Birmingham Medical News January 2023

Oblique Lateral Interbody Fusion

Approach to Correcting Lumbar Degeneration

By Laura Freeman

Sooner or later, almost everyone experiences back pain. It’s one of the most common reasons people miss work days and ask their doctors for pain medications—which could be the first step on the road to a dangerous dependency. For some, the pain may resolve itself with rest and conservative treatment. But for oth-

ers, it becomes a persistent, nagging agony that may progress to the point that surgery could be necessary to stabilize disc space and protect the spine.

“When a disc deteriorates so much that we have to consider fusion, it’s important to match the patient to the procedure we recommend. Oblique lateral interbody fusion, also known as the ante-psoas

Brookwood Baptist First in Alabama with

By Laura Freeman

For women who went for their first mammogram during the early days of the screening technology, it’s an experience they will probably never forget— especially if they made the mistake of scheduling it when tissue was tender.

The tight, pinching squeeze made it a painful topic of conversation for women comparing notes and a subject of dread for their younger sisters. Though women tend to be better at following through with health screenings, the temptation to avoid or delay the appointment card for this annual ordeal seems to be all too common.

”Far too many women around the

world are still dying from breast cancer they likely could have survived if it had been detected earlier,” David Georges of Koning Corporation said. “In some places the issue is access. In others, it’s avoidance. They may have had a bad experience with painful compression during a mammogram or have heard too many stories that made them afraid.

“Our goals through the years of work designing the Koning Vera dedicated breast CT were to eliminate uncomfortable compression, enhance the accuracy of 3D imaging and bring radiation down to the same level as a mammogram. We have achieved those goals and received FDA approval to roll out

the new technology. Brookwood Baptist Medical Center contacted us early about their interest in the potential offered by the new breast CT. They will be the first in Alabama to have the Koning Vera installed and operational.”

Brookwood Baptist Health CEO Jeremy Clark said, “We’re thrilled to be the first hospital in the state to partner with Koning in bringing this innovative piece of technology to our medical center and the patients we serve. Having the ability to detect cancers earlier and faster will help us save lives. We anticipate that the system will be installed and we’ll be ready to begin scheduling patient appointments in January.”

The Koning Vera breast CT is more compact and faster than full body CTs. It is designed specifically for the breast to work with gravity. The patient simply lies on her stomach with the first breast

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approach, was introduced a few years back, but recently the advantages it offers have made it a hot topic in spinal health,” Carl Nechtman, MD, a neurosurgeon and spine specialist with Ascension St. Vincent’s Medical Center and Neurosurgery Associates, said.

“For patients who don’t need direct dorsal decompression, it offers a high success rate for relieving back and leg pain with less recovery time and less discomfort than traditional fusion surgery. A minimally invasive lateral approach preserves the integrity of muscle structures that support the back. It also allows patients to rest better as they recover since they can sleep or lie on their back without having to avoid an incision.

“Typically, patients are out of the hospital the next day and most recover to return to their usual schedule within six to eight weeks. We continue to monitor their progress over the next six months to a year.”

In addition to fusing deteriorating discs, the lateral approach can also be helpful in correcting other spinal conditions including curvature of the spine and other anomalies that begin to cause problems.

In preparing to perform an oblique lateral interbody fusion, the surgical team positions the patient with the right side down on the table and the abdomen facing the surgeon. A three to five centimeter incision is made just above or in front of the left iliac crest, guided by imaging, navigation software and a C-arm to confirm position and protect nerves, blood vessels and key structures.

“This technique minimizes risks to muscular, neural and vascular structures. We have an excellent view of the aorta, and as we gently sweep the psoas muscle back we have a clear, 360 degree view of the spine. The lateral approach also allows us to use a graft with a larger footprint if needed,” Nechtman said. “Preoperative imaging gives us a good sense of the size range a specific patient is likely to require, but during the surgery we can try larger or smaller grafts to get the best fit. Most of the grafts we use are made of titanium, but poly can be used in some cases. The lateral approach also makes using a graft with a larger footprint easier.

“Overall, we’re seeing improvement in fusion success rates to around 90 percent, and indirect decompression of neural elements is also good. It’s an excellent way to restore alignment and it can be combined with other treatment options to give patients maximum relief.”

Back and/or leg pain, and sometimes dysfunction, are symptoms that commonly bring patients to a physician’s offices seeking an evaluation for surgery. Preexisting hernias, some previous abdominal surgeries, and degree of obesity

can be factors to consider in determining whether a patient is likely to be a good candidate for the lateral approach.

“Since healing is usually faster and easier, this technique can be a better choice for patients with co-morbidities that may involve slow healing, such as diabetes,” Nechtman said. “After surgery, we often recommend back braces during the early stages of healing. Whether a physical therapy referral will be helpful during recovery is likely to depend on the individual patient’s condition at the

time of surgery.

“Oblique lateral interbody fusion isn’t a magic wand. It isn’t for every case, but it is a very useful option to have in the neurosurgery toolbox. It can bring relief without the long recovery, greater discomfort and potential for problems that comes with the traditional dorsal approach to spinal fusion.

“For patients who are likely to need surgery soon, it could be well worth an evaluation to determine whether this approach could be a good option for them.”

Carl Necthman MD

cures Breakthroughs

When people with extraordinary talent and passion are given the technology, the facilities, and the support, they achieve great things. The discoveries and innovations happening today will help shape the future of treatments and lead to cures. And it benefits not only the patients and families who come to Children’s of Alabama, but people across the country and around the world for years to come.

Koning Vera Breast CT,

suspended comfortably through the table opening. In just seven seconds, the imaging camera circles the breast gathering 3-D information from every angle. Then the patient slips over to suspend the second breast for imaging and in only seven more seconds, the procedure is finished.

“Since it is so fast and simple, the system can take care of a large number of patients quickly so no one should have to spend a long time waiting,” Georges said. “Positing the patient correctly can be learned quickly. Imaging techs don’t have to deal with the challenges in getting clear mammograms in women who are anatomically difficult to position.

“For example, smaller, denser breasts are often found in younger women who may have family links to breast cancer and need screening earlier. It can be difficult to get all breast tissue between the plates so the entire breast can be screened. The same is true on the opposite end of the spectrum. Women with large breasts or implants may require more mammogram images, which expose them to more radiation.

“The Koning Vera CT allows large breasts and small breasts to be suspended and imaged the same as average size breasts. The entire breast can be seen and radiologists can view what is going on within the tissue from any angle.”

Another advantage of the breast CT is that it can be used with or with-

out contrast dye. If a physician suspects symptoms or a patient’s family history or genetic background is troubling, the physician can order the CT with contrast dye to pick up early signs of changes.

With dye, the breast CT delivers enough data that a radiologist can make a recommendation to quickly begin treatment or schedule a biopsy to confirm the need for immediate surgery.

Unlike some new technologies, the breast CT is finding insurance companies to be welcoming once they understand its potential to not only save lives, but also save money.

“A stage one or two malignancy is usually far less expensive to treat than a stage four cancer,” Georges said. “In patients at high risk and those who have an anatomy that tends to be difficult for a mammogram to give definitive answers, it can be less expensive to start with a breast CT than a mammogram and a call back for another, plus an echo and then a CT. It is definitely less expensive than a breast MRI.”

The ability to get a good answer the first time around is also valuable to patients in a way that someone who has never had to wait through the nerve wracking scare of being called back for a follow up to a questionable mammogram can fully appreciate.

“For patients, peace of mind really matters.” Georges said.

•

The Dilemmas of Gastroparesis

By: Jane ehrhardt

We’ve come a long way in being able to diagnose this,” says Kyle Packer, DO, about gastroparesis, also called gastric stasis, a rare stomach disorder in which food moves through the stomach too slowly.

The symptoms are straightforward but deceptive. “It has a pretty generic symptom profile,” Packer says, listing nausea, vomiting, reflux, bloating, abdominal pain, and dehydration. Since it mimics symptoms of gastritis, peptic ulcers, and reflux, it can be easy to misdiagnose. Abdominal bloating along with chronic nausea or other disease processes can be signal. “If they use those buzzwords together and they’re diabetic, I steer more towards gastroparesis first,” he says.

Around 57 percent of those with gastroparesis are diabetic. “It’s not that common of a condition, but in Alabama, unfortunately there is a large population of diabetic patients. So it’s more common than we think,” says Packer, a general surgeon at Walker Baptist Medical Center in Jasper with a fellowship in advanced gastrointestinal minimally invasive surgery.

The most common test for diagnoses, called gastric emptying scintigraphy, involves eating a special meal of an exact

number of calories and grams of fat, usually scrambled eggs. Tagged with radiation at a radioactivity level equivalent to an hours walk in the sun, the food can then be monitored as it moves through the stomach and digestive system. “We monitor for couple of days on how much contrast moves through stomach,” Packer says. “If it’s slow emptying, then they meet the definition for gastroparesis.”

Packer, DO

Other diagnostic tests exist, such as upper endoscopy or esophagogastoduodenoscopy (EGD). But Patrick has found it to be inconsistent, since some follow-up gastric emptying studies have come back negative. Radioactive capsules offer another diagnostic option. “They’re great for small bowel pathology, but they doesn’t show the motility of the muscles,” he says. “I put most of my faith in gastric emptying.”

About 50 percent of the gastric emptying tests turn out positive among Packer’s patients. “But I probably order more tests than most physicians because I see more patients with these symptoms,” he says. He is one of only three physicians in the Birmingham area who deal with this condition. Between 30 to 50 percent of his patients end up diagnosed with the gastroparesis.

The treatment begins with diet. Four

to six smaller meals a day. Eating solid food in the morning and more blended, liquid intake toward evening to eliminate solids in the stomach at night. No high fat and fiber foods, because they’re hard to digest. Avoiding sugar spikes, such as with sugary drinks, because high blood sugar intensifies gastroparesis. Some patients cannot tolerate any solid food. Medications, such as Reglan (metoclopramide), can help with gastric motility, but have risks so they are generally used short-term and sporadically. Erythromycin induces forceful contractions, but is not well-tolerated by many gastroparesis patients and, as an antibiotic, there is the long-term risk of building up resistance to antibiotics.

More long-term relief can be found in surgical options. Packer uses the gastric neuro stimulator. A battery implanted under the skin of the abdomen connects to two leads attached to electrodes placed on the membrane lining of the stomach. The electrodes send impulses that stimulate muscle contractions to improve gastric emptying.

“The stimulator is a game changer,” Packer says. “It’s been around closer to 10 years, but there have been many advances, and improvements in the physics of the device, including updating the leads for reliability and improved battery life.”

One of his gastroparesis patients suffered nausea daily enduring two episodes

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of vomiting a day. She required multiple trips to the emergency department and hospitalization for IV fluids due to dehydration. “Two weeks ago, she had a gastric neuro stimulator put in, and she has complete resolution of her symptoms now,” Packer says.

The device allows a physician to adjust the rate, voltage, and duration of the impulses to suit the patient’s needs. Typically, patients start at a .1 second energy burst every five seconds. “If they’re doing better but have room for improvement, for example, then we can increase that to a one second burst for every five seconds,” Packer says. Higher numbers deplete the battery faster within three years, which requires a surgical intervention in the OR to replace. A fair number of his patients, though, remain on the low settings, giving them five to six years of use per battery.

“This is a great therapy we have, as long as we continue to advance the tech,” Packer says. “I hate having to put patients to sleep for this so often.”

Since no cure yet exists, the goal for Packer is to improve the patient’s quality of life by 70 to 80 percent. “Most get to 80 percent. They’re so happy because that means they may have been having eight episodes of nausea or be vomiting twice a day. Instead it’s one to two times a week,” he says. “This is all about getting people back to a normal routine in life.”

So you end up happy and satisfied.

Kyle

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The Time is Now for Advance Care Planning Programs That Help Healthcare Providers

By Craig greer

Most people don’t usually think about advance directives until a crisis occurs. This often leads to confusion and sometimes conflict if a person has never discussed the types of care they would want if they were unable to speak for themselves.

Advance care planning is more than just the Advance Directive legal document. True planning means talking with loved ones to make sure they understand the types of treatment you would and would not want if faced with a life-threatening or life-limiting illness. The birth of the Advance Directive came through the courts. Life support technology had outpaced our understanding, which meant that if people didn’t recover, they could still be kept alive. No one knew when it was appropriate to turn off the machines. It had never been discussed before.

Today, we have gotten better with legal document, but we have not improved our discussions with loved ones about our wishes. Too often this conversation only happens when a terminal illness has been diagnosed – and that is the worst possible timing. People often avoid the conversation out of fear of appearing to give up.

Respecting Choices, a group out of La Crosse Wisconsin, has developed a great program for hospitals, medical practices, social workers and churches to use. It encourages advance care planning in three stages.

The first stage is for people over the age of 18 to determine who would make medical decisions for them if they are unable to speak for themselves. This includes a discussion of types of life support they may want and under what conditions. An example: I would want to be on a respirator if there is more than 20 percent chance I will recover, or I want everything done to keep me alive.

The second stage of advance care planning is for people with a chronic illness. For instance, a person with heart failure or COPD can live a long time with good quality of life on medications.

There comes a time when the medications no longer work and it is important to discuss what types of medical treatment a person might want and when they might want to receive only comfort measures instead of aggressive treatments.

The last stage is for those who have been diagnosed with a terminal illness. For these people, it is important to discuss whether or not they would want CPR if their heart stopped beating and other aggressive interventions such as tube feeding or a respirator.

Having these discussions while a person is healthy is never easy, but it is more difficult when faced with a life threatening illness. We should have these discussions periodically throughout our lives as we age and as our health condition changes.

My advance directive was different from my 30s than it is now that I am in my 60’s. My wife and I have had many conversations over the years and have filled our advance directives out together and we are currently reviewing them again. We also make sure our children know our wishes.

Today, physicians are getting better about asking patients what interventions they would want, but this is a conversation that must happen with all members of the family so if and when the time comes, there is clear direction as to the wishes of the patient.

For more than 22 years I worked in hospice and one of the most difficult things to hear from family members is: “I know what I would want, but I don’t know what my father/mother would want.”

There are great, free resources available on the internet including Five Wishes, The Conversation Project Starter Kit and much more.

One of the best gifts you can give your family members is the give of conversation. It is a difficult thing to do, but one of the most important talks you can have with loved ones.

Craig Greer is the Director of Special Projects with KanTime Hospice Software.

Craig Greer

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By marti WeBB SLay

As an independent patient advocate, Jeff W. Byars, NREMT, BCPA wants healthcare professionals to know advocacy for patients doesn’t translate to being adversarial toward physicians and nurses.

“Some hear ‘patient advocate’ and get somewhat defensive,” said the founding advocate of Sun Back Moon. “I’m not necessarily there because there’s a problem. I’m there to help facilitate between the patient care team and my client, their patient. A lot of that comes down to improving communication.

“Hospital-based patients advocates often get pulled in when there’s a problem. Just because I’m in there, doesn’t mean there’s a problem. A lot of what I do is to try and prevent that. I’m there as a tool for the healthcare team to help things along and help improve the outcome.”

Byars will initially spend as much as two to three hours with a client, learning about his or her diagnosis, doctors, and concerns. “Sometimes they aren’t sure what they are looking for,” he said. “The just know they need help.”

His services for his clients can vary widely, ranging from setting up second opinion or followup appointments to helping locate medical records for insurance approval or resolving billing issues.

Sometimes Byars attends physician appointments with his clients. “Often, elderly patients have adult children who can’t pull away from work to go to the doctor with them, and they want someone who can relay the information, make notes and ask questions,” he said. “A patient advocate working with all the specialists can help give a clearer picture to the patient care team. I’m getting the story played out to me over two to three hours in my initial visit, versus a physician who may have 15 minutes with them. It’s not always white coat syndrome, but the pressure to get everything relayed while the doctor is in the room.”

W. Byars, NREMT, BCPA

eled extensively with my daughter and know there are a ton of resources out there that are often overlooked,” he said. “Everyone knows about Ronald McDonald houses, but there are other resources for people who have to travel for medical reasons.”

Moving elderly parents closer to their children is an additional aspect of medical travel that can be difficult to maneuver. “When the parents live three states away and need more care, we can’t just put them in a car and move them. They need to get closer to home by ambulance or air transport. There’s a lot of negotiation involved, and timing can change the price. Insurance doesn’t pay to move a parent three states away for convenience. If we can help negotiate a better price and save the family money, that’s a benefit,” he said.

ernmental insurance, so he was familiar with the business side of healthcare. As an EMT for 30 years with his local fire department, he also knew a great deal about the patient care side of the process. But all that knowledge was challenged when his seven-month-old daughter required treatment for cancer.

“There were a lot of moving pieces, and it was hard for me to navigate,” he said. “If it was hard for me to navigate with my background, for someone with no medical experience at all, it’s a near impossible task.”

In 2018, Byars was one of the first two people in Alabama to become a Board Certified Patient Advocate (BCPA) under the Patient Advocate Certification Board. He said there are now eight or nine certified advocates in the state, some of whom are hospital based. He wishes there were more.

Byars will also coordinate medical travel for clients, if needed. “I have trav-

Byars had worked for many years as an accountant, conducting reimbursement audits for both private and gov-

“I would welcome competition. We are underserved in Alabama compared to other parts of the country,” he said. “I think the more of us that jump into this, the more word will get out.”

Byars said one big drawback for the

Jeff

Private Practice Pitfalls

By JeFF Bonner

If you are a physician in private practice with fewer than four full-time providers, you’re probably making mistakes that you aren’t aware of, and you’re not alone. It is nearly impossible to keep up with both medicine and business. And small practices generally cannot afford an experienced, qualified administrator. So you wing it and do the best you can. In the process, almost by definition, you break rules and laws you didn’t know existed, and/or you pay too much for services because you don’t have the time or expertise to shop them. Here are just a few of the common pitfalls I see in small practices:

1. Isolation . This one causes all the rest. You don’t have anyone going to meetings (MGMA, carrier sponsored meetings, continuing education on coding, legal, etc.). You can get some of the information you need virtually, but you often don’t know what you don’t know.

2. DOL/Wage & Hour violations. Most people tend to think that if you make someone salaried, you don’t have to pay then overtime. The rules here are more complicated than that, and the penalties are substantial.

3. Bad contracts. Sure, your lawyer could look over everything you sign, but who wants to pay for that? And you sign a lot of contracts for things seemingly as innocuous as phone systems, copiers, waste removal, credit card process, and more. Many of these have long terms, and punitive auto-renewal clauses that lock you in for as long as five years at high rates.

4. Handbooks and training. Your employee handbook essentially tells the government or court (in any litigation or audit) what you have promised. If you deviate from it, you are liable.

If you leave something out, you are liable. Keeping that manual, as well as your HIPPA and OSHA manuals and training up to date is a daunting task, one which most small practices don’t have the time or resources to accomplish.

5. This might be the most important –trust. You have an administrator who’s been with you forever and she knows everything. You trust her. She’s honest and is doing what’s in your best interest. But if she leaves, all that knowledge and trust goes with her. You don’t know what was in her head. Cross-training and shared knowledge saves you a huge headache down the road, but small practices generally don’t have enough staff to effectively cross train.

So, you may feel that you’ve done alright so far. But please remember that nothing matters until it matters –and then it REALLY matters. Going 100mph on the interstate doesn’t matter until you crash or see the blue lights in your rearview mirror. As a physician, you need to attend to every detail, just in case. The business side of your practice needs the same attention. You can’t, and shouldn’t, have to do that. Find someone you can trust and hand off that piece. And focus on what you were trained for and love to do.

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Independent Patient Advocates,

continued from page 8

profession is that patients have to pay for their own independent advocates, limiting his ability to help many people who need his services. “My clients have to be in a position to afford it, and I hate that,” he said.

While Byars works on behalf of the patients, he can serve physicians too. “I offer consulting services to physicians and physician groups to help them improve their process, to make it easier for their

patients to navigate and more patientcentered,” he said. “That can include the flow for check-in to being able to call in and reach somebody in patient relations. I’ve spent time on the patient side and know what makes it easier, as well as what makes it more difficult. My ultimate goal is to make healthcare systems better for individuals and families and work with the healthcare team to improve outcomes for everyone.”

Jeff Bonner is the administrator at Growing Up Pediatrics.

Jeff Bonner

The Inflation Reduction Act provides a dose of holiday cheer for providers

By JeSSe neiL and eLLie martin

It’s natural, this time of year, to reflect on the past twelve months and cast a wary eye toward the year ahead. For healthcare providers, 2022 was marked by workforce and labor challenges, unrelenting financial pressures, disruptive supply shortages, rising prices, climbing interest rates, increased operating costs and decreasing margins. And then there’s the global pandemic that was maybe mostly over, or not, but still hanging around.

But it is the holiday season after all, and perhaps we all deserve a little good news—wherever we can find it.

Back in July, the federal Inflation Reduction Act of 2022 was introduced by Senator Joe Manchin (D-W.Va.) who had put the final nails in the coffin of the Biden administration’s Build Back Better bill. Sen. Manchin objected to the $1.75 trillion price tag for Build Back Better, and said the Inflation Reduction Act was an “opportunity to make our country stronger by bringing Americans together.” Congress passed the legislation along party lines, and President Biden signed it into law in August.

So here’s some good news: The new

law provides relief to Medicare beneficiaries and other healthcare consumers, and many of the Act’s healthcare provisions take effect on January 1, 2023.

Starting in 2025, out-of-pocket prescription drug expenses in Medicare Part D will be capped at $2,000 for Medicare beneficiaries. Additionally, the new law requires Part D plans to implement “improved financial protections” that would be phased-in starting in 2024.

Perhaps the bigger story is that the Act gives Medicare the ability to negotiate drug prices directly with pharmaceutical companies and manufacturers. In 2023, Medicare will announce the first ten drugs for which it will negotiate prices. The initial ten must be selected from among the “highest-spending, brandname Medicare Part D drugs that don’t have competition.” Negotiated prices for the first ten drugs will be available beginning in 2026 with additional Part D drugs added in subsequent years. CMS believes that requiring Medicare to negotiate prescription drug prices will encourage “drug makers to create new ways to do business so they can stay competitive.”

To address rapid price hikes for prescription drugs, the new law requires

companies to pay a rebate to Medicare if they increase drug prices faster than the rate of inflation. The law imposes a cap on the out-of-pocket cost of insulin at no more than $35 for a month’s supply.

The American Rescue Plan Act was enacted in 2021 in an effort to offset some of the economic damage being caused by the COVID-19 pandemic. The Act significantly increased premium subsidies to help lower monthly premiums for health insurance obtained through HealthCare.gov and state-based Affordable Care Act Marketplaces. These premium subsidies were set to expire in January 2023, but according U.S. Rep. Terri Sewell (D-AL-7) the new law “locks in lower healthcare premiums for 209,000 Alabamians who will save an

average of $800 annually per person.” So there it is. Some immediate help for healthcare consumers with respect to healthcare insurance, some help in the future with the cap on out-of-pocket prescription expenses for Medicare that arrives in 2025, and the promise of a new era in which Medicare negotiates drug prices with manufacturers. As holiday gifts go, maybe these things weren’t at the top of your wish list, but perhaps the new law will provide a glimmer of hope at a time when it is needed.

Jesse Neil is a partner at Waller where his legal practice focuses on the intersection of healthcare operations and public policy.

Ellie Martin is an associate at Waller where she assists healthcare organizations with mergers, acquisitions and joint ventures.

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By angie Cameron Smith

Your practice receives notification that an online review has been posted about you or the medical practice. You immediately check out the review and realize that the patient has left a scathing, negative review, which you find to be offensive and untrue. You remember the patient but do not recall that there was anything negative about the patient’s visit. You want to respond to the patient (and the public) and provide information on how your treatment was appropriate – it’s only fair that you get to defend your practice and the care you provided. But

before you start typing and uploading a response, be mindful of your ability to disclose information about the patient or you could face an investigation by the Office of Civil Rights for violating the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) Privacy Rule.

In December 2022, the Office of Civil Rights (“OCR”) announced a settlement with a dental practice over a violation of HIPAA when the dental practice disclosed protected health information in response to an online review. OCR received a complaint alleging that the dental practice “habitu-

ally disclosed” patient names, treatment, and insurance information on the online forum, Yelp, in response to posts that may not have mentioned the patient’s name (instead of a Yelp moniker) or insurance information. OCR conducted an investigation into the complaint and determined that the dental practice had compromised protected health information in violation of the HIPAA Privacy Rule. Additionally, the practice failed to have in place adequate policies and procedures related to the HIPAA Privacy Rule. The practice was fined $23,000 and entered into a Corrective Action Plan with OCR. The Corrective Action

Plan (CAP) is effective for two years and requires the practice to develop policies and procedures, report events that might be a violation of Privacy, Security and Breach Notification policies and train its workforce on HIPAA policies and procedures. Additionally, the practice is required to submit an implementation report summarizing how it implemented the CAP and annual reports to the United States Department of Health and Human Services.

A similar settlement occurred in 2019 with another dental practice requiring the practice to pay $10,000. The dental practice had responded to an online review that included protected health information. These types of cases highlight OCR’s increased focus and enforcement activity related to HIPAA violations in the past few years. In fact, there have been a number of recent settlements related to HIPAA violations. According to OCR, it has investigated and resolved over 29,000 cases since the implementation of HIPAA in 2003, and it has imposed civil money penalties of over $133,500,000. The most frequent complaints received by OCR are related to the impermissible use and disclosure of PHI.

As a reminder, HIPAA generally prohibits covered entities from using or disclosing protected health information absent certain specific circumstances. Covered entities include health care providers such as physician practices, dental practices and individual practitioners. Protected health information includes any information related to the past, present or future physical or mental health condition; the provision of health care; or the past, present or future payment for health care. The Privacy Rule only allows disclosure of PHI under the following circumstances:

• To an individual

• For treatment, pay ment and health care operations;

• After an opportunity by the patient to agree/object;

• As otherwise permitted or required by the Privacy Rules; or

• With patient authorization.

There is no provision in the HIPAA Privacy Rule that would allow a medical practice or dental practice (or individual practitioners) to disclose PHI in response to a public posting on the internet or social media. Some might assume that because the patient has offered certain information in a public forum, then the covered entity could in turn respond with similar information to rebut the negative comments. That is not the case. One might also assume that because the patient has made their health condition the issue, the patient

UAB Precision Medicine Identifies Possible Treatment for Rare ADNP Autism Disorder

By marti WeBB SLay

When the Hugh Kaul Precision Medicine Institute at UAB was founded five years ago, the goal was to contribute to the effort of tailoring treatments to the characteristics of individual patients.

One case that came from the parent of a patient has already made it to clinical trials. As a result of research through an in-house artificial intelligence tool, Matt Might, PhD, who serves as director of the institute, suggested that low-dose ketamine might help treat children diagnosed with activity dependent neuroprotective protein (ADNP) disorder, the leading genetic cause of autism. Led by researchers from the Seaver Autism Center for Research and Treatment at Mount Sinai, the study suggests “that low-dose ketamine is generally safe, well-tolerated and effective to treat clinical symptoms in children diagnosed with ADNP syndrome,” according to a Mount Sinai press release.

“Not all cases of autism are linked to a single gene,” Might said. “When we do our work, we tend to split autism between those which are clearly caused by a single gene and those where there is no identifiable genetic cause. It doesn’t mean there isn’t one. It could be a mixture of several genes or genes plus environment. But ADNP is one where there is a very clear single genetic culprit.”

For proper neurological development, children need two healthy copies of the ADNP gene. Those born with ADNP syndrome have only one healthy copy of the ADNP gene, while the other doesn’t produce the ADNP protein.

Several years ago, Might met Sandra Sermone, founder of the ADNP Kids Research Foundation, whose son was the first to be diagnosed with this disorder in the U.S. Then Might met UAB’s Matt Davis, MD, who at the time was chief resident in the Department of Neurosurgery. Davis’s son Benjamin also has the ADNP disorder. At that point, Sermone asked Might if the Precision Medicine Institute could help find a solution.

This was so early in the life of the institute that the in-house AI tool mediKanren had not yet been fully developed, but as soon as the first prototypes were active, Might began running queries. The tool, which has read all of the medical literature and uses AI reasoning to make deductions, came up with a suggestion.

“Low dose ketamine could, it seems, rescue the activity of this gene,” said Might. “This particular disorder is caused by dropping about 50 percent of the normal activity in ADNP. You have one working copy and one broken copy. The strategy outlined by the AI was, ‘can you make the working copy work twice as hard?’ The strategy to do that was even

simpler: Can you make twice the amount in the working copy by increasing the expression of that gene? That’s where it connected the dots from the literature to the low dose ketamine.”

Once Might found a plausible suggestion, he turned the information over to Davis, who began working with it in the context of the ADNP foundation. “They really did their homework, and they came up with all the metrics around plausibility and got it to the point where it became interesting enough to consider a clinical trial. That patient community has strong connections to Mount Sinai, so that’s where they went with it,” Might said.

The Mount Sinai press release reported: “In order to evaluate the effect of ketamine, the Mount Sinai research team used a single-dose (0.5mg/kg), open-label

design, with ketamine infused intravenously over 40 minutes. Ten children with ADNP syndrome, ages six to 12 years, were enrolled. They found ketamine was generally well-tolerated, and there were no serious adverse events. The most common adverse events were elation/silliness (50 percent), fatigue (40 percent), and increased aggression (40 percent). Using parent-report instruments to assess treatment effects, ketamine was associated with improvements in a wide array of domains, including social behavior, attention deficit and hyperactivity, restricted and repetitive behaviors, and sensory sensitivities, a week after administration.”

Clinician-rated assessments also showed improvements.

Might said the goal of the patient community is to do a larger study next. “The

hope is that a larger study would convince the FDA to put ADNP on the label for ketamine, so insurers would cover it.”

“I hope that physicians around Alabama with ADNP patients will contact the Precision Medicine Institute so we can connect them to the larger ecosystem on this. Likewise, if a physician is struggling with what seems to be an intractable diagnosis or just doesn’t know what to do in next steps with therapeutics, they should feel free to reach out to the Precision Medicine Institute as well.”

For more information about the Hugh Kaul Precision Medicine Institute visit https://www.uab.edu/medicine/pmi/

Evan Carstensen M.D Daryl Dykes, M.D. Michael C. Gerhardt, M.D. Lloyd Johnson Ill, M.D. Winston Capel, M.D.

Matt Might, PhD meets with Precision Medicine Institute team members.

Hospital CEO Roundtable

In November, the Birmingham MGMA held a roundtable discussion with the Chief Executive Officers of three Birmingham Hospitals: Jason Alexander, CEO Ascension St Vincent’s Jeremy Clark, SEO Brookwood Baptist Daniel McKinney, CEO Grandview

What follows are a few of the topics discussed.

MODERATOR:

Has the quality of healthcare changed since the pandemic?

Daniel McKinney: I haven’t seen anything that would diminish the quality of healthcare that’s being provided. The priorities of our patients may be a little different because of the pandemic experiences. For example, I’d say our patients are more aware of the cleanliness of their environment. They’re expecting to maybe come into an environment that’s short-staffed because they see that in other places. Nonetheless, the industry quality indicators are still very strong.

Jason Alexander: I don’t know that clinical quality has changed as much as patients’ definition of quality. I would say that access has become very important, along with patients’ desire to not have to come through the big box acute care hospital.

Jeremy Clark: I agree. I don’t think our

clinical indicators have fallen off. Our organization is still absolutely focused on these and working to improve them. Over the last couple of years, we all had visitor restrictions in some form, and that changes a patient’s perception of care.

MODERATOR:

There is a lot of competition for employees today. How are you managing to maintain your workforce?

Jason Alexander: Our salary dollars are up 30 percent over the last three years. That’s not more people, it’s just paying more dollars – and that’s when we can get the staff. This is not sustainable longterm. So we’re more likely to close beds or close ORs than compromise quality. That is happening now which means you guys (administrators) have unhappy doctors because they can’t get their surgeries scheduled or their patients admitted, but it’s an either or situation - either we compromise,

to some extent, quality by keeping beds and ORs open by staffing too lean, which we won’t do, or close some beds or ORs. And we’re all dealing with that.

With staff, it’s a combination of can’t afford them and can’t find them. Some doctors called me just this morning, saying they couldn’t understand why they can’t get their surgeries scheduled tomorrow. It’s staffing.

Jeremy Clark: We all have a desperate need for staff. So we’re taking on a lot more new graduates in areas that we didn’t always hire them in. That takes more training to bring them up to speed. For years, we’ve been hearing that a nursing and staff shortage would be coming, but to see it accelerate as quickly as it did over the last few years has impressed upon all of us the need to recruit and to invest in staff and try to keep them in our organization.

Daniel McKinney: We see these same issues with our staffing. We have a lot of new graduates.

We recently created a new position,

hiring someone we call a Nursing Advisor, who is an additional touchpoint for our new nurses to help them navigate the resources within our organization. This is an additional touchpoint, someone who is not their director, so that they can feel a little more comfortable having an open conversation. This allows us to tailor some training to the individual based on what she feels she needs help with.

We’ve all had to be incredibly creative in how we address training new clinicians in our facilities.

Jason Alexander: I think we’ll see the advent of some type of new position between a certified medical assistant and an RN because there won’t be enough RNs in the market long-term. Facilities will probably experiment with that, trying to figure out where the sweet spot is to let RNs do what they were trained to do, while the other person does the rest. They wouldn’t be clinical, but we can get them trained pretty quickly.

MODERATOR:

There seem to be supply chain issues for certain medications that are affecting cases. What are you doing to address the drugs we need for surgeons to be able to do procedures in your facilities?

Jeremy Clark: The supply chain has been a problem for two to three years and it’s a challenge across the industry. We’ve all had to be flexible to work with our physician customers for alternatives. Being part of a large company has helped us have access to more resources and alternatives.

Daniel McKinney: I’d add that consolidation within that industry has presented a lot of challenges. Consolidation is great until there is disruption along with supply chain.

We’ve been able to pull from our sister hospitals at times, not just with medicines,

(Left to Right) Jeremy Clark, Jason Alexander, Daniel McKinney

“Samm has been our partner in developing several new large sites and has been such a strong advisor. We have sites with high volume and she has guided us with furnishings that hold up for the long term and still look great! Also, she is our ‘go to’ for small orders as well. Very responsive and understands our budget too.”

“Samm has been our partner in developing several new large sites and has been such a strong advisor. We have sites with high volume and she has guided us with furnishings that hold up for the long term and still look great! Also, she is our ‘go to’ for small orders as well. Very responsive and understands our budget too.”

- Thalia Baker, Associate VP, Primary Care, UAB Medicine

- Thalia Baker, Associate VP, Primary Care, UAB Medicine

but with supplies across all categories.

Jason Alexander: We were literally running jets during COVID to pick up supplies. I could not imagine being a stand-alone hospital over the last three years. We were actually helping supply UAB – they’re big, but not national.

MODERATOR:

What is the trend toward employee providers in your facilities?

Daniel McKinney: I think each opportunity is unique. It depends on the service line and what that provider is looking for. I would venture to say that none of us wake up every day and try to go sign up a bunch of provider employees. But sometimes the circumstances dictate that there is a better economic outcome for a doctor with a hospital. In that case, we have to ask whether it’s a good fit for us and for the provider. And is it the right thing for our patients?

Jason Alexander: I have a cynical opinion on this. I started in healthcare in the 1990s and the mandate with my first job was to employ as many physicians as I could. I did that for about five years and I left just before the whole thing imploded, at which time all the employed physicians returned to private practice and they were very angry about it. I still

carry that mindset, and I say publicly that I don’t ever want to employ a physician if we don’t have to. If a physician determines that this is their preference or if it’s necessary, then we’ll do it. But for me, it’s not a strategy at all. Alignment is the strategy and this can come in many ways other than employment. So we want to define the best way to form relationships between physicians and hospitals and if that happens to be employment, then okay.

Jeremy Clark: We’re fortunate in Birmingham to have so many independent groups. That’s not always the norm in other communities where a wave of health system employment has taken over. I think having independent groups along with health system employee groups is a good mix.

MODERATOR:

Some practices are struggling to recruit providers. Is the pipeline thinner?

Jason Alexander: This is specialty specific. There are some specialties in which you can’t find needed providers anywhere in the country. Beyond that, it depends on the market. If the market is viewed as desirable, you won’t have problems finding doctors. That was the case when I was in

Charleston. In Birmingham, we’re pretty lucky. We train a lot of doctors here, and by the time they’re done, they’ve come to like the city and will consider staying. I’ve been in markets that weren’t so desirable and it’s much harder. So it’s specialty specific and market specific.

MODERATOR:

What kind of technology impacted your business during covid and is now here to stay?

Daniel McKinney: Telehealth. We just mentioned how difficult it is for some communities to attract really talented providers. Rural market telehealth will continue to drive a lot of our strategy.

Jeremy Clark: with outlying facilities that are a little more distant, some specialties really have difficulty providing local care. So we think there are telehealth applications with neurological issues and psychiatric. Even tele-ICU and tele-infectious disease are possible. There are a lot of applications that some other groups are providing now that we may be able to better provide internally somewhere down the road.

Negative Online Review? Think Twice Before Responding,

continued from page 12

the right to the protection afforded under HIPAA or has impliedly authorized such responsive disclosure by the covered entity. No such waiver or implied authorization exists under HIPAA. Therefore, if a patient posts information online about his or her health condition or treatment by a physician or practitioner, it does not authorize the physician or practice to disclose any information about the patient or his or her reason for visiting the practice.

The key take away is that health care providers should review their current policies related to the use and disclosure of protected health information and specifically confirm that their policies address the use and disclosure of PHI on the internet or social media sites, including prohibiting the use of PHI in responding to online reviews of the practice.

Angie C. Smith is a Partner at Burr & Forman LLP practicing exclusively in the firm’s Health Care Practice Group. Angie may be reached at (205) 458-5209 or acsmith@burr.com.

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Seeing it through.

Hassan Alkhawam, MD has joined Cardiology Specialists of Birmingham at Ascension St. Vincent’s. He earned his medical degree at Cairo University and performed his residency at Mount Sinai Elmhurst before doing a fellowship at St. Louis University School of Medicine and UAB Hospital.

Alkhawam specializes in interventional and structural cardiology and is one of only a handful of physicians in the state with extensive structural cardiology training. This is a relatively new field the utilizes the least invasive treatment options for many patients, including percutaneous closure of the left atrial appendage (using the Watchman and Amulet devices), transcatheter aortic valve replacement (TAVR), aortic/mitral/ tricuspid valve in valve replacement, transcatheter mitral valve edge-to-edge repair (MitraClip), PFO and ASD closure, and treatment of hypertrophic cardiomyopathy.

UAB Neuroscientist Earns NIH Award

AAMN names UAB School of Nursing Best School for Men in Nursing

For the fourth year in a row, the UAB School of Nursing has been named a Best School for Men in Nursing by the American Association for Men in Nursing.

A review of the school and its work toward inclusivity highlighted educational efforts, partnerships and the higher proportion of male faculty compared to the national average. The school’s faculty is 17.5 percent male, while the National League for Nursing found that, nationally, only 8.4 percent of nursing faculty is male.

Three Physicians Join Grandview Medical Group

University of Alabama at Birmingham neuroscientist Summer Thyme, PhD is a recipient of the Director’s New Innovator award from the National Institutes of Health. The award is part of the NIH High-Risk, High-Reward Research program which supports investigators at each career stage who propose innovative research that, due to its inherent risk, may struggle in the traditional NIH peerreview process despite its transformative potential.

In her research, Thyme is developing new methods for dissecting the genetic underpinnings of neurodevelopmental disease. She does this by studying zebrafish, which share more than 70 percent of their genes with humans. Their genome has been completely sequenced, and their brains are transparent and have architecture and cell types similar to those of mammals. This transparency enables visualization of brain development and neural activity.

Banking for what’s next.

Grandview Medical Group’s primary care network has added three physicians.

Henry Coker, DO, Internal Medicine, has joined Grandview Primary Care located in Trussville. He received his Bachelor of Science in psychology from Samford University, his Master of Science in collaborative special education from Auburn University (with a concentration in autism and behavior disorders), and his Doctor of Osteopathic Medicine from Philadelphia College of Osteopathic Medicine in Atlanta. He completed his residency in internal medicine and pediatrics at University of South Alabama Hospital.

Caroline Studdard, MD, Internal Medi-

cine, has joined Grandview Primary Care – Liberty Park. She earned her undergraduate and medical degrees from the University of Alabama at Birmingham. She completed her Internal Medicine residency with UAB in Huntsville.

Bingyan Wang, DO, Internal Medicine, has joined Grandview Primary & Specialty Care – Homewood. She received her Doctorate of Osteopathic Medicine from Philadelphia College of Osteopathic Medicine - Georgia Campus. She completed her internal medicine residency at Northside Gwinnett Medical Center in Atlanta, where she was also chief resident.

Hassan Alkhawam, MD

Henry Coker, DO Caroline Studdard, MD Bingyan Wang, DO

Summer Thyme, PhD

UAB Ranked in Top Eight Percent of Global Universities

Based on an exceptional academic research portfolio and its global and regional reputation, the University of Alabama at Birmingham has been ranked in the top eight percent of global universities and as the highest-ranked school in Alabama. The ranking is detailed in a new report from U.S. News & World Report that spotlights the Best Global Universities rankings for the 2022-2023 year.

“UAB’s continued ascent in these data-driven rankings speaks to our everincreasing global competitiveness in research and innovation,” said UAB President Ray Watts.

UAB placed 57th out of 280 ranked schools in the United States, or in the top 20 percent of included American universities. UAB was included as one of just 106 U.S. schools in the top 500, with a regional

research reputation ranking of 66, up four places from the 2021-2022 list.

Of note, UAB ranked in seven areas in the top 100 globally, all part of the Marnix

E. Heersink School of Medicine. Rankings and areas include:

34: Best Global Universities for Surgery 42: Best Global Universities for Clinical

Medicine

45: Best Global Universities for Infectious Diseases

59: Best Global Universities for Immunology

64: Best Global Universities for Cardiac and Cardiovascular Systems (tie)

64: Best Global Universities for Oncology (tie)o

70: Best Global Universities for Endocrinology and Metabolism

The Best Global Universities methodology is based on data provided by Clarivate, rather than gathered directly from the institutions by U.S. News. Rankings were calculated using bibliometric indicators such as publications, citations and highly cited papers rather than data about specific programs.

Photo caption: UAB’s research and reputation land it among the top institutions in the world.

East Alabama Health is Second System in U.S. to Offer SoftVue

In December, East Alabama Health become the second health system in the US to offerSoftVue™, the first 3-D whole breast ultrasound tomography system that is FDA approved for use as a supplemental imaging exam to digital mammography for screening asymptomatic women with dense breast tissue.

The SoftVue exam requires no compression or radiation and can be performed at the same appointment as a screening mammogram. Clinical studies have shown that the Softvue system finds 20 percent more cancers in women with dense breasts compared to mammography alone. It’s estimated that 40 percent of women in the U.S. have dense breast tissue, and they have a greater risk of developing breast cancer. Mammography alone misses about half the cancers in women with dense breasts, as dense tissue and cancer both appear white on mammogram images.

The SoftVue System uses a proprietary TriAD™ (Triple Acoustic Detection) technology that characterizes tissue by capturing reflection, speed and direction of sound waves moving through breast tissue, unlike traditional ultra-

UAB’s research and reputation land it among the top institutions in the world.

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sound which utilizes only reflection.

During the exam, the patient relaxes on her stomach with her breast submerged in a warm water bath. The breast is comfortably stabilized and centered with a disposable Sequr™ Breast Interface gel pad. Imaging is per-

formed with a proprietary 360-degree ring transducer, scanning each breast from chest wall to nipple in an average of three minutes, capturing new images every two millimeters. The captured signals are analyzed using algorithms that provide cross-sectional slices of

Cullman Regional Earns Awards & Rankings

the entire volume of breast tissue. After both breasts have been scanned, a radiologist reviews the SoftVue images alongside the patient’s mammography images to determine if any areas need further examination.

Birmingham Medical News is published monthly by Steve Spencer ©2021 Birmingham Medical News, all rights reserved. Reproduction in whole or in part without written permission is prohibited. Birmingham Medial News will assume no reponsibilities for unsolicited materials.

All letters sent to Medical News will be considered Medical News property and therefore unconditionally assigned to Medical News for publication and copyright purposes.

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EDITOR’S NOTE: In the December Birmingham Medical News, we published Cullman Regional’s 2021 American Heart Association Achievement Awards. The following are the 2022 awards:

Cullman Regional Medical Center earned several awards in 2022, including the 2022 American Heart Association Get With The Guidelines® Heart Failure Gold Plus Award and the ® Stroke Gold Plus Award.

The hospital’s awards and rankings indicate its ability to effectively implement quality improvement initiatives. One example is the hospital’s sepsis initiative. Based on calculations used by the Hospital Improvement Innovation Network, Cullman Regional’s implementation of sepsis protocols since 2017 has resulted in an estimated 194 lives saved.

CMS HOSPITAL COMPARETop 10% Performance

Sepsis Early Management Bundle99% (National 57% - State 55%)

Measures compliance with evidencebased management of sepsis and correlates with lives saved.

Outpatient Colonoscopy Screening –100% (National 90% - State 85%)

Measures compliance with best practice screening colonoscopy including communication to ensure ongoing screening at appropriate intervals.

Elective Delivery < 39 Weeks Gestation - 0% (National 2% - State 2%)

Measures avoidance of premature elective delivery. Cullman Regional has no elective deliveries less than 39 weeks of gestation.

CMS HOSPITAL COMPAREAdditional Rankings Outperforming National and State

Stroke Head CT Scan Results – 80% (National 71% - State 56%)

Measures the percentage of patients with suspected stroke who have a head CT report available within recommended time after arrival.

Acute Myocardial Infarction Fibrinolytic Therapy Within 30 minutes - 91% (National 53% - State 60%)

Measures the immediate treatment of heart attack patients. Specifically, administering clot- buster medication within 30 minutes of arrival.

Acute Myocardial Infarction Median Time to Transfer for Intervention – 49 minutes (National 61 minutes– State 71 minutes)

Measures the time from arrival in the ED with a heart attack to the time transferred out for angioplasty or stent placement.

Median Time from ED arrival to departure – 136 minutes (National 155 minutes – State 144 minutes)

Measures the time a patient spends in the ED.

CRMC earned the AHA Gold Plus for heart failure and stroke.

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