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Amy CaJacob, MD

New Supercomputer Revolutionizes UAB Research By daLe short


“Teraflop” is not a word you’re likely to hear at your local computer store. It’s a measure of processing power that allows calculations at a rate of a trillion per second with nine floating decimal points. How about 450 teraflops? That’s the computing speed of the newest generation of UAB’s massive computer, named Cheaha after Alabama’s highest geographic peak. The device is already helping the university’s students, scientists, and re- Components of UAB’s new supercomputer. searchers further their diagnosis and treatment efforts. The processing capacity is four times that of the former computer, which is a boon to researchers such as Frank Skidmore, MD, UAB professor of neurology, who works in the field of Alzheimer’s

New Primary Care Tract Welcomes First Students This Summer With only 73 physicians per 10,000 residents, a 2012 survey ranked Alabama 45th in the country in primary physicians per capita. In rural areas, where transportation can also be a problem, the nearest primary care can be even farther. Some counties have no doctors and eight have no hospitals ... 5

Asthma APGAR Tool Improves Management in Primary Care Setting A study published last month in the Annals of Family Medicine assessing the efficacy of the Asthma APGAR tool in the primary care setting found usage improved asthma control and decreased asthmarelated hospital admissions and emergency room visits ... 9

APRIL 2018 / $5

and Parkinson’s. The supercomputer can process in two hours a high-resolution brain image that formerly took a day. UAB worked with Dell to add the 72 graphics processing units. “Cheaha allows me to accelerate the entire work process,” Skidmore says. “If you can see better, you can plan better and you can treat better.” David Crossman, bioinformatics director at UAB, sends a different type of data to the supercomputer. “We analyze big data that’s being generated from these new sequencer machines,” Crossman says. “What we find can help identify mutations or variants in a particular person’s DNA that could possibly lead to what they’re encountering. (CONTINUED ON PAGE 6)

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Health care insurance is a hotly contested political issue, but the true cost is felt by individuals unable to pay for medical care. Without help, many become seriously ill or live with chronic, often debilitating conditions that prevent the uninsured from maintaining steady employment. This reality is one M-Power Ministries addresses in its Health Center, which provides free primary care services to adult patients with no health insurance. (CONTINUED ON PAGE 10)

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Breathing Easier with Amy CaJacob, MD By Lori Quiller The most recent data finds one in every 10 Alabama adults suffer from asthma. The data also show more than 12 percent of Alabama children are living with the chronic respiratory disease at some point in their lives. Unfortunately, these children live sheltered lives trying to avoid the triggers that can induce an asthmatic episode. Summer camp was not an option for these children until Camp WheezeAway opened 27 years ago. “Camp WheezeAway is one of the longest-running asthma camps in the country. It’s a memorial camp dedicated to Patsy Ruff, who was the world’s first successful double lung transplant in 1987,” said Amy CaJacob, MD, a pediatric allergist/immunologist and the camp’s medical director. “Patsy had asthma, COPD, and was a smoker for 22 years. She wanted a camp for kids with asthma because when she was growing up, she couldn’t go to a summer camp.” Camp WheezeAway is free to qualified applicants – youngsters ages eight to 12 suffering from persistent asthma. Campers are selected in June, and the camp runs the first week of July at YMCA’s Camp Chandler. CaJacob explained the importance of asthma education and how to handle its limitations is as much a part of the camp as having fun.

Amy CaJacob, MD

Kids having fun at Camp WheezeAway.

“Every year on the last night of camp, we have a smokeless campfire after dinner,” she said. “We wheel around an oxygen tank and talk to the kids about the dangers of smoking. We tell them the story of Patsy Ruff, her surgery, and how the camp began. All the campers are at that age where they may want to experiment with smoking. They need to understand how their decisions will affect their health.” If you think asthma education is boring, think again. CaJacob and the staff

of volunteers find new ways each year to make it as interactive and fun as possible for the campers, even if it involves grossing out some of the kids. “We don’t want to bore the kids during the education section,” she said. “So we do a project where we make mucus. It’s messy, but the kids love it. We’ve done skits of how to avoid asthma triggers where the kids dress up as ragweed or cigarettes and a rescue inhaler. Sometimes it’s just hands-on training so they can learn how


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to use their inhalers.” All in all, the campers get a wellrounded experience. From shaving cream battles, kayaking, and horseback riding, to rock climbing and archery, plenty of emphasis is placed on kids with asthma being normal kids. “We do all the things other camps do, but safety always comes first,” CaJacob said. “Camp has changed dramatically over the years regarding the kinds of kids who attend because asthma care has come a long way. We used to have more medically complex kids. At one time there were kids on ventilators for their asthma. Our inhalers and treatments are so much better now. That’s not to say there might not be a child or two we may have to step up treatment during the week by putting them on a little stronger inhaler or an oral steroid. I’m there the entire week, and we have a number of nursing and respiratory therapists who are there as well.” In many instances, Camp WheezeAway is a camper’s first sleepover outside the home. Because campers are not allowed cell phones, CaJacob assures parents they should not worry. A mother herself, she often she shrugs off her physician’s coat for her mom hat. “It’s the first time away from home for many of our campers so we get a lot of homesickness that first night,” CaJacob said. “Part of my job is doctoring, but a lot of it is just being a mom. That first night the kids can’t sleep or have tummy aches, but when they settle in and start having fun, everything is just fine. We take plenty of photos of the children and stay in touch with their parents by sending them photos of the activities, and let them know how things are going.” For more information regarding selection or medical qualifications and limitations, contact Brenda Basnight, CRT, at [email protected]

Affordable Care Update By Leonard J. Nelson, III

At the core of the Affordable Care Act (ACA) is the three-legged stool: (1) insurance reforms; (2) the individual mandate; and (3) premium and cost-sharing subsidies. Removal of any one of these legs could destabilize the ACA. The ACA established insurance marketplaces in every state to provide access to ACA compliant private health insurance coverage (Qualified Health Plans) in the individual and small group markets. The ACA provides premium subsidies on a sliding scale for persons with incomes up to 400 percent of the federal poverty level (FPL) for the purchase of an individual policy on the marketplace exchange. It also provides cost-sharing subsidies for persons with incomes below 250 percent FPL. Prior to the implementation of the ACA, insurers typically used manual rating for rate-making in the individual and small group markets, and exclusions from coverage for pre-existing conditions were common. Age-based rates were typically 5:1. The insurance reforms in the ACA are largely directed at the small group and individual markets (e.g., guaranteed issue/ renewal, no preexisting condition limitations, adjusted community rating capped at a 3:1 ratio for age). Standardization of benefits is achieved by requiring coverage for ten essential health benefits (EHBs) and certain preventive services which in the lat-

ter case services must be provided without cost-sharing. There are winners and losers under the ACA. Relatively unhealthy people that qualify for premium subsidies are the winners. Relatively healthy people that do not qualify for subsidies are the losers. Thus while the ACA has successfully expanded access to health care coverage, it has also resulted in higher premiums and a shift to policies with higher deductibles. There has also been ongoing concern about the withdrawal of insurers from the marketplace exchanges and the resulting lack of competition. During his campaign President Trump promised to “repeal and replace” Obamacare, but in 2017 Congress rejected a Republican plan that would have repealed much of the ACA. Several recent developments could, however, destabilize the ACA: (1) zeroing out of the individual mandate penalty; (2) failure to fund cost-sharing subsidies; (3) increased access to Association Health plan for small employers; and (4) increasing the coverage period for short- term plans from three months to 12 months.

Individual Mandate. The purpose of the individual mandate was to provide incentives for younger, healthier people to sign up for coverage under a Qualified Health Plan thereby mitigating the problem of adverse selection. It required everyone to provide proof of mini-

mum essential coverage to the IRS when filing a tax return. Nonetheless, since the marketplace exchanges began operation in 2014, there has been concern that the penalties were inadequate. Moreover, the penalty could only be collected from a refund due to a taxpayer. In December 2017, as a part of the Tax Reform legislation, Congress zeroed out the penalties attached to the individual mandate beginning in 2019, but did not actually repeal the mandate. CBO estimated that the effect of zeroing out of the penalty would be to reduce the number of people with health insurance by four million in 2019 and 13 million in 2027 “because healthier people would be less likely to obtain insurance and because, especially in the nongroup market, the resulting increases in premiums would cause more people to not purchase insurance.”

Cost-Sharing Subsidies. Congress failed to appropriate money for the cost sharing subsidies. The government continued to reimburse insurance companies during the Obama administration. The House of Representative brought a lawsuit seeking to end the cost sharing subsidies and the U.S. district court for the District of Columbia decided that the Obama administration could not constitutionally reimburse insurers for the costs. In October 2017, the Trump Administration announced that it would discontinue costsharing reimbursements for insurers.

Association Health Plans. The ACA does not require employers with less than 50 full-time employees to provide health insurance to employees. But the ACA requires that all small group plans are subject to the ACA market reforms Adjusted Community Rating (ACR) and Essential Health Benefits (EHBs). Thus small employers with a relatively healthy pool of employees were concerned that the application of these requirements could increase their insurance costs. There are two ways for small employers to avoid the impact of the ACA small group reforms: (1) self -insure; or (2) purchase coverage through an Association Health Plan (AHPs) that would be treated as a large group plan. Large group plans with 50 or more FTEs are not are not required to cover EHBs. Moreover, they are not subject to ACR. AHPs are established by professional groups to provide small groups the benefits of access to a large group plan and avoid state regulations of small group plans. They have been widely used in Oregon and Washington where they are regulated as large group plans under state laws. After passage of the ACA, however, the Department of Labor (DOL), adopted rules that treated AHPs as small group plans under federal law unless the plan qualified as a “bona fide ERISA plan.” This meant that AHPs would generally (CONTINUED ON PAGE 6)

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Managing the Big Picture By Laura Freeman


On one hand, we’re on the threshold of an incredible era in personalized medicine with scientific breakthroughs making possible highly individualized care that could advance both quality and years of life. On the other hand, the providers who will be at the nexus of helping individuals manage their personal health—primary physicians—have rarely been stretched so thin. While major efforts are underway to attract and train more primary physicians, the practice of primary care itself is changing to make more productive use of time and resources. “To be effective, we have to think in terms of care teams and smarter use of information technology,” William Curry, MD, MACP, Governor of the Alabama Chapter of the American College of Physicians and professor of internal medicine at UAB, said. “There has been a progres- William Curry, MD, MACP sion with technology. With telephones, questions could be answered without the need for another face to face visit. However, managing the flow of information through telephones as demand has grown is a headache for both practices and patients. Now online patient portals allow secure electronic messages between patients and practices and some store information like reviewed labs that patients can check whenever the like.” For elderly patients who may need the assistance of family members in keeping track of medications and appointments, the patient can choose to share their password if needed. However, there are some patients who may need more. “This is especially true in complex


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cases with multiple chronic conditions that may be layered with factors related to socioeconomic determinants of health,” Curry said. “They can fall through the cracks between not having insurance and not qualifying for alternatives. They may not have access to medications, transportation and food security. If they can’t afford computers and have no family nearby, they may need more help to get better and stay well.” Care coordination began in hospitals with pre-discharge planning and post-discharge followup to reduce the risk of readmission. The concept is now expanding into medical practice. “Reimbursement is no longer a matter of volume of care,” Curry said. “It’s about the value of care we can offer to help patients stay well. Care coordination saves patients from the risk of avoidable illness and makes better use of health resources. This is true for both hospitals and practices. “It ties back to the evolution of the primary physician as a team leader. In addition to physician assistants and nurse practitioners who can take on responsibilities that help patients stay healthier and free up time physicians can use where it is most needed, lay staff can be trained as health coordinators and navigators. It’s like they say in football. The game may be won or lost on basic blocking and tackling. Simple logistics like making sure patients can get their medications and have transportation for their appointments can make a difference.” Some practices are using technologies like patient check-in kiosks to free up staff time that can be shifted to care coordination. Complex cases may require extended care coordination, from phone messaging and video links to home health visits by nurses. “It is also important to identify the patients most at risk and in need of extended coordination,” Curry said. “Many physicians can name patients who are most likely to run into frequent problems. For others, it can be a matter of looking at utilization and frequency of ER visits. There are also computer algorithms that can be helpful predictors. Extended coordination take time, but it pays off. “When patients have a problem that couldn’t be prevented, it’s easier to fit in an unscheduled appointment. When physicians have to call to find a hospital bed for a patient who needs highly specialized care, it’s much easier if the hospital isn’t on diversion because too many beds and ER rooms are full of patients with diabetic emergencies or heart failure exacerbations that didn’t have to happen,” Curry said. As anyone who has spent time with patients reconciling medications can attest, another area where coordination is helpful is (CONTINUED ON PAGE 6)

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New Primary Care Tract Welcomes First Students This Summer By Dale Short

With only 73 physicians per 10,000 residents, a 2012 survey ranked Alabama 45th in the country in primary physicians per capita. In rural areas, where transportation can also be a problem, the nearest primary care can be even farther. Some counties have no doctors and eight have no hospitals. To address this shortage, the School of Medicine at UAB and the school’s Tuscaloosa regional cam- Craig Hoesley, MD pus at the College of Community Health Sciences are launching a new primary care track in a fouryear medical degree program. The first class begins July 23. Interest in the program has been strong, receiving more applications than anticipated. “The new track will take an innovative approach in medical education,” Senior Associate Dean of Medical Education at the UAB School of Medicine Craig Hoesley MD, said. “Instead of the rotations by specialty that are typically done in a hospital, students will have an opportunity to follow a diverse range of patients longitudinally while working in a primary care environment.” The primary care track will provide students with a strong foundation in clinical medicine focused on preparation for residency training in primary care and other community-based specialty fields. In addition to special programming on population health and physician leadership skills, the longitudinal experiences with patients and time working with mentoring physician will add a real world perspective to the students’ understanding of primary care. “After completing their first two years learning the basic sciences in Birmingham, third year students will begin a longitudinal clerkship,” Hoesley said. “Our Tuscaloosa campus has taken the lead in building the longitudinal model, which embeds students in a primary care setting within a community. “In a sense, the student is helping to care for a community in all its diversity. Instead of studying pediatrics one month and geriatrics the next, and perhaps seeing a patient only once, students see a broad range of patients. From new pregnancies to the diseases of middle age to end of life care, they are there to follow treatment and see how relationships between patients and physicians are built.” The challenge in implementing a longitudinal model is finding enough preceptors to guide and mentor students. “Our alumnae have been wonderful,

and we’ve welcomed primary care professionals around the state who have been very generous in sharing their expertise,” Hoesley said. Advances in medical science and changes in how care is delivered are also changing the skill set new doctors must learn. “Delivering the best quality of care today requires the ability to communicate and work effectively with other health professionals as a team,” Hoesley said. “In addition to physician assistants, nurses and nurse practitioners, our future primary physicians will be working with pharmacists, physical therapists, nutritionist and a range of specialists and health related professions. “We simulate this interaction in teambased learning activities that bring together students from different disciplines. As they work, they learn what different disciplines and different perspectives have to offer and they can practice their listening skills and hone their ability to express themselves clearly.” The primary care office will also be ground zero for the shift in emphasis from curing diseases to preventing them as health care moves toward personalized medicine. “Practicing good medicine is much more than taking a history and assessing symptoms,” Hoesley said. “There are also sociographic and lifestyle de-

terminants that can factor into whether and how diseases develop. Effective evidence-based strategies for intervention and counseling patients are tools our students need to learn. Helping to prevent a disease is as important as accurate diagnosis and prescribing treatment after it happens. “Life-long learning is another emphasis. I tell students, you are never done. As new research findings about topics like genomics move personalized medicine toward more individualized treatment, physicians will need to continue learning

so they can put advances into practice to help their patients.” The initiative to innovate primary care education and encourage more students to go into the field is already bearing fruit even before the first class in the new primary care tract begins this summer. On match day in March at UAB, the number of students matching for a residency in family medicine was up by 50 percent over the previous year. “That is good news for everyone who is hoping to see more primary care physicians in Alabama’s future,” Hoesley said.

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New Supercomputer Revolutionizes UAB Research, continued from page 1 “So I take gigabite upon gigabite of really large files and crunch them through various pipelines to return back to me the mutations that might be there. The format looks much like a large text file containing what we’re sequencing. “The DNA sequence code is very short snippets of the entire genome. And our genome is 3.2 billion bases long, so we take sequences like 75 to 100 bases at a time and then put those back together to find out what has changed compared to the reference genome that we’re looking at. The supercomputer comes in very handy for all of my analysis needs, basically because all these files are so large. “If you tried to take every snippet of DNA that was sequenced from those and align them to the genome using a desktop computer, it would take months, maybe even years, whereas the supercomputer can process that information in less than a day.” Another researcher making use of this amazing processing power is Kristina Visscher, PhD in Neurobiology, whose work involves determining how the parts of the brain involved in attention interact with parts of the brain involved with vision. “We use functional MRI to examine human brain function and activity,” Visscher says. “We ask how an interaction changes with experience; like with the experience of using vision differently after diseases like macular degeneration. “For example, in a person with macular degeneration, we’re looking at people who allocate attention to visual space dif-

ferently because they lost their vision and we think that this changes their brain. Some people who’ve lost central vision get really good at doing things like reading or recognizing faces with their peripheral vision. You wouldn’t even necessarily know they had vision loss if you were to interact with them. “But other people with similar deficits in the eye aren’t able to cope as well. We don’t understand that. We are studying a group of people who have lost central vision in an effort to understand how this loss and use of peripheral vision changes their brains. Does the change in their brain relate to how well they’re compensating? “If it does, then we can start to think

be capable of comparing, mapping, and processing brain images by the hundred and even of sequencing a whole human genome. In fact, it contains the equivalent of the world’s total gene-sequencing machines of only three years ago. “Biomedical research now is big data,” Crossman says. “Our commitment to expanding this infrastructure at UAB gives us an advantage as we attract the top talent and compete for grants,” says UAB president Ray Watts, MD. Visscher said: “The speed with which Cheaha processes data moves some aspects of our work from ‘not do-able in my lifetime’ to ‘very do-able.’”

Managing the Big Picture, continued from page 4 in handoffs between specialists, allied health care, hospitals and primary care practices. “We had hoped electronic medical records would do more to get everyone on the same page,” Curry said. “It’s easier when we are using the same system. When there are different formats, it is possible to do a workaround to create a longitudinal record, but this is an area where we hope to see more streamlining in the future.” Another aspect where coordinating with specialists and other care can get difficult is when patients who can’t afford to pay and have no insurance need help with a serious medical issue. “We see this often in some of the

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about what kinds of training we need for people who have trouble compensating, to make them better able to use their spare vision.” Visscher’s lab is currently recruiting volunteers for the research. “We are looking for all kinds of people to participate in our various studies,” she says. “Right now, we are looking for older adults, especially people who are cognitively healthy and over age 85.” The website for information is participate The newest improvements make the supercomputer not only the state’s fastest by far, but one of the five fastest at Southeastern universities. The device is said to


safety net clinics,” Curry said. “If we have a patient who needs a neurosurgeon or cardiologist, we have to find someone willing to take them on without reimbursement. Physicians are compassionate people, but having to call the same people all the time makes it difficult. “A new program called Project Access is helping patients get the care they need. It’s a combined effort between the Jefferson County Medical Society, UAB, St Vincent’s and a number of clinics and physicians in the area. Project Access is an

excellent way for physicians who want to participate in a worthwhile effort to help with the number of cases they feel they can take on.” Curry expects more progress down the road. “So much is happening in research right now that will make such a difference in the care we will be able to offer patients,” he said. “Keeping in touch with the translational medicine pipeline brings us information on new treatments and advice we can give our patients to help them live healthier lives.”

Affordable Care Update, continued from page 3 be subject to ACA small group market reforms. Under the DOL rules, an AHP could be treated as a “bona fide ERISA plan” unless the group of employers were bound together by a commonality of interest (beyond providing a health plan) with sufficient control by the association so that they effectively operated as a single employer. The DOL guidance stated that this would occur only in “rare instances” where the association of employers could be deemed to be the “employer,” and thus exempt from regulation as a small group plan. On January 4, 2018, however, the Departments of Treasury, Labor, and Health and Human Services issued a proposed regulation to expand access to AHPs by allowing employers “to band together for the express purpose of offering health coverage if they either are: (1) in the same trade, industry, line of business, or profession; or (2) have a principal place of business within a region that does not exceed the boundaries of the same State or the same metropolitan area (even if the metropolitan area includes more than one State).”

Short -Term Coverage. On February 20, 2018, the Departments of Treasury, Labor, and Health and Human Services issued a proposed regulation that would increase the maximum length of short-term health insurance policies to 12 months. Previously, the Obama Administration reduced the term of coverage to three months effective in April 2016. Generally, short -term policies are more af-

fordable option for younger, healthier people. They are not subject to the insurance reforms (e.g., coverage of EHBs, ACRs, and the ban on pre-existing condition limitations). With the availability of a 12 month period of coverage, short- term plans will be a better deal for most healthy people who do not receive subsidies compared to QHPs. It allows people to cover themselves with a short term policy from one annual open enrollment period to another. Thus if they get sick, they will be able to purchase an exchange policy during the next enrollment period. Obviously, reduction of the period made short- term insurance a less attractive option. If the insured was to get sick after the three month period, there could be a gap in coverage until the next open enrollment period. With the return to the 12 month period and repeal of the mandate penalty in 2019, short term policies will be an attractive option for healthy people and adversely affect the risk pools on the exchange. A recent report issued by the Urban Institute estimates that in 2019 the return to the 12 month coverage period will increase the number of people without minimum essential coverage by 2.5 million in the United States and increase premium by 18.2 percent for QHPs in states that permit this option. Leonard J. Nelson, III is Professor Emeritus at the Cumberland School of Law.


Biologics for Treating Severe Asthma By Jane Ehrhardt

“Biologics are wonderful for treating a specific patient,” says Carol Smith, MD with Birmingham Allergy & Asthma Specialists. “Typically there is a group of patients who doesn’t respond to the usual treatment. That group, with severe refractory allergy, is who the biologics are for.” Carol Smith, MD This subgroup covers about five percent of asthma patients who may regularly take high-dose inhaled corticosteroids to fight the inflammation in their airways which may not work effectively. In addition, the steroids can create devastating side effects from their long-term use, such as glaucoma and bone fractures. Biologics, however, relieve respiratory inflammation differently without stimulating the harmful side effects. These relatively new types of drugs target a single biomarker of the condition, such as a certain type of cell. In the last three of the four severe asthma biologics on the market, that biomarker is eosinophils. These specific white

blood cells typically manifest in high numbers in about half of patients with severe asthma. The biologics each block a different subunit of the interleukin-5 receptor on the eosinophil surface. Unable to access this major cytokine, the eosinophil cannot proliferate and even die. “They all work by decreasing the effect of eosinophils on airway inflammation,” Smith says. “And they work really well.” Nucala (mepolizumab) was the first interleukin-5 antagonist monoclonal antibody to target eosinophil levels. By the time of its FDA approval in late 2015, it had been found to reduce eosinophils by approximately 80 percent within four weeks. A few months later, Cinqair (reslizumab) received its FDA approval. Patients receiving reslizumab showed a 92 percent reduction in mean eosinophil counts by week 52. Both drugs are administered every four weeks by injection or intravenous infusion at a physician’s office while patients continue to take their normal asthma medications to maintain adequate control of the disease. The latest asthma biologic, Fasenra (benralizumab), hit the market last November. “Benralizumab is also a mono-

clonal antibody against the IL-5 receptor, but this is against the alpha subunit of the receptor, so it’s a bit different,” Smith says. It also extends the dosing schedule to every eight weeks. Fasenra has shown up to a 51 percent reduction in asthma exacerbations and a 75 percent reduction in daily oral steroid use. The notable downside to biologics is the cost. “They’re very expensive—$600 to $1,500 per vial. And a patient sometimes needs more than one per month,” Smith says. Most of the time, insurance will cover the cost or the drug company will endeavor to work out some sort of assistance. “The justification for purchasing the high-cost drugs is that the biologics keep people out of the hospital, so they reduce their healthcare costs,” Smith says. Currently, the approximately five percent of patients with severe refractory asthma account for approximately half of the expenditures on asthma in the U.S. But getting approval can still be difficult. “It’s time consuming for the offices to do all the paperwork,” Smith says. “And it might get denied several times before the payor finally says OK.” Interestingly, these biologics may be helpful to a broader band of severe asthma sufferers. Allergists have noted that a per-

son does not need dramatically elevated eosinophils to reap a benefit. Even people within the normal 150 range can see an improvement. Although clinicians learned in trials while developing the biologics that the higher the eosinophil count, the better the response. That knowledge could encourage allergists to randomly check the eosinophil count in every severe allergy patient to see if they might benefit from biologic therapy. Though the three biologics may all target eosinophils, because they do so in a different manner means their impact on each patient may differ. “One biologic won’t work for everybody,” Smith says. “You have to look at their endotype, something about that patient that you can target.” “But for physicians treating people with severe asthma, the message of biologics is to keep in mind that there are more than just steroids to treat these patients,” Smith says. “If a patient is having to use steroids more than once or twice a year, and all their comorbid issues, such as smoking and acid reflux, have been dealt with, it might be time to refer them to someone who can evaluate them to see if a biologic might be beneficial.”


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APRIL 2018 • 7

Addressing Physician Burnout By CINDY SANDERS

Work-related stress leading to physician burnout continues to be a growing concern across primary care and medical specialties. Although stress is part of the territory in a profession that is literally charged with making life and death decisions, burnout occurs when physicians are unable to regroup and return to a place where they are engaged and fulfilled by their career. Dike Drummond, MD, founder and CEO of The Happy MD and author of several books Dr. Dike Drummond on physician burnout, noted the downward spiral into burnout begins with the inability to recharge and recover during time off and includes three distinct symptoms: 1) physical and emotional exhaustion, 2) depersonalization of patients, and 3) a reduced sense of personal accomplishment.

Understanding the Depth of the Issue Research released at the end of 2017 by the American Medical Association (AMA), Mayo Clinic, and Stanford University found “the burden and bureaucracy of modern medicine inflict a toll on U.S.

8 • APRIL 2018


physicians and appear to be major factors influencing physicians’ intentions to reduce clinical work hours or leave the profession.” In fact, the research found one in five physicians intended to reduce clinical work hours in the coming year and one in 50 physicians stated their intention to leave medicine for a different career in the next two years. “An energized, engaged, and resilient physician workforce is essential to achieving national health goals. Yet burnout is more common among physicians than

other U.S. workers, and that gap is increasing as mounting obstacles to patients’ care contribute to emotional fatigue, depersonalization and loss of enthusiasm among physicians,” said AMA President David O. Barbe, MD, MHA, a family physician from Missouri. If just 30 percent of physicians actually followed through on their plan to leave medicine over the next two years, the researchers noted that would roughly equal 4,700 physicians exiting the workforce … a loss equivalent to eliminating the gradu-

ating classes of 19 U.S. medical schools in each of the next two years. “The AMA is urging Congress, hospitals, and health plans to recognize the coming crisis as an early warning sign of health system dysfunction,” continued Barbe. “America’s physicians are the canary in the coal mine.” There are a large number of factors that contribute to burnout, and specific triggers can be different for each individual physician. However, some overarching themes have emerged including technology dissatisfaction and administrative fatigue. Last fall, the AMA released research results from a separate study in conjunction with the University of Wisconsin, which found primary care physicians spend more than half their workday at a computer screen performing data entry and other tasks tied to electronic health records. The researchers found in a typical 11.4-hour workday, primary care physicians spent nearly six hours entering information in the EHR during and after clinical hours. “U.S. physicians spend numerous hours daily interacting with EHR systems, contributing to work-life imbalance, dissatisfaction, high rates of attrition, and burnout rates exceeding 50 percent,” said Barbe. Research coming out of UCLA published earlier this year in the Journal of General Internal Medicine looked at physician burnout in the patient-centered medical home (PCMH) setting. While the authors (CONTINUED ON PAGE 14)


Asthma APGAR Tool Improves Management in Primary Care Setting By Cindy sanders

A study published last month in the Annals of Family Medicine assessing the efficacy of the Asthma APGAR tool in the primary care setting found usage improved asthma control and decreased asthma-related hospital admissions and emergency room visits. Barbara Yawn, MD, MSc, FAAFP, lead author of the study from the Department of Research at Olmsted Medical Center in Rochester, Minn., said the cluster-randomized, controlled, pragmatic study enrolled 1,066 patients between the ages of five and 45 across 18 U.S. Dr. Barbara Yawn family medicine and pediatric practices to compare outcomes in patients with persistent asthma using the APGAR tool vs. usual care. The study included 245 children, 174 adolescents and 647 adults. Yawn, who is also chief science officer for the COPD Foundation and an adjunct professor at the University of Minnesota in the Department of Family and Community Health, said participants could not have any

next question specifically looks at triggers, followed by a question about asthma medications taken over the past two weeks and frequency of treatment. The final question asks about response to these medications. A: Activity APGAR Like ACT, APGAR “The reason we creates a score. HowP: Persistence even worked on deever, Yawn explained, G: TriGGers veloping the APGAR the APGAR score is A: Asthma medications tools is because we had tied to a care algorithm seen that ACT – the with specific actions. R: Response to therapy Asthma Control Test – For those with a score has been around 20 years, of zero or one, they are in and it’s still not widely used,” the green zone with asthma in Yawn said of the impetus behind the tool control. A score of two or higher moves and subsequent study. While ACT creates patients to the yellow or red phase of the a score, Yawn said a key issue for many algorithm. providers was how to apply that score to “Anyone with a score of two or greater the next steps. “It became clear to me we is out of control,” she explained. “From needed a tool that was more broadly based previous research, we knew with somefor primary care and was linked to suggeswhere between 60 to 80 percent of asthma tions for action,” she continued. patients, their asthma is not in control, and Working with primary care physicians, they’d be in the yellow part.” office staff and patients, the research team From the questionnaires, it became created the APGAR tool with six quesclear that a number of patients used their tions for patients assessing asthma control. inhalers incorrectly or mixed up rescue The first three questions ask about asthma and maintenance medications. “If a patient in relation to activities and persistence of doesn’t think their medications are working, symptoms during the day and night. The they’re probably not going to take them,” other lung disease such as COPD. The also had to be diagnosed with persistent asthma requiring daily maintenance medication like an inhaled corticosteroid, montelukast, or combination therapy.

Yawn pointed out. “Unfortunately,” she continued, “a lot of times when people are out of control, they just get their medications stepped up … but if they aren’t adhering, giving them twice as much medicine to not adhere to is probably not helpful.” With the algorithm, providers have a stepwise process to address a range of potential issues impacting patient control. “If they’re having an acute exacerbation, you have to deal with that immediately,” said Yawn of moving into the red zone. “Otherwise, before you just step up their medications, think about adherence, correct usage, triggers, etc. It helps you think through what you ought to look at.”

Study Results Participating patients or parents of young children were asked to complete both a baseline and 12-month questionnaire with 65 percent (692 patients) completing both for the researchers to analyze patient-reported outcomes. In addition, electronic health record data was available for 99.7 percent of participants (1,063 patients) to allow the team to evaluate practice outcomes. In the APGAR group, there was a 50 (CONTINUED ON PAGE 10)

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M-Power Bridges the Gap for Those in Need, continued from page 1 The clinic is made possible by a team of generous specialists, including internists, gastroenterologists, pulmonologists, cardiologists, dermatologists and others who give of their free time. Beverly Parker, director of M-Power Ministries Health Center, says the work would not be possible without medical specialists who are committed to giving back. One such role model is Joe Hughes, MD, a retired internal medicine specialist and member of Canterbury United Methodist Church, who takes his volunteering work as seriously as his Hippocratic oath. Hughes has been donating his time to the clinic since its inception. He works there two days a month, bringing with him a team of two doctors, two nurses and usually two or three other associates to assist in the dispensary. Tim Denton, MD, a gastroenterologist and member of Dawson Memorial Baptist Church, was a founding member of the clinic, a physician volunteer and now has returned as a board member. “We have at least 80 volunteer physicians and 60 nurses, as well as pharmacy technicians, pharmacists, and medical techs who volunteer every month,” Parker said. “Other people help us run our front office, our triage and our dispensary, and a lot of UAB pre-med students volunteer. “Seeing physicians, RNs and LPNs carving out time from their busy schedules is encouraging not only to the ministry, but also to members of the community who need help.” The Health Center holds regular orientations to welcome new volunteers. The facility takes a two-pronged approach with its Acute Clinic, a walk-in

Medical students from UAB School of Medicine come every Tuesday to educate patients.

facility open on Tuesdays and Thursdays, beginning at 3:30 p.m. and remaining open until all patients are seen, and the Caring Clinic, open Monday and Wednesday from 8:00 a.m. to 1:00 p.m., where uninsured individuals are seen by appointment for maintenance of chronic health conditions. Now in its 20th year, the clinic has seen more than 40,000 patients since its inception. “The original collection of churches and individuals felt one of the

biggest hurdles for the poor in getting out of poverty was lack of access to health care,” said Dalton Smith, executive director of M-Power. Parker says many of the conditions seen in the clinic are common diseases that are usually managed without problem for insured patients. But living in poverty can make it impossible to purchase the necessary medications. “Our Caring Clinic sees a lot of diabetes, COPD, hypertension, and many of


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these chronic problems that require medication,” Parker said. “In the Acute Clinic, we see issues like sore throat, headache, back pain, and flu.” Patients learn about the clinic through word of mouth, outreach to local shelters, coordination with area churches and referrals from emergency rooms and other medical facilities. In many cases, access to essential medication allows these individuals to stay in the game when they might otherwise have been sidelined by illness. “Our Caring Clinic is seeing a lot of growth,” Smith said. “That’s gratifying for us because our mission is to help people break the cycle of poverty. A patient with a chronic condition can live a normal life with medications and consistent care. So many people without insurance don’t do anything until they present at the emergency desk at a hospital. They go from episode to episode instead of getting the care they need to lead a normal life.” Parker said one patient expressed his appreciation, saying he wouldn’t be able to continue attending school without the free medication the clinic provided. “M-Power has a lot of community support from church partners, individuals and foundations,” Smith said. “We could not do this without the hearts of our volunteers. It’s a win-win because our volunteers have a great depth of caring for the patients. And that makes it rewarding for the volunteers themselves.” “Our patients are always so appreciative of what we provide them,” Parker said. “It is a wonderful feeling to know you are able to help someone improve their life and their health.”

Asthma APGAR Tool Improves, continued from page 9

percent decrease in emergency room visits, hospitalizations and urgent care visits compared to the usual care cohort (10.6% v. 20.9%, P=.004). “We were very excited about that,” said Yawn. “It’s a big number.” Between baseline and one year, patients with “in control” asthma in the APGAR group increased significantly compared to the usual care group (13.5% v. 3.4%, P=.0001 vs. P=.86). “In the usual care group, we didn’t’ improve the rates of patients in control, but we did in the APGAR group. We went from about 41 percent being in control up to about 54 percent being in control. That’s about a 25 percent relative improvement and about a 13 percent absolute improvement.” Additionally, APGAR practices improved adherence to three or more asthma guideline elements compared to the usual practice groups (20.7% increase v. 1.9% decrease, P=.001). Yawn said the study intentionally focused on smaller practices that tend to have fewer resources and staff educators. “We wanted to show that in practices without lots of additional support, you could improve asthma care using these tools,” she stated.

Computer Simulation Can Improve Patient Flow By Marti Webb Slay

When Deborah Flint, director of Performance Engineering at the Kirklin Clinic of UAB Hospital, tackles a project to shorten wait times, streamline a process or improve clinic flow, she and her team have a number of tools they can use for maximum effectiveness. One of these tools is a computer simulation program, Flexsim HC. “The computer simulation helps evaluate different scenarios we may have identified using Lean Six Sigma,” she said. [See article in March issue.] “It helps us validate whether a new approach works. It allows us to see the impact before we pilot an idea. If we don’t get good results, we decide not to implement it.” Users enter rooms, furniture and even staff into the program. “It’s a visual display,” Flint said. “It’s almost like a little 3-D video game. You can watch the patient come in the door, check in, sit in the lobby and go back to the exam room. And you can watch the providers come in.” One example of a project the team might tackle is the problem of patients arriving faster than the clinic can process them at intake. If most providers arrange their schedules on the hour and half hour, the patient influx for the clinic peaks at

Debbie Flint, Director Performance Engineering, and Varun Venkateswaran, Computer Simulation Specialist, review a simulation model.

those times. “You can end up with 10 people arriving in an area that only has two people to process them, or only two nurses to bring them back for intake. They get backed up,” Flint said. Her team’s job is to develop processes that will smooth out the patient arrival and

allow for a more even intake and less waiting time for patients. They may encourage practitioners to set appointments at 10 or 20 minutes after the hour, for instance. “We figure out what might work, and then we run the model in the computer simulation to see if that helps before we

implement changes,” Flint said. “Changing provider schedules is labor intensive. With simulation, we can test ideas and have a higher confidence they will work.’” Flint also participates in a monthly webinar with other Flexsim HC users to share stories, modeling techniques, and results. “Healthcare planners need an evaluative tool that can handle staffing, resource allocation, systems design and every other aspect of healthcare management,” said Lou Keller, Jr., director of Healthcare Systems Applications for Flexsim Software Products, Inc. “Animation is the one tool that simulation brings to the planner’s table that no other evaluative method can compete with. It serves not only as a means of validating the performance of the model but as both a research and teaching tool as well. It can enable a manager to see not only what’s going on, but often why, without opening a single report. “A blueprint is a representation of where things are done. A simulation is a representation of how things are done in that where thing. So the blueprint is solid, but not dynamic. The simulation takes into account all the variances that can be associated with patient care. The combination gives you a great tool for planning.” (CONTINUED ON PAGE 14)

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Treating Samter’s Triad with Aspirin Desensitization By Jane Ehrhardt

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Those who face aspirin-exacerbated respiratory disease (AERD)—also known as Samter’s Triad or aspirin sensitive asthma—may not know it for possibly decades, if ever. Symptoms often do not develop until the person hits their 30s or 40s. “The typical patient is a middleaged to young adult who has a decreased sense of smell, progressive sinus disease, and may not know they have polyps,” says John Anderson, MD with Alabama Allergy & Asthma Center. John Anderson, MD AERD is an acquired condition. The patient will manifest three primary symptoms: asthma, sinus inflammation with nasal polyps, and a sensitivity to aspirin and other non-steroidal, anti-inflammatory drugs (NSAIDs). “What causes this cluster of symptoms to occur together is still be being researched,” Anderson says. People with Samter’s Triad often develop asthma after they have developed sinus disease. They may also complain of facial pain and sometimes have other associated problems, like a constant nasal drip, persistent cough, or ear pressure. “Then they usually end up with an allergist because they took aspirin and had an acute asthma attack that leads to emergency care,” Anderson says. “It’s at this point that aspirin-allergy is discovered.” As a distinct subset of asthma, AERD is not a common affliction. According to a 2015 meta-analysis of literature, it afflicts seven percent of typical adult asthmatic patients and twice that number in patients with severe asthma. This percentage rises to 25 percent among those with both asthma and nasal polyps, according to The Samter’s Society, which estimates that over a million people in the United States have AERD. “We can’t say aspirin causes Samter’s Triad,” Anderson says. “The chronic asthma symptoms usually begin while the patient is tolerating aspirin or even without using aspirin. So the cause is not aspirin, but aspirin unmasks it for us.” An alternative to perpetually medicating the symptoms and avoiding NSAIDs is aspirin desensitization. The process takes two to three day-long sessions in an allergist’s office. During office hours, the patient receives small oral doses of aspirin that gradually increase in three-hour increments. For severe patients with a history of life-threating reactions or very severe asthma, the process is performed in a hospital. “It’s different from other desensitizations, which are done in 30 minute increments, because aspirin patients will

invariably develop a flare of respiratory symptoms during the desensitization,” Anderson says. “They will react before they get better.” Most often the flare symptoms are mild, such as a slight drop in lung function or an increased sinus symptom. “We halt the desensitization then and treat them until they feel better. Then we re-challenge them at the same dose they flared with until they don’t react to that dose,” Anderson says. Flares usually happen once or twice. The process ends when the patient can tolerate 650 milligrams of aspirin. But they must continue taking a daily dose of 650 milligrams twice daily in perpetuity. “We usually inch the dosage down if they’re responding, because of the potential side effects,” Anderson says. The lowest dose prescribed might be one regular-dose aspirin of 325 milligrams once or twice daily. “The problem is that the lower we go, the more we risk insufficient suppression of this pathway and polyp regrowth,” Anderson says. The downside to the daily aspirin dosage includes indigestion or gastrointestinal (GI) bleeding if the patient develops ulcerations. “If they have any underlying GI problems of heartburn or reflux before we do this procedure we often make sure they’re on an anti-reflux regimen, like proton pump inhibitors,” Anderson says. The maintenance dosage is required because, unlike with allergy shots, desensitization does not induce long-term tolerance to a substance at a level where exposure no longer causes an inflammatory response. “So if these patients withhold their daily aspirin, they will be re-sensitized to it. The desensitization is a temporary physiologic state,” Anderson says. This leads to a potentially significant fail rate for the protocol. Some patients cannot maintain the needed consistency. And in others, it may not work. In one trial, 24 (14 percent) of the 172 patients discontinued the medication because of side effects. For those who tolerated a year or more of treatment, 87 percent experienced improvement. Aspirin desensitization offers patients a chance to be free of polyp regrowth and the chronic asthma symptoms by taking two inexpensive pills a day. “If the patient is a candidate for desensitization, then that’s the gold standard approach for the moment, but we have an eye toward the biologic medications,” Anderson says. Xolair, Nucala, and Dupixent have had promising results in small studies. “And they are doing larger studies as we speak,” he says, adding that Alabama Allergy participates in those clinical trials. Anderson says the most helpful change that can be made for those with potential AERD right now is the advice they hear. “People with reactions to aspirin are told not to take that medicine again,’” he says. “What they should be told is, ‘Go see an allergist.’”


Endure: Mind, Body, and the Curiously Elastic Limits of Human Performance by Alex Hutchinson c.2018, Wm. Morrow; $27.99; 306 pages You need a shave. It’s been awhile and, though you’ve been grooming, you’re long overdue – so, maybe just a little off the top. You’ll feel a lot better when you do, and in the new book Endure by Alex Hutchinson, you’ll see how your body will adapt on track, path, ocean, drift, and desert. Prior to 1954, it was believed that the human body was physically incapable of running a mile in less than four minutes – until the late Roger Bannister put that notion to rest. As for today, the Alex Hutchinson belief that a marathon of 26.2 miles can’t be finished in under two hours still holds – but barely. When it comes to endurance, effort, and the human body, we’ve long been fascinated with possibilities. The questions, in fact, go back centuries and countless tests and studies have been (and are

being) done to determine answers when a hundredth-of- a-second means something. Still, one thing’s for sure: says Hutchinson, “the will to endure can’t be reliably tied to any single physiological variable.” Much of the matter of endurance has to do with “the need to override what your instincts are telling you to do.” Perhaps not surprisingly, it very much has to do with the brain, but not in the simple it’s-all-in-your-head manner of self-help books. The science of it all is complex, made even more so by outliers who, for any number of reasons, can and do achieve beyond preconceived limits; which is to say that we still don’t know where the ultimate limits lie. The stories, even so, are tantalizing. Hutchinson writes of Henry Worsley who, at age 48, tackled a South Pole trek that demanded every ounce of his reserves. Hutchinson shows how early scien-

tists helped save the lives of the men who built Hoover Dam. He examines how we pace ourselves, sometimes sub-consciously; why we do better after we’ve suffered; and how hypnosis may increase strength. He explains how deep diving and high climbing pose the same questions; why marathon runners are shrinking; why thirst shouldn’t matter; what diet can do; and how none of this may matter in the future. We’ve all known that can’t-go-another-inch feeling, when a surprising well of reserve is suddenly present. Where did that come from? And can you utilize it at will? In Endure, you’ll see, but this is not just a book for athletes. While it’s true that author Alex Hutchinson writes extensively about men and women who participate in extreme,

even elite, sports, the lip-biting anecdotes inside Endure prove that this is a book for anyone who might find themselves in inclement weather or unusual situations. Yes, it’s mostly about athletic endurance, but its everyday relevance lies in the science Hutchinson brings which, though sometimes a bit too deep for the casual reader, is applicable whether you run to the finish line or the fridge. Athletes and trainers, of course, will soak this book up, and adventurers will jump for it. Even couch potatoes should enjoy it because Endure is razor sharp. Terri Schlichenmeyer 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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Addressing Physician Burnout, continued from page 8 acknowledged the PCMH model might seem an unlikely place for burnout since the model was developed as a team-based approach to care, the research team looked at how much primary care providers (PCPs) actually shared responsibilities and what tasks performed independently by PCPs were affiliated with higher rates of burnout. The team looked at 327 providers from 23 Veterans Health Administration primary care practices within one regional VHA network with specific attention to 14 discrete primary care tasks. The researchers found the tasks most associated with burnout when taken on by a PCP instead of sharing with care team members were interventions regarding lifestyle factors and patient education regarding disease selfcare and management.

Finding Solutions Just as there are varying causes of

physician burnout, there are a variety of resources and solutions emerging to attack the problem from different angles. The AMA has made burnout prevention a core priority and is working with partners across healthcare to help find solutions that enhance physician well-being. Through the AMA Wire®, the national organization is sharing ideas and best practices from sources across the healthcare spectrum to address physician wellness. The AMA also created STEPS Forward™, a collection of practice management strategies to help physicians transform their practices and achieve better work-life balance ( Middle Tennessee-based M*Modal is working to address the hours spent entering data into EHRs. Recognized with a Best in KLAS #1 Speech Recognition: FrontEnd EMR award, the company’s artificial intelligence (AI) and speech-powered solu-

tions works across more than 150 EHRs to allow conversational documentation – rather than sitting at a keyboard typing in notes – to speed the process and decrease administrative burdens on physicians and other clinicians. “We are steadfast in our mission of creating time to care for physicians so that they can focus on their patients,” said M*Modal Chief Technology Officer Detlef Koll. “As a natural extension of our speechdriven solutions and services, our Virtual Provider Assistant brings conversational AI directly into physician workflows to deliver a new level of user experience and efficiency. We are grateful to our clients who continue innovating with us along this spectrum so that clinical documentation is ultimately a byproduct of the patient visit and not a separate, burdensome task for the physician.” Last fall, ProAssurance, a specialty in-

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surer with extensive expertise in healthcare professional liability, pledged an initial gift of $1.5 million to establish an endowed chair for Physician Wellness at the University of Alabama at Birmingham. The new academic chair, which is the first of its kind in the United States, supports a research team focused on issues unique to physicians facing the stress and pressure of caring for patients in a rapidly changing healthcare environment. “Physicians have always been subject to the high levels of stress from a variety of factors such as society’s expectations for successful outcomes, the threat of litigation and the effect of their professional obligations on the quality of their lives, and their families’ lives. As medicine evolves to address the changing dynamic of healthcare in America, we must find ways to address these pressures,” said ProAssurance Chairman and CEO Stan Starnes in announcing the gift. UAB President Ray L. Watts, MD, said the gift would enable the university to recruit an expert in the field of physician wellness to implement well-designed interventions to enhance a sustainable culture of wellness. Additionally, he said the goal would be to provide trainees with tools and resources to manage stress and burnout. “The result will be more engaged physicians who can provide the highest-quality care to their patients,” Watts added. With more than 40 percent of physicians across all specialties and approximately half of PCPs reporting feelings of burnout, finding multiple solutions to address physician well-being will be critical to providing access to care moving forward.

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“Physicians like data,” Flint said. “More often than not, they are open to change once they can see it, and that’s where simulation really helps.” Keller praised Flint’s application of the program at Kirklin. “She set out to develop simulation programs for all the clinical environments, so they can pull them out any time they want to look and see what changes will do to the characteristics of the clinic. It’s like having a drawer full of blueprints,” he said. There are other simulation programs on the market besides Flexsim, but Keller stressed the importance of using one dedicated to healthcare. “Hospitals aren’t factories, he said. “There is no product that leaves the front door when a patient checks out. Thinking of a hospital that way, or of a patient as a product, not only does a massive disservice to the patient, but it also robs the provider of the individuality we depend on to achieve quality care. “Debbie’s mission is not to speed things up. We aren’t asking doctors to shave off 15 minutes from an appendectomy or have a quicker examination of a patient. Her mission is to determine where the impediments are that keep the system from operating the way it is supposed to operate.”

Alabama Legislature Considers Cybersecurity Law By Jim hooVer and anGie Cameron smith

At the time of this writing, Alabama is one step closer to having a law on the books related to cybersecurity. Alabama is currently one of two states along with South Dakota that have not passed a data breach notification law. The legislation Alabama is considering requires certain entities defined as “covered entities,” to report to state agencies and affected individuals when there has been an unauthorized acquisition of “electronic, sensitive personally identifying information.” On March 1, 2018, the Alabama Senate passed SB318, and if passed by the House and signed by the Governor, it would require “covered entities” to notify Alabama’s attorney general, Alabama residents whose information has been compromised, and consumer credit-reporting agencies of a data breach. For healthcare providers covered HIPAA, federal law already requires notification when they experience unauthorized disclosures of protected health information. In addition to HIPAA’s breach notification requirements, the new Alabama law would require reporting at the state level for healthcare providers who experience a data breach. It is important to note that the term “covered entities” in the proposed legislation is much broader than

HIPAA’s definition of “covered entity.” The term in SB318 applies to persons or business entities that acquire or use personally identifiable information. Under SB318, a covered entity is required to investigate any data breach and in some instances report the breach. The investigation must include (1) an assessment of the nature and scope of the breach, (2) identification of any sensitive personally identifying information involved and the individuals involved, (3) a determination as to whether the information was acquired by an unauthorized individual and could result in substantial harm, and (4) identification and implementation of measures to restore security and confidentiality of the system involved in the breach. When determining if a breach is reportable, a determination must be made whether sensitive information is reasonably believed to have been acquired by an unauthorized person, and whether the unauthorized acquisition is reasonably likely to cause substantial harm to the individuals. SB318 sets forth four factors to consider when evaluating whether the information is “reasonably believed” to have been acquired by an unauthorized individual. In making this determination, the covered entity must evaluate “indications that the information is in the physical possession

and control of a person without valid authorization, such as a lost or stolen computer or other device containing information; indications that the information has been downloaded or copied; indications that the information was used by an unauthorized person, such as fraudulent accounts opened or instances of identity theft reported; and whether the information has been made public.” The law however does not provide guidance on whether the breach is reasonably likely to cause substantial harm to the affected individual. Even if a breach is not a reportable event, the covered entity must maintain relevant records for at least five years. For instance, if the covered entity determines the breach is not reasonably likely to cause substantial harm then no notification is required, but the entity must keep all records related to the breach and their determination that notification was not necessary for five years following the incident. SB318 also requires covered entities to implement “reasonable security measures” to protect an individual’s data. Similar to HIPAA, the bill requires the covered entity to designate an employee to coordinate security measures (i.e. Security Officer) and to identify risks of data breaches. In recognizing that not all covered entities face the same risks or have the

same resources, the required “reasonable” security measures should take into account the size of the covered entity, the amount of data maintained and stored by the covered entity and the cost to implement security measures. Good news for healthcare providers, if a healthcare provider has performed the necessary security and risk assessments required under HIPAA, it should meet the standards required in SB318. Not all information qualifies as “sensitive personally identifiable information.” To meet this definition, the accessed information must consist of the individual’s first name or initial and last name in combination with any one of the following data elements: a non-truncated (or shortened) Social Security or tax identification number; non-truncated driver’s license, stateissued identification card number, passport number, military identification number or any unique, government-issued number used to verify identity; a financial account, credit or debit card number along with a required security code, expiration date, PIN, access code or password necessary to access a financial account or conduct a transaction; individual medical or mental history or treatment information; a health insurance policy or identification number; or a user name or email address along with



APRIL 2018 • 15

Where is Your Patient Data Hiding? By Robbie Morris

They were surprised, and you likely be will, too. Of the hundreds of healthcare organizations I’ve helped document HIPAA and meet compliance requirements, most are unaware that their Patient Health Information (PHI) is exposed in some way. If a cyber attacker took advantage of this situation, it could cause damage to your patients, bring giant HIPAA fines, and a loss of reputation. How can you protect your PHI if you don’t know where it lives?

Patient data can be stored in unlikely or unnoticed places. Here are a few hiding places I’ve helped organizations identify: Shortcuts – Your management has been diligent about HIPAA compliance efforts. Your team knows the process for keeping patient data safe. But the managers don’t know about the folder on the desktop of their intake manager’s laptop. She’s been using it as a shortcut for getting patients into the system more quickly. A HIPAA audit today would find more than 300 patients’ PHI on this one laptop. Imagine the shortcuts taken by other employees in the orga-

nization - the amount of exposed data could be staggering. Email - I know what you’re thinking. You know the email you send and receive is secure because that was a priority when your team was looking for the best email option. And I salute your diligence. However, there is a piece that is often overlooked. At any given time, the sent folder on your email users’ phones and PCs can be riddled with patient data that is not protected. Scans - Some photocopiers automatically save copies of scanned documents on their hard drives. If a copier is returned to

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the leasing company without the data being properly removed, that’s a HIPAA violation. These opportunities for exposed PHI are not surprises for the Department of Health & Human Services’ Office for Civil Rights. That’s why they require a true Healthcare Security Risk Analysis, which includes a thorough risk assessment of patient data, review of policies and procedures, employee interviews for a HIPAAHITECH audit, an analysis of operational threats, and more. And remember, any business associate who comes in contact with your patient data is also accountable for protecting it. You have a responsibility to make sure those associates are also diligently protecting your PHI.

a password or security question and answer that gives access to an online account that is likely to contain sensitive personal information. If notification must be made, the covered entity must provide notification as “expeditiously as possible” but no more than 45 days after the determination of the breach. The notification may be made by mail or email and must include the following elements: the date, estimated date, or estimated date range of the breach; a description of the sensitive personally identifying information that was acquired by an unauthorized person as part of the breach; a general description of the actions taken by a covered entity to restore the security and confidentiality of the personal information involved in the breach; a general description of steps a consumer can take to protect himself or herself from identity theft; and information that the individual can use to contact the covered entity to inquire about the breach. A violation of SB318 constitutes a deceptive trade practice, but does not constitute a criminal offense. The attorney general may seek deceptive trade practice penalties when a covered entity or thirdparty agent knowingly violates the notification law. The Deceptive Trade Practice Act penalties would apply for willful or reckless disregard of the notification requirements that could subject the violator to a $2,000-per-person penalty, capped at $500,000. Any entity that made notification after the 45-day deadline, could also be fined up to $5,000 per day. The bill is currently pending before the Alabama House of Representatives, bill number HB410. Jim Hoover and Angie Cameron Smith are partners at Burr & Forman LLP and work exclusively within the firm’s Health Care Practice Group.

The Challenge of Noncompliance with Medical Recommendations By Hall B. Whitworth, Jr, MD

It is often difficult to assess patient compliance. Many patients, not wanting to disappoint their physician, will not be completely accurate about their degree of compliance. Other patients are not able to precisely evaluate their degree of compliance. In one study, 10 percent of patients reported that they were 100 percent compliant with their medication use. Using pill count methods, however, their use of the prescribed medications ranged from two percent to 130 percent of the prescribed pills. Several methods may help to improve patient compliance. One strategy is to attempt to improve the likelihood of compliance at the very beginning. It helps to start by explaining the rationale for therapy. Educate the patient on the benefits of diagnostic studies or therapy, especially if the patient is asymptomatic. Address potential financial limitations or other barriers to lifestyle modifications. In particular, addressing any misinformation regarding a medical condition or possible side effects at the onset of any treatment recommendations may help to improve compliance. Finally, explain the potential consequences of not following specific medical recommendations. Additional recommendations at the

onset of the recommended treatment include: • Speak clearly and briefly and be aware of the patient’s health language literacy. Emphasize the most important information early. • Repeat the information and provide written instructions. • Ask the patient to repeat their understanding of the instructions. • Simplify medical regimens using dosage scheduling charts and pill organizers. Try to coordinate medication schedules with the patient’s usual daily routine. • Discuss potential side effects as well as the consequences of stopping the medication or not taking the medication properly. • Review the optimal way to report any questions or side effects. • Provide clear recommendations and expectations for follow-up and any required treatment monitoring. Following the initial treatment recommendations, an organized plan for monitoring, continuing education, and patient feedback helps to bolster the likelihood of improved patient compliance. Encourage open discussion with the patient regarding potential barriers to treatment or side effects. If the patient elects not to proceed with diagnostic testing, consultations, or continued treatment, you should encourage the patient to report this decision

to the physician in an effort to modify plans for continued care. Utilize support of nursing, social services, pharmacists, and patient’s family members to reinforce compliance. During follow-up evaluation, talking with the patient about their progress with their medical conditions can encourage continued compliance. This is particularly important in asymptomatic conditions, such as elevated cholesterol or blood glucose levels. The provider or staff should follow-up with the patient to confirm that they have completed diagnostic testing or outside consultation. In some specific situations (i.e., anticoagulation monitoring and treatment), the patient may benefit from a medication adherence contract. This should include an explanation of the use of this medication, potential side effects of altering dose or stopping the medication, potential for interactions with other medications, side effects which should be reported, and instructions on proper monitoring and potential for dosage adjustments. Clear explanation of expected follow-up and monitoring schedule as well as how questions can be answered should be included. A signed copy of this contract should be given to the patient and the patient’s family, and placed in the medical record. There may be some circumstances

where, after an informed discussion, the patient elects to decline a particular treatment or test which is certainly well within the patient’s right. In this case, the consideration to include a signed written document indicating “informed refusal” might be included in the medical records. This document should include the indications for the procedure or the medication and overall treatment plan; the risk and benefits of a particular procedure or medication; potential alternative treatment options; the potential consequences for refusing such treatment; and if possible, the reason that the patient declines treatment. Any such discussion should be well documented in the medical records and may include a note from a possible thirdparty witness. At some point, a patient’s continued noncompliance may begin to affect the physician-patient relationship. The patient should be given clear expectations and conditions which need to be met in order to continue active treatment. In some circumstances, a decision to terminate the physician-patient relationship may become necessary. Hall B. Whitworth, Jr, MD is a Board Certified cardiologist practicing in Orlando, Florida and a physician consultant with the MagMutual Patient Safety Institute.

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UAB, Children’s of Alabama Name Fargason Director of Neurodevelopmental Initiatives Crayton “Tony� Fargason, MD has been named Director of Neurodevelopmental Initiatives, a key coordinating role between the UAB School of Medicine, the UAB Department of Pediatrics and Children’s of Alabama. In this role, Fargas- Tony Farguson, MD on will work to integrate activities with UAB’s well-established entities such as the Department of Genetics, the Institute for Precision Medicine and Southern Research, as well as with partner Hudson Alpha. Fargason will also work with community service partners such as Mitchell’s Place, Glenwood and the RISE Center at the University of Alabama to advance collective efforts for patients and families affected by neurodevelopmental challenges. “Dr. Fargason will continue to serve as the Medical Director and Vice President of Clinical Affairs at Children’s, as he has for nearly 20 years, and will continue his work as a Professor in the UAB Department of Pediatrics,� said Selwyn Vickers, MD, dean of the School of Medicine. Fargason received his undergraduate B.A. and B.S. degrees from Tulane University, and earned his medical degree from The Johns Hopkins University School of Medicine. He completed his Pediatric Internship and Residency at Northwestern University Medical School, where he also earned an MBA from the J.L. Kellogg Graduate School of Management. He is board certified in both Pediatrics and Clinical Informatics.

Six UAB School of Nursing Programs Among Top 15 in the USA The Graduate and Professional programs within the UAB schools of Nursing, Medicine, Engineering and Public Health and the College of Arts and Sciences rank among the nation’s best, according to the 2019 U.S. News & World Report Best Graduate Schools Rankings. The rankings show the School of Nursing 2019 Master’s and Doctoral Programs rank No. eight in the country. This year’s graduate specialties include Nursing Administration, No. two; Clinical Nurse Leader, No. seven; Adult-Gerontology Acute Care Nurse Practitioner, No. 15; and Pediatric Primary Care, No. 12. The School of Medicine ranked No. 32 in Medical Research and No. 37 in Medical Primary Care and had a No. 15 ranking in Obstetrics and Gynecology. “The School of Medicine has made tremendous progress during the past year in a number of areas, and we are grateful to have that recognized,â€? said Selwyn Vickers, MD, PhD, dean of the School of Medicine. “One of our missions is to train primary care physicians for the state of Alabama, and our training, research and clinical programs in all facets of primary care at UAB provide a world-class experience for our patients and our trainees. “The Department of Obsetrics and Gynecology boasts innovative educational programs, groundbreaking research initiatives and a robust clinical practice, and its ranking in the top 15 by U.S. News & World Report is a reection of its reputation as a national leader. Our research enterprise, which runs the spectrum from cutting-edge basic science discovery to data sciences and health outcomes research, continues to make a significant impact in science, propelling us toward the top 20 in NIH funding.â€?

UAB Medical Students Celebrate Successful Match Day


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The 2018 graduating class of the UAB School of Medicine celebrated another successful Match Day on Friday, March 16. With 98 percent of students’ matching into residency positions, UAB students will continue their medical educations at 74 institutions in 27 states across the country. “Match Day symbolizes all the hard work put in at medical school coming to fruition,� said Amber Abrams, who matched into psychiatry at UAB. “This has been a long journey, and it’s so nice to see the light at the end of the tunnel.� Students waited in UAB’s Alys Stephens Center until the envelope containing their residency matches was drawn, and then they announced their matches on stage. The largest number of students — 73 — matched into primary care residency programs, which include family medicine, internal medicine and pediatrics. Students also matched into other medical specialties—including 37 in various surgical residencies, 13 in emergency medicine, 12 in obstetrics and gynecology, and eight in neurology. UAB is also celebrating a successful recruitment for residents in its 35 residency programs. A total of 214 new residents, representing 60 U.S. and 27 international universities, will begin this summer in programs at Birmingham, Huntsville, Selma and Montgomery.




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Powel Named Chair at UAB

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Craig Powell, MD, PhD has been named chair of the Department of Neurobiology at the UCB School of Medicine and director of the Civitan International Research Center. Powell is a national leader in research pertaining to molecular mechanisms of learning Tony Farguson, MD and memory, synaptic plasticity, and neuropsychiatric disorders such as autism, intellectual disability and Alzheimer’s disease. Powell comes to UAB from the University of Texas Southwestern Medical Center’s Department of Neurology and Neurotherapeutics. Powell earned both his PhD in neuroscience and MD with Honor at Baylor College of Medicine in 1994 and 1997, respectively. His graduate work was among the first studies to measure lasting biochemical changes during long-lasting synaptic plasticity in the hippocampus. After his medical internship at Baylor College of Medicine, Powell trained at the University of California San Francisco Neurology Residency Program where he served as chief resident in his final year.

The Southeast Gastro at the GivingBack Screening

Southeast Gastro Conducts Free Screening Southeast Gastro conducted a free colon screening event called GivingBack in March at the OSE Surgery Center on the St. Vincent’s East Campus. “We are proud to be a part of the communities we serve. The GivingBack event is a way for us to care for at-risk patients in need,” said Miles Gresham, MD, President of Southeast Gastro. “OSE Surgery Center, St. Vincent’s East, Braintree Laboratories, Aurora Diagnostics, Eastern Surgical Associates, Salix Pharmaceuticals,Cornerstone Media and Means Advertising all stepped up to help support us.”


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550 guests attended the Encompass brand launch.

Encompass Holds Brand Launch Celebration Encompass Health, formerly known as HealthSouth, held a brand launch celebration in February with more than 550 Encompass Health employees and guests in attendance. The celebration was held at the Company’s future home office on Liberty Parkway. Presentation remarks were given by Mark Tarr, president and CEO; Lee Higdon, chairman of the board of directors; and Jay Grinney, former president and CEO. Encompass Health, founded in Birmingham in 1984, manages 127 inpatient rehabilitation hospitals, 200 home health locations and 37 hospice agencies serving 36 states and Puerto Rico. HealthSouth Lakeshore Becomes Encompass Health Lakeshore and Opens New Wing As part of the rebranding, HealthSouth Lakeshore Rehabilitation Hospital is renamed Encompass Health Lakeshore Rehabilitation Hospital. April marks a special milestone for the inpatient rehabilitation hospital as it will open its new patient wing. The 20,220-square-foot addition includes more space for patient rooms, a nursing station, a day room and more space for programming and therapy needs. The hospital’s number of patient beds will not change, but it increases the number of private patient rooms from 20 to 64.


UAB Topped $238 million in NIH Funding for 2016 The University of Alabama at Birmingham had $538 million in research expenditures in 2016, and ranked No. 15 nationally among public universities and No. 31 overall in federally funded research in 2016, according to National Science Foundation data. “Competition is fierce for research funding, so our increases in funding underscore the importance of work being done here,” UAB President Ray Watts said. “UAB will continue to recruit and support the students, faculty and staff who conduct the transformational work that ensures we stay at the forefront of discovery.” UAB now ranks sixth among southeastern universities in federal research expenditures, behind only North Carolina (8), Duke (10), Georgia Tech (11), Vanderbilt (24) and Emory (27). The state of Alabama received $281.5 million in NIH funding in fiscal year 2016, which makes UAB responsible for more than 85 percent of the state’s NIH-funding dollars. UAB continues to produce scientific breakthroughs from advancements on the cutting edge of precision medicine research to new research showing how a component of neurons may protect against Alzheimer’s disease. UAB’s National Institutes of Health funding reached $238 million in fiscal

year 2016, including $186 million to the School of Medicine. That number is expected to top $195 million in School of Medicine funding in 2017, as the school also exceeded 300 principal investigators for the first time in two decades. “UAB is Alabama’s largest single employer, with more than 23,000 employees and an economic impact exceeding $7.15 billion a year. But we have no greater impact than when our innovations improve and save lives,” said Christopher S. Brown, PhD, vice president for Research.

UAB Opens Colorectal Cancer Clinic The UAB Multidisciplinary Colorectal Cancer Clinic has opened, providing a one-stop shop for cancer care. Traditionally, patients with colorectal cancer would see multiple physicians and specialists over the course of several days. “At the new clinic, patients will see multiple specialists in the same day and will leave their initial visit with an individualized treatment plan,” said Greg Kennedy, MD, PhD, director of the Division of Gastrointesti- Greg Kennedy, MD nal Surgery. “The format of the clinic will develop individualized care-plans for organ-

preserving surgeries, high-precision radiation therapy and state-ofthe-art systemic therapies,” said Rojymon Jacob, MD, associate professor in the DepartJacob, ment of Radiation On- Rojymon MD cology . This is a multidisciplinary effort between the divisions of Gastrointestinal Surgery, Hematology and Oncology and the Department of Radiation Oncology. The clinic is seeing patients one day a week on Wednesdays at the Whitaker Clinic, a branch of the Kirklin Clinic of UAB Hospital.

Kenneth Aldridge, MD Receives Award Kenneth Aldridge, MD, a urologist and vice president for medical affairs for the DCH Health System, recently received the Garber Galbraith MedicalPolitical Award from the Medical Alumni Association of the UAB School of Medicine. The award recognizes Aldridge “for outstanding service to the medical profession” in the medical-political arena. Aldridge, who has been active in Alabama medicine for several decades, has serviced on several state committees and boards has helped develop rules and policy that have improved patient safety and increased access to

healthcare in the state, according to the award citation. A Fellow of the American College of Surgeons, Aldridge has served in leadership positions at DCH Regional Medical Center and Northport Medical Center, and in the Tuscaloosa County Medical Society and the Medical Association of the State of Alabama. He served as a board member and chair of the MASA Board of Censors, the State Committee of Public Health and the State of Alabama Board of Medical Examiners. Aldridge currently serves as the President of the Alabama Quality Assurance Foundation Board of Directors. He continues to practice urology part time in Tuscaloosa with West Alabama Urology Associates while serving as the vice president for medical affairs for the DCH Health System.

CoreLife Opens in Birmingham CoreLife, a weight loss clinic based in Maryland, plans to open eight new locations in the Birmingham area this year, including Vestavia, Mountain Brook, Alabaster and Hoover. The Corelife facilities are staffed by licensed medical practitioners, registered dietitians, and trainers with a fitness studio.

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Tim Vines Named CEO of Blue Cross Blue Cross and Blue Shield of Alabama’s Board of Directors has chosen Tim Vines to serve as President and Chief Executive Officer of the company. He assumes the office following the retirement of Terry Kellogg on April 1, 2018. Vines joined Blue Tim Vines Cross in 1994. Since November 2017, he has served as President and Chief Operating Officer. “Tim Vines is an experienced leader who has the vision and commitment to advance the mission of Blue Cross and Blue Shield of Alabama,” Kellogg said. “I’m humbled and honored to be given this opportunity to serve,” Vines said. “We are fortunate to have an exceptional organization, a talented leadership team, and a workforce dedicated to putting the customer first.”

Betz Named COO of DCH Paul Betz, FACHE, has been named Chief Operating Officer of the DCH Health System. Betz will serve as administrator of DCH Regional Medical Center, and the administrators of Northport Medical Center and Fayette Medical Center will re- Paul Betz, FACHE port to him. Betz has over 20 years’ experience as hospital CEO, COO and adminis-

trator. He comes to DCH from Maury Regional Health in Columbia, Tennessee, where he served as COO and senior vice president since 2012. Maury is an independent, community-owned, three-hospital system. He was responsible for two rural hospitals, ancillary and support departments and system-wide strategic planning, construction and freestanding outpatient facilities. Before that, he served in administrative positions in several hospitals in

Tennessee and Florida, and he was the administrator of process improvement for the Memphis market for Baptist Memorial Healthcare Corp. He received his undergraduate degree from Lambuth University in Jackson, Tennessee and his MBA from UAB. He is a fellow in the American College of Healthcare Executives and received the Regents Award from that organization.

Shelby Baptist Offers 3D mammography Shelby Baptist Medical Center is now offering 3D mammography (breast tomosynthesis) for breast cancer screening. Breast cancer screening with tomosynthesis when combined with a conventional 2D mammography has a 40 percent higher invasive cancer detection rate than conventional 2D mammography alone. The tomosynthesis platform is designed to deliver superior screening and diagnostic performance for all breast types. It produces a three-dimensional view of the breast tissue that helps radiologists identify and characterize individual breast structures without the confusion of overlapping tissue. The tomosynthesis screening experience is similar to a traditional mammogram. During the exam, multiple, low-dose images of the breast are acquired at different angles. These images are then used to produce a series of one-millimeter thick slices that The Selenia® Dimensions® breast tomosynthesis system. can be viewed as a 3D reconstruction of the breast.

EDITOR & PUBLISHER Steve Spencer VICE PRESIDENT OF OPERATIONS Jason Irvin CREATIVE DIRECTOR Susan Graham STAFF PHOTOGRAPHER April May CONTRIBUTING WRITERS Cara Clark, Ann DeBellis, Jane Ehrhardt, Laura Freeman, Cindy Sanders, Marty Slay GRAND ROUNDS CORRESPONDENT Frank Sinatra Recipeideas 270 Doug Baker Boulevard, Suite 700-400, 35242 • FAX Ad Sales: All editorial submissions should be mailed to: Recipeideas 270 Doug Baker Boulevard Suite 700-400 Birmingham, AL 35242 or e-mailed to: [email protected] ——————————————


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Jain Joins Grandview Medical Group Rheumatology

UAB Establishes Accountable Care Organization

Archana Jain, MD has joined Grandview Medical Group Rheumatology located on the Grandview campus. Jain specializes in Rheumatology and is board certified in MSK Ultrasound through the American College of Rheumatology. Jain received her medical degree from Archana Jain, MD Maulana Azad Medical College, Delhi University, in New Delhi, India. She performed her residency in internal medicine at St. Francis Hospital in Evanston, Illinois before completing a Rheumatology Fellowship at UAB. Prior to joining the Grandview medical staff, Jain served as an Assistant Professor of Medicine in the Division of Clinical Immunology & Rheumatology at UAB. She also served as Clinical CoDirector of the Musculoskeletal and Skin Module at UAB. Jain is a Fellow of the American College of Rheumatology and is a member of the Southern Society of Clinical Investigation.

The UAB Health System and its partners have established an Accountable Care Organization that manages more than 16,000 covered lives. The ACO members are UAB Hospital, the University of Alabama Health Services Foundation, Medical West Hospital, and two Federally Qualified Health Centers, Christ Health Center and Cahaba Health Center. The Centers for Medicare and Medicaid Services authorized the ACO to begin serving patients in the beginning of 2018. “The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care while avoiding unnecessary duplication of services and preventing medical errors,” said Will Ferniany, PhD, CEO of the UAB Health System. “When managed properly, an ACO can deliver quality care while spending health care dollars more efficiently.” The ACO participates in the CMS Medicare Shared Savings Program with cost savings shared between the partner organizations and Medicare. The ACO is administered by the Alabama Physician Network, which was established by UAB to spearhead initiatives between UAB Medicine and community physicians as part of a clinically integrated network. The APN is managed by its own board of directors, led by physicians and professional health care administrators. The board is chaired by Tony Jones, MD, UAB’s chief physician executive. 13 of its 17 members are physicians.

Orthopedic Urgent Care Opens OrthoExpress opened a free-standing orthopedic urgent care center, the first of its kind in Birmingham, in March. Bryan Wimbish, NP is the clinic’s care provider. OrthoExpress focuses on being a convenience to the patient by being a gateway to care, rather than being an extension of a physician practice. The company is already planning expansion to five other markets in central Alabama.

Gorbatyuk Awarded Research Grant Marina Gorbatyuk, PhD, a researcher at the UAB School of Optometry, has been awarded a $1.25 million grant from the National Eye Institute to study the regulation of protein synthesis in photoreceptors of mice with inherited retinal degenMarina eration. Gorbatyuk, PhD Gorbatyuk’s study will look at molecules that govern the rate of protein biosynthesis in the retinas of mice mimicking human inherited retinal degeneration. Because of the expression of aberrant proteins in the biosynthesis that is present with retinal degeneration, the cells of the retina experience stress. That chronic cellular stress activates an unfolded protein response in the photoreceptors and inhibits protein synthesis altogether, ultimately resulting in vision loss. Gorbatyuk plans to target and reprogram the response, which could slow photoreceptor cell death or even stop it. As a result of the study, targeted therapies could be developed to slow or stop vision loss.

Sample Joins CVA Matthew Sample, MD has joined CVA. Sample has specialized training in the catheter-based treatment of patients with structural and valvular heart disease. He also treats patients with advanced or high-risk coronary artery Matthew Sample, MD disease including those with 100 percent blocked coronary arteries (chronic total occlusions) and those patients requiring mechanical circulatory support. Sample attended medical school at the University of Mississippi Medical Center where he graduated Cum Laude and was inducted into the Alpha Omega Alpha honors society. Following medical school, he completed a residency in Internal Medicine at Vanderbilt University Medical Center. He completed fellowships in Cardiovascular Disease and Interventional Cardiology at Vanderbilt as well. Following his training, he joined a private practice cardiology group in Tennessee where he began, and served as medical director for, a Structural Heart Disease program. Sample performs procedures at Brookwood Baptist Medical Center and Grandview Medical Center.


Microsoft will no longer support many server and workstation operating systems effective January 2020 All software applications have a lifecycle. Lifecycle refers to the dates, or online technical assistance. Knowing key dates in this lifecycle helps you to make informed decisions about when to upgrade or make other changes to your software. Integrated Solutions can help make sure you have the latest compliant applications and updated software that are required under HIPAA Hi-Tech regulations. Without Microsoft support, you will no longer receive security updates that can help protect your Server or PC from harmful viruses, spyware, and other malicious software that can steal valuable patient information. Let Integrated Solutions be your trusted guide to help you actively assess your equipment and software so you plan and budget accordingly. Don’t be caught unprepared.

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April 2018 BMN  

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April 2018 BMN  

Recipeideas April 2018