San Antonio Medicine August 2016 Bexar County Medical Society monthly magazine

MEDICINE SAN ANTONIO

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AUGUST 2016

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VOLUME 69 NO. 8

MEDICINE SAN ANTONIO

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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ELECTRONIC MEDICAL RECORDS

By Joey Berlin, Repoter, Texas Medicine .............14

Take Steps to Protect Your Practice

Courtesy of Texas Medical Association ...............18

HIPAA Breach Trends, 2016 Interim Report

SUBSCRIPTION RATES: $30 per year or $4 per individual issue

BCMS President’s Message ...........................................................................................................8 BCMS Legislative News................................................................................................................10 BCMS News..................................................................................................................................12 Feature: In Real Time: Fronto Temporal Dementia, Part 2 By Rajam Ramamurthy, MD..........................24 Feature: Evolution (or) How I learned to love and appreciate the tastes of San Antonio by Fred Olin, MD. ........................................................................................28 UTHSCSA Dean’s Message By Francisco González-Scarano, MD ........................................................30 Business of Medicine: Capitalizing on Value in Healthcare’s New Reality

By Jon Wiegand, Associate Member, Healthcare Practice Group Cushman & Wakefield ..................34 BCMS Circle of Friends Services Directory .............................................................................................37 Book Review: Run, Leap, Sail, Dunk. A Collection of Stories from a Sports Crazy Father

by Venkat Srinivasan, Reviewed by Rajam Ramamurthy, MD .............................................................42 In the Driver’s Seat...................................................................................................................................44

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Documenting Patient Care in EHRs

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BOARD OF DIRECTORS

ELECTED OFFICERS Jayesh B. Shah, MD, President Sheldon Gross, MD, Vice President Leah Jacobson, MD, President-elect James L. Humphreys, MD, Immediate Past President Gerald Q. Greenfield Jr., MD, PA, Secretary Adam V. Ratner, MD, Treasurer

DIRECTORS Rajaram Bala, MD, Member Jorge Miguel Cavazos, MD, Member Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member John W. Hinchey, MD, Member John Robert Holcomb, MD, Member John Joseph Nava, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Jennifer Lewis, BCMS Alliance President Roberto Trevino Jr., MD, Board of Censors Chair Jesse Moss Jr., MD, Board of Mediations Chair George F. "Rick" Evans Jr., General Counsel

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

CHIEF OPERATING OFFICER Melody Newsom Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director Alice Sutton, Controller

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Rajam S. Ramamurthy, MD, Chair Kenneth C.Y. Yu, MD, Vice Chair Fred H. Olin, MD, Member Esmeralda Perez, Community Member Jaime Pankowsky, MD, Member J.J. Waller Jr., MD, Member

6 San Antonio Medicine • August 2016

PRESIDENT’S MESSAGE

The Future of Maintenance of Certification (MOC)

By Dr. Jayesh Shah, 2016 BCMS President

When it was time to prepare for my board recertification exam again, these thoughts came into my mind — Was the vigorous training in medical school, internship, residency and fellowship not enough? Continuing education hours are needed for medical license renewal. Isn’t it sufficient if physicians kept abreast of the changes and updates in their respective specialties by visiting uptodate.com, or by attending specialty related conferences, grand rounds, and annual meetings? Which physician would not want to practice medicine at its best and provide the best treatments for patients? Is the threat of a malpractice lawsuit not enough to keep them current in what they practice? If I already hold a medical license to practice in a state, is additional board certification, board recertification or maintenance of certification necessary?

I was glad I passed my board recertification exam after many painful hours of hard core studying and what seemed unnecessary mental and financial stress. Many physicians have complained about maintenance of certification (MOC) being time consuming, expensive and irrelevant to their specialty of practice. Some physicians like me who are specialists, have not one but two board recertifications. Every physician finds their own way of continued learning in a better way than what the MOC has to offer. The time has come to revamp the maintenance of certification for all medical specialties.

The Journal of the American Medical Association was the first to study the role of MOC in quality of care and costs. The study showed that patients’ medical outcomes were no better with the MOC and overall costs were only marginally lower in the recertifying group (2.5 percent). Physicians are now challenged with added responsibilities of submitting quality metrics to CMS to accelerate the shift to value-based payment.

A new report from the AMA Council on Medical Education examines the current state of MOC and osteopathic continuous certification (OCC), noting physician concerns around such elements as cost effectiveness and relevance to practice as well as the professional imperative to ensure that the patients are receiving high-quality care.

In the annual meeting of the AMA in June 2016, delegates adopted policy to further efforts to improve the MOC process, including:

8 San Antonio Medicine • August 2016

• Examining the activities that medical specialty organizations have underway to review alternative pathways for board recertification.

• Determining whether there is a need to establish criteria and construct a tool to evaluate whether alternative methods for board recertification are equivalent to established pathways.

• Asking the American Board of Medical Specialties to encourage its member boards to review their MOC policies regarding the requirements for maintaining underlying primary or initial specialty board certification in addition to subspecialty board certification allowing physicians the option to focus on the MOC activities most relevant to their practices.

In summary, many agree that initial certification of a specialty is necessary, but is the maintenance of certification to keep our physicians up to date in the ever changing field of medicine necessary in its present format? We need MOC pathways that will allow physicians to efficiently utilize their time so physicians can spend more time with patients than in activities that have not been proven to improve outcome or quality.

Some believe that the recertification process should be more frequent — maybe annual or biennial, specialty specific, and open book. Some believe that the CME requirement every year should be considered as documentation of ongoing learning. Is board certification, board recertification, or maintenance of certification required? For those who decide to not get recertified, will there be unknown consequences such as affecting their insurance network participation or their hospital privileges? What do you think? The Texas Medical Association opposes the use of board certification as a requirement for reimbursement or licensure.

More importantly, I feel that more regulations are being laid upon physicians and our profession is increasingly being controlled by people not directly involved in patient care, i.e. non-physicians who have no idea of the realities of day-to-day clinical practice. It is about time that we, as practicing physicians, take back the leadership of medicine. With the help of our respective professional organizations, we, the physicians, can and should address our concerns collectively.

BCMS LEGISLATIVE NEWS

Members of the BCMS Legislative and Socioeconomics Committee meet with State Rep.-elect Diana Arevalo during the group’s monthly meeting on May 25.

BCMS LEGISLATIVE AND SOCIOECONOMICS COMMITTEE BUSY MEETING wITh ELECTED OFFICIALS The BCMS Legislative and Socioeconomics Committee continues its work to prepare for the upcoming legislative session in January and recently met with State Representative-elect Diana Arevalo (District 116) to update her on the latest issues of importance to medicine, including balance billing, scope of practice, network adequacy, Medicaid and access to care.

For local discussion on these and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer at mary.nava@bcms.org.

ADDRESSING LOCAL ZIKA VIRUS CONCERNS BCMS president-elect Leah Jacobson, MD was interviewed by reporter, Melissa Vega of News 4 WOAI-TV on the Zika virus and the use of mosquito repellants on children during the BCMS Open House on May 24.

10 San Antonio Medicine • August 2016

BCMS NEWS

VISIT ChENNAI, INDIA

wITh BCMS

By Venkat Srinivasan, MD

BCMS MEMBERS

This is your building.

You are welcome to use it.

The new BCMS building has adequate meeting space available for members to utilize. If your practice group needs space for business or social purposes call BCMS COO Melody Newsom at 210-301-4363 to reserve a time.

12 San Antonio Medicine • August 2016

A delegation of physicians from Bexar County Medical Society is planning to visit Chennai, India from Dec. 24. 2016 – Jan. 4 2017.

San Antonio and Chennai became sister cities in 2007. Sister city relationships are created to foster “a broad-based long-term relationship between two communities in different countries.” As part of this relationship, BCMS has signed agreements with their counterpart organizations in Chennai — Association of Physicians of India, Chennai chapter and the Indian Medical Association, Tamil Nadu Chapter. A joint CME is also being planned during this trip.

Chennai is a bustling metropolis on the Eastern Coast of Southern India with a rich history, vibrant culture and thriving economy. Chennai is also home to world class healthcare institutions like the M.V. Hospital for Diabetes, Sankara Nethralaya Eye Hospital, and the SR Arthroscopy and Sports Sciences Center which tend to the needs of patients from all over India and abroad.

December – January is an excellent time to visit Chennai. The weather is very comfortable with an average temperature of about 76 degrees. For Indian classical music aficionados, The Madras Music Season, considered the largest cultural festival in the world, featuring more than 1,200 live performances, can be quite the treat. Sprawling malls to street vendors offer an irresistible menu of options for the shopaholic. Cuisines from all over the world await the connoisseur.

If this sounds exciting, do contact the BCMS for more details on joining the delegation.

visit us at www.bcms.org

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ELECTRONIC MEDICAL RECORDS

Documenting Patient Care

in EhRs

By Joey Berlin, Reporter, Texas Medicine

Electronic health records (EHRs) and the requirements for maintaining them present a seemingly endless array of complications for physicians — with penalties potentially awaiting doctors who don’t follow the Texas Medical Board’s (TMB’s) recordkeeping rules.

Revisions to those rules, which TMB adopted in the spring, attempt to underscore the importance of accurate information in the data-saturated EHR system and make doctors’ electronic reporting requirements clearer.

14 San Antonio Medicine • August 2016

TMB proposed the rule changes to address three problems the board identified with EHRs: • Records for different patients that looked too similar to one another; • Relevant electronic communications not being properly reflected in the medical record; and • Pre-populated fields in EHRs implying tests had been performed that, in fact, had not.

ELECTRONIC MEDICAL RECORDS TMB adopted the proposed rules on April 10 and published them in the Texas Register on May 15. They took effect on May 20.

The rules spell out that physicians will be required to document in the medical record any communications involving medical decisions and must ensure “non-biographical populated fields” in the record contain accurate information.

Dallas pediatrician Joseph Schneider, MD, chair of the Texas Medical Association Council on Practice Management Services, interpreted the changes as an attempt to bring TMB’s rules into the electronic age.

“We’ve got patients tweeting; we’ve got them Facebooking,” Dr. Schneider said. “It used to be that communications only occurred when you passed your patient in the store or you took a phone call.

Now, there are all sorts of ways that communications are coming to a physician.”

“To me, the most important thing that stands out is that we really need to be aware of clinical information that’s being pulled in from other sources,” said Fort Worth pediatric emergency medicine physician Matthew Murray, MD, chair of TMA’s Ad Hoc Committee on Health Information Technology. “Whether we’re copying and pasting information from an old note to a new note or using templates that automatically bring in clinical information … it is our responsibility to make sure that the information that got pulled in is accurate.”

Rulemaking Adjustments As originally published in the Texas Register in January 2014, the rules would have required physicians to include in the medical record “a summary or documentation memorializing any substantive communication that is transmitted or received by the physician and relates to the health, condition, diagnosis, treatment or care of a patient, including, but not limited to, communications that are verbal or recorded and transmitted via any medium.”

TMA had concerns with potential unintended consequences that might follow the adoption of such rule language. Then-TMA President Austin I. King, MD, said the association was concerned about “the administrative burden placed on physicians to compile all such information, the potential negative impact to patient care caused by excessive information in the medical record, and potential selective enforcement of a rule that would have almost certainly been impossible to fully comply with.”

He went on to note that the proposed standard that a communication in a medical record had to be “substantive” would have been “difficult for physicians to interpret, leading towards overinclusion (and its attendant problems) or well-meaning physicians failing to comply with a rule (and subsequent enforcement).”

In early 2014, TMA asked the medical board to convene a stake-

holder group to examine the implications of proposed EHR rules and alternatives to addressing the three problems that had been identified. The medical board assembled such a group last August. Members included physicians, EHR experts, attorneys, community members, and employees of state agencies.

The board’s new rule language on documenting patient communications underwent some tweaking before taking on its final form, which requires physicians to document any communication the doctor transmits or receives about which “a medical decision is made regarding the patient.”

TMA was more supportive of the eventually adopted language.

Dr. Murray says the final rule’s requirement that physicians document communications with patients that involve medical decisionmaking is sensible.

“The concern was over the possibility that physicians would be required to record every conversation with a patient, which would be burdensome and really wouldn’t add to either the quality of care or to the accuracy of the medical record,” he said. “So with that discussion, we were able to at least narrow the communications down to those that impacted decisions made on patient care, and it is reasonable to include those in the medical record.”

To address the concern of EHR fields being improperly pre-populated, TMB adopted a new subsection in the rule that states, “All non-biographical populated fields, contained in a patient’s electronic medical record, must contain accurate data and information pertaining to the patient based on actual findings, assessments, evaluations, diagnostics or assessments as documented by the physician.”

TMB Executive Director Mari Robinson explains the board began to see instances of EHR computer systems that were pre-populating test results as normal, even when the tests or evaluations hadn’t been performed.

“So the board wanted to make very clear that the only type of things that should be pre-populated are things like name, date of birth, that type of information,” Ms. Robinson said, “versus this idea of pre-populating an outcome of an evaluation or a test when that has yet to be completed.”

TMB adopted the non-biographical populated fields rule provision despite concerns voiced by Dr. King in TMA’s comments about the revised rules. He wrote the section “may be confusing to physicians” and that the phrase “non-biographical populated fields” could potentially be the biggest source of confusion.

TMA suggested changing the provision to refer to “all populated fields containing clinical information” within the record.

Although TMB published that portion of the proposed rule as originally drafted, it did decide to take TMA’s suggestion to publish continued on page 16 visit us at www.bcms.org

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ELECTRONIC MEDICAL RECORDS continued from page 15

a list of frequently asked questions (FAQs) about the new rules, particularly addressing which fields fall under the “non-biographical populated fields” category. TMB will publish the FAQs on its website, www.tmb.state.tx.us, in the future, TMB spokesperson Jarrett Schneider says.

The rules clarify physicians must maintain an adequate medical record of each patient, “regardless of the medium utilized.”

Focusing on Patient Care Dallas orthopedic surgeon Wynne Snoots, MD, whose term on the medical board expired this year, was instrumental in the proposal of the new EHR rules. Dr. Snoots says the changes were a “reactionary measure” to adjust for the way governments, insurance companies, employers, and hospitals are driving the development of health information technology.

Dr. Snoots says those entities are more interested in “population statistics” and the particulars of a patient encounter that pertain to physician payment than in the information that helps the physician treat the individual patient.

“What they’re after is the support for the [medical] bill … so the physician’s caught in the middle,” Dr. Snoots said. “He has to fill out a specific set of data elements, page after page of stuff, in order to get paid. That’s why he looks at the computer when he’s seeing you, instead of being able to listen to you and look at you and touch, and all the other things important for a meaningful patient-physician relationship. And the computer does not let us use natural language or text to provide an outline of what was really done to provide the basis for the decisionmaking. And also on the EMR side, there’s really no emphasis to understand the outcome.”

The changes to the rules, Dr. Snoots said, are an effort “to be sure that the content we need to make a decision about the care of a patient is based on fact, not on just guessing.”

The data that pile up in a patient’s EHR can create a headache for doctors who are primarily interested in the information that pertains directly to a patient’s care. For example, Dr. Murray relayed a story of receiving a recent patient from another emergency department (ED) after a two-and-a-half-hour stay.

“That hospital is on an EMR, and my hospital is on an EMR. But because those EMRs don’t communicate with each other, the patient record is printed and sent with the patient when he or she is transferred,” Dr. Murray said.

“That particular record was 50 pages long. And out of those 50 pages, only two of them had the clinical information that I needed 16 San Antonio Medicine • August 2016

in order to assume care of the patient at that point. The volume of information that’s captured in an electronic medical record is impressive, but much of it is not clinically useful. It was really a burden to sort through the volume of information I received to find out what happened in that two-and-a-half hours in the other ED. And that happens every day.”

Dr. Schneider says EHRs “give us the ability to make mistakes — new kinds of mistakes that we probably would never have done in the paper world.”

A TMB position statement on EHRs states that the widespread implementation and use of EHRs has compromised the board’s ability “to provide efficient and adequate oversight to the practice of medicine.” The position statement emphasized that to improve patient care while using EHRs, the necessary data elements in the record need to be properly identified, recorded, verified, and tagged.

“In recent years, TMB has observed progressive difficulty obtaining medical decisionmaking information from current records, which interferes with the accomplishment of our mission,” the position paper states. “It is not the role of the TMB to endorse EMR software or regulate technology. However, it is clearly within the TMB’s scope and oversight duties to set forth standards and expectations for creating and maintaining a useful, meaningful and readable medical record.”

The medical board’s disciplinary rules establish low- and highsanction guidelines for violations of the Medical Practice Act or TMB rules. A remedial plan for failure to keep proper medical records carries a fine of $500 on the low end, along with continuing medical education (CME) in the “appropriate area,” such as medical recordkeeping. On the high end of the guidelines, an order can include a $2,000 administrative penalty. For example, in November 2014, the board issued $2,000 penalties to two physicians. One

ELECTRONIC MEDICAL RECORDS physician failed to document the rationale for the care of a patient, according to a TMB news release. The other physician inadequately documented conversations with a patient pertaining to the rationale for surgery. If a physician has been issued a prior order

by TMB for inadequate recordkeeping, he or she may be required to take a Physician Assessment and Clinical Education course in recordkeeping.

The board issues administrative penalties at its discretion, however, and can go north of the $2,000 penalty. For example, last April, the board issued a $3,000 penalty to a physician who admitted failing to adequately document medical records for approximately 11 visits and to “making late entries without indicating the amendments were not made contemporaneously with original notations,” TMB said in a news release.

Ms. Robinson says the board’s enforcement activity is complaint-based in the majority of cases. It only has the authority to initiate inspections without a complaint in cases involving officebased anesthesia and pain management. TMB can file a complaint, Ms. Robinson says, “but that generally only happens when we receive information through our offices another way,” such as if the board performs a CME audit and finds a physician doesn’t have the proper credits or if a physician has been found guilty of a crime.

Depending on the final resolution of a case, the board may also be required to report a violation to the federal National Practitioner Data Bank, which has its own guidelines about what certain entities need to report.

“So it could be that there was a small error, and the board feels that the appropriate resolution is a remedial plan, which is a nondisciplinary order that is not reportable to the National Practitioner Data Bank,” Ms. Robinson said. “However, there could be a really, really large and egregious set and pattern of violations.

So depending on the penalty there, if a disciplinary action is taken, it is absolutely reportable to the National Practitioner Data Bank.

So anything connected with the practice of medicine that’s a disciplinary action in the vast majority of cases is federally mandated to be reported.”

Ms. Robinson says TMB does not keep statistics on how many remedial plans it issues for medical record violations. For more information on remedial plans and TMB’s enforcement process, visit www.tmb.state.tx.us/page/enforcement.

Joey Berlin can be reached by phone at (800) 880-1300, ext.

1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.

For more information on medical records, see white papers and informational articles from TMA’s Office of the General Counsel. If you have questions about medical records, contact the TMA Knowledge Center by calling (800) 880-7955 or by email.

Medical Records Q&A The TMA Knowledge Center receives many questions regarding medical records.

Here are the top five: Q: How much can we charge to supply copies of records? Are the fees different for records supplied in electronic format?

A: Per Texas Medical Board rules, physicians may charge up to $25 for the first 20 pages of a paper record and 50 cents per page for every copy thereafter. For copies of an electronic record, doctors may charge up to $25 for 500 or fewer pages, or $50 for more than 500 pages. However, simply charging the maximum amount permitted under the rules is not sufficient unless such a charge is “reasonable” and “cost-based.”

Q: Can we forward copies of records we have received from other physicians?

A: Yes. In fact, you are required to do so when someone requests medical records. The Medical Practice Act requires physicians responding to a request for records to provide “records received from a physician or other health care provider involved in the care or treatment of the patient.” The Medical Practice Act contains no exception for documents stamped “Do Not Copy or Forward” or “Not for Re-Release.”

Q: Can we release medical records of deceased patients to their family members?

A: A family member must be a “personal representative” of the deceased to consent to the release of the medical records. A “personal representative” is someone who has the authority to perform transactions on behalf of the deceased’s estate.

Q: Can we withhold supplying copies of medical records because of a past-due balance for services?

A: No. A physician may generally retain records until payment of a copy fee is made but may not withhold copies of the records because of a past-due balance for treatment.

Q: Do I need patient authorization to forward medical records to another physician for treatment purposes?

A: No. HIPAA permits doctors to disclose patient health information to other doctors for treatment purposes without patient authorization.

visit us at www.bcms.org

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ELECTRONIC MEDICAL RECORDS

Take Steps to Protect Your Practice From

RANSOMwARE Courtesy of Texas Medical Association

14 U.S. agencies issue guidance on how to protect your networks from ransomware.

Here are some tips TMA suggests you follow to protect your practice from ransomware and other malware: • Back up your computer system on a regular basis to an external drive or a backup service.

• Set up your email accounts to deny emails sent with executable files (.exe file extensions).

• Patch or update your software regularly.

• Enable automatic software updates whenever possible.

• Make sure your computer systems are protected by a reputable anti-malware software.

• Protect your system with a software firewall to help detect threats.

• Train your employees on avoiding potential malware threats, such as SPAM. TMA Practice Consulting offers HIPAA training for your practice. For information, call (800) 523-8776.

If you are the victim of a cyber crime, report it to the FBI. The Texas Medical Liability Trust (TMLT) includes comprehensive cyber liability coverage in all of its policies. TMLT also offers customized services to help large groups, small offices, and individual physicians arm themselves against online threats. Learn more about TMLT’s cyber liability coverage.

For more information on cyber security, contact TMA’s health information technology helpline at (800) 880-5750 or by email. Also, check the TMA Education Center for continuing medical education courses on related topics.

18 San Antonio Medicine • August 2016

ELECTRONIC MEDICAL RECORDS

hIPAA BREACh TRENDS, 2016 INTERIM REPORT

By David Schulz, Cyberrisk Associates, LLC

JULY 7, 2016 (Cyber Risk Associates) – During 2015’s blockbuster cyber-attacks, HIPAA breaches increased nearly 10-fold, exposing 113-million health records last year. As a result, network security received tremendous attention. With more than 100-million records lost in only three attacks (on national insurance companies’ networks), we are rightfully anxious about computer hacking as individuals concerned for our own records.

But risk is a complex function of the target and its role and responsibility. As healthcare providers and business associates, fixating only on network security misses two-thirds of the picture and neglects the larger risk.

Healthcare providers remain, year after year, the largest targets of opportunity. Of 140 breaches published since January 1, 106 took place at clinics, offices, hospitals and other front line providers.

Eleven more occurred at business associates and health plans accounted for 23.

20 San Antonio Medicine • August 2016

(Illus. 1 - Percentage of HIPAA breaches by entity type, Jan 1-June 30, 2016. All data from US Department of Health and Human Services.)

ELECTRONIC MEDICAL RECORDS NUMBER OF INCIDENTS PER ENTITY TYPE Total: ..........................................140 Healthcare Provider...............106 Health Plans ...............................23 Business Associates...................11 (Table 1 –Number of HIPAA breach incidents faced by entity type.)

Recognizing that providers face the greatest risk of a HIPAA breach incident, the question is begged: How? How are the records most often exposed?

Surprisingly, not through IT network incursion. The data points us in a different direction, toward the mishandling and loss of records through negligence. Breaches caused by unauthorized access, loss, theft and improper disposal account for twice the healthcare provider’s risk, compared with IT hacking.

(Illus. 2 – Provider risk profile, causes of breaches by percentage.)

PROVIDERS RISK BY INCIDENT CAUSE Total: ......................................................106 Unauthorized Access/Disclosure......38 Theft or Loss...........................................28 Improper Disposal ...................................3 Hacking/IT Incident ..............................37 (Table 2 – Provider breaches, causes by incident.)

Theft may not appear to be a factor of negligence at first, but consider: theft or loss of a laptop or desktop computer, the most typical event reported, does not rise to a violation if properly encrypted as HIPAA mandates!

Many an IT manager is confused by the fact that encryption is listed in the Security Rule as an “addressable” rather than a “re-

quired” mandate. But addressable doesn’t mean optional! The Rule says that if a device is left unencrypted, both the security substitutes put in place instead and the reasons encryption is not employed are fully documented in records. Yet theft of unencrypted laptops is the bane of healthcare and blight on security: more than one-in-ten breaches is thus caused.

While more typically a provider’s issue, even health insurance plans have shown a weakness for losing equipment this year. The largest has been a lost laptop containing 28,000 records from a Montana health plan. Nor is loss limited to equipment:The Lone Star State’s contribution this year includes the loss of 600 paper and film records by Texas Health and Human Services, also considered a health plan.

Unauthorized Access or Disclosure covers a lot of territory concerning staff behavior, from discussing treatment in overly loud voices, to gossip and to mailing records in error. Nevertheless, email has opened the greatest vulnerability in this category, and the criminal attackers’ tool of choice these days is the “phishing expedition,” in which a weaponized email opens a floodgate of data. Worst of all, 93% of all malware in current “phishing” emails is of the dreaded ransomware variety, with all files locked up and inaccessible until extortion is paid.

Defense against this largest risk must be conducted on both technical and administrative fronts. “Cyber hygiene” is de rigueur, but no more so than relentless training and awareness for the staff. The best teams encourage discussion of the changing threat environment to maintain diligent defensive postures. Many concerned firms conduct “faux-phishing” campaigns, challenging their staff and rewarding those who first spot and reveal a threat. Such training tactics might have kept the UT-System Administration from disclosing 794 records through email this January.

When it comes to preventing wholesale record exposure, IT security and a sharp eye on network activity is still a critical path to success. Just ask our friends in Katy, at the Medical Colleagues of Texas, where an intrusion was detected by an alert office employee, noticing unusual activity on the obstetrics group network.

They found a RAT — a remote access tool — had been planted.

Unfortunately, by the time it was identified, 68,631 records were exposed.

Just a week earlier in March, the Eye Institute of Corpus Christi lost 43,961 when they discovered that individuals gained access to the records of all patients, downloaded their protected health information from the EHR, copied those data, and provided them to two physicians formerly employed by the eye clinic. continued on page 22 visit us at www.bcms.org

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ELECTRONIC MEDICAL RECORDS continued from page 21

So for the rest of 2016, these are the three lessons to keep in mind: TAKEAWAY 1 — Providers are the largest (and most vulnerable) target TAKEAWAY 2 — Guarding against theft, loss, or disposal of records AND preventing data from accidental access or disclosure are as vital as IT security.

TAKEAWAY 3 — Issue is Global but the Weakness is Local and Texas is a rich target.

Cyber Risk Associates, llc, is a San Antonio company devoted to assisting small healthcare practices protect privacy and security of patients’ records and comply with HIPAA and State of Texas regulations. All analysis performed by Cyber Risk Associates for the Bexar County Medical Society.

All data as reported by US Department of Health and Human Services, Office of Civil Rights. https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf

22 San Antonio Medicine • August 2016

FEATURE: IN REAL TIME

IN REAL TIME

Part 2

Fronto Temporal Dementia

By Rajam Ramamurthy, MD

The Search for a Diagnosis Dad is not well. I don’t know what is wrong. The first two calls I made was to our son who lives in New York and our daughter who lives in Richmond. I narrated the events after we had returned from Cambodia and Vietnam. My phone conversations were mostly done in our frontyard as I walked around our circular driveway. I did not want to discuss the topic in my husband’s presence. How do you tell grown children that their father is talking “Inappropriate” a word I found much easier to say than ‘Sexual’? The children wanted to 24 San Antonio Medicine • August 2016

come and I asked them to wait till we were further along with the medical investigations. I also called N’s brother, a urologist, who is in the U.S. and I talked to his sister, also a physician, in India.

Our visit with the Neurologist was nerve wrecking for me. For current complaints, N would mention lack of sleep, bad dreams that kept him up and, in one dream, a voice was instructing him. He has repeated this narrative so many times that it is etched in my memory.

I quote, “I am up at 2:30 in the night. My leg is cramping and I want to flex it and the voice is saying, ‘Don’t worry, I will take care of it.’ My nose is itching and I want to scratch and the voice says, ‘Don’t worry, I will take care of it.’ Two and a half hours go by and I want to turn and the voice says, ‘OK, you can turn now.’” N never did or perhaps couldn’t mention the other behavior issues to the neurologist. I would then start narrating the symptoms from my

FEATURE: IN REAL TIME perspective. Retrospectively, being with him for all of his doctor’s visits and sharing my thoughts was one of the sensible things I did.

A thorough neurological exam was normal. An MRI was requested and the appointment would take two weeks. Thanks to a resourceful connection, we had it done that afternoon. An array of blood tests were done including checking vitamin B12 levels that were all normal. An inventory of multiple medications was taken; medicine to keep cholesterol low, to control blood pressure, to address an elevated A1C hemoglobin (predicts risk of Diabetes) to prevent enlargement of prostrate, vitamins, some medication prescribed by the dermatologist for what was described by N as acne, medicine for acid reflux, and another two to three herbal medicines were listed. Melatonin that N takes for jet lag was stopped. N remembered the names of the medicines and the doses to the point. He did not share with the neurologist the fact that he took something called Red Ginseng for several days when he was in Seoul, Korea.

N was suffering, I felt it. He slept fitfully at night. He woke up with frightening dreams. He tried to sit and meditate when he couldn’t sleep. I can’t tell if he could meditate. He felt that he has reached a point in his meditation where he is one with the Supreme Being, that he is a realized person. In the last year, he has been reading a lot about Buddhism and has been trying to practice what is

called mindful meditation. He talked non-stop about this to everyone he met. He would say, “Do you want to become a Buddha, I can make you a Buddha in three days.” It was obvious even to a child that he was not well. From his vantage point, N was not suffering. All around him those who loved him suffered.

N was not religious, however he was very well read on the topic of religion. By birth he is a Brahmin and he had to study the Hindu scriptures to have the ‘Upanayanam’ and was given the holy thread to wear at age 9. He has told me many times that he asked the religious men who came to his house difficult questions trying to understand the complex philosophies of Hinduism and was very disillusioned with their answers. For a very long time he followed the teachings of Swami ‘Yogananda’ and has spent time in the 1980’s and 90’s in the ‘Yogananda Ashram’ in Los Angeles. N was very quickly influenced by religious leaders who seemed to be well read and were excellent orators. He once did research work with one of them who claimed to have healing powers through touch. After that he completely stopped meditation for several years. He started meditating again in the past year and a half after reading about Buddhism and when he was having difficulty sleeping. The overlay of meditation and its effects complicated matters for me in more difficult ways than one can imagine. I will return to this a little later. continued on page 26

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FEATURE: IN REAL TIME continued from page 25

The MRI result was normal. I was thankful that it is not a brain tumor. The blood tests did not point to an infection which was a concern as he had traveled to so many countries just before these symptoms presented. The neurologist requested a ‘Neuro psychological test.’ This is a test administered by a trained psychometrician and interpreted by a psychologist. The test takes 3 ½ to 4 hours to administer and is in the form of a series of questions. The answers are sent elsewhere for analysis. The test was done on Feb. 9 and the results were not back for three weeks. The waiting and the feeling of doing nothing to help N was killing me. I stopped going to my office, social gatherings, shopping, board meetings, restaurants, travelling. None of this registered in N’s mind. There was no empathy nor sympathy. The emotional loneliness was scary.

N continued to be very agitated. He started pinching his face at imaginary bumps. He had created many wounds all over his face and forehead. I would constantly remind him not to pinch, he will immediately stop and resume pinching within minutes. I continued to remind him. His face was in such a state that I did not want to go out anywhere. There were many social commitments that I avoided and the one or two that I tried to attend with N were exhausting as I did not want to leave N unattended. Many times he was very annoyed and would say “Why can’t you leave me alone.”

Our friends were a tremendous support during these times. Some of N’s time at home was spent in watching tennis. The minute tennis was over, N turned to the computer. Then came another call from another good friend. “You cannot have Facebook access for N. the pictures coming on his friends list are not what you want to see.

They get distributed to all others on his friends list and my wife got one. It is not good for his reputation.” I had the Facebook removed for which N has not forgiven me. Then I started surreptitiously watching the screen when N was at the computer. One day he was so intent on clicking on pictures and writing emails he did not realize that I was standing behind him. Little did I know the enormity of the financial precipice I was poised at? The first psychiatrist appointment, the day we will hear about the diagnosis was on our wedding anniversary, it was our 44th.

Suggested Reading: NINDS Frontotemporal Dementia Information Page http://www.ninds.nih.gov/disorders/picks/picks.htm

Rajam Ramamurthy, MD, Professor Emeritus UTHSCSA.

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26 San Antonio Medicine • August 2016

FEATURE: EVOLUTION

(or) How I learned to love and appreciate the tastes of San Antonio

By Fred Olin, M.D.

Don’t get excited, this isn’t about Darwin, creationism, descent (or not) from the primordial jelly or any of that. It’s a short tale about the changes wrought in a Northern city boy by his emigration from Chicago and immigration to Texas, and specifically to San Antonio.

28 San Antonio Medicine • August 2016

FEATURE: EVOLUTION

I like it here. A lot. I don’t want to live anywhere else … not in the “intellectual capitol of the country” up there in Massachusetts, or in the “financial capitol of the world” on the Hudson, or in the oh, so very cool “City” (they always capitalize it) on the bay in the over-taxed so-called “Golden State.” Even the foggy, misty superprogressive city up in Oregon where a bunch of my relatives live, and which does indeed have many virtues (and fine wines and dining) can’t pull me away.

Why, you ask, am I so hooked on San Antonio? One of the major reasons (besides the lack of snow, reasonable traffic, laid back attitude toward almost everything and friendly people) can be expressed in two words: Mexican food. One of my daughters once said that she would never eat Mexican food north of Dallas or east of Houston. I think she spread her net too widely: I might say “…north of Boerne or east of Universal City.”

“What set off this tirade?” you might wonder: On May 30th, 25 or so friends from the band I’m in ended up at a Mexican restaurant after the Memorial Day concert we were supposed to play was canceled because of the rain. Another man, originally from Cincinnati and I commented on just the fact that we were really enjoying the goodies, and how different it was from our youth, and how our tastes had evolved with time. I commented that every now and then my serum enchilada level got so low that I had to get a hit of TexMex. Now, you have to understand that I grew up in the 1950s in an area where salt is considered a spice, and in a family with a tradition of midwesternized Germanic/Scandinavian cuisine. Mexican food on the north side of Chicago consisted of tamales that came out of a can. They were wrapped in a sort of waxed paper and you could open a can of chili to put over them. No one ever had heard of salsa.

On the rare occasions that I got out of the Midwest it was to visit other family or with a youth organization where our choices were limited by how much cash we had. My mother’s and grandmother’s cooking was, if nothing else, nutritious, but no one would ever call it exciting. In 1961, right after graduation from the University of Illinois (not a culinary center), my wife of two weeks and I came to Fort Sam Houston for six weeks of Army indoctrination and we had a tiny exposure to Mexican food at La Fonda on Broadway. It was good, but by our standards today it was pretty bland Alamo Heights Tex-Mex. After two years in Philadelphia we came back here and I went into veterinary practice.

One of the doctors at the first animal hospital I worked at invited us over for a party that first summer and served jalapeño poppers.

OMG! How could anyone eat those? Slowly, slowly I learned to appreciate increasing levels of cumin and chile powder and cilantro and various capsicum peppers. We tried tacos and burritos and chorizo and migas and barbacoa and lengua and flour tortillas and pan dulce and tomatillos and all the rest of it. We went to different Mexican restaurants with different styles and learned the differences.

Then I went to medical school here in San Antonio and, ultimately to the University of Arkansas Medical Center to do my orthopaedic residency. There was one episode of deprivation in between: I did a six-week rotation as a senior student in Portland, Oregon. At the time, the only Mexican food available there was an early Taco Bell.

It helped, but just didn’t compare.

Little Rock in the mid ‘70s was not a hub of ethnic food choices.

Someone told us that there was a really good Mexican restaurant across the river in North Little Rock, so we went over there. Let me limit my criticism to the most egregious thing they did: they put chopped cabbage in their guacamole. The rest of the food wasn’t very good either. We drove home to San Antonio once a year. We packed light so that we could carry essential supplies back to Arkansas: the cooler and the trunk were loaded with frozen tortillas, salsa, preserved jalapeños, etc. and my culinarily talented wife learned to make really superior enchiladas and other delights.

We got back to S.A. as soon as possible and I went into orthopaedic practice and kept the capsaicin levels above deficiency and need for supplementation. After a few years, my wife learned to make tamales from my office manager and she and my staff ladies had a tamale-making hen party each year at someone’s home. It filled the house with great smells … and lots and lots of words. Today, there are still more new restaurants to try, new flavors and combinations and life on the taco front (all types, crispy, soft, puffy, etc.) is good.

So, all of you native Texans are sort of thinking “Big deal. He likes Mexican food.” My friend, go without for a few years. Tex-Mex and real Mexican restaurants abound all over the country now. But, from what I can tell, there’s nothing like sitting in a little storefront restaurant here at home, where we are the only native English speakers, and chowing down on their special lengua and nopales. Can’t do that in Duluth.

Fred H. Olin, M.D., is a semi-retired orthopaedic surgeon and a member of the BCMS Communications/Publications Committee.

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UTHSCSA DEAN’S MESSAGE

UT SCHOOL OF MEDICINE UPDATE: CME OFFERINGS BRING THE LATEST MEDICAL INFORMATION TO SAN ANTONIO

By Francisco González-Scarano, MD

Continuing medical education (CME) is a critical component of every physician’s career. With the comprehensive and broad range of resources available to San Antonio area physicians through the UT School of Medicine at San Antonio (SOM), information on the latest advances in virtually any aspect of medicine is easily accessible close to home.

The SOM’s CME office serves SOM faculty, but as one of the few accreditors in the area, it is also a valuable resource for the entire medical community, delivering a wide variety of educational options and the CME credits necessary for maintaining medical licenses. The SOM’s access to clinical research and a wide range of collaborations with physicians from the community and with national and international experts, offers a wealth of educational opportunities to healthcare professionals.

The School has had a CME program for almost 50 years. Today the program is stronger than ever, with greatly expanded offerings. Since 2010 the CME Office has been led Jan Patterson, MD, MS, CMQ, Associate Dean of Quality and Lifelong Learning and Professor of Medicine and Infectious Diseases. During her tenure, the number of CME activities has increased by nearly 50 percent; 147 are planned for this year. The CME program facilitated 43,686 learner interactions in 2015, including 30,420 physician interactions and 13,266 interactions with other healthcare professionals such as nurses and pharmacists. The School facilitated 2,596 credit hours last year, compared to 542 for the average ACCME accredited provider.

The growth in activity stems in part from new programs. One example is a Clinical Safety and Effectiveness (CS&E) course that pro30 San Antonio Medicine • August 2016

vides healthcare professionals with the skills, tools and knowledge needed to improve quality and patient safety. This project-based course, which began in 2008, has become an integral part of the CME program. It is offered twice each year and consists of eight eight-hour days over six months. Graduates of the CS&E include faculty, administrators and staff from the School of Medicine, Dental School, and our hospital partners: University Health System, CHRISTUS Santa Rosa Children’s Hospital and the South Texas Veterans Health Care System.

The School’s CME program is also successful because it is highly responsive to the needs of the local medical community; from providing convenient online courses to help physicians meet Ethics and Professional Responsibility CME requirements to bridging gaps in the knowledge and skills of practicing physicians.

For example, nationally renowned physician Nilam J. Soni, MD, is an Associate Professor of Medicine and Director of the School’s new Critical Care Ultrasound Education Center. As a leader in integrating point-of-care ultrasound into clinical medicine on a local, national and international level, Dr. Soni recognized that training for this increasingly important technology was not widely available regionally or even nationally. He designed a program to train clinicians in ultrasound procedures, and the CME staff helped accredit the course and provide the logistical support to make the training available to physicians, physician assistants, nurse practitioners and nurses, providing hands-on experience in this increasingly important technology while earning CME credit.

As part of the CME Office’s mission to support the medical community’s educational needs, Dr. Patterson is chair of the Texas Statewide

UTHSCSA DEAN’S MESSAGE Educational Workgroup on Infectious Disease Preparedness and Response, a partnership with the UT System Institute for Transformational Learning (ITL) and the Texas Department of State Health Services (DSHS). The Workgroup was created in 2014 to assess and enhance the state’s existing capabilities to prepare for and respond to pandemic disease such as Ebola. The group is now overseeing the creation and maintenance of a website, Texas Infectious Disease Readiness, https://www.txidr.org, which will facilitate state-wide information sharing, education, training and research associated with infectious diseases of public health significance. The website will offer courses, modules, videos and other educational modalities supportive of healthcare and public health provider education and training on infectious diseases, along with CME credits.

A focus on improving patient care is another factor contributing to the success of our CME program. In 2011, the Office earned “Accreditation with Commendation”, a six-year term awarded to accreditors that demonstrate a commitment to quality improvement activities and an interprofessional focus that provides education opportunities not only to physicians, but also to other health care professionals.

The CME office plays a significant role in major medical conferences, including the San Antonio Breast Cancer Symposium (SABCS), the largest breast cancer meeting in the world. Each year it is held in

December, and attracts around 7,500 health care professionals and others interested in the management and cure of breast cancer. The CME office also supports other meetings such as the Sports Medicine Symposium, now in its 44th year. “Pediatrics for the Practitioner” is an annual conference that draws approximately 250 pediatricians and family practice physicians from across San Antonio, Laredo, the Rio Grande Valley and other parts of the state . Many participants say they rely on this meeting as their main source of education each year.

The CME office also coordinates interactive workshops. For example, the 11th Annual International Fixation Symposium (IEFS), taking place Dec. 8 – 10 in San Antonio, will let participants explore the surgical management of traumatic and diabetic conditions of the lower extremities with local, national and international experts.

This symposium offers hands-on cadaveric workshops as well as didactic lectures led by some of the world’s foremost experts on care of the diabetic foot.

The School’s CME program also brings the latest information presented at national meetings to local physicians. The American Society of Clinical Oncology Annual (ASCO) meeting is the world’s premier oncology event, drawing tens of thousands of participants each year. To bring a comprehensive summary of the ASCO Annual Meeting’s presentations and clinical data to local healthcare profescontinued on page 32

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UTHSCSA DEAN’S MESSAGE continued from page 31

sionals, Virginia Kaklamani, MD, a Professor of Medicine in the Division of Hematology/Oncology and the leader of the Breast Cancer Program at the CTRC, organizes “The Best of ASCO Review Meeting.” This one-day event highlights the most recent research and education from the ASCO Annual Meeting, with the CME office providing support in planning and accrediting the meeting’s education component.

In addition to assisting with accreditation, logistics, registration and meeting planning services for annual events, the CME office oversees the daily grand rounds and similar events taking place at the SOM. These meetings not only provide valuable insight from other physicians, but in many cases, also provide CME credits.

Online education is another tool for broadcasting enduring materials and for disseminating up-to-the-minute information. For example, when the Ebola virus gained prominence as an international public health threat, the Office of CME videotaped a faculty member’s Grand Rounds discussion on the topic that included didactic material and also a demonstration of properly donning and doffing of protective equipment. The recording was made available online where it was viewed hundreds of times by clinicians looking for more information on the infectious disease.

The CME Office also provides online access to high-quality infor-

32 San Antonio Medicine • August 2016

mation on other topics of interest among physicians, such as pain management, palliative care and patient safety and quality. New offerings are made available online every week. A comprehensive list can be found on their website.

All of these activities highlight the important role the CME office plays in the school and in our community: to assist physicians in processing the enormous amount of medical information available today.

From new medications and therapies, to evidence-based practices, the School’s CME department is a support system that helps physicians and others continually move forward in their patient care.

Visit their website at http://cme.uthscsa.edu or call them at (210) 567-4491 to learn more.

Francisco González-Scarano, MD Dean, School of Medicine, Executive Vice President for Medical Affairs, Professor of Neurology, scarano@uthscsa.edu John P. Howe, III, MD, Distinguished Chair in Health Policy, The University of Texas Health Science Center at San Antonio

BUSINESS OF MEDICINE

Capitalizing on Value in healthcare’s New Reality

By Jon Wiegand Associate Member, Healthcare Practice Group Cushman & Wakefield in San Antonio Email at jwiegand@sacadvisors.com, or office (210) 585-4911, mobile (210) 241-2036, fax (210) 824-1840.

Healthcare providers are leading dual lives. In one pursuit, years of education and training have sharpened the abilities that physicians put to use each and every day. Physicians strive to optimize the patient care mission and simultaneously need to achieve financial returns commensurate with years of intense training and delayed gratification. However, as business owners, physicians are required to make significant decisions that fall outside the typical ‘scope of practice.’

Whether owned or leased, a practice’s real estate will have a substantial impact on the physician’s business strategy and personal goals. There is currently an incredible window of opportunity for physicians with owned real estate, enabling them to capture previously unachievable values for their medical real estate Europe’s ‘Brexit’ and America’s made-for-TV presidential campaign race have dominated recent headlines. Between these and other volatile events, the broader markets have experienced tremendous instability. The combination of international chaos and historically low yields from traditional investment avenues has forced capital to seek returns in real estate.

A Focus on healthcare Real Estate In an effort to further safeguard against future downturns, increasing numbers of real estate investors are aggressively pursuing healthcare real estate. With interest rates at all-time lows (as of July, 10-year U.S. Treasury yields dove to 1.366 percent), both private capital and institutional funds have targeted healthcare real estate even more aggressively — moving prices to historically high levels. This pricing surge is unmatched in the history of healthcare real estate and its impact on your medical assets should be evaluated by an expert to capitalize on the opportunity.

34 San Antonio Medicine • August 2016

Reduced Reimbursements As if intended to counteract the good news for physicians and their owned real estate, we are continually reminded that the future of physician reimbursement is murky at best. The Affordable Care Act has increased access to care, but has also contributed to substantial headwinds aimed at reducing provider reimbursements. A recent report detailed that the U.S. healthcare system (including government and private payers) spent 5.5 percent more on healthcare in 2015 than in 2014. Not only does this represent a net increase in year-over-year spending, but, astoundingly, it also represents a more accelerated growth rate than 2014’s 5.3 percent increase.

Given the continued increase in overall healthcare spending, reimbursement reductions are likely to continue. Furthermore, it is near impossible to envision a scenario when providers will receive pay raises from CMS and/or private insurers. Therefore, physicians must consider other avenues to create value and generate returns to counteract the reduction in medical practice compensation.

BUSINESS OF MEDICINE

San Antonio – Increasingly Attractive for Investors While medical real estate has been hot nationally, real estate investors have targeted Texas with more intensity due to steady economic results and impressive population growth. A recent San Antonio Express News article confirmed what we all see. The greater San Antonio MSA has been buoyed by very stable growth, averaging 2.2 percent annual population growth since 2012. More impressively, San Antonio is expected to add 1.1 million people by 2040, an astounding upward trajectory.

Rest assured, if we are reading about these growth metrics in our hometown newspaper, the decision makers at real estate funds are far ahead of the curve. The San Antonio medical real estate market is at a very exciting intersection — the combination of attractive medical assets and eager, well-funded buyers has rewarded many physicians with impressive monetization opportunities.

To take advantage of the current opportunity, physicians can contact a healthcare real estate specialist to evaluate real estate values and to implement appropriate action plans.

Cyclical Timing Currently, we are 7 years into an improving real estate market.

It is important to note that 7 years is a long time for a real estate

cycle — especially when one considers the duration of the two previous cycles when activity and pricing bottomed in 2001 & 2009 (see above).

While value metrics and total transaction volumes remain quite strong, there are concerns that the current acquisition appetite will not continue forever. Some of the most aggressive medical real estate investors, real estate investment trusts (REITs), have dramatically slowed their purchase rate, from $54 billion annually from 2012 to 2014, to just $17 billion dollars in the second half continued on page 36 visit us at www.bcms.org

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BUSINESS OF MEDICINE continued from page 35

of 2015. This is potentially concerning for medical real estate owners as the trend would impact non-core markets such as San Antonio most significantly.

A Specialty Focus for A Special Market Nuances of healthcare real estate differentiate it from other asset classes and require specialization and a particular passion and expertise. The physical properties are unique, different considerations motivate tenants and drive development projects, and perhaps most importantly, the medical real estate buyer is a distinct real estate investor seeking a specialty product type.

In the same way a physician narrows the scope of practice, your healthcare real estate advisor should be focused on the evolving field of medical real estate. The real differentiating factor is my data-driven knowledge of the local market and an understanding of healthcare real estate dynamics. This allows for the envisioned lease, acquisition, development or sale to maximize value for the physician and align with broader business and personal goals. Whether you own or lease, now is the time to take action with a specialist in healthcare real estate.

36 San Antonio Medicine • August 2016

By Jon Wiegand is an Associate Member, Healthcare Practice Group Cushman & WakeďŹ eld in San Antonio. He may be contacted via email at jwiegand@sacadvisors.com, or office (210) 585-4911, mobile (210) 241-2036, fax (210) 824-1840.

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CONTRACTORS/BUILDERS /COMMERCIAL

Huffman Developments (HHH Gold Sponsor) Premier medical and professional office condominium developer.

Our model allows you to own your own office space as opposed to leasing.

Steve Huffman 210-979-2500 Shawn Huffman 210-979-2500 www.huffmandev.com

RC Page Construction, LLC (HHH Gold Sponsor) Commercial general contractor specializing in ground-up & interior finish out projects. Services include conceptual & final pricing, design-build & construction management. Single-source management from concept to completion ensures continuity through all phases of the project.

Clay Page 210-375-9150 clay@rcpageconstruction.com www.rcpageconstruction.com

ELECTRONIC DOCUMENTATION AND TRANSCRIPTION SERVICES Med MT, Inc. (HH Silver 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

38 San Antonio Medicine • July 2016

physicians to keep practicing just the way they like.”

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.

Regional Sales Manager Jason Siegel 512-657-1259 Jason.Siegel@greenwayhealth.com www.greenwayhealth.com

EMPLOYEE BENEFITS

e-ESI (HHH Gold Sponsor) Locally owned since 1999, we believe it’s all about relationships. We keep our partners compliant assisting with human resource administration/management, workers’ compensation/risk management, benefit administration, and payroll.

We help our partners concentrate on what they do best...Service their customers.

Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.com

FINANCIAL SERVICES

Northwestern Mutual Wealth Management (HHHH 10K Platinum Sponsor) Our mission is to help you enjoy a lifetime of financial security with greater certainty and clarity. Our outcome-based planning approach involves defining your objectives, creating a plan to maximize potential and inspiring action towards your goals. Feebased financial plans offered at discount for BCMS members.

Eric Kala CFP®, AEP®, CLU®, ChFC® Wealth Management Advisor | Estate & Business Planning Advisor 210.446.5755

eric.kala@nm.com www.erickala.com “Inspiring Action, Maximizing Potential”

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 of 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 and 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.”

GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A part-time, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time.

Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration

hEALThCARE REAL ESTATE

SAN ANTONIO COMMERCIAL ADVISORS (HHH Gold Sponsor)

Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

hIPAA/MANAGED IT/VOIP/SECURITY

Hill Country Tech Guys (HHH Gold Sponsor) Provides complete technology services to many different industries, specializing in the needs of the financial and medical industries.

Since 2006, our goal has always been to deliver relationship-based technology services that exceed expectations.

Whit Ehrich, CEO 830-386-4234 whit@hctechguys.com http://hctechguys.com/ “IT problems? Yeah… we can fix that!”

hOSPITALS/ hEALThCARE SERVICES

Southwest General Hospital (HHH Gold Sponsor) Southwest General is a full-service hospital, accredited by DNV, serving San Antonio for over 30 years.

Quality awards include accredited centers in: Chest Pain, Primary Stroke, Wound Care, and Bariatric Surgery.

Director of Business Development Barbara Urrabazo 210.921.3521 Burrabazo@Iasishealthcare.com Community Relations Liaison Sonia Imperial 210-364-7536 www.swgeneralhospital.com “Quality healthcare with you in mind.”

Warm Springs Medical Center Thousand Oaks

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research.

Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmira Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com/ Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges.

Miranda Peck 210-482-3000 Jana Raschbaum 210-478-6633 JRaschbaum@selectmedical.com mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”

hUMAN RESOURCES

e-ESI (HHH Gold Sponsor) Locally owned since 1999, we believe it’s all about relationships. We keep our partners compliant assisting with human resource administration/management, workers’ compensation/risk management, benefit administration, and payroll. We help our partners concentrate on what they do best...Service their customers.

Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.com

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.”

INFORMATION AND TEChNOLOGIES

Henced (HHH Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build longlast customer relationships by effectively communicating using our text and email messaging system.

Rainey Threadgill 210-647-6350 Rainey@henced.com www.henced.com Henced offers BCMS members custom pricing.

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need.

Wendell England 512-370-1746 wengland@tmait.org 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.”

Frost Insurance (HHH Gold Sponsor) As one of 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 and 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.

Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

SWBC (HHH Gold Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships.

VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com SWBC Mortgage Jon M. Tober 210-317-7431 JTober@swbc.com www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services Catto & Catto (HH Silver Sponsor) Providing insurance, employee benefits and risk-management products and services to thousands of businesses and individuals in Texas and the United States.

James L. Hayne Jr. 210-222-2161 jhaynejr@catto.com Corey Huffman 210-298-7123 chuffman@catto.com www.catto.com

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians

in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and 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

MedPro Group (HHH Gold Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

Thomas Mohler 512-213-7714 thomas.mohler@medpro.com Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com

www.medpro.com 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 some of the few agents in the state who 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.”

The Doctors Company (HH Silver Sponsor) The Doctors Company is fiercely committed to defending, protecting, and rewarding the practice of good medicine. With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer. Learn more at www.thedoctors.com.

Susan Speed Senior Account Executive (512) 275-1874 Susan.speed@thedoctors.com Marcy Nicholson Director, Business Development (512) 275-1845 mnicholson@thedoctors.com

continued on page 40

visit us at www.bcms.org

39

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39 “With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer” NORCAL Mutual Insurance Co. (HH Silver Sponsor) Since 1975, NORCAL Mutual has offered medical professional liability coverage to physicians and is “A” (Excellent) rated by A.M. Best.

Patrick Flanagan 844-4-NORCAL pflanagan@norcal-group.com www.norcalmutual.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair.

Keith Askew Market Manager kaskew@proassurance.com Mark Keeney Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INTERNET/ TELECOMMUNICATIONS

ferencing systems, surveillance cameras, and voice/data cabling.

Family owned since 1981.

Daniel Simons 210-581-9020 daniel.simons@ics-com.net Robert Foehrkolb 210-225-5427 rfoehrkolb@ics-com.net www.ics-com.net “Providing IT, voice and video solutions for business.”

MARKETING ADVERTISING SEO

Henced (HHH Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build longlast customer relationships by effectively communicating using our text and email messaging system.

Rainey Threadgill 210-647-6350 Rainey@henced.com www.henced.com Henced offers BCMS members custom pricing.

MARKETING SERVICES Time Warner Cable Business Class (HHH Gold Sponsor) When you partner with Time Warner Cable Business Class, you get the advantage of enterpriseclass technology and communications that are highly reliable, flexible and priced specifically for the medical community.

Enterprise Account Executive West Region - Healthcare George Gonzales 210-582-9536 george.gonzales@twcable.com “Time Warner Cable Business Class offers custom pricing for BCMS Members.”

IT SUPPORT/VOIP/ CLOUD SERVICES

ICS (HHH Gold Sponsor) ICS® is a Texas-based provider of business technology integration solutions, including managed IT support, business telephones, VoIP communications, video con-

40 San Antonio Medicine • July 2016

Digital Marketing Sapiens (HHH Gold Sponsor) Healthcare marketing professionals with proven experience and solid understanding of compliance issues. We deliver innovative marketing solutions that drive results.

Irma Woodruff 210-410-1214 irma@dmsapiens.com Ajay Tejwani 210- 913-9233 ajay@dmsapiens.com www.DMSapiens.com

MEDICAL BILLING AND COLLECTIONS SERVICES

Kareo (HHH Gold Sponsor) The only cloud-based medical office software and services platform purpose-built for small practices. Our practice management software, medical billing solution, practice marketing tools and free, fully certified EHR has helped 30,000+ medical providers more efficiently manage their practice.

Regional Solutions Consultant Lilly Ibarra: 210.714.9815 lilly.ibarra@kareo.com www.kareo.com Commercial & Medical Credit Services (HH Silver 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.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHHH 10K Platinum Sponsor) From alcohol pads and bandages to EKGs 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 “BCMS members receive GPO discounts of 15 percent to 50 percent.”

CASA Physicians Alliance (HHH Gold Sponsor) Locally owned, nationwide MultiSpecialty Physicians Buying Group which provides significant savings on Pediatric, Adolescent and Adult vaccines as well as other products.

Physician’s memberships are free.

Shari Smith 866-434-9974 shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net “Providing meaningful vaccine discount programs, products and services.”

MERChANT CARD/ChECK PROCESSING Firstdata/Telecheck (HH Silver Sponsor) We stand at the center of the fastpaced payments ecosystem, collaborating to deliver next-

generation technology and help our clients grow their businesses.

Sandra Torres-Lynum SR. Business Consultant 25 years of dedicated service 210-387-8505 Sandra.TorresLynum@FirstData.com ‘The true leader in the payments processing industry’

MERChANT PAYMENT SYSTEMS/CARD PROCESSING Heartland Payment Systems (HH Silver Sponsor) Heartland Payments is a true cost payment processor exclusively endorsed by over 250 business associations.

Tanner Wollard 979-219-9636 tanner.wollard@e-hps.com www.heartlandpaymentsystems.com “Lowered cost for American Express; next day funding.”

OFFICE EQUIPMENT/ TEChNOLOGIES Dahill (HH Silver Sponsor) Dahill offers comprehensive document workflow solutions to help healthcare providers apply, manage and use technology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes.

Ronel Uys 210-805-8200, ext. 10105 ruys@dahill.com www.dahill.com

PAYROLL SERVICES

SWBC (HHH Gold Sponsor) Our clients gain a team of employment experts providing solutions in all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits.

Kristine Edge Sales Manager 830-980-1207 Kedge@swbc.com Working together to help our clients achieve their business objectives.

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY PhYSICIANS BUYING GROUP

CASA Physicians Alliance (HHH Gold Sponsor) Locally owned, nationwide MultiSpecialty Physicians Buying Group which provides significant savings on Pediatric, Adolescent and Adult vaccines as well as other products.

Physician’s memberships are free.

Shari Smith 866-434-9974 shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net “Providing meaningful vaccine discount programs, products and services.”

REAL ESTATE/ COMMERCIAL

CUSHMAN & WAKEFIELD (HHH Gold Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

Robbie Casey Commercial Realty (HHH Gold Sponsor) Robbie Casey Commercial Realty was founded on the principles of providing thorough market strategies, innovative advertising, superior service, and uncompromising integrity. Robbie is dedicated to each of her clients. She brings enthusiasm and creativity to each project and knows how to get the job done.

Robbie Casey 210-872-8453 robbie@robbiecaseyrealty.com http://robbiecaseyrealty.com

REAL ESTATE/RESIDENTIAL

Roslyn Casey Realty (HHH Gold Sponsor) My extensive experience and expertise in the San Antonio, Alamo Heights and Terrell Hills real estate market will benefit you whether you are looking to buy or sell a home in the area.

Realtor, ABS, ILHM, ALMS Roslyn Casey 210-710-3024 Roslyn@roslyncasey.com http://roslyncasey.kwrealty.com “Communication is key”

www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

To join the Circle of Friends program or for more information,

call 210-301-4366 or email August.Trevino@bcms.org

Visit www.bcms.org

Kuper Sotheby's International Realty (HH Silver Sponsor) My hometown roots are based in Fredericksburg while my home away from home is San Antonio. Local knowledge – exceptional results.

Joe Salinas III 830-456-2233 Joe.Salinas@SothebysRealty.com JoeSalinas.com “Embrace your new life ... I'll help you become a connoisseur.”

SENIOR LIVING Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resortquality environment.

Shane Brown Executive Director 210-305-5713 hello@legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K 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.

Brody Whitley Branch Director 210-301-4362 bwhitley@ favoritestaffing.com

visit us at www.bcms.org

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BOOK REVIEW

Run, Leap, Sail, Dunk

A Collection of Stories from a Sports Crazy Father

By Venkat Srinivasan Reviewed by Rajam Ramamurthy, MD Come and watch this, my husband screamed from the family room where he was sprawled on his favorite couch, watching tennis, his favorite sport. In the U.S. Open in 2011, Roger Federer was serving for game, set and match. It was a fantastic serve and was returned

by Novak Djokovic which turned out a winner. I watched the shot and went off to do my chores. Later, I heard that the cross court forehand by Novak, described by John McEnroe as “one of the alltime great shots,” turned the tide for Djokovic who won the U.S. Open that year. Although momentary, the thrill of a magical moment in sports is what keeps fans rooted to their seats. That is what Venkat Srinivasan’s book “Run, Leap, Sail, Dunk” did to me.

The book, a 116-page paperback, is written with a passion for sports. The 14 chapters about 14 icons in sports not only describes the events that the author thought worthy of including in the book, they also reveal the person who otherwise is private, distant and unapproachable in the minds of the fans.

“It was a small act by a man, but a giant gesture against racism” describes Srinivasan as he recounts the incident when fans were taunting Dani Alves, a native of Brazil and one of the best right backs in soccer who was playing for Barcelona. Dani had ignored for years the monkey calls aimed at his skin color and race. However when a banana landed in front of him when he was about to take a corner kick he could have left the field, kicked the ball at the crowd or cursed; just what the perpetrators wanted. Without a moment’s hesitation, Dani picked up the banana, peeled it and ate it. Later he posted an Instagram of himself eating the banana, “My father always told me: ‘Son, eat bananas, which prevent cramps,’ how did you guess it? Ha ha.” The response to his action was instant and positive when thousands of messages reverberated the air and thousands of celebrities posted pictures eating bananas.

Srinivasan starts each chapter with a quote. “If you can meet triumph and disaster and treat those two just the same” – Rudyard Kipling, opens the fourth chapter. He goes on to describe Debbie Brill, an Olympic high jumper, and her great act of kindness for a fellow athlete, Zola Budd a sprinter from South Africa. Reading this chapter gave me goose bumps for two reasons. The poignant story and a personal experience at the Olympics in 1984. I and my family had bought tickets for several events at the Olympics. The one I most wanted to see was the 100-meters finals and Carl Lewis, the fastest man on earth. He won the gold clocking at 9.99 seconds, two

42 San Antonio Medicine • July 2016

seconds faster than the silver medalist.

I never thought I would sit still, hour after hour, finishing a book about sports. I did not know what a Sky Hook was. Srinivasan describes; “with an esthetic flip of the wrist, Kareem (Kareem Abdul-Jabbar) launched the ball.

The ball traversed a smooth arch and, like a homing pigeon, gently landed in the basket. Kareem had scored again with his Sky Hook.

I thought of a dance movement where I make the students jump as high as they can and land gently, a technique called planting your feet. The description was poetic and seemed as effortless as the Sky Hook.

The 13th chapter also started with a quote. “A leader is like a shepherd. He stays behind the flock, letting the most nimble go out ahead, whereupon the others follow, not realizing that all along they are being directed from behind.” — Nelson Mandela. An apt opening for a chapter on our own David Robinson, who is fondly called by his team mates the Admiral. David Robinson is spoken of as someone who rescued the Spurs from irrelevance when he joined the team. I have seen Mr. Robinson in a very different setting. We requested him to help us raise funds for the Premature Infant Development Program at the U.T. Health Science Center. The program is sustained through donations and fundraising. We wanted to make a poster of David holding a premature infant with our moto “Small beginnings, great expectations.” I was expecting big hands, knobby and toughened with callouses after years of beating from the basketball. He held the baby in his palm with fingers as delicate as a piano player. Even more telling of the kindness and peace in this man was when he spontaneously stopped by the incubator of a very sick baby and placed his hands on the incubator and said a silent prayer.

As I conclude I realize that Srinivasan’s book has evoked so many memories in me, a marginally sports-informed person, and I wonder what the sports connoisseurs among you will do. I will not be surprised if you carry the book in your pocket for a brief break between patients.

Rajam Ramamurthy, MD Professor Emeritus, Department of Pediatrics UTHSCSA

Ancira Chrysler 10807 IH-10 West Gunn Acura 11911 IH-10 West

Ingram Park Auto Center 7000 NW Loop 410

Ancira Dodge 10807 IH-10 West Cavender Audi 15447 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

North Park Mazda 9333 San Pedro Ave.

North Park Subaru at Dominion 21415 IH-10 West

Mercedes-Benz of Boerne 31445 IH-10 W, Boerne

Cavender Toyota 5730 NW Loop 410

Ancira Jeep 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410

Mercedes-Benz of San Antonio 9600 San Pedro Ave. Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604)

Northside Ford 12300 San Pedro Ave.

Cavender GMC 17811 San Pedro Ave. Batchelor Cadillac 11001 IH-10 at Huebner

Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Chevrolet 12602 IH-35 North

* North Park Lexus 611 Lockhill Selma North Park Lexus Dominion 21531 IH-10 West Frontage Road

Ancira Nissan 10835 IH-10 West Ingram Park Nissan 7000 NW Loop 410

Gunn GMC 16440 IH-35 North

* Fernandez Honda 8015 IH-35 South Gunn Honda 14610 IH-10 West (@ Loop 1604)

44 San Antonio Medicine • August 2016

North Park Subaru 9807 San Pedro Ave.

* North Park Lincoln/ Mercury 9207 San Pedro Ave.

Ancira Ram 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410

North Park Toyota 10703 SW Loop 410

* Ancira Volkswagen 5125 Bandera Rd. North Park VW at Dominion 21315 IH-10 West

visit us at www.bcms.org

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46 San Antonio Medicine • August 2016