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August Edition 2021

Inside This Issue

Seven Tips for Telehealth Clinical Documentation By Sue Boisvert, BSN, MHSA Patient Safety Risk Manager II The Doctors Company

T St. David’s Healthcare Launches New Graduate Medical Education Programs See pg. 11

INDEX Legal Matters....................... pg.3 Oncology Research......... pg.4 Mental Health...................... pg.6 Healthy Heart....................... pg.8

Racial Disparities in Prostate Cancer See pg. 12

he standards of care for telehealth are identical to those for onsite medical care: Medical and dental professionals must practice with the same level of skill and expertise as qualified practitioners in the same specialty under the same circumstances. State regulations and associated rules define what constitutes telehealth, third-party payer contracts outline medical necessity expectations and the services that qualify for reimbursement, your organization’s policies and procedures define practice expectations, and case law clarifies the interpretation of all these standards. Clinical documentation plays a significant role in demonstrating regulatory compliance, establishing medical necessity for billing, and supporting your defense in the event of a professional board complaint or medical professional liability claim. The following seven tips outline unique considerations for documenting telehealth care: 1. Modality. Specify clearly in the medical record what modality of telehealth is being used. Examples include “secure interactive audio-video session using Skype,” “medication management visit conducted by telephone,” or

“asynchronous diagnostic test follow-up by portal/text/email.” 2. Geography. Note the patient’s physical location and geography.

on the patient’s needs. In the progress note, include a summary of the discussion and the patient’s decision, as well as a copy of the signed form if used. Find our sample Telehealth Informed Consent form on our Informed Consent Sample Forms page. 4. Identity. Confirm the identity of new patients by asking them to hold a photo ID close to the camera. Document confirmation of patient identity. Patients also have the right to ask for provider identification. 5. Appropriateness. Determine quickly if the patient and environmental conditions are appropriate for a telehealth visit. Some patients may not be appropriate based on their cognitive status. If the patient is unable to answer questions or provide an accurate history and no support person is available, the visit may need to be rescheduled. Documentation in this situation might include “the visit was rescheduled at the patient’s request because her husband could not be available.” Evaluate and address

Following these seven tips can help you ensure t h at you r telehea lt h documentation is patient centered, comprehensive, and effective. For example, including “at her home in Tennessee” is important for billing purposes and for determining venue in the event of a regulatory or professional liability action. Also include the provider’s location (“clinic name and city” or “home office and city”) in the documentation. 3. Informed consent. Advise patients before asking them to consent to treatment by telehealth—about the unique risks of a telehealth visit, including the potential for technical difficulties, information security concerns, and the potential for converting the visit to an in-office visit based

see 14


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Legal Matters Medicare 340B Payment Cut Déjà Vu – Part B Payment Reductions Continue

By Kyle A. Vasquez, J.D. Mary H. Canavan, J.D. Polsinelli, PC


he Centers for Medicare and Medicaid Services (CMS) recently released the CY 2022 Medicare Hospital Outpatient Prospective Payment System (OPPS) Proposed Rule (Proposed Rule). While the Proposed Rule contains a variety of proposed changes for CY 2022, below are key updates affecting 340B Program covered entities and some initial recommended next steps. CMS confirmed it will continue its reimbursement cuts policy for certain 340B covered entities while it awaits a ruling from the Supreme Court in the ongoing litigation brought against HHS by the American Hospital Association (AHA). CMS also signaled that while

certain 340B covered entities (rural sole community hospitals, children’s hospitals, etc.) remain exempt from the reimbursement cuts, those covered entities should continue reporting the “TB” modifier and CMS may revisit the exemption in future rulemaking. Similar to last year, CMS also continued to reference the need for consistent and reliable payments for hospitals for the remainder of the Public Health Emergency (PHE), which could mean that payment changes can be expected following the end of the PHE. Previously, HHS had been tasked with creating a remedy to make 340B entities whole after the D.C. District Court held the reimbursement cuts in 2018 and 2019 were unlawful. As part of its proposed solution, CMS issued its controversial 340B Drug Acquisition Cost Survey (Survey) to gather drug acquisition data from covered entities. CMS stated in this Proposed Rule that they had the authority to use the 2020 survey results to propose a new payment structure but believed the current payment policy is still appropriate, especially with the ongoing PHE. CMS continues to signal that its Survey data

could influence future Part B / 340B drug payment proposals. Covered entities should act now and provide comments directed at the use of CMS’s flawed Survey data. Namely, that the Survey was inappropriate, the method by which CMS sought to collect acquisition cost data was flawed, any reliance on the data would be misplaced given flaws, and results were inconclusive. Notably, although the Biden administration has made staff changes within each agency, it appears that the same CMS personnel who were involved in last year’s 340B payment section of the OPPS rule also participated in developing the Proposed Rule. While not dispositive of any issues, it’s certainly noteworthy as

many industry stakeholders question why the Biden Administration didn’t back down from payment cuts implemented under the prior administration. Part B 340B Drug Payment Rates for Urban Hospitals Ultimately, CMS did not propose any changes to payment for 340B drugs. The same payment policies implemented in 2018 and expanded upon in 2019 will continue throughout 2022 unless the Supreme Court rules in favor of covered entities or CMS alters course in its CY 2022 Final Rule. CMS will continue to pay covered entities ASP minus 22.5% for separately payable, non-pass through 340B drugs. Rural sole community see Legal 13

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August 2021

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Oncology Research Applying Sunscreen – You’re (Probably) Doing It Wrong


By Jeff Yorio, M.D., Texas Oncology– Austin Central


We’re all ready to feel good again, but for our food insecure neighbors there’s no vaccine to fight hunger. The 1 in 5 Central Texas children at risk of hunger deserve a shot at a happy summer.


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August 2021

ugust in Texas means the arrival of 100-degree temperatures and a reminder to pay close attention to skin cancer prevention. The danger of the abundant sunshine we encounter in our ‘wide open spaces’ state is unmistakable: more than 4,200 Texans will face melanoma this year. Using sunscreen is essential to sun protection, but the bad news is that when it comes to applying sunscreen, many of us are doing it wrong. The good news is that doing it right can be summed up in two words: use more. Sunscreen works for a limited time. You should reapply sunscreen every two hours or according to the directions on the product label, but more frequently if you’re swimming or sweating a lot. Wa t e r- r e s i s t a n t sunscreens need to be reapplied every 40 or 80 minutes, according to the product label. Experts recommend using a broad-spectrum (protects against both UVA and UVB rays), water-resistant sunscreen with a sun protection factor (SPF) of at least 30. FDA rules on product labeling prohibit sunscreen being labeled as “waterproof,” “sweat proof,” or “sunblock,” serving as important reminders that one application of sunscreen is not enough. Skin damage from the sun takes many forms, including sunburns, wrinkles, and several types of skin cancer. According to the Skin Cancer Foundation, 20 percent of Americans will develop skin cancer by the age of 70, and those with five or more sunburns are twice as likely to get melanoma. Protecting yourself from sun damage prevents annoyances like sunburns now, and complications like skin cancer later. As the summer heats up, here’s what Texans need to know about sun safety: Be Sun Smart Anyone can get skin cancer, and

everyone can take steps to reduce skin cancer risk. While some risk factors like family history and naturally fair skin cannot be changed, exposure to UVA and UVB rays can be limited. Avoid being outdoors in sunlight too long, particularly in the middle of the day when UV light is strongest, and avoid indoor tanning. Protect your skin and use sunscreen as directed. Check for A, B, C, D, and E Check any moles or changes on your skin against these symptoms, and if they match, consult a dermatologist. • Asymmetry: One half of the mole is different from the other in size, shape, or color. • Border: The edge or border of the mole is not smooth. • Color: The color of the mole contains various shades of tan, brown, black, and in some instances red, white, or blue. • Diameter or Dark: A lesion that

is darker than others, regardless of size. Skin cancer melanomas are usually larger than six millimeters in diameter, but they can be smaller. • Evolving: The mole changes over time or develops new symptoms, such as bleeding, crusting, or itching. Think Beyond Sunscreen To stay safe outside, cover up! Always use sunscreen, even on hazy or cloudy days, since UVA and UVB rays can still penetrate clouds. But there’s more to sun protection than slathering on sunscreen. Wide-brim hats, sunglasses with UVA and UVB blocking lenses, long-sleeved shirts, and long pants or skirts can all help protect your skin. Simple preventative steps now can help protect against more serious complications later. Be smart while enjoying the summer sun and keep your skin safe.

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Mental Health A Machine Learning Approach for Predicting Risk of Schizophrenia Using a Blood Test


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August 2021

n innovative strategy that analyzes a region of the genome offers the possibility of early diagnosis of schizophrenia, reports a team led by researchers at Baylor College of Medicine. The strategy applied a machine learning algorithm called SPLS-DA to analyze specific regions of the human genome called CoRSIVs, hoping to reveal epigenetic markers for the condition. In DNA from blood samples, the team identified epigenetic markers, a profile of methyl chemical groups in the DNA, that differ between people diagnosed with schizophrenia and people without the disease and developed a model that would assess an individual’s probability of having the condition. Testing the model on an independent dataset revealed that it can identify schizophrenia patients with 80% accuracy. The study appears in the journal Translational Psychiatry. “Schizophrenia is a devastating disease that affects about 1% of the world’s population,” said corresponding author Dr. Robert A. Waterland professor of pediatrics – nutrition at the USDA/ ARS Children’s Nutrition Research Center at Baylor and of molecular and human genetics. “Although genetic and environmental components seem to be involved in the condition, current evidence only explains a small portion of cases, suggesting that other factors, such as epigenetic, also could be important.” Epigenetics is a system for molecular marking of DNA – it tells the different cells in the body which genes to turn on or off in that cell type, therefore epigenetic markers can vary between different normal tissues within one individual. This makes it challenging to assess whether epigenetic changes contribute to diseases involving the brain, like schizophrenia. To address this obstacle, Waterland and his colleagues had identified in previous work a set of specific genomic regions in which DNA methylation, a common epigenetic marker, differs between people but is consistent across different tissues in one person. They called these genomic regions CoRSIVs for correlated regions of systemic interindividual variation. They proposed that studying CoRSIVs is a novel way to uncover epigenetic causes of disease. “Because methylation patterns in CoRSIVs are the same in all the tissues of one individual, we can analyze them

in a blood sample to infer epigenetic regulation on other parts of the body that are difficult to assess, such as the brain,” Waterland said. Many previous studies have analyzed methylation profiles in blood samples with the goal of identifying epigenetic differences between individuals with schizophrenia, the researchers explained. “Our study is innovative in various ways,” said first author Dr. Chathura J. Gunasekara, computer scientist in the Waterland lab. “We focused on CoRSIVs and also applied for the first time the SPLS-DA machine learning algorithm to analyze DNA methylation. As a scientist interested in applying machine learning to medicine, our findings are very exciting. They not only suggest the possibility of predicting risk of schizophrenia early in life, but also outline a new approach that may be applicable to other diseases.” The current study also is innovative because it considered major potential confounding factors other studies did not take into account. For instance, methylation patterns in blood can be affected by factors such as smoking and taking antipsychotic medications, both of which are common in schizophrenia patients. “Here, we took various approaches to evaluate whether the methylation patterns we detected at CoRSIVs were affected by medication use and smoking. We were able to rule that out,” Waterland said. “This, together with the fact that DNA methylation at CoRSIVs is established very early in life, indicates that the epigenetic differences we identified between schizophrenia patients and healthy individuals were there before the disease was diagnosed, suggesting they may contribute to the condition.” Using this novel approach, the researchers were able to achieve much stronger epigenetic signals associated with schizophrenia than has ever been done before, said the team. “We consider our study a proof of principle that focusing on CoRSIVs makes epigenetic epidemiology possible,” Waterland said. 

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Healthy Heart


13 Things Primary Care Clinics Can Check to Help Preserve Brain Health By The American Heart Association


rimary care clinics can play an important role in preserving patients’ brain health using the American Heart Association’s Life’s Simple 7 as a guide, as well as addressing 6 other factors associated with cognitive decline, according to an American Stroke Association/American Heart Association Scientific Statement. Preserving brain health in an aging population is a growing concern in the U.S. An estimated one in five Americans 65 years and older has mild cognitive impairment, and one in seven has dementia. By 2050, the number of Americans with dementia is expected to triple, the statement authors note. Life’s Simple 7 focuses on seven lifestyle targets to achieve ideal cardiovascular health: managing blood pressure, healthy cholesterol


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adulthood.” According to the statement: • Recent data show that hypertension, diabetes and smoking in adulthood and middle-life increase the odds of cognitive decline in middle-age and accelerate cognitive decline in older age. • People with dementia experience lower quality of life, and caregivers - typically family members - experience high rates of psychological stress and physical ill-health. Dementia is more costly than heart disease or cancer, with worldwide costs estimated at $818 billion in 2015. • Professional guidelines also recommend routine screening for depression and counseling patients to focus on healthy eating and exercising a minimum of 150

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levels, reducing blood sugar, increasing physical activity, eating better, losing weight and not smoking. The statement suggests primary care professionals also consider assessing risk factors to optimal brain health, including depression, social isolation, excessive alcohol use, sleep disorders, less education and hearing loss. “Studies have shown that these domains are impacted by factors that are within our control to change,” said Chair of the scientific statement writing group Ronald M. Lazar, Ph.D., FAHA, the Evelyn F. McKnight Endowed Chair for Learning and Memory in Aging and director of the Evelyn F. McKnight Brain Institute at the University of Alabama at Birmingham School of Medicine. “Prevention and mitigation are important, because once people have impaired cognition, the current treatment options are very limited. Prevention exists along the health care continuum from pediatrics to August 2021

minutes a week. • Lack of access to primary care services may be a barrier to prevention. Even with the Affordable Care Act, an estimated 15% of Americans adults still lack health insurance, and 25% of Americans do not have a source of primary care. “Many people think of high blood pressure, Type 2 diabetes and other risk factors as affecting only heart health, yet these very same risk factors affect our brain health. Patients might be more likely to pay attention to the importance of addressing modifiable risk factors if they understood the links,” Lazar said. “I’ve given lectures, and what people tell me is, the one thing they do not want to lose during the course of their lives is their mind.” To learn more about AHA’s Life’s Simple 7 visit

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Making small changes every day can add up to big improvements in your overall health. Life's Simple 7 outlines a few easy steps you can take to live a healthier lifestyle. Two of these steps, Get Active and Eat Better, can help jump-start your whole health journey. Making choices that help you eat smart and move more can also help you lose weight,control cholesterol, manage blood pressure, reduce blood sugar and stop smoking. 1, 2, 3

GET ACTIVE Try to get at least 150 minutes per week of moderate aerobic exercise or 75 minutes per week of vigorous exercise (or a combination of both), preferably spread throughout the week. Even short 4 bursts of exercise can be beneficial, and all those little steps will lead to big gains in the long run.

EAT BETTER Eat a colorful diet full of fruits, vegetables, whole grains, low-fat dairy products, poultry, fish and nuts. Try to limit sugary foods and drinks, fatty or processed meats and salt. 1

LOSE WEIGHT Maintaining a healthy weight is important for your health. To lose weight, you need to burn more calories than you eat. Learning to balance healthy eating and physical activity can help you lose weight more easily and keep it off. 5

CONTROL CHOLESTEROL Cholesterol comes from two sources: your body (which makes all the cholesterol you need) and food made from animals. Eating smart, adding color and moving more can all help lower your cholesterol! 2, 6

MANAGE BLOOD PRESSURE Blood pressure is the force of blood pushing against blood vessel walls. Sometimes the pressure in arteries is higher than it should be, a condition known as high blood pressure. Stress and poor diet have both been linked to high blood pressure, so it’s important to be well and eat smart to help positively influence your blood pressure numbers. 1, 7

REDUCE BLOOD SUGAR Blood glucose (aka sugar) is an important fuel for your body. It comes from the food you eat, so it’s important to eat smart. Cut bout added sugars by checking nutrition facts labels and bingredients, limiting sweets and sugary beverages, choosing simple foods over heavily processed ones and rinsing canned fruits if they are in syrup.1 And you can move more, because moderate-intensity aerobic physical activity can also help your body respond to insulin.8

STOP SMOKING Not smoking is one of the best things you can do for your health. Smoking damages your circulatory system and increases your risk of multiple diseases, but the good news is that your lungs can begin to heal themselves as soon as you stop. Moving more can help you on your journey, since physical activity can help you manage stress. 9

1. Van Horn, L., Carson, J. A. S., Appel, L. J., Burke, L. E., Economos, C., Karmally, W., . . . Kris-Etherton, P. (2016). Recommended dietary pattern to achieve adherence to the american heart Association/American college of cardiology (AHA/ACC) guidelines: A scientific statement from the American Heart Association. Circulation, doi:10.1161/CIR.0000000000000462 2. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: The evidence. CMAJ. 2006;174(6):806 3. Van Horn, L., Carson, J. A. S., Appel, L. J., Burke, L. E., Economos, C., Karmally, W., . . . Kris-Etherton, P. (2016). Recommended dietary pattern to achieve adherence to the American Heart Association/American College of Cardiology (AHA/ACC) guidelines: A scientific statement from the American Heart Association. Circulation, doi:10.1161/CIR.0000000000000462 4. U.S. Department of Health and Human Services. (2018, November) Physical Activity Guidelines for Americans, 2nd Edition 5. Hill, J., Wyatt, H.R., Peters, J. (2012). Energy Balance and Obesity. 6. Third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III) final report. Circulation. 2002;106(25):3259-3260. 7. Gianaros, P. J., Sheu, L. K., Uyar, F., Koushik, J., Jennings, J. R., Wager, T. D., . . . Verstynen, T. D. (2017). A brain phenotype for Stressor

‐Evoked blood pressure reactivity. Journal of the American Heart Association, 6(9) doi:10.1161/JAHA.117.006053

8. Benjamin, E., Blaha, M., Chiuve, S., et al. Heart disease and stroke Statistics—2017 update. Circulation. 2017;CIR.0000000000000485 9. Silverman, M. N., & Deuster, P. A. (2014). Biological mechanisms underlying the role of physical fitness in health and resilience. Interface Focus, 4(5), 20140040. doi:10.1098/rsfs.2014.0040 ©2018 American Heart Association

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Austin Medical Times

UT Austin Study Aims to Shield Critical Brain Functions from Surgery, Find New Treatments for Neurological Conditions


he brain controls much of what it means to be human — speech, memory, reasoning and everything we feel, think and believe. When brain surgery is necessary, the areas that control these crucial functions are often perilously close to the surgical site. But what if there was a way to shift critical brain functions farther away from the surgical site, lowering risks to those critical functions? Doctors, engineers and scientists at The University of Texas at Austin are beginning a study to help adolescents who need brain surgery for epilepsy — advances that may one day also lead to new approaches to treat neurological conditions such as stroke, traumatic brain injury and post-traumatic stress disorder. As part of a three-year study, researchers will map the brains of adolescents before and after epilepsy surgery to examine how novel brain-machine interfaces and embodied learning technologies — such as playing games on a

virtual-reality treadmill — can help the brain rewire itself before surgery, move key functions away from the surgeon’s target, and recover more quickly afterward. Lead investigator David Paydarfar, M.D., chair of the Department of Neurology at Dell Medical School at UT Austin and director of the Mulva Clinic for the Neurosciences, compares it to evacuating a site before a nearby building is demolished. “We want to prevent important real estate in the brain from becoming collateral damage to the surgeon’s knife,” he said. “Our initial study will explore how we can do that for young people undergoing surgery for epilepsy, but we hope our findings will have broader implications for brain health.” Rewiring the brain for healing Learning to harness neuroplasticity, the brain’s ability to rewire itself, presents a new frontier for healing from brain disorders. Researchers hope the study, funded by a $2.5 million gift from the Coleman

A 3D model of the brain’s left hemisphere highlights regions responsible for movement and touch (red), speech perception (orange) and speech production (blue).

Fung Foundation, will set the stage for further discoveries in neuroplasticity. “Although neuroplasticity is such a well-understood attribute of the brain, we have not proactively leveraged it in a clinical setting. That’s why I am so excited to support this multidisciplinary team and its groundbreaking research,” said Coleman Fung, a serial entrepreneur whose foundation is also donating the two VR treadmills that will be used in the study. Fung’s latest Austin-based

company, Blue Goji, develops the Infinity Treadmill, which gamifies cognitive and physical rehabilitation. An interdisciplinary approach In addition to Paydarfar, the multidisciplinary research group includes José del R. Millán, Ph.D., from the Cockrell School of Engineering; Liberty Hamilton, Ph.D., from the Moody College of Communication; Elizabeth Tyler-Kabara, M.D., Ph.D., Dell Med associate professor

for a more accurate view of the underlying characteristics of the heart during all EP procedures. The mapping application is one of several “apps” on the EP platform and is designed to provide a more tailored and accurate approach to mapping and ablation, with the goal of increasing accuracy and improving patient outcomes—from

diagnosis through ablation and beyond. The EP platform aims to assist in the treatment of more than 2.7 million patients in the U.S. with atrial fibrillation, in addition to those who require ablation procedures. The technology is currently being readied for submission to the FDA for marketing authorization. 

see Brain 14

Texas Cardiac Arrhythmia Institute Leader Participates in Clinical Trial for World’s First Artificial Intelligence Technology for Complex Cardiac Arrhythmia Procedures


he leader of the Texas Cardiac Arrhythmia Institute (TCAI) at St. David’s Medical Center recently led a clinical study to evaluate the world’s first data-driven artificial intelligence (AI) platform for cardiac electrophysiology (EP) procedures. Andrea Natale, M.D., F.H.R.S., F.A.C.C., F.E.S.C., cardiac electrophysiologist and executive medical director of TCAI, conducted the first-in-human trial in Europe. The NeuTrace EP Platform technology is designed to better guide electrophysiologists during complex cardiac EP procedures to help improve safety and reduce procedure times. “This first-of-its-kind innovative

August 2021

AI-driven EP platform allows us to enhance ablation by providing advanced metrics and comprehensive patient data in real time for a more precise delivery during complex ablation procedures,” Dr. Natale said. “The AI-guided cardiac mapping technology is designed to provide a much safer option for patients and ensure the best possible outcomes.” The EP platform is built on the foundation of an underlying “Data Biome” and leverages AI to provide the most high-fidelity signal quality, advanced metrics, improved visualizations and comprehensive patient data¬¬—including real time, electrical signals and 3-D navigation—

Austin Medical Times

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St. David’s Healthcare Launches New Graduate Medical Education (GME) Programs GME Programs Aim to Increase Residency Opportunities for Physicians


n an effort to increase the limited number of residency options in Texas and retain more graduates in the community, St. David’s HealthCare recently became an Accreditation Council of Graduate Medical Education (ACGME) Sponsoring Institution of several new graduate medical education (GME) programs. In addition to increasing post-graduate residency opportunities for students, the programs are designed to train physicians to support the healthcare needs of the Central Texas community. “In Texas, our medical schools produce a significant number of outstanding graduates, yet the limited number of post-graduate residency slots means that many students leave the state to train and establish their practices elsewhere,” David Huffstutler, president and chief executive officer of St. David’s HealthCare, said. “As a result, Texas loses physicians at a time

when there is a significant need for well-trained doctors.” St. David’s HealthCare’s GME programs began in July with five residents in its initial specialty residency program—General Surgery. The General Surgery residency program is based at St. David’s South Austin Medical Center, with rotations at other hospitals within the healthcare system. Additionally, an Obstetrics/ Gynecology (OB/GYN) program will be added within a year. The General Surgery program will grow to include 25 residents within the next five years, and the OB/GYN program will grow to include 20 residents. Jason Brocker, M.D., a former U.S. Armed Forces trauma surgeon who also has experience in two of the busiest trauma facilities in the country, will serve as the program director for the General Surgery residency program. Dr. Brocker will oversee the five residents who were

From left to right, are as follows: Aileen Ebadat, MD St. David’s South Austin Medical Center Trauma Medical Director and GME Associate Program Director, Kayla Brown, DO, Osamuyi “Semo” Asemota, MD, Sara Kahn, MD, Jason Brocker, MD GME Program Director, John Jackson, MD, Sophia Jimenez, MD, Vincent Choudhry, MD F.A.C.S.

initially matched with the program: “St. David’s HealthCare is one of the largest healthcare systems in the state, and our hospitals have been recognized as leaders in healthcare quality, clinical excellence and patient experience,” Huffstutler said. “We have a depth of expertise and a vast reach which has previously not been accessible to medical students, and we are pleased to welcome our inaugural class.”

St. David’s HealthCare’s national partner, HCA Healthcare, has been dedicated to developing GME programs for the past five years as part of its commitment to address the national physician shortage. St. David’s HealthCare residents will be part of HCA Healthcare’s national GME program, which currently has more than 4,500 residents and fellows across nearly 300 programs in 66 teaching hospitals.

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Racial Disparities in Prostate Cancer Explained at Genomic Level Study Finds Substantially Different Biological Characteristics in the Tumors Of African American Men, Pointing to a Possible Contribution to Higher Prostate Cancer Death Rates By Lindsey Hendrix


t’s been well documented that African American men are more likely to be diagnosed and ultimately die from prostate cancer. Although the cause of this disparity is often attributed to cultural and socioeconomic factors that lead to poorer health outcomes among African Americans, a researcher from Engineering Medicine (EnMed) at Texas A&M University recently found substantially different biological characteristics in the tumors of African American men that he believes also contribute to the disparity. He said the findings provide compelling evidence that clinical therapies and treatments should be tailored to patients based on their race.

“Racial disparities are quite prevalent in health care,” said Kamlesh Yadav, PhD, instructional associate professor for EnMed. “The findings from most of the existing onco-genetic studies are not directly extrapolatable for tumors in all the races. Analyzing genetic drivers of tumors in various races and the clinical outcomes associated with cancer therapy have immense clinical value as we can now tailor therapeutics that would work better for one race versus other.” Yadav worked with a team of researchers at the Mount Sinai Health System in New York City to conduct a retrospective analysis of 1,152 patients who had undergone surgery for prostate cancer. The review included 596 African American men

and 556 men of European descent who had clinical-genomic information available to review. The researchers found that the tumors from men in two groups had distinctly different genomic profiles that would affect a health care professional’s plan for managing and treating the cancer. Specifically, the researchers found that tumors in African American men had higher expression of genes related to immune response and inflammation, and lower expression of DNA mismatch repair genes. Yadav says this means that African American men would benefit more from radiation therapy and platinum-based chemotherapy than their European counterparts. “Cancer is a genetic disease,” Yadav said. “This study has cemented

the understanding that beyond socioeconomic differences, certain genetic factors drive racial disparities observed in prostate cancer. Understanding these genetic factors would benefit patients in getting personalized cancer treatment.” Yadav said EnMed is poised to developing machine-learning algorithms that will help professionals deliver more personalized medicine. “EnMed is at the cusp of not only making remarkable strides in helping uncover these differences but also with the help of our clinical partners, taking the findings to the clinic,” he said.

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Page 13

Age Well, Live Well

Support for Older Adult Survivors of Abuse By Shelby Enman, Texas Health and Human Services Commission


omestic violence (DV) is a widespread issue that can impact anyone. DV includes the use of emotional, physical, financial or sexual violence by a person to gain control of an intimate partner, family member or other loved one. In Texas, 37.7% of women and 26.8% of men experience DV over the course of their lifetime. Older adults can be abused as well. According to the National Council on Aging, about one in 10 adults ages 60 and older nationwide have experienced abuse. Elder abuse is defined as any intentional or neglectful act that causes harm or risk of harm,

including self-neglect. This type of violence can include elements of DV but is specific to abuse of vulnerable adults. A vulnerable adult is defined as any adult who has a disability or who is age 65 or older. Adult Protective Services (APS) investigates allegations of abuse that vulnerable adults experience. Everyone 18 and older in Texas is required by law to report suspicions of elder abuse to APS. If you suspect that an older adult you know might be experiencing abuse, call APS at 1-800-252-5400 or visit Many older adults in Texas seek help from their local family violence program. The Texas Health and Human Services Commission (HHSC) Family Violence Program oversees crisis centers and domestic

violence programs across Texas that support people who have experienced abuse. Of the 64,623 people served by an HHSC-funded family violence program in 2020, about 9% identified themselves as age 50 and older and 785 identified as age 65 and older. “Family violence programs understand the complex issues that survivors of domestic violence face,” said Cody Rothschild, program and policy specialist with the HHSC Family Violence Program. “They offer trauma-informed support services to help people create safety plans and gain access to resources to help them live lives free of abuse. Any survivor of domestic violence can access these services for free.” Although DV and elder

abuse are serious, widespread issues, there are resources and services available to help survivors. If you or someone you know are experiencing abuse, please connect with the following resources below to find support. National Domestic Violence Hotline: call 900-799-SAFE or chat online at Find an HHSC-Funded Family Violence Program in Texas: webappviewer/index.html?id=ac 994e4a3ed94fa6854b18c0e31651 ca Note: Locations reflect only HHSC-funded programs and, for safety purposes, are approximate. 

Legal Matters

Continued from page 3 hospitals, children’s hospitals, and PPS-exempt cancer hospitals would continue to be excepted from this reimbursement cut and would continue to be reimbursed at ASP plus 6%. Update on Ongoing Litigation – American Hosp. Assoc. v. Becerra In the latest on the case, an appeals court ruled in favor of HHS, stating that the Secretary had the authority to make the 340B reimbursement cuts. AHA appealed to the Supreme Court, which agreed to hear the case to determine if the Secretary has the statutory authority

to make such substantial changes to Part B reimbursement for 340B drugs. Additionally, the Supreme Court requested HHS and AHA to address whether AHA’s challenge is valid based on an OPPS statutory provision which purports to limit judicial review of certain agency determinations. The Supreme Court is expected to hear the case during its next term, which begins in October. Key takeaways for 340B Program Covered Entities: • Submit comments to provide input

regarding use of the Survey data and to outline the impact CMS’s continued payment reductions have on covered entity communities. Comments must be submitted by 5 p.m. EST on September 17, 2021. • Continue to report JG/TB 340B drug modifiers and budget for ASP minus 22.5% reimbursement for 340B drugs for CY 2022 until the Supreme Court rules on the case or CMS alters its course. • Monitor billing/coding compliance relative to 340B drugs as failure to

utilize appropriate modifiers can lead to overpayments and duplicate discounts (in the Medicaid context). • Document files relative to the financial impact of the payment cuts for purposes of proving damages, if needed. 

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Austin Medical Times


Continued from page 1 distractions in the environment. Carefully document the patient assessment and environmental conditions as well as any actions taken and recommendations made. For more information on addressing patient distractions, see our article “Telehealth’s Newest Safety Risk: Distracted Patients.” 6. Others present. Document the record with the name and relationship of everyone who is present on the patient’s side of the interaction and the names and roles of everyone present on the provider’s side. The patient’s family members may be present, or the patient may be a minor. For example, document “visit conducted with child sitting on mother’s lap.” Clinical assistants,

students, or a scribe may be present on the provider’s side. An interpreter may assist from a third location by video or telephone. Include documentation of all participants. 7. Assisted assessment. Plan in advance and provide instructions for patient assistance, such as for patients who will obtain and report their own vital signs (including weight, blood pressure, pulse, and temperature). Document the information in the medical record as “patient provided.” If patients also assist in various aspects of physical examination, document the details as “patient assisted.” For more information on patient-assisted assessment, see our article “Strategies for Effective

Patient-Assisted Telehealth Assessments.” Following these seven tips can help you ensure that your telehealth documentation is patient centered, comprehensive, and effective. You can also benefit from familiarizing yourself with the regulatory and payer requirements specific to your practice location(s).

Senior Designer Jamie Farquhar-Rizzo Web Development Lorenzo Morales

Accounting Liz Thachar Office: 512-203-3987 For Advertising advertising@ Editor

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August 2021

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Brain Functions

of neurosurgery and director of restorative neurosurgery; Nicholas Barbaro, M.D., professor and associate chair for education in Dell Med’s Department of Neurosurgery; and Stephen Strakowski, M.D., Dell Med’s vice dean of research and an expert in bipolar disorder and neuroimaging. A professor in the Department of Electrical and Computer Engineering, Millán is known internationally for his work in brain-machine interfaces, including neuroprosthetics, and is a past president of the International Brain-Computer Interface Society. He is also a professor in Dell Med’s Department of Neurology. “Our research program brings together a unique convergence of engineering, neuroscience and clinical perspectives to foster brain plasticity through the use of brain-machine interfaces,” Millán said. “Engineering and neuroscience principles enable users to achieve a seamless connection with their brain-controlled devices, while the integration of clinical principles into brain-machine interfaces promotes rehabilitation and functional recovery.” Hamilton, an assistant professor in the Moody College’s Department

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of Speech, Language, and Hearing Sciences, maps where speech is processed in the brain. She already studies the brains of adolescents preparing for epilepsy surgery, mapping where speech functions occur. Her expertise will be critical in identifying prime areas for rewiring — and assessing whether the rewiring has been successful. “Speaking, language and communication are critical functions in our everyday lives,” said Hamilton, also an assistant professor in Dell Med’s Department of Neurology. “By mapping out specific aspects of language in the brain, including not only the words that are heard but also the melody of a loved one’s voice, we hope to understand which brain areas should be preserved, as well as which functions may be at risk. By harnessing the power of the brain to rewire itself, we hope to provide better outcomes for our patients.” A pioneer in the field of functional neurosurgery and minimally invasive skull base surgery and a researcher of brain-machine interfaces, Tyler-Kabara, who has trained surgeons for internationally successful brain-computer interface

programs, will perform the surgeries involved in the study. She also serves as chief of pediatric neurosurgery and co-chief of pediatric neurosciences at UT Health Austin, the clinical practice of Dell Med. “This extraordinary gift allows us to bring together the world-class researchers at UT in the field of brain-machine interfaces and apply our existing knowledge to help improve the quality of life for our patients. The opportunity to incorporate state-of-the-art virtual reality, which has already proved beneficial in training patients to use brain-machine interfaces, will enhance patient engagement,” Tyler-Kabara said. “The success of brain-machine interfaces in improving patients’ outcomes requires that we explore new and creative applications like this one.” Preparing for surgery — a controlled, precise brain injury — is not the only application for inducing neuroplasticity. It also promises to help people recover after brain illness or injury.

Austin Medical Times is Published by Texas Healthcare Media Group, Inc. All content in this publication is copyrighted by Texas Healthcare Media Group, and should not be reproduced in part or at whole without written consent from the Editor. Austin Medical Times reserves the right to edit all submissions and assumes no responsibility for solicited or unsolicited manuscripts. All submissions sent to Austin Medical Times are considered property and are to distribute for publication and copyright purposes. Austin Medical Times is published every month P.O. Box 57430 Webster, TX 77598-7430

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