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Lynn Batten, MD Alias Dr. Fun If you are wandering the halls of the University of South Alabama’s School of Medicine, hear music and someone counting to the beat, it’s probably Dr. Fun and her colleagues. ... 3

HEALTHCARE IT

Technology Boosts Patient Engagement and Savings By Jane ehrharDt

“We have 17 providers, but only four phone operators, all because of our patient portal,” says Clay Barnett, director of internal programs at Birmingham Internal Medicine Associates (BIMA). This tech allowed them to add four physicians in the last two years without the expense of hiring any additional phone support. Patient portals were forced on medical practices about five years ago as part of the healthcare transition from paper charts to electronic medical records (EMR). The portals serve as secure, direct email between patients and their doctors’ offices. Unlike standard email, the portal’s security allows physicians to freely discuss a patient’s diagnosis, answer questions, send lab results, and—if their office uses a web-based EMR—lets the doctor safely access the portal from any device anywhere. Initially, patients and practices alike shunned patient portals. The tech seemed to be a cold, and confusing way to (CONTINUED ON PAGE 6)

Painful Total Knee Replacement Why it’s Hard for Doctors to Find the Cause It’s an exciting time in orthopaedic surgery and total joint replacement surgery is considered one of the most successful and rewarding procedures performed. Although total knee replacement (TKR) is an effective operation for endstage arthritis of the knee, studies have shown ... 4

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BEHAVIORAL HEALTH

Why Are Depression And Suicide Rates Higher In Alabama? By Laura freeman

Celebrity suicides by people who seemed to have everything have reminded us that depression and suicidal impulses can be as lethal as any physical disease. “The suicide rate in the US has risen by 22 percent since 2000. While the prevalence of depression overall remains steady, there are great geographic differences. At 12 percent, the depression rate in Alabama is double the national average. Suicide rates are also significantly higher,” UAB professor of psyDeLisa West, PhD chiatry Richard Shelton, MD said. The dramatic increase in suicides over the past two decades

goes well beyond those who were known for fame and fortune. Recent news has brought stories about epidemics of suicide among New York taxi drivers who can’t cover their expenses; farmers and ranchers who have lost everything; unemployed factory workers; and soldiers returned from war. The new faces of suicide include far more women than in the past, and more people in their middle years who could no longer see other options to escape their pain. It’s happening everywhere in the US, but why is it happening here more often? (CONTINUED ON PAGE 16)

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HEALTHCARE SPOTLIGHT

Lynn Batten, MD Alias Dr. Fun By Lori Quiller, Communications Director Medical Association of the State of Alabama

If you are wandering the halls of the University of South Alabama’s School of Medicine, hear music and someone counting to the beat, it’s probably Dr. Fun and her colleagues. Dr. Fun, also known as Associate Professor of Pediatrics Lynn Batten, MD, earned the nickname about a year ago, but what may seem like fun and games is a mission from the heart to bring joy and better health to her patients. “We have so much fun doing this, but I will never forget how it got started,” Batten said. “Dr. Fun’s Dance Party USA may have started out as a video for just one patient, but it’s so much bigger and has touched so many more lives. I feel like I’m on a mission from God.” It all began with one patient. A fiveyear-old girl named Synclaire had captured the heart of Batten and her staff. Synclaire had only one ventricle and had already experienced three surgeries and pretty much every complication possible in her short life by the time Batten sent her to UAB to be wait-listed for a heart transplant. 11 weeks later, Synclaire was still waiting. The days grew long and the nights longer. “We would check in with her mother every now and then. One day, her mother said Synclaire really needed a smile, so I asked what her daughter’s favorite song was,” Batten said. Armed with Bruno Mars’ “24K Magic” and her son’s talents at filming, Batten and her staff choreographed their first dance video. It was only 90 seconds long, but all the staff who had worked with little Synclaire had a chance

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Lynn Batten, MD

to dance for her. As Batten’s son was editing the video to post online, the physicians at UAB called. Synclaire wasn’t doing well, but word spread about the video the USA team was putting together for her. Batten’s wanted to have the video posted that evening. At that point, her greatest fear was that Synclaire would pass away before seeing it. “I worried that she might die before we can get this online for her. That a horrible feeling. But, that made me realize there are so many other kids out there who might like to see their doctors dancing

around and having a little fun. We could do videos for kids in the hospital. All these thoughts just started pouring out about what we could do next,” Batten said. Batten emailed Synclaire’s mother the link to the video that night. The UAB staff called her the next morning to let her know Synclaire had coded. She was on life support for about a week before she passed away. “Her mother told me later that Synclaire did see it and it made her heart shine,” Batten said. After that first video, Dr. Fun’s Dance Party USA was officially born with an expanded mission to not only help her young patients by lifting their spirits during hospital stays, but to also motivate them to exercise to stay healthy. The staff who participate in the videos have had so much fun that they continue dancing on their

breaks. “We’re going to keep this going.” Batten said. “There are other kids who might enjoy watching their physicians and medical staff dance around for a couple of minutes. Plus it’s worth it if it brings our patients just a little bit of joy. We want the kids to make requests so we can keep going forward. One of our patients requested ‘Shake It Off’ by Taylor Swift because she wanted something more upbeat to have on her phone so she could stay on her treadmill a little longer each day. That was a lesson for me, too. So now when I tell patients they have to exercise more, I ask what their favorite song is. Two patients have asked to be in the videos with us which makes it even more special.” If you would like to view Batten’s video, go to her YouTube channel at Dr. Fun’s Dance Party USA.

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Painful Total Knee Replacement Why it’s Hard for Doctors to Find the Cause By Herrick J. Siegel, MD

many countries around the world. Patient education is of utmost importance, and most joint centers have It’s an exciting time moved toward a pre-operin orthopaedic surgery ative educational program. and total joint replaceWhile there are many ment surgery is considered potential causes of persisone of the most successful tent postoperative joint and rewarding procedures pain within the first two performed. Although total years following replaceknee replacement (TKR) ment, the most common is an effective operation for are instability, infection end-stage arthritis of the and arthrofibrosis (stiffknee, studies have shown ness). Arthrofibrosis has that nearly 20 percent of many causes and is often a patients have persistent product of dense scar tissue symptoms after this proceformation likely caused by dure. The work-up of painimmobility and increased ful TKR includes clinical ligamentous and tendinous evaluation, radiographic stress. imaging, and in some cases Interestingly, although microbiological analysis. xrays are a highly emphaHowever, it is not unsized part of the work-up, common that there is no they will actually show limobvious underlying cause ited information regarding of the pain. In such a situaany of the three common tion, a plan of management causes of pain and failure. should be made and agreed The clinical exam and upon with the patient. On history are crucial to the some occasions it is impor- Herrick J. Siegel, MD reviews imaging of total knee replacement patient with his orthopaedic evaluation. You can send tant to involve a pain spe- surgery residents. me a patient’s x-rays that cialist early, specifically for show perfect component the prevention of a chronic position and alignment and yet the patient tained use. pain syndrome. While narcotic medicines may be miserable, while another patient Currently, there is a movement tomay be used for short-term pain relief, the with mal-positioned implants does do not ward opiate-free joint replacement surside effects and addictive nature makes experience any pain at all. I need to see gery, which has already been instituted in this intervention a poor choice for sus-

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them, hear their story and examine their joint. Instability in the early post-operative period may be due to uncorrected pre-operative ligamentous imbalance, improper intra-operative ligamentous balancing, mismatch of the flexion-extension gap, surgeon injury to the ligaments during surgery or pre-existing neuromuscular pathology. However, late instability can occur secondary to mal-alignment leading to progressive stretching of the ligaments, wear of polyethylene, loosening of the component and collapse. Patients can go undiagnosed for years. Unless you have examined thousands of knees, some ligamentous instability can be very difficult to detect. An often unrecognized problem with pain total knee replacements is impingement syndromes. A few examples of this include; popliteus tendon impingement, patella clunk and fabellar impingement. While most of these may be treated with anti-inflammatories and conservative treatment, if non-operative treatment fails, surgery may be warranted. Metal sensitivity, also known as allergy, has gained a lot of interest over the past decade. Attention was first noticed in early failure of metal on metal articulations in the hip. Unfortunately, a universally accepted test for predicting sensitivity with a high degree of specificity has not been developed. Metal sensitivity can occur around any metal implant containing cobalt, chromium and nickel; however it appears that some patients are more vulnerable to this than others. Some implant companies have begun either using alternative metals or coatings. All materials will eventually wear and fail. Synthetic materials have no ability to repair themselves from damage. Other potential sensitivities include methymethacrylate bone cement, which also does not have an accepted screening to test to identify ask risk patients. Patients with high levels of cobalt and chromium in their blood have expressed concerns about heart, kidney and neurologic problems. In these circumstances, I have referred them to specialists in these areas to exclude other etiologies. As the US moves toward opiate free, outpatient joint replacement, long acting local analgesics and peripheral nerve blocks are becoming more and more popular. Our surgical instrumentation continues to improve and our understanding of how to prevent future problems continues to advance. Pain management has become an essential part of the team approach to joint replacement. Patients experiencing postoperative problems following knee replacement are encouraged to contact a specialist. Herrick J. Siegel, MD is an Associate Professor of Orthopaedic Surgeon at UAB Medical Center.


The Stark Law: A Reminder and Request By

Chris thomPson

If you ask a healthcare provider to state the healthcare laws and regulations that give them a headache, you are likely to receive a range of responses. The compliance burden in healthcare does not originate from a single law or set of laws, but from diverse sources such as the AntiKickback Statute, MACRA, HIPAA (and the HITECH ACT), EMTALA, the AntiMarkup Rule, the Civil Monetary Penalties Law, and a number of other federal laws and regulations. Then, of course, there are the state laws, licensing requirements, coding and billing guidelines, and the rules of state boards. The list could go on, and branches out in various directions based on the type of provider involved. Many (and perhaps most) of these laws may be necessary evils: they do attempt to serve important functions in a complicated landscape. Yet the burden they impose is undeniable, and one of the most worrisome for many physicians and hospitals is the Physician Self-Referral Statute, more commonly known as the Stark Law (the “Stark Law”). The Stark Law restricts physicians from making referrals for certain designated health services (“DHS”) to an entity with which he or she has a financial relationship, which includes ownership, investment, or compensation relationships, unless the physician qualifies for one or

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more exceptions. The DHS at issue cover a wide range of services, including, but not limited to, clinical laboratory services, therapy services, certain imaging services (such as MRIs, CAT scans, and ultrasound services), durable medical equipment and supplies, and outpatient prescription drugs. In addition to its severe penalties (e.g., liability for all of the payments received under the impermissible relationship; potential False Claims Act or Civil Monetary Penalties consequences; the possibility of exclusion from the Medicare program), what makes the Stark Law so threatening is that it is a strict liability statute. The government does not need to prove an element of intent to establish a Stark Law violation, and unlike the safe harbors of the Anti-Kickback Statute, the Stark Law exceptions must be completely satisfied: there is no mercy extended for practices only slightly outside of an applicable Stark Law exception. With this background established, it is now time to consider the recent request for information (“RFI”) issued by the Centers for Medicare & Medicaid Services (“CMS”) on June 20, 2018. This RFI, titled “CMS seeks public input on reducing the regulatory burdens of the Stark Law,” asks for public comment and recommendations on ways to address undue impacts and burdens imposed by the Stark Law on healthcare providers. As part of its attempt to engage and hear from the provider community and to foster a more value-based healthcare system (what it calls its “Regulatory Sprint to Coordinated Care”), CMS has posed a series of twenty invitations for comment in this RFI covering certain aspects of the Stark Law. These invitations range from such broad comments as “Please share your thoughts on the compliance costs for regulated entities,” to more detailed queries regarding necessary exceptions for providers participating in alternative payment models and the utility of current exceptions like

Stark Law is a significant, formidable, and indeed ever-changing regulatory pillar in the healthcare landscape. Regardless of whether a particular provider chooses to offer its input to CMS as to the Stark Law’s regulatory burden, there is no time like the present for a physician practice, hospital, or other provider who engages physicians in the delivery of DHS to review its compliance with the Stark Law. This is especially the case with regard to changes to or clarifications of the law over the past few years. Particularly for large physician practices, the consequences of failing to do so can be severe, since noncompliance with regard to one or a few physicians can spell costs for the entire practice. But no physician can afford to avoid the requirements of this strict liability law: ignorance is even less of an excuse here than it is elsewhere in the compliance arena.

the personal services exception. The focus of this particular RFI is to find means to lessen the obstacles that the Stark Law creates for improving care coordination and collaboration among providers. Better coordination of healthcare delivery has been and remains an important goal of many health reform efforts, yet by its nature it involves a degree of referral between providers, many of whom are subject to the Stark Law. In the words of CMS’ current administrator, the current form of the Stark Law “may prohibit some relationships that are designed to enhance care coordination, improve quality, and reduce waste.” Providers and other observers have been making similar claims for some time; the government is at least signaling that it will give these arguments a fair hearing. If a health care provider wishes to offer his, her, or its input—or simply read in more detail CMS’ perspective on these issues— the RFI can be found on the online federal register (search for 83 FR 29524). This RFI does more than represent a request by the government for comments. It also offers a reminder that the

Chris Thompson is an attorney practicing within the Health Care Industry Group of Burr & Forman LLP.

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Technology Boosts, continued from page 1

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interact about medical situations. But with the public gaining familiarity with electronic, screen-oriented customer service, patient portals looked more appealing. “Once patients realized doctors do respond quickly through the portal, they were receptive,” Barnett says. Like with email, a doctor’s response is rarely immediate. But because doctors can sign in to the portal from anywhere at any time, patients do see responses on their computers or phones appear outside the expected office hours. Kiosks allow patients to bypass the check-in counter for many types of “Physicians no longer have appointments, including submitting copays. to come into the office to send a reply to a patient’s query,” Barnett says. check-in kiosks welcoming them as they On Sundays—the only day the pracenter the waiting room. “One in three patice is closed—an operator accesses the tients walk in during the day needing to portal to handle an array of messages, only sign in to say ‘I’m here’,” Barnett including those that says. The kiosks fill that role. might require an apKiosks serve an even more practical pointment, such as a purpose at Andrews Sports Medicine & refill request that first Orthopedic Center. “Standing up and sitrequires a doctor visit. ting down for orthopedic patients is often In those cases, the difficult,” says CEO Lisa Warren. “To operator sets up apbring a clipboard up and down to the front pointments and alerts desk is a mess for these patients.” the patient to the sugAt their check-in kiosks, patients enter gested appointment their date of birth, and they scan in their inClay Barnett time, all through the surance card and their driver’s license. The portal. “We can be proactive with the porkiosk then verifies their insurance and, using tal,” Barnett says. “We can make patients their finger on the screen, patients can sign feel like we are always here for them, as forms, if needed. “They can even pay their opposed to 10 years ago, when they had to copay using a credit card,” Warren says. call us after 9:00 a.m. and before 5:00 p.m. “It’s such a better experience for a lot of our on weekdays.” patients who struggle with their mobility.” With the use of the tech over the last “We’re saving a whole lot of effort 18 months, phone calls have dropped by and data entry with these devices,” Barnett 62 percent—from over 800 to around 300 says. “We should need double our front per day. “That, in large part, is because desk staff. But because of the tech, we now the portal cuts down on repeat calls,” Baronly have to handle patients who are not nett says. Patients who left voicemails in tech savvy.” the past would call back until they heard For those reluctant tech users, front from a doctor. “With the portal, we can desk personnel take them into a private respond that we heard you and the doctor area and go through the tablet questions, will get back to you.” continuously showing them the screen. Barnett credits their physicians with “After we start, they may say, ‘If that’s all it driving patients to use the portal. “75 peris, I can do that’,” Barnett says, admitting cent of our large Medicare population now that some patients prefer staff to handle use it. It’s their primary method of comthe tablet for them every time. “But our munication with us,” he says. patients are our guests, and we have time In the waiting room, technology to devote to being more personable becontinues to boost efficiency and savings. cause of the time saved with technology.” BIMA utilizes tablets to check in patients The kiosks are only a month old at and gather new patient information. The BIMA. Initially only three percent of pa18 bright orange tablets are hard to mistients eligible to use the tech bothered, but place or walk out with, and they connect that number more than tripled over the directly to the EMR. “No more paper next three weeks. “We don’t want to take forms to scan in. It all digitally integrates away the personal side or have patients feel into our EMR immediately,” Barnett says. like they’re part of an assembly line. Or, Currently 60 percent of the estimated on the other hand, we don’t want to slow 1,000 patients seen each week use the down folks who want to get in, see a doctablet. Patients can also bypass the tablets tor and get out,” Barnett says. “We try to by completing any pre-visit forms online meet patients where they are comfortable, through the patient portal. Those patients offering different styles of communication become eligible to use any of the three for what they see as helpful.”


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Stolen PHI Records Have a New Market By Jane Ehrhardt

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The days of stealing personal information for credit cards no longer holds the greatest appeal for hackers of medical facilities. “Credit card companies stand behind their clients,� says Russ Dorsey, manager of information services at Kassouf & Co. Purchases are rapidly questioned, cards are voided, and Russ Dorsey card holders rarely get dinged. Hackers now find value in piecing together data on people from a multitude of sources — social media, credit card activity, patient records — to build a fairly accurate and often invasive picture of that person. The newest market for these stolen insights has become countries, such as Taiwan and China. “These nations are looking for leverage through patient records,� Dorsey says. “I know this sounds farfetched, but it is happening. “These governments are looking for information on industry secrets and processes. So how do they steal that material? They find someone with a sick family member or credit problems, knowing that they may be able to compromise that person with cash. That’s why patient information is so important.� On the black market, stolen credit cards sell for $10, but protected health information (PHI) goes for $1,500 per record, Dorsey says. “This is why hackers are willing to go to so much trouble for PHIs. “Years ago, when they were writing these HIPAA laws, we wondered why all this was so important, and now it’s coming to fruition. We’re understanding how much detail is in our healthcare records. It’s almost a matter of national interest now.� Stolen patient records can also reveal opportunities for fraud. For instance, a CEO or financial officer out on medical leave can open the way for hackers to imitate that person in a wire transfer request. “They know that that person is a soft target to exploit because their company probably can’t reach them,� Dorsey says. With the advancement of office and healthcare technology, access points for data breaches have multiplied. For instance, multifunction copiers typically have access to the facility’s network. “Many of these have hard drives and store that information inside the copier,� says Robert Robert Morris

Morris, vice president of healthcare and security solutions at Teklinks. “So when that machine goes off-lease, that information can be rolled right out the door. That’s a breach.� Besides office equipment, medical devices also pose a large vulnerability with their newer connections requiring internet connections. Researchers at Trend Micro analyzed these medical devices and systems and found that patient data gets exposed by hospitals and practices configuring their network infrastructure incorrectly. Work-arounds to connect computer systems, applications, or software to work with each other are common and dangerous. Staff may email lab results to a referring physician because their two EMRs differ, for example, which ignores HIPAA safeguards. Web-based emails, such as Google and Yahoo, are equally unsecure. “You’ve got to know who accessed the data and when,� Morris says. “With email, even with a read receipt, you don’t know it got to the person who it was intended for.� All certified EMRs, meaning they meet Meaningful Use (MU) requirements, have secure messaging modules that are built to talk to any other certified EMR, no matter the maker. “Many places have it, but they’re not using it,� Morris says, adding that it could be as simple as a tab on the EMR screen. Like patient portals, these pathways are secure tunnels for passing and discussing patient information, and include login data to verify who received it and when. The function, warns Morris, may come with an additional fee. “But according to MU, you should have it. If you don’t know if you have it, contact your vendor,� he says. For those devices and software without secure messaging, Morris says to invest in an interface. This builds the secure pathway for data to flow between two systems or software, such as a lab and a clinic. The customization and ongoing support may run up to $5,000. “But the alternative could be fines for a breach, and fines are just staggering,� Morris says. “Lost patient records can cost millions.� In June, a Texas clinic reported two thumb drives stolen from a home, along with a laptop. The drives contained a total of 18,500 patient records. The Office of Civil Rights, which audits and fines for healthcare breaches, set a $3.4 million fine. The Department of Health and Human Services report that one-third of all breaches are caused by business associates and third-party vendors. “A provider should not release PHI to anyone, other than patients themselves, without a signed Business Agreement,� Morris says.


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Another layer of data security regulations has been added to healthcare, this time by the state. The 50th state to pass such a law, the Alabama Data Breach Notification Act of 2018 went into effect on June 1 with the intent to protect and alert Alabama residents to breaches of their personal data stored or used by most any company. “Don’t think this doesn’t apply to you just because your healthcare business comes under HIPAA,” says Randy Rupp, CISSP, with ICS Medtech. “You could easily bleed over between the two laws.” Unlike the Health Insurance Portability and Accountability Randy Rupp Act (HIPAA), the state act pertains to any company or person that acquires or uses sensitive personally identifying information (SPII). Also unlike HIPAA, it not only requires these entities to install security measures to protect that data, but also to assess those measures. “Basically you should have plain, clear information on how you address any risks to that data and how you measure whether it is effective,” Rupp says. Though HIPAA does allude to the need for assessing the effectiveness of safeguards in a written risk assessment, it does not require that those measures be spelled out. The new state law also specifically states that external breach risks must be identified, unlike HIPAA. HIPAA only requires internal risks be noted. “It’s more vague, interpretative language,” Rupp says. “Alabama’s law is the same requirements but in more detail than HIPAA.” “It speaks to the same thing,” says Curtis Woods with Integrated Solutions. “The intention was already there in HIPAA/HITECH. Alabama just used the wording. It really doesn’t change what should be done.” Alabama’s law also requires each company to specify Curtis Woods one employee as the cyber-security officer. “Every company must now have someone designated in writing as responsible for coordinating all of the data security measures,” Woods says. This kind of specificity has brought approval from IT experts for the new law. “We love it,” Rupp says. “Rather than just giving you a mandate, they tell you

what to do to meet the mandate.” For instance, Alabama lists the exact pieces of personal data that fall under the auspices of the law, such as an individual’s health insurance policy number or an email address with a password that would permit access to an online account. “The average person can read it and understand it, and it’s only 17 pages long,” Woods says. “It’s also stronger than some other states.” Whereas most states require breaches to be reported in 90 days, Alabama halves that to 45 days. “And if remediation is not occurring in a timely fashion, then the Alabama Attorney General can issue a $5,000 fine per day up to $500,000 per breach,” Woods says. Those fines would be in conjunction to whatever the federal government may levy on a provider for the breach. The fines and the cost of responding to breaches now means every healthcare business also needs cyber-security insurance. “You’ve got to have it. It’s as important to a business as having professional liability insurance,” Woods says. “I just upped ours.” Most practices get $50,000 as a rider to their malpractice insurance, says Rupp. “But there’s no way this is ever going to be enough to cover you in case of a breach.” “Half a million would be a minimum for anybody,” Woods says. “You have all the legal fees, forensics, the audit per HIPAA, filings with authorities, all the mailings to notify those affected, plus to cover your time spent dealing with this. And if you have to pay fines, that half million could get eaten up in a heartbeat.” Cyber-security insurance not only means financial coverage, but can also offer expert guidance when a breach occurs. “Your insurance company should be your first call,” Woods says, to ensure their steps and professionals are followed to ensure coverage. Many cyber insurers have their own lawyers and forensic teams. They may also take care of filing, reporting and notifications, along with satisfying any other states’ breach laws that could apply to patients living outside of Alabama. “You can’t run your business if you have to focus on all that,” Woods says. “There are a lot of steps you have to go through.” The Alabama law also fills a gap left by HIPAA — the handling of third-party vendors. Last year, 56 percent of breaches were caused by a third-party, a seven percent increase from 2016, according to the Ponemon Institute Data Risk in the Third-Party Ecosystem study. “In the last three years, the biggest breaches have been by third-party vendors,” Rupp says. Hackers burrowed their way into Target through the HVAC vendors, who remotely controlled the temper(CONTINUED ON PAGE 19)


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HEALTHCARE IT

Betting on Blockchain

Its Technology, Efficiency Offer Great Promise for Healthcare By CINDY SANDERS

“It’s simple from our point of view,” noted Chris Sloan, a shareholder with Baker Donelson who is chair of the firm’s Emerging Companies group and also leads the Blockchain & Cryptocurrency team. “We believe blockchain is going to become a very widespread and widely Chris Sloan adopted technology across almost all industries. It makes sense for us to get on board early to be able to advise our clients on it.”

Blockchain has become a hot healthcare buzzword over the last several years. One key reason so many in the healthcare industry are working to unlock the technology’s potential is the promise it holds to revolutionize the field by creating a safer, more cost-efficient data sharing system with both clinical and back office application. Still in its infancy, there are numerous hurdles to clear to fully deploy blockchain throughout healthcare, but a number of companies have already begun utilizing the technology. “Three or four months of ‘blockchain time’ is like a year of regular time … so much is happening so fast,” said Kristen Johns, a partner at Waller in the firm’s Intellectual Property practice group. Considering the regulatory and legal hurdles that come with any transformative Kristen Johns change, it is perhaps not surprising that some of the earliest blockchain experts have come from the legal field.

Blockchain Basics Sloan likened blockchain technology to the Internet in the late 1990s. “You’ve got a disruptive technology that has significant and diverse applications across all industries, and it’s colliding with existing legal and regulatory schemes,” he pointed out. Like the Internet, he anticipates those issues ultimately will be addressed to make way for broad deployment of the technology. “Blockchain works really well anytime you have an intermediary that’s necessary to complete a transaction,” he added of

6:30

the decentralized technology that lends itself to process automation. “The other area where blockchain works very well is where you need to preserve the integrity of the data.” Johns was immediately intrigued by the potential power of blockchain when she was first introduced to the concept a couple of years ago. There was a competition to write a white paper about blockchain for the National Institute of Standards and Technology (NIST) and the Office of the National Coordinator for Health Information Technology (ONC). “I flippantly said, ‘That’s a nobrainer,’ and then sat down and figured out how hard it was,” she said with a laugh. Although Johns didn’t win the competition, she did gain a great deal of insight into the new technology and now leads Waller’s Distributed Ledger/Blockchain practice. Recognizing the concept of blockchain can be difficult to grasp for experts and certainly for providers, Josh Ehrenfeld, Corporate and Tax partner at Burr & Forman Josh Ehrenfeld and a member of the

firm’s Blockchain, Cryptocurrency and Electronic Transactions group, suggested thinking of the technology as a baseline platform with cryptocurrency and various other financial and clinical functions being related applications just as Excel and Word are programs under the Microsoft Office umbrella. “At the end of the day, it’s a databased platform,” he continued. “It allows for a more efficient and locked-in transfer of information. It takes the blocks and locks them up … they’re immutable.” Ehrenfeld added that once information is put into the system, it cannot be changed so if an error is initially made or circumstances shift, a new block must be added to update the original information.

Back Office Functions One of the benefits of having a decentralized permanent record is that it allows everyone to see the same information without having to re-input the data for each user . . . thus minimizing transcription errors and making it nearly impossible to surreptitiously alter data once its entered. However, Sloan pointed out, that doesn’t necessarily mean blockchain will eliminate fraud. “Just like any system, it’s only as (CONTINUED ON PAGE 14)

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Physician Focuses on Osteoporosis Care By Dale Short “Coincidentally, I had recently hired my physician assis tant and was looking for a way to A love of physics influenced get her busy quickly. As an unChris Heck, MD when choosing dertreated medical population, his medical specialty. this was a perfect opportunity “I initially wanted to follow to find a patient population that my father’s footsteps and beneeded care and for whom there come a cardiothoracic surgeon,” was little competition. Heck says. “I grew up seeing pa“My PA and I subsequently tients and their families appreciwent to educational seminars ate his efforts. and became ‘Physician Champi“However, during medical ons’ which means we understand school, I realized that was not the problem, believe in the treatthe career path for me. Having ment, and educate other health been intrigued by physics in colcare providers to provide treatlege, orthopaedics attracted me ment or refer to us for treatment.  as it utilized the effect of physics “An astonishing statistic is to mend the body.” that each year more than 34,000 After a 10 year stint as a hip fractures occur (more than 90 surgeon at Southern Orthopaea day) in the U.S. But published dics in Montgomery, he recently medical studies show that while joined Southlake Orthopaedics 80 percent of patients who have a in Hoover. heart attack will begin medication Over the course of his ca- Chris Heck, MD performing spinal surgery at Grandview Medical Center. to prevent future heart attacks, reer, his work has led him to a only 20 percent of patients who side interest in osteoporosis. broken bones. They are the highest risk break a bone due to osteoporosis will begin “Initially, the pharmaceutical comgroup for future fracture as they have almedication to prevent future fractures. pany representatives called on me and ready demonstrated that their bone is of “And consider this: a patient over 65 made a point that as orthopedic surgeons, poor quality.   years of age with a hip fracture has a 20 we see the patients most in need of treat“As a spine surgeon who is an orthopercent chance of breaking his/her other ment - those who have already broken a pedic surgeon, I not only see the broken hip within a year. That’s two hospitalizabone,” Heck says. “Since the goal of oships, wrists, and ankles, but also the vertions, two recoveries, and two events that teoporosis medication is to prevent future tebral fractures of the spine which far outrisk the patient’s life within a single year. A fractures, the patients most in need of this number hip, wrist, and ankle fractures.   patient who sustains an osteoporotic fractreatment are those who have already

ture is eight times more likely to sustain an osteoporotic fracture of any type than a patient who has not broken a bone.” Why is recognition and treatment for osteoporosis problematic? Heck says patients are in denial about needing treatment. Some say they are healthy and don’t need it, while others think they are too old to take more medicines. Heck tries to educate them on their high odds of having breaking another hip, explaining that medication is the only way to avoid this. Heck believes that physicians can also be are in denial. “Whether it’s your primary care physician or your orthopaedic surgeon, most physicians assume that your only problem was the broken hip,” he says. “The problem is that the bones were never good to begin with. Another road block to treating osteoporis is that medications cost money that patients may not have. Fortunately, the drug companies will provide assistance to any patient in financial need. His advice for family physicians: “Don’t rely on the DEXA (osteoporosis screening) as the holy grail. Use the entire clinical picture (history of fracture, family history, comorbidities such as smoking, diabetes, and renal failure) to determine if treatment is needed.” Heck hopes that more orthopaedic surgeons will work on caring for the cause of the fracture, rather than focusing on the effect which is the fracture itself.

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Betting on Blockchain, continued from page 6 good as the data put into it. It won’t stop fraudulent data that was put in from the start but would be easily visible if manipulated once in.” All three legal experts agreed back office functions have seen the most blockchain activity thus far. “It’s a powerful tool to reduce transaction cost because most transactions can be replicated, and it allows you to replicate them in a more efficient and less costly manner,” said Ehrenfeld. Johns said some of the first functions utilizing blockchain technology are the ‘low hanging fruit’ applications that are easier to roll out with more complex uses to come as technology and legal hurdles are addressed. Still, she said, the movement is rapid. “The conversation is not so much about education now. It’s about use cases and where do we start and where do we go?” she noted of making the leap to the next level of deploying blockchain in healthcare.

Clinical Support “The holy grail of blockchain is medical records,” stated Johns, who added a number of regulatory concerns must first be addressed. However, she said, the potential for improved communication … and, in turn, improved quality and safety … is too great to be ignored. “Is the promise of blockchain the ability to connect across the continuum of care? The answer is a resounding, ‘yes.’ How that happens, time will tell,” she said.

Ehrenfeld noted one of the major upsides to using the technology with electronic health records is its decentralized nature, which allows participants across the chain to access information from different locations. Everyone from a patient’s internist to specialists to an urgent care provider seen while on vacation could potentially have access to the EHR and pertinent clinical information including medication allergies and co-occurring conditions. However, he noted, “Once you start putting someone’s health record on this chain, if someone hacks into it, you have a huge issue. Security becomes that much more critical.” Data is, of course, encrypted … and Ehrenfeld pointed out those using blockchain in a clinical setting face the same issues as an individual office with protected health information. In both cases, a strong cybersecurity plan should be in place that looks at processes, risk management and action plans in case of a breach. “The treatment you have from the protection and response side is similar to existing protocols but will ultimately have to be tailored and enhanced to account for blockchain technology.”

Barriers Sloan said there are a number of barriers to broadly implementing blockchain ranging from regulatory concerns with existing laws to inertia. “Historically,

the healthcare industry has been one of the slowest adopters of technology,” he pointed out. “Is it better now than 20 years ago? Exponentially so, but I still think it’s going to take a little bit longer than people think.” Sloan noted it isn’t the young, nimble companies that are the issue in deploying blockchain. “It’s that you have to get so many disparate groups on board – providers, payers, regulators – it’s a lot of mouths to feed.” Johns said scalability is an issue and noted many potential applications aren’t readily available, as the underlying technology doesn’t currently exist. “We can see what is possible, but we’re just not there, yet,” she said. Ehrenfeld reiterated the barriers are different on the clinical front where there are more variables than with back office functions. “You are taking the art of medicine and trying to marry that with an executable and replicable set of activities,” he pointed out. Working through complicated medical scenarios and permissions are key reasons Ehrenfeld thinks it will take more thought and time before blockchain is widely deployed on the clinical front. “I have no doubt someone will figure it out, I just don’t know what that looks like, yet.”

Next Steps While there are multiple hurdles to overcome, blockchain is increasingly

being considered as a way to innovate business functions. Johns, Ehrenfeld and Sloan all three said it was easy to see the allure of the technology in the healthcare setting. “It adds efficiency and integrity to any system that involves data moving back and forth between multiple parties,” Sloan pointed out. “Anyone in healthcare can probably think of a dozen areas where a blockchain network could save time, save money, reduce errors and add transparency … and that’s powerful for healthcare.” Ehrenfeld echoed those thoughts, saying, “It’s a powerful tool to achieve these results, but the devil is going to be in the details.” Johns noted, “Some entities are calling what they’re building a blockchain when it isn’t at all … but that’s okay. It’s still innovative and offers more efficiency, greater transparency and improved security.” She continued, “Even if blockchain isn’t your answer – and often, it isn’t – that’s okay. It has still forced you to look at your infrastructure, existing procedures and even policies in a fresh way. Blockchain technology can inspire those conversations.” Johns added, “I think it would be a mistake to ignore this. Even if you are a skeptic, you should pay attention. It would be naïve to say this is a passing fad. It’s not a matter of if … it’s a matter of when … and that answer will depend on the use case.”

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BEHAVIORAL HEALTH

UAB Counseling Clinic Provides Affordable Mental Health Care More than 1,000 people seeking low-cost mental health services have been served by the UAB Community Counseling Clinic since its creation in 2011. The goal of the clinic, run by faculty and students in the UAB School of Education Counseling Program, is to increase access to outpatient mental health counseling services in Jefferson County while also providing an innovative educational experience for UAB graduate counseling students. “In our area, access to counseling can be hard to come by if you do not have insurance,” said clinic director Sean Hall, PhD. “There are places in the community that accept patients without insurance for a reduced fee. However, availability of those services can be limited. We are working to fill the gaps.” The clinic offers individual, group, family, and couple and marital counseling services and accepts clients starting at age eight, to adults and seniors. Clients are accepted through referrals from hospitals and other providers, social service directories, and self-referrals. Fees are determined by income and family size and range from $5 per individual session to no more than $30 per session. Individuals go through an initial screening via telephone in order to determine if the clinic’s outpatient services are the best fit for them or if they should be referred to a different provider. Well-trained graduate students, supervised by experienced faculty members, conduct all counseling sessions. The program is unique because most university programs that operate similar clinics do so in a doctoral program setting. Students in the UAB Counselor Education program are able to take part in this training at the master’s level. To provide students with a rich training experience and best serve clients, several technologies are utilized to enable supervisors to send messages digitally while observing each session from a control room. Students can also send a one-touch message to supervisors, such as “please advise,” without derailing the session. Since the clinic is also a teaching center, all counseling sessions are recorded so that program faculty can review and assess client progress, monitor the need for medical services, and evaluate clinical interventions. “The process is similar to a football

From left: Clinic director Sean Hall, PhD; clinical student, Richard Krebs; faculty supervisor, Shannon McCarthy, PhD; clinical student Morgan Sieck; faculty supervisor, Larry Tyson, PhD; and clinical student Gina Helms

coach’s reviewing game tapes with players,” Hall said. “The counselors and their supervisors break down small segments of each session in order to help students understand the dynamics that occur be-

with students and supervisors to discuss treatment goals, progress toward those goals, barriers to progress, interventions they are using and how they are working, and how to make improvements. Students in the UAB Counselor Education Program go on to work in a variety of mental health service professions, such as private practices, small group therapy and counseling clinics, psychiatric hospitals, community treatment centers, and residential treatment centers. The clinic staff provide counseling services for a range of mental health challenges, such as anxiety, depression, stress, relationship conflicts, grieving and loss, recent recovery from substance abuse, self-esteem issues, adjustment problems, job loss, parent and child conflicts, school and/or studying problems, and time management problems.

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BEHAVIORAL HEALTH

Why Are Depression And Suicide Rates Higher In Alabama? continued from page 1 “It’s a perfect storm for depression,” Shelton said. “Alabama is a rural state where social isolation and lack of access to mental health services are a double burden. There is so much entrenched poverty, yet few people qualify for mental health services under Medicaid. People with jobs and insurance may also find it difficult to fit mental health services in between family budgets and the limited mental health reimbursement benefits offered by many health plans. “Even those with resources may find themselves waiting for an appointment. Alabama has fewer mental health providers than any other state in the nation. “Another major risk factor for depression is poor physical health. Alabama’s high rates of obesity, metabolic health disorders and the health problems that come with them add to the risk.” DeLisa West, PhD, of West Neuropsychology said, “There is also still a stigma and a reluctance to ask for help.” A common problem is the cultural stereotype that men stoically deal with their problems and women should be steel magnolias who can handle anything. Some fear that people would see them differently if they knew, or trust them less in ways that could affect their career. “We need to change attitudes and normalize mental health services so seeking treatment is as accepted a part of stay-

ing healthy as making an appointment with an internist,” West said. Another factor in higher suicide rates results from having the means to commit suicide readily available when the impulse strikes. States where suicide rates are highest also correlate with the highest percentage of guns in the home. Suicide attempts using guns tend to be more successful. There is no lag time for someone to call 911, and no second chances to get the supportive help they need. The roots of depression are no longer seen in simple terms of a biochemical or

situational reaction, but as a more intricate combination of factors that vary by case and are influenced by prior experiences. “Depression tends to be triggered by a stressor. However, many people can experience the same event and react very differently,” Shelton said. “Most people who experience a loss don’t develop serious long term depression, just as most soldiers who return from war don’t develop PTSD. “There is a ‘double hit’ hypothesis that people who experience a serious loss or trauma, abuse or bullying earlier in life may be more vulnerable to responding to future stressors with depression.” In treating suicidal depression, researchers at UAB have been making progress using ketamine, and have developed a ketamine nasal spray that is expected to be approved by the FDA within the coming year. Before treatment can work, however, depression and suicidal ideation have to be identified. The lack of access to mental health services puts healthcare providers on the front lines in identifying patients who need help. “With every health care encounter, we need to look at the patient’s emotional health and ask the questions,” Shelton said. Any new stresses at home or work?

Anything on your mind lately that has been difficult? If there are indications that suggest depression, ask the next question: have you had thoughts that life may not be worth the effort? “It’s a difficult conversation to bring up,” West said. “People have to feel safe talking with you. When you ask the question, you need to be ready for the answer. A patient may not have the resources for private mental health services, but they need to know that help is available. They do have better options to deal with the pain. You need to be ready to refer them to agencies, crisis lines, and online help.” Those who heal the body can also save lives by listening.

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BEHAVIORAL HEALTH

We’re #51

What Does Being Last In Mental Health Providers Cost Alabama? By Laura Freeman

Every other state—and the District of Columbia—has more mental health care providers per capita than Alabama. Beyond the financial and distance limitations on access to mental health care, the lack of trained professionals is hurting the people who need help they aren’t getting—and all the lives that their lives touch. Emotional turmoil and abuse in families, interpersonal stress in the workplace, and even road rage endangering strangers on the highway are only some of the collateral damage that can happen when access to mental health services is limited. “We are all connected and play different roles in different circles,” clinical psychologist DeLisa West, PhD, of West Neuropsychology, said. “When mental health needs aren’t addressed, the effect is like ripples that touch many lives.” Richard Shelton, MD, UAB professor of psychiatry, said “We know that when parents are depressed, their depression affects their families. Children may have conduct problems or develop emotional difficulties. When we treat the parent’s depression, the children also get better.” Richard Shelton, MD With only one mental health provider per 1260 people, Alabama is in last place, but it definitely isn’t alone. According to Mental Health America data, 56 percent of American adults with a mental illness do not receive treatment. What happens to these people and those around them? Untreated mental conditions affect physical health. Much of the bad news we hear every day can be traced back to a time when intervention and emotional support might have prevented the drug dependency, violence, bullying and the horrific shootings we are seeing in schools and workplaces. Many people manage to muddle through, missing out on the happiness they might have had, and passing along the second hand stress. Some leave families grieving for lives cut short or diminished by alcohol, aimlessness and an inability to form meaningful relationships. To see where all too many cases of untreated mental illness lead, look at America’s prison systems and incarceration rates compared to the rest of the world. The National Alliance on Mental Illness reports that two million people with mental illness are booked into jails each year. Nearly 15 percent of men and 30 percent of women in jail have a serious

mental health condition. The Washington Post reported that a Treatment Advocacy Center survey found that in 44 of the 50 states, the largest prison held more people with serious mental illness than the largest state psychiatric hospital. Compared to the cost of taxpayerfunded prisons, mental health services are a bargain. There is still, however, the barrier of a lack of trained people to provide those services. In specialties like neuropsychology, the shortage is particularly acute. “There are so few of us to assess deficits due to neurological conditions like Alzheimer’s, head injuries and strokes,” West said. “A neuropsychology assessment is very different than a typical doctor’s appointment. It can take hours or most of the day, depending on the complexity of the case. Getting an appointment may take a while. “We need to encourage more people to go into the field and to practice in underserved areas where they are so very much needed.” The laws of supply and demand would suggest that where there is a high unmet demand for more mental health providers, we should be seeing more of them. Why is there such a serious shortage? The answer may be found in the differences between how mental health services are reimbursed and how physical health services are reimbursed. How many job openings will current reimbursement policies fund? A professor of psychiatry at UAB, Shelton said, “We are training the next generation of mental health providers. When medical students consider whether to go into this specialty and where to practice, they have to think about where the career opportunities are.” As the value of healing the mind begins to be seen in a similar light to healing the body, perhaps broader reimbursement policies will open up new opportunities for more mental health providers to build careers—and rebuild lives.

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BEHAVIORAL HEALTH

Before Stage Four

Identifying, Addressing Depression with Early Intervention By CINDY SANDERS

Last month, suicide dominated national news. The high profile deaths by suicide of Kate Spade and Anthony Bourdain came amid a new report from the Centers for Disease Control and Prevention that found suicide rates have increased dramatically over the last two decades in the United States.

Scope of the Issue The CDC’s Vital Signs: Trends in State Suicide Rates1 noted suicide rates in the United States have risen almost 30 per-

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cent since 1999. In 2016, there were nearly 45,000 suicides among those aged 10 and over, making it the 10th leading cause of death and one of only three leading causes of death that is on the rise. From 1999-2015, the report cited increased suicide rates among both sexes, all geographic areas, across all racial/ethnic lines, and in all age groups under 75. The largest absolute rate increase was among adults aged 45-64. As a result, 44 states saw significant increases in suicide rates with 25 states experiencing increases greater than 30 percent over that time period. In addition, U.S.

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emergency departments witnessed the rate of nonfatal selfharm rise by 42 percent from 2001 to 2016.

Missing the Signs While much of the country was in shock over the CDC news, mental health experts weren’t nearly as surprised. Most experts agree that suicide isn’t caused by a single factor and that interventions too often happen downstream. While the CDC report included 2015 data from 27 states that indicated 54 percent of suicide decedents were not known to have mental health conditions, Paul Gionfriddo, president and CEO of Mental Health America (MHA), pointed out ‘not known’ isn’t the same as ‘not having.’ He believes one issue Paul Grionfriddo is a lack of routine screening for early warning signs that could lead to interventions well before suicidal ideation is present. “Death by suicide is the ultimate Stage 4 event in the progression of many mental health conditions, whether or not they have ever been recognized and labeled,” said Gionfriddo. “People don’t just go from

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being perfectly healthy one day to having suicidal ideation the next, just as they don’t go from being perfectly healthy one day to having any other late stage chronic condition the next.” He continued, “Most suicide prevention activities over the last decade have tried to focus on breaking the connection between suicidal ideation and suicide. My response to that is that’s too late. It’s too late to start an intervention … we need to walk it back years.” Gionfriddo pointed out providers wouldn’t expect great outcomes if the first intervention was at Stage 4 of any other disease. “If you’re focusing on suicide or suicidal ideation, which is also a late-stage event, then we’ve really lost many opportunities to intervene early and look for early warning signs.”

Screening Opportunities Part of the frustration with catching the depression that can lead to suicide so late in the game is that an evidence-based tool is readily available to help identify warning signs at a much earlier point. “The most commonly used mental health screening is the PHQ-9,” said Gionfriddo. The patient questionnaire, which is available at no charge on the MHA website (screening.mentalhealthamerica.net), features nine questions about feelings and activities over the last two weeks with answers measured in terms of frequency (from ‘not at all’ to ‘nearly every day’). “This screening is recommended by the U.S. Preventative Services Task Force for everyone over the age of 11 on a regular basis, but relatively few clinical providers are using that tool,” he continued. Gionfriddo added it’s easy to administer and to score. He said about 3,000 people a day have come to the MHA screening site over the last four years with about half of those taking the PHQ-9 depression screen, which means the organization has amassed de-identified data on approximately 3.25 million individuals with half focused on depression. Of the nine questions, he noted, suicidal ideation is eighth … near the bottom … in terms of frequency, which is significant because it points to being able to catch signs of depression in earlier stages. “The initial warning signs happen way earlier than suicidal thinking,” noted Gionfriddo. “That gives us the greatest chance for success.” Asked how providers might identify those at risk and intervene before patients get to Stage 4, Gionfriddo said (CONTINUED ON PAGE 19)

18 • JULY 2018

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Before Stage Four, continued from page 18

adopting the PHQ-9 as a routine part of every visit is an easy first step. “They’ll find people who answer three, four, five questions positively often years before thinking about suicide and before they act on it,” he said. “That’s what clinicians could do and what clinicians should do … and oh, by the way, it’s reimbursable,” he stated.

Warning Signs, Now What? One of the possible reasons the screen isn’t more widely adopted is a feeling of ‘now what?’ Many areas have a shortage of mental health professionals, and other providers often aren’t aware of what local resources exist to help a patient identified as having early warning signs for depression. “Not knowing is not helping,” stated Gionfriddo. He added people typically want one of four things once identified as being at risk for depression and suicide: • Referrals to care and treatment (often the only one considered by clinicians), • More information, • Do-it-yourself tools like stress-reducing activities including journaling, exercise and improved nutrition, and • Engagement or peer connections. “At least one of those four things is available in every community, and often two, three or all four of those things are available,” he said. “When people complete screens on our website, they’re given information on all four of those areas,” he continued, adding MHA is also happy to provide interested clinicians with information on area resources. “That’s the answer to ‘then what?’” Gionfriddo concluded. “It might not be perfect, but it’s better than not knowing.” Stone DM, Simon TR, Fowler KA, et al. Vital Signs: Trends in State Suicide Rates – United States, 1999-2016 and Circumstances Contributing to Suicide – 27 States, 2015. MMWR Morbidity and Mortality Weekly Report 2018; 67:617-624. 1

Alabama’s New Data Breach Law, continued from page 10

ature. “Don’t just think of IT vendors. Think of anybody who touches your environment no matter what they do. You have to know and document how they access anything in your environment and, most importantly, how that vendor will make sure any SPII data is safe and secure.” Breaches, say IT experts, are no longer about embarrassment when precautions are taken. “No place is safe anymore,” Woods says, including the cloud and off-site data storage facilities. “But breaches are not an everyday occurrence in Alabama, either.” The HHS (HIPAA enforcers) website shows seven breaches in the state over the last 18 months. “These are only the confirmed ones. Most of them are not reported.” But Alabama’s new breach law may help bring more to light and raise the vigilance of companies, including in healthcare. “The law is good. It’s strong. It does protect,” Woods says. “Now let’s see if it will get enforced.”

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Dealing with Violent Patients By Jane Ehrhardt

Last month, a patient came into the Internal Medicine Specialists for his appointment. A middle-aged, average man, he’d been coming to the practice for several years. And he was a tinderbox. “It wasn’t the first time he’s been angry here,” says Cheryl Keith, administrator for the practice located on the Brookwood Medical Center campus. “He’s been abusive in the past. This time, he talked about violence.” He was frustrated about his insur-

ance coverage and wanted the front desk to submit his claims for him to the supplemental plan. “He was trying to bully them into filing that second insurance, and he blamed the front desk Cheryl Keith for his having to pay a copay,” Keith says. “He was so intense that another patient in the waiting room videoed it.” For several minutes, the man yelled

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and cursed. Then he told the women they were lucky he was not a violent man. They managed to tamp down his anger enough to gather his copay and move him on. But as the nurse escorted him back to the exam room, he commented about shooting up the front desk. She left him with the doctor and headed to Keith’s office to relay his aggressive statements. Keith talked with the front desk employees who were afraid. She also knew, at the end of the exam, the doctor had already planned to terminate the patient’s relationship with the practice based on past outbursts. She decided to alert security about the verbal threat, and then informed the doctor. About five minutes later, ten Homewood police officers charged through the front office in full tactical gear with guns out, locked the front doors, shut down the office, and rushed to the exam room. “It scared me,” Keith says. She was only expecting a few building security officers. “But they were totally prepared. I was proud of the way those officers handled it.” The police restrained the patient on the floor and questioned him. After interviewing others involved, they had Keith write the dismissal letter and present it to the man. “They told him he is not allowed on the campus of Brookwood or any Tenet premises,” Keith says. “If he

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did, 911 would be called, and he would be escorted off. “What was even more bizarre was that about half of the officers were called away during our situation to a shooter at a nearby Walmart.” After a half-hour interviewing witnesses and collecting written statements, the officers released the man with the warning. They also told Keith they offer free in-office training on handling active shooters. A few weeks later, all 40 practice staff members and 11 physicians participated in an hour-long training session with the Homewood police. Held in the practice waiting room, the officer presented videos of real active-shooter situations and had staff role play scenarios. The officers later conducted a longer training session for Brookwood hospital staff where they closed off a wing and incorporated mock gunfire. The active-shooter training focuses on staying alive. “You fight to live,” says Detective Gabe Ferguson with the Homewood Police Department. “First, you run. Don’t try to assess the situation or talk to the shooter. Instead of hiding under a desk and being easy prey, run to a place where you can deny them access. Put a filing cabinet in front of the door or tie the doorknob to something so they can’t open it all the way.” Keith says their trainer told them to buy simple rubber stoppers for each exam room to jam beneath the door from the inside. “You only need to buy time,” she says. “Get enough time for the people to arrive who can take that person out.” An officer also assessed their facility, suggesting tactics like adding keypad locks to several doors to restrict easy access. Ferguson cites the average response time for active-shooter calls at about four minutes. “That’s a long time if someone is shooting at you,” he says. “But even if you have 30 seconds, you should be able to get into a room and secure it.” On auto-close doors, he says, like in public restrooms, wrap the elbow-shaped, metal hinge at the top with a belt or computer cable to prevent it from moving and opening the door. “After the training, everybody felt a little safer and a little more aware,” Keith says. “They’re also more aware of reporting these things quickly now. There’s no more asking, ‘should I?’” Several of the physicians took the selfdefense classes held by Homewood police, as well. “This is not becoming a normal call for us,” Ferguson says. “But that could be because people aren’t taking the threat seriously.” Keith agrees. “The problem today is nobody is called out on their verbal threats and they get more confident about acting on that threat,” she says. “We need to tell them that we’re going to take them at their word; that nobody will even tolerate the possibility of violence.”


The Literary Examiner BY TERRI SCHLICHENMEYER

Shapeshifters: A Journey Through the Changing Human Body by Gavin Francis, MD c.2018, Basic Books; $27.00; 283 pages Change, they say, is good. on the woman who endures predictable, It’s the opportunity for growth. It’s a but sometimes unpleasant, changes. Of chance to take a breath, reassess, reconcourse, a fetus isn’t exactly having fun durfigure. It makes the landscape look fresh; ing pregnancy, either, and in between the it also muddies the waters. And yet, you two, there’s puberty, which is infamously bounce back and, as you’ll see difficult. When that hits, says in Shapeshifters by Gavin FranFrancis, puberty wreaks drascis, so does your body. tic changes in a teen’s body Summer, spring, fall, and in his/her mind, and those and winter. Whether by lookchanges can extend well into a ing through your window person’s twenties. or through your newspaper, Speaking of age, no matyou know that seasons come, ter how many skin-care prodchange happens, and each new ucts you use, your skin will thing is connected to all others never be restored to that of somehow. your youth. There is an exEver since medical school, planation for the old “hair Gevin Francis, MD Gavin Francis, MD has found turned white overnight” myth. such connections – especially those within And because there are different kinds of the human body – to be things of “revermemory, there are different ways of reence, the unfolding of a kind of joy.” membering. Take, for instance, our very beginNatural change is one thing, but nings, and birth. Francis also touches upon change we On a mother’s part, says Francis, cause ourselves: we can ensure that our pregnancy is proof that we aren’t in charge genders match our brains, for example. of our own bodies, and it’s physically hard We can sleep, or not, or need more if we

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fly across time zones. We can diet, take drugs, and work around lack of limb. We can laugh; “Most cultures,” Francis says, “have stories of muscle-bound strongmen.” And one in four Americans has a tattoo. And just so you know (because about a quarter of all tattooed folks regret their ink), the removal of said ink hurts way more than it did when you got the tat to begin with. Don’t let the contemplative tone of Shapeshifters fool you. Don’t let it lull you into believing that this book is like a meditation. Really, it’s more like being at a fireworks extravaganza: every few minutes, there’s a chance to say “Wow!” Now, admittedly, author Gavin Francis writes with a pronounced sense of serenity, and a feeling of reverence that he

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admits to, early in this book. That belies its liveliness. You will read topical philosophy and history before you meet pseudonymous patients who must learn how the human body deals with various kinds of physical and mental changes, welcomed or not. It’s in the ensuing and inevitable facts and observations, as Francis shares them, that you’ll have abundant chance to be genuinely amazed. We humans, as you’ll see in Shapeshifters, are predictable, unique, and resilient. We are alike and different and change, as they say, is a good thing. And so is this book.

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Your Front Office First Impressions By tammie LunCeforD, CmPe, CPC

own device at their convenience. Benefits of Kiosk Sign-ins include: reduction in the staffing at the front desk, decrease in patient wait time, and most impressively, is the increase of time of service collections. You may not be ready for a kiosk at your registration desk but you should review key areas for process improvements to assure you are preparing your practice for success at the front line. The MGMA Connection magazine reported an increase in the patient out of pocket expense by 30 percent in the last two years. Previous reports had already noted significant increases in patient deductibles and co-pays outside of the office co-pay. Failure to educate your front office staff, evaluate workflows, review software for accurate verification of benefits, and the lack of consistent financial policies could cost you at the end of the revenue cycle, and hurt your practice in the long-run. All this is to say that first impressions are vital to a practice. A second experience

I recently visited a specialty practice at a major health system. As I approached the registration desk a posted sign directed me to a standing kiosk to sign in. The family member I accompanied to the visit was unable to stand at the kiosk, so I provided the needed information and signed her in. Although it was a quick and seamless process, I was concerned because if I needed assistance, there were no employees to ask. Many practices have implemented kiosk sign-ins and have someone to assist a patient with the process if needed. Practice administrators have made the decision to implement kiosk to assure verification of the current insurance policy and prompt the patient to pay any out of pocket expense before they see the doctor. Many of the kiosk solutions allow a pre-registration via email to allow the patient to populate data and upload information from their

I had is that when I walked into the practice, the first thing I saw was each of the front desk staff members were on the phone and did not acknowledge the patients walking in until they hung up. They were scheduling tests, getting pre-certifications and poorly collecting information and money. The staff had so many tasks that they were unable to perform any of them well and with intention. Focus your front office staff on key functions: greet the patient, collect data, verify data, and collect money. Setting goals and seeing improvement will engage your staff in the big picture and train your patients to expect quality and consistent service and furthermore, be willing to pay for it. The changes in healthcare have caused us to focus on efficient and high quality services at a reduced cost. As administrators, physicians, and staff members, we rarely enter the office from the front door so we fail to see our operations from the patient

perspective. Understanding how patients view your practice can drive your practice to the next level. Paper registration is a hassle to update and likely skipped if the phones are ringing off the hook. Patient satisfaction is vital to any medical practice and patients are learning that technology can enhance their experience. The primary goal of the front desk should always be to provide great customer service because it is easier to collect from a happy patient. Once you assure education, define processes, and establish best practices for the front office, it is time to set goals. Track performance (such as co-pay collection rate), reward success, monitor compliance, and watch your practice grow. Tammie Lunceford, CMPE, CPC, is a Healthcare Consultant with Warren Averett.

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Congratulations to Augusta S. Dowd for a successful year as the 142 nd President of the Alabama State Bar.

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