MEDICINE SAN ANTONIO
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MEDICINE SAN ANTONIO
TA B L E O F CO N T E N T S
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AUGUST 2014
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VOLUME 67 NO. 8
San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.
Medicine & The Law
Do you know your cyber liability risks? By John Southrey, CIC, CRM .....................................10
Electronic health records pose malpractice risks By David B. Troxel, MD ..................................14
EDITORIAL CORRESPONDENCE: Bexar County Medical Society 6243 West IH-10, Suite 600 San Antonio, TX 78201-2092 Phone: (210) 582-6399 Email: editor@bcms.org
A view from inside the Texas Medical Board: Licensure committee assists physicians, organized medicine By Michael R. Arambula, MD, PharmD .....................16
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‘HIPAA-secure’ doesn’t have to mean complicated Special to San Antonio Medicine .....18 President’s Message by K. Ashok Kumar, MD, FRCS, FAAP ........................................................8 BCMS establishes sister cities agreement with Nuevo Leon physicians ....................................20
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San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.
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BOARD OF DIRECTORS
OFFICERS K. Ashok Kumar, MD, President Jayesh B. Shah, MD, Vice President Leah Hanselka Jacobson, MD, Treasurer Maria M. Tiamson-Beato, MD, Secretary James L. Humphreys, MD, President-elect Gabriel Ortiz, MD, Immediate Past President
DIRECTORS Josie Ann Cigarroa, MD, Member Chelsea I. Clinton, MD, Member John Robert Holcomb, MD, Member Luci Katherine Leykum, MD, Member Carmen Perez, MD, Member Oscar Gilberto Ramirez, MD, Member Adam V. Ratner, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Miguel A. Vazquez, MD, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Luke Carroll, Medical Student Representative Cindy Comfort, BCMS Alliance President Nora Olvera Garza, MD, Board of Censors Chair Rajaram Bala, MD, Board of Mediations Chair George F. "Rick" Evans Jr., General Counsel
CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer
CHIEF OPERATING OFFICER Melody Newsom
DIRECTOR OF COMMUNICATIONS Susan A. Merkner
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Fred H. Olin, MD, Chair Estrella M.C. deForster, MD, Member Jay S. Ellis Jr., MD, Member Diana H. Henderson, MD, Member Jeffrey J. Meffert, MD, Member Sumeru “Sam” Mehta, MD, Member Rajam S. Ramamurthy, MD, Member John C. Sparks Sr., MD, Member Chittamuru V. Surendranath, MD, Member J.J. Waller Jr., MD, Member Jason Ming Zhao, MD, Member
6 San Antonio Medicine • August 2014
PRESIDENT’S MESSAGE
A new home for BCMS By K. Ashok Kumar, MD, FRCS, FAAFP 2014 BCMS President
He that has a house to put's head in has a good headpiece. ~William Shakespeare, King Lear
Owning a home is an essential part of the American Dream; it is one's proudest possession and a reflection of one's character. Ever since I started my leadership role at the Bexar County Medical Society, I always wanted us to have our own building, regularly bringing the issue up in our BCMS meetings. Many of the leaders in the BCMS have the same desire that we need a place of our own. There are always pros and cons for anything we do in life. I firmly believe that there are a lot more positives than negatives in pursuing this dream. The course of living in a rented space from one lease to another never did run smoothly, and while we spend all that money on rent there is no accumulation of equity for the society. Furthermore, we are one of the oldest medical societies in the country, and the first medical society to be chartered in the state of Texas, and while many of our far younger sister societies in the state have their own building, we still do not. It is high time that we build a home for BCMS. I am delighted to let you all know that the idea took shape last year, and we started looking at the opportunities to find a place which is convenient to the membership and also embody our ideals. At the same time we do not have to spend an arm and a leg. We surveyed the membership about selecting a desirable location. We also formed a group of BCMS members under the leadership of Dr. Buddy Swift, who has extensive experience in building. He and the BCMS leadership and staff under the guidance of Steve Fitzer, and with the help of our general counsel Rick Evans, started our efforts to find a great place for us to build a structure or buy an existing building. Finally, I have some good news to share with you. We found a piece of land ideal for constructing our future home. The plan is to build an office which will not only meet our own needs as a medical society, but also build extra office space for rental which will be a source of ongoing revenue for the society. This will be one small step toward self-reliance and sustainability.
8 San Antonio Medicine • August 2014
According to the current estimates we need a lot more money than we have in the bank. That means we need to raise additional funds to fulfill our dreams of owning our own home for our medical society. We need to use our resources, we need to get a mortgage, and we need to raise more funds. In the most recent board meeting we brainstormed as to how to achieve this goal of raising the necessary funds. I was so thrilled to see overwhelming enthusiasm from all of our BCMS board members (even among the quietest members), and we discussed many creative ideas long past our usual meeting time. We came up with many ideas which I will be sharing with you. In the meantime, I plead with you to share your own thoughts and ideas with me. Certainly we need help from our friends in the community, and we have plans to approach them. However, there was a strong sentiment among members that we should first raise money from among ourselves before we ask for donations from others. I heard so many passionate testimonials from long-time members about how they came to the society's rescue when the medical society needed help before. I request all of you to show your support and commitment once again, both emotionally and financially. The board has come up with a plan to ask $75 from each member for each of the years 2015 and 2016 to help fund the cost of the building. In addition to your contributions, we need your ideas to raise more funds. I would be most grateful if you would contact me with your advice. I am going to form a fundraising committee, and if you are willing to volunteer, please call or write to me (kumark2@uthscsa.edu). We deserve a building of our own. Let us work hard to make that a reality. True hope is swift, and I firmly hope and believe that you will be proud of our own BCMS building. Kaparaboyna Ashok Kumar, MD, FRCS, FAAFP, is the 2014 president of the Bexar County Medical Society.
MEDICINE & THE LAW
Do you know your cyber liability risks? By John Southrey, CIC, CRM
Texas Medical Liability Trust (TMLT) has received more than 100 cyber liability claims from policyholders since adding cyber liability coverage to all policies in December 2011. The majority of these claims involved breaches of electronic protected health information (ePHI) stored on unencrypted computers and mobile devices that were either stolen or lost. These incidents were all possible violations of Health Insurance Portability and Accountability Act (HIPAA) privacy laws. Among the more sinister cyber claims reported to TMLT was a cyber extortion claim involving more than 6,000 electronically stored patient records.
A CYBER EXTORTION CLAIM A physician arrived at his practice and was unable to access his electronic patient records. A cyber criminal had hacked the practice’s servers and installed “ransomware” to encrypt the medical records and deny access to them. The hacker left a message demanding several thousand dollars before he would decrypt the files and permit access to the records. The physician immediately notified the FBI Cyber Crime Division and local police about the data breach. He contacted the TMLT claim department to initiate coverage under his cyber liability policy. The physician also hired an attorney to assist with reporting the breach to the U.S. Department of Health and Human Services (HHS). HHS enforces the breach notice provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Under HITECH, healthcare providers are required to report a breach of unsecured PHI to HHS if the breach involved the impermissible use or disclosure of PHI of more than 500 individuals. Notification is to include the affected patients and local media. HHS also places a press release about the breach on its website. Providers are required to report the breach to HHS within 60 days after its discovery. The physician’s attorney hired a forensic computer specialist to recover the inaccessible patient records. A media release vendor and a fraud detection/credit monitoring vendor were hired. The physician incurred expenses for a call center to answer patients’ 10 San Antonio Medicine • August 2014
questions. These direct costs did not include the potential damage to the physician’s reputation resulting from the media reports and patient notifications. The physician received a letter from the Office of Civil Rights (OCR) notifying him of their investigation of the breach. (OCR is responsible for enforcing federal privacy laws.) “Please be advised that the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) received your breach notification report on …, 2013, pursuant to the HITECH Breach Notification Rule, 45 C.F.R. § 164.408 and § 164.414. “Per the notification, you reported to OCR that … [the clinic] might not be in compliance with the Federal Standards for Privacy of Individually Identifiable Health Information and/or the Security Standards for the Protection of Electronic Protected Health Information (45 C.F.R Parts 160 and l64, Subparts A, C, D, and E, the Privacy and Security Rules). Specifically, you reported a breach of approximately 6,300 patients’ protected health information by a hacker that infected your network and encrypted your medical records. The hacker then demanded money in return for allowing access into your medical records. These allegations could reflect violations of 45 C.F.R. §§164.502(a), 164.530(c), 164.404, 164.406, 164.308(a)(1)(ii)(A), 164.308(a)(1)(ii)(B), 164.308(a)(5)(ii)(B), 164.308(a)(6)(ii), 164.308(a)
MEDICINE & THE LAW (7)(ii)(A), 164.308(a)(7)(ii)(B), 164.312(a)(1), and 164.312(c)(1), respectively. “Covered entities must cooperate with OCR during a complaint investigation (45 C.F.R §160.310(b)) and permit OCR access to its facilities, records and other information during normal business hours or at any time, without notice, if exigent circumstances exist (45 C.F.R. §160.310(c)). “If we are unable to resolve this matter voluntarily, and if OCR’s investigation results in a finding that [the clinic] is not complying with the Privacy and Security Rules, HHS may initiate formal enforcement action, which may result in the imposition of civil money penalties … We have enclosed a separate fact sheet explaining the penalty provisions under the Privacy and Security Rules. The fact sheet also explains that certain violations of the Privacy and Security Rules may be subject to criminal penalties, which the U.S. Department of Justice is responsible for enforcing. “Under the Freedom of Information Act, we may be required to release this letter and other information about this case upon request by the public.” Also attached to this letter was a “data request” consisting of a three-page matrix of checklists that cited numerous potential compliance failures. The physician had only 14 days from the date of the letter to provide the requested information, including documentation of his “internal investigation and corrective action regarding the incident” and proof that a HIPAA Security Rule risk analysis was done. The physician is still dealing with this matter and will be for quite some time. It is not clear what corrective actions the OCR will require of the physician’s practice. In the interim, he has retained new IT staff and implemented new privacy and security protections. The ransom demand was never paid, and the forensic computer specialists were unable to restore all of the medical records from the original server. The physician paid and incurred expenses for this claim that exceeded the $50,000 limit of his TMLT cyber liability coverage.
FINES, PENALTIES CAN BE SERIOUS As of Sept. 23, 2013, all healthcare providers were required to comply (there are a few exceptions) with the expanded privacy protections mandated in the HIPAA Omnibus Final Rule. The Omnibus Rule is a comprehensive update of the regulations enacted under the HIPAA Privacy and Security Rules that expanded the rights of patients and tightened federal breach notification requirements. The Privacy Rule applies to all forms of PHI (oral or recorded in any form or medium) and the Security Rule applies only to ePHI. Under the Security Rule, covered entities are required to imple-
ment suitable administrative, physical and technical safeguards to ensure the confidentiality, integrity and security of patients’ ePHI. They also must conduct an analysis of the risks and vulnerabilities of their ePHI. The OCR expects organizations to have reasonable and appropriate safeguards in place to protect patients’ ePHI — especially if that information is accessible over the Internet. Providers are becoming increasingly exposed to unauthorized access, acquisition, use and disclosures of unsecured PHI/ePHI that could result in costly violations. Breach vulnerabilities are abundant in healthcare. A workforce that is untrained about privacy and security protocols; storage of unencrypted ePHI especially on portable devices; ongoing hacking and virus attacks, and privacy breaches by disgruntled employees represent several possible exposures. It is widely recognized that healthcare IT lags other industries in employing adequate privacy and security practices. In 2012, OCR director Leon Rodriguez stated that healthcare providers need to get their HIPAA policies and procedures in working order or they will face more audits and increased civil monetary fines. Two recent data breach examples involving ePHI are representative of the OCR’s call-to-action. 1. In 2012, Phoenix Cardiac Surgery of Phoenix and Prescott, Ariz., agreed to pay HHS a $100,000 settlement and take corrective action to employ policies and procedures to safeguard the PHI of its patients. The OCR’s investigation found the practice was posting clinical and surgical appointments for its patients on an Internet-based calendar that was publicly accessible. The OCR also found Phoenix Cardiac Surgery had implemented few policies and procedures to comply with HIPAA Privacy and Security Rules and had only limited safeguards in place to protect their patients’ ePHI. Rodriguez highlighted this case as a warning. “We hope that healthcare providers pay careful attention to this resolution agreement and understand that the HIPAA Privacy and Security Rules have been in place for many years, and OCR expects full compliance no matter the size of a covered entity.” 2. For the first time, the OCR pursued a HIPAA breach of less than 500 patient records. The Hospice of North Idaho (HONI) reported to HHS that an unencrypted laptop computer containing the ePHI of 441 patients had been stolen in June 2010. In 2012, HONI agreed to pay a $50,000 settlement to HHS because HONI did not conduct a security risk analysis to safeguard the ePHI of their patients and they did not have policies or procedures in place to address mobile device security, as required by the HIPAA Security Rule. Once again, Rodriquez used this case to admonish the healthcare community. “This action sends a strong message to the healthcare industry that, regardless of size, covered entities must take action and will be held accountable for safeguarding their patients’ health information. Encryption is an easy method for making lost information unusable, unreadable and undecipherable.” Continued on page 12 visit us at www.bcms.org
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MEDICINE & THE LAW Continued from page 11
With penalties and random audits expected to escalate, it is imperative for healthcare providers to carefully identify their risks and vulnerabilities to a data breach and to employ privacy and security policies and procedures to safeguard all PHI. On Sept. 1, 2012, Texas House Bill 300 (HB 300) became effective, and it significantly revised the Texas Medical Records Privacy Act for covered entities who store PHI. HB 300 increased a provider’s cyber liability exposure by adding more stringent safeguards than those found in HIPAA and HITECH.
A CLEAR MESSAGE Providers must dedicate sufficient attention, resources, staff training, and systems to comply with state and federal laws to minimize their risk of violations and reputational harm. It appears assertive enforcement of data breaches by the OCR will fall hard, particularly on healthcare providers who have clearly failed to address and remedy privacy and security issues. The liabilities and potential assessment of civil penalties associated with such failures can inflict heavy time and financial burdens. All covered entities should review their HIPAA policies and procedures, conduct a risk assessment, update their notice of privacy practices, and generally ensure they are in compliance. Specifically, physicians should: • update their HIPAA privacy notices; • conduct a HIPAA security risk analysis; • revise HIPAA employee training to comply with the 2013 changes required by the Omnibus Rule, HB 300, and by Senate Bills 1609 and 1610; • revise Business Associate Agreements to include the language required under the HIPAA Omnibus Rule and HB 300 to obtain written assurances that your business associates will similarly protect patients’ PHI; • implement technical safeguards such as encryption to all ePHI stored on portable devices or that is electronically transmitted; and • develop breach notification policies and procedures and a response plan for staff. Cyber liability insurance policies are available from TMLT and other sources. John Southrey, CIC, CRM, is manager of consulting services at Texas Medical Liability Trust. He may be reached at john-southrey@tmlt.org.
This information is provided on behalf of a valued BCMS Circle of Friends sponsor at the platinum level, but it is not an endorsement. Donations from Circle of Friends sponsors help keep down the cost of dues and allow BCMS to continue to provide quality service to its members. The society continues its pledge to you and only will involve itself in services and programs that benefit you, the member, and your patients. 12 San Antonio Medicine • August 2014
RESOURCES • HHS guidance: www.hhs.gov/ocr/privacy • National Institute of Standards and Technologies information: www.csrc.nist.gov • Mobile Devices: Know the RISKS. Take the STEPS. PROTECT and SECURE Health Information: www.HealthIT.gov/mobiledevices • Understanding Your Cyber Liability Coverage: http://resources.tmlt.org/PDFs/cyber-liabilitybrochure-2013.pdf • U.S. Department of Health and Human Services, Breaches Affecting 500 or More Individuals: www.hhsgov/ocr/privacy/hipaa/administrative/bre achnotificationrule/breachtool.html • American Medical Association, The Health Insurance Portability and Accountability Act (HIPAA) omnibus final rule summary: www.amaassn.org/resources/doc/washington/ hipaa-omnibus-final-rule-summary.pdf • HHS’ Office for Civil Rights (OCR) has developed an array of tools to educate consumers and healthcare providers about the HIPAA Privacy and Security Rules, including a video titled The HIPAA Security Rule for small providers to help them establish basic safeguards and to comply with the Security Rule’s requirements: www.youtube.com/user/USGovHHSOCR The OCR has also developed three modules for providers about compliance that are available at Medscape.org:
• Patient Privacy: A Guide for Providers www.medscape.org/viewarticle/781892?src=ocr • HIPAA and You: Building a Culture of Compliance www.medscape.org/viewarticle/762170?src=ocr • Examining Compliance with the HIPAA Privacy Rule www.medscape.org/viewarticle/763251?src=ocr
MEDICINE & THE LAW
Electronic health records pose malpractice risks By David B. Troxel, MD
The integration of the electronic health record (EHR) into medical practices has great potential to advance both the practice of good medicine and patient safety. However, there are always unanticipated consequences when new technologies are adopted — and the EHR is no exception. Real and potential liability risks are beginning to be recognized, and it is important for physicians to become familiar with them. Doctors are responsible for information to which they have reasonable access — and there is increased access to e-health data from outside the practice that is accessed from the practice EHR or website or through Health Information Exchanges, e.g., hospital charts, consultants’ reports, lab results and radiology reports, and community medication histories. EHR metadata documents what was reviewed. If patient injury results from a failure to access or make use of available patient information, the physician may be held liable.
CAPABILITIES, BENEFITS E-prescribing is being adopted rapidly, driven by federal financial incentives, and is currently used by more than 50 percent of office practices. Potential capabilities and benefits include: • Most electronic prescriptions are transmitted via a Surescripts network (which has data on more than 70 percent of patients) to all chain pharmacies, 60 percent of independent pharmacies and most insurance formularies. • EHRs have an e-prescribing module, which is a required capability under the federal financial incentives for “Meaningful Use” of EHRs. E-prescribing provides electronic routing to pharmacies, quick access to drug formulary and eligibility information, and the patient’s prescription history. • Standalone e-prescribing software also is available at no cost from Allscripts and the National ePrescribing Patient Safety Initiative (NEPSI). • Most e-prescribing programs check for drug interactions, dosage errors, medication allergies and patient-specific medication factors. • Office prescription renewal requests can be synchronized with most e-prescribing systems. • E-prescribing encourages patients to fill prescriptions (currently 30 percent do not), because the prescription is sent to 14 San Antonio Medicine • August 2014
the pharmacy electronically and is ready to be picked up when they arrive. • Costs are lowered by flagging generic and “on-formulary” drugs. However, practices are exposed to community medication histories through e-prescribing. For example, Dr. A renews a medication, and his e-prescribing program sends an alert advising him that the medication could interact with another drug the patient is taking. He has not prescribed that drug, so his office staff will have to contact the patient to identify who has prescribed it, and then Dr. A will have to contact Dr. X to “negotiate” which drug will be discontinued or changed. If failure to take action results in patient injury from a drug interaction, Dr. A may be liable. Drug-drug interaction lists generate frequent, annoying and disruptive alerts, and doctors may develop “alert fatigue” and ignore, override or disable them. If it can be shown that following an alert would have prevented an adverse patient event (this will be documented in the metadata), the physician may be found liable for failing to follow it. Doctors may copy information from a prior note or the history and physical (H&P) and paste it into a new note or H&P (known as “cloning”), making changes where appropriate. This works well for the past history but is risky for the physical examination, which may change. This may result in irrelevant over-documentation, and the patient may appear to have more or less complex problems since the prior encounter. By substituting a word proces-
MEDICINE & THE LAW sor for the physician’s thoughtful review and analysis, the narrative documentation of daily events and the patient’s progress may be lost, thereby compromising the record of the patient’s course. The quality of notes and documentation may be further compromised by the use of templates. The computer may become a barrier between the doctor and the patient. When the doctor fills in a computer template, it may divert attention from the patient, limit interactive conversation and restrict creative thinking. This may depersonalize and weaken the doctor-patient relationship. The computer’s location in the office is an important ergonomic consideration; i.e., the location of electrical outlets shouldn’t force you to sit with your back to the patient.
DEPOSITION QUESTIONS Many EHRs autopopulate fields in the H&P (from data derived from data fields in a prior H&P) and in procedure notes (from personalized or packaged templates). While over-documentation may facilitate billing, entering erroneous or outdated information may increase liability. For example, an internist was deposed and his EHR was the medical record. Some of the autopopulated fields contained obviously wrong information. At deposition, the plaintiff ’s attorney asked these questions: “So is the information in this record accurate or not?” “Do you bother looking at your records?” “If these ‘autopopulated’ fields are incorrect, can we trust anything in this record?” “Do you deliver the same level of care as you do in recordkeeping?” EHRs are certified for compliance with Meaningful Use requirements, e.g., computerized provider order entry (CPOE), e-prescribing, Clinical Decision Support (CDS), and patient connectivity through patient portals. Patients must be provided with clinically relevant, disease-specific educational and drug safety materials through these portals. Providers are responsible for the content, which creates risk. Some EHRs have patient questionnaires that use an algorithm to interview the patient through these portals. The questionnaires may address — and memorialize in the record — issues that physicians are not prepared to pursue (depression, substance abuse, sexually transmitted disease, etc.) Lack of or incomplete follow-up can create potential liability — and provide a clear record for the plaintiff ’s attorney to follow. Vendor contracts may attempt to shift liability resulting from faulty software design or CDS data onto the physician. Malpractice policies may exclude coverage for product liability and indemnification of third parties. Read all contracts carefully. Electronic discovery: Lawyers may request printed copies of the EHR and also copies in native format, which shows how the data was used. (Were CDS alerts and prompts followed or overridden?) They also will request the metadata, which includes logon and logoff times, what was reviewed and for how long, what changes or
additions were made, and when the changes were made. Smartphone and e-mail records are also discoverable. All physician interactions with the EHR are time-tracked and discoverable. Templates with drop-down menus facilitate data entry. However, drop-down menus are usually integrated with other automated features. An entry error (accidentally selecting the medication above or below the one desired on the menu) may be perpetuated elsewhere in the HER — and it may be overlooked, resulting in a new potential for error. Erroneous information, once entered into the EHR, is easily perpetuated and disseminated.
CHECK PRESCRIBING INFORMATION EHRs provide e-prescribing drug information and CDS databases (required by Meaningful Use). Clinicians should know the source of the medication and CDS information in their EHRs, because it may be in conflict with the clinical standards of care or practice guidelines for their specialty and with the information in U.S. Food and Drug Administration (FDA)–approved drug labels or drug alerts. Computer-assisted documentation uses point-and-click lists, drop-down menus, auto-fill, templates and canned text to bypass natural language and produce structured progress notes. These contain redundant, formulaic information, making it easy to overlook significant clinical information that is lost in a sea of normal or irrelevant findings. Communication with on-call and consulting physicians may be compromised, and abnormal lab and imaging test results may be missed. CDS provides alerts, warnings and reminders for medication and chronic disease management and preventive care, but physicians may have to justify departures from these guidelines (documented in the EHR’s native format) if an adverse event occurs. Always document why a prompt was overridden. David B. Troxel, MD, is medical director, board of governors, for The Doctors Company. The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered. Reprinted with permission. ©2014 The Doctors Company (www.thedoctors.com). This information is provided on behalf of a valued BCMS Circle of Friends sponsor at the silver level, but it is not an endorsement. Donations from Circle of Friends sponsors help keep down the cost of dues and allow BCMS to continue to provide quality service to its members. The society continues its pledge to you and only will involve itself in services and programs that benefit you, the member, and your patients. visit us at www.bcms.org
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MEDICINE & THE LAW
A view from inside the Texas Medical Board Licensure committee assists physicians, organized medicine By Michael R. Arambula, MD, PharmD
Having lived in Texas all of my life, I was eager to spend time in the Windy City during my forensic psychiatry fellowship training many years ago. And while my enthusiasm for new learning was robust, running as fast as I could in a top-ranked program, I carried a hole in me. I missed our great big skies, our climate (yes, this is true), our friendly people, and the air of independence that can only be called Texan. After serving on the Texas Medical Board for the past seven years, I have concluded to more than a reasonable degree of medical certainty: I am a prouder Texan than before. Fairly soon after Gov. Rick Perry appointed me to the board, Dr. Roberta Kalafut asked me to chair the licensure committee. Sitting at the head of our conference table, I caught a glimpse into how great our state really was. On the heels of tort reform, licensure was a busy place. New license applications (averaging 2.7K per year) had increased by more than a third (to an average of more than 4K per year). Since then, those figures have not let up. In fact, there has been yet another notable increase in applications received over the past two years, and our projected figure of new license applications this year will exceed 5K.
TAKING CARE OF PATIENTS In the trenches, I recall hearing a physician mention that moving to Texas would decrease his malpractice premiums by almost $100K. Another physician, whose application had been flagged for excessive suits that proved frivolous, told me that he was thankful for having the opportunity to practice medicine in our state and focus on patient care. There are many cases just like these, where doctors simply want to do what they spent most of their life preparing for – taking good care of patients. Indeed, thousands of new citizens are looking for opportunity in our great state. A recent (Forbes) study
16 San Antonio Medicine • August 2014
showed that four cities in Texas sat atop the list of our nation’s best cities for good jobs. Facts speak for themselves. In licensure, it is our duty to accredit medical schools, residency programs and fellowships programs in the state (although we honor and depend upon the Accreditation Council for Graduate Medical Education (ACGME) processes). Herein lies the most important discovery that I’ve made serving on the board: We have some of the finest medical centers and training programs on this planet. Despite my appraisal (and I do not stand alone on this), our medical centers and training programs probably won’t ever receive the recognition that they deserve simply because they exist in Texas. This incongruence is eerily akin to the vibes that I sometimes pick up on when sitting in a Federation of State Medical Boards conference room with other state medical board representatives, where I steadfastly represent our sovereign rights as a state agency while the scent of federalism – fighting words, no less – permeates the air. On a positive note, I come away from that debate knowing that others respect us. After all, our state board has been a trailblazer in keeping abreast of the changes in medicine and creating policy that protects the public and encourages the growth of medicine. Lastly, I have been fortunate to work with an array of excellent clinicians who oversee the training of our young doctors. The
MEDICINE & THE LAW stakeholder meetings we held last year allowed us to hear of the subtle changes that had commenced in the evaluation of our young physicians per the national accrediting bodies. More importantly, we (licensure) have adjusted our analyses of new applicants who carry training concerns so as to avoid unnecessary disciplinary action against them.
POSITIVE MEMORIES I harbor countless memories from my interactions with physicians during medical board proceedings. Naturally, there are memories that I would rather forget. A very low feeling still pervades my air space when board counsel describes the harsh conditions of a disciplinary order to a physician; more so when a physician has gambled away an entire medical career running a “pill mill.” Alternatively, I carry mostly positive memories. The image of a physician suddenly breaking down in tears when his case was dismissed comes to mind. The gratitude that a previously impaired physician expressed to me for stepping into his life so that he could change the path he was on also comes to mind. So too do the remarks I heard during a break that one physician could crack their chests. Sentiments like these give me confidence that what we strive for is to do the right thing.
I must give a “shout-out” to the Texas Medical Board staff. Simply said, they are superb. Still, there is a rumor that something must be wrong with those who serve on the Texas Medical Board. If that rumor means that my service can help people who reside in this great state that I will never meet, that my service can help physicians who have difficulty helping themselves, that my service can provide opportunities for physicians to come to Texas and practice medicine, that my service can adapt to the training needs of our future medical professionals, that my service can sustain the sovereignty of our great state in the arena of medicine, and that my service allows me to get up in the morning and look forward to the good fight that all of us (board members) engage in, then I wholeheartedly embrace that something must be wrong with me and furthermore, that I would do it again in a heartbeat. Michael R. Arambula, MD, PharmD, is vice president of the Texas Medical Board and chairman of the licensure committee. He carries board certifications in general and forensic psychiatry and an adjunct faculty appointment at UTHSCSA. He is a long-time member of BCMS.
visit us at www.bcms.org
17
MEDICINE & THE LAW
‘HIPAA-secure’ doesn’t have to mean complicated Special to San Antonio Medicine
In many situations, texting is the fastest and most efficient way of sending information, and reports show that texting among physicians is widespread and that they are texting clinical information. Physicians who text each other clinical information risk exposing themselves to the privacy and security violations of the Health Insurance Portability and Accountability Act (HIPAA). Seeing the need for an answer that supports a physician’s desire to communicate and collaborate quickly while still mitigating the risk of HIPAA violations, Bexar County Medical Society partnered with DocbookMD, a secure messaging app for physicians that combines the ease and mobility of texting within a HIPAA-secure framework. DocbookMD, available for iOS, Android and PC/Mac, was created and developed by the Austin husband-and-wife team of Tim Gueramy, MD, and Tracey Haas, DO, MPH – both Texas Medical Association members. “DocbookMD allows you to look up another doctor at the point of care. You can then either call the physician or send a text message with room numbers, medical record numbers, even attach photos of wounds, X-rays and EKGs,” said Dr. Gueramy, an orthopaedic surgeon. “All of this is sent securely and in a way that meets HIPAA requirements.” 18 San Antonio Medicine • August 2014
The app allows physicians to: • Have a simple communication solution, in and out of the office; • Coordinate across the full care team, including nurses, PAs and office staff; • Access an up-to-date, extensive physician directory; • Send fast, HIPAA-secure messages; and • Attach high-resolution images, including X-rays and EKGs. All BCMS member physicians have free access to DocbookMD, and their non-physician staff and care team members also can download the app to communicate securely with the member physicians, through a simple invitation process that keeps physicians in control of their accessibility. Nurses, PAs and staff members can send messages to any physician who has invited them to be a part of their care team, as well as to other members of their team. Reports from physicians -- across all specialties and settings around Texas -- have been overwhelmingly positive about the potential of DocbookMD. Wichita Falls otolaryngologist Jed Grisel, MD, has been using DocbookMD for the past year, and says it helps him coordinate with primary care physicians and other specialists alike. For instance, he and his colleagues at Head and Neck
MEDICINE & THE LAW
Surgical Associates work with a dermatologist who removes skin cancers from patients. After having the cancer removed, patients sometimes need to return to have the area reconstructed. "Using DocbookMD, the dermatologist can send me an image of the skin defect prior to the surgery I'll be performing. It really helps to have that picture in advance because I can begin planning how I'll reconstruct the defect. Bypassing the need for an extra patient visit, I'm ready to go, and care is coordinated in a HIPAAcompliant way," Grisel said. Hospitals and large groups, including Memorial Hermann Physician Network in Houston, also are deploying an enterprise version of the DocbookMD HIPAA-secure platform. Docbook Enterprise offers additional integration and administrative capabilities, such as allowing doctors to get answering service messages and radiology reports, such as stat X-rays, CTs and MRIs, directly on their mobile device, and provides the ability to securely connect physicians in a hospital setting not only to one another, but to other physicians in the local medical community as well. This ability to connect physicians to colleagues and healthcare resources within an entire region is what sets Docbook Enterprise apart from other communication platforms. Most enterprise tech-
nologies use a closed network that allows physicians within a hospital or group to communicate securely only with colleagues and staff who are inside that organization, but DocbookMD's guiding vision has always been to break down the barriers that prevent physiDR. JED GRISEL cians from sharing critical communications with all of those involved in their patients' care. DocbookMD is a benefit of your BCMS and TMA membership, and you can start taking advantage of it immediately! Across the country, DocbookMD is offered as a free benefit through more than 300 county/state medical societies and is now used by more than 25,000 physicians in 40 states, including more than 8,500 Texas physicians. To begin using DocbookMD, download the app to your iPhone, Android or tablet and follow the registration instructions. For more information or help getting registered, contact BCMS at (210) 301-4391, and be sure to view the video tutorials on how to use the app at docbookmd.com/videos. visit us at www.bcms.org
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BCMS NEWS
BCMS establishes sister cities agreement with Nuevo Leon physicians
BCMS representatives and Nuevo Leon healthcare professionals signed a medical sister cities agreement June 20 in Monterrey. Bexar County Medical Society (BCMS) officially entered into a sister cities agreement with medical professionals in the state of Nuevo Leon, Mexico, effective June 20. The sister cities agreement is the third between BCMS, the professional organization for San Antonio physicians, and medical professionals elsewhere in the world. BCMS established a sister cities relationship with Kumamoto, Japan, in 1992, and with Chennai, India, in 2008. Through the programs, BCMS member-physicians visit their international counterparts, touring medical facilities, comparing healthcare services, and exploring historical and cultural landmarks. BCMS members also host groups of medical delegates from Japan and India -- and now Mexico – to share the Alamo City’s medical, cultural and historical accomplishments. Roberto San Martin, MD, 2014 chairman of the BCMS International Relations Committee, said the medical sister cities agreements enable physicians and other healthcare personnel to share best practices with international colleagues. “San Antonio, in some ways, is the northern border of Mexico,” said Dr. San Martin, a board-certified ophthalmologist who has been in clinical practice for 35 years. “Many of our physicians studied in Mexico, and many San Antonio residents also have lived there. Our culture is identical. We have a shared language and heritage.” Representatives from BCMS and the Colegio de Médicos Cirujanos del Estado de Nuevo León, A.C., marked the new agreement at a signing ceremony June 20 in Monterrey, Nuevo Leon. Attending on behalf of BCMS were Dr. San Martin; Dr. Geraldo Ortega, 2001 BCMS president, and his daughter, Karen; Dr. Hugo Casteneda; John Dauer and Yolanda Perez, RN. Representing the state of Nuevo Leon were Dr. Fernando R. García García, 2012-14 president of the Colegio de Médicos Cirujanos del Estado de Nuevo León, A.C. The colegio represents 20 San Antonio Medicine • August 2014
3,000 physicians in the northern Mexico state. San Antonio representatives presented a ceremonial proclamation signed by Mayor Julian Castro. Shahrzad “Sherry” Dowlatshahi, chief of protocol and head of international relations in the City of San Antonio’s Intergovernmental Relations Department, called the agreement momentous. “We are thrilled to see an excellent example of cooperation among sister cities,” Dowlatshahi said. “The role that BCMS is playing in our sister city relationships by entering meaningful relationships with sister medical societies in Kumamoto, Japan; Chennai, India, and now Monterrey, Mexico, is important to highlight.” The City of San Antonio has sister city agreements with nine cities. In addition to Kumamoto and Chennai, they include two cities in Mexico -- Monterrey, Nuevo Leon, and Guadalajara, Jalisco; two in the Canary Islands of Spain – Las Palmas and Santa Cruz de Tenerife; as well as Gwangiu, South Korea; Kaohsiung, Taiwan, ROC; and Wuxi, Jiangsu Province, China. Sister Cities International is an initiative started in 1956 by President Dwight D. Eisenhower to develop economic, cultural and technical exchanges between U.S. cities, counties and states with corresponding communities worldwide. BCMS and its medical sister cities agree to have groups of delegates visit their respective cities in alternate years. A group of 16 Japanese visitors came to San Antonio in August 2012 and are expected this month, and 13 BCMS delegates visited Kumamoto in September 2013. The first BCMS delegation to Chennai visited India in January 2012. Dr. San Martin said the Monterrey trip was successful. “Our colleagues were most gracious, very professional and excited for the opportunity to engage with their sister medical society. Our mission was well received. They were impressed with our presentation, friendship and, of course, our ability to speak in Spanish.”
BCMS NEWS
LEGISLATIVE AND ADVOCACY NEWS
Members of the BCMS Legislative and Socioeconomics Committee welcomed U.S. Rep. Lamar Smith (Texas Congressional District 25) on April 22 for a meeting to discuss the recent SGR patch and to hear from the congressman about other issues of interest to physicians.
For information, contact BCMS Chief Governmental and Community Relations Officer Mary E. Nava, MBA, at mary.nava@bcms.org.
NOTEWORTY A group of BCMS physicians attended a TEXPAC dinner at Paesano's Restaurant in support of State Sen. Donna Campbell, MD (District 25), on June 20.
SAVE THE DATE Sept. 18: BCMS Foundation Golf Tournament, Quarry Golf Club. Register at www.bcms.org. Sept. 24: BCMS Fall General Membership Meeting, Hilton at the Airport. CME and legislative updates.
22 San Antonio Medicine • August 2014
Sept. 28: Siclovia, Alamo Plaza. www.siclovia.org. Oct. 9-10: Texas Health Literacy Conference, La Quinta Inn and Suites Medical Center. www.healthcollaborative.net. Oct. 16: BCMS Auto Show, BCMS office parking lot. Buffet and cocktails; new model vehicles; family and friends welcome.
BCMS life member Charles R. Bauer, MD, was one of four gold-level recipients of the 2014 TMA Awards for Excellence in Academic Medicine at the May TexMed meeting in Fort Worth. The award recognizes academic physicians who are consummate teachers, role models and medical professionals.
IN MEMORIAM Samuel B. Bashour, MD, FACS, died June 14, 2014, at age 94. A surgeon, Dr. Bashour was a BCMS member and a member of the TMA 50 Year Club. Jack Leigh Eidson, MD, died June 15, 2014. Dr. Eidson, 93, was a BCMS member. James R. “Dick” O’Neill, MD, died May 25, 2014, at age 96. Dr. O’Neill, a cardiologist, was a BCMS life member.
BCMS NEWS
FINANCIAL AID SOUGHT FOR LECTURE Dr. Alain Touwaide will present a lecture on “The Archaeology of Health in the Ancient Mediterranean World� at 7:30 p.m. Oct. 20 in Chapman Hall at Trinity University. The event is free and open to the public. Dr. Touwaide is a science historian who specializes in the history of medicinal plants in the cultures that flourished around the Mediterranean Sea from antiquity to the 17th century CE. His lecture is sponsored by the Southwest Texas Archeological Society (SWTAS), a branch of the Archeological Institute of America. Financial support is being sought to cover the approximate cost of $2,000 for expenses. Contributions of all sizes are appreciated by the SWTAS, which is a 501(c)(3) organization. Contributions can be sent to AIA SWTAS. The check should be mailed to: Laura Childs, 2858 Burning Log, San Antonio, TX 78247. The check should stipulate Touwaide Lecture.
NEW MEMBER WELCOME PARTY BCMS members, guests and Circle of Friends sponsors filled the Argyle Club June 3 for the annual new member mix and mingle, which featured complimentary beverages and buffet. Live entertainment, including a set by Rick Cavender, and door prizes were included.
Dr. Marvin Eng (left) visits with BCMS President K. Ashok Kumar at the new member mix and mingle.
Aisha Ross (left) and Dr. Kimberly Crittenden chat on the porch of the Argyle Club at the New Member Welcome.
visit us at www.bcms.org
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CARE SYSTEM PROFILES
Methodist Healthcare System
A journey to excellence in which best practices save lives By Kenneth Davis, MD, Chief Medical Officer, Methodist Healthcare EDITOR’S NOTE: This is the ninth article in a planned series of Care System Profiles, highlighting various healthcare providers in Bexar County in the pages of San Antonio Medicine. The goal of the series is to inform BCMS members about the relationships that exist within and among various local institutions. Articles will focus on what distinguishes one system from another, and what is unique about each organization. Representatives of local healthcare delivery systems are being invited to submit an article describing their institutional initiatives for publication in the series. Organizations are featured in the order in which their articles are submitted and approved. Members of the BCMS Communications/Publications Committee review articles before publication, and content may be edited for format, style and clarity. For guidelines and more information, email editor@bcms.org.
As the most preferred and trusted healthcare provider in San Antonio, the Methodist Healthcare System has been recognized by the community for its outstanding team of nurses, medical professionals and physicians for more than 50 years. Since opening its first hospital in 1963, Methodist Healthcare has expanded its vision of world-class healthcare to residents in San Antonio and the 26 surrounding counties and to patients from around the world. Methodist Healthcare is the fifth-largest healthcare system in the country and the largest healthcare provider in South and Central Texas, with 27 facilities, including nine acute-care hospitals serving more than 90,000 inpatients and 390,000 outpatients annually. The system’s ownership structure is a 50/50 co-ownership between not-for-profit Methodist Healthcare Ministries and investorowned Hospital Corporation of America (HCA), a truly unique business model for health systems in the country. Methodist Healthcare Ministries is a private, faith-based, not-for-profit organization dedicated to providing medical and health-related human services to low-income families and the uninsured in South Texas. Methodist Healthcare Ministries is second only to the government in providing healthcare to the indigent population in a 26-county area. HCA, based in Tennessee, is the nation’s leading provider of healthcare services, composed of 163 hospitals and 105 freestanding surgery centers in 20 states and England.
MISSION, VISION Our mission is “serving humanity to honor God by providing exceptional and cost effective healthcare accessible to all.” Our vision is to be a world-class healthcare provider, continually raising the standards of performance excellence and advancing the health 24 San Antonio Medicine • August 2014
status of the community. Led by a culture of Methodist Excellence, the more than 8,000 staff and volunteers, combined with a medical staff of more than 2,500, dedicate themselves to continuous quality improvement by committing to live by the Methodist Excellence mission, vision and values. Methodist Excellence is the foundation of all aspects of the healthcare system; from the hiring process to the strategic planning process. This commitment to quality and process improvement enables us to provide better service and outcomes to our patients and that is what drives us to be nothing less than excellent. Our journey to excellence is based on the National Malcolm Baldrige Quality Award criteria. The Baldrige Award was established by Congress in 1987, envisioned as a standard of excellence that would help U.S. organizations achieve world-class quality. The award is based on seven key areas. In the healthcare industry, we are all facing the same cost pressures. Whether a hospital or a physician, we must provide high-quality care at a lower cost. Our journey to excellence has provided a way for us to address this issue in collaboration with our physicians.
PHYSICIAN INVOLVEMENT For the last five years, we at Methodist Healthcare have worked through teams of doctors, nurses and other clinical staff organized by service lines to improve care. Physicians’ involvement is critical to our journey. Each clinical service line is co-managed by a physician leader and an administrative leader. Working together, these teams have created protocols that have resulted in efficiencies of physician and staff time, cost savings and patient-flow.
CARE SYSTEM PROFILES
Using the Baldrige template has allowed us to learn from successes achieved in other industries. It has encouraged us to embrace new approaches, challenged us to learn a new language, and helped us grow by sharing our experiences with others. Working closely with our physician leaders, Methodist Healthcare has been recognized with several quality awards. In 2012, Methodist Hospital and its affiliated campuses received one of only two gold awards presented by the Texas Medical Foundation Health Quality Institute for distinguished efforts in healthcare quality improvements. This was quite an achievement as the competitive field included 214 hospitals throughout the state. In 2013, Methodist Hospital received the Bill Aston Quality Award for innovations in quality, based on the Methodist Hospital Cardio-Hospitalist Program and clinical outcomes. Methodist Healthcare recently received the Texas Award for Performance Excellence (TAPE) from the Quality Texas Foundation, representing the highest level of quality an organization can achieve in the state of Texas. This award is based on the Malcolm Baldrige criteria. Methodist Healthcare is the first healthcare system in South Texas to receive the TAPE award since the inception of the award in 1994.
MILESTONES REACHED Excellence is a journey, not a destination. Here are a few of the many milestones that Methodist Healthcare has reached along our journey: • Evidenced Based Care Measures (Composite Core Measures) are in the top 10 percent of the nation, for those care interventions known to improve patient mortality and complications. • The Methodist Healthcare in-hospital mortality rate is only 50 percent of what is expected given the severity of illness levels of system patients. For Methodist this translates into 530 fewer patients dying each year than should be expected given patients’ risk factors. • The Patient Safety Indicator (PSI) 90 is a composite score of several in-hospital patient complications. Methodist Healthcare scores significantly lower (better) at 0.46 than the national average of 0.6, indicating a much lower hospital complication rate than most hospitals. • Methodist Healthcare’s quality initiatives include a reduction in hospital acquired conditions (infections, etc.) and a reduction in heart failure readmissions. Methodist Excellence recognizes that best practices save lives. When people see real results — patients receiving better care, doctors using their time more effectively, and staff experiencing increased job satisfaction — their commitment to excellence grows stronger and leads to continuous quality improvement throughout the system.
Our goal is not just to be the best in San Antonio, but to be the best in the nation. Achieving this lofty goal requires a close collaborative working relationship with our physicians. Kenneth Davis, MD, has served as the chief medical officer for San Antonio’s Methodist Healthcare since 2008. Prior to joining Methodist, he served for 16 years as the chief medical officer at North Mississippi Health Services, winner of the Malcolm Baldrige National Quality Award in 2006 and again in 2012. Dr. Davis was in private practice specializing in internal medicine and geriatrics for 20 years. He is a fellow in the American College of Physicians.
METHODIST HEALTHCARE Methodist Hospital and its campuses: Methodist Children’s Hospital Methodist Heart Hospital Methodist Specialty and Transplant Hospital Metropolitan Methodist Hospital Methodist Texsan Hospital Northeast Methodist Hospital Methodist Ambulatory Surgery Hospital Methodist Stone Oak Hospital
EXPANSION DETAILS • Largest-ever expansion of Methodist Hospital and Methodist Children’s Hospital and the biggest expenditure in the hospital system’s history • Addition of nearly 500,000 square feet, increasing their footprint in the medical center nearly 40 percent • New adult patient tower with beds for general acute care and critical care • New six-story tower for pediatric patients • Nine-story parking garage with underground access to surgical services • Both hospitals will have new entrances • Conversion of 90 percent of patient rooms at both hospitals to private rooms • Increase of number of beds in the newborn intensive care unit from 78 to 94 • Expansion of emergency departments in both hospitals • Upgrades in the hospitals’ cancer and heart services, labor and delivery unit, general surgery and neurosurgery areas and pediatric services • Expected completion in 2017
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25
BCMS FOUNDATION
BCMS Foundation resumes its mission:
creating scholarships
The Bexar County Medical Society Foundation resumed its educational mission in May, led by the Foundation’s executive director Steve Fitzer, Foundation manager Lisa Robertson and Gerardo Ortega, MD, the Foundation’s acting president. The Foundation will return to its goals of raising scholarship money for graduating high school seniors who are planning to enter the field of medicine, whether as physicians, nurses or in other allied health positions. This is the original purpose under which the Foundation was created when it was granted an endowment by the then Methodist Foundation, said Fitzer, BCMS executive director/CEO. “BCMS is excited about this philanthropic effort and plans to begin offering scholarships in the spring of 2015,” Fitzer said. “The generosity of BCMS physicians together with its sponsors make this entire effort possible, benefitting not only students but also patients as these future medical workers contribute through clinics, hospitals,
26 San Antonio Medicine • August 2014
surgery centers, physicians’ offices and the like. In addition, the Foundation enables great social events that unite the medical community.” Foundation board members include Douglas Browne, Cindy Comfort, Steve Fitzer, Gigi Gross, Jim Kelso, K. Ashok Kumar, MD, Monty LaPierre, Jesse Moss, MD, John Nava, MD, Gerardo Ortega, MD, Sharvari Parghi, MD, Lee Rodgers, MD, Shirley Sanders, Reema Shroff, Rebecca Waller and Tolbert Wilkinson, MD. The Foundation’s first event is a golf tournament Sept. 18 at the Quarry Golf Club. A Valentine’s Day Gala is planned for February 2015. BCMS and the Foundation welcome participation from sponsors and volunteers to help create scholarship opportunities for San Antonio’s future medical workforce. For information, contact Lisa Robertson at lisa.robertson@bcms.org.
BUSINESS OF MEDICINE
QUALITY and your bottom line By Pamela C. Smith, PhD Quality is a resounding buzzword in the industry today. A sim-
need an app for scheduling appointments? Do you provide free
ple Google search for “quality of care” can result in more than 4.4
wi-fi? Dr. Lawrence “Rusty” Hofmann, in a Feb. 21, 2014, blog
million hits. Search results include everything from Medicare to
in the Huffington Post, argues these operational and administra-
Medicaid, and scholarly articles attempting to define what quality
tive goals are a mistake . Should patient satisfaction be based on
of care really means. The Affordable Care Act’s National Quality
how well you are able to manage the patients’ chronic condition?
Strategy is not the first, and won’t be the last, attempt at defining
There is no concrete right or wrong answer.
quality and its impact on the healthcare community.
In an attempt to balance this issue of patient satisfaction and
From a physician’s standpoint, the definition of quality also
define quality of care, physician practices can turn to the Con-
varies. No matter how you define quality, it is crucial to under-
sumer Assessment of Healthcare Providers and Systems Clinician
stand that quality does affect your bottom line. Furthermore, a
and Group Surveys (CG-CAHPS) for answers. The goal of these
newer and vaguer aspect of quality will affect your practice’s costs
surveys is to focus on patient experience with care, such as how
– patient satisfaction. The Texas Medical Association (TMA) em-
well providers communicate with patients; are patients able to re-
phasizes physicians need to become more aware of the importance
ceive timely appointments; how helpful/courteous is the office
of quality of care and patient satisfaction measures. Medicare is
staff. Under Medicare’s PQRS, CAHPS surveys are required and
now providing incentive payments (an additional 0.5 percent
provided at no cost to group practices of 100 or more physicians.
through 2014) based on quality reporting through the Physician
This requirement directly links potential incentive payments to
Quality Reporting System (PQRS).
patient experience/satisfaction. For smaller practice groups of 25
Beginning in 2015, penalties will be assessed to eligible profes-
to 99 physicians, patient feedback is optional for the PQRS qual-
sionals who are not “successful reporters.” These professionals will
ity data, and CMS does not cover the cost. In addition to affecting
be paid 1.5 percent less than the Medicare Physician Fee Schedule
Medicare reimbursements, some accreditation agencies also may
(PFS) amount for 2015 services. Under the PQRS the types of
require assessment of patient satisfaction.
quality measures will vary yearly, and are based on specialty and
Our evolving industry continues to focus on quality of care
reporting method used. The Centers for Medicare and Medicaid
which is difficult to define. The increasing trend toward patient
Services (CMS) state focus areas include patient safety, clinical ef-
satisfaction is flooding the Internet with strategies to “boost your
fectiveness, population/community health, efficiency and cost re-
patient satisfaction.” This trend will lead some to question:
duction, person/caregiver centered experience and outcomes.
Should your Medicare reimbursement be linked with the convenience of your parking garage?
PATIENT ‘SATISFACTION’ One aspect of quality often discussed nowadays is patient “sat-
Pamela C. Smith, PhD, is an associate
isfaction.” For example, a hospital website states, “Our definition
professor of accounting at the University of
of quality reflects our commitment to excellence and combines
Texas at San Antonio. She teaches in the un-
patient outcomes and patient satisfaction.” What really consti-
dergraduate and graduate tax program, as
tutes patient satisfaction is debatable. Does it mean you need Star-
well as the MBA program, business of
bucks coffee provided in your waiting room? Does your practice
healthcare track. visit us at www.bcms.org
27
PHYSICIAN AS PATIENT
Physician as Patient
EDITOR’S NOTE: This is the fifth in a series of articles written by San Antonio anesthesiologist Jay Ellis, MD, a member of the BCMS Communications/Publications Committee. The series, published monthly in San Antonio Medicine, examines the physical, emotional, financial and spiritual burden of life-threatening illness
The economics of serious illness By Jay Ellis, MD What does it cost to get sick? It costs a lot. Here is a breakdown of just some of our expenses during the first six months of my illness.
MEDICAL COSTS There is a commonly accepted belief that medical costs are the primary cause of bankruptcy in the United States. Whether or not that statement is true depends on how you define the cause of bankruptcy. It is true that medical bills and serious illness are a major factor in bankruptcies for many people. Whether or not they are the primary cause in the majority of cases depends on how you define your terms. I don’t want to debate the issue, but let’s say that if your finances are precarious, a major illness will push you over the edge. Why? Let’s review my costs. From September 2013 through February 2014, my private insurance paid just under $120,000 for my care. Tricare paid another $8,000. The table published here shows approximate costs for various items. Chemotherapy seems very expensive (and from my personal experience, worth every penny), but the bulk of the cost is for two drugs. Insurance pays around $5,000 for rituximab and $3,000 for pegfilgastrim. The hospital payment for a three-day stay in the ICU and two days on the rehab floor was just under $20,000. One would think that with all that money flowing out I would be off the hook. Not true. 28 San Antonio Medicine • August 2014
Since I was unlucky enough to get ill at the end of one year and the beginning of another, I had to meet two sets of deductible limits. I guess the moral of that story is don’t get sick in December unless you can be out of the hospital by New Year’s Eve. My share after the $120,000 was $14,000. In truth, I paid a fraction of this because I also have Tricare insurance, which paid once I met my annual $3,000 cap. I also have other advantages such as a flexible spending account. It is also true that my treating physicians extended professional courtesy on several occasions despite my pleas to send a bill. We live in a great medical community. It is easy to see how serious illness could devastate the financial reserves of some people. Medical bills alone can be overwhelming, especially if you have a high deductible policy and you happen to have an illness that covers two calendar years. In that situation you could end up paying $10,000 before insurance pays a dime.
PHYSICIAN AS PATIENT
Tejas Anesthesia staff include (seated from left) Jennifer Villanueva, Darla Herlitz, Heidi Barrera and (standing from left) Jo Ann Morris and Marta Reyna. Courtesy photo
I remember waiting for my chemotherapy appointment and seeing the faces of people emerging from the financial counselor’s office. Having a life-threatening illness and facing bankruptcy at the same time seems an unbelievably cruel predicament.
MISSING WORK Working half-time does not result in half the pay. As every business owner knows, you work most of the month to pay expenses and taxes. The last week of the month represents your profit, and if you miss that week, there is no profit. I watched my paycheck gradually dwindle in size until it reached a nadir of $236 for one month. It reminded me of my days pumping gas in high school. This is when disability insurance proves critical. I have friends who don't have disability insurance because it is too expensive. It is expensive, but not having it may prove catastrophic. When I became ill, I spoke to people in my group who faced disability. David Davis was a great source of advice. He told me that waiting too long to file for disability is a serious mistake. Insurance companies base your replacement income on your current earnings. The definition of the time period used in the earnings calculation is specified in the disability policy. He advised me to file right away when I was first diagnosed, which I did. I claimed disability from the day of my first chemotherapy. It would prove to be a wise decision. With all disability policies there is a waiting period. I had three policies, two with a three-month waiting period and one with a six-month waiting period. My first payments from the three-month policies would coincidentally begin the month I had to stay home. I heard horror stories of insurance companies denying payment, or reducing payment because of problems proving income. My insurance carriers were helpful and empathetic. They tried to
make the application process easy, but they do require a mountain of paperwork. I had to produce five years of income tax returns, with all schedules. I had to produce productivity data for 12 months from my practice. Fortunately my group, Tejas Anesthesia, was invaluable. They produced reports without any effort on my part, and all I had to do was stand at Kinko's for one hour copying tax returns. It was fortunate that I was still well enough to accomplish these tasks. I asked my wife, Merrill, what she would have done had I not been able to do this, and she gave the right answer. She would speak to our administrator John Spiekerman. If she had problems with insurance she would talk to my office manager Marta Reyna. Those were good answers, but I still made sure she understood where I kept all the insurance documents and contact phone numbers. Another advantage I have is a military pension. It really is a form of disability insurance, in that it pays throughout the lifetime of the veteran, whether you are employed or not. We never had a time when there wasn't at least some money coming in. I wouldn't want to live on my military pension, but it helped keep us afloat in those months before the disability insurance payments kicked in. Personal savings are essential to weather a serious illness. The light bill, the mortgage payment, the car payment, the medical insurance payment and any other expenses you might have still come when you are ill. Merrill and I put away a considerable amount in savings, one year’s living expenses. We didn't do this because we thought one of us might become ill. We did it because I was afraid that after retirement, the U.S. military might call me back, and we would have to exist on my Air Force salary. Having a cash cushion kept us from having to worry about money while we were also worrying about my illness. Continued on page 30 visit us at www.bcms.org
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PHYSICIAN AS PATIENT Continued from page 29
SAVING YOUR PRACTICE Even with disability insurance, personal savings and the luxury of a military pension, I still wondered if I would have a practice to which I could return. I realized that though I was sick, other people’s lives would go on. My patients would still need care, my referring doctors would still need help, and the surgeons I worked with in the operating room would still need coverage. It was at this time that I began to fully appreciate what a wise choice I made in joining Tejas Anesthesia. My partners in my pain practice, Jim Growney, Tim Orihel and Arnold DeLeon, saw all my patients and made sure that they had uninterrupted care. My office staff was instrumental in explaining my predicament to my patients, and my patients’ loyalty was overwhelming. I cannot count how many other members of Tejas Anesthesia offered to back me up if I wanted to take call or provide relief if I got tired while in the OR. Before I became deathly ill, Vanessa Weems, who does our scheduling, would offer me stipend work if extra shifts became available. Without their support I would have had to rebuild my practice from scratch, hustling like a new grad, except now I’m
30 San Antonio Medicine • August 2014
58 years old and recovering from a serious illness. That is not a pretty picture. When I was in the military, young doctors would often ask me for advice while looking for a job. I told them the two least important questions to ask are, “How much money will I make, and how much call will I take?” The most important questions to ask are, “Would I let these doctors take care of my family, and if I drop my wallet and turn my back would there be any money left in it?” If you can say yes to both of these questions most other issues will work themselves out. In truth, I didn’t save my practice – my partners and my group did. I will be forever grateful for their support. I challenge everyone to perform this thought experiment: How will my organization react if I become ill and I am gone for several months? I challenge every organization to ask the question: How will we support our members if they become incapacitated? In retrospect, I realize that we were quite blessed to get through the financial part of this illness so well. As a physician, I have many advantages not available to the average person. While I would like to say that I made a great financial plan that saved us,
PHYSICIAN AS PATIENT
Tejas Anesthesia physicians include (from left) Dr. Timothy S. Orihel, Dr. Jay Ellis, Dr. Arnold DeLeon and Dr. James L. Growney. Courtesy photo
the truth is many of the decisions I made were never done with the thought there would come a time I couldn’t work. Like many doctors, I considered myself invincible, dare I say, indestructible. I will never hold that belief again.
NEXT: Recovery.
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HASA
Coordinating high-quality care with HIT By Vince Fonseca, MD, MPH, FACPM
A previous column described various quality and clinical performance reports that can be done using HASAFacts to support Accountable Care Organizations (ACOs). There are 33 clinical quality reports to be done for the ACO’s aggregate population of at least 5,000 patients. ACOs were created by the 2010 Patient Protection and Affordable Care Act (ACA) to improve care and lower the rate of cost increases in Medicare. The same ACO approach can be applied to any provider’s panel of patients to improve health by improving care and also provide better value (the “triple aim” of healthcare). The key to these aims is better coordination of the delivery of higher-value services and decrease lower-value services. Patients see a variety of providers, both outpatient and inpatient, and sharing timely clinical information between providers, especially the primary care provider, is critical to effective care coordination and better outcomes. HASA is able to provide some of the services so that providers participating in the care of the patient are able to get this integrated information more quickly and completely.
FOUR KEY TECHNOLOGIES A recent article in the American Journal of Accountable Care1, “Four Key Technologies for Physician-led Accountable Care Organizations,” describes what HIT features best support physicians as they work to improve quality of the care they provide to their patients. EHRs are not enough because they don’t yet easily allow sharing of patient information. A system of HIT services is needed (e.g., HASA services) to securely share patient information so that care can be coordinated based on the individual needs of each patient. The first area of innovation is risk stratification so that a personalized care plan can be made for the patient and then kept current. A previous column covered risk stratification using the comorbid conditions found in a patient’s records to provide a stratification of clinical complexity. Psychosocial complexity is also important, and gathering patient-generated health data on personal barriers to better health allows for stratification.
32 San Antonio Medicine • August 2014
The second area the authors describe is that of “advanced network management” to allow for better coordination across consultants, inpatient and postacute providers. Near real-time sharing of clinical information is available using HASAProviderAssist between outpatient and inpatient providers. The third innovation area is to alert providers of emergency department visits and hospital admissions, discharges and transfers (ADTs). An ED visit or unplanned hospitalization indicates that there is an opportunity to review and perhaps improve the care plan. A discharge summary from an ED visit or hospitalization is helpful to the outpatient provider when providing post-discharge services and adjusting care plans. ED and ADT alerts are available in HASAFacts, and discharge summaries are in ProviderAssist. The fourth innovation area is “patient outreach and engagement.” MyHASA is the patient portal that allows patients to view their clinical information that comes from multiple providers and EHRs. Patient portals have been shown to improve patient engagement, especially when they are not tethered to just one EHR. MyHASA also allows for patients to have proxies and thus engage the family and other caregivers. With HASA services developed in conjunction with providers and organizations, BCMS members will be better situated to improve care provided to their patients and to meet quality and cost benchmarks. 1
http://www.ajmc.com/publications/ajac/2014/2014-1-vol2n1/four-key-technologies-for-physician-led-accountable-care-organizations/2#sthash.CXT53nkG.dpuf Vince Fonseca, MD, MPH, FACPM, is the director of medical informatics at Intellica Corp., and the medical advisor for Healthcare Access San Antonio (HASA), the local Health Information Exchange (HIE) provider authorized by the state of Texas to create a community-based, regionwide HIE in Bexar County and 22 surrounding counties. Visit www.hasatx.org.
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UTHSCSA DEAN’S MESSAGE
SOUTH TEXAS EPILEPSY CENTER: Advancing and extending care By Francisco González-Scarano, MD In the United States, about 2.3 million adults and a half million children – including more than 200,000 Texans – have epilepsy. One hundred fifty thousand new cases are identified annually, approximately a third in children; most cases of epilepsy – about two-thirds – are idiopathic. Although epilepsy is not usually thought of as a fatal disease, certainly not in the majority of individuals, it is estimated that 50,000 people a year die from seizures and related causes, an issue that has received increased recognition, as many of these deaths appear to be from seemingly unrelated causes such as automobile accidents. While with treatment most individuals can have a productive life, in some circumstances epilepsy can result in poor school performance, inability to work and drive, and in an uncertain economic future. The South Texas Comprehensive Epilepsy Center (STCEC) at the UT School of Medicine opened in 1995 in collaboration with the University Health System (UHS). It is one of the largest epilepsy programs in the state and the only Level IV comprehensive epilepsy treatment center for adults and children in Central and South Texas. This is the highest accreditation awarded by the National Association of Epilepsy Centers (NAEC), and it is given to epilepsy centers that deliver state-of-the-art care to adults and children, particularly those whose seizures are not fully controlled by medications.
MULTIDISCIPLINARY TEAM Dr. Charles Akos Szabo, a neurologist who trained at the Cleveland Clinic Foundation’s epilepsy program, leads the center and cares for patients at UHS and at the UT Medicine Medical Arts and Research Center (MARC) “Comprehensive epilepsy care requires a multidisciplinary team, including epilepsy specialists, neurosurgeons, psychologists, psychiatrists and neuropsychologists,” says Dr. Szabo. “My goal was to bring them all together to create a state-of-the-art center for adults and children with epilepsy – both for medical and surgical treatment.” Dr. Lola Morgan, a fellowship-trained epilepsy specialist, is the co-director of the clinical program of the STCEC, and oversees the inpatient service at UHS, monitors the quality of care, and directs the clinical neurophysiology fellowship program. Dr. Jose Cavazos, who trained at Duke University, is also a clinical neurophysiologist and heads the associated Epilepsy Center 34 San Antonio Medicine • August 2014
of Excellence at the Audie Murphy VA Hospital. Dr. Linda Leary, who trained at Columbia University in New York, focuses on pediatric epilepsy patients for UT Kids. Other key neurologists on the epilepsy team are Drs. Kameel Karkar and Octavian Lie, who are also fellowship trained in epilepsy. All of these neurologists work very closely with two of the UT neurosurgeons who focus on epilepsy: Drs. Alexander Papanastassiou, who undertook an epilepsy surgery fellowship at Yale University, and Jean-Louis Caron, who was trained at the Montreal Neurological Institute, one of the pioneer centers for epilepsy surgery. With more than 5,000 patient encounters a year, our program also includes outreach clinics in South Texas; these have recently expanded from a single one in Harlingen, to four now, including Del Rio, Laredo and Eagle Pass. These clinics are part of a partnership between the STCEC and the Epilepsy Foundation, and are supported by state and federal grants to bring much-needed epilepsy specialists to the area for both the insured and uninsured. The center’s clinical and laboratory research, focused around improving the lives of people with epilepsy, involves collaborations with scientists at the Health Science Center’s Graduate School of Biomedical Sciences, the Research Imaging Institute, and Southwest Foundation for Biomedical Research. Funding comes from the National Institutes of Health and the Veterans Administration. The center’s most recent publication is an article by Dr. Cavazos on the effectiveness of combining anti-seizure medications, published in JAMA online. Although the center treats many forms of epilepsy, one of the crucial areas in which our program distinguishes itself is in the availability of surgical treatment. Approximately 25 epilepsy surgeries are performed each year for epilepsy, and 30 vagal nerve stimulators are implanted or replaced annually. Resective surgery for epilepsy is indicated for medically refractory seizures that originate in a single region of the brain. The goal of the surgery is to remove or ablate, as precisely as possible, the tissue responsible for the initiation of the seizure without harming the rest of the brain. Epilepsies that are candidates for surgical treatment often include those associated with tumors, blood vessel abnormalities, scar tissue or developmental abnormalities of the brain. A distinguishing feature of our program is that surgery can be performed in many areas of the brain, not just
UTHSCSA DEAN’S MESSAGE
the temporal lobe, which is the most common area for surgical resection in epilepsy. There are also other surgical options available to patients when indicated. These include neurostimulation, hemispherectomy and corpus callostomy. Pre-surgical evaluation is an understandably elaborate process, and several tests are performed before any recommendation for surgery is considered. Video-EEG monitoring, magnetic resonance imaging (MRI), single photon positron emission computerized tomography (SPECT), and positron emission tomography (PET) are used to help locate the seizure onset zone. MRIs can reveal structural abnormalities that can cause seizures, such as tumors, cerebral or vascular malformations, or scar tissue. PET scans are used to measure the metabolism of glucose or blood flow, indicating the health of brain regions in patients when they are not having seizures. Potential risks to surgery are determined with neuropsychological testing, the intracarotid amobarbital procedure, as well as functional neuroimaging. A neuropsychological assessment is also done to assess memory and language areas. These tests are carried out before and after epilepsy surgery to evaluate potential risks posed by the surgery and cognitive outcome. The intracarotid amobarbital procedure (IAP) is performed in concert with a neuroradiologist, who by injecting one carotid artery with amobarbital causes half of the brain to fall asleep and identifies the hemisphere responsible for language function. Functional PET and MRI are also important for the mapping of motor, sensory and language areas. The IAP and functional neuroimaging studies are crucial for the surgeon to plan for the safety of the patient during surgery. In the pre-surgical evaluation, candidates are admitted to the epilepsy monitoring unit (EMU) at University Hospital for a 24hour video observation that records any visible evidence of a seizure in conjunction with electroencephalography (EEG). With almost 400 admissions per year for video-EEG monitoring, some patients can be identified as potential epilepsy surgery candidates, which is ideal for those for whom 100 percent of the seizures originate from one focus. The new Sky Tower at UHS includes a new monitoring unit that includes 10 adult and four pediatric beds. The SPECT scanning is performed in the same unit by administering a shortacting radioactive tracer during a seizure. This helps to further define the seizure focus, which has a high metabolic rate and concomitant increase in blood flow relative to a control state. The assessments are presented to our multidisciplinary team of epileptologists, neurosurgeons, neuroimaging specialists, psychiatrists and neuropsychologists, and the intervention most beneficial to the patient is then crafted. In the final steps, the patient is examined by the neurosurgeon, who will also discuss the risks and benefits of the proposed surgery. The STCEC has adopted newer and less invasive tools for evaluating and treating epilepsies amenable to surgical treatment.
Stereotactic EEG (s-EEG) is one method for mapping where seizures originate, used by relatively few centers in the United States. S-EEG uses up to eight depth electrodes with sensors to monitor brain activity on each side of the brain. These are placed through tiny burr holes, obviating the need for a craniotomy and placement of a more complex surface grid. This method also allows for sensors to record in areas that are very difficult to access via craniotomy, such as the recesses areas between the two brain hemispheres, or deeper structures, such as the insula. Another promising treatment adopted by the neurosurgeons at the STCEC is an ablation therapy using a stereotactically guided laser that also avoids a craniotomy. Administered through a small burr hole and guided by an MRI, the technique has proven effective with much less risk to the patient and much faster recovery times. Outcomes have been very positive; one study tracking 130 cases reported that 83 percent of temporal lobe resections result in Class 1/2 outcomes, meaning that the patients are seizure free or have rare seizures after one year. In the extratemporal resections, 64 percent of cases were Class 1/2. This lower rate for the extratemporal group is attributed to the need to preserve some areas of the epileptogenic focus in order to maintain critical neurological functions.
EFFECTIVE SURGICAL TOOL A vagal nerve stimulator is another effective surgical tool as well, and requires little postoperative care other than regular neurological follow-up for programming the device. A similar device will be adopted by the STCEC team using electrodes implanted into the brain to sense the beginning of a seizure and automatically block its evolution with a small current. The system is type of therapy is referred to as responsive neurostimulation. There are many members of this multi-disciplinary team: neurologists, neurosurgeons, psychiatrists/psychologists and other specialists, nurses, nurse-case managers, social workers and others. They function as a unit to improve the quality of life in patients who have few or no alternatives. The significance and impact of the work they have done to advance the broad categories of epilepsy treatment – and the patients who can now access this care -- cannot be understated. My congratulations to them all. To learn more or refer a patient, please contact UT Medicine at 210-450-9700 or email epilepsy@uhs-sal.com. Dr. Francisco Gonzålez-Scarano is dean of the School of Medicine, vice president for medical affairs, professor of neurology, and the John P. Howe III, MD, Distinguished Chair in Health Policy at the University of Texas Health Science Center at San Antonio. His email address is scarano@uthscsa.edu. visit us at www.bcms.org
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BOOK REVIEW
Short reviews of two excellent books ... and a brief mention of a third Reviewed by Fred H. Olin, MD I recently had the pleasure of reading two really engrossing novels. If the quality of a piece of fiction can be rated by one’s eagerness to get back to reading when interrupted, both of these rank very high. The first, “Red Sparrow” by Jason Matthews, is a current-day spy thriller which centers around two young intelligence operatives, Nathan Nash of the CIA, who is in Moscow on his first assignment, and Dominika Vassileyevna Egorov, the beautiful niece of a highranking official in the SVR, Russia’s Foreign Intelligence Service. An envious rival had cut her promising ballet career short by a bit of sabotage, and she’s recruited by her uncle to be a counterspy. As part of her training she is sent to the “Sparrow School,” where young people of both genders are taught to sexually seduce potential sources of information. Her first assignment is to try to recruit Nate Nash. The story develops as she is delegated to find a “mole” in the SVR. It turns out that the mole’s handler is our boy Nate, who is disliked by the Moscow chief of station, and is demoted to Helsinki … but his mole is high enough in the SVR that he periodically travels, and their relationship continues. Dominika is sent to Finland, and the story accelerates. There are the usual ins and outs, twists and turns of this genre. For example, there is the expected “boy meets girl” plot line, but it doesn’t develop as one might expect. We encounter only one real-life personage: President Vladimir Putin. He is just as lovable in this book as he seems to be in real life. Every chapter contains a reference to food, somehow, and as a bonus there are rudimentary recipes for the mentioned dishes at the end of each chapter. These little items were actually really interesting. The second book is “The Cuckoo’s Calling” by Robert Galbraith, who isn’t Robert Galbraith at all, but J.K. Rowling, the author of the Harry Potter series, writing under a pseudonym. This is a Londonbased detective story of the “noir” variety, featuring a somewhat down-and-out, debt36 San Antonio Medicine • August 2014
laden former member of the British military’s criminal investigative branch, who lost a leg in Afghanistan. The protagonist, whose name is Cormoran Strike, and whose lack of business has him down to sleeping in his office, engages a temporary receptionist, the recently betrothed Robin Ellacott. As one sort of expects, Robin becomes his sidekick. The story takes off when, on Robin’s first day, a new client shows up and asks Strike to investigate whether the death three months earlier of his adoptive sister, Lula Landry, a supermodel, was really suicide, as determined by the police, or if it could have been murder. The story delves into the realms of high fashion, the aristocracy, addiction, adoption, shelters for the homeless, racial politics, pop music, paparazzi and, of course, police activities. Just like “Red Sparrow,” it has convoluted convolutions, surprising relationships, unexpected findings and interesting characters. The London streets that Strike traverses are accurately described, and when I went looking for the location of his office, I found the building, and it even had the street-level bar mentioned in the book. (Google Maps comes through again!) In summary, this is a first-rate mystery, with believable characters and an unexpected resolution, set in a variant of the real world that may, just may, be real indeed. Now, for the brief mention. On the recommendation of friends, I read “If the Devil Had a Wife” by Frank Mills. It’s a true, well-documented story about corruption in Orange, Texas, the University of Texas at Austin, the ultimate dysfunctional family, multiple murders by poison, embezzlement, forgery, theft, etc., etc. I tried to write a real review of it. I couldn’t figure out how to encapsulate the complexity. Read it. You won’t be disappointed. Be aware that it’s not a new book, and you might have to search it out somewhere. The San Antonio Public Library has a copy or two, I know. Just be warned: I couldn’t put it down. Fred H. Olin, MD, is a semi-retired orthopaedist and chair of the BCMS Communications/Publications Committee.
BCMS GROUP PURCHASING AND SERVICE DIRECTORY Please support our sponsors with your patronage; our sponsors support us.
• ACCOUNTING Anderson, Johns & Yao CPAs (HH Silver Sponsor) We strive to provide a professional and friendly atmosphere for all your accounting and financial needs Ann Yao, CPA/PFS, 210-696-9400 yao@ajycpa.com www.ajycpa.com San Antonio based CPA firm with 30 plus years of experience Padgett Stratemann & Co. LLP (HH Silver Sponsor) Padgett Stratemann is one of Texas’ largest, locally-owned CPA firms, providing sophisticated accounting, audit, tax, and business consulting services. Vicky Martin, CPA 210-828-6281 Vicky.Martin@Padgett-CPA.com www.Padgett-CPA.com Offering Service. More Than Expected. On every engagement. Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets. Jim Rice, CPA, 210-384-8000, ext 112 jprice@ssacpa.com www.ssacpa.com Dedicated to working with physicians and physician groups
• ATTORNEYS
Carabin Shaw Law Firm Texas Prompt Pay Lawyers (HHHH Platinum Sponsor) Paul L. Sadler psadler@carabinshaw.com www.carabinshaw.com 210-222-2288 Cox Smith Matthews, Inc. (H Bronze Sponsor) The largest Texas law firm headquartered in San Antonio and one of the top 25 largest Texas
law firms. Dan G. Webster, III 210-554-5500 dgwebste@coxsmith.com www.coxsmith.com Pulman, Cappuccio, Pullen, Benson & Jones (H Bronze Sponsor) The attorneys at Pulman, Cappuccio, Pullen, Benson & Jones, LLP have over 150 years of combined experience providing exemplary representation for clients. Eric Pullen, 210-222-9494 EPullen@pulmanlaw.com
BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance. BB&T offers banking services to help you reach your financial goals and plan for a sound financial future Ed L. White, Jr. 210-247-2989 ewhite@bbandT.com www.bbandt.com
• BANKING
Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with 5 core values; Attention, Accountability, Appreciation, Adaptability & Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett 210-343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com Community Banking Partnership
BBVA Compass (HHH Gold Sponsor) A multinational banking group providing financial services in over 30 countries,and to 50 million clients throughout the world. Commercial Relationship Manager Zaida Saliba, 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com Working for a better future
Broadway Bank (HHH Gold Sponsor) Broadway Bank is a full service personal and commercial bank with a specialized Healthcare banking team committed to supporting our medical community. We offer 40 convenient locations in San Antonio, Austin and surrounding areas. Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com We’re here for good.
CROCKETT NATIONAL BANK (HHH Gold Sponsor) Crocket National Bank is a leading Texas community bank specializing in mortgage, ranch and commercial real estate lending providing superior customer service and competitive financial products. Lydia Gonzales, 210-384-9304 lydiagonzales@crockettnationalbank.com www.crockettnationalbank.com Doing what we promise.
Frost (HHH Gold Sponsor) As one the largest Texas-based banks,Frost has helped Texans with their financial needs since 1868, offering award-winning
customer service and a range of banking, investment, insurance services to individuals and businesses. Lewis Thorne 210-220-6513 lewis.thorne@frostbank.com www.frostbank.com Frost@Work provides your employees with free personalized banking services.
The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are one of the few agents in the state that specialize in Medical Malpractice and all lines of insurance for the medical community. Brandi Vitier 210-807-5581 brandi.vitier@thebankofsa.com Citi Commercial Bank (HH Silver Sponsor) Chris McCorkle 210-408-5014 christopher.a.mccorkle@citi.com www.citi.com Bank SNB (HH Silver Sponsor) Bank SNB combines the resources of a full-service bank with the expertise of healthcare specialists to deliver services that maximize your revenue and profit. Sandy Cilone, 210-442-6145 sandycilone@banksnb.com www.banksnb.com The opportunity to work with a team of healthcare advisors to achieve the financial goals of your practice.
Continued on page 38
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BCMS GROUP PURCHASING AND SERVICE DIRECTORY continued from page 37
Baptist Credit Union (HH Silver Sponsor) It is Baptist Credit Union’s mission to meet our members needs by providing extraordinary service, quality financial products, and personal financial education. Sarah Chatham 210-525-0100, ext 201 memberservices@baptistcu.org www.baptistcu.org We commend your dedication to the health & wellbeing of our community. Firstmark Credit Union (HH Silver Sponsor) Address Your Office Needs. Upgrading your equipment or technology? Expanding your office space? We offer loans to meet your business or personal needs. Competitive rates, favorable terms, and local decisions. Gregg Thorne, SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org St. Joseph's Credit Union (HH Silver Sponsor) A Credit Union providing savings, checking, IRA, club, and CD accounts. Plus, Auto, signature, Lines of Credit, MasterCard and Real Estate Loans. Debra Abernathy 210-225-6126 lending@sjcusatx.net www.sjcusatx.com Better Rates on Auto loans, Signature loans and Platinum MasterCard Jefferson Bank (H Bronze Sponsor) Full service bank specializing in mortgages, wealth management & trusts. Ashley Schneider 210-734-7848 ext 7848 aschneider@jeffersonbank.com www.jeffersonbank.com Security Service Federal Credit Union (H Bronze Sponsor) Business financing, specializing in low interest commercial real estate transactions Luis Rosales 210-845-8159 lrosales@ssfcu.org BCMS members can get up to half a percent off the origination fee
Texas Farm Credit (H Bronze Sponsor) Rural, homestead and acreage lending. Tiffany Nelson, 210-798-6280 www.texasfcs.com
• BUSINESS CONSULTING/ COACHING The Growth Coach Kay Wakeham (H Bronze Sponsor) k.wakeham@thegrowthcoach.com www.thegrowthcoachsanantonio.com 210-492-2400
• CATERING Corporate Caterers (H Bronze Sponsor) Mr. Ricardo Flores 210-789-9009 Heavenly Gourmet Catering (H Bronze Sponsor) 210-496-9090 www.heavenlyg.com
• CONTRACTOR/ BUILDERS HUFFMAN DEVELOPMENTS (HH Silver Sponsor) Steve Huffman, 210-979-2500 Shawn Huffman, 210-979-2500 www.huffmandev.com San Antonio Retail Builders (HH Silver Sponsor) Specializing in remodeling/finish out of medical offices. H.B. Newman 210-446-4793 brett@texaspremiercapital.com Rick Carter 210-367-7909 rick@texaspremiercapital.com Next 6 months Architectural Space Plan / Rendering No Cost or Obligation
• EDUCATION Alpha Bilingual Preschool (H Bronze Sponsor) Our mission is to provide young children with an integral early education in a Spanish immersion environment. Ms. Tania Lopez de Pelsmaeker 210-348-8523 tldp@hotmail.com Give your children the gift of speaking a second language.
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• ELECTRONIC MEDICAL RECORDS
Greenway Health (HHH Gold Sponsor) Greenway Health offers a fully integrated electronic health record (EHR/EMR), practice management (PM) and interoperability solution that helps healthcare providers improve care coordination, quality and satisfaction while functioning at their highest level of efficiency. Jason Siegel 512-657-1259 jason.siegel@greenwayhealth.com www.greenwayhealth.com
• FINANCIAL SERVICES
NORTHWESTERN MUTUAL WEALTH MANAGEMENT COMPANY (HHHH Platinum Sponsor) Comprehensive Financial Planning Insurance and Investment Planning Estate Planning and Trust Services. Eric Kala CFP, CLU, ChFC, Wealth Management Advisor 210-446-5752 eric.kala@nm.com www.erickala.com
Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction,confidence, and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com Get what you deserve… Maximize your Social Security benefit!
Frost Leasing (HHH Gold Sponsor) As one the largest Texas-based banks, Frost has helped Texans
with their financial needs since 1868, offering award-winning customer service and a range of banking, investment, insurance services to individuals and businesses. Laura Elrod Eckhardt 210-220-4135 laura.eckhardt@frostbank.com www.frostbank.com Commercial leasing for a doctor’s business equipment and vehicle. Platinum Wealth Solutions of Texas LLC (HH Silver Sponsor) Comprehensive financial planning firm who assists medical professionals to protect their income, their wealth, their practice and legacy. Tom Valenti 210-998-5023 tvalenti@jhnetwork.com Eric Gonzalez: 210-998-5032 ericgonzalez@jhnetwork.com www.platinumwealthsolutionsoftexas.com Understanding the uniqueness in the financial life as a physician. Retirement Solutions (HH Silver Sponsor) Committed to providing comprehensive, reliable consultation to help you navigate the complex world of retirement planning. Robert C. Cadena 210-342-2900 robert@retirementsolutions.ws www.retirementsolutions.ws Bold Wealth Management (H Bronze Sponsor) Comprehensive Investment Advisory and Retirement Planning Services for Businesses and Individuals. Richard A. Poligala, 210-998-5787 richard.poligala@natplan.com www.boldfinancialgroup.com Complimentary no-obligation retirement plan review to BCMS members
• GOLF TPC San Antonio (H Bronze Sponsor) 18-hole championship golf courses designed by two of golf's most innovative architects, Pete Dye and Greg Norman. Matt Flory, 210-491-5816 www.tpcsanantonio.com
BCMS GROUP PURCHASING AND SERVICE DIRECTORY • HEALTHCARE CONSULTING TNT Healthcare Consulting LLC (H Bronze Sponsor) We want physicians to concentrate on what they were trained to do, treating patients. Tom Tidwell, CMPE 210-861-1258 Thomas.tidwell@att.net Let TNT healthcare consultants evaluate your practice and improve efficiency and cost.
• HOSPITALS/ HEALTHCARE SERVICES
SOUTH TEXAS SINUS INSTITUTE (HHH Gold Sponsor) The South Texas Sinus Institute is a state of the art facility dedicated to in-office Balloon Sinuplasty using the unique Painless Sinuplasty Anesthetic Linked Method. Sue Musgrove 210-225-5666 stsisue@gmail.com www.southtexassinusinstitute.com. We will offer convenient same day or lunch appointments to BCMS members.
Clemente Sanchez 210-269-8028 csanchez@elitercaremarketing.com Rosie Clark 210-771-0141 rclark@elitecaremarketing.com www.elitecareemergency.com Get seen by an experienced physician within 10 minutes. Select Rehabilitation of San Antonio (HH Silver Sponsor) At Select Rehabilitation Hospital of San Antonio, we provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges. Miranda Peck 210-482-3000 mipeck@selectmedical.com http://sanantonio-rehab.com/ Offers patients a higher degree of excellence in medical rehabilitation. Southwest General Hospital (HH Silver Sponsor) Southwest General Hospital is a 327-bed, state-of-the-art hospital located in San Antonio, Texas. Southwest General offers comprehensive healthcare services. Craig Desmond, 210-921-3521 Elizabeth Luna, 210-921-3521 www.swgeneralhospital.com
• HUMAN RESOURCES
Warm Springs Medical Center Warm Springs Thousand Oaks Warm Springs Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate,expert care during the rehabilitation process & support recovery through education & research. Central referral Line 210-592-5350 Joint Commission COE Elite Care 24 Hour Emergency Center (HH Silver Sponsor) We are a fully equipped emergency room open 24 hours a day and 7 days a week, staffed by experienced emergency physicians. We provide the same level of emergency medical care that you would receive in a hospital ER.
Employer Flexible (HHH Gold Sponsor) Employer Flexible doesn’t simply lessen the burden of HR administration. We provide HR solutions to help you sleep at night and get everyone in the practice on the same page. John Seybold 210-447-6518 jseybold@employerflexible.com www.employerflexible.com BCMS members get a free HR assessment valued at $2,500. Pinnacle Workforce Corp HR. Services (H Bronze Sponsor) Dan Cardenas 210-344-2088 dancardenas@pinnacleworkforce.com
• INFORMATION
TECHNOLOGY Allison Royce Business Technologies (H Bronze Sponsor) Business Technology Provider, specializing in HIPAA Compliant Managed IT Services and IT Support since 1993. Jeff Tuttle,210-564-7000 jtuttle@allisonroyce.com www.allisonroyce.com PitCrew IT Services (H Bronze Sponsor) Provides reliability for your business computers or network, enabling you to operate smoothly. Eric Murcia, 210-547-0305 eric@pitcrewit.com
• INSURANCE
Frost Insurance (HHH Gold Sponsor) As one the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment, insurance services to individuals and businesses. Bob Farish 210-220-6412 bob.farish@frostbank.com www.frostbank.com Business and personal insurance tailored to meet your unique needs.
Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Donnie Hromadka 512-338-6151 dhromadka@humana.com www.humana.com Nationwide Insurance Joel Gonzales Agency (H Bronze Sponsor) What matters to you, matters to us! Joel Gonzales 210-314-7514 gonzj8@nationwide.com www.nationwide.com/jgonzales
Texas Drug Card (H Bronze Sponsor) The Texas Drug Card program is a FREE statewide Rx assistance program available to all residents. Todd Walker 512-569-5547 twalker@texasdrugcard.com http://texasdrugcard.com/index.php
• INSURANCE/MEDICAL MALPRACTICE
Texas Medical Liability Trust (HHHH Platinum Sponsor) Texas Medical Liability Trust is a physician-owned health care liability claim trust, providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 14,000 doctors in all specialties who practice in all areas of the state. TMLT is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, the Dallas, Harris, Tarrant, and Travis County Medical Societies. Patty Spann, 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended Partner of the Bexar County Medical Society.
Medical Protective Medical Malpractice Insurance (HHH Gold Sponsor) Medical Protective, the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Thomas Mohler 512-213-7714 thomas.mohler@medpro.com www.medpro.com
Texas Medical Association Insurance Trust (HHH Gold Sponsor) Created and endorsed by the Texas Medical Association (TMA), the Texas Medical Association Insurance Trust (TMAIT) helps physicians, their families, and their employees get the insurContinued on page 40
visit us at www.bcms.org
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BCMS GROUP PURCHASING AND SERVICE DIRECTORY Continued from page 39
ance coverage they need. James Prescott, 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org We offer BCMS members a free insurance portfolio review.
The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are one of the few agents in the state that specialize in Medical Malpractice and all lines of insurance for the medical community. Katy Brooks, CIC, 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com Serving the medical community.
API/ProAssurance Medical Malpractice Insurance (HH Silver Sponsor) ProAssurance is about YOU — and, more specifically, treating you fairly when it comes to professional liability insurance and related products and services. Paul Schneider, MBA, RPLU pschneider@proassurance.com 512-314-4340
The Doctors Company Medical malpractice insurance (HH Silver Sponsor) Kirsten Baze 512-275-1874 KBaze@thedoctors.com www.TheDoctors.com
• INTERNET/ TELECOMMUNICATIONS Time Warner Cable Business Class (HH Silver Sponsor) When you partner with Time Warner Cable Business Class, you get the advantage of enterprise-class technology and communications that are highly reliable, flexible and priced specifically for the medical community. Rick Garza, 210-582-9597 Rick.garza@twcable.com
Time Warner Cable Business Class offers custom pricing for BCMS Members.
• MARKETING SERVICES Phiskal LLC Marketing and Promotion (H Bronze Sponsor) A leading edge marketing and development firm using proprietary Artificial Intelligence engines to enhance your presence with websites, apps & database applications. Sundeep Sadheura 210-865-4520 Sunnys@phiskal.com HTTP://PHISKAL.COM/
• MEDICAL BILLING & COLLECTIONS SERVICES Commercial & Medical Credit Services (H Bronze Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com Make us the solution for your account receivables.
DataMED (HHH Gold Sponsor) Providing your practice with the latest compliance solutions, concentrating on healthcare regulations affecting Medical Billing and Coding changes allowing you and your staff to continue delivering excellent Patient Care. Anita Allen (210) 892-2333 aallen@datamedbpo.com www.datamedbpo.com BCMS members receive a discounted rate for our billing services. PriMedicus Consulting Inc. (H Bronze Sponsor) A physician-founded and built company, dedication to your success. Sally Combest MD. 877-634-5666 s.combest@primedicusconsulting.com www.primedicusconsulting.com PriMedicus Consulting for the Health of Your Practice.
40 San Antonio Medicine • August 2014
URGENT CARE BILLING SOLUTIONS, LLC (H Bronze Sponsor) UCBS provides superior practice management services and revenue optimization services to the healthcare community in a virtual office environment. ANN DeGrassi.CMIS 210-878-4052 adegrassi@ucbillingsolutions.com www.urgentcarebillingsolutions.net
• MEDICAL SUPPLIES & EQUIPMENT
Henry Schein Medical (HHHH Platinum Sponsor) From alcohol pads and band aids to EKG’s and Ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines, and pharmaceuticals serving office based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com/medical BCMS members receive GPO discounts of 15%-50%. McKesson Medical-Surgical (H Bronze Sponsor) MCKESSON is a leading distributor of Medical Supplies and Equipment. Karan Cook 210-573-2117 karan.cook@mckesson.com
• PAYMENT SYSTEMS/ CARD PROCESSING Heartland Payment Systems (HH Silver Sponsor) Sherry Willis 210-885-0201 sherry.willis@e-hps.com
• PUBLICATION MANAGEMENT FIRM Traveling Blender (H Bronze Sponsor) Publication Management Firm Janis Maxymof, 210-413-9731 janismaxymof@gmail.com 10% discount on display advertising in magazine for members.
• PRINTING SERVICES SmithPrint (H Bronze Sponsor) SmithPrint offers custom printing, branding, graphic design, signage and more!
Robert Upton 210-846-5268 Robert@smithprint.net http://www.smithprint.net/ New customers: 10% discount on print materials at SmithPrint.
• REAL ESTATE/ COMMERCIAL Cano and Company Commercial Real Estate (HH Silver Sponsor) Experienced and respected commercial real estate representation. We specialize in office leasing, property acquisition, and commercial real estate investment. Dennis Cano, Agent 210-731-6613 www.canoandcompany.com Dennis@canoandcompany.com Effective commercial real estate solutions for your practice and investments. Newmark Grubb Knight Frank (H Bronze Sponsor) Commercial Real Estate Darian Padua 210-804-4841 Dpadua@ngkf.com Stream Realty Partners (H Bronze Sponsor) Carolyn Hinchey Shaw 210-930-3700 cshaw@streamrealty.com www.streamrealty.com
• REAL ESTATE/ RESIDENTIAL SA Luxury Realty (HH Silver Sponsor) Effective real estate transactions (Buy, Sell, Lease, Syndicate, etc..) within the shortest time possible and for maximum results! Matin Tabbakh 210-772-7777 matin@saluxuryrealty.com www.saluxuryrealty.com Accredited Luxury Home Specialist. Call us today. Becky Aranibar Realty Group Keller Williams (H Bronze Sponsor) Offering Real Estate Services to the San Antonio Medical Community. Carlo G. Aranibar, MBA, 210-862-4022 BARgrouptx@gmail.com www.beckyaranibar.com Offering free comparative market analysis to determine your home's value.
BCMS GROUP PURCHASING AND SERVICE DIRECTORY • REAL ESTATE/ INVESTMENTS Texas Premier Capital (HH Silver Sponsor) A real estate development company offering and managing real estate investment funds in the South Texas area. H.B. Newman 210-446-4793 brett@texaspremiercapital.com Rick Carter 210-367-7909 rick@texaspremiercapital.com www.texaspremiercapital.com
• REGULATORY COMPLIANCE Hildebrand Regulatory Compliance (H Bronze Sponsor) HEDIS, Accreditation, PCMH, ICD10 Patricia Hildebrand, 432-352-6143 Pati.Hildebrand@HildebrandHealthcare.com www.hildebrandhealthcare.com
• RESEARCH STUDIES/ BIOTECHNOLOGY
ICON Development Solutions (HHHH Platinum Sponsor) We are a respected clinical research organization that has an extensive reputable history in diabetes research. Depending upon the current studies, ICON may establish working relationships with local physicians. Your expertise may be invaluable to our efforts to identify subjects Dr. Dennis Ruff 210-283-4572 dennis.ruff@iconplc.com www.iconplc.com Find out how ICON can help your Practice.
• STAFFING SERVICES
Favorite Healthcare Staffing (HHHH Platinum Sponsor) Serving the Texas healthcare
community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency, and protect their revenue cycle! Brian Cleary, 210-301-4362 BCleary@FavoriteStaffing.com www.favoritestaffing.com/public/medicalsocieties/bexar_count y/bexarcounty_index.aspx Favorite Healthcare Staffing offers preferred pricing for BCMS members.
• TITLE COMPANIES Alamo Title Company (HH Silver Sponsor) Corina Cashion 210-698-0924 Corina.Cashion@fnf.com
• TRANSCRIPT SERVICES Med MT, Inc. (H Bronze Sponsor) Narrative transcription is physicians’ preferred way to create patient documents and populate electronic medical records. Ray Branson 512-331-4669 branson@medmt.com www.medmt.com The Med MT solution allows physicians to keep practicing just the way they like. As of July 15, 2014
For more information, call 210-301-4366, email August.Trevino@ bcms.org, or visit www.bcms.org.
visit us at www.bcms.org
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42 San Antonio Medicine • August 2014
Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Acura 11911 IH-10 West
* Fernandez Honda 8015 IH-35 South
* North Park Lincoln/ Mercury 9207 San Pedro Ave.
Porsche Center 9455 IH-10 West
Gunn Honda 14610 IH-10 West (@ Loop 1604) Ancira Chrysler 10807 IH-10 West Cavender Audi 15447 IH-10 West
Ingram Park Auto Center 7000 NW Loop 410
Ancira Ram 10807 IH-10 West * Gunn Infiniti 12150 IH-10 West
Ingram Park Auto Center 7000 NW Loop 410
Ingram Park Auto Center 7000 NW Loop 410
Ancira Dodge 10807 IH-10 West BMW of San Antonio 8434 Airport Blvd.
Ingram Park Auto Center 7000 NW Loop 410
Mercedes-Benz of Boerne 31445 IH-10 W, Boerne Ancira Jeep 10807 IH-10 West
Ancira Elite Motorcars 10835 IH-10 West
Mercedes-Benz of San Antonio 9600 San Pedro Ave.
Ingram Park Auto Center 7000 NW Loop 410 Cavender Toyota 5730 NW Loop 410
Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604) Northside Ford 12300 San Pedro Ave.
North Park Subaru 9807 San Pedro Ave.
Ancira Kia 6125 Bandera Road
* Mini Cooper The BMW Center 8434 Airport Blvd.
* Ancira Volkswagen 5125 Bandera Rd.
Batchelor Cadillac 11001 IH-10 at Huebner Cavendar Cadillac 801 Broadway
Cavender GMC 17811 San Pedro Ave.
* North Park Lexus 611 Lockhill Selma
Ingram Park Nissan 7000 NW Loop 410
* The Volvo Center 1326 NE Loop 410
visit us at www.bcms.org
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AUTO REVIEW
Defying gravity: Audi Q7’s diesel engine combines good drivability, fuel efficiency By Steve Schutz, MD The Audi Q7 is defying gravity — sales gravity, that is. Despite being close to its replacement date, the Q7 continues to sell strongly. Audi moved 15,978 Q7s in the United States in 2013, an impressive 4,970 units (45 percent) more than in 2012, and that momentum is not abating: Sales for the first quarter of 2014 are tracking at more than 40 percent above those strong 2013 levels. As you might imagine, it’s typical for sales of any car or light truck to drop as it nears the end of its life cycle and rare for sales to grow. I credit ongoing incremental improvements and the availability of a diesel engine option for the Q7’s continuing popularity, but really, the diesel option should probably get most of the credit. Diesel models now make up about 40 percent of Q7 sales, and that percentage has grown every year since the TDI was first offered in 2009.
TORQUE PROVIDES MUSCLE The TDI version of the Q7 — TDI stands for turbo direct injection — is increasingly favored because its modern clean diesel engine combines good drivability with impressive fuel efficiency. Producing an OK 240 HP and OMG 406 ft-lbs of torque, the TDI feels as strong as the 333 HP gasoline-powered 44 San Antonio Medicine • August 2014
Q7 3.0T Premium Plus model, which seems odd given the fact that the TDI gives up 93 HP to the 3.0T. The reason the TDI feels so muscular is torque, a much more important contributor to off-the-line oomph than horsepower. Since all diesels have significantly more torque than similarly-sized gasoline engines, they feel stronger than they really are. (For the record, the gas versions of the Q7 actually accelerate slightly faster than the diesel.) Another advantage of diesels is that they typically give owners better fuel economy than their EPA numbers would suggest. That’s especially nice given the fact that hy-
brid vehicles generally do worse than the EPA cycle predicts. When you consider that a Q7 TDI (19 mpg city/28 mpg highway) can take you over 700 miles once you fill its 26.4-gallon tank, is it any wonder more customers are choosing diesel Q7s over their gasoline-powered siblings? The exterior design of the Q7 is aerodynamic and attractive, particularly with larger wheels. As I’ve written previously, on one hand, the Q7 incorporates edgy design elements such as an aggressive, almost angry, front end highlighted by a big grille and angled headlights. Yet its sides and profile are a study in soft curves and gentle contours that
AUTO REVIEW
reassure the eye. While merging edgy and soft in one vehicle seems contradictory, it works in this case. Still, this popular SUV has been on the market for six years, so it’s time for a new design. While Audi has done a Lexus-esque job of keeping the Q7 fresh with new color combinations, wheel design updates, and the addition of cool LED lighting, I’m looking forward to seeing an all new Q7. Audi has not announced when it will appear, but UK’s Car magazine says they expect it to be released sometime in late 2014 or early 2015. The Q7 drives more like a car than most other big SUVs, and that’s saying something with the very nice Mercedes GL, BMW X5 and Lexus GX available to cross shoppers. In town, the Q maneuvers and parks easily; on twisty roads, it turns confidently, and on the highway, it cruises serenely. Having said that, I’d say the Q7 TDI is most at home on the
highway, particularly at speeds greater than 75 or 80 mph.
USEFUL EXTRAS Naturally, the Q7’s interior is well trimmed-out, as all Audis are these days. I especially like the gauges with their bright white numbers and red accents. The Q7 TDI has a starting price of just under $53K, and the version I drove with the Premium Plus package stickered at over $60K. That package includes such useful extras as navigation, parking-assist sensors with rearview camera, panoramic sunroof, HID headlights, and LED running lights and turn signals. The extra-lux Prestige package adds about $12,000 to the price of the Q7 and adds adaptive headlights and cruise control, lane-departure warning, and many other features too numerous to list here. And, of course, there are numerous other trim
packages and stand-alone options to choose from if you so desire. Audi is defying gravity with the Q7 TDI, and after driving one for a week, I can see why it continues to sell strongly, even though it’s approaching the end of its life cycle. It has good looks, a top-shelf interior, and the classic diesel benefits of great torque and fuel efficiency. Steve Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. For more information on the BCMS Auto Program, call Phil Hornbeak at 3014367 or visit www.bcms.org. visit us at www.bcms.org
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46 San Antonio Medicine • August 2014