San Antonio Medicine May 2020

NON PROFIT ORG US POSTAGE

PAID

SAN ANTONIO, TX PERMIT 1001

COVID-19 PANDEMIC S A N A N TO N I O

MEDICINE SAN ANTONIO

TA B L E O F CO N T E N T S

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

•

WWW.BCMS.ORG

•

$4.00

COVID-19 – Pandemic

Telemedicine During COVID-19 Pandemic – A Savior for Physicians and Patients

By Jayesh Shah, MD ........................................................................12

Telemedicine & COVID-19 By Zeke Silva, MD...................................14 COVID-19: Swimming Lessons for the Greater Good

By Venkat Srinivasan, MD and Ajeya Joshi, MD ................................15 What the Media Does Not Tell You About – A Coronavirus Perspective By Alan Preston, MHA, ScD........................................17 An Important Lesson on Quarantine By Maaz Ahmed.....................19 Strategic National Stockpile By Diane Simpson, MD...........................22 Matching Amidst a Pandemic By Darren Donahue, MS4 .................23 Personal Protection Equipment – PPE Donors and Recipients – Thank You! By Medical Students Aaron Verbeelen, Yvette Lopez, Gwendolyn Quintana and Kayla Pineda .............................................24 Personal Protective Equipment (PPE) Conservation Strategies From the CDC: Strategies to Optimize the Supply of PPE and Equipment 04/03/2020) .......................................26 Can I Avoid Contract Obligations Because of the Corona Virus? By George F. “Rick” Evans, Jr. ....................28 When is a Ventilator or ECMO Dependent Patient Dead? By George F. “Rick” Evans, Jr. ................................29 Possible Treatments and Vaccines for COVID-19 By Kenny Chang, DO, UIW Family Medicine Resident ............30 Keeping Your Practice Viable From Texas Medical Association ............................................................................31 Strategies Ophthalmology Clinics are Using for Patient Safety for COVID-19

By Sejal Lahoti, Huy Nguyen, MD and Richard Jones, MD...................................................................................33 It’s a Pandemic Crisis! What is the Medical Society Doing? Count on BCMS and TMA Being Here For You By Mary E. Nava, BCMS Chief Government Affairs Officer............................................................34 TMLT Offers Malpractice Insurance at No Cost to Retired Physicians Who Volunteer during the COVID-19 Crisis From Texas Medical Liability Trust ...........................................................................................36 The COVID-19 Paradigm Shift Should Stick Around By Brittany R. Johnson, MPH ...........................................37 Changes to Telemedicine Laws From Texas Medical Association........................................................................38

BCMS President’s Message................................................................................................................................................8 BCMS Alliance..................................................................................................................................................................10 BCMS Circle of Friends Physicians Purchasing Directory ..................................................................................................40 Recommended Auto Dealers............................................................................................................................................44 PUBLISHED BY: Traveling Blender, LLC. 10036 Saxet Boerne, TX 78006 PUBLISHER Louis Doucette louis@travelingblender.com BUSINESS MANAGER: Vicki Schroder vicki@travelingblender.com ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@travelingblender.com

4

San Antonio Medicine • May 2020

SAN ANTONIO: Madeleine Justice madeleine@travelingblender.com Gerry Lair gerrylair@yahoo.com PROJECT COORDINATOR: Amanda Canty amanda@smithprint.net

For more information on advertising in San Antonio Medicine, Call Traveling Blender at 210.410.0014 in San Antonio and 512.385.4663 in Austin.

•

MAY 2020

•

VOLUME 73 NO. 5

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.

EdITORIAl CORRESPONdENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org

MAGAZINE AddRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org

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

AdvERTISING CORRESPONdENCE: Louis Doucette, President Traveling Blender, LLC. A Publication Management Firm 10036 Saxet, Boerne, TX 78006 www.travelingblender.com

For advertising rates and information Call (210) 410-0014 Email: louis@travelingblender.com

San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS, its members, or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

SmithPrint, Inc. is a family owned and operated San Antonio based printing and publishing company that has been in business since 1995. We are specialists in turn-key operations and offer our clients a wide variety of capabilities to ensure their projects are printed and delivered on schedule while consistently exceeding their quaility expectations. We bring this work ethic and commitment to customers along with our personal service and attention to our clients’ printing and marketing needs to San Antonio Medicine magazine with each issue.

Copyright © 2020 SmithPrint, Inc. PRINTED IN THE USA

BCMS BOARD OF DIRECTORS ELECTED OFFICERS Gerald Q. Greenfield, Jr., MD, PA, President Rajeev Suri, MD, Vice President Rodolfo “Rudy” Molina, MD, President-elect John Joseph Nava, MD, Treasurer Brent W. Sanderlin, DO, Secretary Adam V. Ratner, MD, Immediate Past President

DIRECTORS Michael A. Battista, MD, Member Brian T. Boies, MD, Member John D. Edwards, MD, Member Vincent Paul Fonseca, MD, MPH, Member Danielle Hilliard Henkes, Alliance Representative David Anthony Hnatow, MD, Member Lyssa N. Ochoa, MD, Member Gerardo Ortega, MD, Member Manuel M. Quinones, Jr., MD, Member John Milton Shepherd, MD, Member Richard Edward Hannigan, MD, Board of Ethics Co-chair Nora Lee Walker, MD, Board of Ethics Co-chair Charles Gregory Mahakian, MD, Military Representative George Rick Evans, Legal Counsel

6

San Antonio Medicine • May 2020

Jayesh B. Shah, MD, TMA Trustee Ramon S. Cancino, MD, Medical School Representative Corinne Elizabeth Jedynak-Bell, DO, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Stephen C. Fitzer, CEO/Executive Director (ex-officio)

BCMS SENIOR STAFF Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Yvonne Nino, Controller August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE Kristy Yvonne Kosub, MD, Chair John Joseph Seidenfeld, MD, Vice Chair Louis Doucette, Consultant Charles Hirose Hyman, MD, Member Tzy-Shiuan B. Kuo, MD, Member Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member David Schulz, Community Member Alexis A. Wiesenthal, MD, Member Tyler Adams, Student Member Chinwe Anyanwu, Student Member Darren M. Donahue, Student Member Donald Bryan Egan, Student Member Christopher Hsu, Student Member Aishwarya Devesh Kothare, Student Member Anirudh Madabhushi, Student Member Anjali Surya Prasad, Student Member Teresa Samson, Student Member Cara Jillian Schachter, Student Member Stephen C. Fitzer, Editor

PRESIDENT’S MESSAGE

Physician Leadership in a Pandemic

By Gerald Q. Greenfield Jr., MD, 2020 BCMS President The current coronavirus pandemic demonstrates the importance of physician leadership in our society. While politicians are responsible for the management of many aspects of oversight for our population, including laws, economics, and defense against foreign powers, they have little knowledge of the management of public health emergencies. defending against the assault or invasion of a foreign power requires the coordination of multiple organizations, including industry, the military and local civilian government agencies. but social and economic goals can only be accomplished by the presence of a healthy workforce. leadership and management of public health must come from medical professionals. Physicians must lead and manage in that arena. Medical leadership includes identification of the source of problems, types of infection, sensitivity and treatment options, vaccine production and disease avoidance techniques.

The response to the current pandemic has highlighted the need for medical professionals to provide information and guidance to the political leadership. This includes epidemiology to forecast the pattern of illness and its spread, infection specialists to define treatment options and patient care specialists (including physicians and nurses) to provide care for those members of the population who are affected by the disease process.

When politicians are allowed to make medical decisions without appropriate guidance, they have a high likelihood of providing erroneous information and incorrect instructions, leading to potentially disastrous results. In many cases, without sometimes forceful leadership by physicians, our politicians are at great risk of making a difficult situation worse. Conveying medically sophisticated information to someone with no medical background requires great skill. The information must be accurate and provide a basis for actions which may be unpopular and difficult to follow. However, the medical leader must be able to do this in order to avoid poten8

San Antonio Medicine • May 2020

tial catastrophe. Each episode of missed information has potentially disastrous results and can make a grave situation even more difficult.

Perhaps one of the problems we as physicians have is a knowledge deficit as to the lexicon of politics. Our training in natural sciences may leave us unprepared to discuss the population effects of medical issues from a fiscal or financial standpoint. The young physicians who are now earning degrees in business administration and law in addition to their medical training will in the future hopefully be better able to guide our political leaders. This greater breadth of knowledge should allow them entrance into those chambers were political decisions are made. Armed with a vocabulary which can pierce the ears of politicians, they will be better able to lead elected and appointed officials in the best direction to provide healthcare for the population.

Even in the current pandemic we have seen how medical leaders have been able and willing to speak truth to power. While not hanging crepe, they have been able to heighten the contrast in what has been presented as a rosy picture. The true leader must provide consistent, accurate and truthful information. If members of the population are to have confidence in their leaders, they must have confidence in the information provided by those leaders. In the current global medical catastrophe, physician leadership will be necessary in order to enable a healthy workforce which will then allow the global economy to recover. It is only with accurate and consistent medical information that political leaders will be able to provide the guidance that the population requires.

Gerald Greenfield, MD, is an Orthopedic Surgeon in Bexar County and is the 2020 President of the Bexar County Medical Society.

BCMS ALLIANCE

BCMS ALLIANCE MEMBERS SHARE THEIR STORIES

In the bleakness of fighting this terrifying disease, one constant has ignited hope and brought light into the darkness: love. love has many names, like service, sacrifice, steadfastness. For the last several months, our Alliance families have lived this love. These are their stories.

SERVICE

tive role in combating the pandemic.”

“It is heart wrenching hearing stories of health care workers who cannot adequately protect themselves and therefore, are putting their lives at risk. The fear of bringing COVID-19 home to their families is real and daunting. Being the spouse of an OMS3 has provided me insight into the severity and significance of the PPE shortage. Donations help spread positivity in a time of such uncertainty, while empowering the community to take on an ac-

Heather Davila, Dental Hygienist (Edwin davila, 3rd year Osteopathic Medical Student)

STEADFASTNESS bCMS Alliance Past President Jennifer lewis, NICU SlP/Feeding Therapist, is pictured with other members of the NICU team at Methodist Hospital/Stone Oak. In spite of daily changes to control the spread of infection in the community, one thing that remains constant is the commitment demonstrated by this team caring for the tiniest patients. While physician husband, Cannon lewis, Md serves as vice Chief of Staff and Colorectal Surgeon in the same hospital, their paths rarely cross. Only back at home are they able to share highs and lows of doing whatever needs to be done to get patients of all ages strong enough to go home with their families.

10

San Antonio Medicine • May 2020

SACRIFICE “Being married to medicine, it is not uncommon to assume the role of default parent as our physician spouse gets called away due to high demands on their time. As a biology college professor, I find myself educating my students about virology in addition to our normal curriculum. As a mother, I struggle to find age-appropriate ways of speaking to an inquisitive fiveyear-old about why her world has so drastically changed in such a short time. I listen to her fears, try to help her process the changes, and wonder how her mind will reflect on this when she is older. ‘Hey Mommy! I wish a virus was a good thing…and I could go back to school and play with my friends. Can I watch Frozen 2 again??’ ‘Yes, Helen, me too…but can you please let me finish giving my lecture to my students??…. JULIE! Stop climbing on the table!’ (perfect activity for a 2 year old)!! At least my students get a kick out of this chaotic snapshot into my life through their computer screens!”

Lori Boies, Instructor of Biological Sciences at St. Mary’s University, BCMS Alliance Past President (brian boies, Md, Assistant Professor and Program director of the Anesthesiology Residency at UT Health San Antonio)

COVID-19 PANDEMIC

TELEMEDICINE

During COVID-19 Pandemic A Savior for Physicians and Patients

By Jayesh Shah, MD

Never in my lifetime have I seen such a disruption to our healthcare system as during this battle we wage against COvId-19. Many of us have transitioned to Telehealth technology within a matter of days. When I last wrote about telemedicine, only a handful of providers used telemedicine. In a matter of weeks now, telemedicine has become a household phenomenon; both patients and doctors are getting used to the telemedicine technology. Someone has rightly said, “Necessity is the mother of invention”. The COvId19 pandemic, and the consequent lockdown, forced most of us physicians to communicate with our patients by any available means so that we can discourage them from going to emergency rooms and hospitals, keeping them in their own homes which is typically the safest place for them right now during this pandemic.

CMS was quick to relax patient engagement rules so patients can be taken care of during these unusual circumstances; I have never seen in my career so many regulatory rules lifted. Even HIPAA rules were lifted. “during the COvId-19 emergency declaration, the U.S. Health and Human Services (HHS) Office of Civil Rights (OCR) will not penalize physicians for noncompliance with HIPAA when they service patients in good faith through common communication technologies such as Face Time or Skype.” At the same time, CMS allowed use of the same billing codes as office visit Evaluation and Management codes for telemedicine. during this public health emergency, rural and site limitations are removed. Telehealth services can now be provided regardless of where the enrollee is located geographically and type of site, which allows the home to be an eligible originating site. However, newly eligible locations will not receive a facility fee.

I hope some of these changes will last in the post-pandemic period as both physicians and patients are getting used to the tele-visit technology now. For me, telemedicine has been very helpful for the nursing home patients. We are able to do virtual wound care rounds with a wound care nurse at the nursing homes. I am able to get first-hand in12

San Antonio Medicine • May 2020

formation on what patients are getting for their offloading in nursing home settings. I can talk to a dietician, a therapist or a medical director and truly provide multidisciplinary care. likewise, I feel telemedicine is a great service for elderly patients who do not have to travel by ambulance to a clinic or another facility and can be treated at the point of service, allowing us to provide the same level of care. It is interesting that once we started telemedicine service, we started getting consults from a rural area where there are no wound doctors. Home Health Nurses from these rural areas were thankful that we could help them take care of their patients in their own homes.

I feel that by the time this pandemic is over, telemedicine will become part of everyone's practice. The patients who are less sick, patients who are working, and busy parents with no babysitters or who are traveling from afar will prefer telemedicine for follow-ups.

Patients will still have to come to the clinic if they require procedures and, if patients are very sick, they can be referred to an ER/hospital. Post-surgery follow-up can also routinely be done through telemedicine now.

I feel telemedicine is a boon and a real savior to physicians and patients. because the pandemic disrupted the provision of health care so quickly, I feel that there is an urgency to enhance the evidence for telehealth technology applications as clinicians and consumers expand its use in numerous areas. All my colleagues are now using real-time video consultations with off-site specialists in all fields such as family practice, internal medicine, cardiology, dermatology, psychiatry, behavioral health, gastroenterology, infectious disease, rheumatology, oncology, wound management and vascular specialties.

Primary care doctors are using tele-visit to screen COvId-19 patients and to set-up drive-thru testing centers. They are using televisits for counseling, medication prescribing and management, and management of long-term treatment for diabetes, chronic obstructive pulmonary disease and congestive heart failure.

COVID-19 PANDEMIC I encourage physicians to look at telemedicine as a long-term strategy for their practice as telemedicine is here to stay. Here are some things I have learned about telemedicine: • Use a secure, encrypted technology that is HIPAA-compliant; execute a business associate agreement (bAA) with the vendor.

A sample bAA agreement for physicians is on TMA’s HIPAA resource center: www.texmed.org/HIPAA. • before looking around for a Telemedicine vendor, check if your own Electronic Health Record has those capabilities.

• Once you have selected a vendor, and if you are ready to sign the contract, you can get your contract evaluated free by TMA if you are a TMA member.

• Inform your liability insurance carrier that you will be providing telemedicine services with an effective date.

• The standard of care and documentation requirement for televisits is the same as for face-to-face visits.

• Physicians licensed in Texas are only allowed to perform televisits in Texas.

• You will need to design a workflow that works for your practice.

In our practice, the secretary schedules tele-visits, creates the encounter, verifies insurance and collects copayment like any faceto-face patient. The secretary also connects the patient just

before their appointment and keeps them in a virtual waiting room so physicians' time is utilized wisely.

Hope you find this information helpful. The following resources have more detailed information on Telemedicine.

Jayesh B. Shah, MD is board certified in Internal Medicine and Undersea and Hyperbaric medicine, is a member of the Board of Trustees of the Texas Medical Association, and was the 2016 President of Bexar County Medical Society.

Resources 1 https://www.nejm.org/doi/full/10.1056/NEJMsr1503323? query=recirc_curatedRelated_article https://www.ama-assn.org/practice-management/digital/ digital-health-payment 2 https://www.acponline.org/practice-resources/covid-19-practice-management-resources/telehealth-coding-and-billing-during-covid-19 TMA task force has written extensive document about Telemedicine 3 https://www.texmed.org/uploadedFiles/Current/2016_Practice_Help/Health_Information_Technology/Telemedicine/CO vId-19%20Telemedicine%20Getting%20Started.pdf

visit us at www.bcms.org

13

COVID-19 PANDEMIC

TELEMEDICINE & COVID-19

By Zeke Silva, MD COvId-19 became a reality for our practices almost overnight.

As our energy and focus shifted to the new disease, a broader social-distancing mandate became a part of our everyday lives. Suddenly, our patients were required to stay home, making traditional office visits difficult. Those affected included patients across the spectrum from wellness to severe disease, with anything even potentially related to the new virus. Physicians and patients were forced to find a way to provide care while maintaining safe distancing. One solution: telemedicine.

Telemedicine has been gaining momentum for several years. We now have numerous Current Procedural Terminology (CPT) codes to describe telemedicine. This includes synchronous and asynchronous communications between physicians and patients. Also included are communications among physicians, such as consultations.

There also are several codes for remote patient monitoring (RPM) (1). Coverage for these codes was, however, limited. For instance, these services had originating-site, geographic-site, and store-andforward restrictions. We also faced limitations on the non-physician providers eligible to provide these services, and not all the codes, such as the telephonic codes, were covered.

Then, COvId-19 struck. The momentum I describe above went into overdrive. Physicians, patients and health care workers had to be kept safe, but patient care needs remained. The first major change came shortly after the President’s COvId-19 emergency declaration. The administration announced that for the duration of the emergency declaration, telemedicine visits provided by a twoway audiovisual interface would be paid at the same rate as a comparable face-to-face office visit. The previous originating-site and geographic-site, as well as store- and-forward restrictions were lifted.

For example, both the physician and the patient could each be at home during the visit, and all Medicare beneficiaries were covered.

HIPAA requirements were also relaxed, as were security and compliance requirements. This was a positive step, but there were some shortcomings. What about patients not capable of utilizing a twoway Av interface? How would the physical exam, a billing requirement for new patients, be performed? And what about non-office-based services, such as ICU care, home care and inpatient follow-up visits? All could require, or at least benefit from, distancing. (2, 3) The passage of the CARES Act (4) and the COvId-19-related interim-final rule (5) further accelerated telemedicine’s role and sought to address the shortcomings of the earlier policy changes.

The list of covered services was expanded to include Ed visits, in14

San Antonio Medicine • May 2020

patient care, nursing home visits, critical care, domiciliary care, home visits, neonatal and pediatric critical care, neonatal continuing care, care planning for cognitive impairment, psychological and neuropsychological testing, PT and OT, radiation treatment management, social worker, clinical psychologist, and speech language pathology services. More important, telephonic services are now covered, but with the specific telephonic CPT codes (99441-3) instead of the corresponding E/M codes. RPM was expanded to now include new and established patients, as well as acute and chronic disease. Even a single disease may be monitored with the RPM codes. Frequency requirements around several services were reduced, such as those for subsequent inpatient visits, subsequent skilled nursing visits and critical care consultations. Important changes for substance abuse services, ESRd care and nursing home care were put into place. Requirements included in national and local coverage determinations for face-to-face care were lifted and beneficiary consent for telemedicine was made easier.

There were several important technology updates as well. For the most part, any two-way audiovisual platform may be used, including FaceTime, Skype or Zoom. Platforms with a public-facing component, such as Facebook live, Twitch or TikTok, however, are not allowed. The Office of Civil rights has pledged to use enforcement discretion on such matters as security risk analyses, business associate agreements (bAA) and HIPAA penalties. Applications such as Skype for business, Updox, vSee, Zoom for Healthcare, doxy.me, and Google G Suite Hangouts may be determined to comply with HIPAA and appropriate for a bAA. In general, physicians are encouraged, but not specifically required, to notify patients of potential security risks.

COvId-19 has dramatically accelerated telemedicine access to enable patient and provider safety, allow ease of access to care and better control of disease spread. The changes apply only for the du-

COVID-19 PANDEMIC

COVID-19:

Swimming Lessons for the Greater Good

By Venkat Srinivasan, MD and Ajeya Joshi, MD

ration of the national emergency declaration. during this time, safely providing the highest quality of care through telemedicine is an important opportunity. done with proper documentation and mindfulness of security and patient protection is important. doing so ensures that physicians will be wellpositioned to inform the next chapter in telemedicine’s evolution, once this crisis resolves.

Ezequiel "Zeke" Silva III, MD is a member of the South Texas Radiology Group and Co-Chair of the AMA Digital Medicine Payment Advisory Group. Dr. Silva is an active member of the Bexar County Medical Society.

References: 1. AMA digital Health Implementation Playbook. https://www.ama-assn.org/amaone/ama-digital-health-implementation-playbook. Accessed April 11, 2020.

2. Special Coding Advice during the COvId-19 public health emergency. https://www.amaassn.org/system/files/2020-04/covid-19-codingadvice.pdf. Accessed April 11, 2020.

3. President Trump Expands Telehealth benefits for Medicare beneficiaries during COvId-19 Outbreak. https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak. Accessed April 11, 2020 4. Coronavirus Aid, Relief, and Economic Security Act (CARES Act).

Available at: https://www.congress.gov/bill/116th-congress/senatebill/3548/text. Accessed April 11, 2020.

5. Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COvId-19 Public Health Emergency. Available at: https://www.cms.gov/files/document/covid-final-ifc.pdf. Accessed April 11, 2020.

These are incredible times, putting it mildly. Not only are hospitalists and intensivists fighting the epidemic in the trenches, but every one of us has been affected–socially, financially, morally and ethically. It doesn’t matter whether we are in academic medicine or private practice, a trainee looking to start his/her first job, or a seasoned practitioner. Unsettling questions are raised during this year of COvId-19: existential threats to practice viability from declining revenue but ongoing overhead, decimation of our investment portfolio and shattering of our nest eggs, mounting debt and imminent repayment deadlines, clinical inactivity and the guilt of having to let go of loyal staff, combined with new rules for social engagement, the loss of simple pleasures in our lives like vacations, eating out, recitals and road trips.

The core of each of us as a professional, a family member, a citizen and verily, a person is threatened. Add to these those great uncertainties – how long, how bad and most importantly, if we or our loved ones will make it through this crisis alive – loom over everything we do. Compounding this is the realization that for the very first time in a long time, we are not in control.

In reality, we never were truly in control. Were it not for this pandemic and its accompanying worries, we would still be worried about the imperfect surgical outcome, the stroke our patient sustained, the prospect of academic promotion, the rising overhead and decreasing reimbursements and soforth. Tack onto these concerns the global uncertainties, market fluctuations, election outcomes, societal attitudes and even family behavior (as anyone who has had a teenager at home would attest to).

It is crucial then, in this moment, to recognize and accept that stressors big and small will be an ongoing presence in our lives. We learned in medical school about encountering the proverbial saber-toothed tiger that represented a threat thousands of years ago and the way our body would react: The sympathetic system goes into overdrive and we mobilize energy and activate muscles through the HPA (hypothalamuspituitary-adrenal) system and adrenergic systems, parasympathetic systems like digestion and sex drive shut down, we get ready to fight or flee; all succinctly described by Walter Cannon - whatever promotes survival. continued on page 16

visit us at www.bcms.org

15

COVID-19 PANDEMIC

Swimming Lessons for the Greater Good continued from page 15

It’s still important to generate this stress response, although these days that tiger is figurative and not literal.

However, the inability to turn it off, a problem many of us have, is destructive and dangerous. Persistent cortisol and other biochemical stress mediators in our bodies lead to adverse mental and physical consequences; decreased immunity, impaired glucose metabolism and fatigue, among others.

The stress response, however, is an internal reaction over which we can gain control, and, by choosing and emphasizing constructive measures for self-care, we can regulate it effectively. These measures include resiliency building to counter stress and its harmful effects along with other aspects of healthy living. doing so will help us physicians as individuals to endure this crisis without feeling beaten or broken, and, by extension, will help us to be optimally helpful to our families, patients and the community. We can do it, and we and those around us will be better off as a result!

Salutogenesis (Aaron Antonovsky) is a concept unlike the traditional pathogenic medical model separating health and illness. The pathogenic model, to use an analogy, views the riverbank as ‘health’, and preventive care attempts to keep us on the riverbank. Illness is falling in the river, at which point health care team members jump in to save us and pull us back onto the riverbank (cardiac catheterization, gallbladder removal, additional cholesterol medicine prescribed). However, a more accurate notion is that life’s stressors amount to our constantly being in the river; the only issues are how deep is the river and how well can we swim. Salutogenesis calls for better coaching/training so we can swim more effectively.

Swimming more effectively amounts to building resiliency and emphasizing self-care principles. Augmenting resiliency is entirely achievable, no matter what our age, background, assumptions, prior habits or seniority in the medical profession. The need is for consistent and concerted efforts to gain an enhanced state of physical and mental health, equipping us to better cope and thrive in the face of life’s inevitable stressors. let us not forget the principles that we have known and have been taught by our grandparents and our teachers. A healthy diet, appropriate exercise and adequate sleep are indeed cornerstones of health. On top of these, science has also proven the effectiveness of various other modalities. Optimism, humor, companionship and the arts can all nudge us towards the healthier end of the spectrum.

16

San Antonio Medicine • May 2020

The relaxation response was discovered dr. Herbert benson, decades later but in the same lab at Harvard Medical School as Walter Cannon. The relaxation response is a process of profound physical and mental calming changes invoked by a deliberate, intentional practice. Whether it be meditation, yoga or another mindfulness practice, abundant literature in the field of Mind-body Medicine (MbM) documents healthy behavioral, biochemical, anatomic and epigenetic improvements in those learning and implementing the relaxation response. Irrespective of the method adopted being spiritual or secular, the relaxation response has been scientifically proven to be effective and reproducible. It can be learned in person from a preceptor or through online apps.

Let us swim, not sink. We can. We must.

If we need a coach, let us seek one.

Venkat Srinivasan, MD is board certified through the American Board of Internal Medicine, and a diplomate of the American Board of Lifestyle Medicine. He is a certified trainer of the SMART (Stress Management and Resiliency Training) Program, and has written a book on Mind-Body Medicine.

He delivers primary care using Lifestyle Medicine principles at Hill Country Lifestyle Medicine Center.

Ajeya Joshi, MD is board certified through the American Board of Orthopedic Surgery, and a diplomate of the American Board of Lifestyle Medicine.

He is implementing population health strategies with various organizations at Hill Country Lifestyle Medicine Center.

What the Media Does Not Tell You About

COVID-19 PANDEMIC

A Coronavirus Perspective

By Alan Preston, MHA, ScD Every day that I listen to the news, I understand why people are concerned about the COvId-19 virus. One would believe that this pandemic (i.e., an epidemic that crosses three or more countries) is more significant than the great Influenza of 1918 (i.e., The Spanish Flu). The pandemic of 1918 killed approximately 600,000 Americans; more than Americans who died in battle in WWI. The Spanish flu was the first of two pandemics caused by the H1N1 influenza virus; the second was the swine flu in 2009.

Why is the COvId-19 getting so much media attention? First, it is unusual for an epidemic to spread to a pandemic. However, the baseline for COvId-19 is zero. Therefore, it does not take a lot of cases to become an epidemic. Unlike the seasonal flu, there are often 20 to 40 million people in the USA that are infected each year. And since the seasonal flu (i.e., typically from October to April) occurs every year, that flu is considered an endemic. Meaning we are used to it every year and expect millions of people to become infected and thousands of people to die from it every year. Of course, you are not told this in the media; and shame on the media for not providing perspective.

One of the challenges in reporting statistics is that the media fails to report the statistics in context. It leads people with impressions that may not be accurate or over or underestimated when looking at raw data. The field of epidemiology and biostatistics is very unique. I don't expect the media to always comprehend it. When I taught epidemiology, even the doctors in my class were surprised about how we look at the transmission of disease and calculate and predict the burden of disease.

The media every day reports the number of newly infected cases of COvId-19 and the number of deaths. What the media is not telling you is that the number of "new" cases may not be confirmed cases and still under investigation as to whether it was travel-related or person-to-person contact. Furthermore, the number of flu deaths they calculate includes pneumonia. And often the pneumonia is bacterial related and secondary. Nevertheless, there is a correlation between the flu and pneumonia.

The calculation for pneumonia and influenza percentage is compared to a seasonal baseline of pneumonia and influenza deaths. It is then calculated using a periodic regression model and applied to data from the previous five years. An "epidemic threshold" is 1.645 standard deviations above the seasonal baseline of pneumonia and influenza deaths. This helps us understand whether the flu for any one year is normal or reached epidemic proportions. Each year, we consider the usual number of deaths related to the flu to be in a range of 12,000 to 61,000. So why are we in such a panic when the

death toll of the COvId-19 is over 6,500? Part of the answer is that the media has not put this virus in perspective.

Often, I hear that the COvId-19 is different because it is being transmitted at a faster rate than the regular flu. The facts and evidence suggest otherwise. If there are two Influenza strains (lima vs. Romeo as an example) and lima infects about 30,000,000 people in 6 months or five million per month on average, and the Romeo flu infects about 100,000 per month, which is the one with the higher transmission rate? The lima strain is a clear and convincing answer. And the lima strain is the regular flu, not COvId-19. Part of the lower rate of infection of COvId-19 may be due to the steps the US is taking to mitigate the spread. Nevertheless, the evidence regarding the spread and deaths of the regular flu is compelling when the statistics are placed up against COvId-19.

Another comment I hear a lot is the death rate is high with COvId-19. This is another fallacy. In the world of epidemiology, we do not use the incidence rate to calculate death rates. We use continued on page 18

visit us at www.bcms.org

17

COVID-19 PANDEMIC

What the Media Does Not Tell You continued from page 17

prevalence rates. And, because widespread testing did not begin until late March (1.6 million people have now been tested), we do not have enough evidence to predict the prevalence rate accurately. I suspect the prevalence rate is about ten times what the media is indicating. Therefore, the number of cases is likely closer to 2 to 3.0 million people infected. However, if I am correct, that would suggest that the death rate is closer to a range of .23% to .31% (7,000 ÷ 2,000,000 = .0035 X 100 = .35% and at 3mil = .23%). The death rate for regular flu is about .15%. To put this in perspective, the likelihood of living if one becomes infected with COvId-19 is 100 .23% = 99.77%. One would never get that impression while listening to the news. Granted, if you are older (>65) and have comorbidities of heart disease, type-2 diabetes, vascular problems, COPd, and compromised immune systems, the odds become higher of dying, as much as a seven-fold increase.

I am also told that the COvId-19 is scarier because we do not have a vaccination for this new strain. Indeed, we do not have a vaccine for COvId-19 yet; however, since we have a vaccine for the seasonal flu, explain to me why up to 9,000,000 to 45,000,000 people become infected every year? Again, perspective is essential when presenting statistics.

However, a diagnosis of influenza virus infection often is not confirmed with sensitive and specific laboratory diagnostics, particularly among older persons, and even when identified, is rarely recorded on death certificates. Many deaths associated with influenza infections occur from secondary infections such as bacterial pneumonia or complications of chronic conditions such as congestive heart failure and chronic obstructive pulmonary disease. Therefore, estimates using underlying respiratory and circulatory mortality data (which include pneumonia and influenza causes) can provide an upper bound for influenza-associated deaths.

The average annual rate of influenza-associated death is about 2.4 deaths per 100,000 (range: 0.4--5.1). deaths among persons aged ≥65 years accounted for 87.9% of the overall estimated average annual influenza-associated deaths with underlying pneumonia and influenza causes.

CdC estimates that influenza has resulted in between 9 million – 45 million illnesses, between 140,000 – 810,000 hospitalizations and between 12,000 – 61,000 deaths annually since 2010. deaths among persons aged ≥65 years accounted for 87.9% of the overall estimated average annual influenza-associated deaths with underlying pneumonia and influenza causes. Yet I do not recall shutting down the entire economy to save the lives of these infected people. And since over 87% of the deaths will occur in older people, shouldn't we mitigate the spread of disease to this cohort? let the rest of the nation get back to work in a meaningful and pragmatic way. Those exposed to customers every day, make sure they wear an N95 mask. Require employees to wash their hands frequently. Stress to employees the importance of not touching their face. Make employees wear gloves and keep their distance (6 feet or more) away from customers. There 18

San Antonio Medicine • May 2020

is no reason we cannot be sensible in managing this pandemic.

Furthermore, not every community in the USA has a population density of New York City. Every county is different, and even zip codes in each county are different. Indeed, we are smart enough to drill down to the level of a zipcode as to whether or not there should be a stay at home edict.

The coronavirus is not new. COvId-19 is a new strain of a coronavirus. I suspect it will behave very similarly to the other six strains we have become familiar with.

1. 229E (alpha coronavirus) 2. Nl63 (alpha coronavirus) 3. OC43 (beta coronavirus) 4. HKU1 (beta coronavirus) OTHER HUMAN CORONAvIRUSES 5. MERS-Cov (the beta coronavirus that causes Middle East Respiratory Syndrome, or MERS) 6. SARS-Cov (the beta coronavirus that causes a severe acute respiratory syndrome, or SARS) 7. SARS-Cov-2 (the novel coronavirus that causes coronavirus disease 2019, or COvId-19) Influenza "A" viruses are divided into subtypes based on two proteins on the surface of the virus: hemagglutinin (H) and neuraminidase (N). Current subtypes of influenza A viruses that routinely circulate in people include A(H1N1) and A(H3N2).

Seasonal flu vaccines do not protect against influenza C or d viruses. besides, flu vaccines will NOT protect against infection and illness caused by other viruses that also can cause influenza-like symptoms. There are many different viruses besides influenza that can result in influenza-like illness (IlI) that spread during flu season.

In the spring of 2009, a novel influenza A (H1N1) virus emerged.

It was detected first in the United States and spread quickly across the United States and the world. This new H1N1 virus contained a unique combination of influenza genes not previously identified in animals or people. This virus was designated as an influenza A (H1N1)pdm09 virus.

From April 12, 2009 to April 10, 2010, CdC estimated there were 60.8 million cases (range: 43.3-89.3 million), 274,304 hospitalizations (range: 195,086-402,719), and 12,469 deaths (range: 8,868-18,306) in the United States due to the (H1N1)pdm09 virus. Where was the panic as a result of this pandemic? However, (H1N1)pdm09 virus continues to circulate as a seasonal flu virus and cause illness, hospitalization and deaths worldwide every year.

I am also reminded of Italy. Italy is one of the countries that people tell me their evidence of how deadly COvId-19 is. Again, here is what the media fails to say to you as to WHY Italy is having problems.

Over the last thirty years, Italy has been using cheap labor to produce many high-end Italian textile products. Chinese investors purchased textile and leather-good factories in northern Italy. Nonstop

COVID-19 PANDEMIC flights were established between China and Rome to accommodate Italy's new foreign labor force.

Chinese made a slow and steady move into Italy.

As per a news report, there are more than 300,000 Chinese and over 90% of them work in the Italian garment industry. Has the news media shared this information as to why Italy may have more COvId-19 cases?

As of Tuesday, of March 17th, there were 31,506 infections, and 2,503 deaths reported from Italy alone, the highest after China and the US. The novel coronavirus outbreak has hit Italy on two major counts; first is the high number of casualties. Nearly 60% of the population is aged 40 and over, of which about 23% is over 65 years of age. This puts almost one-fourth of the population at grave risk. Thus, the high infection rate can be explained by the high number of Chinese workers going back and forth from Italy to China, and Italy has one of the highest numbers of elderly populations of the 190 countries in the world. Also, given there are approximately 60 million people in Italy, 69% live in urban areas and densely populated at 500 people per square mile.

Again, perspective is essential when drawing conclusions. does this suggest we should ignore the new coronavirus? Absolutely not. What it suggests is that we need to be vigilant as to how we protect ourselves first and foremost. Common sense should prevail with our citizens and our elected officials in managing the public health crisis. I am just not convinced COvId-19 is a crisis. At least not at the level where we should shut down the entire economy.

Consider the number of deaths related to automobile accidents every year. Over 37,000 people die in road accidents each year; 2.35 million are injured or disabled by their accidents. I can assure you that losing a loved one from a car death or COvId-19 is equally tragic. Over 650,000 people die each year from heart disease.

The point is we cannot shut down the economy as a way of preventing deaths. There are smarter ways to mitigate disease and accidents, and it is time to get smart about this. We must first put things in perspective.

Alan Preston, MHA, Sc.D. is an Epidemiologist and Biostatistician.

An Important Lesson on

QUARANTINE

By Maaz Ahmed Italy has been under lockdown for over a month now, people’s lives have been interrupted in unprecedented ways, and the Italian prime minister has said this is his country’s worst crisis since the Second World War. As promising data inevitably emerges showing the number of new cases per day beginning to decline, it will be tempting to ease quarantine measures despite the fact that doing so can lead to a recurrence of new cases. However, extending the quarantine prolongs the disruption of people’s lives and has a greater negative effect on the economy. Governments around the world have to balance these two priorities. continued on page 20

visit us at www.bcms.org

19

COVID-19 PANDEMIC

An Important Lesson on Quarantine continued from page 19

Number of new cases per day in Italy [d]

The Italian government has said that while it recorded its lowest number of coronavirus-related deaths in a week on Wednesday, April 1st, it would continue applying harsh measures to combat the disease until the virus is completely defeated. “Experts say we are on the right track and the drastic measures we have taken are starting to yield results,” the Italian health minister said. He also warned it would be “unforgivable to assume this was a definitive defeat [of COvId-19]” and that ultimately, for the Italians and the world, it will be “a long battle”. [a] Other countries had different responses. Chinese authorities, after apparently managing to curtail the spread in their country, decided to ease restrictions and allow people to emerge into the general spaces again. However, many experts are fearful that this could cause another outbreak which would begin to present itself in China around the end of April [b].

The way things unfold in China and around the region will be extremely pertinent to the responses of many European countries and several US states, some of which have closed their borders, schools, universities, and businesses. However, several examples of steps taken after a successful containment of COvId-19 cases already exist.

Hong Kong’s government implemented strict measures and responses that were lauded by 20

San Antonio Medicine • May 2020

many epidemiologists. However, the city loosened its quarantine too quickly. Hong Kong’s citizens resumed life, emerging from their dense homes. Streets were repopulated as people headed back to work, gyms, and little noodle and dim sum shops lining street sides. They welcomed back tourists and students who were stranded overseas. [c] While they had their guard down, the coronavirus attacked again and Hong Kong’s cases of COvId-19 resurged.

On Saturday, March 21st, 48 new infections were recorded in Hong Kong. by Wednesday, March 25th, as travelers returned back to their city, more than 400 cases were reported. [d] Responding as quickly and decisively as before, the government ordered everyone back into their homes. The city that had just reopened was closed again. Public libraries, sports facilities, businesses, and museums were once again rendered lifeless by the smallest of enemies. Hong Kong authorities even stopped new visitors from coming into the city for two weeks. [c] Hong Kong wasn’t the only victim of a second wave of coronavirus cases. Singapore made the same expensive error to loosen its mitigation measures preemptively. Two record-breaking numbers of new cases occurred on April 5th and 7th. This was after several weeks of measures that successfully controlled the outbreak within Singapore’s borders. The same story also occurred in Taiwan, where early action controlled coronavirus spread, but premature withdrawal of the measures led to a second wave of infections. [e] [f] Modeling done of the coronavirus outbreak in the UK showed that measures such as social distancing, school closures, and restrictions of the use of public spaces, may need to be sustained for significant proportions of the next two years until some sort of vaccine may be available. This would ensure that hospitals can cope with the surge of COvId-19 patients.[g] There is almost universal agreement among US public health experts regarding the efficacy of the current quarantine in preventing American deaths due to coronavirus. [e] However, President Trump and several members of his administration are keen on reopening the economy.

The President offered an optimistic reading of U.S. efforts to combat the coronavirus pandemic on Friday. This was despite his top health advisers cautioning that it is not yet time to abandon the stringent measures undertaken to mitigate COvId-19 incidence.

"In the midst of grief and pain, we are seeing clear signs that our

COVID-19 PANDEMIC aggressive strategy is saving countless lives," the President said in a briefing of the coronavirus task force. Referring to government projections from last week that the pandemic could claim anywhere from 100,000 to 240,000 American lives, the president said "I think we will be substantially under that number." [h] While the president’s comments may be reasNumber of new cases per day in the United States [d] suring, we could very well end up approachhttps://www.nature.com/articles/d41586-020-00938-0. Pubing those numbers if the mitigation efforts are ended early. Surgeon lished March 30, 2020. Accessed April 12, 2020.

General Jerome Adams said, "There are places around the country c: Sataline S, Sataline S, Sataline S, et al. Hong Kong's lesson: dethat have seen consistently low levels. And as we ramp up testing feating Covid-19 demands persistence. STAT. https://www.statand can feel more confident that these places can actually do surnews.com/2020/03/26/coronavirus-hong-kong-resurgenece-h veillance and can do public health follow-up, some places will be olds-lesson-defeating-it-demands-persistence/. Published March able to think about opening on May 1. Most of the country will not, 26, 2020. Accessed April 12, 2020. to be honest with you, but some will. [‌] And that's how we'll red: COvId-19 Map. Johns Hopkins Coronavirus Resource Center. open the country: place by place, bit by bit, based on the data." [h] https://coronavirus.jhu.edu/map.html. Published April 11, May 1st seems too early to open up the country. We have seen 2020. Accessed April 12, 2020. this story before and the early easing of quarantine measures in Sine: Enten H. Trump keeps wanting to reopen the economy. voters gapore, Hong Kong, and Taiwan should be a valuable lesson to us. disagree.

CNN. When the time comes (it definitely has not yet) and the number of https://www.cnn.com/2020/04/11/politics/trump-economynew cases per day in the US begins to significantly fall, we should coronavirus-analysis/index.html. Published April 11, 2020. Acinstead respond similarly to the Italians and apply sustained efforts cessed April 12, 2020. until we have completely defeated this plague. Reopening the econf: Cachero P. Singapore's second wave of cases is a glimpse at what omy too early would very likely lead to a second wave of COvIdthe US may be in for. business Insider. https://www.businessin19 cases and land us back to square one. The economic cost would sider.com/singapores-second-wave-shows-us-in-for-looseningthen be far greater and, more importantly, so would the human one restrictions-2020-4. Published April 8, 2020. Accessed April 12, as we again lose countless lives to this disease.

2020. g: Ferguson NM, laydon d, Nedjati-Gilani G, et al. Impact of Maaz Ahmed is an MD Candidate, Class of 2023, UT Health San Annon-pharmaceutical interventions (NPIs) to reduce COvId- 19 tonio, Long School of Medicine. mortality and healthcare demand. Imperial College COvId-19 Response Team. March 2020.

References: h: FORGEY QUINT. Health officials bearish on Trump's drive to a: Henley J. Italy records lowest coronavirus death toll for a week. re-open economy by May. POlITICO. https:// The Guardian. https://www.theguardian.com/world/ www.politico.com/news/2020/04/10/surgeon-general-coun2020/apr/01/italy-extends-lockdown-amid-signs-coronavirustry-not-open-may-1-178790. Published April 10, 2020. Accessed infection-rate-is-easing. Published April 1, 2020. Accessed April April 12, 2020.

12, 2020. b: Cyranoski d. 'We need to be alert': Scientists fear second coronavirus wave as China's lockdowns ease. Nature News. visit us at www.bcms.org

21

COVID-19 PANDEMIC

STRATEGIC NATIONAL STOCKPILE

By Diane Simpson, MD

Background “The US Strategic National Stockpile (SNS) was established in 1999 to ensure that the US could respond quickly to chemical and biological terrorist attacks.” “Containing broad spectrum antibiotics, Iv fluids, airway maintenance equipment, bandages, vaccines, antitoxins, the SNS role is to supplement and resupply state and local public health agencies during emergencies that could affect large numbers of civilians.” “In the 20 years of its existence the SNS has been deployed during 12 of those years in response to 19 different events, including the attack on the World Trade Center; anthrax contaminated letters, H1N1 influenza, botulism outbreak, Ebola and Zika cases; flooding in N. dakota and in response to 11 hurricanes.”1 “The SNS consists of several large warehouses in undisclosed locations around the US and its territories.”3 “US Marshals provide the SNS with law enforcement protective services.” “The warehouses are located such that a ‘push pack’ of drugs and supplies capable of addressing a variety of emergency medical needs can be shipped to anywhere in the US or its territories within 12 hours of an event. As more information about an event is obtained, more specific supplies can be delivered within 24-36 hours.”4 “Antidotes to chemical agents which require almost immediate administration are provided through the SNS’s CHEMPACK program. CHEMPACKs are kept in 1340 different locations and can be delivered in no more than 2 hours and sometimes in minutes.”5 “The SNS can also deploy non-emergency, small medical centers to care for persons displaced during a national disaster who have special medical needs.”3 Management of the SNS originally resided with the Centers for disease Control and Prevention in Atlanta, GA. In late 2018, the program transferred to the department of Health and Human Services (dHHS) Office of the Assistant Secretary or Preparedness and Response (ASPR). “The current budget of approximately 600 million dollars funds planning, business management, operational logistics, purchasing, training, subject matter scientific expertise, and coordination and relationships with state and local public health.”6 “In an emergency, requests for assistance come from the state’s governor. dHHS and other federal agencies evaluate the situation and the request and then determine what assets are most appropriate for release.”7 ”The Association of State and Territorial Health Officers (ASTHO) notes on its website that the SNS should not be the first response, but rather is to supplement state and local supplies.”4 22

San Antonio Medicine • May 2020

The SNS role in the COVID-19 Response Most previous SNS responses have been to localized or regional events. Only the H1N1 influenza pandemic in 2009-2010 encompassed the entire country. In 2008, the SNS only had about 4,000 ventilators on hand. With an influx of funding in 2009 the inventory grew to 8,000 in 2010. On March 24 of this year the number was increased again to 16,600, the amount suggested by the American Association for Respiratory Care for use in a severe influenza pandemic. by April 10 of this year, almost 8,000 of these ventilators had been distributed.

Personal Protective Equipment (PPE) also is kept with the SNS. “As of April 7, the SNS reported that 10,628 tons of cargo had been shipped, 310 flights and 2008 trucks had transported supplies, more than 175 staffers were assisting in the stockpile’s operation center, and more than 50 private industry partners had been engaged to assist with delivery and the medical supply chain” (Office of the Assistant Secretary for Preparedness and Response, Stockpile Responses History, 2020).1 “With this activity, all but 10% of the PPE supplies, the amount kept in reserve for federal facilities, had been distributed including over 26.5 million surgical masks, 22.6 million gloves, and 11.7 million N95 respirators.”8 “Working through the 22 Regional Advisory Councils (RACs), the SNS has sent Texas 1.15 million surgical masks, 219,000 face shields, 179,000 gowns, 637,000 gloves and 484,000 N95 respirators.”9 In bexar County, about 80% of these supplies have been distributed to Texas hospitals, with 20% going to local and state government entities.

“Several factors contribute to the rapid depletion of the stockpile.

Efforts by hospitals to become more efficient by utilizing software to streamline inventories and relying on quick buying (“just-intime”) of needed products have reduced storage of items within a hospital system.”10 “Second, the amount of PPE that China exported to the US dropped in early 2020 as China faced its own COvId-19 epidemic. China had supplied 48 percent of total US imports of PPE in 2018, including 45 percent of protective garments. In early 2020, the amount of PPE exported by China to the US decreased by 19%.”11 Finally, delayed testing has required patients suspected of COvId-19 to remain in isolation longer than may have been necessary while they waited results, resulting in more PPE usage.

COVID-19 PANDEMIC What can Texas do to better protect themselves in the future? “A bill that included the establishment of a state medical stockpile was proposed in the 84th Texas legislative session but failed.”12 “One published model concluded that a supply of ventilators in each of the eight state health regions would be the most optimal means to achieve self-sufficiency in a pandemic” (Huang et al. 2017).13 “However, stockpiles in-and-of-themselves are not enough. Any cache of medical equipment requires attention, maintenance and rotation to assure quality. In addition to maintenance, ventilators require sufficient trained staff to operate them during a pandemic.”14 Once the worst is past, we can collectively evaluate how well our supply chain functioned in this pandemic. determining the best way forward needs careful review of the problems and successes of this pandemic, study and discussion of appropriate solutions and, most likely, significant funding.

Diane Simpson, MD, PhD, MPH.

MATCHING

Amidst a Pandemic

By Darren Donahue, MS4 at UT Long School of Medicine On the drizzly morning of March 20th, with my wife and my daughter, I found out where we’ll be moving so I can begin my residency in anesthesia. Typically, tens of thousands of medical students assemble all-at-once to open envelopes containing their match results informing them where they will be completing their training.

And for many, this day is the most memorable occasion of medical school. For these students, Match day events are a chance to be surrounded by classmates, family, and friends when learning where the coming years will take them; for some, an occasion more momentous and happier than graduation.

Match day 2020 was held virtually this year (the first time ever) due to social distancing guidelines in response to the COvId-19 pandemic. Even ten days prior, many assumed that the originally planned events could go on. but in the week preceding March 20th, the situation deteriorated rapidly with various authorities recommending against gatherings in excess of 500… a number which quickly shrunk to 250, then 50, then 10. While the exact limit varied by city, one thing was clear: Match day 2020 would look different than all others before it. And so, the long School of Medicine at UT Health San Antonio, held a virtual match day, live stream for all to participate from their disparate locations.

At 11:00 AM, all matched senior medical students received an email rather than a sealed envelope. After that, everyone was able to

References 1 Stockpiles Responses History. Office of the Assistant Secretary for Preparedness and Response. 2020.

2 Chemical Hazards Emergency Medical Management. 2020.

3 Stockpile Products. Office of the Assistant Secretary for Preparedness and Response. 2019.

4 Emergency Use Authorization Toolkit: Strategic National Stockpile Factsheet. Association of State and Territorial Health Officers. 2011.

5 Public Health Matters blog. Centers for disease Control and Prevention. 2015.

6 ASPT FY 2020 budget-In-brief. Office of the Assistant Secretary for Preparedness and Response. 2020.

7 Chemical Hazards Emergency Medical Management. 2020.

8 Pulver and Mansfeld. 2020.

9 Platoff. 2020.

10 Arndt. 2018.

11 brown. 2020.

12 Texas Hospital Association. 2015.

13 Huang et al. 2017.

14 John Hopkins Center for Health Security. 2020. choose how they wanted to learn their results. Some students had a friend print the email and place it in envelope, some logged in from their phones, and one even had to pop a balloon to find out where they matched. While initially everyone celebrated separately, students quickly began emailing pictures and their results to the virtual match stream hosted by our deans. And in this way, it became a community event, with the deans cheering as they pinned our results to a United States map, joined by our classmates’ comments on the stream: virtual shouts and confetti explosions taking the place of the real deal. due to the efforts of the long SOM administration, our virtual match day went as well as anyone could hope, but I know I speak for most when I say that this is not how we originally wanted to celebrate. It may go without saying that the makeshift stage of my front porch is not what I expected. To a senior medical student, Match day is where all their prior efforts finally pay off and it’s reasonable to hope for an occasion that matches the significance. In the days leading up to it, I felt like something had been taken away from us; that now our whole medical school experience was going to end not with a bang but with a whimper.

Of course, Match day isn’t really the end. It’s the beginning of our formal training and as such, the beginning of our careers as clinicians. The Class of 2020 will be moving all across the country to begin our residencies this summer. While COvId-19 can mar a celebration, it will not prevent us from starting our intern year. We may have missed out on a bit of celebration but we are all still as excited as ever to move on to the next stage in our careers. Congratulations to the Class of 2020!

Darren Donahue, is an MS4 at UT Long School of Medicine, and a member of the Bexar County Medical Society. visit us at www.bcms.org

23

COVID-19 PANDEMIC

Personal Protection Equipment - PPE Donors and Recipients

Thank You!

By Medical Students Aaron Verbeelen, Yvette Lopez, Gwendolyn Quintana, Kayla Pineda From adversity comes innovation and compassion. Seeing a dire need for personal protective equipment (PPE) in healthcare facilities, local medical students Gwendolyn Quintana, Kayla Pineda, Yvette lopez, and Aaron verbeelen assembled a plan to action. What started as a single donation from a local construction company, Moore Erection lP, quickly grew into an outpouring of community support for frontline healthcare personnel in the form of PPE. As the call to action on the local San Antonio community expanded, healthcare students across the city came together to distribute community donations of PPE. The bexar County Medical Society is honored to serve as a collection, storage and distribution point for these PPE supplies, to collaborate on this project and to watch the individual donations transform into a life-saving strategic operation for distributing PPE to our members. Online platforms were established and, thanks to meticulous tracking of inventory and an organized effort, these needs are effectively being met.

Special consideration goes out to donors such as the vietnamese community of San Antonio, the Church of Jesus Christ of latter-day Saints, Masks for docs, and the Garrison brothers and Ranger Creek distilleries for their continuous supply of sanitizing products. #bexarPPE

Oncology SA – Using PPE

Amanda Taylor, DO – Using PPE

Gwendolyn Quintana - Med Student Volunteer

CommuniCare

Joeming Dunn, MD – Using PPE

24

San Antonio Medicine • May 2020

North SA Family Medicine – Using PPE

COVID-19 PANDEMIC

Dr. Jesse Moss Using PPE

Donated PPE

Dr. Harnisch and Dr. Thomas – N95 Masked

Yvette Lopez - Med Student Volunteer

Gwendolyn Quintana receiving from San Tran and Do Tran – Vietnamese Community Contribution

Donated Hand Sanitizer

Mika Cole, MD – Using PPE

Kayla Pineda – Med Student Volunteer

BCMS Staff and Med Student Volunteers

Gwendolyn Quintana

visit us at www.bcms.org

25

COVID-19 PANDEMIC

Personal Protective Equipment (PPE) Conservation Strategies (See CDC: Strategies to Optimize the Supply of PPE and Equipment 04/03/2020)

In unique circumstances of overwhelming patient surge, depleting PPE supply, and crisis, CDC recommends the following strategies to conserve PPE: • Cancel all elective and nonurgent procedures and appointments for which PPE is typically used by health care personnel.

• Use PPE beyond the manufacturer-designated shelf life during patient care activities.

• Implement limited reuse of PPE. limited reuse of face masks is the practice of using the same face mask by one health care worker for multiple encounters with different patients but removing it after each encounter. As it is unknown what the potential contribution of contact transmission is for SARS-Cov-2, care should be taken to ensure that health care personnel do not touch outer surfaces of the mask during care, and that they remove and replace masks in a careful and deliberate manner.

• PPE should be removed and discarded if soiled, damaged, or hinders breathing.

• Not all PPE can be reused. Face masks that fasten to the user via ties may not be able to be undone without tearing and should be considered only for extended use, rather than reuse. Face masks with elastic ear hooks may be more suitable for reuse.

26

San Antonio Medicine • May 2020

• Health care personnel should leave patient care area if they need to remove a face mask. Face masks should be folded carefully so that the outer surface is held inward and against itself to reduce contact with the outer surface during storage. The folded mask can be stored between uses in a clean, sealable paper bag or breathable container.

• Prioritize face masks for selected activities such as: – Providing essential surgeries and procedures, – during care activities where splashes and sprays are anticipated, – during activities where prolonged face-to-face or close contact with a potentially infectious patient is unavoidable, and – Performing aerosol-generating procedures, if respirators are no longer available.

For further information about PPE and most issues relating to COVID-19, go to the CDC website at:

www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/

COVID-19 LEGAL ISSUES

CAN I AVOID CONTRACT OBLIGATIONS BECAUSE OF THE CORONA VIRUS?

By George F. “Rick” Evans, Jr. If the virus has impacted your income, honoring contractual obligations like rent, equipment leases, car payments, insurance bills, etc. can be problematic. Even if your income hasn’t taken a hit, it may be impossible to fulfill a contractual obligation to provide or partake of a service you previously agreed to by contract. What does the law do about these things?

Here, everything is very case specific. There is no one, over-arching rule akin to “Thou shalt not steal.” Every person’s circumstance is legally different but here are some principles which may help you figure out your particular situation.

FORCE MAJEURE This relatively unknown contract clause is something the virus has shone a light upon recently. It’s pronounced force mah-jer. In French, it means superior force. lawyers appropriated the concept for use in contracts as a legal reason to excuse a party’s performance under the contract because of a “superior force.” A superior force was typically something well beyond the party’s control and unforeseeable. Common examples were things considered to be an “Act of God”, like a hurricane, earthquake, volcanic eruption or flood. lawyers were quick to expand the concept to include other “manmade” events like war, terrorism, fire, labor strikes, electricity or other basic infrastructure failures, etc.

The purpose of the clause was to excuse one or both parties from the contract if an event beyond their control made performance impossible. It has to be impossible; not impractical. So, a contract to rent an outdoor venue for a wedding is still enforceable even if it rains but wouldn’t be enforceable if a flood engulfed it.

Not all contracts have a force majeure provision and not all contracts define all the events that may qualify as a force majeure. In many contracts the clause is written to benefit just one of the parties and not the other. That’s why you have to look at your particular contract to determine if you have this “escape clause” in it, its terms and who it benefits.

Many force majeure clauses don’t include a pandemic or plague.

It’s such an alien concept to us today that many lawyers didn’t have it on their radar screen when drafting the agreement. but there may be a catch-all sentence to the effect that it includes “any and all other causes beyond the control of the parties.” This pandemic would likely fall in that category.

Just because your contract may have a force majeure clause that covers the pandemic doesn’t necessarily mean you can walk away from the contract. That’s because the virus doesn’t necessarily stop you from honoring your agreement, depending on the purpose of 28

San Antonio Medicine • May 2020

the agreement. For example, if you have a contract to pay rent, the virus doesn’t stop you from paying it. by contrast, the virus has cancelled all NbA basketball games, so if you had an agreement to buy tickets to a game, you’d be excused from that obligation now.

The point is that you have to be able to show specifically how the virus has totally stopped you from honoring a contract. You can pay your rent (it may be hard or extremely difficult because you have no income, though it’s still possible) but you can’t go to a basketball game. You can have your outdoor wedding in pouring rain, but you can’t have it if the venue was destroyed by a hurricane. Got it?

So, the bottom line requires that you perform this analysis. 1. does your contract have a force majeure clause? 2. does it apply to you rather than just the other party? 3. Is it broad enough to encompass a pandemic? 4. Is the subject matter of the contract such that the pandemic literally makes it impossible for you to comply with your obligations under the contract. If the answer is “Yes” to all four questions, there’s a very good chance you can be excused from your contractual obligation. Pay attention to #4. The test is impossibility; not whether it’s extremely difficult to perform or would make no sense to perform.

DOCTRINE OF FRUSTRATION What if your analysis shows that force majeure doesn’t apply?

You’re not necessarily out of luck. There are legal doctrines recognized by most states that excuse contractual requirements if a party can show that the circumstances are such that a party can’t perform his obligation or that to do so basically defeats the very purpose of the contract. You have to show that performance is impractical, impossible or makes no sense given an unforeseeable change in circumstances beyond the party’s control and not his fault and which he can’t overcome.

For example, suppose you’re a roofer who agreed to put a new roof on a house but a fire burned the house down. There’s no longer a house to put new shingles on so you’re excused from the contract. Or, turning to the virus, suppose you agreed to do something that required you to be in groups larger than 10 people or fly to China, you simply couldn’t do it given current government regulations. Therefore, even without a force majeure clause in your contract, the law might still excuse you from performing.

There are three legal excuses typically recognized by the Courts to trigger this doctrine (which is also known as the doctrine of Impossibility of Performance). They are (1) death or severe disability of the person, or (2) governmental rule, regulation, law or decree that prevents performance such as the quarantine and shelter in

COVID-19 LEGAL ISSUES place rules we’re now seeing, or (3) an event occurred, the non-occurrence of which was a fundamental premise upon which the agreement was made.

CONCLUSION The virus may make your contractual obligations extremely inconvenient or difficult to fulfill. It may create a very hard economic hardship. It may not make much sense anymore to proceed with the agreement. It may be very unprofitable to proceed. These typically won’t qualify as legal excuses. The virus doesn’t serve as some super excuse that lets people walk away from each and every one of their contract obligations. You have to show that the contract itself had a clause that includes a pandemic as a reason to excuse

your performance. Failing that, you have to show how the virus has resulted in a situation where you literally or practically can no longer comply with the contract even if you desperately wanted to.

The law has a bias towards enforcing our agreements with each other. The law isn’t inflexible and allows for non-performance under compelling, specific circumstances but the exceptions are narrow and must be clearly applicable to your situation. Applying the principles discussed in this article should give you a good sense as to whether you’re excused from a contract or not.

George F. “Rick” Evans, Jr. of the law firm Evans, Rowe & Holbrook, is the General Counsel for the Bexar County Medical Society.

When is a Ventilator or ECMO Dependent Patient Dead?

By George F. “Rick” Evans, Jr.

If COvId-19 results in one of your patients becoming ventilator or ECMO dependent, there may come a time when it’s not entirely clear if the patient is dead and the ventilator or ECMO withdrawn without being accused of murder or assisted suicide. You may also need to know the legal definition of death in these circumstances in order to advise family members and medical staff.

Texas law states a patient is dead when there is irreversible cessation of spontaneous respiratory and circulatory functions. but, if artificial support (i.e. a ventilator or ECMO) precludes determination of this, then the patient is dead when there is irreversible cessation of all spontaneous brain function. death must be pronounced before artificial support is withdrawn.

The law does not define “irreversibility”, but most lawyers would agree it’s the impossibility of recovery regardless of any medical intervention. The law also does not specify how a provider determines irreversible cessation of all spontaneous brain function.

Hospitals should have in place a written protocol for that purpose with which you should become familiar. Typically, such protocols require the performance of certain tests which could include serial flat line EEGs, apnea tests, failure to respond to specific painful stimuli, failure to demonstrate certain reflexes (i.e. pupillary/corneal responses or gag reflex). Some protocols require one or two neurologists to confirm the determination at different intervals in time.

The point is that you need to determine the specific protocol in place at the patient’s health care facility and make sure it’s followed. lastly, the pronouncement of death obviously can be by a physician but also by an RN, PA, or APRN if the patient’s health care facility has a written policy allowing that.

George F. “Rick” Evans, Jr. is an attorney at Evans, Rowe & Holbrook and is General Counsel for the Bexar County Medical Society. visit us at www.bcms.org

29

COVID-19 PANDEMIC

Possible Treatments and Vaccines for COVID-19

By Kenny Chang, DO, UIW Family Medicine Resident There are currently three main approaches to treating COvId19 patients: a vaccine, monoclonal antibodies, and antiviral drugs.

In this editorial, I will focus on the current status of development of antiviral drugs, immunotherapy, and vaccines.

Anti-viral drugs These drugs prevent the development of the virus inside the human body. They target the viruses at different stages of the life cycle to stop production. In the end, the number of virus particles in the body are reduced and stopped from spreading.

One antiviral-drug candidate is a combination of the HIv protease inhibitor lopinavir and ritonavir. lopinavir has modest antiviral activity against SARS-COv2, and is used together with ritonavir, which increases its bioavailability. However, Cao and colleagues conducted a randomized clinical trial for the drug in Wuhan China, and unfortunately, the results were not satisfactory. The key takeaway was that lopinavir-ritonavir is not highly effective in patients with COvId-19. However, the study did show us that rapid, clinical randomized trials are possible in a pandemic. Still, this drug combination has continued to be used in patients as no proven effective antiviral treatment is yet available. For example, in a case study in Singapore, five individuals requiring supplemental oxygen were treated with lopinavir-ritonavir. In three of the patients, fever resolved and supplemental oxygen was reduced within three days, but two of the patients deteriorated with progressive respiratory failure.

The World Health Organization (WHO) is launching a multi-arm, multinational clinical trial called the SOlIdARITY trial, for potential therapies. Four drugs already licensed and used for other illnesses will be tested- resdesivir, lopinavir-ritonavir, lopinavir-ritonavir plus interferon beta, and the antimalarial drug chloroquine.

Immunotherapy Immunotherapy works by having monoclonal antibodies flag the 30

San Antonio Medicine • May 2020

presence of the virus in the body, prompting the immune system to kill the cell.

Convalescent plasma was recommended as empirical treatment during outbreaks of Ebola virus in 2014, and is suggested to be effective in other viral infections such as H5N1 and avian influenza.

Therefore, it has been proposed as a treatment option for COvId19. “In a preliminary uncontrolled case series of five critically ill patients with COvId-19 and ARdS, the use of convalescent plasma containing neutralizing antibodies was followed by improvement in their clinical status.� Further evaluation is necessary in a randomized clinical trial.

Aside from convalescent plasma, biotech companies and research groups have been studying possible neutralizing antibodies against SARS-COv-2. First, Regeneron isolated hundreds of neutralizing antibodies against SARS-COv-2 from a humanized mouse model and from humans recovered from COvId-19. The top two antibodies would be administered to at-risk people before exposure, or as treatment for infected individuals. Regeneron hopes to start clinical trials in the early summer.

Second, a human monoclonal antibody that neutralizes the SARCOv 2 has been discovered. It will target the spike glycoprotein on the viral surface. Wang et al published an article on biorxiv and their article is under review for Nature journal. The team at Utrecht University is looking for a pharmaceutical company to produce the candidate on a large scale.

Third, Chinese scientists isolated several antibodies that are effective at preventing viral entry. Zhang linqi at Tisnghua University in beijing said his team discovered a drug made with antibodies using plasma could be more effective than current approaches described above. At a hospital in Shenzhen, antibodies were taken from recovered COvId-19 patients, and of 206 antibodies, 20 were tested and four were found to block viral entry. The group is working with brii biosciences, a sino-U.S. biotech company. Scientist hope to test this in humans in 6 months.

COVID-19 PANDEMIC Vaccine Development vaccines can protect most people within a population before they contract a virus. It works like this - both live and inactivated vaccines function by inserting a small amount of a non-infectious strain of virus into the patient to start the body’s immune response towards it. In the future, the patient would have antibodies in the blood to kill the virus before symptoms present.

The Coalition for Epidemic Preparedness Innovations (CEPI) is preparing up to eight vaccine candidates for clinical trials. On January 23rd, CEPI funded Innovio, Moderna Inc, and the University of Queensland to develop COvId-19 vaccine candidates. Countries such as Norway, UK, and Germany have invested millions of dollars in CEPI to advance vaccine development. On March 17, CEPI partnered with Moderna and the National Institute of Allergy and Infectious diseases (NIAId) for the start of the first in-human trial of COvId-19 candidate vaccine. If these vaccines are safe and effective in animal models, they could be ready for clinical trials as early as June.

Kenny Chang, DO, is a UIW Family Medicine Resident.

Resources 1 Insight. The Sunday Times. February 16, 2020. Audrey Tan. The Straits Times.

2 https://www-nejm-org.uiwtx.idm.oclc.org/doi/full/ 10.1056/NEJMe2005477 3 https://jamanetwork-com.uiwtx.idm.oclc.org/journals/ jama/fullarticle/2762688?resultClick=24 4 https://www.statnews.com/2020/03/18/who-to-launch-multinational-trial-to-jumpstart-search-for-coronavirus-drugs/ 5 https://jamanetwork-com.uiwtx.idm.oclc.org/journals/ jama/fullarticle/2763983?resultClick=1 6 https://www.fiercebiotech.com/research/fast-moving-regeneron-eyes-summer-clinical-trial-for-covid-19-antibody-cocktailtherapy 7 https://www.biorxiv.org/content/10.1101/2020.03.11.987958v1 8 https://www.erasmusmagazine.nl/en/2020/03/14/unique-discovery-in-erasmus-mc-antibody-against-corona/ 9 https://www.reuters.com/article/us-health-coronavirus-chinascientists/chinese-scientists-seeking-potential-covid-19-treatment-find-effective-antibodies-idUSKbN21J4QW 10 https://cepi.net/covid-19/ 11 h t t p s : / / w w w - n e j m - o r g. u i w t x . i d m . o c l c . o r g / d o i / full/10.1056/NEJMp2003762

visit us at www.bcms.org

31

COVID-19 PANDEMIC

Strategies Ophthalmology Clinics are Using for Patient Safety for COVID-19

By Sejal Lahoti, Huy Nguyen, MD, and Richard Jones, MD

The severe acute respiratory syndrome coronavirus 2 (SARSCov-2), the virus that causes COvId-19, has quickly become a pandemic and public health emergency. The high transmissibility is coupled with higher mortality in the elderly and those with weakened immunity.1 As of this writing, the number of US cases has escalated to be greater than 400,000 and in bexar County greater than 600 cases.2,3 Currently, transmission of COvId-19 is thought to primarily be through respiratory droplets, while some studies have found it can be in conjunctival tears as well.4 The method of transmission is particularly concerning to eye care specialists who routinely conduct slit-lamp examinations with face-to-face distance of less than twelve inches.

Governor Abbott issued a statement on March 22nd that ordered physicians to indefinitely postpone all surgeries and procedures that are not immediately necessary, in order to preserve needed supplies.

In addition, the American Academy of Ophthalmology (AAO) has released guidelines to determine the urgency of different ophthalmic surgeries.5,6 Since many ophthalmic surgeries are considered elective, these guidelines have drastically decreased the surgical volume in the community. visits for chronic or non-urgent pathologies are also being delayed to decrease patient and staff exposure. The unprecedented nature of this pandemic, without a predictable timeline, has left practices to re-schedule and triage patients mostly at their own discretion.

The Centers for disease Control (CdC) and AAO have frequently updated recommendations to help ophthalmologists make changes during this time for emergent cases that need to be seen.7 They recommended that all patients be screened prior to their appointment. Recommended triage questions include: recent fever, respiratory symptoms, travel to high risk areas or contact with a sick person in the past two weeks.7 To minimize exposure by keeping patients out of the waiting area, they encourage patients to enter the building precisely at their appointment time and then return to their car while waiting for dilation. Finally, slit lamp barriers should be used, and rooms should be sterilized after each use.7,8 To protect the safety of the public and health care workers, many changes have occurred in the method which San Antonio and Austin ophthalmologists operate their practice. To better understand these changes and provide shared learnings around the community, we interviewed four ophthalmologists in our local community: drs. Armitage Harper, James lehmann, Charles McCash, and Anhtuan Nguyen.

Triaging Patients Most practices are triaging patients according to the CdC and 32

San Antonio Medicine • May 2020

AAO guidelines.7 If a patient has had recent surgery or calls about an urgent problem, all practices report screening the patient beforehand. When a patient comes to the clinic, all providers related that the patients were asked to stay in the car until their designated time.

For pediatric patients, practices have asked that only one parent accompany the child to the visit. While not all practices have a definite time period of rescheduling, the earliest a practice hopes to restart non-emergent surgeries is in May, which is subject to change based on guidelines.

Policy for Personal Protective Equipment While protecting patients and staff has been a priority for providers, there are still challenges with the limited access to masks worldwide. All of the interviewed physicians stated that they and their staff are now wearing masks when interacting with patients, with some practices providing paper or cloth masks. The CdC has recommended the use of cloth mask coverings among other precautions while in public settings as of April 2020.9 While the slit lamp is vital to the practice of most ophthalmologists, many specialists have tried to reduce exposure time and risks by implementing strategies including triaging, telemedicine, and slit lamp barriers.

Changes in Practice Flow All ophthalmology practices are operating at a much lower capacity, from as low as just a few patients a week to as high as 40% of pre-pandemic volume. Practices with multiple providers have reduced their clinic coverage to one physician and minimal support staff in the office at one time. Full-time employees have been maintained with financial reserves, but many part-time employees have had their contracts discontinued. Some of the ophthalmologists noted that federal policies, such as Coronavirus Aid, Relief, and Economic Security (CARES) Act, with the Payroll Protection Program and Small business debt Relief Program, will be helpful for private practices nationwide, but less likely for large multispecialty academic groups such as UT Health.10 Use of Telemedicine Telemedicine has found fertile ground in segments of ophthalmology such as teleretinal imaging in primary care practices as part of screening for diabetic retinopathy. However, most ophthalmic pathologies require specialty-specific equipment currently not accessible at home. The slit lamp is an ophthalmologist’s most common diagnostic tool, and it does not have an inexpensive and easily accessible alternative for patients to use unassisted. For other parts of the encounter, physicians can conduct telemedicine calls through

COVID-19 PANDEMIC their electronic medical records, FaceTime, or with services such as doxy.me. While requirements have become more lenient during this time, the major long-term challenges to telemedicine are finding a HIPAA compliant service and sustainable reimbursements from Medicare, Medicaid, and private insurance groups.11 Thus, most of the ophthalmologists who are using telemedicine services are using it as a triaging tool or as a courtesy to their patients. When asked about the tools that would be most helpful, retina specialists spoke about the need for technology with clear photos of the retina or optical coherence tomography images, the glaucoma specialist needs intraocular pressure measurements, and the pediatric specialist needs accurate visual acuities and eye alignment. While there are some creative solutions, like camera phone lens for viewing the anterior segment or smartphones and magnifiers for the retina, the current options are far from perfect and are cost prohibitative.12,13 Ultimately, many of the ophthalmologists commented on how the current telemedicine technology is not sufficient for their needs. However, they noted if patient care is expected to be delayed for more than a few months, then there might be a greater role for telemedicine technology.

Other Barriers and Challenges One of the other reported barriers and concerns are how appointments will be fairly delivered once patient care resumes. Since many specialty care providers are booked months in advance, there will be challenges in scheduling patients in the future and getting access to care. Many patients have missed surgeries and appointments, and there will be a huge surge of patients that will need to be seen.

Overall, specialists are trying to best support patients while prioritizing patient safety. For many specialties like ophthalmologists, patient access has substantially decreased in these unprecedented times. The future will hopefully bring new policies and sustainable options for telemedicine. In addition, there will need to be more support provided to business in the future as they are faced with the challenge of reintegrating the patient care that has been delayed during this time.

References: 1. Jun, I.S.Y., Hui, K.K.O., Songbo, P.Z. (2020). Perspectives on Coronavirus disease 2019 Control Measures for Ophthalmology Clinics based on a Singapore Center Experience. JAMA Ophthalmology. E1-E2.

2. Centers for disease Control. (2020, April 9). Cases in U.S. https://www.cdc.g ov/coronavir us/2019-ncov/casesupdates/cases-in-us.html.

3. Metropolitan Health district City of San Antonio. (2020, April 9). Novel Coronavirus (COvId-19). www.sanantonio.gov/ health/news/alerts/coronavirus.

4. Xia, J., Tong, J., liu, M., et al. (2020). Evaluation of Coronavirus in Tears and Conjunctival Secretions of Patients with SARS-Cov-2 Infection. Journal of Medical virology.

5. Office of the Texas Governor. Governor Abbott Issues Executive Order Increasing Hospital Capacity, Announces Supply Chain Strike Force For COvId-19 Response. (2020, March 22). https://gov.texas.gov/news/post/governor-abbott-issues-executive-order-increasing-hospital-capacity-announces-supplychain-strike-force-for-covid-19-response.

6. American Academy of Ophthalmology. (2020, March 27). list of urgent and emergent ophthalmic procedures. https://www.aao.org/headline/list-of-urgent-emergent-ophthalmic-procedures.

7. American Academy of Ophthalmology. (2020, April 8). Important coronavirus updates for ophthalmologists. https://www.aao.org/headline/d6e1ca3c-0c30-4b20-87e07668fa5bf906. Published April 8, 2020.

8. lai, T.H.T., Tang, E.W.H., Chau, S.K.Y. et al. (2020). Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong.

Graefes Arch Clin Exp Ophthalmol. https://doi.org/10.1007/s00417-020-04641-8 9. Centers for disease Control. (2020, April 3). Recommendation Regarding the Use of Cloth Face Coverings, Especially in Areas of Significant Community-based Transmission. https://www.cdc.gov/coronavirus/2019-ncov/prevent-gettingsick/cloth-face-cover.html

10. U.S. Senate Committee on Small business & Entrepreneurs.

(2020). The Small business Owner’s Guide to the CARES Act. https://www.sbc.senate.gov/public/_cache/files/2/9/29fc1ae7 -879a-4de0-97d5-ab0a0cb558c8/1bC9E5Ab74965E 686FC6EbC019EC358F.the-small-business-owner-s-guide-tothe-cares-act-final-.pdf.

11. American Academy of Ophthalmology. (2020, April 3). Coding for Phone Calls, Internet and Telehealth Consultations. https://www.aao.org/practice-management/news-detail/coding-phone-calls-internet-telehealth-consult.

12. Myung, d., Jais, A., He, l., et al. (2014). Simple, low Cost Smartphone Adapter for Rapid High Quality Ocular Anterior Segment Imaging: A Photo diary. Journal of Mobile Technology in Medicine. 3:1-8.

13. American Academy of Ophthalmology. (2018). Telemedicine for Ophthalmology Information Statement -2018. https://www.aao.org/clinical-statement/telemedicine-ophthalmology-information-statement.

By Sejal Lahoti, BA MS3, Huy Nguyen, MD PGY-2, and Richard Jones, MD PGY-3 at UTHSA. Editor’s Note: If you are an ophthalmologist or know of an ophthalmologist using novel telemedicine technology, then please reach out to lahotis@livemail.uthscsa.edu. visit us at www.bcms.org

33

COVID-19 PANDEMIC

It’s a Pandemic Crisis! What is the Medical Society Doing?

In the Best of Times...and the Worst of Times...

You can Count on BCMS and TMA being here for you!

By Mary E. Nava, BCMS Chief Government Affairs Officer

As with any other new year, bCMS started 2020 as usual, with the hustle and bustle of installing the 2020 officers and preparing and planning for another year of meetings, events and other activities that normally occur throughout the year. Never did a thought about coming face-to-face with a pandemic cross anyone’s mind; not here, anyway. Pandemics happened in other places, in other countries. That was, of course, until the beginning of March.

That’s when we got word that things were about to change, for all of us. TMA and bCMS jumped into action to help physicians. locally, the City’s Emergency Operations Center (EOC) was activated. very quickly, conference calls and meetings began to be implemented by and between numerous organizations, from hospitals, physicians, clinics, health care institutions, bCMS, Metro Health, and the South Texas Regional Advisory Council, to city, county and state elected officials. At the state level, TMA was quickly participating in similar meetings and calls. From the outset, immediate thoughts turn to what and how to begin the process of disseminating critical and timely information to our bCMS members.

TMA began conference calls with county medical society executives from around the state to provide updates by key personnel within their organization on many aspects of this extreme event that now had a name – Novel Coronavirus or COvId-19. In early 34

San Antonio Medicine • May 2020

March, the bCMS board leadership called upon Metro Health to meet with them to bring everyone up to speed as to what to expect or plan for, in addition to learning more as to what this virus was causing in our community and what bCMS could do to help. Suddenly, distancing ourselves from each other began happening way before anyone uttered the words “social distancing”. This meeting with Metro Health was the last large-group, in-person meeting held at bCMS, which at the time of this writing, took place about six weeks ago. bCMS began compiling information for physicians and immediately created a COvId-19 Resources page on the bCMS website, www.bcms.org, including links to key Coronavirus authorities from the local, state, national and world, phone and hotline numbers for quick access to information for physicians, their patients and the public. To date, the website is updated as information becomes available. Additionally, critical information is distributed to members weekly via the bCMS electronic newsletter, The Weekly Dose (make sure your email system is allowing this newsletter to come to you!). TMA, as well, developed a COvId-19 page on their website to also offer news, updates and practice resources for physicians.

Spring break came and went, except this time there was the added concern that because there are so many people who vacation during

COVID-19 PANDEMIC this time, the virus could be spread faster due to the increased travel.

It was during the middle of March that bCMS leadership approved the cancellation of all in-person meetings previously scheduled at the bCMS offices, whether internal board or committee meetings or external events, as well as meetings scheduled by other organizations. The March meeting of the bCMS board was the first virtual meeting of the group. The use of a virtual Zoom meeting was a brand-new tool that bCMS staff members were basically learning how to use in real time. bCMS has a host of volunteer committees in which physician members participate. Two committees in particular that quickly mobilize during crisis situations are the Public Health and Patient Advocacy Committee chaired by John Nava, Md and the Emergency Preparedness Committee, chaired by Timothy Tong, Md. When the next regularly scheduled meeting of the Public Health and Patient Advocacy was to take place, it was at the direction of our CEO/Executive director, Steve Fitzer, that the Executive Committee be invited to be part of the discussions and thus, the new ad hoc bCMS Task Force was formed.

The first Zoom meeting of the bCMS COvId Task Force, led by the Public Health Committee presiding chair, John Nava, Md took place on March 30. discussions have focused on a number of public health topics, including, but not limited to, the importance of hand-washing, social distancing and the status of PPE. The group has been meeting weekly since then, and has now added the bCMS legislative and Socioeconomics Committee, led by Chair Alex Kenton, Md to the COvId Task Force. This is because of the important legislation coming out of Washington pertaining to not just COvId-19, but also to how physician practices are being affected by this pandemic. City, county and state elected officials also interact with members of the bCMS legislative and Socioeconomics Committee regarding COvId. On a separate note, bCMS COvId Task Force members also participate in weekly digital TeleTown Hall meetings led by Metro Health to hear the latest stats and information updates on COvId-19 cases on the local, state and national fronts. Melody Newsom, the bCMS Chief Operating Officer, also listens in on calls with UT Health/University Health System, department of State Health Services (dSHS), Regional Medical Operations Center (RMOC) and TMA, and participates on the Metro Health COvId-19 Testing Task Force and keeps the bCMS Task Force informed on relevant matters.

Recent actions approved by the Joint Committee include the submission of a letter to the editor of the San Antonio Express-News, under the signature of John Nava, Md, in support of public health measures established – the importance of hand-washing, maintaining social distance and adhering to the city and county “stay-athome orders”. To our surprise, the Express-News editorial staff notified bCMS that the entire letter would run as an opinion piece article on April 11 in the paper’s editorial page. Committee members also approved plans to send letters to the Mayor, County Judge and Governor in support of continuing with the established public

health measures, and to call for the expansion of these measures to include encouraging everyone to wear masks when out in public, #Mask4All. At the time of this writing, discussions with our Mayor and county leaders and state legislators are ongoing. All are fully aware that bCMS stands ready to assist in any way possible. On April 15, the office of Mayor Ron Nirenberg contacted Jayesh Shah, Md via phone in response to a letter submitted by dr. Shah regarding these issues. The Mayor’s office informed dr. Shah that Mary Nava, chief government affairs officer for bCMS, will have access to the City’s Public Health Office for future discussions and collaboration on these issues and will serve as the main point of contact between the Mayor’s office and bCMS. At the state level (at the time of this writing), TMA had announced that a series of letters have been sent to the Trump Administration, the Governor and also state agencies covering several topics, including: • A joint letter with the AMA, along with other state associations, asking the Administration to take $25 billion of the $100 billion in the congressional bill and get this money quickly to physicians to support medical practices • A letter to the Governor asking that the Texas department of Insurance suspend prior authorization requirements • A letter on privacy regarding the loosening of the Federal HIPAA to match state law • A letter to the Governor and leadership of HHSC on Medicaid coverage issues • A letter on PPE asking that some of the PPE that is coming to the state be carved out immediately for ambulatory care • A letter to the Gov. on practice liability protections Additional information, including copies of these letters, can be found on the TMA website at www.texmed.org/COvId-19.

On the news media front, bCMS works in tandem with TMA on a variety of topics, including any COvId-19 media inquiries. In preparation for media inquiries, TMA asked the county medical societies to identify physician spokespersons for this purpose. Physician spokespersons recommended by the bCMS board, include: John Nava, Md, vincent Fonseca, Md and Ruth berggren, Md. The pandemic crisis has brought forth not only new causes for concern but also new opportunities for learning and for carrying out our daily life activities, including our work responsibilities from a very different perspective. Know that your county medical society leadership and staff, along with the TMA leadership and staff, are very much involved and in tune with all discussions on COvId-19 taking place now and throughout the duration of the pandemic. As more information becomes available, we will share it. We are here for you.

For more information, contact Mary Nava at mary.nava@bcms.org. visit us at www.bcms.org

35

COVID-19 PANDEMIC

TMLT Offers Malpractice Insurance AT NO COST TO RETIRED PHYSICIANS WHO VOLUNTEER DURING THE COVID-19 CRISIS Texas Medical liability Trust (TMlT) is offering insurance coverage at no cost to retired Texas physicians who resume practicing medicine during the COvId-19 public health emergency.

This medical professional liability coverage will be offered without premium to any retired Texas physician working on a volunteer basis and in direct response to a governmentally declared emergency order regarding the COvId-19 crisis.

Details of the coverage include:

• Coverage will be offered to retired physicians working on a non-paid, volunteer basis only.

• All retired Texas physicians are eligible, whether they have been TMlT policyholders or not.

• Membership in the Texas Medical Association is not required.

To apply for coverage, please go to the TMLT website at www.tmlt.org/join/apply and download the application. Email your completed application to underwriting@tmlt.org.

You can also call TMLT’s underwriting department at 800-580-8658 or 512-425-5800 or email at underwriting@tmlt.org to apply or learn more.

“To offer additional support to Texas physicians and the public, TMlT is offering medical liability coverage, at no cost, to retired physicians who come back to work and help their colleagues during the COvId-19 emergency,” says Robert donohoe, president and CEO of TMlT. “It is our job to assist physicians in any way possible as this crisis continues to intensify.”

TMlT has also extended its business hours, to better serve physicians working beyond their own traditional work hours. TMlT now has staff members from its Customer Service, Risk Management, Claims, and Underwriting departments available to answer phone calls from 8 a.m. to 8 p.m. at 800-580-8658.

If calling outside of business hours, callers can follow telephone prompts to report a claim, ask a risk management question, or ask a question about their accounts.

36

San Antonio Medicine • May 2020

The COVID-19 Paradigm Shift

COVID-19 PANDEMIC

Should Stick Around

By Brittany R. Johnson, MPH

In response to the 2020 coronavirus pandemic, the Centers for Medicare and Medicaid Services, in collaboration with medical societies and associations, published recommendations to postpone non-essential surgeries and procedures. The recommendations advocated a tiered approach to curtailing non-emergent elective medical services, in recognition of “the importance of reducing burdens on the existing health system and maintaining services while keeping patients and providers safe.”

In a similar fashion, the American College of Surgeons recommended curtailing the performance of “elective” surgical procedures and issued the following statement regarding the triage of non-emergent surgical procedures: “In general, a day-by-day, datadriven assessment of the changing risk-benefit analysis will need to influence clinical care delivery for the foreseeable future. Plans for case triage should avoid blanket policies and instead rely on data and expert opinion from qualified clinicians and administrators, with a site-specific granular understanding of the medical and logistical issues in play.” In an article published by The Atlantic, Fred Milgrim, an emergency medicine resident physician in New York City, professed to potential patients “if you have mild symptoms, assume that you have the coronavirus. Stay home, wash your hands, call your doctor. don’t come to the emergency department just because of a fever or cough…we don’t want you to expose yourself to those who definitely do have the virus.”

In a recent CNN coronavirus townhall, dr. Robert Redfield, director of the US Centers for disease Control and Prevention, said the most powerful weapon against coronavirus is social distancing.

Undeniably, social distancing and quarantine have become ubiquitous terms in public discourse, beseeched upon the national population by both political leaders and healthcare professionals alike.

The aforementioned occurrences and the plethora of similar incidences nationwide share a common denominator. They are all manifestations of the paradigm shift evoked by COvId-19. The guiding principles of the practice of medicine have drastically transformed, and the new mantra promotes several key themes: allocate the healthcare system’s in-person resources for the most acutely ill; rethink the necessity of all nonessential medical interventions; and accentuate modification of patient behavior as the primary means of disease prevention. Without a doubt, these strategies are imperative within the context of a pandemic. but they need not be reserved for pandemics or states of emergency.

On the contrary, the line of thinking underlying recent coronavirus policies offers great utility for the American healthcare system even in times of relative normalcy. Pandemic or not, physicians should always pragmatically ponder who truly needs hospital admission,

and who can reasonably be managed from home. Pandemic or not, surgeons should always be asking, “is this surgical intervention really necessary at this time?” or “what nonoperative management can be offered to this patient, as an adjunct to or even in lieu of a surgical procedure?”

Pandemic or not, the objective of public health efforts should always be to empower patients and people with the knowledge to spur behavioral change. Pandemic or not, healthcare professionals must always operate under the belief that the modification of health behaviors and not pharmaceutical interventions is what overcomes health challenges. Pandemic or not, the American healthcare system has long been ripe for multi-level drastic change.

Eventually, COvId-19 will dissipate and there may be a rush to return to “normal.” during these times of waiting, now is an opportune time to revisit and modify our versions of normal. Applying this level of introspection to the American healthcare system, we see that what was “normal” was hardly functional or effective.

In a 2012 report, the National Academy of Medicine estimated that the U.S. healthcare system squandered 765 billion dollars per year, about one fourth of all the money spent each year on healthcare.

The waste was attributed to unnecessary services, excessive administrative costs, fraud, and other problems. Moreover, inefficiencies cause needless suffering. In short, American healthcare is plagued by frivolous spending and suboptimal outcomes across the board.

COvId-19 did not create this reality; it was here when COvId-19 arrived, and it will still be here when COvId-19 leaves, if we revert to old habits.

The heightened pragmatism surrounding the value of medical intervention in the face of coronavirus is the same type of pragmatism we need to rectify the problem of worthless medical spending and poor health results. So, while we all await the exit of the coronavirus pandemic, perhaps the medical paradigm shift should be welcomed to stay.

Brittany R Johnson, MPH, MS is a DO Candidate, Class of 2023 at the University of the Incarnate Word School of Osteopathic Medicine, and is a member of the Bexar County Medical Society. visit us at www.bcms.org

37

COVID-19 PANDEMIC

Changes to Telemedicine Laws

By Texas Medical Association www.texmed.org/Telemedicine/ Insurers to Cover Visits Governor Abbott waived certain regulations and directed the Texas department of Insurance (TdI) to issue an emergency rule relating to telemedicine provided through state-regulated insurance plans. Contracted or preferred physicians and other health care professionals will be eligible for payment from TdI-regulated insurance plans for medical visits they conduct over the phone instead of in person at the same rate they would receive for in-person visits.

HIPAA Restrictions Suspended Effective immediately, the U.S. Health and Human Services (HHS) Office for Civil Rights will not penalize physicians for noncompliance with HIPAA when they serve patients in good faith through common, nonpublic-facing communications technologies, such as FaceTime or Skype.

Medicare Telehealth Expands The Centers for Medicare & Medicaid Services (CMS) has temporarily broadened telehealth access to Medicare patients. Medicare can pay for office visits furnished via telehealth in all areas of the country (not only rural areas) and in any setting, including in a patient’s home. Physicians may reduce or waive cost-sharing for telehealth visits paid by federal health care programs.

Payor Policies for Telemedicine Services In the wake of COvId-19, TMA is getting calls about which payers are covering telemedicine. TMA developed this quick reference guide to help you navigate telemedicine reimbursement.

For a list of vendors and how to contact them, go to the Texmed.org website:

https://www.texmed.org/uploadedFiles/Current/2016_Practice_Help/Health_Information_Technology/ Telemedicine/Telemedicine%20vendor%20Options.pdf For a checklist on how to evaluate telemedicine providers, go to the Texmed.org website:

https://www.texmed.org/uploadedFiles/Current/2016_Practice_Help/Health_Information_Technology/ Telemedicine%20Criteria%20-%20chart.pdf For Payer policies for Telemedicine, go to the Texmed.org website:

https://www.texmed.org/uploadedFiles/Current/2016_Practice_Help/Health_Information_Technology/ Telemedicine/Telemedicine%20Quick%20Reference%20Chart%20for%20Payers.pdf

38

San Antonio Medicine • May 2020

PHYSICIANS PURCHASING DIRECTORY Brought to you by the BCMS Circle of Friends

By supporting these sponsors with your patronage, you are supporting the BCMS. ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Celebrating our 40th anniversary, our detailed knowledge of medical practices helps our clients achieve a healthy balance of financial, operational, clinical and personal well-being.

Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

ACCOUNTING SOFTWARE

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

ARCHITECTURE LK Design Group, Inc. (HH Silver Sponsor) LK Design Group has over 24 years of experience designing various medical and hospital buildings. We have experience in both ground up developments and re-design of interior spaces for medical professionals.

Lynn Kuckelman Peters President 210-824-8825 Lynn.p@lkdesigngroup.com Kristin Savage Director of Business Development 210-824-8825 Kristin.s@Lkdesigngroup.com www.lkdesigngroup.com

40

San Antonio Medicine • May 2020

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice.

Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector.

Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

ASSETT WEALTH MANAGEMENT

Bertuzzi-Torres Wealth Management Group (HHH Gold Sponsor) We specialize in simplifying your personal and professional life.

We are dedicated wealth managers who offer diverse

financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning.

Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

BANKING

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability.

We work hard and together with our clients to accomplish great things.

Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services.

Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com

Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community.

Ken Herring 210-283-4026 kherring@broadwaybank.com Daniel Ganoe Mortgage Loan Originator 210-283-5349 www.broadwaybank.com “We’re here for good.”

Synergy Federal Credit Union (HHH Gold Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need.

Synergy FCU Member Services (210) 750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com

BUSINESS CONSULTING Waechter Consulting Group (HH Silver Sponsor) Want to grow your practice? Let our experienced team customize a growth strategy just for you.

Utilizing marketing and business

development tactics, we create a plan tailored to your needs!

Michal Waechter, Owner (210) 913-4871 Michal@WaechterConsulting.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”

COMMERCIAL PROPERTY MANAGMENT

Investment Realty Company, L.C. (HHH Gold Sponsor) We act as Trusted Advisors leveraging our expertise as we assist Physicians in making the best commercial real estate decisions for their practices whether it's leasing, purchase or asset acquisiton.

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

DIAGNOSTIC IMAGING

Touchstone Medical Imaging (HHH Gold Sponsor) To offer patients and physicians the highest quality outpatient imaging services, and to support them with a deeply instilled work ethic of personal service and integrity.

Caleb Ross Area Marketing Manager 972-989-2238 caleb.ross@touchstoneimaging.com Angela Shutt Area Operations Manager 512-915-5129 angela.shutt@touchstoneimaging.com www.touchstoneimaging.com "Touchstone Imaging provides outpatient radiology services to the San Antonio community."

FINANCIAL ADVISOR

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals.

Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

Elizabeth Olney, Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabetholney "Making Sense of Investing"

FINANCIAL SERVICES

Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning.

Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life.

Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help

you achieve your financial goals.

Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing" Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference.

Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

HEALTHCARE BANKING

Amegy Bank of Texas ( Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive

advice, and customized solutions in cash management, lending, investments, insurance, and trust services.

Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

HEALTHCARE CONSULTING

CareAllies (HHHH 10K Platinum Sponsor) CareAllies works side-by-side with health care providers to accelerate the transition to valuebased care, helping improve the quality, value and experience of care for patients and make health care better for everyone.

Sabrina Moreno, Network Operations Senior Manager (713) 437-3088 X 523088 Sabrina.Moreno@careallies.com info@careallies.com https://www.careallies.com/ “For Better Health and Better Business”

HOSPITALS/ HEALTHCARE SERVICES

Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research.

Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com

continued on page 42

visit us at www.bcms.org

41

PHYSICIANS PURCHASING DIRECTORY continued from page 41 INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

INSURANCE

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

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care.

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

OSMA Health (HHH Gold Sponsor) Health Benefits designed by

42

San Antonio Medicine • May 2020

Physicians for Physicians.

Fred Cartier Vice President Sales (214) 540-1511 fcartier@abadmin.com www.osmahealth.com “People you know Coverage you can trust”

INSURANCE/MEDICAL MALPRACTICE

providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior).

Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

MEDICAL BILLING AND COLLECTIONS SERVICES Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies.

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more.

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a check-up?

Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency.

Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL FURNITURE

CBI Group (HHH Gold Sponsor) From reception to waiting rooms to workstations, CBI Group is your trusted partner for turnkey office furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline.

Brent Warrilow 210-504-3740 brent.warrilow@cbi-office.com Brody Whitley 210-741-0438 brody.whitley@cbi-office.com Craig Hewines 210-941-1257 craig.hewines@cbi-office.com www.cbi-office.com

MEDICAL PRACTICE

IntegraNet Health (HHHH 10K Platinum Sponsor) Valued added resources and enhanced compensations. An Independent Network of Physicians with a clinical and financial integrated delivery network, IntegraNet Health serves as your advocate and partner.

Margaret S. Matamoros Executive Director, San Antonio 210-792-2478 mmatamoros@integranethealth.c om Nora O. Garza, MD Medical Director, San Antonio 210-705-3137 ngarza@garzamedicalgroup.com www.integranethealth.com “We encourage you to learn more about how IntegraNet Health can help you “

UT Health Physicians (HHH Gold Sponsor) UT Health Physicians, the faculty practice of UT Health San Antonio, features the region's most comprehensive array of specialists & sub-specialists. Now offering free, secure access to your patients’ records. Most health plans accepted.

For referrals or questions, contact: Jose Gamez, Director, Physician Relations (210) 450 8347 GamezJ4@uthscsa.edu www.UTHealthcare.org “Offering daily grand rounds with no-cost CME to local physicians since 1969.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHH Gold Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

MOLECULAR DIAGNOSTICS LABORATORY iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases.

Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

MORTGAGE

PrimeLending (HHH Gold Sponsor) Doctor Loans, Construction Loans, VA Loans, Conventional and FHA Loans.

Cleo Garza Sr. Loan Officer NMLS#218858 210-483-4907 cleo.garza@primelending.com www.lo.primelending.com/cleo.garza Home Loans Made Simple

OFFICE FURNITURE

CBI Group (HHH Gold Sponsor) From reception to waiting rooms to workstations, CBI Group is your trusted partner for turnkey office furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline.

Brent Warrilow 210-504-3740 brent.warrilow@cbi-office.com Brody Whitley 210-741-0438 brody.whitley@cbi-office.com Craig Hewines 210-941-1257 craig.hewines@cbi-office.com www.cbi-office.com

PRACTICE SUPPORT SERVICES

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims

to accelerate their growth with proven successes and systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a check-up?

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio.

Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more!

President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

Tom Tidwell, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

CARR Healthcare (HHH Gold Sponsor) CARR Healthcare is the nation’s leading provider of commercial real estate services for tenants and buyers.Our team of healthcare real estate experts assist with start-ups, lease renewals, expansions, relocations, additional offices, Purchases and practice transitions Matt Evans Agent 210-560-1443 matt.evans@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

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

Investment Realty Company, L.C. (HHH Gold Sponsor) We act as Trusted Advisors leveraging our expertise as we assist Physicians in making the best commercial real estate decisions for their practices whether it's leasing, purchase or asset acquisiton.

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

KW Commercial (HHH Gold Sponsor) We specialize in advising Medical Professionals on the viability of buying & selling real estate, medical practices or land for development Marcelino Garcia, CRE Broker Assciate 210-381-3722 Marcelino.kwcommercial@gmail.com Leslie Y. Ayala Business Analyst/ CRE Associate 210-493-3030 x1084 Leslie.kwcommercial@gmail.com www.GAI-Advisors.com “Invaluable Commercial Real Estate Advice for The Healthcare Professional”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Donna Bakeman Office Manager 210-301-4362 dbakeman@favoritestaffing.com

TELECOMMUNICATIONS ANSWERING SERVICE

TAS United Answering Service ( Gold Sponsor) We offer customized answering service solutions backed by our commitment to elite client service. Keeping you connected to your patients 24/7.

Dan Kilday Account Representative 210-258-5700 dkilday@tasunited.com www.tasunited.com “We are the answer!"

For questions regarding services, Circle of Friends sponsors or joining our program please contact August Trevino, Program Director at 210-301-4366, August.Trevino@bcms.org, bcms.org/COF.html

Join our Circle of Friends Program The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties.

For questions regarding Circle of Friends Sponsorship or, sponsor member services please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366 www.bexarcv.com/secure/ bcms/cofjoin.htm

visit us at www.bcms.org

43

RECOMMENDED AUTO DEALERS • • • •

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave New Braunfels, TX 78130 Matthew C. Fraser 830-606-3463

We will locate the vehicle at the best price, right down to the color and equipment.

We will put you in touch with exactly the right person at the dealership to handle your transaction.

We will arrange for a test drive at your home or office. We make the buying process easy!

When you go to the dealership, speak only with the representative indicated by BCMS.

11001 IH 10 W at Huebner San Antonio, TX Esther Luna 210-690-0700

Northside Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Northside Ford 12300 San Pedro San Antonio, TX

David Espinoza 210-912-5087

Marty Martinez 210-525-9800

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Honda 14610 IH 10 W San Antonio, TX

Coby Allen 210-625-4988

Eric Schwartz 210-680-3371

Northside Honda 9100 San Pedro San Antonio, TX 78216

Cavender Audi Dominion 15447 IH 10 W San Antonio, TX 78249

Sean Beardsley 210-988-9644

Rick Cavender 210-681-3399 KAHLIG AUTO GROUP

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Mazda 9333 San Pedro San Antonio, TX 78216

William Taylor 210-366-9600

James Godkin 830-981-6000

Scott Brothers 210-253-3300

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Subaru 9807 San Pedro San Antonio, TX 78216

North Park Lexus 611 Lockhill Selma San Antonio, TX

North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX

North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257

Mark Castello 210-308-0200

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211

North Park Lincoln 9207 San Pedro San Antonio, TX

North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257

Justin Boone 210-635-5000

Sandy Small 210-341-8841

James Cole 800-611-0176

Cavender Toyota 5730 NW Loop 410 San Antonio, TX Gary Holdgraf 210-862-9769

Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.)

San Antonio, TX Ed Noriega 210-561-4900

Porsche Center 9455 IH-10 West San Antonio, TX Matt Hokenson 210-764-6945

Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org

THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA

MEDNAX

Dermatology Associates of San Antonio, PA

Peripheral Vascular Associates, PA

Diabetes & Glandular Disease Clinic, PA

San Antonio Eye Center, PA

ENT Clinics of San Antonio, PA

San Antonio Gastroenterology Associates, PA

Gastroenterology Consultants of San Antonio

San Antonio Infectious Diseases Consultants

General Surgical Associates

San Antonio Pediatric Surgery Associates, PA

Greater San Antonio Emergency Physicians, PA

South Alamo Medical Group

Institute for Women's Health

South Texas Radiology Group, PA

Little Spurs Pediatric Urgent Care, PLLC

South Texas Renal Care Group

Lone Star OB-GYN Associates, PA

Star Anesthesia (USAP Texas-South)

M & S Radiology Associates, PA

The San Antonio Orthopaedic Group

MacGregor Medical Center San Antonio

Urology San Antonio, PA

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of April 23, 2020.

46

San Antonio Medicine • May 2020