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Osman Ahmad, MD

OCTOBER 2017 / $5

Innovative Cardiac Pump a Lifesaver for Critical Patients By ann B. DeBellis

ON ROUNDS

Face2Gene App Searches Photos for Diagnostic Clues Some diseases are so rare that a primary care physician may see only one or two cases in an entire career. The problem with the math in daily practice, however, comes from the sheer number of rare diseases— more than 8,000 known so far. Even low prevalence disorders add up to the likelihood that one in ten patients who walk through a primary physician’s door are ... 3

As medical technology advances, physicians are able to treat high-risk patients who may not have been candidates for procedures in the past. The Impella® heart pump simulator is a great example of how a minimally invasive device helps cardiologists treat their sickest patients. The Impella® heart pump simulator is a new heart support technology that is used to assist the pumping of the heart during certain procedures and to treat patients in cardiogenic shock. This breakthrough technology is offered at the St. Vincent’s Birmingham and St. Vincent’s East Abiomed representative demonstrates the use of Impella® heart pumps for St. Vincent’s staff. hospitals. “St. Vincent’s was one of the few health systems selected, and the only one in Birmingham, to have an in-depth look at this cutting-edge technology with a special learning lab training opportunity,” says Gordon Wesley, Administrative Director for Cardiovascular Services for St. Vincent’s Health System. The Impella® heart pumps are approved by the FDA to provide treatment during elective, high-risk percutaneous coronary intervention (PCI) procedures and in the emergent treatment of cardiogenic shock. “In the past, many of these patients did not survive, but this pump(CONTINUED ON PAGE 14)

GENETICS

Proposed Changes to MIPS Tame this Year

Two Major Genomics Initiatives in Alabama

“The new changes in the 2018 reporting period are actually not terribly drastic,” says Joni Wyatt, MHA, MHIA, CPHIMS, FHIMSS, with Kassouf & Co about the Meritbased Incentive Payment System (MIPS) ... 7

By laura Freeman

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Bruce Korf, MD, PhD speaks at the Alabama Genomic Health Initiative announcement conference.

Two major genomics projects are beginning in Alabama. The Alabama Genomic Health Initiative, one of the nation’s first statewide efforts to use genomic analysis to identify those at risk of genetic diseases, has moved into recruitment at UAB clinics in Birmingham. HudsonAlpha Institute for Biotechnology, in cooperation with the UAB School of Medicine and the University of Mississippi Medical Center, has also been awarded a $10 million NIH grant to investigate how genome sequencing can help with the diagnosis of babies with birth defects and genetics disorders. In the early history of the United States, immigrants from different parts of the world tended to settle in different regions, creating subtle differences in gene pools. Scandinavians (CONTINUED ON PAGE 4)

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HEALTHCARE SPOTLIGHT

Pediatrician Brings Care to Syrian Refugees in Jordan By Cara Clark

It has been over six years since Syrians experienced the tumultuous Arab spring that forced many to flee their homes for refuge in nearby regions or far from their native country. Osman Ahmad, MD, a pediatric gastroenterology fellow at UAB, saw firsthand the costs of being displaced by war. In May, Ahmad joined 10 physicians from various specialties for a five-day medical mission trip to Amman, Jordan, traveling with the Islamic Medical Association of North America. “When you hear about how to help people in need, giving money is great, and they need lots of it,” Ahmad said. “But if you have the skill and can use that to help, it’s important to do that. I practice medicine and can take that anywhere in the world. It means so much to the people you help.” Ahmad learned of the organization and its work when a friend in New York posted information about his trip on Facebook. As he learned more, he planned his own mission trip to aid refugees, whose needs were often straightforward, but critical. “We saw people who had hypertension and diabetes that had gone untreated,” Ahmad said. “Here, if you run out of insulin or blood pressure medicine, a doctor will refill it. Even if these refugees

Osman Ahmad, MD stands with some of the children he attended to (abve left). He saw 300 patients in Jordan.

could have gotten a refill, they would not have been able to afford it. We were able to provide simple things that we take for granted here, like vitamins and common antibiotics like amoxicillin.” Going into a conflict zone, Ahmad was uncertain about the peril and about the people he would be assisting. In meeting them, he realized most had been financially stable or affluent with well-ordered lives before war upturned their world. “When you get there and see the kind

of conditions these people are living in, you realize that our lives are different but we want the same things,” Ahmad said. “You try to put yourself in their shoes, and I don’t think I could do what they have done and be as hopeful as they are.” As he provided medical care, he realized one of their greatest needs of refugees was to connect on an emotional level. “The biggest part of what we did was just listening to their stories,” he said. “It was like therapy for them to tell somebody

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else about it, and they wanted us to go out and share their stories. It’s amazing that they still have so much hope.” Ahmad said many of the refugees wish to eventually return to their homes, while others accept there is nothing left to return to because their family and friends have been killed. They left their homeland with young children and now are raising teenagers. “It made me grateful for running water and electricity, but I was also thankful for things like being able to take my kids to the park — things we take for granted,” Ahmad said. “When I came back, I felt very blessed to live in a place like America.” Ahmad was born in Orlando, Florida, where his immigrant parents met and married. His mother, a pediatrician from India, and his father, an engineer from Pakistan, epitomized living the American dream with him and his three sisters. Going to Jordan and working at these clinics was his way of giving back. He personally saw at least 300 patients, and his group saw more than 2,500 in that short time.  “One of the reasons I wanted to do this and found it so rewarding is that you can give a little hope — even if that changes the life of just one person,” Ahmad said. “I saw a mom with three kids when I was there. The older son was the one who really touched me. He was very quiet. Through a translator I asked, and his mother said he saw much more than he should have. He had bedwetting issues and nightmares. “I can’t even imagine what this family was going through, but we were blowing bubbles for them, and he smiled. They had a moment of happiness they all could share.” Such moments for this widow and her children are fleeting, Ahmad realizes, and he plans to work with other such medical mission trips in the future. 


GENETICS

Face2Gene App Searches Photos for Diagnostic Clues By Laura Freeman

Some diseases are so rare that a primary care physician may see only one or two cases in an entire career. The problem with the math in daily practice, however, comes from the sheer number of rare diseases—more than 8,000 known so far. Even low prevalence disorders add up to the likelihood that one in ten patients who walk through a primary physician’s door are likely to have or develop a debilitating or life-threatening rare disease. The difficulty in detecting one rare disease among so many possibilities leads patients on an average diagnostic journey of more than seven years and seeing an average of seven different specialists. Although high throughput molecular testing is becoming more available, the odds of finding a diagnosis is still only 25 percent without enough patient data to sort out which genetic variants are clinically relevant. However, a new tool that is as near as your smart phone is improving the odds and providing clues on where to look next. The Face2Gene app developed by FDNA, Inc. (Facial Dysmorphic Novel Analysis) is free to physicians and available in Iphone, Android, PC and Mac formats.

“You simply upload a photo of the patient to a HIPAA secure and verified server,” UAB medical geneticist and pediatrician Anna Hurst, MD said. “The image is translated into mathematical calculations of more than 140 data points. Measurements and ratios are then compared to a vast database of facial variants linked to many different disorders. The patient’s features are analyzed Anna Hurst, MD in seconds and the app generates a list of syndromes that match or show similarities. “The app doesn’t take the place of the physician’s judgment, but it can provide added confirmation when you are considering additional testing. It helps to narrow the field when there are too many possibilities. And when you’ve eliminated everything likely, it provides clues on where to look next.” When Hurst was in training, her mentors were beta testers of the app, and today she is on the advisory board as a clinician using Face2Gene in real world practice. “In some disorders with a genetic basis, there are characteristic differences in facial

features, such as in Down syndrome. Other variations may be less defined, but are common in specific genetic diseases. The analysis looks at things like spacing and angle of the eyes; the position and shape of the ears; the structures of the nose; corners of the mouth and size of the chin; placement of the neck bones and overall facial proportions,” Hurst said. The app can search the London Medical Database for correlations between patient photos and such disorders as Noonan’s syndrome, Smith-Magenis syndrome and Russell-Silver syndrome, as well as diseases with facial differences that may be less apparent. “UAB is active in Neurofibromatosis research, and we often see patients who have been referred to us for diagnosis and treatment. The Face2Gene app can be helpful in confirming the diagnosis and in identifying other factors that might be involved,” Hurst said. The entire database has been crowdsourced from real-world patient cases through broad networks of clinical, lab and research users, and additional data is being contributed on an ongoing basis. Using facial analysis, artificial intelligence, and deep learning algorithms, the app transforms data into actionable genomic intelligence to

help clinicians recognize syndrome-related phenotypes and disease-causing genes. In research, as new clinical features and genes are discovered, it can assist in developing disease-predicting biomarkers. The data can also be accessed by drug companies to develop, test and market new therapeutics for rare diseases around the world. “As of now, the app is being used clinically primarily by specialists involved in evaluations of genetic disorders and rare diseases, but physicians who are distant from a referral facility or who have a case they suspect may have a genetic basis might want to download the app,” Hurst said. “It is free and available from Google Playstore and the App Store, but you will need to register, since it can only be used by health care professionals. “The patient’s privacy is also well protected. Only the person who uploads the photo can see it. The photo is immediately translated into mathematical data that is encrypted so even the people who manage the database can see only numbers and no faces. “However, the data Face2Gene returns can help you look at a case more clearly. Any matches are prioritized in order of correlation so you can see the most likely places to start looking to find answers for your patients.”

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GENETICS

Two Major Genomics Initiatives in Alabama, continued from page 1 tended to settle in the northern midwest; eastern European, Jewish and Italian populations made their homes along the northeastern coast; while Scottish settlers arrived in the Carolinas and made their way to northeast Alabama, joining Native Americans and English, French and African American populations to the south. Subsequent waves of immigrants from all over the world continue to add to Alabama’s unique gene pool. A better understanding of the specific risks for inherited disorders within this gene pool, as opposed to incidence within a broader nationwide population, could help improve health in Alabama. That is why the Alabama legislature appropriated $2 million to fund the Alabama Genomic Health Initiative (AGHI), which is being conducted as a cooperative effort between UAB and HudsonAlpha. A

pilot project recruiting the first 100 participants to fine-tune informed consent procedures, educational materials, and privacy measures was completed in May. “We have opened recruitment locations at the Kirkland Clinic and Medical Towers in Birmingham, and we hope to enroll 2,000 participants the first year. Over the next five years, we will open new locations around the state and hope to analyze the genomes of more than 10,000 volunteers, including people from every county in Alabama,” UAB medical geneticist Anna Hurst, MD, said. Bruce Korf, MD, PhD, chair of the UAB Department of Genetics and codirector of the AGHI, said “This project will result in immediate health benefits to some participants, and in the long term will help to address problems of chronic disease and rising health care costs in

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the state. It will also position Alabama as a leader at the forefront of 21st century medicine.” Greg Barsh, PhD, faculty investigator at HudsonAlpha and co-director of the AGHI, said “The AGHI could lead to identification of new genetic diseases and treatments. Researchers working on finding cures to conditions like diabetes, heart disease, epilepsy and cancer will be able to utilize knowledge from these Greg Barsh, PhD data to identify genetic factors that predispose people to these diseases as well as rare disorders.” Volunteering for the study requires only about thirty minutes, which includes a briefing about AGHI by a patient navigator and a simple blood draw to collect DNA. “The genotyping array test will assess around 650,000 genomic biomarkers. It will particularly look for variants in 59 ‘actionable’ genes known to contribute to diseases and for which there is a potential for treatment,” Hurst said. “There is no cost to participants, and they can choose whether or not to be notified if a genetic risk is identified. If so, genetic counseling is in place, and we can guide them to preventive treatment as needed.” The actionable genes targeted include BRCA1 and BRCA2, which are associated with a genetic risk of breast and ovarian cancer. The list will change over time, as new genes are recognized that can

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lead to improvements in medical care for an individual being tested. Some participants with signs of a genetic condition of undetermined origin will receive a more extensive evaluation using whole genome sequencing. All of the genetic information of consenting participants will be saved in a database for research use. The second genomic initiative partnering UAB and HudsonAlpha will start in neonatal units. The $10 million NIH grant for the “Clinical Sequencing Across Communities in the Deep South” project is part of a network of nationwide sites called the Clinical Sequencing EvidenceGenerating Research Consortium, or CSER2. It will enroll infants with birth defects or other signs suggestive of a genetic disorder. Aimed at developing better ways to integrate genome sequencing with clinical care, the project is being led by HudsonAlpha faculty investigators Greg Cooper, PhD; Greg Barsh, MD, PhD; and UAB professor and chair of the Department of Genetics Bruce Korf, MD, PhD. “A major goal of CSER2 is to try to empower non-genetics trained health professionals to explain the results of genomic testing to families,” Korf said. “Because of a shortage of trained medical geneticists, we need new paradigms in order to provide the benefits of genomic testing to more patients. The need is especially acute in our underserved populations.” The CSER2 clinical sites include Birmingham and Jackson, Mississippi. “These regional partnerships improve our ability to help children by providing a genetic diagnosis as early as possible,” said Barsh, who brings 20 years of experience as a medical geneticist to the CSER2 team. CSER2 grants have been awarded to six clinical sites, including a coordinating center, all with a goal of recruiting at least 60 percent of participants from diverse or underserved settings. To learn more about the Alabama Genomic Health Initiative please visit www.aghi.org. To participate, call 1-855462-6850.

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Palliative Medicine Manages Symptoms in Chronically Ill and Terminal Patients By Ann B. DeBellis

Patients who are facing a chronic or terminal illness can find relief from symptoms, pain and stress through treatment provided by a palliative medicine team. The goal of palliative medicine, the newest board specialty in Internal Medicine, is to improve the quality of life for both the patient and family. Greg Ayers, MD became board certified in palliative medicine in 2012 and formed the Palliative Medicine service at Princeton Baptist Medical Center seven years ago. He serves as medical director for the Princeton team as well as for the newly established palliative care team at Brookwood Baptist Medical Center, which began providing Palliative Medicine consultations in May. Ayers also serves as Regional Director for Curo Health Services in North Alabama and Mississippi. Curo is a national hospice service provider that serves patients across 21 states. “Palliative medicine may be a new specialty, but doctors have actually always provided palliative care. Someone just gave it a name,” Ayers says. “Physicians have always worked to relieve suffering. That’s what palliative care is – relief of suffering.” Palliative care is a broad philosophy that includes hospice care. While hospice care is reserved for terminally ill patients during the last six months of life, palliative care can be employed while patients continue life-prolonging treatments through different phases of a serious illness. Treatment may include pain management, the understanding of care options toward the end of life, help at home, and emotional/ spiritual support. Ayers says palliative care is generally discussed in the context of a serious illness like chronic, progressive pulmonary disorders; renal disease; chronic heart failure; HIV/AIDS; progressive neurological conditions; cancer; etc. A team of health professionals cares for the patient and family, generally in a hospital. “With us, you get a whole team – a medical director, nurses, a pharmacist that specializes

Greg Ayers, MD, center, consults with members of the Brookwood Palliative Care team.

in palliative care, social services, and a chaplain,” Ayers says. “I chose this field because I want to help relieve the suffering in patients with serious illnesses.” Palliative care is important for hospice patients who want an accurate prognostication for their end of life. “We have a lot of prognostication discussions with people with an advanced terminal disease, like cancer,” Ayers Says. “Those are difficult conversations, but families appreciate it because it helps them make plans. The patient might want to take a last trip or see a certain loved one, so it is important to have an accurate date. “To maximize effectiveness, palliative care should be started earlier in the disease process when the symptom burden begins to increase. And by making plans for care in advance, the family reduces stress. We conduct family/patient conferences where we ask the patient what types REPRINTS: If you would like to order a reprint of a Medical News article in a PDF format or request an additional copy of an issue, please email: [email protected] for information.

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of treatments he wants at the end of life. We also determine the appropriate decision maker who will speak for the patient when she is no longer able to make decisions. That is an important discussion because I have seen patients put on ventilators and medications without the consent of the patient or the family.” Studies show that palliative care makes a difference in patients’ lives. “It improves quality of life, reduces time

spent in the hospital, and decreases hospital readmissions. With hospice enrollment, we are also able to arrange good support services in a patient’s home which can prevent a patient having to return to the hospital,” Ayers says. “Patients who receive our consultations generally have fewer invasive procedures and code blues. That translates to better quality of life when you don’t have to endure all those procedures at the end.” There are currently only a few palliative medicine physicians in Alabama. “Facilities are improving, but not enough doctors are trained in palliative care,” Ayers says. “UAB started the first service in the state and also has a training program for physicians in the field. Nonetheless, our outstanding teams at Princeton and Brookwood have improved access to this specialty for our patients here in Birmingham. Our teams provided care for more than 110 patients at Princeton and more than 50 at the new Brookwood program in the past month alone. Getting the word out about the field of palliative care is important. We need to increase awareness among insurance companies and the media. We also need physicians to promote the specialty more. Improving public knowledge will make it easier to spread the word to the people who need this care the most.”

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Medical Practices are Required to Document Equipment Maintenance By Marti Slay

Whether it’s a simple scale, a scope or an autoclave, every physician’s office has equipment that needs maintenance, calibration and occasional repair. “State code requires that any medical equipment that is portable -- meaning it can be unplugged and moved -- be checked annually to assure safety and that a performance verification be completed,” said Rich Godwin, owner of Med Tech Biomedical Services. The Alabama Department of Public Health performs inspections to make sure practices are following code. “However, since there are a limited number of inspectors, they mostly go to the hospitals and surgery centers, and they generally only go to a doctor’s office if there has been a problem,” Godwin said. Nonetheless, medical equipment technicians warn against wait- Rich Godwin of Med Tech performs equipment maintenance. ing for a problem or an inspection dustry experts many times. If a doctor can’t to have equipment serviced. provide documentation that equipment has “Once you have an incident, it’s too been maintained according to manufaclate,” said Todd Fentress, co-owner of turer specifications, he can be held liable. Medical Incorporated Equipment Service We’ve seen hospitals that didn’t have to and Repair. “We’ve been deposed as in-

6 • OCTOBER 2017

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write a lawsuit check because they had maintenance documentation.” Mitchell Sargent, Mohs Technician for Ginsburg Dermatology Center, is responsible for maintaining equipment in their lab, which includes documenting the maintenance daily. “My goal is to be as compliant as possible,” he said. “The number of clipboards and charts and logs for quality control is daunting. If an inspector were to walk in the door, I’d want them to notice the faint smell of bleach in the air, from wiping down the equipment with bleach wipes. I try to keep the lab organized and maintained above and beyond what they expect. “I don’t want our equipment to slip into disrepair because I’m concerned about my safety, my coworkers’ safety and the welfare of the patient. It’s too important not to address on a daily basis.” Despite the most diligent maintenance schedule, however, equipment will, sooner or later, break down. That’s when an outside service is needed. “Equipment fails,” Fentress said. “Cars break down and we have wrecks. But if you can produce documentation that equipment was maintained to manu-

facturer recommendations, you will have a better time with your insurance company.” “A service contract doesn’t mean they won’t have a problem,” Godwin said. “But saying you don’t need it because you’ve never been inspected is like saying you don’t need auto insurance because you never had a wreck. It’s cheaper to pay for it up front rather than after you have a problem.” Professional maintenance services offer one-time repairs on a particular piece of equipment as well as regularly scheduled maintenance check-ups for an entire practice. “Once a practice reaches out to us, we come in and check their equipment and educate them,” Fentress said. “We verify that the equipment is working, and then we calibrate it and repair it, if necessary. A scale is the simplest piece of equipment. We bring in 500 to 600 pound weights and prove it is weighing what it is supposed to weigh. And we’ll check equipment right up to x-ray and anesthesia machines.” It is no small task to keep up to date on the breadth of equipment by various manufacturers and the many maintenance regulations. “There are hundreds of modalities of equipment. It’s like trying to nail down jello,” Fentress said. “Healthcare practice (CONTINUED ON PAGE 10)


REIMBURSEMENT

Proposed Changes to MIPS Tame this Year By Jane Ehrhardt

“The new changes in the 2018 reporting period are actually not terribly drastic,” says Joni Wyatt, MHA, MHIA, CPHIMS, FHIMSS, with Kassouf & Co about the Merit-based Incentive Payment System (MIPS). “CMS is trying to move slowly and not scare physicians away from participating.” 2018 marks the second year of the Joni Wyatt program, which was implemented by CMS and changes how physicians will be reimbursed for Medicare claims. These first two years focus solely on gathering data which will determine a score for each physician. That score, based on a comparison with peers, may set their reimbursement rate. Data gathered next year will determine the score for 2020. The proposed changes to MIPS for next year will come as a relief to physicians after this year’s tumultuous start. “CMS tried to keep what worked and take comments on how to change the parts that were difficult to accomplish,” Wyatt says. The biggest change is the drop in the threshold for exemption from MIPS. Last year, physicians were exempt if they had allowable Medicare Part B charges totaling less than $30,000 and fewer than 100 unique Part B patients. For 2018, that proposed threshold more than doubles to less than $90,000 in allowable charges and fewer than 200 patients. The outcome presents a double-edged sword for the approximately 36,000 physicians in the U.S. who fit the new conditions. “Providers that have invested in the process and the tech in order to participate in MIPS might be disappointed if they no longer meet the requirements and are not eligible for incentive money,” Wyatt says. However, those physicians who chose not to participate in MIPS this year and now match the new criteria will ultimately get a reprieve from the mandatory penalty to their Medicare reimbursements. They will still be hit with the four percent penalty throughout 2019 on their Medicare claims. “But a lot of those providers didn’t participate in Meaningful Use (MU) or PQRS, so they may have been experiencing penalties well above five percent already,” Wyatt says. MU and PQRS are the outgoing reimbursement programs from CMS. “So a four percent penalty under MIPS is basically a raise.” But starting in 2020 under the proposed higher threshold, the additional qualifying nonparticipants would be deemed exempt from MIPS and drop to zero penalty. “So they’re still better off if they have invested nothing and they’re ultimately without penalty,” Wyatt says. ”If they do not meet exemption, the nonparticipants in 2018 will be assessed a five percent penalty

in 2020. “I think you can see why the participating providers who invested and now fall below the threshold might be disheartened,” Wyatt says. “Because they’ve done everything they’re supposed to do, but may not get the benefits from it.” Physicians hindered in the MIPS scoring system by smaller patient populations could see another beneficial change in 2018. CMS will allow any combination of solo providers and physician groups of less than 10 (under the same tax ID number) to a form virtual group. The virtual group bolsters patient populations which can raise a physician’s score in some MIPS measures. “If you don’t have the minimum patients for a particular measure, you’ll max out at three points,” Wyatt says. “An average score of three points per measure is low and will likely result in a very insignificant increase on Medicare claims; whereas as part of a virtual group, your patient population is combined and you’re able to compete for a higher score. “We could write a book on MIPS strategies. It’s unfortunate that, while MIPS is meant to reflect a physician’s performance, in some ways it only reflects a physician’s ability to capture data. In essence, it’s like knowing how to take a test versus really knowing the material.” One of the biggest complaints from physicians about MIPS revolves around the lack of credit for treating the sickest patients. The 2018 changes propose a Complex Patient Bonus to compensate. Physicians could be awarded up to three points on their final score based on their average Hierarchical Conditions Category. “Essentially it’s a risk adjuster that is driven by diagnosis codes,” Wyatt says. “So in 2018, the key is to use specific diagnosis codes to clearly identify the burden of illness for your patient population.” Other proposed changes include an improvement award based on increases in the quality measure scores from 2017 to 2018. “It could be worth up to 10 points additionally in that category,” Wyatt says. Practices with fewer physicians could also automatically accrue points. “MIPS has disproportionately affected smaller practices with its demand for resources of both money and staff to implement it,” she says. “CMS is trying to help these smaller groups out.” These proposed changes may still be altered. The final ruling could come out as early as October, but CMS has until December 31 to release additional changes. “Historically, we’ve not had a single year where they have not made a change in the final ruling to the performance period, hardships, exemptions, or penalties,” Wyatt says. “There always seems to be last minute exceptions and changes with MIPS, so it’s important to keep up.” For the latest information straight from CMS, visit qpp.cms.gov.

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REIMBURSEMENT

ICD-10 Codes Will Affect Physician’s Scores By Jane Ehrhardt

The annual update in ICD-10 diagnostic coding went into effect this month with 363 new codes, 142 deleted codes, and 250 codes with revised definitions. “Last year, we had thousands of changes,” says Tammie R. Olson, CPC, CPCO, with Management Resource Group. “700 is not a lot when you consider that ICD10-CM totals over 69,000 codes. I’m surprised we didn’t have more.” Most of the Tammie R. Olson changes relate to definition. “They added specificity,” Olson says. “Substance abuse remission can now be coded as mild, moderate or severe. Non-pressure ulcer codes can pinpoint location. They just added to the existing code set to give you more options.” The same holds with identifying the quadrant for an unspecified lump in the breast or specifying in a pregnancy code whether a problem resides on the left or right side. Blindness and low vision, though, has 50 new subcategories. “In the past, blindness in both eyes wasn’t specified by category before,” Olson says. “Often in the

documentation, they say there’s blindness in both eyes, but this gives us codes to quantity and qualify this.” Myocardial infarction became its own category. “They include a new specific action for type 2,” Olson says, adding that pulmonary hypertension now offers coding to better define the cause. “Too many will look at the list of new codes and won’t look at the guidelines that go with them,” says Kim Huey with KGG Coding and Reimbursement Consulting. Authored by the Centers for Disease Control (CDC) who edits the U.S. version of ICD-10 diagnosKim Huey tic codes, the coding handbooks arrive with the previous year’s guidelines. To find the current guidelines, physicians need to visit www.cdc.gov. EHRs are also unreliable in correctly interpreting the subtleties of the guidelines. For example, a patient with diabetes and myopathy is now one code, though both codes still exist as separate diagnosis. “But the EHR won’t lead you there,” Huey says. The software generally provides a list of coding options, but not the guidelines on choosing the most ac-

curate one. Accuracy is now crucial for attaining the highest reimbursement rating. “For instance, under Alzheimer’s, there used to be one code for Alzheimer’s patients with behavioral disturbances,” Huey says. “Now there are two; one for Alzheimer’s and one that specifies behavioral issues. If you’re not coding correctly for every diagnoses that’s appropriate for that patient, then you’re losing value, because payers are measuring your cost of care with that patient’s severity of illness.” A similar situation falls under pregnancy coding. “There is a guideline that if the patient is pregnant, anything she has is assumed to be a pregnancy complication, unless the doctor specifies that it’s not,” Huey says. “This makes a difference is in the quality payment programs, because if you’re not coding correctly, then you’re missing out on showing how sick that patient really is.” That will play a significant role in determining a physician’s score in CMS reimbursements. ICD-10 also helps physicians better define why a patient’s treatment may not be effective. “I call these physicians’ frustration reliever codes,” Huey says. In ICD-9, one code covered all the reasons a patient may be blocking their treatment’s success.

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In ICD-10, codes now specify that a patient is not taking meds as prescribed and the reason, such as he cannot afford them, refuses to take them, or cannot remember to take them. “And I’m encouraging physicians to use these codes whenever they can, because they’re being judged now on cost of care versus quality, and if a physician is doing everything she can, this shows that the patient is not doing his part,” Huey says, adding that physicians have been hesitant to use these in the past. “But if we’re being judged on this, we need to show every reason that that care is being affected beyond our control.” For help using all the codes, Huey suggests the quarterly, on-line newsletter “Coding Clinic.” This is published by the American Hospital Association which, along with three other entities, has the authority over physician coding. “A lot of physicians don’t know this publication exists,” she says. It answers questions like how to code if a patient smokes. “Because there is one for use and for tobacco dependence. But if you look it up in the coding handbook under smoking, there’s nothing there. This pub answers things that aren’t completely evident.” For a subscription, visit www.ahacentraloffice.org.

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REIMBURSEMENT

Billing Errors that Can Cost Thousands By Jane Ehrhardt

Last year, a medical practice lost over $30,000 in revenue from skipping a basic step in the billing process. “These are billing 101 mistakes,” says Sae Evans, CPA, with Warren Averett. “When it comes to billing, little oversights can make a huge difference over time and can significantly impact physician compensation.” The error at the practice was simple. No one verified that the billing statements generated each day matched the patients seen. “You have to check that the doctor hasn’t forgotten to close out any of his procedures and diagnostics performed for the day,” says Delena Chappel with MediSYS. “They didn’t do that and that caused money to be thrown out the window.” Delena Chappel If mistakes go unnoticed long enough, reimbursements become impossible. “Heavy payers — CMS or Blue Cross — won’t accept claims after a year or two,” Chappel says. “But United, Viva, and TRICARE have something like a 90-day file limit. If you have dates of service before June not submitted yet, that’s now money down the drain.”

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A diagnostics center nearly lost around $42,000 through a similar mistake. “They did not reconcile with the daily audit,” Chappel says. The center had no process in place to ensure that the claims sent were acknowledged as received by the payers. Two weeks later when the funds did not show up, they called the payer. The payer had no record of those claims, and though the center could prove the claims had been transmitted, they had no proof of acceptance or rejection by the payer. “We hear this all the time,” Chappel says. “Because many carriers, such as Medicaid, store their registers of received claims for only seven days, these errors generate costs in staff time to resubmit the batches and interrupt cash flow. All your work is meaningless if the claims don’t reach the payer.” The ever-advancing abilities of EHRs (electronic health records) can also inadvertently lead to billing errors. “EHRs are great if used to their full capability, but they present some potential dangers,” says Jim Stroud, CPA, with Warren Averett. “They tend to prompt physicians to upcode a Jim Stroud visit.” For instance, a patient visit that would normally be billed as a level 3 can end up coded as a level 4 because the EHR assesses only the pattern of boxes checked

by the physician, not the context. “The largest payer in our state has engaged an outside source to identify users of level 4 and 5 visits deemed to be outside the norm for their specialty,” Stroud says. Physicians on their radar will have received letters saying the coding pattern is excessive. “If so, you’re already on their radar screen. So be careful that your EMR is not auto-producing billing points,” Stroud says. “If a practice has this problem, they have other problems as well.” The EHR can help, however, with another reimbursement requirement. “Moving forward, payers want to know as many as 12 diagnosis codes per patient,” Evans says. Insurers use the codes to establish a financial allotment towards the annual care for a patient. CMS will use the codes to assess how well a physician manages the cost of care for that patient. For instance, treating a patient with abdominal pain will score differently than treating abdominal pain in a morbidly obese, diabetic patient with a history of heart disease. “You score better if your care is given to a very sick patient,” Stroud says, because those conditions complicate the decision-making. At a meeting with orthopedists, Evans found they averaged 1.5 diagnosis codes per patient. “They’re thinking is that if you have a knee fixed, why show all these other diagnosis codes that we’re not treating,” he says. “But they’re making decisions for treatment cognizant of those other conditions and should get credit for that.”

On January 1 of each year, insurers wipe those codes. “Physicians then have to repopulate those diagnosis codes,” Stroud says. But a good EMR will contain the codes from the last visit, freeing physicians from having to manually reenter them. also cautions physicians to be aware of reimbursements related to the use of mid-level providers, such as nurse practitioners and physician assistants. “They can really increase a physician’s volume, but that can put them on the payer’s radar screen.” If a physician can normally see 30 patients a day, but with mid-providers, sees 50 or 60, “that can raise eyebrows from payers if it isn’t billed properly,” Evans says. For a physician to have one mid-level provider raises no red flags. “If you get to more than one, and you don’t let them bill under their own numbers, this would immediately improve your cash flow but in the long term, it could put you out of business. Payers will de-panel you,” Stroud says. The goal for claims should be an immediate 100 percent acceptance. “Get it right the first time, every time,” Stroud says. “And every time, not only correct it, but find out where in the process the mistake was made and correct that. It may seem impossible, but getting the clean claims rate up to 97 percent is crucial to building an efficient and profitable medical practice.”

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REIMBURSEMENT

New Cms System Changes Focus From Punitive to Education By Cara Clark

The Centers for Medicare & Medicaid Services (CMS) unveiled a new protocol this year that shifts the focus from punitive to educational in terms of proper coding of Medicare claims. To replace the Recover Audit Contractor (RAC) system in which contractors reviewed 100 to 200 claims, the modified sample size will be reduced to 20 to 40 claims under the new Targeted Probe and Educate Medical Review Strategy (TPE), which went into effect in July. Under the RAC system, auditors reviewed claims to determine if they were paid appropriately, and if not, demanded

the funds back. Even relatively minor medical coding errors would cause claims to be denied. “RAC was more about punishing than teaching,” Buzz Coons, director of Healthcare Services for Pearce, Bevill, Leesburg, Moore, says. “Some of our clients had to hire lawyers and spend thousands of dollars to fight this thing. Consultants Hal ‘Buzz’ Coons were telling physicians they were billing correctly – the documentation may have been light, but the billing

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was correct. In actuality, we needed to help them understand how to bill.” “Not every patient is the same, and the auditors examining the charts were not trained as physicians,” Coons says. “They were trying to determine if the right medical decision was made simply by looking at a chart of paperwork. It was a costly procedure that made the system much more complicated and stressful for physicians.” All that changed this year with the introduction of the new secretary of Health and Human Services, Dr. Tom Price, a 63-year-old orthopedic surgeon. In his own practice, Price ordered durable medical equipment and high-cost procedures that auditors tend to scrutinize for cost effectiveness. “Dr. Price has experienced these situations,” Coons said. “He is more sympathetic to what physicians go through and wants to help solve problems.” In his drive for solutions, Price created Targeted Probe and Education (TPE) to replace the RAC system. “In this system, the auditors are not out for blood,” Price said. “They are out to train.” Under the new guidelines, if an auditor finds problems, the recourse is to educate the practice on the findings and how to re-code files to become compliant. Then the physician is given 45 days or longer to address issues before the auditor returns to assess another 30 to 40 claims. If those are found to be compliant, the physician won’t

experience another audit for at least one year. The new system, basically a threestrike approach, reduces stress on physicians and leads to long-term compliance. “After round one or two, my clients will be compliant,” Coons said. “I think everyone is going to do a great job. If someone is not complaint after round three, the auditor will refer back to CMS to decide what to do.” When appointed head of HHS in February, Price summed up the problem by saying people make errors (in billing and coding), and errors can be corrected. Those who are trying to cheat the system will face repercussions, while honest errors will be fixed. That straightforward approach will eliminate a financial burden in terms of manpower hours spent defending legitimate claims. “Physicians I work with are very positive about the change,” Coons said. “With the new TPE audits, it’s a learning experience. I think it’s absolutely perfect with an orthopedic surgeon running the system. Obviously, we know orthopedic specialists are not doing unnecessary surgeries, but they do utilize the healthcare system more than some others do. Now we have a guy who is head of HHS who was probably scared himself of these audits when he was practicing.” The bottom line, Coons says, is that after a practice is penalized for a coding error, they may or may not learn from the experience, but if someone is assigned to educate the practice, the trickle-down effect will solve problems for years. “Once you train a physician and they build a system to comply, it will carry over into the practice long after the TPE occurred,” Coons says.

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managers have to be on top of a moving target.” “No one person can know it all,” Godwin said. “This is a learning process every day. I’m qualified to talk to people who do know and to convey the answers to the parties who need my help.” “It’s our job to know what is required for whom,” Fentress said. “We do a risk assessment for a practice based on the type of equipment and its use. An ultrasound in an operating room is used more and should be checked more often than one in an ob/ gyn office, for instance. A defibrillator is a life saving device, and the manufacturer recommends that it be checked quarterly. A scale only needs to be checked annually, because you aren’t going to die if it’s off. Physicians don’t have time to keep up with all these regulations. They need to let us be the equipment professionals so they can take care of patients.”


The Promise of Blockchain

How the Technology Could Transform Healthcare Transactions By CINDY SANDERS

What if data could be stored in a decentralized, agnostic database in a permissioned ledger format where users could be added to access only the data pertinent to them and for a controllable amount of time with everyone linked using cryptography to create immutable, time-stamped, secure transactions? That is the promise of blockchain technology. Change Healthcare Chief Technology Officer Aaron Symanski sat down with Medical News during the recent Summit of the Southeast health tech event to talk about the financial and clinical potential of blockchain. One of the nation’s largest independent healthcare technology companies, Change Healthcare sits at the nexus of revenue cycle management, improved workflow, and delivery of quality care. The company has been one of the national leaders in exploring the ways blockchain might be deployed to transform the industry. “Blockchain is a database, a distributed ledger, where every participant in the network holds the same ledger … that’s the essence of it,” explained. Symanski. While the technology and tools required to create a blockchain are a little more expensive on the front end, Symanski noted, “It makes it far more effective in doing business.” For example, he contin-

ued, if a provider and payer are routinely sharing hundreds or thousands of records and a question pops up about a patient transaction a month ago, there’s no confusion about what transpired or need to spend hours researching the transaction. “I see what you see. They are never going to be different,” he said of the ledger views. “That’s what blockchain brings to the table.” Anyone who has ever used Bitcoin, a global cryptocurrency, has been exposed to blockchain technology. “Every participant has a complete record of every coin that’s ever been in anyone’s hands and every movement that coin made between all the parties,” Symanski said. In healthcare, of course, there are myriad rules and regulations that would make some data – such as protected health information – undesirable to be open to everyone on the blockchain. However, Symanski explained, blockchain is really a platform where layers can be added that would control permissions. He said startups across the country are looking at applications that take into consideration smart contracts, interoperability, privacy – “They are all talking about protocols on top of that blockchain mechanism of identical storage.” Symanski continued, “A lot of what you see in blockchain today is financially based. It is a blockchain amongst a very

small set of parties who are all comfortable with that complete visibility.” Moving into patient information adds a long list of new considerations … but ones that can be addressed. For example, it could be that a provider has access to all the encrypted data on a blockchain but cannot decrypt without a key that grants access only to the specific, limited dataset that they have been cleared to receive. “That’s another part of the conversation that’s really interesting. Who controls the patient data?” Symanski asked. One thought is it’s the patient. “One of the pieces of the conversation right now is that it’s the patient’s key to decide to distribute. A patient might want to provide a mental health status key to one provider but not to another.” On the other hand, Symanski said a lot of providers feel like feel like they should control the key since liability could move around with the record. There’s a valid argument for a physician wanting to ensure another provider accessing a patient record sees more than raw data. The initial provider wants the story and interpretation of that data to be part of the record, he said. “There are a lot of opportunities right now to move that conversation,” Symanski noted of the gathering momentum behind using blockchain more widely. “Is there

one? Are there many? Are there many that are connected together?” Additional questions also have to be considered as to whether information could be accessed globally. Even within the United States, Symanski pointed out it’s like working with 50 different countries that each has its own rules and regulations. Drilling down further, does one payer want another payer to see their volume and have access to their decision criteria? “What we’re working through, as we bring more parties to the table around blockchain in healthcare, is what are the right pieces to assemble that work,” said Symanski. “These are the great conversations that are happening right now because the technology makes it possible,” he added with clear excitement about the promise blockchain holds. From a boots on the ground perspective, he noted, “We’ve got a lot of innovation going on, and we want to bring that out to the market faster and faster … every company does. We see blockchain as being a platform we can build upon. Everything we do can be enhanced, we think, as blockchain technology rolls out and becomes more and more widely available.’ Symanski concluded, “We’re excited about the technology. The hope is it’s used everywhere that it will create value.” And the belief is that it can create value throughout the healthcare industry.

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Keeping PACE with The Continuum Of Care Programs of All-Inclusive Care for the Elderly (PACE) began in San Francisco as an effort to both help and honor elders. Today the program, which now enrolls more than 42,000 adults aged 55 and over in 31 states, continues to live up to that original promise of coordinated, patientcentered, community care. “PACE serves nursing home-eligible populations but serves them in the community as long as possible,� explained Robert Greenwood, senior vice president of Public Affairs with the National PACE Association (NPA) in Alexandria, Va. Greenwood said the PACE protocol Robert Greenwood was developed in California by On Lok Senior Health Services. The program traces its roots back to the early 1970s as people were beginning to experience longer lifespans. On Lok, which means “peaceful, happy abode� in Cantonese, was formed in response to community concerns about caring for older individuals in San Francisco’s Chinatown, North Beach, and Polk Gulch neighborhoods. A consultant was brought in to assess building a nursing home in Chinatown but ultimately advised against it because the elders wanted to stay in their homes as long as possible and be fully connected to their family and community. By 1973, On Lok had opened one of the nation’s first senior day centers where elders came for socialization, health services, and hot meals before returning to their homes in the evenings. “The original concept was built on the British Day Hospital,� said Greenwood. He explained the U.K. model essentially created a nursing home with no bedrooms but all the other services traditionally found in a skilled nursing facility including physical therapy, occupational therapy, a health clinic and social services. By 1979, On Lok had launched a Medicare-funded demonstration project. However, Greenwood said, the team began to see gaps in services that weren’t typically reimbursable but would keep seniors home longer, including transportation and social services. In 1983, On Lok received waivers from the Centers for Medicare & Medicaid Services for a new funding mechanism for long-term care that used a risk-based capitation model and allowed On Lok flexibility in how the money was spent to address the full spectrum of an individual’s needs. “They did that as an experiment, and it was very successful,� Greenwood said, noting that success paved the way for PACE to take off nationally.

“In the Balanced Budget Act of 1997, PACE became a permanent provider type,� said Greenwood. “The core of PACE is there is an interdisciplinary team that delivers and coordinates their care.� He added, “It’s a requirement that your medical director is a gerontologist.� With a provider shortage, though, he said it is possible for a program to ask for a waiver. The team, he continued, works out of a PACE center so they are under one roof for improved communication. Much like hospital huddles, the team has a morning meeting to discuss any health or behavioral changes noticed among patients, a rundown of who is in the hospital and what is needed to support them at discharge, gaps in care or services, and any other items to improve coordination. One of the great advantages of the structure is the ability to tailor care to each patient and have the nimbleness to adjust the care plan whenever needed. The central mechanism of having a provider team under one roof that makes the program work so well, however, is also a perceived disadvantage for some potential participants. “That’s the number one objection – they don’t want to give up their community doctor,� said Greenwood, who added many PACE programs actually allow one or two visits each year back to the community physician with PACE reimbursing the provider for that visit. “The experience, though, is that once they are in the PACE program, they don’t usually ask for that,� he noted. Greenwood said PACE participants are split fairly equally among those who live by themselves, those living with a family member, and those who live in a congregate setting. Care plans are as varied as participants and are centered on a patient’s personal goals, which might be very different from the goals of another patient. “The diagnosis might be exactly the same, but the care plan could be quit different,� he noted. While the payment model for PACE services has evolved over the years, it remains a capitated plan. “By federal law on the Medicaid side, we have to be paid less than what they (CMS) would expect to pay in a fee-for-service model,� Greenwood explained “Medicare is risk-adjusted like a Medicare Advantage plan.� New programs, said Greenwood, are almost always launched in conjunction with a sponsoring organization such as Johns Hopkins, which sponsors the PACE program in Baltimore. “By nature of being a managed care model, there are a lot of startup costs before you ever enroll the first patient,� he explained. “Usually the first year, you haven’t enrolled enough people to cover your month-to-month costs.� However, Greenwood continued, once (CONTINUED ON PAGE 14)


New Partnership and LLC IRS Audit Rules Become Effective in 2018 By Gerard J. Kassouf, CPA

The Internal Revenue Service has announced new rules for auditing partnerships and their partners for Partnership and Limited Liability Company returns filed for partnership tax years which begin after December 31, 2017. Under the new rules, if an entity taxed as a partnership is selected for examination, the IRS will audit items of income, gain, loss, deduction, or credit, and any distributive share of these items for the tax year in question. Adjustments will be calculated at the partnership level (and not at the partner level, as is the current case) and all payments for additional tax, interest and penalty will be assessed to the partnership. The IRS in not required to provide individual partners any information or opportunity to participate in the audit process. In some cases, the partnership will be allowed to elect out of these new rules. These rules provide that the partnership representative may elect to have the partners make payment of any amount due. The election must be made no later than 45 days after the IRS mails the notice of final adjustment. By making the election, the partnership is no longer obligated for the payment, but each partner will be li-

able for their share of tax, interest and penalty. The interest charge on any underpayment of tax will be two percentage points higher if the election is made. Partnerships may elect out of these new rules if two conditions are met: first, if the partnership has 100 or fewer qualifying partners requiring a Schedule K-1 for Form 1065; and second, all partners must be “eligible” partners. “Eligible” partners include individuals, C Corporations, S Corporations, and estates of deceased partners. The proposed IRS regulations state that if a partner is 1) a trust, including a grantor trust, 2) another partnership, or 3) a disregarded entity such as a single member LLC the partnership is not eligible to elect out of the new rules. The partnership is required to designate a “partnership representative,” replacing the formerly known “tax matters partner.” The partnership representative, who is not required to be a partner of the partnership, will have exclusive authority to take actions on behalf of the partnership, without regard to any contrary position in the partnership agreement, or any other formal agreement between the partners. The partnership representative is designated on the entity’s timely filed

tax return, and the designation by law, is made annually. If the partnership does not name a partnership representative, the IRS may select any person of its choosing. The proposed rules explain how the IRS’s selection will work, and prohibits the partnership from making a change to the IRS appointed representative without its consent. There is no requirement that the IRS communicate with anyone except the partnership representative. Therefore, it with be the partnership’s responsibility to inform the partners of the examination and any other IRS proceedings. The new rules state that the underpayment of tax will be calculated at the highest rate of federal income tax in effect for the year under audit. Under current tax rates, the rate would be 39.6 percent. The statute of limitations for making adjustments for any partnership tax year is generally three years, but this period may be extended under certain conditions. Partnership agreements must consider the problems that may be created by partners that have withdrawn, and partnerships that have dissolved between the tax year under audit and the year the deficiency in tax is resolved. Collection of prior-year taxes due from more difficult without specific remedies under a binding

partnership agreement. This is a major consideration in the amendment to any agreement currently in place, or a reason to formalize a verbal agreement. In summary, the new rules make it easier for the IRS to audit partnerships and collect tax. The fact that there is no notice or participation rights to individual partners allows partnerships to be under audit without notification to the partners. By collecting the tax from the partnership, the payment moves from the partner to the partnership, Congress estimates that partnership audits under the new rules will generate approximately $10 billion in tax revenue. Consider the following for immediate action: • Amend partnership and LLC operating agreements to implement the new rules by December 31, 2017 • Designate a Partnership Representative and provide requirements for representation • Restrict transfers of interests to entities that are eligible partners or members • Coordinate with partners or members who sell or transfer their interest after the year under audit

Recipeideas

(CONTINUED ON PAGE 14)

OCTOBER 2017 • 13


Innovative Cardiac Pump a Lifesaver for Critical Patients, continued from page 1 ing device is saving lives,” says E. Merritt Cullum, MD, a cardiologist at St. Vincent’s Birmingham. “It is inserted into a patient’s left ventricle, the main pumping center of the heart, and pumps blood into the aorta. It also supports the left ventricle in high-risk stenting procedures for patients with a severely weakened heart muscle. We use it in patients who are having a heart attack and are E. Merritt Cullum, MD in cardiogenic shock to help generate an adequate blood pressure to supply blood throughout the patient’s body.” Impella® pumps are left ventricular assist devices that are placed in the leg instead of the heart muscle. Prior to the development of the Impella® pump, the only option for these patients was an intra-aortic

balloon pump (IABP). “The IABP has applications, but not in high-risk patients,” Cullum says. “The risk of dying from cardiogenic shock during a heart attack is high unless you aggressively correct the low blood pressure quickly. That is what this device does. I always say that the difference between an IABP and an Impella® device is like the difference between a Yugo and a Ferrari. Both are cars, but that’s where the similarity ends. Both of these devices are cardiac devices, but in very sick patients, the Impella® pump is an absolute life saver. I have seen many patients who would not have survived without it.” The various Impella® heart pumps have supported more than 50,000 patients in the United States. The Impella 2.5®, Impella CP® and Impella 5.0® are FDAapproved heart pumps used to treat heart attack patients in cardiogenic shock and have the unique ability to enable native heart recovery, allowing patients to return

home with their own hearts. The Impella 2.5 and Impella CP devices are also FDA approved to treat certain advanced heart failure patients undergoing elective and urgent percutaneous coronary interventions (PCI), such as stenting or balloon angioplasty, to re-open blocked coronary arteries. The Impella RP® device is approved to treat certain patients experiencing rightside heart failure. According to Cullum, the only downside of the device is its large size, but the benefits far outweigh this. “I haven’t found the size to be a problem so far,” he says. “It puts a large hole in the artery, but when done correctly, it has great benefit to the patient.” In addition to its ability to save the lives of critical patients, the Impella® heart pump simulator can support a patient’s blood pressure adequately without medication. In the past, physicians treated these patients intravenously with vasopres-

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PACE, continued from page 12 programs get over that initial hump, they usually hit their stride. In fact, PACE programs have met with so much success that the hope is to extend the reach. The NPA worked with Congress to pass the PACE Innovation Act in 2015 to look at replicating the program in younger populations with physical or mental challenges. “There are other populations out there who need access to a continuous model of care,” said Greenwood. “I think the PACE success story is really the enhanced quality of life for a participant,” Greenwood said. In the original patient population, he continued, “it’s really about managing that end-of-life process and making it as enjoyable and meaningful for the enrollee and their family as possible.”

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sors, medications that artificially support a patient’s blood pressure while the heart heals. Those medications can negatively affect kidney function and other parts of the body. “The Impella® device is the most physiologically natural way to support blood pressure in patients who have had a severe heart attack and cardiogenic shock,” Cullum says. He says that St. Vincent’s cardiologists and cardiovascular surgeons use the Impella® devices and work together to provide a team-based approach that is best for each patient. “This is another tool in our toolbox that we can use to help ensure our patients get well.”

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Interested in learning more about launching a PACE program? Information is available at npaonline. org. The organization’s annual meeting is also being held Oct. 15-18 in Boston, and the 2018 Spring Policy Forum is set for March 19-20 in Washington, D.C.

New Partnership, continued from page 13 • Determine partner consent, if any, for making elections or settlements by the partnership representative This is a brief discussion of a complicated tax topic, and is not meant to provide a complete explanation of the new centralized partnership audit rules. It is meant to inform you of a major change in the way the IRS will audit partnerships and limited liability companies. These rules are effective in 2018. If you are a partner in a partnership, or a member of a limited liability company, you are affected, and need to take action. Gerard J. Kassouf, CPA is a director at the Birmingham, Alabama firm of Kassouf & Co. P. C., Certified Public Accountants and Advisors--representing privately-held and family-owned businesses. You can reach him at [email protected]

14 • OCTOBER 2017

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The Literary Examiner BY TERRI SCHLICHENMEYER

Bored and Brilliant: Rediscovering the Lost Art of Spacing Out by Manoush Zomorodi; c.2017, St. Martin’s Press; 208 pages Pay attention! Bet you heard that plenty when you were younger. Look up here, listen to me, watch this, eyes forward. Eventually, it sunk in: you kept your eyes open, your mouth closed, and you are the better person for it‌ aren’t you? Peep this, pay attention – or, as in the new book Bored and Brilliant by Manoush Zomorodi, never mind. A decade ago, as a new mother with a colicky baby, Manoush Zomorodi spent countless zombified hours pushing a stroller around her New York neighborhood, to calm her son. At first, it was one of the most boring tasks she could imagine – but after awhile, she began to notice things: birds, architecture, people, and ideas. Weeks after returning to work, she was fuzzy-headed. That was when she understood that time off solved problems and cleared her mind. Taking a moment to reflect, she realized that “my main accomplice was my phone.â€? That led to a bold experiment: Zomorodi, a radio show host,

asked her listeners to join a “Bored and Brilliant Project,� in which they would agree to give up (or at least cut back on) mobile device usage. Thousands of listeners signed on.

Boredom, she says, is the “second most commonly suppressed emotion after anger,� even though humans need to be bored. Our brains require a certain amount of wandering to stay at peak efficiency. When we are daydreaming – something teens and children are more prone to doing – it activates a default mode, which enhances problem-solving and creativity. Says Zomorodi, “without distraction, your mind goes into some interesting and unexpected places.� Though it may sound funny, there are things you can do to combat a lack of boredom. Keep track of your digital habits. You’ll be surprised how much you’re on your phone. Put your device away while you’re walking, so you’re not tempted to use it on the fly. Stop taking photos for one day. Delete that App that you can’t live without (because, guess what? You can!). Be unconnected now and then; peoplewatch; visit a park without your device. And finally, remember that if electronic devices are doing this to you, think about what they’re doing to your kids.

How many times in your life did you bug your mother with whines of boredom? You’ll take them all back, once you’ve read Bored and Brilliant. If you’ve ever had a love-hate relationship with your overly-connected world, this is the book for you. Author Manoush Zomorodi knows your pain - it was a process for her and her listeners to disconnect - and because she went through the same kind of withdrawl, she doesn’t promise that it’ll be easy for you, either. The stats are good here, and the tiny-step encouragement is better but it’s the honesty that’s best inside this book. The Seven-Step Program is also a big help. Beware that there’s plenty of irony in reading this book on a device, but read it you should. In our heavily-connected society, Bored and Brilliant needs your attention. 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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Nurse Practitioners Partner with Physicians tioner must earn their Masters of Science in nursing with a specialty. While it is possible to make While most nurses begin in the transition from RN at any the profession by providing bedside time, Somerall urges nurses to care, many advance their career by begin the process sooner rather pursuing additional training. One than later. option is to become a nurse prac“If students enroll in the titioner. nurse practitioner program after “Nurse practitioners are a huge practicing 25 or 30 years, it can part of the solution for the lack of be difficult for them to become primary care providers in rural an order giver rather than an areas,” said D’Ann Somerall, DNP, order receiver,” she said. “If FNP-BC. The assistant professor someone comes to the program and family nurse practitioner speafter about three to five years’ cialty track coordinator at the UAB experience, they can easily inteSchool of Nursing is an advocate grate into the role of making infor nurse practitioners, despite the dependent clinical decisions that perception that jobs can be difficult D’Ann Somerall, DNP (left) and William Curry, MD review a patient’s chart. are evidence-based.” to find. All coursework for the UAB program “My students are able to negowith the physician as needed, enabling a is online, making it distance accessible, but tiate a wage,” she said. “When I finished clinic to extend hours without the physician it also requires a degree of comfort with school in 1999, there were very few providbeing present. technology. ers hiring nurse practitioners, and most of “The additional oversight required While nurses find the extra degree to the people who got jobs were earning exof the physician with young nurse practibe beneficial, doctors also discover advanactly the same wage they had been making tioners can lead to employment barriers,” tages in having nurse practitioners as part in hospitals. Some were even taking jobs for Somerall said. “When physicians decide to of their practice. less, just to get the experience under their hire a nurse practitioner, they tend to look “We don’t have enough primary care belt. Students now are asking for $85,000 for someone with experience because this physicians now. The demand is increasing, to $115,000 and getting it. necessitates less of the physician’s time.” and the workforce is aging faster than we “I agree that for every opening there “I review charts for quality improveare producing new physicians,” Curry said. are probably 15 to 20 applicants, but the ment,” said Somerall’s collaborating physi“Just from the standpoint of capacity and same thing is happening in nursing overall. cian, William Curry, MD, MACP. “When being able to manage the patients, having There may be a glut in Birmingham, but there is a question or an interesting case to nurse practitioners is advantageous. there are many jobs for nurse practitioners discuss, D’Ann and I will talk about those. “Nurse practitioners also bring a in underserved areas.” But for most of the routine care, the nurse different set of skills. I tend to be more Alabama requires that nurse practitiopractitioner sees the patient, takes care of grounded in basic science, pathophysiolners work with a collaborating physician. him, makes a plan, and decides when to ogy, mechanisms of disease and pharmaFor the first two years, they must spend bring the patient back without my having cology. Nurse practitioners have some of at least 10 percent of their time with the to be involved at that moment.” that, but are more oriented toward behavphysician. Eventually they can collaborate Nurses desiring to be a nurse practiBy Marti Webb Slay

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ioral problems, counseling, patient engagement and care management. So we have a slightly different set of skills that complement one another.” Somerall and Curry agree that typically, patients spend more time with the nurse practitioner discussing barriers to care and other personal and behavioral issues including diet and exercise. “Patients often tell nurses things they don’t want to ‘bother’ physicians with,” Somerall said. Curry, who is professor of the Division of General Internal Medicine and associate dean for primary care and rural health at the University of Alabama School of Medicine, says his clinic is moving toward a model that will significantly expand the number of nurse practitioners over the next three or four years. He also sees their number increasing in specialties such as cardiology, intensive care units and emergency departments. He suggests that Alabama may be a little slower than other states in embracing the concept of nurse practitioners. “Our law was not well-defined for a number of years, so we had a generation of physicians who were not familiar with how to make the best of collaboration with nurse practitioners. That’s becoming more standardized and physicians are becoming more comfortable with that style of practice,” he said. For nurses seeking to become nurse practitioners, an increasing interest in making them part of the medical team is good news.

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16 • OCTOBER 2017

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Patient Access to Medical Records - A Refresher by

Kelli Fleming

Healthcare providers are constantly receiving requests for copies of patient medical records. Some requests come by way of the patient exercising his/her right to access his/her medical records, some come by way of patient authorization, and some come by way of another method (e.g., request from another treating provider). The Office of Civil Rights (“OCR”), the federal entity overseeing HIPAA compliance, has recently made patient requests for records a priority in terms of enforcement and guidance. For example, OCR published extensive guidance on a patient’s right to access records, the form and format for responding to such requests, and the fees that can be charged for a response to such request. Thus, now is a good time for a refresher on a patient’s right to access records and a healthcare provider’s obligations in responding.

Form of Request: Under HIPAA, a patient has the right to access his/her medical information--with a few exceptions, (e.g., psychotherapy notes). A patient wanting to exercise his/her right to access their medical records can do so in two ways: (1) the patient can request that copies of the records be sent to the patient directly (or inspected by the patient); or (2) the patient can request in writing that his/ her records be sent to a designated thirdparty (this designation must be signed by the patient and clearly identify the designated person and where to send the records). Timeframe For Response: When the patient exercises his/her right to copy medical records, the records must be provided to the patient within 30 days of the request. If the request is denied, the denial notice must be sent within the 30day period. If the 30-day period cannot be achieved, the patient must be notified of the delay within the initial 30-day period and the provider will be allowed an additional 30 days in which to respond to the request. Only one 30-day extension is permitted. Form of Response: The patient must be provided with access in the form or format requested, if the information is readily producible in such form and format. If not, the patient must be provided the information in a readable hard copy form or other form agreed to by the parties. If the request is for an electronic copy of the information, the patient must be provided the information in the electronic form and format requested if it is readily producible in such electronic form and format, and if not, in an electronic format agreed to by the parties. Paper copies may only be provided if the patient declines to accept any of the electronic formats readily producible. Fees for Response: When the patient exercises his/her right

to copy medical records, the fees charged must be a reasonable, cost-based fee consistent with both state and federal law. Because the state law provisions and the HIPAA provisions differ, this is where we see many providers in Alabama fall short in terms of compliance. Many providers are complying with the state law provisions, which allow a flat search fee and a per page fee, but are failing to comply with the more stringent federal law provisions, which do not allow a search fee and only allow a per page fee under certain circumstances. The fee that may be charged to patients under HIPAA for copies of medical records may only include the following: • Labor costs for copying the records to only include the labor associated with creating and delivering the copy in the form and format requested once the information has been identified, retrieved, and compiled; • Postage if records are requested to be mailed; and • Supply costs, including costs for electronic media if the patient requests that an electronic copy be included on portable media. • Alternatively, a flat fee for an electronic copy of the records may be charged, as long as the flat fee does not exceed $6.50, including labor, supplies, and postage. Under either scenario, the fee charged may not include costs associated with reviewing the request, verifying the information, documenting the request, searching for and retrieving the records, reviewing the records, compiling the response, maintaining systems, or recouping capital for data access/storage/or infrastructure. Importantly, HIPAA does not allow you to charge a flat search fee. With regard to the labor costs that can be charged under HIPAA, there are two ways in which the costs can be calculated: • Actual costs incurred to fulfill the request. An example of the actual costs would be the time it takes for an employee to copy the records multiplied by the employee’s reasonable hourly rate. • Average costs based on the average labor associated with a specific type of request. This can be calculated as a per page fee only if the information is maintained in paper form and the request is for a paper or scanned copy of the records. Under HIPAA, per page average costs are not allowed for paper or electronic copies of information maintained electronically, even though such is allowed under state law. Thus, the next time you receive a request for medical records, review the request carefully to determine the type of request being made, and if it is a request by a patient to access records, make sure that any response complies with the guidelines stated above.

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OCTOBER 2017 • 17


GRAND ROUNDS

St. Vincent’s East Family Medicine Residency Program Chosen for Patient Safety Collaborative

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The St. Vincent’s East Family Medicine Residency Program has been selected as a Pathway Leader by the Accreditation Council for Graduate Medical Education (ACGME). As one of nine chosen nationwide, the St. Vincent’s East Family Medicine Residency Program will form a Patient Safety Collaborative focused on creating and testing a framework for residents and fellows to engage with their learning environments in promoting a culture of safety. The Patient Safety Collaborative is the first in a series of collaboratives that will focus on optimizing the engagement of residents and fellows among the six focus areas of the ACGME’s Clinical Learning Environment Review (CLER) program: patient safety, health care quality, care transitions, supervision, fatigue management (well-being), and professionalism.

Blue Cross and Blue Shield of Alabama was recently honored for having one of the best workforce health and well-being programs in the nation by the National Business Group on Health, a non-profit association of 425 large U.S. employers. Blue Cross is among 48 U.S. employers that received the 2017 Best Employers for Healthy Lifestyles® award. Blue Cross received a Gold Award for outstanding well-being strategy to improve workforce health initiatives with demonstrated results. This marks the eighth year Blue Cross has received a Best Employers for Healthy Lifestyles® award. Blue Cross’ BeWell Program promotes a workforce culture that encourages individuals to make healthy lifestyle choices. Participation and outcome data indicate many employees continue to make lifestyle changes as a result of these wellness initiatives.

Girouard Named to Top Midmarket IT Executives List Mike Girouard, Executive Vice President of Enterprise Sales with Teklinks, has been named to The Channel Company’s Top Midmarket IT Executives list. “Mike Girouard is a strategic leader with more than 22 years of experience in IT,” said TekLinks’ Mike CEO Jim Akerhielm. “His Girouard level of commitment to his team stands out, and we couldn’t be prouder to have him at the helm of our Enterprise Sales department.” Girouard joined TekLinks in 2007, leading a sales team that produced revenue growth from $19.3M in 2006 to $135M in 2016.

BBH Primary Care Opens at Shelby Baptist Brookwood Baptist Health Primary Care Network has opened a new Internal Medicine practice in the Physician’s Center at Shelby Baptist Medical Center. John Looney, MD is the provider in the practice. Looney is board-certified in Internal Medicine and has over 26 years of experience in Emergency Medicine and Primary Care. He earned his undergraduate degree at UAB, and went on to receive his medical Looney, degree at the University of JohnMD South Alabama College of Medicine. He performed his residency at Carraway Methodist Medical Center. Looney joins the Brookwood Baptist Health Primary Care Network from Red Bay Hospital in Red Bay, Alabama where he has been an emergency room hospitalist since 1991.

New Physicians Join Southeast Gastro Wiley Truss, MD, MPH practices as Hospitalist at the Brookwood location. Truss obtained his undergraduate degree from Birmingham-Southern College. He then went on to earn his Masters in Public Health at UAB and his medical degree from the UAB School of Medicine. He also completed his internal medicine internship and residency training as well as his gastroenterol- Wiley Truss, MD, MPH ogy fellowship at UAB. Truss is board certified in Internal Medicine and Gastroenterology (pending). His clinical interests include gastrointestinal malignancies and GI bleeding. He has particular Molly McVey, MD research interests in small bowel bleeding as well as GI bleeding in high- risk populations, for which he has contributed several publications. Truss is a member of the American College of Gastroenterology, American Gastroenterological Association, and the American Society of Gastrointestinal Endoscopy. Molly McVey, MD practices at the Grandview, Gardendale and Prattville locations. McVey obtained her undergraduate and medical degree from the University of Mississippi. She then completed her internship, residency and chief residency in Internal Medicine at the Medical University of South Carolina (MUSC). She remained at MUSC to complete her fellowship in gastroenterology. McVey is board certified in Internal Medicine and in Gastroenterology (pending). Her interests include inflammatory bowel disease, liver disease, esophageal disorders and colorectal cancer. She is a member of the American College of Gastroenterology, American Gastroenterological Association and American Society of Gastrointestinal Endoscopy.


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OCTOBER 2017 • 19


GRAND ROUNDS

Subscribe to Online Recipeideas Free! Get the current edition of Recipeideas delivered to your desktop. FREE! Simply go to the website and find Subscribe Here on the right sidebar.

Mason Promoted to CEO of Grandview Medical Center

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Drew Mason has been promoted to Chief Executive Officer of Grandview Medical Center. He succeeds Keith Granger who was promoted to the position of CHSPSC, LLC Regional President and Market CEO of Alabama. Mason was named Drew Mason Chief Operating Officer of Grandview in 2015, having first come to Birmingham as Assistant Chief Executive Officer of Trinity Medical Center in 2014. Since Grandview’s opening in the fall of 2015, Mason has been instrumental in Grandview’s growth. Under his leadership the medical center has added over 1,000 new employees and 300 new physicians. Mason previously served in adminis-

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trative roles at Chestnut Hill Health System in Philadelphia, Pennsylvania, and Gadsden Regional Medical Center in Alabama. Recently, Mason was appointed by the Governor of Alabama to serve on the Statewide Health Coordinating Council. Mason received his bachelor’s degree in business administration from Villanova University. He received his master’s degree in business administration with specialization in healthcare from Owen Graduate School of Management at Vanderbilt University.

Bouknight and McLean Join Alabama Fertility Specialists Janet McLaren Bouknight, MD and Mamie McLean, MD have joined Michael Steinkampf, MD and Beth Malizia, MD at Alabama Fertility Specialists. Bouknight earned her medical degree from Harvard Medical School and completed her residency in Obstetrics and Gynecology at the Brigham and Women’s and Massachusetts General Hospital combined training program. She completed her fellowship and a Master of Science degree in Clinical Epidemiology at the University of Pennsylvania. She previously directed the IVF program at UAB. McLean attended the University of Virginia for her undergraduate education and the Medical College of Georgia for medical school. She completed her residency training in Obstetrics and Gynecology at the University of North Carolina at Chapel Hill. She completed her fellowship training in Reproductive Endocrinology and Infertility at UAB and stayed on as faculty for the past three years where she directed the oocyte donor program.

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20 • OCTOBER 2017

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Beginning Jan. 1, 2018, all Alabama Controlled Substances Certificate holders will be required to obtain two AMA PRA Category 1 CreditTM or equivalent (Cat. 1-A, prescribed hours, cognates) every two years in the areas of: • Controlled substance prescribing practices, • Recognizing signs of the abuse or misuse of controlled substances, or • Controlled substance prescribing for chronic pain management.


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GRAND ROUNDS

Champion Sports Medicine Names Andrews National Director Select Medical, the parent company of Champion Sports Medicine has named James Andrews, MD its new national medical director within its Outpatient Division. As part of the Select Medical Outpatient Division family of brands, Champion James will partner with Andrews Andrews, MD on a vast array of sports injury prevention, education and safety protocols for

athletes. Andrews currently serves as a team doctor for the Washington Redskins and Auburn University. He has mentored over 250 orthopaedic/sports medicine fellows and more than 45 primary care sports medicine fellows. He has also made presentations on every continent and has authored numerous scientific articles and books. As Select Medical’s medical director, Andrews will work with Champion Sports Medicine and other brands within the Outpatient Division to provide sports medicine expertise and sup-

port to help ensure patients are getting cutting-edge programs. He will develop educational materials, make appearances via virtual technology on topics in sports medicine and assist in the development of orthopaedic diagnosis rehabilitation protocols.

Russell Named CEO of HealthSouth Shelby County Rehab Hospital Robert Russell has been named chief executive officer of HealthSouth’s future inpatient rehabilitation hospital located in Pelham.

Russell, with a background in respiratory therapy, brings over 20 years of operational leadership experience to his new role. He earned a master’s degree in business admin- Robert Russell istration from the University of Georgia in addition to a bachelor’s degree in respiratory therapy from Biosystems Institute. The future 34-bed inpatient rehabilitation hospital will provide rehabilitation services and medical management, including dialysis, for patients recovering from stroke and other neurological disorders, hip fractures, brain injury, spinal cord injury, amputation, complex orthopedic conditions. The hospital, HealthSouth’s seventh hospital location in Alabama, will open to patients in spring 2018.

EDITOR & PUBLISHER Steve Spencer

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GRAND ROUNDS

Arthur Freeman, III, MD is Honored Arthur Freeman, III, MD has recently received several awards for his professional service. The International Association of HealthCare Professionals has recognized him as a Leading Physician of the World and top adult psychiatrist in Birmingham. Arthur The Who’s Who organi- Freeman, III, MD zation has named him top psychiatrist in the state and an outstanding physician in America. Freeman graduated from Harvard and received his medical degree from

Vanderbilt University School of Medicine. He completed a fellowship in biochemistry at the Karolinska Institute in Stockholm and a fellowship in clinical hepatology at the University of London. He interned in internal medicine at the University of Florida and did his psychiatry residency training at Johns Hopkins Hospital where he was selected Chief Resident. During his 50 years of practice, Freeman served as Vice-Chair of psychiatry at UAB, Chair of psychiatry and later Dean of the LSU School of Medicine-Shreveport. He was also Chair of psychiatry at the University of Tennessee Health Sciences Center in Memphis.

Neurosurgical Associates Performs Alabama’s First Robotic Assisted Spinal Fusion Using Intraoperative Imaging The state’s first spine procedure using the Mazor Robotic System in conjunction with intraoperative imaging was recently performed by neurosurgeons with Neurosurgical Associates, PC at St. Vincent’s Birmingham. Few facilities in the world have this capability which is extremely helpful in lumbar spine procedures. Neurosurgeons at St. Vincent’s Birmingham are the first in Alabama to adopt the Mazor technology and have completed multiple procedures using this advanced technology. The Mazor system allows surgeons to preplan a custom procedure for each patient using a CT, or intraoperative scan exclusive to St. Vincent’s called Scan and Plan. The surgeon is then able to plan the procedure and implant trajectories with extreme precision in The Mazor Robot and the O-Arm which provides Mazor’s advanced software. The robot the intraoperative piece of the technologies. then assists the surgeon’s plan during the procedure with unparalleled accuracy allowing for much of the surgery to be achieved percutaneously. This percutaneous approach limits the amount of muscle retraction needed to achieve adequate access during the procedure. Surgeons have reported less blood loss, faster recovery time, less exposure to radiation, and overall improvement in the procedure when compared to traditional open procedures.

Nephrology Clinic Opens at UAB Medicine-Leeds The UAB Division of Nephrology, part of the School of Medicine, has opened a new weekly patient clinic each Friday at UAB Medicine-Leeds. UAB nephrology physicians Gaurav Jain, MD, and Vinay Narasimha Krishna, MD, will be on-site each Friday to provide care. UAB Medicine-Leeds opened in October 2015, offering with it a glimpse of the future of outpatient medicine — where patients have one central location to effectively receive primary and specialty care. UAB Nephrology physicians at the clinic will provide timely consultations to patients with complex renal issues, including acute kidney injury, chronic kidney disease, uncontrolled hypertension, electrolyte disorders and glomerular disease. Gaurav Jain, MD and Vinay Narasimha Krishna, MD will be at the UAB Other nephrology services offered at UAB Medicine-Leeds clinic each Friday. Medicine-Leeds include: • On-site laboratory services • On-site imaging, including renal ultrasound, CT scans and MRI • Evaluation and management of a wide spectrum of renal-related diseases Physicians can refer a patient by calling the UAB Medicine Access center at 205934-3411. Urgent consults can be made by calling 205-934-2646. UAB nephrology physicians aim to accommodate all consults within a week and provide communication back to the referring physician’s office based on the evaluation of the patient. UAB Nephrology is recognized as one of the top 15 nephrology divisions in the country by U.S. News & World Report, and it is an NIDDK-funded UAB-UCSD O’Brien Core Center, one of seven such centers in the nation.

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