same password at work that you use anywhere else, either,” Sester says. “You’ve heard about all the breaches. If you use the same password in multiple places, they can test that on other websites, including your workplace.” Safeguarding the Workstation “Set all your monitors to go to the password screen after 15 minutes if there’s no activity,” Kane says, because allowing the public to view computer screens that contain patient health information violates HIPAA requirements. “You should also install privacy filters on any computer where patients can see the monitor,” Perry says. The filter, a thin skin that overlays the screen, distorts anything on the screen unless viewed from the front of the computer. Texting The desire to expedite workflow regularly supersedes thoughts of protecting PHI. “That’s why unsecured texting is a rampant violation at practices,” Sester says. “For instance, if the nurse texts the doctor at the hospital that his patient, Mary Smith with chest pains is in a certain bed, that’s protected health information. Think about what you’re supposed to shred in the office. That’s what you don’t share unless it’s secure.” The solution is secure text messaging. “Many software developers have apps for that,” Sester says. But there’s no way to ensure an app is HIPAA compliant or secure. Sester recommends using common sense. “If it says in print and on their website that the app is secure, it’s likely to be. But if only a sales rep tells you or it’s a mom-and-pop app, that’s different.” Business Associate Agreement Besides the tech itself, a common unintentional HIPAA violation lays in the (CONTINUED ON PAGE 24)
ACA Impact on the Healthcare Industry By Robert S. Ellerbrock, III
While most companies are struggling to ensure that they have everything in order to comply with the requirements of the Affordable Care Act (ACA), few people outside of the healthcare industry have considered the impact this sweeping legislation will have on this industry. It is estimated that as a result of ACA, over 30 million people will gain healthcare. This means that an industry that many feel is already understaffed is going to be even more so as a result of the ACA. These 30 million new healthcare recipients may have a false sense of security thinking that they now have readily available access to healthcare. While one thing ACA did is to offer incentives for individuals to pursue the medical field such as scholarships and loan repayments, it will take time for these to actually impact the short-staffed industry. Until then, this flood of new recipients may lead to longer wait times at the doctor’s office, less time with the doctor, and possibly even limited access to doctors. What does this all mean? Potentially more unhappy patients. With the amount of changes mandated by the ACA, there are many ways in which healthcare providers could be affected. As a result of ACA, some healthcare providers fear that they will experience decreases in their rates while seeing an increase in the rules and regulations governing healthcare facilities which will lead to an increase in the amount of paperwork required. This increase in administration will mean additional costs for healthcare providers, which in turn could result in an increased cost of care for the patient. It is estimated that ACA will result in 190 million hours of paperwork per year. This will require additional personnel at medical facilities. As a result of the cost of implementing many of the ACA requirements, some hospitals and physician groups are considering mergers in order to address the needs of the evolving healthcare market. This not only decreases costs but also results in shared financial risks, gives them more bargaining power with insurance companies and tends to increase quality and efficiency by coordinating care. While these consolidations may make sense, it is important to remember that the relevant antitrust laws still apply. While enhanced efficiencies and patient care may be laud-
Every Monday and Thursday, we’ll feature healthcare professionals discussing important medical topics. www.birmingham medicalnews.com In top navigation bar, click on blog
able goals, potential merger partners must consider the competitive impact of such a merger. Consideration of the competitive impact will require a detailed analysis of the relevant market—both its geographic and product or service components—and the likelihood of increasing reimbursement rates following such a planned merger. Keep in mind that antitrust enforcement agencies will seek input from payors regarding likely competitive effects of a merger as well as the contours of the relevant market. Some doctors may choose not to merge or consolidate but rather restructure their practice. One possibility would be to offer concierge medicine. Concierge doctors are doctor’s offices that require an annual retainer in exchange for enhanced care and limited patient loads. In today’s fast paced society where time is money, people may become more willing to pay additional money to cut down on the amount of time they have to spend at the doctor’s office. Concierge doctors have grown in popularity since ACA, and this trend is expected to continue. Another popular trend has been the number of employers switching to Consumer Driven Health Plans (also called high deductible health plans). In these plans the employee pays all or the majority of the initial cost of medical care and then the insurance company picks up after a certain deductible is met. The idea behind consumer driven healthcare is that by placing a substantial amount of the initial cost burden on employees, it will make consumers carefully consider when a trip to the doctor is necessary. While employers did this with the focus on savings, it could also significantly cut down on the number of doctor’s visits and claims. The increase in these plans could help combat the shortage in the healthcare field as it could decrease the number of times people go to the doctor.
These are just a few of the ways that healthcare reform is changing the healthcare industry. It is anticipated that even the delivery of healthcare services will change. For example, in recent years we have seen an increase in the number of medical providers offering telemedicine especially in more rural areas. As ACA
evolves, so too will the healthcare industry. Thus, it may be years before we know its full impact. Robert S. Ellerbrock, III practices with Balch & Bingham where he specializes in Employee Benefits/ERISA.
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The Literary Examiner BY TERRI SCHLICHENMEYER
This is What You Just Put in Your Mouth? by Patrick Di Justo; c.2015, Three Rivers Press; $15.00 / $18.00 Canada; 255 pages Borborygmus. That’s the technical term for what you’re experiencing now: great big rumbles from beneath your navel; snarls from your stomach, a reminder that it’s snack time. Aside from sugary-salty goodness, though, and a feeling of satisfaction, what will you consume? To find out, read This is What You Just Put in Your Mouth? By Patrick Di Justo, and hang on to your gut. But first – the vending machine.
The vending machine is close, so let’s start out with a cuppa joe, which includes an ingredient that “helps give real butter its flavor” and one that actually keeps bacteria off your teeth. So far, so good. Real good, in fact, so you might follow it up with something sweet to get you through your day, complete with “artificial human salivary enzymes,” perhaps topped with a product that contains “a high percentage of air.” Uhhh, or maybe not. How about
something cheesy – some “cheese, processed cheese, cheese food, or cheese spread” – each of which are different, says Di Justo. Or salty, which might contain three ingredients that cause addiction in lab rats. If you’re watching your weight, though, beware. Federal
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regulations state that serving size is generally based on what a fouryear-old can consume. And expiration dates? Nope. There’s “no federal regulation to date food at all.” Well, now, your appetite is gone. In fact, you might want to lie down somewhere; like, in front of a fire, where you might burn birdseed and “a giant sideways candle in your fireplace.” Or maybe you just need to be with friends, so put in your contacts (the solution for which may contain a product used with anticancer drugs) and mascara (which you definitely do not want to wear near a magnet!) and head down for your favorite libation (which could cause irregular heartbeat). Or maybe you’ll just skip it all to spend time with the dog (and feed him something that’s “deliberately stinky”) or the kids (and give them what “attempts to artificially re-create something that already exists”). Bon appétit! “If you’re looking for shocking stories of the gigantic corporate conspiracy to poison America, then you’re reading the wrong book,” says author Patrick Di Justo. Without intending to scare, he says he looked at various products with curiosity and the notion that knowing what’s there is better than not knowing. It can’t be an accident that he also entertains readers, then, can it? I don’t think it is: in this collection of Wired magazine articles, Di Justo is hilarious, as he explains how he learned what’s inside everyday products, not just food. What he finds may surprise and delight you. For sure, you’ll read ingredient labels a whole lot closer. Depending on how you look at it, this is a consumer’s dream, or it’s a nightmare. Either way, it’s a twistedly-fun and very eye-opening book to have. This is What You Just Put in Your Mouth? will give you food for thought. And it might make you growl. Terri Schlichenmeyer. Terri is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.
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Research Notes Cells Too Stiff to Scavenge Leads to Lupus
More than 50 billion cells die in the human body every day, a spectacle of programmed cell death called apoptosis. These cells undergo internal degradation and then fracture into apoptotic bodies that are scavenged by immune cells, all without triggering the body’s immune system defense. One of the most dangerous places for cells to die is near the follicles of the spleen. The follicles are primed to mount intense immune attacks against infectious bacteria or viruses. If an apoptotic cell (AC) goes into the follicle, it can trigger an autoimmune response. This can lead to autoimmune diseases like systemic lupus erythematosus, where the immune system attacks its own body. Macrophages in the spleen marginal zone around the follicles keep the ACs out, acting like the defensive line in football,” says John Mountz, MD, PhD, professor of medicine in the UAB Division of Clinical Immunology and Rheumatology. In a paper published online in the Journal of Clinical Investigation, Mountz and colleagues, including Hui-Chen Hsu, PhD, and Hao Li, PhD, present a new model of why this defensive line becomes porous in mouse models of lupus, and they show the mechanism that underlies this breakdown. Just as “location, location, location” is the difference between good and bad real estate, the Mountz group say that the location of immune system B cells is a key difference between healthy animals and those that develop autoimmune disease. The wrong location leads to macrophage cells that have problems in their cytoskeletons — they become too stiff to engulf and digest dead cells. Mountz found that the presence of B cells in the marginal zone outside the follicle is essential to maintain the defensive line of macrophages. They found that type I interferon — which is elevated in lupus — causes the B cells to migrate away from the marginal zone and into the follicle, which interrupts vital cross-talk between the B cells and the marginal zone macrophages. In this model, the definition of an autoimmune pathogenic B cell is now based on its anatomic location. Experiments by the Mountz group show the mechanism of this cross-talk: B cells in the marginal zone of the follicle interact with the marginal zone macrophages by means of a membrane lymphotoxin present on the surface of the B cells. This lymphotoxin binds to a lymphotoxin receptor on the surface of the macrophages. That connection stimulates a mechanosensing complex in the macrophage, triggering the production of a gene regulator called megakaryoblastic leukemia 1 (MKL1) that regulates the cell’s actin cytoskeleton and enables a macrophage to respond to and engulf ACs. Without that B cell interaction, MKL1 expression in the macrophage decreases, changing the activity of the actin cytoskeleton. This signaling axis — from B cell to macrophage to mechanosensing signal-
ing — keeps the defensive line of macrophages strong. In contrast, mice that have had the MKL1 gene knocked out begin to resemble lupus-model mice as they age. They show decreased AC clearance, a deficiency of macrophages in the marginal
zone of spleen follicles and increased production of autoimmune antibodies. This suggests a key role for macrophage mechanosensing signaling in lupus. Examination of slides of spleens from human systemic lupus erythematosus
patients showed a pattern similar to that seen in mouse models of lupus: reduced numbers of B cells surrounding the follicle, increased numbers of B cells inside the follicle and a loss of MKL1 expression in the marginal zone.
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Grand Rounds Princeton Baptist One of Seven Hospitals in the U.S. to Receive MAP Award
Princeton Baptist Medical Center has been named as a recipient of the 2015 MAP Award for High Performance in Revenue Cycle, sponsored by the Healthcare Financial Management Association (HFMA). Winners of this national award demonstrate inventive, patient-centered revenue cycle practices that deliver sustainable financial performance. Princeton Baptist is one of only seven hospitals in the U.S. to achieve this distinction and the only hospital in Alabama and the Southeast. This is Princeton’s fourth year to earn this honor. As an award winner, Princeton has excelled in meeting industry standard revenue cycle benchmarks, implementing the patient-centered best practices embodied in HFMA’s Healthcare Dollars &
and administrative roles. Doughty’ s education includes two post graduate degrees from UAB: a Master’s degree in Health Administration in 2007 and a Master’s degree in Quality and Outcomes Management in Health Systems in 2004. He earned his Bachelor’s degree in nursing from the University of North Alabama in 1997. Doughty served as a commissioned officer in the U.S. Army Reserves from 2001to 2007. He is active in many local and regional organizations, serving on the boards of the Community Free Clinic, HEALS Clinic, Calhoun Community College Foundation, and the Huntsville Housing Authority Advisory Board. He is a graduate of Leadership Huntsville/ Madison County and Leadership Alabama. He is also a past board member of the Huntsville Madison County Chamber of Commerce, North Alabama African American Chamber of Commerce, and previously served as the Young Executive Chair of the Committee of 100. Professionally, Doughty is a member of the American College of Healthcare Executives and the National Society of Health Services Executives.
Sense™ initiatives, and achieving outstanding patient satisfaction.
Doughty Named Senior VP of Operations at Huntsville Hospital
Tracy T. Doughty has been promoted to Senior Vice President of Operations at Huntsville Hospital. Doughty’s expanded responsibilities will focus on “operations at the Main/ Adult Hospital campus on Gallatin Street. Doughty has served as Vice President of Emergency & Trauma Services Tracy T. Doughty and the hospital’s Physician Network since 2010. His career at Huntsville Hospital began in 1998 as a surgical/trauma nurse. Since then, he has served in a variety of clinical
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National Search Yields New Leader for UAB Biomedical Engineering
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Jianyi Zhang, MD, PhD, a national leader in myocardial bioenergetics, biomaterial and stem cells for cardiac repair, has been named the chair of the UAB Department of Biomedical Engineering, a joint department in the schools of Medicine and Engineering.
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Zhang will come to UAB from the University of Minnesota Medical School, where he is the Engdahl Family Foundation Chair in Cardiovascular Regenerative Therapies and a professor of med- Jianyi Zhang, MD, PhD icine and biomedical, electrical and computer engineering. He was chosen to lead the Department of Biomedical Engineering after a national search. Zhang will succeed longtime department chair Timothy Wick, PhD, who stepped down last year to accept a role as senior associate dean in the School of Engineering. Zhang’s research is leading the field in myocardial energetics in hearts with postinfarction left-ventricle remodeling and congestive heart failure, biomaterials, and stem cells for cardiac repair. The research evaluates myocardial high-energy phosphates using nuclear magnet resonance spectroscopy to examine the mechanisms of energy production, transportation and utilization in the in vivo heart during normal and diseased conditions, as well as in response to different therapeutic interventions. Findings may lead to better diagnostic and therapeutic modalities for patients with heart failure. Born in Shanghai, China, Zhang earned his MD from Shanghai Medical University in 1983 and his doctorate in biomedical engineering from the University of Minnesota in 1992. He also earned a Master of Science degree in engineering in 1987 and a certificate of business administration in 1987 from Tufts University. Prior to joining the faculty at Minnesota, Zhang completed postdoctoral work in the university’s cardiovascular division.
Easy Ways, continued from page 22 relation with vendors who access patient data, including IT companies. “You need to have them sign a Business Associate Contract. It’s an agreement to not share the data with others,” Kane says. In case of a breach at the hands of the third party, it shifts some liability off the practice and onto the vendors. A sample business associate contract can be downloaded at the hhs.gov website. “If practices, especially smaller ones, try to dot every i and cross every t to be 110 percent compliant with HIPAA, they’d be out of business, because they don’t have the resources to pull all this off,” Sester says. He recommends that if an administrator or physician hears something about a HIPAA/HITECH regulation, to take note. “If you see it mentioned again, pay attention. If you see it a third time, you know it’s serious,” Sester says. “And you need to make sure you’re compliant.”
Grand Rounds Samford’s Ida V. Moffett School of Nursing Receives $1.7 Million Grant
Samford University’s Ida V. Moffett School of Nursing has received the second largest award nationally of the 86 Nurse Faculty Loan Program (NFLP) grants for 2015-16. This is the 13th year for Samford to receive the grant from the U.S. Department of Health and Human Services, Health Resources and Services Administra-
tion (HRSA). Samford’s grant of $1,741,140 is second only to Case Western Reserve University in Ohio. It is one of only five grants nationally that exceed $1 million. NFLP grants are designed to help ease a national shortage of nursing educators, according to Jane Martin, associate nursing dean and the HRSA grant administrator at Samford. Students who receive loans for master’s or doctoral degree programs can
have up to 85 percent of the loan forgiven in exchange for service as full-time nursing faculty members at an accredited school of nursing. “Across the country, the faculty shortage is impeding our ability to address the increased demand for nursing professionals,” said Eleanor V. Howell, dean of Samford’s nursing school. “As we prepare for the projected need of more than 900,000 RN positions in the U.S. by 2020, this Nurse
Faculty Loan award allows the Ida V. Moffett School of Nursing to address this need.” According to a report by the American Association of Colleges of Nursing (AACN), U.S. nursing schools turned away 68,938 qualified applicants from baccalaureate and graduate nursing programs in 2014. Almost two-thirds of the nursing schools responding to the survey pointed to faculty shortages as a reason for not accepting all qualified applicants.
Priority Ambulance Hits Milestone
St. Vincent’s One Nineteen Holds Block Party
St. Vincent’s One Nineteen held its 9th annual Block Party and Health Festival on Saturday, June 13. This year’s event was a celebration of its 10th anniversary, as well as its expansion project to be completed later this year. The Block Party featured a wide range of offerings, including live music, healthy information booths, bubble soccer, a rock climbing wall, a 70-foot inflatable obstacle course, food vendors, and more. In addition, community members had the opportunity to meet local physicians and participate in free health screenings. Admission to the event was free. Block Party attendees also celebrated the St. Vincent’s One Nineteen expansion project by signing a beam to be placed in the completed building. The expansion will offer urgent care, outpatient surgery and more physician offices to the community.
Priority Ambulance has logged a significant milestone: The company currently transports more than 100,000 patients per year across its six-state footprint. Priority Ambulance operates at Shoals Ambulance in Alabama. The company is the exclusive emergency ambulance provider for the City of Florence, Lauderdale County and Franklin County and provides emergency and nonemergency service to the City of Bessemer, Birmingham and Jefferson County. Headquartered in Tennessee, Priority Ambulance was founded by Bryan Gibson, who has over 30 years’ experience managing ambulance operations. Gibson founded Shoals Ambulance in 2012, which merged with Priority Ambulance CEO Bryan Gibson. the national company when he started Priority Ambulance in 2014. Today, the company includes more than 600 employees and 100 ambulances in six states.
Birmingham Medical News
JULY 2015 • 25
Grand Rounds UAB named among top for cancer care in the United States
UAB Hospital has received a 2015 Women’s Choice Award for being named one of America’s Best Hospitals for Cancer Care. Women’s Choice Award is a consumer advocacy group that has recognized an elite group of about 340 hospitals, out of 1,300 that were analyzed, as America’s Best Hospitals for Cancer Care. UAB Hospital was selected based on being accredited by the American College of Surgeons Commission on Cancer, having an above-average patient recommendation rating from the Centers for Medicare and Medicaid Services, having available chemotherapy, radiation and hospice services on-site, participation in clinical trials and research, and satisfactory clinical performance with regard to patient safety
measures. The UAB Comprehensive Cancer Center is the only National Cancer Institute-designated comprehensive cancer center located in the six-state area including Alabama, Arkansas, Georgia, Louisiana, Mississippi, and South Carolina. UAB was also named one of the top breast health centers in the U.S. by the WCA earlier this year.
Trinity Names Assistant CEO
Justin Bryant, RN, has been named Assistant Chief Executive Officer at Trinity Medical Center. Prior to this appointment, Bryant served as an Administrative Specialist at Flowers Hospi- Justin Bryant tal in Dothan and five years in a clinical setting as a staff nurse in CVR/
CVSU. Bryant is a graduate of Auburn University where he earned a Bachelor of Science degree in 2005. He completed a Bachelor of Science degree in Nursing from UAB in 2008, followed by a Master of Business Administration degree from UAB in 2013 and a Master of Science in Health Administration from UAB in 2014. Bryant is a member of the American College of Healthcare Executives and the American Association of Critical Care Nurses.
To receive a Blue Distinction Center+ for Bariatric Surgery designation, a healthcare facility must demonstrate success in meeting patient safety as well as bariatricspecific quality measures, including complications and readmissions, for gastric stapling and/or gastric banding procedures. A healthcare facility must also have earned national accreditations at both the facility level and the bariatric care-specific level, as well as demonstrate better cost efficiency relative to its peers.
Trinity Receives Blue Distinction® for Bariatric
Blue Cross and Blue Shield of Alabama has recognized Trinity Medical Center as one of the first healthcare facilities in the nation to receive a Blue Distinction® Center+ designation in the area of bariatric surgery.
EDITOR & PUBLISHER Steve Spencer VICE PRESDIENT OF OPERATIONS Jason Irvin CREATIVE DIRECTOR Susan Graham STAFF PHOTOGRAPHER Jimmy McGillis
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