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Do Not Resuscitate

ON ROUNDS

By Jane ehrhardt

Morgan Perseveres Through Challenges Micah Morgan, CRNP has never shied away from a challenge. After earning her nursing degree from UAB in 2011, Morgan began working at the UAB Medical Intensive Care Unit and quickly developed a passion for caring for the critically ill ... 3

“Because of TV, people think that the patient gets brought back most of the time. It’s just the opposite in reality,” Ayers says. “The perception is that a Do Not Re“Many of these heroic efforts are not successsuscitate order—at least for families and paful, because they’re meant for people who are tients—translates as do not treat. That’s a in pretty good shape. Hospitalized patients communication hurdle we have to overcome with a poor prognosis, however, have a poor regularly,” says Greg Ayers, MD, director of chance of surviving.” palliative medicine at Princeton and BrookIn 1991, Congress passed the Patient Selfwood Baptist Medical Centers. “Probably a Determination Act (PSDA) requiring most better phrase for it would be to allow natural healthcare facilities to inform patients about death.” such end-of-life planning tools as a living will In other words, people create a Do Not and DNRs, both of which stipulate their care Resuscitate (DNR) order to define whether in the case of them losing the ability to make or they wish to die naturally in the case of loss communicate their own healthcare decisions. of a heartbeat or whether they want healthAlmost 15 years later, only 65 percent care professionals to try to bring them back of nursing home residents and 88 percent to life using intense measures. These attempts Greg Ayers, MD of discharged hospice care patients had at could involve cardiopulmonary resuscitation least one advance directive (AD) on record, (CPR), advanced cardiac life support (ACLS), defibrillation, artificial ventilation, tracheal intubation, and ad- according to the CDC National Center for Health Statistics. The vanced resuscitation drugs such as antiarrhythmic agents and data stemmed from 2004 and 2007 surveys of nursing home and (CONTINUED ON PAGE 10) opioid antagonists.

UAB’s New HyperArc™ High-Definition Radiotherapy

Hugh Kaul Precision Nonsurgical Hemorrhoid Treatment Provides Relief

By Marti WeBB Slay

“Everyone has hemorrhoids,” said Rajat Parikh, MD, president of Birmingham Gastroenterology Associates. “That’s a common misconception among patients and many physicians.” ... 4

FOLLOW US

The HyperArc™ delivers radiation that conforms to the size of the tumor, sparing surrounding tissue.

A new radiotherapy option, developed by UAB in collaboration with Varian Medical Systems, is delivering high-quality treatments to patients with brain cancer. UAB was the first in the nation to use HyperArc™ HighDefinition Radiotherapy on brain cancer last fall, but the team that helped develop the technology hopes they will not be the only location offering the treatment for long. With HyperArc™, clinicians can deliver more compact radiation doses that closely conform to the size, shape and location of brain cancer tumors, while sparing more surrounding healthy tissues. “The most common indication for radiosurgery is metastatic cancer,” said John Fiveash, MD, professor and vice chair for Academic Programs in the UAB Department of Radiation Oncology. (CONTINUED ON PAGE 12)

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HEALTHCARE SPOTLIGHT

Morgan Perseveres Through Challenges By Stephanie Clarke

Micah Morgan, CRNP has never shied away from a challenge. After earning her nursing degree from UAB in 2011, Morgan began working at the UAB Medical Intensive Care Unit and quickly developed a passion for caring for the critically ill. “I loved learning from the critical care team and caring for critically ill patients,” Morgan said. “I became passionate about caring for people in the end stages of life. I also got to see patients regain control of their health and leave the hospital.” And she learned a lot about striving to meet expectations, even under the harshest of circumstances. It was this passion that led to ® Morgan with a group of runners. her decision to seek a nurse practi- The Badwater is one of most grueling races in the world. tioner’s degree. Morgan didn’t want that she discovered in herself when she dium and forget the process that gets us death come to mind. When I looked beto only provide the best care possible was first working at UAB. “I was part of there,” Morgan said. “I was able to overyond what was directly in front of me, my to people already in the hospital – she a team that persevered throughout each come pain, failure, stress, fear, and injury attention was captured by the vastness of wanted the autonomy to help give them work shift. We went through many emoto reach a goal and cross a finish line. This mountain ranges and incredible pigmenthe knowledge to keep themselves out of tions during a shift and pushed each other bleeds into real life as well. I have learned tation of those mountains. I have realized it altogether. daily. I was able to find the deeper meanno matter what obstacles are in my way, I that whether it is a difficult patient or life “I love the opportunity to educate my ing of perseverance during this time.” can overcome them.” circumstance, there is a bigger picture patients on disease processes, medications As for what Morgan took away from Morgan also took inspiration from and we have to step back in order to see it and a healthy lifestyle. I enjoy listening to her Badwater® 135 journey, there is a the landscape itself, finding motivation sometimes,” Morgan says. their concerns and questions,” said Morlot to unpack. “I have learned that I am and beauty where she least expected it. “I Morgan will continue striving to help gan, who now practices with Southeast a tough woman. I have the drive to push realized throughout Badwater that there is her patients succeed now that the maraGastro. “If I can offer a creative solution through adversity. When we dream, we beauty in the desert. When thinking about thon has ended – and who knows where to motivate them to take control of their often see ourselves at the top of the poa desert, images of dryness, loneliness, and the next race might take her? bodies, I feel my work day was successful.” This commitment to health hasn’t only served Morgan well in the workplace. In 2018, she took part in the 41st edition of the Badwater® 135, one of the world’s most demanding foot races. Spanning 135 miles from Death Valley to Mount Whitney, California, the race is full of challenges that can deter even the most dedicated runners. If the heat doesn’t get to you – and it is considerable, with the 2018 race being the hottest on record – the increasing elevation almost certainly will. Morgan took this challenge in stride, pushing through the obstacles and finishThe Birmingham Pain Center believes that referring your ing ninth overall and third among female patient to pain management is the best initial course of contestants. This is only the latest marathon in her running career. “I ran my action for your patients with chronic pain. Our strategy is to first marathon shortly after college,” Morprovide individualized, definitive care in a multidisciplinary gan said. “I began to develop a passion for running which led to more races and approach, as soon as possible, while removing the burden training with faster runners. They pushed of pain management from the primary care physician. me to train harder and to be competitive.” This is also where she met her husband, who has become her biggest supporter. Of the race itself, Morgan acknowledges that it was incredibly challenging. “Difficult moments will happen in an ultrarace. It is hard to be positive 100 percent of the time. All ultra-runners speak of dark patches at some point in every race that You can either you must push through. You have to fight • Send referrals electronically from your EMR to ours www.birminghampain.com your brain telling you to stop, and listen to • Download a referral form from the Resources page of our website Phone 205 • 313 • 7246 | Fax 205 • 939 • 1911 the inner voice in your heart pushing you to never give up,” Morgan said. 4515 Southlake Parkway, Suite 200, Birmingham, AL 35244 • Contact us to request a referral form This is the same kind of persistence

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Birmingham Medical News

OCTOBER 2018 • 3


GASTROENTEROLOGY

Nonsurgical Hemorrhoid Treatment Provides Relief By Marti Webb Slay

“Everyone has hemorrhoids,” said Rajat Parikh, MD, president of Birmingham Gastroenterology Associates. “That’s a common misconception among patients and many physicians.” And for those with problems severe enough to require treatment, surgery can be effective, but recovery is difficult. “Over the past few decades a lot of work has been put into treating hemorrhoids with medicine, which had pluses and minuses. They’ve been quite equivocal in my experience,” Parikh said. When possible, Parikh prefers to treat patients with two nonsurgical therapies, hemorrhoidal banding or ligation, and hemorrhoidal energy therapy (HET). “Surgery is required when someone has a clot -- or thrombosis hemorrhoid,” he said. “But many people have chronic symptoms such as bleeding, pain, itching, rectal leakage or prolapse, and these are the symptoms we are trying to treat without surgery. “First we will address lifestyle modification and make sure the problem is not confused with another disease such anal or rectal cancer, or IBD. We never as-

Rajat Parikh, MD holds a hemorrhoidal energy therapy bipolar forceps.

sume hemorrhoidal bleeding and want to make sure there isn’t another cause. We’ll increase fiber and hydration and try to normalize bowel movements. All physicians do that, but patients often require something beyond that, and that is when

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these therapies come into play.” The banding procedure can be done in a physician’s office and requires no prep on the part of the patient. “We have a device that can be used with or without an anoscope to visualize the hemor-

rhoidal vessels feeding the hemorrhoids,” Parikh said. “Almost everyone has three vessels feeding the hemorrhoidal plexus. We pass the hemorrhoidal ligator through the anus to just above the internal hemorrhoids and band the vessel. We’re actually not even touching the hemorrhoidal plexus. We are banding the vessel feeding the hemorrhoid, decimating the blood flow to it.” Three bands are required, one on each vessel, to complete the therapy. Most patients experience pain and other discomforts when all three bands are placed at the same time, so one band is placed every two to three weeks until all are in place. Each procedure takes only two to three minutes and is done without sedation. “It’s well tolerated and quite effective,” Parikh said. The other procedure, HET, can also be performed without sedation, although most patients choose to have it. The patient preps in much the same way as for a standard sigmoidoscopy, and the procedure is performed in an endoscopy center. As with the banding procedure, the goal is to eliminate blood flow to the internal hemorrhoid. “Under sedation we are able

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GASTROENTEROLOGY

Adjusting Diet to Resolve Gastric Problems By Marti Webb Slay

When it comes to gastroenterological issues, the first line of attack is to look at diet. But discovering what foods a given patient is sensitive to is a lengthy process that physicians don’t have time to do. That’s when health coaches can contribute, according to Rebecca MillsAnderson, CHHC (certified holistic health coach). “We believe if you give the body the right tools, it will heal itself,” she said. “We work as part of a team with doctors. I serve as a health coach, allowing doc- Rebecca Mills-Aderson tors to do their job.” Diet and lifestyle can have significant impact on treatment for patients with gastric issues. “A study on one particular diet had a 75 percent reversal rate on IBD. Although it was a small study, that is still impressive. And that’s just one dietary problem,” Mills-Anderson said. As an autoimmune and neurological specialist, Mills-Anderson does rely on a variety of tests to help determine how she works with her patients. “I run a complete stool test that will check for infection, yeast overgrowth, parasites and inflammation markers,” she said. “One of the markers I look at is SigA. It tells me about the immune system.” She also runs gene tests to help determine a course of action. “I gene test based on the Shoemaker protocol,” she said. “This

test tells me what toxins a person is unable to neutralize. What toxins may be triggering disease if this person has been exposed to them? It helps me find the culprit of what could be causing widespread inflammation. After finding out someone carries a certain gene, I’m going to take out foods that are suspect because of that gene.” Mills-Anderson, clinical director of BringingSozo in Birmingham, is clear about her role as a health coach working with patients and physicians. “I don’t use the test results to diagnose, treat or prevent illness,” she said. “A doctor has seen test results and gives me feedback. I use that feedback to determine the best approach for a diet and lifestyle to support the patient’s healing.” Working in concert with a physician can make a critical difference for the patient, since most insurance doesn’t cover tests she orders. If a doctor requests the tests, however, insurance is more likely to pay for them, and she and the physician have laid the groundwork for a team approach. “Most people have food sensitivities,” she said. “I start every patient on some kind of food elimination diet. The big question is, which one? It depends on the person, and I only work with people who are very motivated. “Different people with the same disease may need a different approach to bring balance back to their body. One may be a suppressed immune system and one might be an overactive one. One might be lacking enzymes and another lacking good bacteria. What it takes to put a person back in balance is very indi-

Nonsurgical Hemorrhoid, continued from page 4 to pass an anoscope and forceps to carry out a bipolar ablation cautery of the tissue above the vessels leading to the internal hemorrhoids,” Parikh said. “We aim for 5 to 10mm above the apex of the internal hemorrhoids, proximal to the dentate line (where the rectum becomes the anus). Tissue is folded in the forceps, clamped, heated to 55 degrees Celsius and released. We do this for 360 degrees until all the tissue is ablated.” Both procedures have proven to have long term benefits, even if the patient is not particularly compliant with the rec-

ommended lifestyle changes. “Recurrence is possible,” Parikh said. “But that number is small.” No post-procedure pain medications are required for either procedure. “Both techniques are excellent,” Parikh said. “I leave it up to the patient to choose which procedure they prefer. The HET is done in one procedure but requires patient prep and sedation. The banding can be done in the office without prep, but the patient has to come three times to complete the therapy. Both have good long term data.”

vidual. I tell my clients I’m helping put the puzzle together.” As a bottom line, she generally begins with eliminating dairy and gluten. “There’s tons of research that says even one meal with gluten can cause damage to the gastrointestinal tract, whether you are having symptoms or not,” she said. The test results, along with information from both physicians and the patient, may mean other foods are added to the elimination diet. Then food is slowly added back one at a time to determine if it may be the cause of the problem. “My goal is to begin adding some foods back within 30 to 60 days,” Mills-Anderson said. “Although it can take six months, I’m very calculated about what order we introduce food back into their diet and when. There’s an art to this, as well as a science.” “Health coaches can take the time to sort out the puzzle and put it together for improved health of the clients. At the end of the day, I’m having clients eat more vegetables, more healthy fats, drink more water and take care of themselves. I’m not going to give them anything they can’t buy at Whole Foods. But it’s not an easy fix. If it were, everyone would be doing it.”

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Four grades of hemorrhoids Hemorrhoids originate from the superior hemorrhoidal plexus. 1. Grade 1 hemorrhoids do not prolapse. 2. Grade 2 hemorrhoids do prolapse, beyond the anal sphincter, but they reduce spontaneously without any manipulation. 3. Grade 3 hemorrhoids prolapse and require a manual reduction. 4. Grade 4 hemorrhoids constantly prolapse. Even if you try to manually reduce them, they will prolapse again. Grades 3 and 4 will usually require surgical attention. Hemorrhoidal banding and HET are generally reserved for Grade 1 and 2 hemorrhoids.

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Cyber-Incident— Now What? Kelli Fleming

by

In this day and age, where a vast amount of information is stored electronically and you can buy almost anything with a “one-click” purchase, it comes as no surprise that cyber-incidents are on the rise, especially among healthcare providers. The attacks are becoming more sophisticated, thereby stumbling even the most savvy and educated employees. Thus, every health care provider should spend some time thinking about how to prepare for a cyber-attack and respond to a cyber-attack if one were to occur. In relation to cyber-attacks, I once heard someone say, it is not “if it will occur” but “when it will occur.” In order to prepare for an attack and perhaps reduce your exposure, here are a few steps that can be taken on the front end: Put Together an Incident Response Team: Put together an incident response team made up of members of your workforce and consultants who can assist with responding to an incident. Think about the people within your organization who have the authority to make decisions on behalf of the organization (e.g., President, Administrator, etc.), as things move very quickly once an incident occurs. Also think about the people within your organization who have expertise and experience that may be of value in response to an incident. For example, the Chief Security Officer or the HIPAA Privacy Officer. Finally, think about whether you want to include anyone from outside the organization on the team (e.g., your attorney) and go ahead and execute Business Associate Agreements with such persons. Put a Plan in Place: Implement a plan addressing how to respond to a cyber-incident. Gather the input of you incident response team when drafting the plan. The plan should include such items as what security measures need to be implemented, how to back up the relevant data, who is responsible for certain tasks, how to contact members of the incident response team, and ways to preserve evidence and maintain documentation. Review your Insurance Policy: As incidents continue to rise, several entities are now obtaining insurance policies that provide coverage for cyber-incidents. Further, some general liability policies may provide coverage for certain costs and expenses. Review the insurance policies you have in place to determine what is covered, how it is covered, and the

steps that must be taken in order to obtain the coverage. For example, many policies do not provide coverage until the carrier is notified. As previously mentioned, you have to move quickly in response to a cyber-incident, so knowing upfront that you need to first provide notice to your carrier will help move things forward. Some carriers also require that you use a specific law firm or specific forensics firm to address the incident. Update Your Risk Assessment: HIPAA requires healthcare providers to conduct a risk analysis of their electronic systems to identify risk areas that may need to be addressed. It is important that your risk analysis incorporate all your systems and be up to date—a risk analysis from five years ago, before you implemented an electronic health record, is not sufficient. Not only is the risk analysis legally required, but it is also a good exercise to help determine your highest areas of risk so you can address those risk areas before an incident occurs. Review and Update Your HIPAA Compliance Plan: In addition to security policies and protocols, your HIPAA Compliance Plan should contain a breach notification policy addressing the requirements for what notifications should be made when a cyber-incident involves patient information. Become familiar with the HIPAA breach notification process, as well as any state law notification requirements. In that regard, keep in mind that Alabama recently enacted a data breach statute that contains certain notification provisions that are more stringent than HIPAA. Conduct Employee Training: Train employees on what cyber-incidents look like (e.g., provide an example of a phishing e-mail), what not to do, and who to call if an incident occurs. Research shows that unintentional employee actions account for a significant percentage of data breaches. Taking these steps upfront before a cyber-incident occurs will help you respond to the incident when it does occur (not “if it does occur”), and, hopefully, will reduce your exposure. Kelli Fleming is a partner at Burr & Forman, LLP and practices exclusively in the healthcare industry group.


Donation Program for Umbilical Cord Blood by Jane

Ehrhardt

Eight years ago, Ashley Tamucci, MD, an OBGYN at Brookwood Baptist Medical Center, was talking with an expectant mother who wanted to donate her umbilical cord blood (UCB) to a donor bank. This was new territory for Tamucci. The patient worked as a nurse at Children’s Hospital. “She told me that she saw kids die every day because they couldn’t get a match for a bone marrow transplant,” Ashley Tamucci, MD Tamucci says. Bone marrow and umbilical cord blood (UCB) hold the same ability, through stem cells, to help rebuild healthy cells in diseased blood. “But cord blood has not been exposed to very many antigens, so it has much less chance of being rejected,” Tamucci says. The patient had found a company to accept her cord blood donation, but because she delivered her baby on a Saturday, the courier service was unable to pick up the sample. “It was a very disappointing day,” Tamucci says. That’s when Tamucci made it her mission to create an UCB donor program at Brookwood Baptist that would leave no donation wasted. “We wanted it be easy for the patients, where they didn’t have to do anything but sign a piece of paper,” she says. It took years for the collection process to be organized and implemented. But in 2014, Tamucci, along with her OBGYN colleague Sarah Aultman, MD, succeeded in starting the only hospital-based, free UCB donation program in Birmingham. Last year, the program collected more than 750 cord blood samples. “I just thought it was common sense,” Tamucci says. “If you can save lives with something that we’re disposing of, why wouldn’t we do it.” UCB transplants are easier to administer than bone marrow transplants. “They don’t have to place the cord blood into the bone marrow. They just put it in the patient’s vein, and it helps them regrow healthy cells,” Tamucci says. Umbilical cord blood is also known to have up to 10 times more stem cells than adult bone marrow. The collection process is straightforward. “Once the baby is delivered, whether C-section or vaginal, the baby is placed skin-to-skin with its mother,” Tamucci says. “We can then collect the blood from the cord, and the mother isn’t even aware that I’m collecting the donation. “It only takes 60 seconds to make the

collection. The nurses have the kit laid out and all I have to do is stick a needle in the cord, draw the blood, and hand the bag off to the nurse.” The quantity normally gathered from a cord runs between 200ml and 300ml.” The kits are given to the hospital for free by the donation bank, LifeCord, who also processes and provides the UCB to recipients at no cost. Tamucci points out that drawing blood from the cord is already part of every birth. “We normally take a specimen anyway to get the baby’s blood type and do a blood gas test for the hospital. Then what’s left is either collected or thrown out. We might as well utilize this resource to save a life.” The donation process does not require a physician’s involvement other than drawing the blood. All of the OBGYN nurses at Brookwood Baptist are trained in the process. They can provide expectant mothers with the materials and informed consent to sign. All of the supplies are then already available in each delivery room. The interest in umbilical cord blood has spread worldwide. More than 100 UCB banks exist for public use in North America, South America, Australia, Europe, Asia, and the Middle East. In the U.S. last year, an estimated 700,000 UCB units had been donated for public use and another four million units had been stored for private use. With 15,000 people needing bone marrow transplants each year, according to the Health Resources and Services Administration, and only 30 percent have a matching donor in their families, umbilical cord blood can fill a massive void. Currently just 13 percent of transplant patients receive cord blood from a public cord blood bank and the FDA has only approved the use of UCB transplants to treat leukemia and lymphoma in adults and children. But interest in its potential is evolving fast. Medical research is in place for testing UCBT as a treatment for anything from autism and arthritis to irritable bowel syndrome and corneal disease. Outcomes from transplants continue to improve with advancements in human leukocyte antigens matching, cord blood unit selection, refinement of conditioning regimens, and expanded infection prevention. “The research may not be there today to support other uses yet,” Tamucci says, “but who knows where this will end up.” Tamucci has received multiple calls from health professionals seeking to set up UCB donation programs. “Doctors have also called to find out how to get a program in their hospital,” she says. “So we know there’s an interest.”

ARE YOU READY?

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GENETICS

Genes in Healing By Laura Freeman

been grabbing most of the headlines over the past few years, but Lamb said there have been adScalpel, stethoscope, antivances in a range of gene editing biotics--as each landmark tool tools that can be selected to fit the earned its place in the physinature of the targeted gene and cian’s bag, it brought a leap forthe objective. ward in patient care. Perhaps “We see a lot of work in blood today’s most anticipated new disorders. A clinical trial is geartools are those growing out of ing up to test CRISPR gene-edthe mapping of the human geited therapy for treating patients nome. with ß-thalassemia and sickle cell With the eagerness of a anemia,” Lamb said. “CRISPR family road trip, it has been difis also being used to modify iPS ficult not to keep asking “are we cells in stem cell therapy. In anithere yet?” “Soon” is the anmal models, CRISPR modificaswer we keep hearing, and now tions allow us to study what is that we are 15 years down the going on in diseases. We can look road on a long journey, perhaps at a mouse with the same mutait’s time to look and see how far tion as the patient and see how it we’ve come. responds. A report just came out “We’re seeing some reCRISPR and gene editing have become hot topics of discussion in the world of showing proof of concept for cormarkable successes in gene science. recting a muscular dystrophy mutherapies and in genetic infortation in a dog.” mation advancing other forms So far, researchers are focusing on of treatment. Right now we’re at the very vember, the zinc fingers nucleases gene disorders caused by a single gene mutabeginning of directly using gene editing technique was used to treat a patient with tion. Tools with the capabilities to address to correct disorders in humans,” Neil Hunter’s Syndrome. Other patients have diseases involving multiple genes are still Lamb PhD, faculty investigator for Hudbeen treated since then, and the early rebeyond the horizon. sonAlpha Institute for Biotechnology, sults have been promising,” Refining and improving gene editing said. “The field is only around five years CRISPR Cas9 (Clustered Regularly tools, including CRISPR, are a current old, and most of that time the work has Interspaced Short Palindromic Repeats) focus of research. been on human cells in the lab. Last Nois the gene editing technique that has

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“There were some reports showing that earlier forms of CRISPR may be a bit too permissive and could have some off-target effects. Newer versions are more specific, and we’re also seeing a more compact form that can be used to do different things,” Lamb said. Whereas gene therapy is often used to add a gene, gene editing can be used to remove a mutation or replace it with a corrected version. The compact version of CRISPR allows space for more carrying capacity of chemicals like methyl groups and it uses CRISPR’s ability to recognize specific sequences to guide the chemical where it is needed to turn the volume of a protein’s production up or down, depending on whether more or less is needed. Gene therapies already approved by the FDA include an injectible treatment for a form of hereditary blindness. “Over the past four years, this treatment for an RPE65 mutation has helped blind patients regain some sight so they can see shapes, shades and colors. It is an expensive treatment that can only be done on one eye at a time, but it is a first step toward restoring sight in people with genetic blindness,” Lamb said. Oncology is an area at the forefront of precision medicine, using genetics (CONTINUED ON PAGE 12)

Left to right: Neil Lamb, PhD; Kiran Musunuru, MD, PhD, MPH; Eric Green, MD, PhD

Genomics Briefing in Washington Neil Lamb, PhD, vice president for Educational Outreach at HudsonAlpha, recently provided an overview of the current state of genomic science for legislative aides in Washington, DC. Lamb, along with Eric Green, MD, PhD, Director of the National Human Genome Research Institute and Kiran Musunuru, MD, PhD, MPH, scientific program chair for the American Society of Human Genetics, discussed current research, clinical advancements, and educational efforts in genomics. The panel also answered questions on current topics including privacy, bioethics, and insurance reimbursement. “Genomics is a rapidly-evolving field, with advancements being made almost daily regarding individual genes and the relationships within the genome that contribute to human health and disease,” said Lamb. “Our goal is to serve as a resource to our nation’s lawmakers by the providing scientific information they are seeking as they serve in office.” Lamb and the Educational Outreach team also published a Congressional Guidebook, which outlines current topics in genomics and how these topics relate to federal legislation.


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Do Not Resuscitate, continued from page 1 hospice care facilities. Physicians, however, overwhelmingly have DNRs. In a 2013 survey led by a Stanford University School of Medicine researcher, 88 percent of the 1,081 physicians participating opted for DNRs. Yet physicians often hesitate to discuss end-of-life options with patients. “I think some doctors sometimes shy away from difficult discussions because they’re

afraid of destroying hope,� Ayers says. “It’s just the opposite, patients want to talk about these things. They want to have this talk with their doctors.� “Ultimately, the discussion is about matching treatment to values,� says Michael Barnett, MD at the UAB Center for Palliative and Supportive Care. “It’s figuring out what’s more important to patients and family in the context of what

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we know about their illness. So a lot hinges on honest and open conversation about prognosis and expectations.� Physicians should also appreciate their valuable role of providing patients with a Michael Barnett, MD knowledgeable perspective on their prognosis. Otherwise, patients may rely on less informed social workers or nurses at a facility for guidance. “A physician can know the situation from a different level,� Ayers says. “The patient may get more information about the disease prognosis and things that will be done if a code blue does happen.� “There’s so much uncertainty in the course of a disease,� Barnett says, explaining that with their unique experience, physicians can present patients considering DNRs with medical scenarios that they may not think of and that their families, counselors and lawyers may not know exist. For instance, if a patient is dying of lung cancer, they may want a DNR. However, that might not be true in all situations. “They may want to aggressively treat what is reversible even in the face of a potentially incurable, irreversible illness,� Barnett says, such as terminal lung cancer patient with a DNR but wishing to be resuscitated if a short-term affliction, such as influenza, created an end-of-life episode from which they could potentially recover and live comfortably for quite some time. “Medicare pays for advanced care planning,� Ayers says. Code 99497 covers the first 30 minutes of face-to-face conversation with the patient, family members, and/or the surrogate about making out advanced directives and what can be done in the event of a lifechanging illness. Code 99498 covers additional 30-minute increments. “It

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encourages physicians to have this talk before patients are gravely ill,� he says. “It’s a great tool. For those caught without a DNR or healthcare power of attorney that designates a surrogate decision-maker, Alabama law clearly outlines the hierarchy of the decision-makers—court-appointed guardian, spouse, adult children, parents, siblings, and then extended family. “Common law spouses used to exist in Alabama, but that ended in 2017,� Barnett says. Though anyone defined as a common law spouse prior to 2017 retains that title. Ayers reminds physicians facing tricky DNR situations that they have a support network to call on at hospitals; for instance, if an unconscious patient with no advanced directives is reliant on an estranged brother and a close companion who is significant to the person. “If the two disagree on the DNR order, you want to get the right decision for the patient,� Ayers says. “You might refer it to the ethics committee, which each hospital has, and have them help the physician determine which decision is most in line with the patient’s decision.� Both physicians agree that most family members and friends desire to make good decisions and not see the patient suffering, no matter how vehement their disagreement on the end-of-life care for their loved one. “More times than not, when they get together, when they hear what the others are concerned about, they often get on the same page,� Barnett says. “It takes time. It may take more than one meeting and giving people time to work through their grief,� Ayers says. The moment a loved one sees the patient on a life-support machine or hears a dire prognosis, they may begin grieving at that point. “You may have to let those things play out.� But generally those involved come to a consensus. “You may find that hard to believe,� Ayers says. “But they talk these things out behind the scenes. I can’t emphasize the importance enough of multiple meetings and giving them time and space.�

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UAB’s New HyperArc™ High-Definition Radiotherapy, continued from page 1 “Radiosurgery has the advantage over other kinds of radiation in that it is focal to each individual spot and doesn’t treat the normal tissue as much. You can give a higher dose to the tumor and lower dose to the normal tissue, compared to wholebrain radiation therapy, which is problematic because of potential cognitive or memory problems for the patients.” Also, with HyperArc™, multiple tumors can be irradiated at the same time without repositioning the patient. As a result, more metastatic brain cancer patients are now eligible for treatment than before. “When we used a Gamma Knife™, we had to do a radiation plan for each tumor,” Fiveash said. “So if you had five tumors, you had five times the amount of work and time for the patient, and it could easily become not feasible either to generate the plan or to deliver the plan, because the patient had to stay there a long time. HyperArc™ takes a few minutes

of treatment, regardless of the number of tumors.” In addition, HyperArc™ doesn’t use a stereotactic frame, another improvement over the Gamma Knife™. The stereotactic frame, a metal John Fiveash, MD halo that enables physicians to locate tumors exactly, has to be screwed into bone. “Now we can take pictures and do the same thing,” Fiveash said. The patient comes in for a prep day and consult, then returns a few days later for the actual treatment, which lasts only a few minutes. “This program was originally designed to complement the Gamma Knife™, to treat larger tumors and patients with a larger number of tumors,” Fiveash said. “Now the quality has improved and the ease of planning and de-

livery is superior to the Gamma Knife™, so our patients and our doctors prefer it. It’s a better experience for the patient.” “The efficiency of HyperArc™ makes for an improved use of resources,” said Richard Popple, PhD, professor and assistant vice chair for physics in the Department of Radiation Oncology. “Patients have the convenience of being in and out of the room more quickly, which also means we can better accommodate the treatment team. It’s a more efficient utilization of resources, which in turn means we can provide care to more patients.” Richard Popple, PhD UAB collaborated with four other institutions to make the treatment more accessible. “Varian wanted to make our expertise available to the community,” Popple said. “We also

Genes in Healing, continued from page 8 to identify specific types of ter ways to deliver genetic treatment cancer cells and any vulnerto different areas of the body. This ability that might make spealso includes work in small molcific therapies more effective. ecules capable of crossing the blood Genetic tools are also being brain barrier to treat conditions in used to harness the power of the brain. immunotherapy and to make Looking down the road, Lamb the patient’s cancer more debelieves we will see an increasing tectable to improve the ability number of gene therapies targeted of the body’s own defenses to to more disorders. fight it. In chimeric antigen re“Gene editing will be crossing ceptor (CAR T) cell therapy, over into mainstream medicine,” he cells from patients are modisaid. “But the most powerful thing fied and re-inserted back into we have learned from the work that the patient to help the imhas grown out of sequencing the mune system recognize and genome is a better understanding fight cancer cells. The FDA of how diseases develop. Knowhas approved two CAR T cell Neil Lamb, PhD, Vice President for Educational Outreach at HudsonAlpha ing more about what is happentherapies in humans. One is ing opens the door to developing adults with advanced lymphomas. for treating children with acute lymphomore effective treatments to help our Researchers are also working on betblastic leukemia (ALL) and the other for patients.”

had that interest and had published our ‘recipe.’ We teach a course several times a year, and a component of that course was how to perform this treatment with our recipe, but we still found that people struggled. It took a certain level of expertise.” Varian began to develop a product to package the UAB team’s knowledge. “The goal was to make safe, quality treatment available to centers that didn’t have the same level of expertise as academic centers,” Popple said. “We wanted to make it more available. “We test drove a lot of the initial products. We benchmarked what their system produced against what we would have done with our expertise until we arrived at the same place. The software is wizard driven and asks a series of questions along the way. The computer prompts the user every step of the way. We’re still feeding back what we learn and helping to drive the development of the product.” It is now the default treatment at UAB, and Popple hopes other treatment centers that couldn’t previously afford dedicated resources will avail themselves of the new technology, which is relatively easy to learn and makes this treatment more accessible to patients with metastatic brain cancer.

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Princeton’s Cardiovascular Bridge with China By Jane

ehrhardt

It began in 2008 with two Chinese cardiologists—a man and a woman. They were the first to participate in a cardiovascular fellowship program between Chinese physicians and Princeton Baptist Medical Center. They stayed six months and the program took off. “This has been not only something outstanding in clinical experience for the Fellows, but for me personally. It’s built wonderful friendships,” says Farrell Mendelsohn, MD, an interventional cardiologist at Princeton and co-founder of the Chinese Cardiovascular Fellowship Program at Princeton. This year, the 100th Chinese physician has completed the fellowship. “It was such a success in the beginning, that two more physicians wanted to come after that first one. There was so much interest throughout the country,” Mendelsohn says. “We went from two cardiologists coming every six months to four to six cardiologists coming every three months now. We are close to having had a physician from every province in China.” The number of physicians teaching the fellows has also grown from two originally into a broad team of Princeton cardiologists, cardiovascular surgeons, vascular surgeons and other medical experts. Just two years into the program, the Chinese health ministry officially endorsed

Farrell Mendelsohn, MD visited China.

it and named Mendelsohn as an advisor to the ministry for training. Then a few years later, in 2014, the director of the Chinese Ministry of Health, Chen Ran, personally visited Princeton. “It was incredibly exciting to have her here,” says Mendelsohn, because Ran served as the top healthcare official in the country. As the program grew, the involvement by the Chinese government took another positive leap. Hospital presidents

had started nominating physicians to participate. “We ended up getting an official director of the program in China,” Mendelsohn says. “A man who is in the top two or three in the country. He’s one of these people who is editor or associate editor of 15 to 20 medical publications internationally and setting national standards and guidelines.” As the head of the Heart Center at Peking University First Hospital in Beijing, Yong Huo’s involvement added a new level of credibility to the Fellowship in China. “Having a leader like that involved in the process only enhances the program,” Mendelsohn says. For the Fellows, Huo’s signature on the certificates of completion “means a lot for their advancement in China.” Besides viewing regular cardiac procedures, the Fellows have been exposed to cutting-edge research procedures. They witnessed the first stem cell transplants into the heart in Alabama and the first in the world gene therapy protocols. “They got to see some really novel tech,” Mendelsohn says. Now the curriculum also includes exposure to structural heart disease. “It’s a whole new field that’s so new to them and they really enjoy that,” Mendelsohn says. He says that what the Fellows have found most surprising during their training is the surgical options available for cardiac patients. “Many types of cardiac conditions that we would send to surgery,

they are almost forced to fix with interventional techniques, such as complex stenting procedures,” Mendelsohn says. Back in China, past Fellows have kept in touch over the past eight years through social media outlets, sharing knowledge. That recently spawned reunions of the Fellows, with Mendelsohn attending the latest this summer. “Now these physicians are leaders at their own hospitals or in cath labs,” he says. Held every two years, the symposiums allow the cardiologists to present their interesting cases and share expertise. “It’s amazingly evolved over there since my first visit,” Mendelsohn says. “Their resources have grown tremendously. They have, in some areas, more technology than we have. In other areas, they are a little behind.” For instance, in structural heart disease, such as fixing valves with new devices, Mendelsohn witnessed some lagging. But in other tech, they surpass the U.S., such as the use of special balloons coated with medications. Mendelsohn says the program allows the cardiologists to learn techniques and standards of excellence, and to have some of their own skill sets reinforced on an international stage. It also fosters ties between the medical communities of two countries during a time of escalating geopolitical unrest. “It’s been to me not just a fabulous medical exchange program, but a fabulous cultural exchange program,” Mendelsohn says.

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Birmingham Medical News

OCTOBER 2018 • 13


Addressing the Gap Between Need & Access in Treating Addiction By CINDY SANDERS

Largely driven by opioid usage, there is a strong consensus on a local, state and federal level that substance abuse is at epidemic proportions in the United States. Numerous interventions have been rolled out across America – from equipping law enforcement officials with the opioid antagonist naloxone to efforts aimed at keeping opioid naïve patients from being introduced to highly addictive pain medications. However, a major stumbling block remains for those tasked with treating substance abuse disorders … need far outstrips capacity.

Barriers to Care Lawrence Weinstein, MD, ABHM, is chief medical officer for American Addiction Centers (AAC), a publicly traded national treatment provider. In his role, Weinstein has oversight of medical staff and operations for AAC’s more than 30

locations across the United States. Triple board certified in psychiatry and neurology, addiction medicine, and holistic medicine, Weinstein joined AAC in August after previ- Lawrence Weinstein, MD ously serving as CMO for Humana Behavioral Health. When discussing the gaps between need and effective intervention, Weinstein said there are multiple issues to be considered. First is the sheer volume of individuals in need of help. “It is upward of 20 million people, and we know that only one in 10 receives treatment,” he said. Then, there are resources allocated to addressing addiction. “There is only 1 percent of total medical spend that goes into substance use treatment,” Weinstein added. On the access side of the equation, Weinstein said there are roughly 12,000 treatment centers across the country with

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about 40 beds on average per facility … leaving a huge access gap for inpatient services. “Right now, about 90 percent of all addictions centers are outpatient facilities,” he continued, “and we know that 55 percent of all U.S. centers experience a shortage of behavioral health providers.” Weinstein added the provider shortage is even more ominous when drilling down a little deeper. Many of today’s providers are nearing retirement age. “Coupled with that, you have a shrinking number o residents going into psychiatry. We’re coming into a perfect storm,” he noted. With the growing opioid crisis, he anticipates additional investment in the $35 billion treatment industry. “You will see over the next three to five years expansion in treatment facilities, but you will not have enough providers to see folks,” he predicted. In addition to affordability and access issues, substance abuse continues to be viewed by many in a pejorative manner so that those impacted by the disease feel equal parts shame and discrimination. In an effort to encourage treatment while shielding patients, Title 42 CFR Part 2 was enacted in 1987 to address the confidentiality of alcohol and drug abuse patient records. While care models are increasingly focused on the whole person, Weinstein said the federal law – which includes tighter restrictions than required by HIPAA – has made it very difficult to provide integrated care, particularly for those dealing with substance abuse and comorbid medical conditions. “By virtue of having these additional restrictions, you make this kind of a discriminatory experience,” he said of the regulations. “Really, they stem from the old belief that substance abuse is a moral fail-

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ing rather than brain disease,” Weinstein continued. “Our notion of the disease has evolved over the last 10 to 15 years, but the policies have lagged.” Last year, for the first time in three decades, 42 CFR Part 2 regulations saw some updates. However, the American Psychiatric Association noted the relatively minor changes intended to align better with HIPAA and allow more providers to take value- and team-based approaches lacked the technological solutions to implement significant change. “Until this issue is fully addressed, various components of Part 2 may continue to act as a barrier to integrated care efforts,” the organization stated on its website. A lack of standardization has also exacerbated already fragmented care. Weinstein said there is disagreement across the specialty as to what even constitutes success in a disease that is prone to relapse and requires lifelong self-management, along with professional care, to address addiction.

Potential Solutions While there are plenty of issues impacting access to evidence-based, high quality care, Weinstein said there are also several potential solutions being explored. “It’s a multifactorial disease that will require a complex approach … a multipronged approach … to address these issues,” Weinstein said. Certainly, he noted, efforts are underway to try to increase interest in the field and encourage more medical students to consider psychiatry and addiction medicine as a specialty. However, he pointed out, this is only one part of the overall strategy and would likely take years to have any real impact considering attrition from retiring providers. “You can certainly try to influence policy on the state level to allow mid-level providers and extenders to assume more responsibility in a patient’s care,” he added of more immediate efforts to expand the workforce by allowing other providers to practice to the full scope of their profession. Technology, Weinstein continued, is a disruptor that holds significant possibilities to expand access … particularly the use of telepsychiatry. Utilizing telehealth protocols that are already in place for other specialties offers a relatively quick way to reach underserved populations. “We’ll need to work with medical boards and regulatory agencies to standardize processes by which providers are allowed to monitor, evaluate and prescribe via telepsychiatry,” he added. Weinstein said the Centers for Medicare and Medicaid Services have only allowed telepsychiatry to be used in rural areas with provider shortages. However, he noted, there are also shortages within metro areas that could potentially be addressed through telehealth platforms. He added, CMS is considering changes to the (CONTINUED ON PAGE 18)


The Literary Examiner BY TERRI SCHLICHENMEYER

The Incurable Romantic and Other Tales of Madness and Desire by Frank Tallis; c.2018, Basic Books; $27.00; 304 pages Oh, how your heart beats for your beloved! Well, most of the time, anyway. At other times, love makes you act like a fool. It makes you a little loco but The Incurable Romantic by Frank Tallis proves that it’s not your heart’s fault. Your brain is absolutely to blame. Boy meets girl and falls in love. It works that way in the movies and music, but not so in real life, as most adults can attest. When boy + girl = problems, we feel angry, sad, desperate and, as a psychotherapist, Frank Tallis has noted each of those emotions and more. Love, as he’s seen, is a complicated thing and can be completely one-sided. He describes a former patient, a rather plain woman who fell inexplicably and instantly in love with her handsome dentist. The problem was that he was happily married to someone else. For most people, Tallis says that love stands on three legs: intimacy (closeness);

passion (sexual); and commitment. Take away one of those things, he indicates, and a relationship will falter and die. Then again, he writes of one long-married couple that endured with a total absence of one leg. In some relationships, an ugly green monster rears its head and when that happens, it can ruin any happiness that might exist. Tallis says that about ten percent of all murders are committed in the name of jealousy. The one he offers here didn’t get that far, but readers can surely see where it might have. Having relationship psychotherapy, he says, can have parallels to the Catholic confessional. It can “be likened to an emotional striptease” as layers are revealed to get to a truth. Love itself can be joyous, painful, or both, concurrently, and it should never be trivialized, no matter what the age of the lovelorn. Love can be illegal, which demands a squirmy and delicate dance with a psychotherapist.

It can be confusing and unwanted, secret, imperfect, uncomfortable, selfish, and – in at least one case that Tallis presents – love can be very dangerous. Why do we love the ones we love? Biology, conditioning, parenting, or hardwiring, there are dozens of things that make someone attractive. In The Incurable Romantic, you’ll see how those things can go wrong in dozen of ways. Still your heart, though: author Frank Tallis isn’t the guy who harrumphs at Valentine’s Day. It’s apparent, as you read the accounts he shares, that relationships are endlessly fascinating to him, and that’s contagious. You’ll want to watch as Tallis helps his patients help themselves. There’s a slightly voyeuristic feel to that, as though we’re overhearing awkward living room

conversations or peeking into messy bedroom windows. Tallis doesn’t share this in a prurient way, however. Instead, his compassion for the lovelorn shows in considerate diagnoses and sometimes even befuddlement. This is a great book for romance readers who want a little less fluff, for people-watchers, and for anyone curious about how we tick. If you’ve ever loved or loved and lost, The Incurable Romantic can’t be beat. Terri Schlichenmeyer is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.

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The Quest for Quality in Clinical Trials By CINDY SANDERS

GIGO – or ‘garbage in/garbage out’ – was coined as a computer science term for the flawed output that comes from inputting flawed data. Over the years, the GIGO principle has been broadly applied to other areas of analysis where flawed logic impacts outcomes. Perhaps nowhere is that more evident than in a poorly designed or improperly executed clinical trial. Earlier this year, Jody Black, deputy director of the Office of Extramural Research at the National Institutes of Health, introduced the acronym ‘SCT’ at the annual meeting for the Association of Clinical Research Professionals. Although the NIH has supported their fair share of ‘small, crappy trials’ over the years, the national funding source has spent the last decade enhancing oversight, monitoring, reporting and transparency to improve the quality of trials, which in turn improves the quality and credibility of research findings. While some poorly designed, executed or reported trials are simply a waste of dollars, others have deadly consequences. Faulty ‘research’ published in 1998 linking vaccines to autism is still widely disseminated online. To this day, there are a significant number of fearful parents who refuse to vaccinate their children, which has led to the reemergence of several serious infectious diseases.

Research GIGO Jim Kremidas, executive director of the Association of Clinical Research Professionals (ACRP) said the not-for-profit organization works to enhance and improve the grassroots implementation of clinical research by supporting the individuals involved. “A poorly designed trial has a negaJim Kremidas tive impact … but so does a poorly executed trial,” noted Kremidas. He added writing a protocol might seem simple, when in reality the wording has the potential to taint the entire process. “It’s so critical that you ask the question correctly so that you get an answer that actually means something,” he stressed. “We don’t want spin in science.” Operational concerns and execution can also derail a clinical trial. “You could have a brilliant, scientifically designed study, but operationally you couldn’t do it,” he pointed out. Kremidas said he has seen trials with such narrow inclusion criteria that it becomes difficult, to the point of nearly impossible, to find patients to enroll. Even with a trial that is well designed, he continued, “If the people executing the trial aren’t doing it correctly, you won’t get the

6:30

data needed.” Kremidas added, “I think the key to getting rid of those SCTs is we have to have the right experience and expertise in the people designing and implementing these studies.”

Developing Skills While there have been a number of advances in technology and processes to improve the quality of trials, Kremidas said the people on the frontlines are often overlooked. Outside of major academic centers, those doing the heavy lifting on clinical research often aren’t specifically trained in the exacting tasks that come with being a principal investigator or study coordinator. “There hasn’t been historically any standards set for who can be a clinical researcher,” he explained. “Study coordinators … most of them just fell into the job. It’s been totally serendipity how people came into the field.” He continued, “About half of the doctors who do a clinical trial only do it once. Clinical practice is not the same as clinical research.” To drive the organization’s mission of research excellence, Kremidas said much of the ACRP’s focus has been on education and development. “We’re trying to grow the workforce, and we’re also trying to help individuals keep up with changes in the industry,” he explained.

“If you’re going to be a principal investigator, you need to be trained appropriately … you need to have certain competencies,” Kremidas pointed out. To that end, the organization has created a competency framework. “We think it will help people transition into better clinical researchers if they know what they’re getting into,” he said. Kremidas continued, “We also do certification of clinical researchers. We’re now offering subspecialty designations. We just launched one this year for project management and had more than 200 sign up for the exam already.” Available certifications include ACRPCP (certified professional), CCRC (certified clinical research coordinator), CCRA (certified clinical research associate), and CPI (certified principal investigator).

Growing the Workforce Another area of emphasis for the ACRP is on workforce growth. As science explodes, so does the need for qualified researchers to oversee clinical trials. “We just recently announced a new initiative – Partners in Workforce Advancement (PWA),” he said of the effort to raise awareness of clinical research as a career path by reaching out to medical students and nursing students about the importance of field. The PWA motto is: In clinical research, people are everything. The litera(CONTINUED ON PAGE 18)

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Tax Changes – 2018 Planning Now May Save Money By Gerard Kassouf, CPA CFP®

2018 is a year of change. Your income tax return, while not a postcard, will incorporate the new tax rules passed by Congress in late 2017. The Tax Cuts and Jobs Act is the first major change in the income tax code in over 30 years. These changes affect individual taxpayers with new tax rates and brackets; an increased standard deduction; the loss of the personal and dependent exemptions; an increasing child tax credit and limitations to tax and interest deductions, for example. Many provisions of the Act are effective between 2018 and 2025, so plan accordingly. The tax rates and tax brackets are based on your filing status—single, married filing jointly, married filing separately and head of household. The new act provides seven tax rates, beginning at 10 percent with several brackets as high as 37 percent. Generally, the new brackets are two to three percent lower than previous brackets. The new Standard Deduction amounts are almost double the previous ones. The new Married filing jointly standard deduction amount is $24,000 and the Single standard deduction is $12,000. If your total

allowable itemized deduction amounts are lower than the standard deduction amounts, you are allowed to claim the higher standard deduction. As a planning opportunity, consider bunching your itemized deductions into alternate years. Itemize one year and take the standard deduction the next year. You may not be able to do so with every deductible expense, but there are ways to create a tax saving approach. Personal exemptions have been suspended until 2026. Children who were previously taxed at their parent’s tax bracket will now calculate tax on earned income at single taxpayer rates, and unearned income at estates and trusts rates. The alternative minimum tax now has a higher exemption amount. This higher amount will reduce the number of taxpayers subject to the tax. The Act changes the deductibility of home mortgage interest for primary and second homes purchased on December 15, 2017 or later. Homes purchased before that date remain subject to the old rules. The new rules reduce the maximum first mortgage loan amount and equity line of credit amounts used for acquisition indebtedness (for the purchase or substantial improvement of primary and secondary homes)

from $1,000,000 down to $750,000 (onehalf that amount if married filing separately). Interest paid for home equity loans not used for acquisition indebtedness is no longer deductible. Tax deductions for property tax, income/sales tax and automobile tag tax is now limited to $10,000 ($5,000 MFS). Charitable contribution limits have increased from 50 percent of adjusted gross income to 60 percent of adjusted gross income. Most other charitable contribution rules are unchanged. However, the new law eliminates charitable tax deductions for a contribution to a college or university for the right to buy tickets to an athletic event. The Internal Revenue Service has released guidance on the deductibility of gifts to Scholarship Granting Organizations. Donations made after August 27, 2018 will no longer be deductible as charitable contributions on your Federal income tax return. The State of Alabama will continue to allow a dollar-for-dollar tax credit for your gifts on your Alabama tax return. Medical expense rules were changed to allow for a reduced threshold of 7.5 percent for all taxpayers. The new law changes the taxation and deduction for alimony and separate main-

tenance agreements or modified after December 31, 2018. Payments made under alimony or separate maintenance agreements executed after 2018, generally, will no longer be considered deductible by the payor or income to the payee spouse. Under the new law, the deduction for any miscellaneous itemized deduction subject to the two percent floor is suspended. As a planning opportunity, if you currently have an arrangement with your employer where you pay and deduct these expenses on your form 1040, consider modifying your compensation arrangement to have them pay or reimburse you for them. On a positive note, the loss of itemized deductions if your income level exceeded a threshold has been suspended. With some exceptions, the itemized deduction for moving expenses is eliminated, including amounts received directly or indirectly from your employer. Moving expenses paid in connection with a new job greater than 50 miles from the prior place of work to your residence has also been eliminated for most taxpayers. Significant changes have been made to the child care credit for children under the age of 17. The amount of the credit has doubled from $1,000 to $2,000.

Birmingham Medical News

(CONTINUED ON PAGE 18)

OCTOBER 2018 • 17


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current policy to expand use. Weinstein said technology has the potential to not only impact accessibility but also overall affordability to the system. A patient discharged from the inpatient setting still needs outpatient care. If the first available appointment isn’t for two or three weeks … or two or three months … the risk of relapse dramatically increases, resulting in either a visit to the ED or readmission into an inpatient facility. “Not only is it a costly event but a disruptive event in a person’s recovery,” he said. Addressing standardization and quality of outcomes is another area where Weinstein believes technology could play a role. A patient who travels to another state for inpatient treatment should expect continuity of care on an outpatient basis when returning home. “Ideally, we would like to have continuation of treatment regardless of where you came from or are going back to. Currently, you have inconsistent approaches and inconsistent outcomes. Technology can be used to address that fragmentation and inconsistency,” Weinstein said. Broader use of Cognitive Behavioral Therapy (CBT) is also being explored. CBT, which was pioneered by Aaron Beck, MD, in the 1960s, has the benefit of numerous validating studies over the last 50 years. American Addiction Centers, for example, uses CBT to help individuals identify and address self-defeating thoughts and behaviors that often drive addiction. A group out of the University of Louisville has developed a computerized version of the

therapy (CCBT) and is currently working toward commercialization. Weinstein said a number of other companies are developing similar wearable technologies to validate medical adherence, serve as virtual breathalyzers, and support those in recovery. “All of this is on the horizon and will improve access and availability,” he said, adding that deploying this type of technology also leads to standardization of protocols. “With that, the treatment will become less costly by moving out of the inpatient, high acuity setting. It will be more standardized and produce improved outcomes, and that should lead to less readmissions and utilization of the Emergency Department,” Weinstein said. The next step in technology-enabled disruption is the use of artificial intelligence and big data to pinpoint those at risk for relapse, what interventions work best in various populations and how comorbid conditions impact outcomes. “American Addiction Centers will have available data that will be able to identify populations at risk,” Weinstein noted of work that has already begun. “We know early intervention leads to much better outcomes.” Finally, Weinstein said research has led to a better understanding of the human brain and a more comprehensive view of the impact of psychoactive substances. “Those studies and that improved understanding of our brains will lead to improved pharmacologic interventions so drug research is another important part of the solution,” he concluded.

The Quest for Quality, continued from page 16

Our legal

18 • OCTOBER 2018

Addressing the Gap, continued from page 14

ture associated with the initiative points out that without an adequate pipeline of qualified, competent professionals, the clinical trial community will fail to both sustain the workforce and improve the efficiency and quality of medical discovery. “Medical technology is advancing so fast,” noted Kremidas. “There’s an exponential growth in clinical trials, but there’s only a linear growth in PIs, CRCs, and CRAs … the people who actually do the trials.”

Without a robust workforce, he continued, “That leads to slower introduction of new therapies to the market, and that … in my opinion … is a public health problem.”

More Information Founded in 1976, the ACRP has 13,000 members who work in clinical research in more than 70 countries. For more information on the Washington, D.C.based organization or any of its programming initiatives, go online to acrpnet.org.

Tax Changes, continued from page 16 The phase out income levels have increased from $110,000 for married taxpayers filing a joint return to $400,000. There is also a new credit for non-child dependents such as parents or children over the age of 17 in the amount of $500 per year. The new law eliminates the itemized deduction for casualty and theft losses for individuals. This would include losses arising from fire, wind and theft. However, there are exceptions for losses which arise in federally declared disaster areas. The Act modifies the rules for college savings funds (529 plans) allowing distributions to include tuition payments to elementary or secondary institutions for amounts up to $10,000 per year. Institutions include public, private and religious operated

schools. There are also significant modifications to the estate and gift tax rules effective during the period from 2018 through 2025. The amount of the estate and gift tax exemption doubles this year from approximately $5.5 Million to $11 Million per decedent. Many opportunities for planning in 2018 exist for taxpayers. Taking time to plan, making changes allowed under the new Act, and preparing for your particular situation will allow for better tax results. Be proactive and plan now. Gerard Kassouf, CPA CFP® is a director in the tax, accounting and advisory firm Kassouf & Co., P.C.


CMS Proposes Accelerated Shift to Provider Risk in ACOs By Jesse Neil

To facilitate the American healthcare system’s transformation from volumebased to value-based payment, CMS is requesting public comment regarding its newly proposed rule that would shift the amount of risk that participants in Accountable Care Organizations (ACOs) assume under the Medicare Shared Savings Program (MSSP). An ACO is a group of physicians, hospitals, and other healthcare providers that care for a group of beneficiaries under Medicare Parts A and B. The core principles of the system are to streamline care and reduce costs within a cohesive structure. Under the current MSSP framework, ACOs may join one of three tracks with each differing primarily on the

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amount of risk each ACO opts to assume. Currently, 561 of the 649 ACOs are members within one of the tracks, with 82 percent of the 561 being enrolled in Track 1. Under Track 1, the ACOs only experience “upside-risk,” which means the ACO members are eligible to receive any achieved savings but are not financially responsible if the ACO incurs a loss. (Tracks 2 and 3 consist of only eighteen percent of enrollees with varying degrees of two-sided risk. Track 3 becomes the ENHANCED approach in the proposed rule.) CMS Administrator Seema Verma, however, recently opined that “[t]he results show that ACOs that take on regular levels of risk show better results for cost and quality over time.” As a result, CMS is requesting comment on a new proposed rule, entitled “Pathways to Success,” to shift more of the downside risk to providers to incentivize more efficient care and across-the-board savings. The proposed framework establishes two tracks: (1) BASIC and (2) ENHANCED. Each ACO would be permitted to choose the track that best fits its needs while also being able to enter into five-year agreements as opposed to three-year. This would enable the ACOs

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to adjust to the risk that will need to be assumed over time while also learning to manage the associated costs. The BASIC approach will permit the ACOs to assume risk over a fiveyear period with the first two years being upside-only risk with a “glide path” into years three, four, and five with increasing risk assumption. One caveat to the glide path is that ACOs currently within an upside-only risk plan, such as Track 1, would be limited to one of the two years of upside-only risk under the BASIC track. However, after year five, this newlyassumed risk would qualify the ACO as an Advanced Alternative Payment Model (APM), permitting the ACO to receive additional incentive payments for meeting quality thresholds. Under the ENHANCED approach, ACOs may enter the program immediately qualifying as an APM at a set risk amount for the entire five-year period as long as the risk is greater than year five of the BASIC approach. On the other hand, ACOs that have had no experience under a two-sided risk approach may enter into any of the BASIC’s glide paths or enroll into the ENHANCED model from the start. Due to the differences that exist be-

tween low revenue (i.e., physician practices) and high revenue (i.e., hospitals) entities, those who qualify as low revenue would be eligible to reapply for another five-year BASIC program at the highest level of risk. High revenue entities would be required to move into the ENHANCED track and assume additional risk. Some stakeholders may see a competitive advantage to an accelerated move to downside financial risk. For others, it could lead them to withdraw from participation in the program altogether. Regardless, it is a critical moment in the transition to a value-based system, and these programs will benefit immensely from thoughtful, practical feedback from the physicians, hospitals, payors, and even investors that are trying to lead the way. CMS is accepting comments until 5:00 pm EST on October 16, 2018. Jesse Neil is a partner with Waller Law where specializes in healthcare operations and public policy. Thanks to Clay Brewer, Belmont University College of Law, for his assistance in preparing this article.

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Pharmacogenomics as Predictor By laura FreeMan

Medications form the main modality of treatment for diseases. Medications are efficacious in most but not all patients. Moreover, adverse effects are common. So there are questions to answer when prescribing: which drug? What dose? Too little and it might not work at all. Too much and you could be putting the patient at risk from the drug itself. Physicians have always personalized medication therapy considering factors specific to the patient. Every prescription a physician writes has a decision-making process involved, and it goes

well beyond weight, age and gender. Both genes and physical condition affect how an individual responds to medication. Unfortunately, the patients most

likely to need more or less than the average dose aren’t usually included in clinical trials. There is an interplay between genes, environment and physical function that influences response. People of African descent have often been underrepresented in clinical trials for drug approval, even though they may have novel genetic influences such as the CYP2C single nucleotide polymorphism that exerts a clinically relevant effect on warfarin dose. Patients with serious illnesses that affect kidney, liver and heart function would not qualify for the trial. However, they are

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many of the real-world patients who are likely to need medications. Over the past 15 years, UAB anticoagulant research focusing on warfarin has been open to everyone, which afforded researchers the opportunity to study a cross section of the patients, including a number of people of African descent, enabling researchers to learn about how genetic factors not found in European populations influence drug response. Researchers were also able to look at how kidney, liver and heart function diminished by disease processes affect dosage requirements. Since around 90 percent of medications on the market are metabolized by the liver and drugs are prescribed for very diverse populations across the country and around the world, the UAB researchers’ findings could be a consideration for prescribing many types of medications. They found that diminished renal function may have implications for a larger proportion of warfarin users than previously estimated. When kidneys are less efficient at removing toxins, the production of enzymes in the liver needed to clear medications from the body is reduced. In heart failure, the diminished flow of blood also inhibits the liver’s ability to remove medications. Warfarin is the most widely prescribed oral anticoagulant in the US and it has a very narrow therapeutic index with a large interpatient variability in the dose required to achieve target anticoagulation. Patients with impaired kidney, liver and heart function may need to be initiated at a lower dosage and monitored more closely. In patients of African descent, who may vary in both body mass and genetic influences, race-specific pharmacogenetic algorithms, rather than race-adjusted algorithms, should be used to guide warfarin dosing. When heart patients requiring a stent come to UAB, clinicians use a swab sample for rapid testing of key genes to help physicians determine which combination of anticoagulants is likely to be most effective. In 70 percent of patients, aspirin with Plavix works well. But 30 percent need a different choice. The UAB research team tracked this intervention to verify that it was having a positive effect on outcomes and found that after a year, mortality rates for this population were down by 50 percent. In addition to anticoagulants, UAB is investigating medications for depression and chronic conditions. Depression medications tend to work in only around 40 percent of patients. It can be a long search to find the drug that works best in the individual, leaving patients at risk. Hopefully, the use of pharmacogenomics may help health care professionals find faster, more effective ways to identify the drug and dose likely to work best. The response to many other drugs, including opioids, has genetic underpinnings that could be helped with pharmacogenomics.


RESEARCH NOTES

Caffeine Consumption can aid in Pain Modulation According to a 2014 study, 85 percent of the U.S. population consumes at least one caffeinated beverage per day, with coffee as the leading source by far, for an average intake of 165 mg per day across all age groups. People ages 50 to 64 are the biggest caffeine consumers, with an average 226 mg per day. That is a very large group of people ingesting “the most widely consumed psychoactive substance in the world,” as UAB researchers described caffeine in an article published last month in the journal Psychopharmacology. So, naturally, scientists have lots of questions about what caffeine does for people. The Mayo Clinic notes that consuming up to 400 milligrams of caffeine per day, which is equivalent to roughly four cups of coffee, appears to be safe, although children and women who are pregnant or are breastfeeding are urged to limit caffeine use. A team led by UAB graduate student Demario Overstreet and Burel Goodin, PhD, an associate professor in the UAB College of Arts and Sciences Department of Psychology, with a research focus on pain modulation, wondered whether a person’s daily Burel Goodin, PhD intake of caffeine had an effect on their sensitivity to pain. Caffeine is already used in acute pain treatments (and it is an ingredient in some headache medicines). But does higher caffeine consumption in the diet make people experience less pain? To find out, the researchers recruited 62 participants ages 19 to 77 and asked them to record their daily caffeine consumption for seven days. The average was 170.8 milligrams per day, while the highest was 643.6 milligrams per day, or roughly 6.5 cups of brewed java — well above the “safe” recommended maximum. Researchers then put the participants through a series of uncomfortable tests using heat and pressure, recording how long they tolerated the pain before pressing a button to end the trial. The result, according to their paper: “greater self-reported daily caffeine consumption was significantly associated with higher heat pain threshold, higher heat pain tolerance and higher pressure-pain threshold.” Each additional 100mg of daily caffeine consumed, for example, was associated with a 0.5 degree Celsius (0.9 degrees Fahrenheit) increase in heat pain threshold. Previous studies have shown that caffeine blocks receptors for the neurotransmitter adenosine, which interferes with pain-signaling. This study “provides l evidence suggesting that greater levels of habitual dietary caffeine consumption may alter the nociceptive [related to the body’s primary pain receptors] processing of pain signals,” the authors wrote.

New research shows that, irrespective of weight loss, a proper diet can decrease the severity of pain, Goodin says. But this message is not widely understood, he added: “People just don’t realize that their diet, including caffeine consumption, can be used as a pain intervention.”

New Breathing Tube for Cardiac Arrest Could Save Thousands A study comparing two breathing tubes used by paramedics during outof-hospital cardiac arrest shows that the King laryngeal tube was superior to the more commonly used endotracheal tube. Findings of the Pragmatic Airway Resuscitation Trial, led by investigators at the UAB Alabama Resuscitation Center and published in the Journal of the American Medical Association, show that the King LT was quicker and easier for EMS crews to insert than the traditional endotracheal tube, or ETI.

“Out-of-hospital cardiac arrest is a major public health problem in this country, with some 424,000 cases per year,” said Shannon Stephens, EMTP, a researcher in the UAB Department of Emergency Medicine in the School of Medicine and the national project director for PART. “Only about 10 percent survive, and airway management during cardiac arrest is an extremely important aspect of treatment.” Paramedics often care for patients with cardiac arrest by inserting a plastic endotracheal tube into the lungs to assist with breathing. The King LT is a newer device. The study examined the performance of the two devices to see whether either produced higher 72-hour survival rates in adults with cardiac arrest treated by EMS responders. “If all EMS systems across the country were to shift to King LT as the primary advanced airway for out-of-hospital cardiac arrest patients and experienced similar survival rates, more than 10,000 extra lives would be saved each year,” Stephens said. Both breathing tubes are approved by the FDA and are not considered investigational devices. The two devices had not previously been compared to each other to determine whether one works better than the other until now.

27 EMS agencies from five metropolitan areas in the United States participated in the PART study. A total of 3,004 subjects were enrolled, with 1,505 assigned to initial King LT and 1,499 assigned to initial ETI. Patient demographics and arrest characteristics were similar in both groups. Henry Wang, MD, formerly the vice chair for research in the UAB Department of Emergency Medicine and now in a similar role at the University of Texas Health Sciences Center, was the national primary investigator of the study. “The elapsed time from first EMS arrival to airway start was shorter for King LT than ETI by more than two and a half minutes,” Wang said. “EMS crews successfully inserted the King LT tube on their first try 90 percent of the time, while the ETI group had an initial success rate of just 51 percent. The ETI group was more likely to require more than three insertion attempts, about 19 percent of the time, while the King LT group needed more than three attempts under 5 percent of the time.” The main outcome of the study, 72hour survival, was significantly higher for King LT than for ETI, (18.3 percent vs. 15.4 percent). Secondary outcomes were also better for King LT than ETI, including survival to hospital discharge (10.8 percent vs. 8.1 percent), and favorable neurological status at discharge (7.1 percent vs. 5.0 percent). The study was conducted in Birmingham, Dallas, Milwaukee, Pittsburgh and Portland. The Bessemer, Alabama, Fire Department was the first EMS agency in the country to take part.

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OCTOBER 2018 • 21


GRAND ROUNDS

Children’s and Lakeshore Partner to Open Children’s at Lakeshore In September, representatives of the Children’s of Alabama, UAB Division of Pediatric Rehabilitation Medicine and the Lakeshore Foundation cut the ceremonial red ribbon for the grand opening of Children’s at Lakeshore – the latest chapter in a partnership among the institutions. Children’s at Lakeshore, located on the Lakeshore Foundation campus, provides UAB physician care and Children’s physical therapy, occupational therapy and speech-language pathology services to children and adolescents with acute onset or chronically disabling conditions. By combining a medically-based model of care and community-based healthy living and transitional services, Children’s at Lakeshore is designed to help each child achieve their highest level of independence. Referrals to Children’s at Lakeshore are made primarily by UAB physicians following an inpatient rehabilitation stay or clinic appointment, and based on the potential patient benefit from the services available at Children’s at Lakeshore. Children’s at Lakeshore represents a bridge between the Children’s medical rehabilitation model and Lakeshore Foundation’s strong reputation in the world of sports, fitness and recreation, with the additional Savannah Gardner played on the National Championship team. commitment to expanding the pediatric footprint via the UAB/Lakeshore Research Collaborative. Children’s at Lakeshore is only steps away from wheelchair basketball practice and after-school recreation classes in Lakeshore’s Fieldhouse, and swim lessons and teen swim club in the Aquatics Center. Savannah Gardner, a former Children’s patient and Lakeshore athlete who went on to play wheelchair basketball at the University of Alabama and win a national championship, spoke at ribbon cutting and shared with guests how Children’s and Lakeshore have impacted her life. “Children’s, from a medical standpoint, allowed me to be my best self,� said Gardner, who was diagnosed with cerebral palsy at 13 months of age. “Children’s is where I learned how to sit up. Children’s is where we found out about surgeries that would help me walk better. I learned exercises and stretches that I can do to help my body be the best that it could be. It’s where I learned to engage my core and use a lot of the muscles that I was able to strengthen once I started playing wheelchair basketball. Lakeshore gave me the opportunity to just be a kid and not a kid that had to be in therapy. As I got older, it was Lakeshore that fostered the competitive spirit in me. “If Children’s and Lakeshore could have impacted my life as much as they have by being separate, imagine how much more both of you can do now partnering together. The influence is unimaginable and the result of the children coming out of these organizations is unstoppable.�

Northside Opens Urgent Care This month, Northside Medical Associates opens Accel Urgent Care in its original building on the campus. The new clinic comes on the heels of the construction of a two-story facility that includes primary and specialty care. Northside Medical Home includes Birmingham Heart Clinic, Alacare, Alabama Oral and Facial Surgery, Eastern Surgical, Vision First and a pharmacy, all under one roof. “Acel is the next phase of developing a comprehensive primary care delivery method,� said Rock Helms, MD, the CEO of Northside Medical Associates. “It’s going to be unique due to its blend of primary care, emergency level care and urgent care in Rock Helms, MD one building with patients having access to advanced diagnostics, a full range of lab services, CT scan and ultrasound.� Patients will be able to see a primary care doctor more quickly – sometimes that same day – because of that connection between the urgent care services and Northside’s primary care practice. In a typical urgent care setting, the patient is generally asked to follow up (continued on page 23)

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GRAND ROUNDS with their primary care doctor. With Accel, if they are a Northside patient, the physician is just a phone call away. If they don’t have a primary care doctor, the referral can be immediate. “It improves the transition of care,” Helms said. Northside Medical Associates have recently doubled in size, partnering on clinics in underserved areas of Springville, Ashville and Trussville, and the announcing intentions to partner on a Wellness Center venture.

Morgan Named Director of UAB Division of Gastroenterology & Hepatology Douglas Morgan, MD, a global expert in the epidemiology and prevention of gastric cancer has been named Director of the UAB Division of Gastroenterology and Hepatology. Morgan has been Douglas Morgan, MD on faculty at Vanderbilt University, where he has practiced since 2011. His priorities include expanding the division’s clinical, educational and research programs to best meet the needs of Alabamians and to advance the treatment of GI diseases globally. “It is an honor to join one of the top institutions in the nation,” Morgan said. “We look forward to further growing our mission.” Morgan has extensive global health experience, rooted in service as a Peace Corps engineer in Central America. He currently directs or codirects National Institute of Healthfunded programs for gastric cancer in molecular epidemiology, chemoprevention and appropriate technologies in Honduras, Nicaragua, El Salvador, Colombia and Puerto Rico. Prior to practicing at Vanderbilt, he was a member of the faculty of the University of North Carolina at Chapel Hill, where he founded UNC’s Center for Latino Health. For his service, he was awarded the Ohtli Award, one of the highest honors awarded by the government of Mexico to a foreign national. He takes over for Mel Wilcox, MD, who has served as director of the division since 2001.

Lincoln Health System and Huntsville Hospital Health System Enter Affiliation Lincoln Health System (LHS), a county-owned, non-profit corporation, has entered into a strategic affiliation agreement with Huntsville Hospital Health System (HHHS) to become part of a larger affiliated health care system that will allow for more efficient delivery of services to residents of southern Tennessee and northern Alabama. The new entity will be governed by the same local hospital Board of Trustees and senior leadership team in Lincoln County.

Through this affiliation with Huntsville Hospital Health System, LHS will benefit from shared services, purchasing cooperatives for cost savings, physician services like specialist rotation and recruitment support, as well as assistance with other services. The goal of the affiliation is to enable LHS to grow its services and capabilities in the region it serves. “Due to the increasing challenges facing small rural hospitals, LHS has been looking for a strategic partner for several years. We are excited to have

found this in a fellow non-profit health system so close to our own,” said Lincoln Health System CEO, Candie Starr. The strategic affiliation is neither a purchase nor an acquisition. It allows LHS to leverage access to many services and expertise that would be difficult to source alone. LHS remains locally owned and the current leadership team remains responsible for dayto-day operations and management, including retaining all revenue generated by LHS.

“We are very pleased to have Lincoln Health System join us,” said David Spillers, CEO of Huntsville Hospital Health System. “We’ve had a longtime relationship with the community and the hospital. Our values are similar.” “We welcome Lincoln Health System and we look forward to working closely with the LHS team in helping serve the patients of Lincoln County and southern Tennessee,” said Philip Bentley Jr., Chairman of the Health Care Authority of the City of Huntsville.

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Birmingham Medical News

OCTOBER 2018 • 23


GRAND ROUNDS

Grover Named CEO of UAB Callahan Eye Hospital & Clinics Rett J. Grover has been named chief executive officer of UAB Callahan Eye Hospital & Clinics. “It has been the privilege of a lifetime to work alongside our world-class physicians, researchers and health care professionals, and I am humbled by the opportunity to lead this great organization into the future,” Rett J. Grover Grover said. His goals for UAB Callahan Eye Hospital & Clinics include expanding and enhancing access to the highest quality of care, continuing clinical ex-

cellence, and continuing to recruit and retain world-class clinical providers. Grover completed his administrative residency at the University of Mississippi Medical Center in Jackson, Mississippi, and assumed the position of director of Business Operations for the Department of Orthopedic Surgery and Rehabilitation in 2010. After several years at UMMC, he joined UAB Callahan Eye Hospital & Clinics as the operations administrator. In 2015, Grover became the hospital’s chief operating officer, and in November 2017, he transitioned into the role of interim chief executive officer. During his time spent as interim chief executive officer, the hospital saw significant operational progress and financial growth. Grover is a member of the Ala-

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bama Hospital Association Birmingham Regional Council and the American College of Healthcare Executives. He serves as a board member for the Alabama Chapter of the American College of Healthcare Executives, the Ophthalmology Services Foundation and the Eyesight Foundation of Alabama. Grover completed his undergraduate studies at the University of Alabama, and received his Master of Science degree in health administration and Master of Business Administration degree from UAB. He then went on to complete his administrative residency at UMMC. Grover replaces Brian Spraberry, who served as chief executive officer for seven years and then transitioned into the role of chief administrative officer with the UAB Health System.

Blake New Alabama Eye Bank CEO Alan Blake, CEBT, CTBS has been promoted to President and CEO Alabama Eye Bank. Blake, who currently serves as the Executive Director of the Alabama Eye Bank, has worked with the nonprofit for nearly 15 Alan Blake years. His responsibilities have ranged from overseeing the daily operations to ensuring compliance with federal, state and industry regulations. “I am honored to take over the role as President and CEO of the Alabama

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Eye Bank,” Blake said. “I’m grateful to Doyce Williams for his exemplary leadership over the past decades.” Blake earned a Bachelor of Science degree from Birmingham-Southern College in 2001. Upon graduation, he began his career at the Alabama Eye Bank. He then moved to Illinois, where he worked for the Illinois Eye Bank until he re-joined the Alabama Eye Bank in 2004. Blake is replacing Doyce Williams, current President and CEO of the Alabama Eye Bank since 1980. Williams will serve as Special Advisor to the President for two years. During Williams’ tenure, the Alabama Eye Bank has ranked in the top 10 eye banks in the world for more than 20 years in tissue placed for transplant. “I am thrilled that my colleague and friend, Alan Blake, will be replacing me as President and CEO of the Alabama Eye Bank,” Williams said. “I am confident in his ability to lead this wonderful organization into the future.” Since 1969, the Alabama Eye Bank (AEB) has been collecting and distributing donating tissue for the purpose of providing sight to the visually impaired and blind. The AEB is federally regulated, licensed and accredited 501-C3 not-for-profit organization.

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Hawkins Named COO of Princeton Kidada Hawkins, MHSA, MBA, FACHE has been named chief operating officer of Princeton Baptist Medical Center. Hawkins joins the Brookwood Baptist Health System from Shoals Hospital in Muscle Shoals where he served as chief execu- Kidada Hawkins tive officer for the past three years. Hawkins’ tenure in the healthcare industry spans more than a decade. His career began at Stringfellow Memorial Hospital in Anniston where he served consecutively as director of marketing and assistant administrator before being named associate administrator. In 2010, he joined St. Vincent’s Hospital in Birmingham as chief operations officer of rural hospital operations in Blount and St. Clair Counties. In 2015, he assumed his current role at Shoals Hospital.

BlueCross BlueShield of Alabama Announces No Rate Increases for C Plus Medicare Plans BlueCross BlueShield of Alabama C Plus members will not see a premium increase on their 2019 C Plus Medicare Select Plans. This is the 11th year since 2002 and the third year in a row that C Plus

members have had no premium increase. Blue Cross’ C Plus Medicare Select Plans help pay for eligible out-of-pocket expenses not paid by Medicare. In Alabama, C Plus members have access to Blue Cross’ network of more than 10,000 doctors and 111 Alabama hospitals. Blue Cross has offered C Plus to Medicare-eligible Alabamians since 1966.

Blue Shield of Alabama. Blue Cross’ BeWell Program promotes emotional, financial, physical and social wellness for holistic well-being at Blue Cross and Blue Shield of Alabama. The Healthy Action Program supports physical wellness, offering a Fitbit credit

incentive for completing preventive screenings, online health activities, care management programs or a tobacco cessation program. Additional rewards are given for completing a wellness visit, walking challenges, a health assessment and/or weight challenges.

BlueCross BlueShield of Alabama Recieves Award The National Business Group on Health, a non-profit association of more than 420 large U.S. employers, is honoring Blue Cross and Blue Shield of Alabama for providing one of the best workforce employee well-being programs in the nation. Blue Cross is among 49 U.S. employers that received the 2018 Best Employers for Healthy Lifestyles® award presented at the National Business Group on Tim Vines Health’s Workforce Strategy 2018 Conference. This marks the ninth year Blue Cross has received a Best Employers for Healthy Lifestyles® award. “It is a privilege to be recognized nine years for our company’s ongoing commitment to support our employees’ health and well-being.” said Tim Vines, President and CEO, Blue Cross and

Princeton Receives Baby-Friendly Designation Princeton Baptist Medical Center has been named a Baby-Friendly hospital by Baby-Friendly USA. The Baby-Friendly recognition acknowledges Princeton Baptist’s commitment to providing an optimal level of care for breastfeeding mothers and their babies. The hospital successfully completed an on-site assessment confirming the implementation of Baby Friendly Hospital Initiative’s Ten Steps to Successful Breastfeeding Program. Studies have concluded that babies who breastfeed have lower risks for certain illnesses. “Being named a Baby-Friendly hospital affirms our commitment to ensuring high-quality mother/baby care,” said Pat Franklin, RN, BS, Manager of Women and Infants at Princeton Baptist Medical Center. “As one of only two Baby-Friendly hospitals in Birmingham, we are dedicated to providing mothers with the education and support they need.”

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Birmingham Medical News

OCTOBER 2018 • 25


GRAND ROUNDS

Children’s of Alabama Honors Board Members, Physicians with Endowed Chairs

Endowed Chair in Pediatric Orthopaedics. Gilbert is chief of the orthopaedic division at Children’s of Alabama and a professor of surgery at the University of Alabama in the division of orthopaedic surgery. Children’s of Alabama has been served by a volunteer Board of Trustees since its founding in 1911.

Children’s of Alabama, the state’s only freestanding pediatric hospital, has honored several long-time members of its Board of Trustees with the establishment of endowed chairs in their names. Among those board members honored for 20 years of service to Children’s are Ralph Frohsin Jr.; Susan Nabers Haskell; Virginia Walker Jones; Philippe Lathrop; L. Gwaltney McCollum Jr.; and Benjamin Russell. “These community leaders have had tremendous impact on the ill children of our state through their service on the Children’s Board of Trustees,” said Children’s CEO and President Mike Warren. “Their work helps us provide exceptional healthcare to our patient. The same applies to the physicians who now hold these chair distinctions. Their research and clinical care will advance the reputation of Children’s of Alabama as well as the endowed chairs’ namesakes.” Jack H. Crawford, MD, PhD is the first holder of the Philippe Lathrop Chair in Pediatric Cardiac Anesthesiology. Crawford is a cardiothoracic anesthesiologist Jack H. Crawford, and associate professor MD, PhD of anesthesiology and perioperative medicine. Jennifer Dollar, MD is the first holder of the Susan Nabers Haskell Endowed Chair in Pediatric Anesthesiology. She is a pediatric anes- Jennifer Dollar, MD thesiologist and chief of anesthesiology at Children’s. Shawn Gilbert, MD is the first holder of the L. Gwaltney McCollum Jr.

Mike Neuendorf Named Chief Executive Officer of Princeton Mike Neuendorf has been named chief executive officer of Princeton Baptist Medical Center. Neuendorf joins Tenet Healthcare from Community Health Systems, having served as CEO of Merit Health Wesley Hospital in Hattiesburg, Mississippi for the past eight years. Neuendorf’s tenure in the healthcare industry spans more than 20

years. A member of the Alabama and Georgia Army National Guard for more than a decade, he served as a Senior Management Consultant for the Veterans Health Administration for North- Mike Neuendorf east Alabama Regional Medical Center in Anniston. Thereafter, he worked for Ascension Health as Director of Internal Consulting at St. Vincent’s Hospital in Birmingham before joining Community Health Systems as Chief Executive Officer of the South Baldwin Regional Medical Center in Foley. According to Keith Parrott, CEO, Brookwood Baptist Health, “Mike’s healthcare experience – coupled with his military background – provide him with innate leadership skills that will be of significant value in the role of CEO. I

U.S. News & World Report’s 2017-2018 Best Hospitals report ranks UAB cardiology and heart surgery number 18 in the nation, jumping 12 spots from last year’s ranking and 19 spots from its 2015-2016 ranking. “The UAB cardiovascular service line is proud of our continually improving U.S. News and World report ranking, now at No. 18 nationally,” said Division of Cardiothoracic Surgery Director James Davies. “We are currently the only ranked program in the state of Alabama, and we are in the top three programs in the Southeast. Every memUAB Division of Cardiothoracic Surgery Director James Davies, MD ber of the team should performs surgery. be applauded for his or her efforts in making this program so valuable for the patients of Alabama.” Cardiology and Heart Surgery is one of 10 specialties at UAB ranked in the top 50 and one of four specialties at UAB ranked in the top 20.

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The Children’s of Alabama Mayfair Medical Group in Homewood welcomes Jamie Powell, MD to the practice. Powell joins the practice after receiving her medical degree from the UAB Medical School and completing her pediatric residency at Chil- Jamie Powell, MD dren’s of Alabama. Powell received a Bachelor’s of Science in Biology and a Bachelor’s of Arts in Spanish from Wofford College. She received her Masters of Public Health and Doctor of Medicine at UAB. Dr. Powell is a member of the American Academy of Pediatrics.

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