VOL. LVII • NO. 8 • 2016
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VOL. LVII • NO. 8 • AUGUST 2016
EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD
THE ASSOCIATION President Daniel P. Edney, MD President-Elect Lee Voulters, MD
MANAGING EDITOR Karen A. Evers
Secretary-Treasurer Michael Mansour, MD
PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD Ex-Officio and the Editors
Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Executive Director Charmain Kanosky
JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: 662-236-1700, Fax: 662-236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2016 Mississippi State Medical Association.
Official Publication
MSMA • Since 1959
SPECIAL ARTICLE Mississippi Telemedicine: Interviews with the Innovators Mary Jane Collins, DHA; Claude Brunson, MD; Ellen Jones, PhD
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SCIENTIFIC ARTICLES Top 10 Facts You Should Know about Melanoma Ashton B. Davis, BS; Vinayak K. Nahar, MD, MS, PhD; Robert T. Brodell, MD; Stephanie K. Jacks, MD
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Case Report: Unusual Manifestations of NSAID Overdoses Nicholas E. Hoda, MD; Robert L. Galli, MD
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DEPARTMENTS From the Editor – The Perils of Telemedicine Lucius M. Lampton, MD, Editor
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Legalese - Patient Health Information Breaches: What Now? Rusty Comley, JD; Abram Orlansky, JD
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Poetry and Medicine Robert Ray “Bob” McGee, MD
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President’s Page – Address of the 148th President Dan Edney, MD Daniel P. Edney, MD; MSMA President
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MSMA Physicians Leadership Academy – Daniel Venarske, MD
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Una Voce– What Happened to National Doctor’s Day? Dwalia S. South, MD
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RELATED ORGANIZATIONS AMA– New Policies UMMC–“Queen of GME” Reduces Hours but not Commitment
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ABOUT THE COVER Howlin’ Wolf’s “Little Red Rooster” on the side of West Point’s Main Street Depot—Pictured on the cover is part of a larger mural painted on a
century-old brick wall dedicated to Clay County native Chester Burnett, also known as “Howlin’ Wolf.” The Howlin’ Wolf Blues Museum opened its doors on Thursday, September 1st, 2005, with a dedication ceremony to pay homage to the Wolf and Mississippi’s blues heritage. Rev. Slick and Blind Mississippi Morris provided music. The museum is located at 307 W. Westbrook Street. Held every Labor Day weekend, this year’s festival marks the 11th year as new blues awareness enlightens and enhances the community. There is a sense of pride that a bona fide music legend was born in White Station out in the countryside, just three miles from West Point. Richard Ramsey, program director for the local Howlin’ Wolf Blues Society and curator for the Howlin’ Wolf Blues Museum, remembers sneaking out to White Station at age 13 to see and hear Wolf play in a local juke joint called Roxy’s. He was in awe as Wolf stuck one harp under his nose and another harp to his lips and blew them both at the same time! Wolf sang and wailed, his eyes rolled back, and he crawled on the floor as the music rocked the juke joint and people danced and swayed to the hypnotic sounds. Little did young Richard know, as he watched Wolf work his musical magic, that years later he would play a role in bringing local recognition, pride, and appreciation to this legend of the blues? Ramsey notes Mr. Sam Phillips, of Sun Records, was the first to record “The Wolf.” Photo by Martin Pomphrey, MD. VOL. LVII • NO. 8 • 2016
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F R O M
T H E
E D I T O R
The Perils of Telemedicine Sometimes, the TV really is talking to you. The geri-psych facility in my rural hospital is utilizing telemedicine with some of their psychiatry sessions. The practice of psychiatry seems a fertile field for telemedicine, especially in rural areas with profound deficiencies in psychiatrist numbers. Psychiatry is more cognitive as an art than physical, with much of the psychiatric skill interviewing, listening, Lucius M. Lampton, MD watching, and interpreting a visual and Editor audio scene, not touching and physically examining. (That said, of course the human touch is important in psychiatry, but with a primary care physician on the ground to place a hand on the patient or with an established psychiatric relationship, positive and high quality psychiatric care can be rendered via telemedicine.) No better and natural alliance is there with primary care than psychiatry, except for perhaps public health. The future of psychiatry no doubt will be enhanced with the training of our primary care physicians to be skilled partners in psychiatric care, with improved
psychiatric access in every primary care clinic. Right now, without telemedicine, there is no psychiatrist available for large numbers of our citizens. Imagine a family physician in rural Mississippi who has a patient present with profound depression consulting a psychiatrist immediately via telemedicine in their office and obtaining prompt psychiatric care. Down in Magnolia, the first day of telemedicine went very well, with positive interaction achieved. Before the first interviews, the nursing staff explained to the patients that the psychiatrist Dr. “X” was going to talk to them today over the television. All had previously seen Dr. X and seemed to understand and enjoy the experience. Sounds easy, perhaps? However, for those with schizophrenia and dementia, with active delusions and hallucinations, telemedicine can have its perils. After interviews and other organized activities, the patients are placed in a large day room to relax, sitting in their wheelchairs or on the couch, their eyes glued to the usual TV fare of sitcoms, talk-shows, or some other neon buzz. For the rest of the week, I heard the nurses talk of some patients thinking “Dr. X” was counseling them over the TV when it was actually Andy Griffith, Dr. Phil, or Ellen. Contact me at LukeLampton@cableone.net. — Lucius M. Lampton, MD, Editor
JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic
Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford
Michael Artigues, MD Pediatrician, McComb Children’s Clinic
Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg
Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of Mississippi Medical Center, Jackson Rep. Sidney W. Bondurant, MD Retired Obstetrician-Gynecologist, Grenada Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Matthew deShazo, MD, MPH Assistant Professor-Advanced Heart Failure/ Transplant Cardiology, University of Mississippi Medical Center, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist, Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson
248 VOL. 57 • NO. 8 • 2016
Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport
Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson
Lillian Lien, MD Professor and Director, Division of Endocrinology, University of Mississippi Medical Center, Jackson
Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson
William Lineaweaver, MD Editor, Annals of Plastic Surgery, Medical Director, JMS Burn and Reconstruction Center, Brandon
Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland J. Edward Hill, MD Family Physician, North Mississippi Medical Center, Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Daniel W. Jones, MD Sanderson Chair in Obesity, Metabolic Diseases and Nutrition Director, Clinical and Population Science, Mississippi Center for Obesity Research, Professor of Medicine and Physiology, Interim Chair, Department of Medicine Ben E. Kitchens, MD Family Physician, Iuka
Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems Heddy-Dale Matthias, MD Anesthesiologist, Critical Care Internist, Madison Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood
Jack D. Owens, MD, MPH Neonatologist, Newborn Associates, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Shou J. Tang, MD Professor and Director, Division of Digestive Diseases, University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon, Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer, Brentwood Behavioral Healthcare, Flowood Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson
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WE’RE GROWING AGAIN Mississippi Sports Medicine & Orthopaedic Center is proud to announce
James A. “Jimbo” Moss, Jr. is joining the practice.
Jimbo Moss, a fellowship-trained hand and wrist specialist, returns to his native Jackson to join the team of specialists making sub-specialized expert number 17.
BACHELOR’S DEGREE: University of Mississippi, Engineering MEDICAL DEGREE: University of Mississippi Medical Center RESIDENCY: University of Mississippi Medical Center FELLOWSHIP: University of Alabama at Birmingham Medical Center, Hand and Microsurgery
Make an appointment by web, mobile app, or phone. 601.354.4488 www.MississippiSportsMedicine.com
Any Age. Any Sport. Any Injury. We’ve got you covered.
Mississippi Sports Medicine • Full-Service Orthopaedics • 17 Specialists Jackson • Madison • Flowood
S P E C I A L
A R T I C L E
Mississippi Telemedicine: Interviews with the Innovators MARY JANE COLLINS, DHA; CLAUDE BRUNSON, MD; ELLEN JONES, PHD MARY JANE COLLINS, DHA., CLAUDE BRUNSON, MD, ELLEN JONES, PHD
Introduction Health disparities and poor health behaviors continue to plague MissisIntroduction
sippi. low ratio of physicians to the behaviors populationcontinue places every HealthThe disparities and poor health to county plague in the state in a medically underserved category. In an effort to reMississippi. The low ratio of physicians to the populationalign places sourcescounty and provide citizens,underserved Mississippi has taken action every in the access state intoaits’ medically category. In an in the form of telemedicine. By enacting legislation and supporting the effort to align resources and provide access to its citizens, Mississippi innovative accessintothe theform population and amongBypractitioners, Missishas taken action of telemedicine. enacting legislation sippi leaders have provided an alternative that could not only increase and supporting the innovative access to the population and among access but hasMississippi the potential to savehave significant spending when compractitioners, leaders provided an alternative that pared with office and emergency room visits.save As asignificant result, the could not traditional only increase access but also potentially University of Mississippi Medical alongoffice with private telemedispending when compared with Center, traditional and emergency cine providers havea not only connected patients physicians, but have room visits. As result, the University of toMississippi Medical provided an avenue for physician to specialist communication and Center, along with private telemedicine providers, have not cononly sultation. Since its beginnings in Mississippi, quickly connected patients to physicians but have telemedicine provided an has avenue for grown to address the needs of the population. the treatment of physician-to-specialist communication and From consultation. Since existing conditions to actively participating in wellness care, telemediits beginnings in Mississippi, telemedicine has quickly grown to cine attempts to offer applications in aligning thetreatment state’s resources and address the needs of the population. From the of existing establishing needed resources for the betterment of the population. conditions to actively participating in wellness care, telemedicine attempts to offer applications in aligning the state’s resources and In this landscape, made strides inofoffering compreestablishing neededinnovators resourceshave for the betterment the population. hensive care to the underserved population. Two pioneers in the fieldthis are The University of Mississippi Center,ina universiIn landscape, innovators have Medical made strides offering ty-based telemedicine provider and Telehealth One, the state’ s first comprehensive care to the underserved population. Two pioneers private telemedicine Through research, Medical strategic Center, planning,a in the field are The supplier. University of Mississippi and quality improvement, theseprovider, suppliersand notTelehealth only provide access university-based telemedicine One, the but also provide valuable insight into the future of telemedicine in state’s first private telemedicine supplier. Through research, strategic Mississippi.and Mary Jane improvement, Collins, D.H.A,these askedsuppliers these Telehealth planning, quality provideleadnot ers to share their experience and thoughts about opportunities for only access but also valuable insight into the future of telemedicine patient outreach,Mary provider support,D.H.A., and better outcomes. in Mississippi. Jane Collins, askedhealth these Telehealth Representatives of these innovative providers share how they are leaders to share their experience and thoughts about opportunities using telemedicine, what applications exist outside the hospital sysfor patient outreach, provider support, and better health outcomes. tem, what challenges lie ahead, and what Mississippi Representatives of these innovative providers share physicians how they can are expect from telemedicine as relates to the health of the population. using telemedicine, what applications exist outside the hospital system, what challenges lie ahead, and what Mississippi physicians can expect from telemedicine as it relates to the health of the population.
Richard Summers, MD, is the Associate Vice Chancellor for Research at the University of Mississippi Medical Center.
Richard Summers, MD, Associate Vice Chancellor Mary Jane Collins (MJC): for Research, University of Dr. Summers, from the perMississippi Medical Center
spective of Associate Vice Chancellor for Research at Summers the University of Mississippi Medical Center, how is teleMary Jane Collins Dr. Summers, from the medicine being used in(MJC): Mississippi? perspective of Associate Vice Chancellor for Research at University of Mississippi Medical how is Dr.the Summers: Telemedicine began in this stateCenter, almost 13 years ago as a meansbeing to support care in critical access hostelemedicine usedemergency in Mississippi?
pitals. It is currently being used in a variety of specialty formats ranging from telemergency to telepsychiatry telepathology in Dr. Summers: Telemedicine began in thisto state almost 13 almost all as corners of our state. The telehealthcare services at theaccess Uniyears ago a means to support emergency in critical versity of ItMississippi includeofover 30 different hospitals. is currently(UMMC) being usednow in a variety specialty formats medical including to adult and pediatrictospecialties, and ranging specialties, from telemergency telepsychiatry telepathology extend to more than 100 clinical sites. The underlying principle in almost all corners of our state. The telehealth services at the in each of these venues is (UMMC) that telemedicine is intended todifferent support University of Mississippi now include over 30 the existing local infrastructure rather trying specialties, to usurp orand remedical specialties, including adult andthan pediatric place the workforce already available. The greatest use has been extend to more than 100 clinical sites. The underlying principle in each rural of communities varied services do not exist or these venueswhere is thatthese telemedicine is intended to support are only available at certain limited time periods. It is our experithe existing local infrastructure rather than to usurp or replace ence that our Mississippi patient population hasuse greathaschallenges the workforce already available. The greatest been in in transportation often presents the appropriate medical rural communitiesand where these variedto services do not exist or are specialist late. This technology takes the service to the patient available only at certain limited time periods. It is our experience rather than trying to accomplish the oftenhas difficult of bringthat our Mississippi patient population great task challenges in ing the patient to the place where they can get the help they need. transportation and often presents to the appropriate medical specialist late. This technology takes the service to the patient MJC: What applications existtheoutside of thetask hospital sysrather than trying to accomplish often difficult of bringing tem? the patient to the place where they can get the help they need.
Dr. Summers: With the widespread availability of broadband MJC: What applications exist outside of the hospital technology and the almost ubiquitous presence of audio and visual system? JOURNAL MSMA
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Dr. Summers: With the widespread availability of broadband tech-
nology and the almost ubiquitous presence of audio and visual communications, telemedicine can be practiced almost anywhere. I had some firsthand experiences with telemedicine being used on the International Space Station and realized that literally the sky was the limit. Most recently, telemedicine consultation by our UMMC staff has been used in home monitoring of some patients with chronic disease states that require daily surveillance. But we are also providing some corporate telehealth consultation services available at the worker’s office desk computer and plan to enhance some student health services in the near future. With our fast paced society and the limited availability of health care providers, these services will hopefully provide timely and ready access to professional advice regarding minor medical illnesses, increase worker productivity and reduce absenteeism. The challenge for the healthcare provider in offering these kinds of services outside a medical facility is in delivering adequate and safe care.
MJC: What are short-term and long-term challenges for telemedicine? Dr. Summers: We are still in the process of learning how to pro-
vide good telemedicine services in an atmosphere of an ever evolving healthcare environment. And this learning process is happening with both the provider and the patient. The available technology is also growing at an exponential rate and there is an inherent cost associated trying to keep up with the latest changes. However, I foresee that our most difficult challenge will be in determining what really works in the practice of telemedicine and how can it most effectively be used. There is a limited objective evidence base to the practice of telemedicine, and we need a considerable amount of research centered around patient outcomes to inform our future efforts. There also need to be national guidelines developed for this new type of clinical practice. It is probable that the control and oversight of medical providers will no longer be limited to that within state boundaries. Liability issues will also undoubtedly be a part of the new landscape. I do not think we even know what all our challenges will be, and they may change with time. However, it is certain that the promise that the technology could bring will outweigh any of these challenges.
MJC: What can local doctors look forward to in the future of telemedicine and better health? Dr. Summers: I think one of the greatest difficulties that primary care
physicians practicing in limited rural environments have encountered in recent years is the implicit requirement to provide state-of-the-art care in a world with increasing medical specialization and advancing diagnostic and treatment technologies. Yet, they provide an incredibly important role as the frontline in these disparate and underserved areas of our state. Telemedicine offers the promise of supporting these healthcare providers with the tools and nuanced expertise that would be available to any patient in any large city in the United States. Hopefully, by embracing the advantages that telemedicine might provide, 252 VOL. 57 • NO. 8 • 2016
these heroes of the medical community will no longer feel as though they are lone foot soldiers in our battle against health disparities.
Melissa H. King, DNP, FNP-BC, ENP-BC, Director of Advanced Practice Providers, Director of TelEmergency, University of Mississippi Medical Center
King
MJC: Dr. King, from the perspective of the Director of TelEmergency at the University of Mississippi Medical Center, can you tell me more about how telemedicine is currently being used in Mississippi? Dr. King: Mississippi has high levels of poverty and the worst
health outcomes in the country. There is only one academic medical center, and 65% of MS residents must drive over 40 minutes for specialty care. Basically, telemedicine in being used throughout the state to improve access, reduce health cost, and improve health status. It is being used to help the entire healthcare eco-system. With the use of technology, we are not only providing remote medical care but also promoting health education, building partnerships, enhancing clinician recruitment and retention, and keeping patients and families in their communities. UMMC’s Center for Telehealth offers wellness care, disaster response, workforce development, business development, and education to people in all parts of our state. Since our program’s inception in 2003, we have provided high quality emergency care to many Mississippians in need. With over 30 different specialties, our services currently extend to over 100 clinical sites and provide care across the lifespan. UMMC’s Center for Telehealth is eliminating geographical barriers to quality health care for Mississippians. Basically, Telemedicine in MS is equipping providers and health systems with innovative tools to provide patient centered quality healthcare to a larger population with more efficiency.
MJC: What applications exist outside of the hospital system? Dr. King: Applications available outside hospital system are vast
and multifactorial. These include clinics, schools, corporations, colleges, prisons, urgent care centers, and patient’s homes. Pretty much, any place there is a gap, telemedicine can be the filler.
Specialty care includes allergy, immunology, dermatology, endocrinology, nephrology, obstetrics, gynecology, infectious diseases, ophthalmology, pulmonology, radiology, sleep medicine, wound care, and pediatrics. As an example of specialty offerings, cardiology services provide EKG reading services, Echo reading services, Holter reading services, stress test reading services, CTA reading services, and teleconsults. Telemedicine can be provided via store and forward, remote monitoring, or real-time interactive services. In an attempt to align providers and/or communities with appropriate service lines and setting UMMC apart from other telemedicine providers, we provide a gap analysis tool to assist in customization of services. Whether through education, training, business development, strategic planning, or linking to existing services, we support developing a strong local community health base both inside and outside the hospital. Finding the right telehealth access point that bridges the gap and is sustainable is key to success for all applications and services.
Dr. King: The future is exciting and is whatever we want it to be in
the realm of telemedicine. As healthcare hits this paradigm shift, technology will be an indispensable part of the equation. Telehealth is at the heart of the population health trend! Overall, we hope to improve Mississippi’s population health, improve the health of healthcare systems, and generate quality data to drive healthcare decisions. Telemedicine should be used as a tool that acts as a cost effective portal to improve quality care. The future can offer positive population health trends, more patient medical homes, decrease in emergency related expenses, and decrease in costly hospital readmissions. Supporting wellness care, we hope to find more engaged wellness centers in lieu of chronic care centers. Telemedicine has the ability to aid in creating an efficient health care system with a healthy population and a healthy Mississippi. UMMC hopes to stay engaged as a leader in this vision.
MJC: What are short-term and long-term challenges for telemedicine?
David Powe, Ed.D, Chair, Board of Directors, TeleHealthOne, LLC
Dr. King: Short-term challenges include regulatory, licensing, and
reimbursement barriers. Also, eliminating the misconception that rural areas are the only areas that benefit from telemedicine needs to be common language. Multiple hubs that share and maintain quality with strategy led at the state level will be key in the future. However, our goal has been and will always be to improve access, improve outcomes, and eliminate disparities. At the heart is the patient and adherence to standard of care. Short-term, we are working to increase knowledge and set a standard of care for telemedicine. Telehealth standards should always mirror those of bedside care. Through evaluation and strategic planning, we are working to improve efficiencies in the health care system. Our message is that telemedicine is a method to increase capacity of provider practice, increase efficiency, and allow more face-to-face time for more complex conditions. In the case of emergency medicine, time is brain and time is muscle. With time being quality and a performance based metric, telemedicine can help eliminate the time barrier and improve quality emergency care despite a patient’s geographical location. Our central long-term challenge surrounds data sharing and technology. We must leverage tools that are cost effective that also maintain quality. We are evaluating the flow of data, creating metrics, and creating a system of data sharing to measure success. But again, at the heart of the telemedicine is the patient while ensuring standard of care and maintaining quality. We continue to measure and evaluate quantitative outcomes for developing standard of care for telemedicine, while extending this care across borders nationally and internationally.
MJC: What can local doctors look forward to in the future of telemedicine and better health?
Powe
MJC: Dr. Powe, from the perspective of Chairman of the Board of Directors of TeleHealthOne, can you tell me more about how telemedicine is currently being used in Mississippi? Dr. Powe: TeleHealthOne is the first privately owned telemedi-
cine company located in Mississippi. The company focus is to provide convenient access to healthcare, at an affordable cost, with the ultimate goal to provide quality outcomes for patients. For simple problems this could reduce the number of potentially non-emergent emergency room visits on an already overtaxed healthcare system. In Mississippi, telehealth visits are being sought to treat complaints of sinus/ear infections, sore throats, respiratory infections, skin problems, urinary tract infections, and allergies. Consultations may also address mental health symptoms including anxiety, depression, and life changes. In addition, telemedicine is being used for primary and specialist referral services, remote patient monitoring, and to access consumer medical and health information. Primary care and specialist referral services may involve a primary care or allied health professional providing a consultation with a patient or a specialist assisting the primary care physician in rendering a diagnosis. This may involve the use of live interactive video or the use of store and forward transmission of diagnostic images, vital signs and/or video clips along with patient data for later review. Remote patient monitoring, including home telehealth, uses devices to
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remotely collect and send data to a home health agency or a remote diagnostic testing facility (RDTF) for interpretation. Such applications might include a single, specific vital sign, such as blood glucose, or a variety of indicators such as blood pressure, ECG, weight, pulse oximetry, etc. Such services can be used to supplement the use of visiting nurses. Medical and health information may be shared securely by consumers to obtain specialized health information and in on-line discussion groups to provide for peer-to-peer support.
MJC: What applications exist outside of the hospital system? Dr. Powe: There are many, including primary care offices, pharma-
cy based clinics, outpatient services, and nursing facility care services. Telemedicine can be and is being used for consultation, patient education, care transition, and counseling. Both individual and group health behaviors can be assessed and followed with intervention services. As an example, assessments and intervention services for alcohol and substance abuse can be accomplished via telemedicine. Patient educational services include disease education services, diabetes self-management training services, and smoking cessation services. Telemedicine can be used to help bridge transition of care with services such as pharmacological management, individual and group medical nutrition therapy, and stroke management services. The modality can also be used outside the hospital to interview and counsel individuals, families, and other groups with issues of psychotherapy and behavioral health concerns.
MJC: What are short term and long-term challenges for telemedicine? Dr. Powe: Physicians face an increasing array of non-clinical de-
mands on their time — in some practices doctors spend as much time working on documentation and sorting through insurance denials as they do seeing their patients. With the expansion of both private healthcare insurance and Medicaid in many states under the provisions of the Patient Protection and Affordable Care Act (ACA), demand for healthcare services has increased while the amount of time doctors have to see new patients has been reduced. Patients, too, face long wait times at their physicians’ offices, often for minor ailments or routine follow-ups. Because consultations can be difficult to schedule, patients often skip follow-up visits. This not only erodes the doctor-patient relationship but also potentially puts the patients’ health at risk. Telemedicine solutions can help physicians provide more convenient, real-time interactions with their patients while simultaneously relieving the scheduling pressure on the physician practice. Telemedicine (sometimes referred to as telehealth) is a suite of technology solutions that enable doctors to communicate with and treat patients via text, video, and remote monitoring, while also enabling improved communication with other physicians and staff. Telemedicine is one of the fastest growing segments in healthcare. According to the American Telemedicine Association, there are currently about 200 telemedicine networks with 3,500 service sites in the U.S., 254 VOL. 57 • NO. 8 • 2016
and nearly 1 million Americans are currently using remote cardiac heart monitors. Half of all U.S. hospitals now use some form of telemedicine. A study by Global Data indicates that the worldwide telehealth and telemedicine market was set to grow 14% between 2011 and 2018, while the 2014 World Market for Telehealth report from HIS Technology estimates the number of patients using such services will increase to 7 million in 2018. The potential for telemedicine is vast, but before it can be realized, a number of challenges must be overcome. High-speed internet access is not yet available in some areas of the country, and telemedicine’s role in the transition to a fee-for-performance model needs to be supported by clearer reimbursement guidelines. Despite the positivity surrounding the field of telemedicine, a number of issues remain to be addressed, not the least of which is access to a broadband connection. Many rural clinics and many patients themselves don’t have high-speed internet access. As an example, in states like New Mexico, which are large or have large areas of rough terrain, remote care would be a valuable service to patients, but greater connectivity is needed. Hospitals and health systems are implementing telemedicine programs. Virtual health coaches, web consults with specialists, telemedicine hospital rooms, and cloud-based physicians are increasingly common. Telemedicine and telehealth have the potential to increase access to care, improve quality of care, and decrease costs. Hospitals and other health systems in rural areas have seen faster adoption of telemedicine implementation because of the needs of the population and geographical constraints. Travel times, lack of specialty physicians, and smaller hospitals witness a vast improvement in quality of care thanks to telemedicine. However, telemedicine could significantly influence the entire healthcare industry in urban, community, and even international settings.
MJC: What can local doctors look forward to in the future of telemedicine and better health? Dr. Powe: Because rural communities face specific challenges regard-
ing access to health care providers, they historically have suffered health disparities compared to urban communities. While the Affordable Care Act created programs to strengthen the health care workforce, rural communities are likely to continue experiencing provider shortages and inadequate access to care. Telehealth allows an opportunity to help ameliorate this problem. Equipped in many ways to serve rural health needs, telehealth allows patients, providers and state governments to leverage existing provider networks and potentially improve rural health outcomes. Although challenges exist, telehealth continues to expand and offer new services as technology advances; state governments are working to keep pace. Despite its challenges, however, telehealth, coupled with many other rural health policy initiatives, has the potential to revolutionize rural health care. Through telemedicine, the public will be provided greater access to healthcare at a lower cost, thus
increasing the engagement of local doctors for primary care services. Aligning resources to meet patient needs, telemedicine has the potential not only to increase access to care but also to lower healthcare costs for all parties. State leaders and legislators continue to support reimbursement and growth of these services for Mississippi’s underserved population. Collectively, the University of Mississippi Medical Center and TeleHealthOne have identified a comprehensive focus on primary care, specialist care, behavioral care, and wellness services. Though vast applications exist inside and outside the physical hospital setting, both entities point to adoption of telemedicine as a challenge. These pioneers also agree that telemedicine will expand while improving services and technology. With attention to wellness care, providers state a healthier workforce and a healthier population as a primary goal. Through legislative support and the vision of innovative providers, telemedicine offers a healthcare alternative for many Mississippians who need care.
rather than becoming a threat or competitor as perceived by many. The state of Mississippi has invested millions of dollars in such programs such as rural scholarship programs and a new medical school building at the University of Mississippi Medical Center to increase the number of physicians in training, all in an effort to get more physicians into rural areas to practice. The economic impact of getting a physician to set up practice in a rural community adds approximately two million dollars per annum to that local economy, a very good return on investment to the state for these programs. For these rural practitioners, who often take care of uninsured and underinsured patients, the threat of telemedicine taking any of their few commercial pay patients that help to offset the cost of care for these indigent care patients could be the difference between remaining in practice in that community or closing shop to move to more lucrative environments, further exacerbating the access to care issues in those communities.
Conclusion
Telemedicine has the potential to bring highly specialized services to areas with limited access to specialty medical care, provide economic sustainability to local primary care medical practices while augmenting the local economy by keeping patients and their dollars in their communities and bending the cost curve of ever increasing health care costs. A full understanding and integration of telemedicine into the medical care system across the state should move us toward the goal of a healthier Mississippi. n
One final challenge to full integration of telemedicine to improve access to care and to improve the health of Mississippians is adoption of this modality of medical practice into the practice of physician providers throughout the state, especially rural medical practices. It is incumbent on telemedicine providers to educate these practitioners on how telehealth can augment their practices and improve the care they provide to their patients, especially the potential to offer specialty services and actually improve the sustainability of their practices
Author Information
Mary Jane Collins, DHA, CRNA is one of the first graduates from the Doctor of Health Administration Program. The University of Mississippi Medical Center (UMMC) offers the state’s only doctoral program in health administration (DHA). This program trains leaders in administration, education, and clinical areas to navigate changes in the healthcare environment and strategically plan for the future. Faculty at UMMC and partner experts offer students a unique opportunity to obtain the DHA in a three year, on-line cohort model. For more information visit https://www.umc.edu/DHAinfo/. Collins
Claude D. Brunson, MD, Professor, Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center
Ellen Jones, PhD, Assistant Professor of Health Administration, School of Health Related Professions, University of Mississippi Medical Center
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AMA Adopts New Guidance for Ethical Practice in Telemedicine CHICAGO – New ethical guidance adopted at the American Medical Association’s (AMA) June Annual Meeting will help physicians understand how their fundamental responsibilities may play out differently when patient interactions occur through telemedicine, compared to traditional patient interactions at a medical office or hospital. The new ethical guidance on telehealth and telemedicine was developed over the past three years by the AMA’s Council on Ethics and Judicial Affairs and adopted by a vote of physicians from every corner of the country. The development of the new guidelines coincides with innovations in technology that are changing the ways in which people live their lives, including reshaping the ways they engage with medicine. “Telehealth and telemedicine are another stage in the ongoing evolution of new models for the delivery of care and patient-physician interactions,” said AMA Board Member Jack Resneck, MD. “The new AMA ethical guidance notes that while new technologies and new models of care will continue to emerge, physicians’ fundamental ethical responsibilities do not change.” In any model for care, patients need to be able to trust that physicians will place patient welfare above other interests, provide competent care, provide the information patients need to make well-considered decisions about care,
respect patient privacy and confidentiality, and take steps needed to ensure continuity of care. The evolution of telehealth and telemedicine capabilities offers increasingly sophisticated ways to conduct patient evaluations as technologies for obtaining patient information remotely continue to evolve and improve. The AMA guidelines permit physicians utilizing telehealth and telemedicine technology to exercise discretion in conducting a diagnostic evaluation and prescribing therapy, within certain safeguards. “Physicians who provide clinical services through telemedicine must recognize the limitation of the relevant technologies and take appropriate steps to overcome those limitations,” said Dr. Resneck. “What matters is that physicians have access to the relevant information they need to make well-grounded recommendations for each patient.” The AMA guidelines also recognize that a coordinated effort across the profession is necessary to achieve the promise and avoid the pitfalls of telemedicine. Active engagement should support ongoing refinement of telemedicine technologies and relevant standards while also promoting initiatives that will help make needed technology more readily available to all patients who want to use telemedicine services. n
New Policy Builds upon the AMA’s Efforts to Create the Medical School of the Future Recognizing that formalized training in telemedicine is not widely offered to physicians-in-training, the American Medical Association (AMA) also adopted policy aimed at ensuring medical students and residents learn how to use telemedicine in clinical practice. The new policy specifically encourages the accrediting bodies for both undergraduate and graduate medical education to include core competencies for telemedicine in their programs. The new policy also reaffirms existing AMA policy, which supports reducing barriers to incorporating the appropriate use of telemedicine into the education of physicians. “The vast majority of medical students are not being taught how to use technologies such as telemedicine or electronic health records during medical school and residency. As innovation in care delivery and technology continue to transform healthcare, we must ensure that our current and future physicians have the tools and resources they need to provide the best possible care for their patients,” said AMA Immediate Past President Robert M. Wah, MD. “In particular, exposure to and evidence-based instruction in telemedicine’s capabilities and limitations at all levels of physician education will be essential to harnessing its potential.” Today’s policy action extends the AMA’s ongoing work with 32 of the nation’s leading medical schools to create the medical school of the future. As part of the AMA Accelerating Change in Medical Education Consortium, the 32 schools are working together through a learning community to incorporate the newest technologies that will help prepare future physicians to practice in
the changing health care environment and better provide health care services to underserved populations. Several of the schools are developing and implementing innovative projects focused on technology. For example, Indiana University School of Medicine created a teaching electronic health record (EHR) using de-identified data to ensure medical students have access to EHRs during their medical training, which is now being implemented in other medical schools. Additionally, the University of North Dakota School of Medicine and Health Sciences is using advanced simulation and telemedicine technologies to help students develop skills specific to the needs of rural or remote communities. The AMA launched its Accelerating Change in Medical Education initiative in 2013 to bridge the gaps that exist between how medical students are trained and how healthcare is delivered. The AMA has since awarded $12.5 million in grants to 32 medical schools to develop innovative curricula that can ultimately be implemented in medical schools across the country. These innovative models are already supporting training for an estimated 19,000 medical students who will one day care for 33 million patients each year. The AMA’s initiative is also supporting medical school projects aimed at accelerating student progression through medical school, allowing them to enter residency sooner and contribute more rapidly to expanding the physician workforce. n
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Top 10 Facts You Need to Know about Melanoma Ashton B. Davis, BS; Vinayak K. Nahar, MD, MS, PhD; Robert T. Brodell, MD; Stephanie K. Jacks, MD
Malignant melanoma (MM) is a tumor that results from the malignant transformation of melanocytes, the cells of the skin that produce the pigment responsible for skin color. MM is the most deadly form of skin cancer due to its aggressive nature, with an overall mortality rate of 2.7 per 100,000 men and women per year. While other relatively benign forms of skin cancer such as basal cell carcinoma and squamous cell carcinoma very rarely metastasize, MM is associated with a vertical growth phase that increases the risk of metastasis of this tumor to sites other than the skin. During this phase, tumor cells grow deeper into the skin, and some subtypes of MM are associated with a particularly rapid progression to the vertical growth phase. As the depth of the melanoma increases, survival rates correspondingly decrease. Thanks to increasing public awareness, including the ABCDEs of MM campaign, more of these aggressive tumors are being detected at earlier stages when complete excision can be curative. Options for treating MM have expanded greatly in recent years improving the outlook even for patients with metastatic melanoma. Table 1. The Early Detection of Malignant Melanoma using ABCDE Mnemonic.
The ABCDEs of Melanoma Asymmetry
One half unlike the other half
Border
Irregular, scalloped, or poorly defined border
Color
Varied from one area to another; shades of tan, brown, or black; sometimes white, red or blue
Diameter
Melanomas are usually greater than 6mm (the size of a pencil eraser) when diagnosed; however, they can be smaller
Evolving
A mole changing in size, shape or color. The “ugly duckling” nevus that is different than the other nevi on the patient is another indication of change.
The top 10 facts you need to know about melanoma are:
1
Early diagnosis can save a life. A landmark, large-scale study of the general population in Germany from 2003-04 showed that skin cancer screening by a physician led to a 47% reduction in mortality from MM among men and 49% reduction among women. Multiple other studies have shown that MM detected during both routine physical examinations by primary care physicians and by dermatologists during focused skin examinations are significantly thinner, which leads to decreased deaths from MM.1
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2 3
Many melanomas are asymptomatic. The most frequent signs or symptoms of MM are changes in size or color of a pigmented lesion on the skin, but the onset of bleeding, itching, or pain; breakdown of the skin; or a lump under the skin are also causes for concern. About one out of four patients with MM will experience no symptoms at all that would raise suspicion for the diagnosis.2
While most melanomas initially grow radially (outward), some immediately grow downward without lateral growth: Nodular melanoma. Nodular melanoma accounts for up to 15% of all MM, and they most commonly present as a blue-black to red nodule on the trunk, head, or neck. As a consequence of the vertical growth, these tumors tend to be diagnosed at a thicker, more advanced stage and have a poorer prognosis.3
4 5 6 7
Some melanomas have no pigment at all: Amelanotic melanoma. Amelanotic melanoma is a particularly challenging diagnosis to make, as the lesions do not show the characteristic pigment of the other more common types. Amelanotic melanoma may be mistaken for basal cell carcinoma, squamous cell carcinoma, or warts. Despite their appearance, amelanotic melanomas behave similarly to pigmented MM in terms of prognosis and response to therapy.3 The depth of the melanoma is the single most important histopathologic prognostic factor. Vertical tumor thickness, also known as Breslow depth, is the most powerful predictor of survival among MM patients. The presence of ulceration, advanced age of the patient, and number of nodal metastases are other important prognostic factors.4
African Americans get a special kind of melanoma: Acral lentiginous melanoma. Acral lentiginous melanoma occurs on the non-sun-exposed areas of the palms, soles, or around the nails. While acral lentiginous melanoma accounts for only 5% of all MM, since darker-skinned people do not typically develop sun-related MM, this subtype represents a disproportionate percentage of MM diagnosed in Africans (up to 70%) and Asians (up to 45%). Diagnosis is often delayed due to lower suspicion of MM at these sites and in darker-skinned populations.3 The minority of melanomas arise from pre-existing moles. Both the number of common moles and the presence of atypical moles are important risk factors for the development of MM, mainly as an indicator of how much sun exposure has occurred in the patient. More than 75% of MM lesions probably arise de novo without a precursor nevus lesion. The risk of any particular mole transforming into MM is very low; therefore, the routine excision of benign-appearing moles is not recommended.3,5,6 Dermatologists use the ABCDE criteria, as well as specialized tools such as dermoscopy, to determine whether a mole should be biopsied for histopathologic examination to rule out MM.
8
Primary melanomas usually arise in the skin, but primary lesions can arise in the eye (retina), GI tract, and nervous system. While MM most commonly originates in the skin, it can arise at any site where melanocytes are found including the mucosal epithelium of the gastrointestinal or genitourinary tracts, the choroidal layer of the eye, and the leptomeninges that surround the brain and brainstem.7
9
The sun is the primary etiologic factor known to cause melanoma that can be affected by preventive measures. The total risk for MM development is probably determined by a combination of genetic factors and exposure to sunlight, particularly intermittent exposures and exposures during childhood and adolescence. A study in Australia demonstrated that regular use of sunscreen with a sun protection factor (SPF) >15 reduced the incidence of MM even 10 years later. Other sun-protective measures include the use of protective clothing and hats and avoiding mid-day sun.8
10
New targeted therapies can extend life in patients with metastatic melanoma, but only a small minority have long term remissions. Until recently, there were few options for treatment for patients with metastatic MM; however, researchers have gained understanding of the errors that occur in cellular signaling pathways leading to the development of MM. Targeted therapies, such as the BRAF inhibitor vemurafenib, aim to overcome the aberrancies in signaling that result from mutated oncogenes. Resistance can develop, however, as alternative signaling pathways are activated in the cells. Combination therapies that target multiple molecules simultaneously are being studied as a way to overcome this resistance.3
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Conclusion While MM accounts for less than 2% of cases of skin cancer, the vast majority of skin cancer deaths are due to MM.9 It is important that physicians are aware of the means to prevent, diagnose, and treat this disease, particularly in a climate such as Mississippi where patients experience increased exposure to the sun.
References 1. Mayer JE, Swetter SM, Fu T, Geller AC. Screening, early detection, education, and trends for melanoma: current status (2007-2013) and future directions: part II. Screening, education, and future directions. J Am Acad Dermatol. 2014;71(4):599.e1-599.e12. 2. Negin BP, Riedel E, Oliveria SA, Berwick M, Coit DG, Brady MS. Symptoms and signs of primary melanoma: important indicators of Breslow depth. Cancer. 2003;98(2):344-8. 3. Bolognia JL, Jorizzo JL, Schaffer JV. Dermatology, 3rd ed. 2012;Philadelphia:Elsevier Saunders. 4. Balch CM, Soong SJ, Gershenwald JE, et al. Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system. J Clin Oncol. 2001;19(16):3622-34. 5. Stadler R, Garbe C. Nevus associated malignant melanomas-diagnostic validation and prognosis. Hautarzt. 1991;42(7):424-9. 6. Stolz W, Schmoeckel C, Landthaler M, Braun-Falco O. Association of early malignant melanoma with nevocytic nevi. Cancer. 1989;63(3):550-5. 7. Das P, Kumar N, Ahuja A, et al. Primary malignant melanoma at unusual sites: an institutional experience with review of the literature. Melanoma Res. 2010;20(3):233-9. 8. Green AC, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol. 2011;29(3):257-63. 9. American Cancer Society. Cancer Facts & Figures 2015. http://www.cancer.org/acs/groups/content/@editorial/documents/document/ acspc-044552.pdf. Accessed February 17, 2016.
Journal of the Mississippi State M
Author Information: 1 Medical Student, School of Medicine, University of Mississippi, 2 2500 N. State St., Jackson, MS, 39216 ABDavis@umc.edu (Ms. 3 Davis). Clinical Affiliate Faculty, Department of Dermatology, University of Mississippi Medical Center, 2500 N. State 4St., Jackson, MS, 39216 and Assistant Professor, Department5of Health, Physical Education, and Exercise Science, School6of Allied Health Sciences, Lincoln Memorial University, 6965 7 Cumberland Gap Parkway, Harrogate, TN 37752 vinayak. 8 nahar@LMUnet.edu (Dr. Nahar). Professor and Chair, 9 Departments of Dermatology; Professor, Department of 10 Pathology, University of Mississippi Medical Center, 2500 11 N. State St., Jackson, MS, 39216 rbrodell@umc.edu. Clinical Instructor, Department of Dermatology, University 12 of 13 Rochester School of Medicine and Dentistry, 601 Elmwood 14 Ave., Rochester, NY 14642 (Dr. Brodell). Clinical Director, Pediatric Dermatology; Assistant Professor, Departments15 of Dermatology and Pediatrics, University of Mississippi Medical 16 Center, 2500 N. State St., Jackson, MS, 39216 sjacks@umc.edu 17 (Dr. Jacks). 18 Corresponding Author: Vinayak K. Nahar, MD, MS, PhD Lincoln Memorial University School of Allied Health Sciences 6965 Cumberland Gap Parkway Harrogate, TN 37752 Phone: (662) 638-5126 E-mail: vinayak.nahar@LMUnet.edu
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CRITICAL CARE/ PULMONARY/ SLEEP FACULTY POSITION The Division of Pulmonary, Critical Care and Sleep Medicine at the University of Mississippi Medical Center is currently seeking faculty at all levels for the Divisions of Critical Care, Pulmonary and Sleep Medicine. Divisional activities are located in the Conerly Critical Care Hospital, the University Hospital, and the G.V. “Sonny” Montgomery Veterans Affairs Hospital. The division has active programs in critical care, cystic fibrosis and interventional pulmonary medicine. The Pulmonary Division has a strong fellowship program. Collaboration with basic sciences and the National Heart Lung and Blood Institute-sponsored Jackson Heart Study is encouraged. Jackson, Mississippi, the state capital, is a family friendly city with a temperate climate, allowing year-round water and sporting activities. Please forward your CV to John Spurzem, M.D., Professor of Medicine and Interim Director, Division of Pulmonary, Critical Care and Sleep Medicine, The University of Mississippi Medical Center, 2500 N. State St., Jackson, Mississippi, 39216. EOE, M/F/D/V Ph: 601-984-5650 or email: jspurzem@umc.edu.
C A S E
R E P O R T
Unusual Manifestations of NSAID Overdoses NICHOLAS E. HODA, MD, PHD; ROBERT L. GALLI, MD Introduction Non-steroidal anti-inflammatory drugs (NSAIDs) are a commonly used class of medication for their antipyretic and pain-controlling properties and are available in over-the-counter and prescription strengths. In general, NSAIDs have been associated with multiple adverse effects, most commonly gastrointestinal toxicity and nephrotoxicity.1 105,545 NSAID exposures were reported in the 2014 National Poison Center database.2 Non-combination ibuprofen was the most commonly reported NSAID exposure (71,615 cases) with 61,902 exposures of only ibuprofen. The second most common exposure was for naproxen (14,060 cases) of which 8,438 involved naproxen alone. Of the ibuprofen alone exposures, 54 exposures resulted in major effects (life-threatening results or significant residual disability or disfigurement) including 2 deaths. Naproxen exposures resulted in 7 major adverse results with no deaths. In fact, the 2 deaths in the ibuprofen alone exposures were the only 2 reported deaths with any NSAID exposure. Given the rarity of the severe morbidity of NSAID exposures, many providers are unfamiliar with the potential side effects other than gastrointestinal and renal effects. For this reason, two case reports with significant adverse effects after NSAID overdoses are presented below.
Case 1 A 17-year-old female with no past medical history was brought to the ER by family with chief complaints of chest pain and shortness of breath that began several days ago. She had several wisdom teeth extracted 2 weeks ago and had been prescribed hydrocodone/ acetaminophen for the pain but her family reported that she had only been allowed to take one of these as they did not want her to develop an addiction to narcotic pain medications. She had reportedly fainted twice at school in the past week for which she had not sought medical care. While waiting to be seen, the patient vomited and collapsed to the ground with generalized weakness in the waiting room. Her triage vital signs were blood pressure of 107/88, heart rate 128 beats per minute, respiratory rate of 24, oxygen saturation of 96% on room air, and a temperature of 97.5 degrees Fahrenheit. She was immediately placed in an examination room where her initial Glasgow Coma Scale (GCS) was estimated to be 14/15 with a very drowsy but arousable appearance. She revealed that she had taken 14 200mg ibuprofen in the past 6 hours to relieve her chest pain. Her fingerstick glucose was 84mg/dL. An arterial blood gas was drawn revealing a metabolic acidosis with respiratory compensation at pH 7.36, paCO2 21mmHg, and paO2 65mmHg on room air. A point-of-care lactate was elevated at 3.8mmol/L. Lab studies including chemistry, liver function tests (LFTs), CBC, urinalysis, urine drug screen (UDS), acetaminophen and salicylate levels, volatile alcohols, and a gas chromatography mass
Figure 1. Relative abundance of ibuprofen on GC/MS for Case 1.
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spectrometry (GC/MS) of her urine were ordered. The patient was placed on oxygen and additional crystalloid fluids were given. Her mental status declined, her heart rate suddenly plummeted to the 50’s, and then she went into cardiac arrest. The patient was unconscious and intubated without any medications. Two rounds of CPR including epinephrine, bicarbonate, and atropine were given resulting in return of spontaneous circulation. She arrested again several minutes later. The initial cardiac rhythm was pulseless electrical activity (PEA) and CPR was resumed. During the arrest insulin, dextrose, and calcium were given in addition to the code drugs for possible hyperkalemia. The code was discontinued after 45 minutes when ultrasound confirmed that her heart had no intrinsic activity. Her laboratory results revealed an anion gap metabolic acidosis (bicarbonate 16, anion gap 21) and hyperkalemia (5.3). LFTs were mildly elevated with a direct hyperbilirubinemia (total 1.13, direct 0.41) and ALT 39, AST 66. The clean catch urine specimen had trace leukocytes, negative for nitrite, large blood, 19 white blood cells, and >100 red blood cells. The toxicology results indicated the absence of acetaminophen, salicylates, ethanol, and volatile alcohols. UDS was positive for amphetamines and otherwise negative. The qualitative GC/MS identified ibuprofen metabolites (Figure 1) and there was no evidence of amphetamines on the GC/MS results. The GC/MS test was not conducted as a confirmatory test, however, which ensures evaluating the sample at lower temperatures at which opiates are stable. Case 2 A 12-year-old female with no past medical problems was brought to the Pediatric ER by her mother with a chief complaint of altered mental status. The patient was asymptomatic that morning prior to going to school. At school, she developed a headache for which she reportedly took a headache pill which she was given by a classmate. She became very drowsy, was speaking nonsensically and with slurred speech , and almost fell out of her chair. The patient’s mother was called to come to the school for her abnormal behavior. The mother reported that her daughter was unable to walk independently out of the school to their car because the patient was so drowsy and weak. The patient was then
driven directly to the Pediatric ER. On arrival, she was placed into an examination room and her vital signs included blood pressure of 121/84, heart rate of 131, respiratory rate of 20, an oxygen saturation of 100% on room air, and a temperature of 97.7 degrees Fahrenheit. Her GCS was estimated to be 14/15. Her fingerstick glucose was 74mg/dL. The patient was given a bolus of crystalloid fluids while her workup was begun which included serum studies of chemistry, LFTs, CBC, ethanol level, and acetaminophen and tylenol levels and urine studies including pregnancy, urinalysis, UDS, and GC/MS. While in the ER, the patient’s slurred speech continued and she began having visual hallucinations of “babies under the bed.” All general lab tests were returned within normal limits and the UDS, ethanol, tylenol, and salicylates were negative. The GC/MS identified naproxen and metabolites of naproxen (see Figure 2). The patient was continued on dextrose and crystalloid fluids and admitted to the floor for overnight monitoring. By the following afternoon, the patient’s mental status had returned to normal with no further hallucinations and she was discharged in good condition. Discussion NSAIDs are used primarily for their ability to prevent prostaglandin production, thereby decreasing the activation of an inflammatory response and production of pain and fever. Due to the widespread availability of NSAIDs as over-the-counter medications and the common misconception that they must have few harmful effects, intentional and unintentional overdose is not uncommon. Overdose of NSAIDs generally results in little morbidity and even less mortality. Significant morbidity such as acidosis, renal failure, coma, and death have been reported with ingestions exceeding 400mg/kg.3 Ingestions of large amounts of NSAIDs, particularly ibuprofen and naproxen, can cause increased anion gap metabolic acidosis in part due to the weak acids and also due to a lactic acidosis that occurs. NSAID ingestions have been reported to cause widely varied effects from the routinely recognized renal effects to the less common central nervous system effects (Table 1).4,5
Figure 2. Relative abundance of naproxen on GC/MS for Case 2.
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Table 1. Effects of NSAID Ingestion Neurological Cardiovascular Cardiac dysrhythmias Headache Vision changes Hypotension/ Ataxia cardiovascular collapse Gastrointestinal Nystagmus Disorientation Nausea CNS depression Vomiting Drowsiness Ulceration/bleeding Renal Apnea Respiratory depression Acute renal failure Coma Acute papillary necrosis Allergic Electrolyte Disturbance Metabolic (lactic) acidosis Urticaria Anaphylaxis
References 1. Solomon DH. Nonselective NSAIDs: Overview of adverse effects. Uptodate. Retrieved 6/5/2016 from http://www.uptodate.com/contents/nonselective-nsaids-overview-of-adverse-effects. 2. Mowry JB, Spuker DA, Brooks DE, et al. 2014 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 32nd annual report. Clin Toxicol. 2015;53:9621147. 3. Levine M, Khurana A, Ruha AM. Poluria, acidosis, and coma following massive ibuprofen ingestion. J Med Toxicol. 2010;6:315-317. 4. Hall AH, Smolinske SC, Conrad FL, et al. Ibuprofen overdose: 126 cases. Annals of Emerg Med. 1986;15:1308-1313. 5. Wood DM, Monaghan J, Streete P, et al. Fatality after deliberate ingestion of sustained-release ibuprofen: A case report. 2006. Crit Care. 10;R44.
Author Information Despite attempts to develop a nomogram to provide some guidance on which patients are at increased risk of harmful effects, there has been no consistent relationship between serum levels and toxic effects to date. Additionally, there is no specific antidote for any of the NSAIDs. NSAIDs are weak acids with a small volume of distribution but are strongly protein bound and thus cannot be dialysed. Oral bioavailability approaches 100%, achieving peak levels in 1-2 hours. Orogastric lavage is recommended for very recent ingestions. Otherwise, supportive care is generally recommended. In the evaluation of a patient who may have ingested NSAIDs, utilization of an initial measure of pH by arterial or venous blood gas in addition to lactate may be beneficial particularly when these results are available immediately as point-of-care tests. Significant or worsening acidosis may be evident by hypotension or even cardiovascular collapse or may be warning of the oncoming resuscitative needs. Supportive care has included bicarbonate and even hemodialysis to treat the resulting acidosis, benzodiazepines to treat seizures, fluids to treat hypotension, and even ECMO has been used to treat refractory hypotension. In both cases, the GC/MS was reported by the toxicology lab technician to have markedly elevated levels of the respective NSAID. The large relative abundance in both of these cases, as well as the lack of additional compounds to explain either patient’s presentation, led us to conclude that NSAID overdose was the cause of the morbidity and mortality in these cases. In both of these cases, the toxicology lab technicians reported that the identification of each substance on the GC/MS each yielded a spike that was significantly larger than they had seen in their experience. It is worth noting, however, that the GC/ MS provides qualitative results as no quantitative methods have been established. This is in part due to the variation in urine output which greatly affects the concentration of any substrates. n
Fourth year emergency medicine resident at the University of Mississippi Medical Center in Jackson, MS (Dr. Hoda). Professor in the Department of Emergency Medicine and the Medical Toxicology Service at the University of Mississippi Medical Center in Jackson, MS and also serves as a Medical Toxicologist at the Mississippi Poison Control Center in Jackson, MS (Dr. Galli). n
T he Pen is Mightier
than the Sword.
Express your opinion in the JMSMA
through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention its headline and issue date in your letter. Guest editorials or comments may be longer, with an average of 600 words, including no more than 10 references. Also, include your contact information. While we do not publish street addresses, e-mail addresses, or telephone numbers, we do verify authorship, as well us try to clear up ambiguities, to protect our letter-writers. You should submit your letter via email to KEvers@MSMAonline.com or mail to the JMSMA office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.
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M S M A
P R E S I D E N T ’ S
P A G E
Address of the 148th President Daniel P. Edney, MD MSMA Annual Session Jackson Hilton August 12, 2016
W
hat a wild and wonderful year this has been and what a tremendous honor it has been serving as your 148th president. It has been an honor to have served as your spokesperson and to have had the privilege of representing you in meetings with all levels of state elected officials, Congressmen, at the state capitol, national meetings, the media. But most importantly, it has been an honor to represent MSMA with other physicians and patients all over our unique state; and, it’s been an honor that I have not taken lightly and have grown to respect more and more every day. It is also an honor that I never could have completed without the help of so many. It has been an incredibly busy year full of issues extremely important to physicians in our state. Our MSMA has been engaged all year long in defending the profession and working, speaking, and fighting on your behalf to protect your ability to practice medicine as your experience, training, and education enables you to do and as your patients need you to do. It hasn’t been an easy year in this fight but it has been successful. We have successfully fought back an attempt by a minority of nurse practitioners at independent practice, successfully defeated an attempt by an out of state company to redefine telehealth in a manner that would be devastating to the quality of care for our patients and to the ability for primary care to survive in our state. We successfully fought back yet another attempt by the anti-vaccination crowd to weaken our state’s model vaccine legislation that is recognized as the nation’s best law in protecting school age children from childhood illnesses that used to wreak havoc in our country and will again should we fail in this effort. Despite these important successes, three commonalities became clear to me with each victory: 1. Without the vigilance efforts of MSMA members, staff, and leadership, we would have lost all three battles. 2. MSMA did not win these battles alone but necessarily led a coalition of specialty societies, government agencies, educational institutions, and patients to rally the support needed to succeed. 3. All three of these battles will be back before us with the 2017 legislative session. This is why we must remain vigilant, work proactively and remain united as a profession. The only hope for those who oppose us is to successfully divide the House of Medicine. However, with your strong united support, the prognosis for our profession in this state is excellent. Our MSMA has also worked hard this year with the issues of physician wellness and the national opioid epidemic. Significant professional education has been accomplished by both the American Medical Association, MSMA, and especially by our outstanding Journal MSMA edited by Dr. Luke Lampton. The Journal featured the topics of physician health and wellness focusing on diagnosis and treatment of physician burn out, depression, suicide prevention and the management of substance use disorders among physicians. These efforts will save physician lives and careers. I don’t have to tell you how much attention has been directed to the opioid epidemic now considered our country’s number one public health crisis by the Centers for Disease Control (CDC). Our MSMA has convened a work group of experts who have been reviewing the CDC and other national and state guidelines for responsible opioid prescribing and are developing recommendations to present to this body and our board regarding how these guidelines should be implemented in our unique and challenging healthcare environment.
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We also are working with the Governor and legislative leadership to develop a coalition of interested parties to study and recommend comprehensive solutions to the drug crisis in our state and will continue both efforts going forward. Physicians and our profession as a whole must be seen by the public and government leaders as the catalyst for solution rather than the main cause of this crisis. In that light, I have been giving interviews as your spokesperson to outline the issues and present our view of solutions as doctors to several media outlets including the Mississippi Public Broadcasting radio special report which aired this week. MSMA will continue to convey the positive message that physicians are desperately needed to lead our state’s efforts to treat our way out of this problem based on sound medical practices and education. Finally, we have before us several important resolutions all of which need our due deliberation. However, the issue of improved access to quality healthcare for our working poor remains an important issue which we will debate this meeting. MSMA has been working to maneuver through the present political minefield of Medicaid expansion since the enactment of the Affordable Care Act. We understand that any push toward Medicaid expansion is dead on arrival with the current executive branch administration and with legislative leaders at the Capitol and that it brings concomitant political repercussions. Despite this, we have been communicating privately with leadership outlining the desperate need for better access. Physicians need to study possible solutions. This year I traveled this state from top to bottom visiting with doctors at their clinics, in their hospitals, at their component societies, at both medical schools and at residency sites in Tupelo, Meridian, and University of Mississippi Medical Center in Jackson. It is obvious to me that the need for relief is as critical now as it has ever been -- for our colleagues and their patients who seek appropriate coverage for healthcare. We as a profession need to discuss this issue openly and respectfully and will do so at this meeting. My challenge to you is this: understand that our membership appears to be fairly evenly split on the issue of Medicaid expansion. As I wrote in the Journal recently, both viewpoints have valid concerns and deserve to be fully heard and considered by the opposing viewpoint. However, I have confidence that with the intellectual power, clinical experience, and professionalism represented in this House of Delegates, we as an organization can develop a strategy that addresses the issue of access for the working poor, the various concerns of all of our membership, and develop a plan that is politically palatable for our political leaders. Yes, I know it is a great challenge. I also know that each of you has already confronted and managed many difficult clinical challenges this week. Together we can manage this one as well. Thank you members of the House of Delegates for all that you do for our profession every day. Whether you are a medical student at William Carey University or UMMC, a resident or fellow at any of our fine training programs, whether you are an employed physician or in independent private practice, whether you are in academics or retired, you are valued and needed by this association. I look forward tomorrow to assume the post that our 147th president Dr. Claude Brunson claims is the very best job of the Association: that is the position of Immediate Past President. I do look forward to serving under your leadership this coming year. Thank you all for allowing me to serve in the very best job that I never want to do again, President of MSMA. But, do understand that I am forever grateful that you have allowed me to serve our profession in this capacity this year. It will always remain the zenith of my professional career. Thank you and let’s have a great meeting! n
Daniel P. Edney, 2015-16 MSMA President JOURNAL MSMA
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[This month, we print another poem by Robert Ray “Bob” McGee, MD, a Clarksdale internist. McGee writes under the pseudonym of Thomas Browne, MD. To obtain a copy of his poetry collection (“Case Reports and Other Epiphanies”) go to lulu.com or write to Dr. McGee directly at 303 Cypress Avenue, Clarksdale, MS 38614. Here on the brink of fall, many Mississippi physicians will appreciate this appropriate tribute to our holy red fruit. Indeed, who has not come close to a spiritual experience when eating the classic Southern tomato sandwich (also known as the “Sink Sandwich,” so drippy you have to eat it over the sink!)? Just slice a tomato, place between 2 pieces of soft bread (or on top of one), spread with Hellmann’s mayo, and season with salt and pepper. So simple and such is what a Mississippi summer tastes like! Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@ cableone.net.]—Ed.
Seven Tomatoes
S
even tomatoes on the kitchen counter
I gather them
Round, red and ripe
I look at the tomatoes
Fruits of September
And wonder at the miracle and mystery
Squirrels or chipmunks or some other
Of God’s making a tomato
Garden raider ate the early ones
My kitchen is a Holy place
Still green
—Thomas Browne, MD Clarksdale
Now on the brink of fall
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L E G A L E S E
Patient Health Information Breaches: What Now? Rusty Comley, JD and Abram Orlansky, JD; Watkins & Eager, PLLC
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ll medical professionals understand the importance of protecting their patients’ private information. As anyone reading this is well aware, the federal government’s regulatory attempt to enforce this important privacy interest is called the Health Insurance Portability and Accountability Act, or HIPAA—and the resulting regulations promulgated by the Department of Health & Human Services.
HIPAA contains various structures regarding the use and disclosure of patients’ “Protected Health Information” (PHI). When it comes to HIPAA compliance, though, one thing all medical professionals must understand is the truth of the old cliché, “it happens to the best of us.” That is to say, even those who follow the rules in every way and have sensible, workable HIPAA policies to which they adhere faithfully may occasionally find themselves dealing with a breach of patient PHI. When and if that happens, there is a well-defined set of steps to take. What is a “Breach?” It is important to first ensure you understand when a “breach” has occurred under HIPAA regulations. According to 45 C.F.R. § 164.402, a breach happens when a patient’s PHI—including medical, personal, and/or financial information—is acquired, accessed, used, or disclosed in a manner which compromises its security and/or privacy, and is not specifically allowed by the HIPAA regulations. Certain exceptions do apply, such as when an employee of an entity covered by HIPAA accidentally accesses PHI in good faith and does not further disclose the information. Another example that should not necessarily be considered a “breach” is when office personnel mistakenly fax a patient record to the wrong pharmacy or medical clinic. Because both the pharmacy and medical clinic have a legal obligation to protect the privacy, security, and confidentiality of patient information, there is a low probability that the information disclosed was compromised, and therefore, that any breach occurred. Breaches come in various forms and sizes. On one end of the spectrum, we have assisted clients who mistakenly provided online access to one patient’s information to another patient with a similar name. In a case of similarly small magnitude, we have also assisted where a physician left a briefcase with patient documents in his car, and his car was stolen with the briefcase still inside. The other end of the spectrum includes largescale cyberattacks, like the one perpetrated against Community Health Systems in 2014 which affected the health records of 4.5 million patients. Preventing Breaches in the First Place It should go without saying that the most important step your practice must take with respect to these issues is to ensure you take every reasonable precaution to avoid breaches at the outset. Have a strong, easy-to-follow HIPAA policy in place and incorporate it into your practice’s daily operations. We have assisted several clients in crafting new or updated HIPAA policies that are designed to be workable within each practice’s unique situation. Pay special attention to any communications involving patients’ protected health information, and engage in some self-analysis about the way your records are stored, used and transported, and the security or lack thereof in your system. Use encrypted communications wherever possible. It is vitally important to stress that your HIPAA policies and procedures must be kept up to date, and you must make every effort to fully comply with your own policies and procedures. HIPAA enforcement is the purview of the federal Department of Health and Human Services (“HHS”), and specifically its Office for Civil Rights (“OCR”). The entire purpose of OCR is to protect patients’ nondiscrimination and health privacy rights; one of the ways in which it accomplishes this goal is by investigating violations of HIPAA and enforcing its rules. In the event of a breach (or any other HIPAA violation), a patient has no legal right to sue in court. Therefore, a complaint to OCR is the sole enforcement mechanism available to affected patients. Note, however, that civil liability can arise if the PHI involved in the breach also contains personal or financial information that assists in fraud against or identity theft of the affected patients. In recent years, OCR has become more aggressive in enforcing HIPAA’s strictures. When its investigation reveals a violation, OCR can resolve it either by: 1) simply obtaining the covered entity’s agreement to a corrective action plan, or 2) obtaining such a plan and imposing a civil monetary penalty. In 2012 (the most recent year such data is available on the OCR website), 36% of all complaints resulted in corrective action— up from just 22% in 2004, the first full year of data. One recent example illustrates how a security breach can open the door to a much larger problem for a covered entity. In November 2015, Lahey Hospital and Medical Center in Burlington, Massachusetts, agreed to pay $850,000 and to follow a strong corrective action plan due to deficiencies in its HIPAA policies. The only reason OCR was investigating in the first place was a breach: a single laptop computer was stolen from an unlocked room in the hospital, whose hard drive contained 599 individuals’ PHI. JOURNAL MSMA
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In such instances—when OCR begins an investigation after learning of a breach—the first questions a covered entity will be asked are likely to be: 1) who is your designated security officer? and 2) where is a copy of your most recent risk analysis? This brings us back to the main point: maintaining and following a complete set of HIPAA policies and procedures is vitally important, not only to protect your patients’ privacy but also to ensure OCR is satisfied that any breach took place in spite of your organization’s compliance level, and not because of it. Regarding the risk analysis specifically, 45 CFR §§ 164.306(e) and 164.308(a) require continuing evaluations “as needed to continue provision of reasonable and appropriate protection” of PHI. A full explanation of what goes into a proper risk analysis is a subject for another article, but we generally recommend a covered entity revisit its risk analysis annually. In the event of an OCR investigation, it is preferable to be able to show investigators that you have updated your risk analysis each year in order to take into account any new information on how security breaches may occur. After a Breach: Step-by-Step In the event a breach occurs despite your best efforts, we recommend undertaking the following steps to ensure both you and your patients are adequately protected. The first two steps are telephone calls: first to your insurance carrier to report the situation and seek liability coverage for it. If your carrier indeed covers the expense of rectifying the breach, the carrier will make the second call for you: the one to your attorney. Legal representation is vital in this situation because a breach could possibly expose you to additional liability, depending on the manner in which you store data and whether your general practices are fully compliant with HIPAA’s regulations, as well as the type of information subject to the breach (e.g. personal or financial information that leads to identity theft or fraud). Once you have engaged your attorney, (either on your own or through your carrier), he or she will guide you through the remainder of the process. The requirement that a covered entity take certain actions to notify and work with affected individuals is governed by the regulations found at 45 C.F.R. §§ 164.400 – 414. In the event of a breach affecting 500 individuals or fewer, the regulations require the covered entity to take the following actions: The covered entity must notify the affected individuals of the breach “without unreasonable delay,” within an absolute time maximum of sixty (60) calendar days from the date you discover the breach. The breach is considered “discovered” on the first day it is known to the covered entity, or on the first day on which it would have been known had the covered entity exercised reasonable diligence. The regulations contain specific requirements for the content of this notification, including a description of the breach, the types of unsecured PHI that were affected, recommended steps for individuals to take to protect themselves from potential harm resulting from the breach, an explanation of what the covered entity itself is doing to ameliorate the situation, and contact procedures for any individuals seeking additional information. The notice itself must be sent via first class mail, except in certain circumstances such as the covered entity having insufficient or outdated contact information for a certain individual. The regulations provide guidelines for substitute notice in such situations. In the event the breach might possibly allow third parties to use the affected individuals’ personal information in any nefarious way (e.g. identity theft), we have recommended to clients in the past that they offer affected individuals the opportunity to opt in for some period of credit monitoring at the covered entity’s expense. We have also recommended a critical analysis of the practices that might have led to the breach, and amendment of the covered entity’s HIPAA policies to specifically address those issues. These best practices are helpful in the next step of the regulations’ required process: notifying OCR of the incident. OCR now has its breach-notification form posted online, and a covered entity can simply fill out the form and submit it over the Internet. Your attorney will be helpful in this process as well to ensure the information provided complies with the regulations. Among other questions, the form asks what actions have been taken to mitigate the breach’s harm and what corrections have been made to prevent such breaches in the future—hence our recommendations in the previous paragraph. In situations where the breach affects more than 500 individuals, an additional step is required: notification to the media. The notification to “prominent” local and/or state media must meet the same requirements as the above-referenced notice to the affected individuals and must also be sent within sixty (60) days of discovery of the breach. Dealing with a breach of a patient’s personal information can be a frustrating and, frankly, somewhat embarrassing experience. Try to remember that many other entities have found themselves in the same situation and that your insurer and attorney can often help you through it. While the ideal is obviously to avoid a breach in the first place, addressing such a situation head on and quickly can help build and maintain trust on the part of your patients as well as reduce the potential for civil litigation. n Rusty Comley (l.) and Abram Orlansky (r.) are litigators at Watkins & Eager, PLLC in Jackson, who advise and defend providers in HIPAA breach, data breach, and cyber-liability matters. They can be reached at rcomley@watkinseager.com and aorlansky@watkinseager.com.
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U N I V E R S I T Y
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M I S S I S S I P P I
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“Queen of GME” Reduces Hours but not Commitment
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Gary Pettus, UMMC Public Affairs
ne patient who profoundly influenced Dr. Shirley Schlessinger’s life is someone whose name she didn’t learn and whose fate she doesn’t know but whose plight she’ll never forget. That patient encounter decades ago thrust Schlessinger on the path she followed for much of her career, a career - including more than a quarter century at UMMC as a clinician, educator and administrator - that is slowly winding down. But, even as Schlessinger’s working hours are diminishing, her memories of and devotion to her work are not. “It’s painful to leave when you’ve been here this long and when you’ve been part of the growth of this program,” said Schlessinger, professor of medicine and associate dean of Graduate Medical Education. “Part of the reason I’m not retiring right now is I love it here.” On the UMMC faculty since 1993, Schlessinger is the former interim chair of the Department of Medicine and the one-time program director for the Internal Medicine Residency Program; for the past 13 years she has led the GME program, directing the entire crop of medical residents, today numbering 650, including fellows. Her professional reputation at UMMC and beyond can also be credited to her dedication to an initiative that is, for her, more of a calling than a job: organ recovery and transplantation. As a medical student, she met the patient who stoked those allegiances, more than 30 years ago. “This young woman, 20-25 years old, had end-stage lung and heart disease,” Schlessinger said. “She needed a heart-lung transplant to live. “Organ donation was in its infancy then, and it struck me how much difference organ donations can make in a person’s life and in the lives of those close to that person. Because of her, I went right home that day and got my organ donor card.” In the long run, she did more than that, becoming medical director for the Mississippi Organ Recovery Agency; today she chairs MORA’s board. But she has an ardor for the well-being of all patients, whatever their needs, said Dr. LouAnn Woodward, vice chancellor for health affairs and dean of the School of Medicine. A 1991 graduate of UMMC’s School of Medicine, Woodward said that from her early years here, Schlessinger has been “a fighter for patients’ rights. She was on a mission.
Dr. Shirley Schlessinger has been associate dean for Graduate Medical Education for 13 years.
“She was a champion for someone who needed a champion. She absolutely did not back down. That early experience was a forecast of the Shirley who later became the queen of GME.” Patient care is her “favorite thing,” Schlessinger said. “But, easily, the second favorite thing I’ve done here is watching these young doctors come in and learn their specialties.” The Louisiana native became a young doctor herself in 1985 after graduating from the LSU School of Medicine in New Orleans, four years after she met her future husband on their first day of medical school: Dr. Louis Puneky, now a UMMC associate professor of medicine and clinical oncologist. They earned their medical degrees together and then interviewed for their residencies at 17 different sites, choosing UMMC where Schlessinger trained in internal medicine for three years. She worked with some of the Medical Center’s legendary figures: transplant surgeons Dr. James Hardy and Dr. Seshadri Raju, and renowned nephrologist Dr. John Bower. Schlessinger
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But she knew that would not be the end of her training. “I had taken care of kidney transplant patients in 1987, and the difference between them and those on dialysis was phenomenal,” she said. “When you see that, it’s easy to get enthusiastic about transplants. That’s why I chose nephrology. As a nephrologist, you get to see all aspects of internal medicine. You’re a souped-up general internist.” At the University of Alabama-Birmingham, Schlessinger did her nephrology residency, profiting from exposure to what she said was then the largest kidney transplant program in the country. But UMMC was her ultimate destination. In 1993, she and her husband returned to the city where they had first trained as residents and where they would bring up their two children. “I came back to do two things,” she said. “To lead the internal medicine residency program and lead the organ recovery agency on this campus as medical director, when it was part of the Department of Surgery.”
began working with Schlessinger on the Resident Quality Council. “Some people put on their job face when they come to work. Yes, they want to do a good job, but Dr. Schlessinger went beyond that,” Stacy said. “She was deeply and genuinely concerned about your well-being as a person and a resident. She wanted you to succeed. “You need someone you can go to about work problems. You need a confidential source of wisdom who’s trustworthy, which she was. As a person and a leader, she’s been an example for me.” By the time Stacy finished his graduate medical training, residency slots had doubled from 325 since Schlessinger began leading GME. There were about 32 separate residency programs when she started; now there are 61. But UMMC has some 100 slots that are not funded, all or in part, by such Stacy outside sources as Medicare, the VA Medical Center and partnering hospitals. The Medical Center must pay for those 100 with funds from clinical operations. “We struggle every year over whether we can offer raises that will keep us competitive with other institutions in the southeast region,” Schlessinger said. “Even so, we’re trying to increase the number of residents, because that’s our mission.”
Schlessinger introduces herself to Dr. Sohiel Khoshroo, left, an anesthesiology resident, and neurosurgery resident Dr. Zachary Smalley during an orientation session for new Medical Center residents in June.
Schlessinger helped post several Medical Center milestones such as the opening of the kidney dialysis service in the Jackson Medical Mall. She was part of the team that dialyzed inmates at the Central Mississippi Correctional Facility in Rankin County when UMMC held that contract.
Officially, that mission is now headed by Dr. Rick Barr, the Suzan B. Thames Professor and Chair of Pediatrics. Barr, who has also held the title of senior associate dean of GME since January, has been preparing for the transition for several months. For her part, Schlessinger has had to deal with a separate and painful - in every way - change: Some time ago, she decided to give up seeing patients because of “musculoskeletal” and other medical issues that limit the use of her hands.
“The inmates were very grateful,” she said. “That was the most appreciated I’ve ever felt as a dialysis doctor.” Inside the Medical Center, her reputation for “being outspoken,” she believes, may have eventually led to her being tapped as leader of the GME, the second-ever associate dean of the program. “I wanted to do this job,” she said. “I thought it would be a lot of fun helping young faculty develop leadership and teaching skills. This was an opportunity to influence the educational process for the institution. It was definitely the right decision.” It was, as far as Dr. Jason Stacy is concerned. Now on staff as a neurosurgeon at North Mississippi Medical Center in Tupelo, Stacy finished his residency at UMMC on June 28 - seven years after he 270 VOL. 57 • NO. 8 • 2016
Barr and Schlessinger take a break during orientation day for new residents.
“Humility is not my strong point,” she said. “I’ve always thought of myself as a very good physician, but when I felt I could no longer be a very good physician, I knew I should not be doing patient care.” She will stay on as an administrator, she said, for at least another year.
Schlessinger’s Achievements 1. Worked to maintain the highest level of accreditation possible for the institution while increasing the gaps between accreditation cycles.
As part of the GME transition, Schlessinger trimmed her work week to three days starting last month but retains the title of associate dean as she collaborates with Barr on such projects as faculty evaluations, accreditation, and quality improvement; she continues to serve on the Physician Burnout Task Force, on top of her other duties.
2. Established an orientation process and development programming for residency program directors.
“I’m so happy she’s not retiring,” said Barr, who also assumed the title of Designated Institutional Official on July 1.
4. Streamlined protocols on such issues as moonlighting.
On June 29, the day before Schlessinger’s last official day as a full-time employee, she was shepherding UMMC’s contingent of 174 newlyarrived residents. It may be the last new group she’ll ever get to know.
5. Developed a new tool for annual review of all GME training programs.
“Countless people - many residents, students, and faculty (myself included) - are better for having walked a bit along the journey with Shirley,” Woodward said. “She has put the needs of the patients, the residents, the institution before herself.
MSMA
“This strong woman with a tender heart has extended herself to help others without fail and without question, without ever expecting anything in return and without keeping score.” n
3. Put into place a process for identifying and dealing with problem residents.
6. Established standards with Human Resources for the support of GME programs. 7. Developed resources for trainees who are academically challenged. 8. Developed training for chief residents. 9. Involved residents in quality control. 10. Secured more funds and slots to maintain and increase the number of residency positions.
Physician
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Your patients can enjoy a healthier life. They just need a little extra motivation. Motivated to Live a Better Life is a free six-week workshop designed to help Mississippians better manage chronic conditions and take the right steps to lead a healthier, more active life. Learn more about this evidence-based approach to health management by calling the Mississippi State Department of Health Office of Preventive Health at 601-206-1559 or visiting HealthyMS.com/MLBL.
Motivated to Live a Better Life is licensed by the Stanford University Chronic Disease Self-Management Program.
M S M A
This is part of a spotlight series on the MSMA Physician Leadership Academy class of 2016.
Daniel Venarske, MD
D
aniel Venarske, MD knew from an early age that he wanted to pursue a service-oriented career. “I always saw myself as leading a life that contributes to the improvement of our world,” he explains. As a student in the esteemed Plan II honors program at The University of Texas at Austin, he considered a career as a judge or as an international diplomat. “But after much thought and prayer, I decided in my junior year to aspire to a career in medicine. I entered a summer pre-med program at the Texas Medical Center and was able to see first-hand the tremendous impact a physician can have on the lives of a patient and their family.” It was during medical school at the Baylor College of Medicine in Houston when Dr. Venarske first began to find his niche in respiratory care: “An opportunity one summer to work in Cystic Fibrosis research sparked my interest in the lungs,” he recalls. “During my Med-Peds intern year at UMMC I came in contact with the exceptional physicians Jim Haltom, MD and Rick deShazo, MD whose specialties involve the lungs. I also recognized that a career in Allergy, Asthma, and Immunology would allow me to continue to provide care for patients of all ages.” The compassionate care Dr. Venarske provides his patients can be partially credited to the mentors he found during his residency at UMMC. “As a resident in the NICU, I believe that I learned more about professionalism and empathy from Bobby Heath, MD, in a short period than I could have ever imagined at the time.” It was also during this time when he started on a collaborative project that he still considers to be his greatest accomplishment. “While I worked with children of all backgrounds in the Blair E. Batson North Pediatric Clinic, I noticed that books were commonly missing from the lives of so many Mississippi children, and I was determined to do something about it,” he recalls. “So I started a project with Dr. Tammy Brooks and Dr. Ruth Patterson that still makes me smile when I see it promoted at bookstores and as volunteer opportunities in schools today: Reach Out and Read.” Today, Dr. Venarske is in private practice at The Mississippi Asthma and Allergy Clinic, which sparked his interest in organized medicine. “Just in the short time that I have been in practice I have seen numerous distractions arise in our goal of helping patients return to health. I hope to see the focus of healthcare return to providing care for patients in a truly meaningful way and recognize that it will take involvement to help make that change.” As a Physician Leadership Academy scholar, Dr. Venarske hopes to become a better communicator, but his ultimate goal extends beyond the practice of medicine and back to his philanthropic roots. “I come from a huge family of volunteers who won the Houstonian Volunteer award and hope to pass along that desire to be involved in our community and to be the positive change we want to see.” n
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Whatever Happened to National Doctor’s Day? Dwalia S. South, MD
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n the morning of Wednesday, March 30, I sat looking at my date book and trying to pinpoint the vague sense that some noteworthy event was supposed to occur that day. A friend’s birthday? A forgotten dental appointment? I had noted nothing special on my schedule. I shrugged it off and went about my usual day seeing patients at the clinic. Reading the North Mississippi Daily Journal at home that night I came across an ad placed by Tupelo’s North Mississippi Medical Center wishing all their physicians a “Happy Doctor’s Day 2016” and thanking them for their service. So THAT was the significance of March 30 which I couldn’t recall that day. Apparently, National Doctor’s Day is not very relevant or much recognized anymore. A few years ago our small local hospital would host a nice breakfast gathering in honor of its physicians on that day. Drug reps, God bless ‘em, would bring donuts or a decorated cake in to the office to be shared by all. And I fondly recall the old days of private practice when I might arrive at the clinic to find a flower, or balloons, or perhaps a box of chocolates with a cheerful note of Doctor’s Day greeting from the nurses and office staff. Apparently these happy and fattening observances have gone the way of the rotary phone and the manual typewriter…simply into oblivion. I thought, “Oh, well, I’m being petty and narcissistic to even think about this minor oversight.” Then I remembered that the same thing happened last year, exactly nothing. I sang “Let It Go, Let It Go!” softly and silently to myself and then looked up the history of National Doctor’s Day. Eudora Brown Almond, the wife of a physician, instituted it in 1933 to commemorate Dr. Crawford Long’s 1842 discovery of surgical anesthesia. Doctor’s Day has been a yearly-observed event in my career as a physician for as long as I can recall. Wanting to write something in this Journal MSMA about the reasons for the lapse but thinking that it would be construed as petty or self-serving, I let time and the expression of my dismay go sliding by. Then in early May there was recognition of National Nurses’ Week… yes, a solid week of happy greetings, candy, and gifts floated around. I’m not jealous: nurses are generous folk and they shared their bounty and sweet fortunes with all. But, a WEEK of it? I googled National Nurses’ Week and learned that it originally had been one day in May, Florence Nightingale’s birthday, declared a holiday in 1974 by President Richard Nixon. In 1991 the recognition was expanded to a week long annual celebration so designated May 6-12 by the American Nurses’ Association. Then I looked to see if Nurse Practitioners have a day of recognition. They also have a one week commemoration which occurs annually in November. Oh, well, guess we’ll party then, too. So I let it go again. About a month ago now, the North Mississippi Daily Journal ran a supplemental magazine called “Reader’s Choice Awards.” This is very commonly done now in the hometown newspaper world apparently as an advertising ploy in this day of diminishing subscriptions. I expected to see a category which never fails to stick in my craw… “Best Doctor Award.” Instead there was a section where readers voted for “Best Family Practitioner.” Contained in their list of ‘winners and also-rans’ were Family Medicine Physicians, Internal Medicine Physicians, more than a few Family Nurse Practitioners, and the names of several walk-in clinics. This informed me that neither the journalistic team responsible for the featured supplement nor many of the newspaper’s readership understand the differences between the myriad forms of medical professionals people view as their Family Doctor. This is not surprising since all health care professionals are now regretfully lumped into one service category called “Provider.” I suppose Doctor’s Day was mainly forgotten because no one seems to know who their actual doctor is these days. Other categories in the “Reader’s Choice” section included categories for Best Cake Bakery, Best Tattoo Salon, Best Chicken Restaurant, well, you get the idea. I wrote a letter to the Tupelo Newspaper complaining about this, which was well received by the Editorial Page Editor who promised to run it the following day. It never ran because the Managing Editor vetoed its publication, stating that the Advertising/Marketing Department was to blame and he would see that they received the written letter of complaint. Then, I let it go. A couple of weeks back I entered an exam room to see a long time patient, a factory security guard and a sort of rough and tumble girl in her mid-40’s. As with so many people these days she was entertaining herself by fiddling with her smart phone while waiting on me. I had been in the market for a new phone for some time and asked whether she liked hers and if she’d mind me looking at it. She happily obliged. She didn’t bother to close the ‘APP’ she was using. She was texting a friend while waiting and the content of the text was the first thing that popped into view. “I am sittin here in the damn doctors office waitin on the damn doctor to come in here and see me. I HATE DAMN DOCTORS!” I said, “Whoa, girl, I don’t guess you meant for me to see this, did you?” She turned 50 shades of red and sputtered “Naw, ma’m, that wasn’t meaning you; I just meant I hated going to the doctor’s office in general. I LOVE you, you know that. I was just blowin’ off steam and runnin’ off at the mouth.” I suppose physicians have at last joined the ranks of lawyers. The post-millennial public now views both professions with disdain and distrust as a whole, not with the esteem accorded them in the past. But when you hold a fellow’s feet to the fire, when trouble comes calling, they sing a different tune. One’s personal physician or attorney is then needed, sought after, and, yes, even at times said to be loved. I got a big laugh out of the “damn doctor” incident and some good mileage out of telling the story several times. And then, I let it go. n 274 VOL. 57 • NO. 8 • 2016
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CME NOVEMBER 19-22, 2016 • WALT DISNEY WORLD®
with Mickey Mouse
Earn up to 10 CME credits on pediatrics, surgery, trauma, dermatology, cardiology, Medicaid, women’s health, infectious disease and more. Trauma surgeon Chadwick Smith, MD, will discuss how his team responded to the tragic Orlando nightclub shooting in June 2016. Dr. Smith is an acute care surgeon with Orlando Health Physicians Surgical Group. He is board certified in general surgery, surgical critical care and neurocritical care. He is a fellow of the American College of Surgeons, and a member of the Society of Critical Care Medicine, the Eastern Association for the Surgery of Trauma and the Southeastern Surgical Congress. He is the current president of the Florida Society of Critical Care Medicine. Other CME speakers include Cindy Brown; Chadwick Smith, MD; Steve Chevalier, MD; Stephen Helms, MD; Vern Antoine Keller, MD; Shannon Orr, MD; and Michelle Owens, MD.
Visit www.MSMAonline.com/CMEDisney to register, reserve your room at Disney’s BoardWalk Inn, and purchase park tickets. For more information, contact: Jenny White 601-853-6733, ext. 332 or JWhite@MSMAonline.com Becky Wells 601-853-6733, ext. 340 or BWells@MSMAonline.com DISNEY PROPERTIES/ ARTWORK: © DISNEY