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Serving a 24 County Area, Including Birmingham, Huntsville, Montgomery & Tuscaloosa ON ROUNDS UAB Lays Groundwork for NIH Genomic Risk Assessment Project

AUGUST 2021 / $5

Cutting edge cardiology LAMPOON procedure now available in Birmingham

A year ago, UAB was selected as one of the top national research centers invited to join an NIH consortium in a five-year program to create a tool that will help physicians quickly assess and better manage their patients’ genomic risk for developing common diseases. ... p3

By Marti Webb Slay

When the structural interventional cardiologists at Cardiovascular Associates (CVA) had to send patients to Emory for a specialized mitral valve surgery known as LAMPOON (laceration of the anterior mitral leaflet to prevalent outflow obstruction), they decided it was time to train in the procedure themselves, so they can offer cutting edge care to their patients locally. After training, they completed the first Birmingham LAMPOON surgery in May.

Christ Health Center Services People in Need Some people spend decades searching for their purpose in life. For Robert Record, MD, ... p4


The team that did the first Birmingham LAMPOON surgery.

Intimacy and the Urinary Tract Infection that Follows Fifty percent of women will have a Urinary Tract Infection (UTI) in their lifetime. ... p5

Evidence on Shinrin-yoku and the Therapeutic Benefits of Nature Imagine a gently winding forest path stretching out before you, in sight of a place that feels friendly and familiar ... p8

2021 Med-Mal Market: “Crisis” or “Realities” If you are a physician, administrator, or hospital executive, and if you have been paying attention to the current state of Medical Professional Liability (MPL) ... p9

We Will Always Need Nurses By Ann B. DeBellis

“Historically, nursing shortages have shown a somewhat cyclical pattern, so a cyclical reactive response may have prevented a true crisis in our state. However, the COVID pandemic and other realities have challenged any presump-

tion of normalcy. The time to engage in a paradigm shift from reactive to proactive workforce planning strategies is now so that we don’t experience a nursing shortage crisis in Alabama.” Last year, Dick conducted a survey of Chief Nursing Officers (CNOs) with acute care facilities that focused on supply and demand for acute care registered nurses in our state. The results raised red flags even before the pandemic hit. The survey findings revealed that 68 percent of participants had a high degree of difficulty in filling registered nurse (RN) positions. Another 24 percent reported moderate

Healthcare facilities exist to deliver care, but without an adequate supply of healthcare professionals, the system cannot function. Currently, the United States is in the midst of a nursing shortage, and Alabama has been affected. Tracy K. Dick, PhD, RN, CNE, COI, Assistant Professor at the UAB School of Nursing, has been following these statistics. “I have been amazed at how the words nursing shortage in Alabama have elicited only a low-level response, especially among those outside of the nursing profession,” she says. Tracy Dick talks with a UAB nurse about the long-term outlook for the profession. YOU KNOW MEDICINE.




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UAB Lays Groundwork for NIH Genomic Risk Assessment Project By Laura Freeman

A year ago, UAB was selected as one of the top national research centers invited to join an NIH consortium in a five-year program to create a tool that will help physicians quickly assess and better manage their patients’ genomic risk for developing common diseases. It will also suggest actionable interventions to prevent, delay or ease the effects of the disease and then follow outcomes to measure the effectiveness of those interventions. “This is the first project that combines genomic data with family history and clinical data along with social and environmental determinants of disease to provide a genome-informed risk assessment for common diseases,” Nita Limdi, PharmD, PhD said. Principal investigator for eMERGE at UAB (NIH Electronic Medical Records and Genomics Risk Assessment and Management Network), Limdi is director of UAB’s program of Translational Pharmacogenomics and codirector of the Hugh Kaul Personalized Medicine Institute. In the first year, seven subgroups have been hard at work defining parameters, setting up protocols, and develop-

ing strategies for collecting information and moving it into clinical practice. When preliminary plans are approved, which is expected to be soon, UAB will begin recruiting a diverse cohort of 2500 participants. “Each center participating in the network has a focus in addition to the primary mission. Some are working on legal aspects or ethical concerns like protecting privacy. For UAB, that focus is diversity,” Limdi said. “To this point, most genomic data has been gathered from populations of European ancestry. One of the major goals of this study is to understand how genomic data reflects health risks in other populations, particularly people of African descent and underserved communities.” It has long been established that the risks for some disease as well as the response to treatments can vary significantly in people with different ethnic backgrounds. One of UAB’s strengths is its experience caring for African Americans. “In addition to the large number of African Americans who come to our clinics and hospitals, we have included many in previous studies. Our REGARDS study of regional differences

Nita Limdi, PharmD, PhD, principal investigator for eMERGE at UAB.

in hypertension and related disorders recruited 30,000 people, including 40 percent who are of African American ancestry. In the eMERGE study, we want to make sure that the genomic information we collect and interventions we recommend hold true for everyone and that people of all ethnic backgrounds will benefit from our work.” When plans are finalized, UAB will begin recruiting participants between the ages of three and 75, with a goal of

including a high percentage from underserved communities and diverse genomic backgrounds. The network has asked each center to propose 20 common diseases that meet the criteria of study. “The diseases we will be studying must have a genomic component and be widely found in all populations. To help the most people, in this particular study, we won’t be looking at disorders found only in one (CONTINUED ON PAGE 6)

A Dozen Reasons to Celebrate! Alabama Pain Physicians is celebrating a dozen years! We’re honored to serve this community and committed to improving the quality of life for our patients for years to come! To us, this is more than just a job, it’s our calling. It’s a sweet treat to see our patients thrive. Thanks to our team, our patients and referring providers for trusting us the past 12 years.


Birmingham Medical News

AUGUST 2021 • 3

Christ Health Center Services People in Need By Laura Freeman

Some people spend decades searching for their purpose in life. For Robert Record, MD, that sense of purpose came at the age of 17, walking across the farm fields of Louisiana. “That’s when the dream began,” he said. “I saw the compassion and patience my mother showed as a social worker at a mental health facility. I wanted to help the sick and needy and to one day be part of a place that could bring healing of body, mind and spirit to those who need access to care.” In 2009, that dream became real when Record helped to found Christ Health Center in Birmingham’s Woodlawn neighborhood. “We live in the most generous city in the world,” Record said. “With the help of the medical community, churches, foundations, grants, donations and volunteers, we grew from a staff of four on opening day to a full time and volunteer staff of 110 plus 35 residents. Last year we served more than 25,000 unique patients.” Often, rather than referring to patients, the staff at Christ Health talk about helping neighbors. “Those who come to us for care are the people who bag your groceries, serve your table or clean your office,” Record

Robert Record, MD

said. “They are mostly the working poor. About 40 to 50 percent are uninsured, 35 percent have Medicaid, 10 percent Medicare and 10 percent have private coverage.” Around 75 percent of the center’s operating budget is funded by earnings for the care it provides, with 10 to 15 percent coming from federal grants and 15 percent from donations.

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Birmingham Medical News

The center has continued to grow and expand the services it offers. “In some ways, we’re like what a small town doctor’s office used to be, but we have about the same facilities and services you’d find in most clinics,” Record said. “From obstetric and newborn checkups to end of life care, we provide the full range of family medicine. We also offer behavioral health services with psychiatrists and counselors, and our residency program cares for patients at a clinic in Chalkville.” Before the pandemic, Christ Health Center also offered a full range of dental services. Plans are underway to re-open the dental clinic when restaffing is completed. During the pandemic, the center performed more than 16,000 COVID tests and so far has done more than 10,000 vaccinations, 44 percent of which were for minority patients. They have also cared for many patients showing symptoms and arranged hospitalization for those whose condition needed more advanced care. “The physicians and hospitals here have been wonderful,” Record said. “We often have patients with heart disease, cancer, facial deformities, or other serious conditions that need advanced care, and when we call for help, so many step

up and gladly help. The support we receive has been incredible. It has allowed us to grow and make more services available to more people. Still, demand remains greater than supply, so we are continually working to upgrade and expand our facilities to meet the need. “We are upgrading our ultrasound capabilities, and we are just now opening an administrative office on Montclair Road. This will free up more space here for so we can build additional exam rooms. We already offer some home visits through our residency program for patients who are home bound or have a condition that makes it difficult to go out. In the future, we hope to also have a mobile health unit so we can take care to patients who can’t come to us.” For those most in need, the dream continues to grow. It is a blessing to those who need care and also to those who give it. It’s also a wonderful opportunity for volunteers to make a real difference, and for physicians and medical staff to practice the kind of medicine that inspired their decision to go into healthcare.

Intimacy and the Urinary Tract Infection that Follows By Heather Williams, CRNP

Fifty percent of women will have a Urinary Tract Infection (UTI) in their lifetime. A portion of those women will identify sexual intercourse as a precursor to their symptoms. Typical UTI symptoms include painful urination, lower abdominal pain, urinary frequency, urinary urgency, foul-smelling urine, and blood in their urine (hematuria). A woman may only have one of these symptoms that prompts her to present for a clinical evaluation. Women are naturally at risk for developing a UTI due to a shorter urethra adjacent to the vagina and rectum, which harbors microorganisms that may contribute to a UTI. The gastrointestinal organism Escherichia coli (E.coli) is the most common organism and accounts for about 80 percent of UTIs confirmed with a urine culture. Estrogen levels play a role in the prevention and development of a UTI. The premenopausal woman has adequate estrogen levels that contribute to healthy genital tissues. However, a postmenopausal woman has decreased estrogen, which contributes to thin, fragile genital tissues. Vaginal tissues that lack estrogen or are hypoestrogenic are easily irritated and prone to infection due to the lack of


Heather Williams, CRNP

the genitalia’s natural barrier created with estrogen. As vaginal estrogen decreases, the prevalence of painful sex (dyspareunia) and UTIs will increase. Hypoestrogenic tissue is treated by the replacement of hormones at the source of atrophy. Vaginal estrogen cream or an estrogen ring is best for improving vaginal tissue to prevent the occurrence of a UTI. Women must understand that, although their symptoms may present after intercourse, a UTI is not a sexually transmitted infection. Regarding the onset of symptoms after sex, it is helpful to inform women that the frequency of sex, new sex partner, type of lubricants and spermicides, are additional risk factors for a UTI. Overall health status is essential when considering the cause for UTIs as women with underlying health

issues such as diabetes, renal failure, kidney stones, neurologic disease, sickle cell, and sickle cell trait. Intake of concentrated cranberry juice, low dose antibiotic after sex, vaginal estrogen, boric acid vaginal suppositories, D-Mannose supplement, and applying antiseptics to the urethra before sex are proven beneficial in the prevention of UTIs related to sexual intercourse. Studies lack sufficient evidence that supports the prevention of a UTI when emptying the bladder before and after sex. Despite its lack of supportive evidence, maintaining good hygiene is beneficial and recommended as a prophylactic measure.

At the UCA Women’s Center, we create an individualized care plan for each woman. The anticipation of discomfort after or during sex will decrease sexual desire, which can cause a relationship strain for some couples. If a UTI is negatively impacting a woman’s life, we want to evaluate, diagnose, and treat it so that she can embrace her sexuality and engage in intimacy without hesitancy. We encourage women to express any concern regarding intimacy and seek help. Heather Williams, CRNP is a board certified Adult-Gerontology & Women’s Health Nurse Practitioner with the UCA Women’s Center.


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Birmingham Medical News

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We Will Always Need Nurses, continued from page 1 difficulty. When the CNOs were asked specifically about hiring experienced RNs, the high difficulty percentage increased to 80 percent. “I wasn’t able to identify anyone in Alabama who has been studying supply and demand of the nursing workforce,” Dick says. “Before my study, there was anecdotal evidence of a shortage but no research-supported evidence. That is the point I am trying to make. Alabama needs ongoing research about the nursing workforce, because it impacts health care. Nurses comprise the largest percentage of health care professionals, so there can be far reaching effects.” Additional workforce demand is expected to increase as the current workforce ages. Alabama’s growing percentage of individuals 65 years or older, combined with the state’s sustained chronic disease burden, promises that the demand for health care services will continue to increase. “Coupled with that, the U.S. Census Bureau recently reported an anticipated decline in the number of people considered part of the workingage population across the United States,” Dick says. “A critical shortage of nurses could occur if the anticipated decline in the working-age population numbers proves to be correct in Alabama. “The nursing profession is a great career opportunity and is expanding exponentially. When I was in nursing school,



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Birmingham Medical News

there was talk about the expanding role of an advanced practice nurse. I thought then that it was just around the corner. We are finally seeing that reality. We now have many opportunities for advanced practice nurses. That is fantastic and much needed, but we need an increasing number of expert frontline nurses too. When you have an experienced nurse leave the frontline for advanced practice, it creates a position to fill. “There will always be a need for nurses to serve at the bedside in acute care facilities. The front line is exciting but can also be challenging. It is physical and emotional work. Most acute care facilities use a 12-hour shift model. Although younger nurses typically like the 12-hour shift, experienced older nurses often seek positions with more flexibility in work hours. I believe that to realize higher quality health care and prioritize patient safety, we must increase the focus on the work of nurses and their value to healthcare. “I have been a nurse for 32 years, and I want to do everything I can to draw attention to this current nursing shortage and the long-term outlook. I am passionate about this. We need an adequate workforce to provide health care for the people in Alabama. We have an opportunity at this critical juncture to discuss, collaborate and to act to avoid a future critical nursing shortage in our state.”

UAB Lays Groundwork for NIH Genomic Risk Assessment Project, continued from page 3 ethnic group,” Lindi said. “The disease, whether adult or pediatric, must also be actionable. That action may be medication, but it could also be changes in nutrition, activity, habits or environment. In some disorders, it might be earlier screening or more frequent testing,” Thus far, UAB has identified 10 major diseases that meet all criteria. “In analyzing the genomic risks of participants, we might find an indication of BRACA, signaling a strong risk for breast cancer,” Lindi said. “In that case, we could let the woman’s physician know she needs to be screened early and often. She would in turn be able to warn relatives of the risk and perhaps save their lives.” Finding the best ways to translate this new information for clinical use is also one of the primary goals of the project. “Co-principal investigator James Cimino, MD, is director of the UAB Informatics Institute,” Limdi said. “He is leading one of the work groups and using UAB’s strong background in informatics and personalized medicine to take the information we find into patient records where physicians can use it in a clinical setting to assist in patient care. We’re also looking for the best ways to communicate with clinicians so they can quickly get up to speed, perhaps through a brief flier or message, or a short video.”

Another challenge for informatics is to find a way to track risk factors as predictors of disease, whether clinicians are using the information to optimize care, and whether those changes are improving outcomes. “We need to be able to follow the patient with having a researcher go through every file. We’re developing an algorithm using coding to flag changes in health status that might be linked to a genomic risk,” she said. In the case of a patient with a strong genomic risk for type 2 diabetes, the physician may want to begin using metformin earlier, or to try nutrition, exercise and lifestyle intervention along with more frequent testing to monitor blood sugar levels. “As time goes on, we would like to check back to see whether knowing about the genomic risk of diabetes has helped to prevent or delay onset, or to lessen the impact on the patient’s kidneys, vascular system, eyes and overall health before the damage is done,” Lindi said. In four years when the project is complete, physicians will have a powerful new tool to improve and personalize patient care in many common diseases. It could be the first step toward better, more personalized treatment for heritable disorders in years to come.

Cutting edge cardiology LAMPOON procedure now available in Birmingham, continued from page 1 LAMPOON prevents the obstruction of blood flow in the left ventricular outflow tract (LVOT) during transcatheter mitral valve replacement (TMVR). “It’s an adjunct incremental step that allows us to offer TMVR to more patients,” said Matthew Sample, MD, structural interventional cardiologist. “Over the past decade, we’ve had an explosion in our ability to do percutaneous valve surgeries, valve replacements and valve repairs.” “One of the things we’ve done over the past five to 10 years is use an aortic valve prosthesis placed in the mitral valve position through the leg,” said Stephen Bakir, MD, structural interventional cardiologist. “In some of those patients, when we place a new mitral valve inside the old, the leaflet gets in the way and causes outflow obstruction. The only way to fix that is to cut that piece of mitral valve out. When the surgeon has the chest open, it’s nothing to cut that piece out. But LAMPOON allows us to put a valve in through the leg, and using electrosurgery, which is a guidewire that’s electrified, we make a precision cut in the leaflet of the mitral valve, which opens it and allows the new valve to go in without obstructing the outflow to the heart.” Since an obstruction to outflow is immediately fatal during transcatheter surgery, this procedure opens the door for many patients who are not able to withstand open heart surgery and are at risk obstruction during TMVR. The procedure requires a talented multi-program team, and the team completing the procedure in May was no exception. In addition to the two structural interventional cardiologists, the team included a structural cardiac imager, Luiz Pinheiro, MD and a cardiac thoracic surgeon, Will McAlexander MD. “Dr. Pinheiro gave us the eyes and ears to guide us through this with 3-D echo,” Bakir said. “And Dr. McAlexander made modifications on the current iteration of the heart valve prosthesis.” “A lot goes into this,” Sample said. “It’s very technical and challenging. This is not a standardized procedure at this point. It is continually being modified. The procedure we did was the most recent iteration, the tip-to-base LAMPOON, otherwise known as reverse LAMPOON.”


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The procedure is even considered controversial, but Sample and Bakir are confident it will prove to be a viable option for those patients who are not candidates for other courses of treatment. “It’s a niche for patients who have very few options and would not otherwise survive surgery for percutaneous mitral valve,” Bakir said. “If all goes well, they can walk out the next day with a BandAid on their leg.” In fact, they see the potential for a new field of medicine. “The collection of these techniques, and there’s more than just LAMPOON, is called cardiac electrosurgery,” Sample said. “It involves using a very small electrified wire to cut structures in the heart. If this is as effective as developers think, it will create an entirely new field within interventional cardiology. That is the lofty goal. It will have to be borne out in the data, but I think it’s going to work.” Sample and Bakir traveled to Emory to be trained in LAMPOON. “We contacted the developer and went to observe the procedure on a patient we referred to them. When we got there, they were doing another on the same day, so we were able to see two,” Sample said. “This is not something you want to attempt without knowing how to do it step by step,” Bakir said. “There are other applications for this electrosurgery procedure that we have already incorporated into our practice.” Once they had trained for the procedure, Sample and Bakir felt confident proposing and using LAMPOON when a patient presented who could benefit from it. The operation took place in early May. It went well, and they sent the patient home two days later with a Band-Aid on his leg, as expected. “We kept him two days out of an abundance of caution, but he felt well enough to leave the next day,” Sample said. A follow up appointment will be needed at two months, and the doctors expect to check his echocardiogram annually in the future, but he will be under no activity restrictions.

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Evidence on Shinrin-yoku and the Therapeutic Benefits of Nature Imagine a gently winding forest path stretching out before you, in sight of a place that feels friendly and familiar. Subtle sounds provide the soundtrack as you take slow, steady steps through the path’s vibrant color, light and shadow, followed by a deep inhale. It’s likely these three simple sentences lead you to a cultivation of calm. The idea of being with nature and experiencing presence in such solitude may seem an obvious benefit to most. But the healing reality of this profound sense of connection in an otherwise disconnected world is finding scientific substance in the actions of Chinese-born physician, Dr. Qing Li, and the fantastical forests of Yakushima Island. Decades ago, friends invited Li to Yakushima, where they camped overnight within the roots of 1,000-year-old trees. When he returned home, he realized he was a changed man. Shinrin-yoku, translated as “forestbathing” describes the subtle-yet-powerful interactions that occur when one spends time with the differing densities of organic environs. Simple studies held by Dr. Li provided doses from 20 minutes to overnight stays in forests near inpatient and outpatient facili-

Micah Howard, MD

ties. The findings, corroborated by the Japanese Society of Forest Medicine, demonstrated reduced blood pressure, improved mood, increased focus — even in children with ADHD — accelerated recovery from surgery or illness, increased energy level and improved sleep in subjects. These results support the longknown quality contentment and potent nepenthe found in interactions with mountain vistas or ocean waves. But this latest data on nature’s immunologic interactions with the human organism may help spread the good word even farther. Phytoncides — volatile, allelochemical compounds released by plants for cellular signaling, anti-microbial and

It takes a woman to know a woman.

anti-fungal defense — have been found to have paracrine and immuno-modulating effects noted to lead to improved levels of cortisol and salivary alpha-amylase: biomarkers for stress. Furthermore, definitive documentation (fig 1.) explains increases in proportions of human Natural Killer (NK) cells and enhancement of NK activity in a dose-dependent manner. Human NK cells, particularly the NK92MI variety, produce TNFalpha and IFN-gamma in effort to provide direct control of viral infection and their direct natural cytotoxicity against primary tumor cells and suppression of

metastasis via inhibition of proliferation. Their role in healing, especially through frequent commune with nature, necessitates a prescription for reconnection to the natural world. Our self-isolation convinces us we are different from what we see, hear, touch, taste and smell. May we all experience the truth today, somewhere beautiful. To view the study: pmc/articles/PMC2793341/ Micah Howard, MD practices family medicine in Decatur, Alabama.

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Birmingham Medical News

Heather Williams, CRNP Nurse Practitioner

2021 Med-Mal Market: “Crisis” or “Realities” By Blair Voltz This is the first of a three-part series. By the end of the series, I hope to have covered national, regional, local, and personal realities of the medical malpractice market so that the reader (especially physicians, practice administrators, office managers, and hospital executives) has a sense of the current disturbing developments they may be experiencing.

If you are a physician, administrator, or hospital executive, and if you have been paying attention to the current state of Medical Professional Liability (MPL), commonly referred to as Medical Malpractice or Med-Mal, then you are aware that the Med-Mal world has entered a challenging time. Some professionals in the field consider it to be a crisis. In order to best navigate the situation, I believe it is important to look at the current realities and anticipate how they will affect you. In 2020, despite fewer court cases being tried due to closed courthouses because of the pandemic, Med-Mal insurers saw their sixth consecutive year of underwriting losses according to a recent A.M. Best report. The report, Continued Uncertainty Clouds the Horizon for MPL sees a negative outlook for the national Med-Mal sector due mostly to: • A rise in total claims payouts; • Diminishing reserves due to

Blair Voltz

unfavorable prior year reserve loss development; • Rate inadequacy (rates have been too low for too long); • Rising loss trends; • Rising defense costs; • Competitive market conditions.

Unfortunately, for the consumer of Medical Professional Liability, there has been an exceptional surge in the percent-

age of companies reporting a year-toyear increase in premiums. Between 2010 and 2018, the share of premiums that increased remained steady at between 12 to 17 percent. However, in 2019 that almost doubled to 26.5 percent and went up again in 2020 to 31.1 percent. The overall premium rate for the US in 2020 was the highest in nearly 15 years. It appears that trend shows no sign of slowing. According to the Insurance Journal article in May of 2021, rate hardening (i.e., rate increase) is expected to gain further momentum this year as unfavorable profitability trends persist. On the national scene • In Texas, Capson Physicians Insurance Company was placed into liquidation; • In Washington D.C., the D.C. Department of Insurance placed Fairway Physicians Insurance Company, RRG (Risk Retention Group) into liquidation; • In Kasas, the Kansas Insurance Department had to take over Physician’s Standard Insurance Company; • In Montana, Doctor’s and Surgeon’s National RRG was liquidated; • In Missouri, Missouri Physician

Mutual was declared insolvent. Some states in our region that reported significant increases in premium were Kentucky (29.6 percent), South Carolina (27.8 percent), Georgia (14.8 percent), Texas (9.2 percent), and North Carolina (6.7 percent). The leading Med-Mal carrier in Georgia filed for and received a 6.1 percent rate increase in April 2020. Later that same year, in October, that same carrier filed for a second rate increase, said to be for about another 10 percent. The Georgia Department of Insurance rejected that second request due to a Georgia Department of Insurance rule that forbids two rate increases in the same year. Despite the rejection, the company resubmitted for the rate increase in December to be effective in early 2021. The company also stated that their actuarial indications call for a 15.9 percent increase across their book of business. The Georgia Department of Insurance granted that second increase for 2021 at 8.5 percent, thus giving the company a 14.6 percent increase over the two-year period, which is still not enough, according to them. According to S&P Global Market Intelligence the 14.6 percent rate increase was one of the largest MPL rate increases through (CONTINUED ON PAGE 11)

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AUGUST 2021 • 9

The DOL’s Covid-19 ETS For Healthcare Providers Is Now Effective by Lindsey Phillips, Cayman Caven, Howard Bogard, and Matthew Scully

On June 21, 2021, the Occupational Safety and Health Administration (“OSHA”) published an Emergency Temporary Standard (“ETS”) that requires healthcare employers to take certain precautions to protect workers from COVID19. The requirements of the ETS went fully into effect on July 21, 2021. This article briefly discusses who exactly the ETS applies to and some of the requirements the ETS imposes. The article culminates with our answers to some frequently asked questions regarding the ETS. Who the ETS Applies To

The ETS applies to “all settings where any employee provides healthcare services or healthcare support services.” The ETS does not apply to the following situations: • The provision of first aid by an employee who is not a licensed healthcare provider; • The dispensing of prescriptions by pharmacists in retail settings; • Healthcare support services not performed in a healthcare setting; • Telehealth services performed outside of a setting where direct patient care occurs; • Non-hospital ambulatory settings where non-employees are screened for COVID-19 prior to entry and people

management • Vaccination • Training • Anti-retaliation • Recordkeeping and reporting While each of these categories contain detailed requirements, we discuss a few in more detail below. Personal Protective Equipment

with suspected or confirmed COVID19 are not permitted to enter; • Well-defined hospital ambulatory care settings (e.g., non-hospital physician practices, outpatient practices, ambulatory surgical centers, and specialty clinics) if all employees are vaccinated, all non-employees are screened for COVID-19 prior to entry, and people with suspected or confirmed COVID-19 are not permitted to enter; • Home healthcare settings if all employees are fully vaccinated, all non-employees are screened for COVID-19 prior to entry, and people with suspected or confirmed COVID19 are not present In the situations mentioned above, “screened” means asking questions

to determine whether a person has COVID-19 or symptoms of COVID19, and “ambulatory care” means “healthcare services performed on an outpatient basis, without admission to a hospital or other facility.” What the ETS Requires

The ETS mandates 12 different types of requirements on covered healthcare providers. Those categories include: • Creation of a COVID-19 Plan • Patient screening and management • Personal protective equipment • Physical distancing • Physical barriers • Cleaning and disinfection • Ventilation • Health screening and medical


The ETS requires employers to provide face masks to their employees and ensure employees wear them over the nose and mouth when indoors or occupying a vehicle with other people for work purposes. The ETS further requires employers to ensure that employees change their face masks at least once a day – and even more frequently if the mask is soiled, damaged, or patient care requires changing. The ETS does allow exceptions to the face mask requirements in the following circumstances: • An employee is alone in a room. • An employee is eating and drinking at the workplace, provided each employee is maintaining social distance from any other person. • It is important to see the employee’s mouth (e.g., communicating with a deaf individual) and a clear plastic face mask or barrier is not feasible. • An employee cannot wear a face mask due to medical necessity, a medical condition, a disability (as that term is defined by the Americans with Disabilities Act), or a religious belief. • When the employer can demonstrate that the use of a face mask presents a risk of serious injury or death. Vaccination

The ETS also requires employers to support COVID-19 vaccination administration by providing reasonable time and paid leave for vaccination and side effects experienced after vaccination. Anti-Retaliation

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Pursuant to the ETS, employers are required to inform employees that they have a right to the protections afforded by the ETS, and all requirements of the ETS must be implemented at no cost to employees. Furthermore, employers are prohibited from discharging or discriminating against employees who exercise the rights afforded to them under the ETS. FAQs about the ETS

In this section, we answer some FAQs that are pertinent to the issues discussed above. If an employer is exempt from the ETS requirements by screening everyone who enters the facility, does the employer need to keep documentation of screening? Yes, employers should keep documen(CONTINUED ON PAGE 11)

The Dol’s Covid-19 Ets For Healthcare Providers Is Now Effective continued from page 10 tation demonstrating that they screened everyone, including employees and patients, in order to prove that they met the exemption under the ETS.

At this time, employers should assume that the DOL intends to enforce these requirements unless the DOL releases guidance to the contrary.

Can employers utilize KN95 masks if N95 masks are not available?

Will hospital employers who have mandated vaccines, but still have a small percentage of employees who are unvaccinated as an accommodation under either the ADA or Title VII, be able to be exempt from PPE and other physical barrier requirements?

Yes, the ETS permits use of any FDAapproved surgical, medical, dental, or isolation mask. Can vaccinated employees stop wearing masks? Mask requirements do not apply in well-defined areas where there is no reasonable expectation that any person with suspected or confirmed COVID-19 will be present and where all employees are fully vaccinated. If employees are not in an environment that meets these requirements, or one of the mask exceptions does not apply, masks are required. Furthermore, the CDC requires healthcare personnel working in a healthcare setting to wear well-fitting source control at all times while they are in the facility. Will the Department of Labor (“DOL”) enforce the requirements that employers pay employees for time related to vaccine side effects? OSHA is a division of the DOL, which enforces federal wage and hour laws.

We do not have a definitive answer from OSHA at this time. However, OSHA recognizes that there are instances where an employee may not be vaccinated because of a religious belief. So, it appears the employer could still be exempt if the rest of the workforce is vaccinated. Lindsey Phillips is an associate at Burr & Forman LLP practicing exclusively in the firm’s Healthcare Industry Group. Lindsey may be reached at (205) 458-5370 or lphillips@burr. com. Cayman Caven is an associate at Burr & Forman LLP practicing exclusively in the firm’s Labor & Employment Group. Cayman may be reached at (205) 458-5151 or Howard Bogard is a partner at Burr & Forman LLP practicing exclusively in the firm’s Healthcare Industry Group. Howard may be reached at (205) 458-5416 or Matthew Scully is a partner at Burr & Forman LLP practicing exclusively in the firm’s Labor & Employment Group. Matthew may be reached at (205) 458-5321 or

2021 Med-Mal Market: “Crisis” or “Realities”, continued from page 9 April of 2021. The largest Med-Mal carrier in Alabama was downgraded and placed on negative watch, and was sued in a large class-action suit for violations of the Securities Exchange Act, having to do with a large underwriting loss of over $100M loss on a single account. “But,” you say, “my practice/hospital is in Alabama. What does what’s happening in these other states have to do with me?” Excellent question, and I’ll answer that in parts two and three of this blog when we take a more in-depth look at what is happening in our state. But for now, I’ll tell you that there are two ways in which what is happening nationally affects MPL rates here in Alabama: 1) Every time an MPL insurer goes into liquidation, or reduces their appetite for writing certain segments of the MPL market, or gets out of the MPL business, it reduces what is know in the insurance world as capacity. You might also think of this as supply. When the capacity available to write MPL insurance shrinks: a. Supply gets reduced; b. Underwriting becomes stricter as companies become more selective; c. The cost of reinsurance goes up, and therefore;

d. The cost to the consumer goes up. 2) Actuaries take into account what is happening in each state, the region, nationally, and even around the world, when setting rates. Bad news anywhere is bad news everywhere. Actuaries and insurers then adopt a cautious approach to underwriting and as a result, rates go up. In general, hospitals are experiencing even more of the rate pressures than physicians. You can rest assured that, if you haven’t experienced a rate increase in your Professional Liability costs, it is probably coming with your next renewal. So, these are the current realities, and yes, one could say with confidence that nationally we are entering a crisis period. Next month, in part two, we will take a closer look at the state of Alabama in particular, how the primary carriers in Alabama are being affected, and how that will affect you. While this article focuses on bad new, in part three I will be able to give you good news. Blair Voltz began his career in medical professional liability in 1987, spending the next 25 years with Alabama’s largest medical malpractice carrier before establishing Voltz Professional Risk Advisors in 2011. Since then, he has helped over 200 physicians and a major hospital system improve their coverage, as well as their bottom line.


 AUGUST 5 M. Wes Love, MD, FACS of Cahaba Valley Surgical Group Evolution of hernia repair  AUGUST 10 Blair Voltz of Voltz Risk Advisors Alabama Carriers Affected in Med-Mal Market  AUGUST 17 James F. Henry of Phelps Dodge Legal Issues Facing Practices  AUGUST 19 Tammie Lunceford of Warren Averett Space Considerations- A New Era in Practice Management  AUGUST 24 Children’s Hospital Handling Pediatric Infections  SEPTEMBER 7 William Presson, ERPA of Pinnacle Plan Design Retirement Plan Issues When a Doctor Leaves a Practice

TO VISIT OUR BLOG Go to and click blog on the far right column or go directly to While there, you are welcome to scroll down for past blog articles.


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UAB Recruits for Rural Health Study The University of Alabama at Birmingham School of Public Health has started recruiting for The Risk Underlying Rural Areas Longitudinal Study (RURAL) that will attempt to learn what causes the high burden of heart, lung, blood and sleep disorders in southern rural communities. It will recruit 4,600 multi-ethnic participants from 10 rural counties in Alabama, Kentucky, Louisiana and Mississippi. In Alabama, the study will recruit 1,100 participants from Dallas and Wilcox counties, which experience higher rates of heart and lung disease than other counties in the state. Rural residents have not often been included in research studies because they are not located near research hospitals and clinics. To help recruit research participants, UAB will use a mobile clinic which will travel to each study location to provide medical exams for participants and promote study engagement in diverse communities. Familial, lifestyle and behavioral factors, along with medical history including risk for heart, lung, blood and sleep disorders, will be recorded. Environmental and economic factors will also be studied. “The RURAL Heart and Lung Study clinic will bring technology to rural communities that provides access to diagnostic tests that are not routinely done in rural settings,” said Suzanne Judd, PhD,

Inside the mobile clinic. co-principal investigator of the study and a professor in the Department of Biostatistics at the UAB School of Public Health. “The project is an engineering challenge, a community engagement challenge and a disease prevention challenge, which makes the work incredibly exciting.” Participants will be given an exam that will take pictures of the heart and lungs and collect other measures of heart

and lung function, such as inflammation in the blood, blood pressure and history of heart disease. If a health problem is identified during the exam, the participant will be notified immediately of the issue. If participants do not have a doctor, study coordinators will work with local doctors who can help participants with their condition. If they do have a doctor, researchers will work with that person’s

primary care doctor to provide test results and improve care. The six-year, $21.4 million cohort study is funded by the National Heart, Lung and Blood Institute, part of the National Institutes of Health, and includes 50 investigators from 15 institutions. For more information, visit the RURAL Study website at https://www.


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Donald Battle, MD Joins Cullman Regional Medical Group Donald Battle, MD, who specializes in Occupational Medicine, has joined the Cullman Regional Medical Group. Battle, a board-certified Family Physician, is a graduate of Emory Donald Battle, MD University who completed medical school at the University of Virginia School of Medicine. He completed his post-doctoral training through Duke University and the Medical College of Virginia. Battle has more than 20 years of experience and training in occupational medicine, specializing in the treatment of work-related injuries and illnesses. He will be treating patients in Cullman Regional’s Occupational Health Clinic, WorkMD located at 1958 AL Highway 157 in Cullman.

Charles Welden, IV MD Joins Gastro Health Charles V. Welden, IV, MD has joined Gastro Health where he is practicing in the St. Vincent’s East and Pell City clinic. He has special interests in colorectal cancer prevention, Inflammatory Charles V. Welden, IV, MD Bowel Disease, cirrhosis, and esophageal disorders. Welden completed his medical degree, his internship, and his residency at the University of Alabama at Birmingham. His GI fellowship was completed at the Medical University of South Carolina in Charleston. Welden, who is board certified in Internal Medicine, is a member of the American Gastroenterological Association, the American Society of Gastrointestinal Endoscopy, and the American College of Gastroenterology.

Laura Crandall Brown Foundation Announces 9th Annual A State of Teal Awareness Campaign This September, in recognition of Gynecologic Cancer Awareness Month, the Laura Crandall Brown Foundation (LCBF) will initiate its 9th annual A State of Teal Awareness Campaign and host its 12th annual Head Over Teal 5K/10K. The campaign’s goal is to highlight the importance of increasing awareness of gynecologic cancers. Awareness is spread through the use of radio advertising, digital advertising, and events including Head Over Teal. Teal lighting will be observed in many businesses and cities th The Head Over Teal 5K/10K will return to the Town Hall in the Hoover

Preserve subdivision on Saturday, September 25, 2021. Social distancing guidelines will be observed during packet pick-up, and hand sanitizer stations will be available on race day.  Event features include: 5K race, 10K race, family friendly games, face painting, food, and live music.  Participants have the opportunity to raise funds individually and/or as a team. Lead race times will be eligible for a Trak Shak gift card. Social media engagement is encouraged using the hashtag #headoverteal. LCBF social media platforms include Facebook @LCBFoundation, Instagram at lcbfoundation, YouTube at Laura Crandall Brown Foundation, and Flickr at Laura Crandall Brown Foundation.

Casey Named to Who’s Who in Birmingham Healthcare Maddox Casey, CPA with Warren Averett was named to Birmingham Business Journal’s Who’s Who in Birmingham Healthcare 2021, his second Maddox Casey, CPA year in a row to make the list. Casey is a practice leader for the Warren Averett Healthcare Division. His team serves over 650 physician practices across the Southeast. He earned his Bachelor of Science in Accounting and his Master of Business Administration from The University of Alabama at Birmingham. “It’s an honor to be recognized,” Casey said. “In recent months, physician practices have faced new challenges and it has been gratifying to help physicians maintain their profitability, navigate the new environment and help as many patients as possible. It is my goal to continue helping my clients thrive in all their endeavors.”

Clevenger Joins HudsonAlpha Josh Clevenger, PhD has joined the HudsonAlpha Institute for Biotechnology where he will be involved in plant research. Clevenger, who Josh Clevenger, PhD earned his PhD from the University of Georgia, was previously a research scientist with Mars Wrigley Chocolate, specializing in peanut genetic improvement by leveraging genomics technologies, and developing computational tools for high-throughput sequence-based genotyping. He also played a large role in the industry-led Peanut Genome Initiative, developing genomic tools and markers for molecular breeding. HudsonAlpha’s work in plant genomics includes research looking for genetic markers that can help make agriculture more efficient through increased yields, improved disease resistance and reduced water use. “My lab will focus on using genom-

ics for crop improvement, especially crops in the southeast and in Alabama,” Clevenger said. “I look forward to joining HudsonAlpha’s team of plant genomics researchers and using the tools that we develop to improve disease resistance for crops in the state. I’m passionate about getting farmers the varieties they need to be successful.”  

New Study with Electrical Stimulation for Depression

A new study by the University of Alabama at Birmingham is using a device originally developed to treat seizure disorder to treat patients with treatmentresistant depression. Vagus nerve stimulation therapy consists of a small device, the size of a quarter, implanted just below the collarbone that sends out mild pulses to a nerve in the neck. It was approved in 2005 as a safe and effective treatment option for use in difficult-to-treat depression but has not been widely used, due to a lack of reimbursement from payers. Matthew Macaluso, DO and study

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AUGUST 2021 • 13

GRAND ROUNDS coordinator Katlyn Jackson, from the UAB School of Medicine’s Department of Psychiatry and Behavioral Neuroscience, are participating in a national study assessing the results of VNS Therapy® in individuals whose depression continues despite trying four or more treatments. “When the VNS device started being used for seizure disorders, doctors noticed that their patients seemed to feel happier,” Macaluso said. “This was due to the device’s stimulating the vagus nerve, which increases activity in the frontal cortex, helping patients with their mood. The study may provide evidence that Medicare and other insurers need in order to cover it.” The device is implanted in an outpatient setting with most patients able to go home the same day. Those eligible to participate include Medicare patients with four antidepressant treatment failures in a depressive episode. The most common side effects of the VNS device include voice changes such as hoarseness, tingling in the skin, sore throat, and breathlessness, and these tend to improve over time. The most reported side effect from the implantation procedure is infection, which occurs less than one percent of the time. The UAB study site is recruiting 37 patients to participate. If you are interested in joining the study, contact Katlyn Jackson at katlynjackson@uabmc. edu or 205-975-6426.

The O’Neal Comprehensive Cancer Center at UAB

O’Neal Cancer Center Receives American Cancer Society Lodging Grant   Cancer patients undergoing treatment frequently require assistance getting to and from facilities, often creating a financial and logistical burden. That is why the American Cancer Society has awarded an Emergency Lodging Grant to the O’Neal Comprehensive Cancer Center at UAB. These funds will be used to address the lodging needs of cancer

patients in Birmingham. “Many patients have to travel long distances for daily cancer treatment,” said Jordan DeMoss, vice president for Clinical Operations at UAB Hospital. “And many of them are too fatigued or sick to drive themselves to treatment each day and cannot afford to pay for lodging in the city where they receive


Same great patient care, new name Alabama Allergy & Asthma Center Soon to Be AllerVie Health


14 • AUGUST 2021

Birmingham Medical News

treatment. Access to care is a big problem in our country, with low-income people of color and those living in rural communities suffering the most from disparities. Lodging programs are vital for these patients to get the treatments they need and deserve.”

Our name is changing, but our commitment to our patients is not

Cullman Regional Names New Chief Marketing Officer Todd Goodall has been named the new Chief Marketing Officer for Cullman Regional Medical Center. Goodall has worked closely with Cullman Regional to drive business development in a Todd Goodall contract capacity since March of this year. He brings over 25 years of leadership experience to the hospital. Goodall, who holds an MBA in healthcare administration from Marylhurst University, has a successful track record in strategic planning, business development and marketing. He has held leadership positions with large health systems including Memorial Hermann Health System, Tenet Healthcare, Dignity Health, Cancer Treatment Centers of America and Good Samaritan Hospital in Los Angeles. “Todd is a consummate professional who understands today’s healthcare system and how to drive expansion for the needs of those we serve,” Cullman Regional President and CEO James Clements said. “Cullman Regional is on the precipice of unique growth and expansion, and I am proud to be on board with its outstanding leadership team to extend its footprint,” Goodall said.  


UAB Undergrad Awarded Grant to Study Drug’s Effect on Retinal Disease EDITOR & PUBLISHER Steve Spencer VICE PRESiDENT OF OPERATIONS Jason Irvin CREATIVE DIRECTOR Katy Barrett-Alley CONTRIBUTING WRITERS Cara Clark, Ann DeBellis, Jane Ehrhardt, Laura Freeman, Cindy Sanders, Marty Slay Birmingham Medical News 270 Doug Baker Boulevard, Suite 700-400, 35242 205.215.7110 Ad Sales: Jason Irvin, 205.249.7244 All editorial submissions should be mailed to: Birmingham Medical News 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242 or e-mailed to: —————————————— All Subscription requests or address changes should be mailed to: Birmingham Medical News Attn: Subscription Department 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242

Fight for Sight, a foundation that has provided funding for vision research since 1946, has awarded a grant of $2,500 to Seth Hubbard, an undergraduate student studying neuroscience and member of the Honors College at the University of Alabama at Birmingham. The grant allows Hubbard to study the potential sight-boosting effects of a drug, commonly used to treat heart disease, on the retinas of mice. Retinitis pigmentosa, an eye ailment, affects nearly 40 percent of people with inherited retinal disease, yet there are no known universal therapies for treatment. A Fight for Sight collaborator identified carvedilol, a drug used for heart disease, while screening zebrafish expressing rhodopsin Q344X, a mutation found in humans that causes autosomal dominant RP. Upon treatment, it was found the mutant fish’s sensation of dim light improved, and rod cells within the retina were preserved. Hubbard will test the efficacy of carvedilol in rhodopsin Q344X mice by examining the carvedilol-treated retina and comparing it to untreated controls at different time points. The post-treatment analysis of these mice will reveal any potential delays in retinal degeneration.

Charbonneau named to Modern Healthcare’s 50 Most Influential Clinical Executives Elissa Charbonneau, DO, MS, who serves as Chief Medical Officer for Encompass Health, has been recognized by Modern Healthcare as one of this year’s 50 Most Influential Clinical Executives. This is her

Lisa Charbonneau

Hubbard will study the drug’s effects on the retina.

“I am beyond grateful to have been selected for this honor, the $2,500 and the opportunity to continue my work on delaying retinal degeneration using an FDA-approved drug,” Hubbard said.

Hubbard aspires to join an MD/PhD program and continue his love for vision science through specializing in ophthalmology postgraduation and performing vision research.

second consecutive year on the list. The recognition program acknowledges clinicians working in the healthcare industry who are deemed by their peers and an expert panel to be the most influential in terms of demonstrating leadership and impact. As chief medical officer, Charbonneau oversees the medical operations for 140 inpatient rehabilitation hospitals across the country. Charbonneau, who has been affiliated with Encompass Health for 29 years, was named chief medical officer in June 2015 having previously served as the company’s vice president of medical services. From 2001 to early 2015, she was

the medical director at New England Rehabilitation Hospital of Portland, a joint venture of Maine Medical Center and Encompass Health, where she held a staff physician role since 1992. Charbonneau received her Doctor of Osteopathic Medicine from New York Institute of Technology College of Osteopathic Medicine, a master’s degree in natural sciences/epidemiology from the State University of New York at Buffalo and a bachelor’s degree from Cornell University. She is board certified by both the American Board of Physical Medicine and Rehabilitation and the American Osteopathic Board of Rehabilitation Medicine.

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Get off the bench and back in the game. Football, baseball, soccer, cross country and other activities are a way of life in Alabama. If you’re participating in any sport or outdoor activity, we’re here to cheer you on and let you know that the doctors at Precision Sports Medicine and Orthopedics are available in case you need care. Some of the services we offer and conditions we treat include the following: Sports injuries, trauma and sideline care Arthroscopic surgery Muscle, tendon and joint pain Broken bones or stress fractures Concussion management Regenerative medicine Shin splints, plantar fasciitis and iliotibial (IT) band pain

Knee problems Sciatica (numbness or pain in or around lower back, hip or knee) Joint replacement surgeries Nonsurgical orthopedic care Musculoskeletal injuries Arthritic care Acute and chronic tendon injuries

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Cutting edge cardiology LAMPOON procedure now available in Birmingham

Birmingham Medical News August 2021  

Cutting edge cardiology LAMPOON procedure now available in Birmingham

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