san antonio medicine august 2014

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THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • AUGUST 2014 • VOLUME 67 NO. 8

MEDICINE

Medicine

Law& theMedicine

Law& the

4 San Antonio Medicine • August 2014

Medicine & The LawDo you know your cyber liability risks? By John Southrey, CIC, CRM.....................................10

Electronic health records pose malpracticerisks By David B. Troxel, MD ..................................14

A view from inside the Texas Medical Board:Licensure committee assists physicians,organized medicine By Michael R. Arambula, MD, PharmD .....................16

‘HIPAA-secure’ doesn’t have to meancomplicated Special to San Antonio Medicine.....18

President’s Message by K. Ashok Kumar, MD, FRCS, FAAP ........................................................8

BCMS establishes sister cities agreement with Nuevo Leon physicians ....................................20

BCMS News ................................................................................................................................22

Care System Profiles: Methodist Healthcare System ..................................................................24

BCMS Foundation ......................................................................................................................26

Business of Medicine: Quality and your bottom line by Pamela C. Smith, PhD ..........................27

Physician as Patient Part 5: The economics of serious illness by Jay Ellis, MD..........................28

HASA: Coordinating high-quality care with HIT by Vince Fonseca, MD, MPH, FACPM ......................32

UTHSCSA Dean’s Message by Francisco González-Scarano, MD ............................................34

Book Review: Short reviews of two excellent books ... and a brief mention of a third

by Fred H. Olin, MD..................................................................................................................36

Circle of Friends BCMS Group Purchasing and Service Directory........................................................37

In the Drivers’ Seat ................................................................................................................................43

Auto Review: Audi Q7 by Steve Schutz, MD ........................................................................................44

T A B L E O F C O N T E N T S

MEDICINETHE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • AUGUST 2014 • VOLUME 67 NO. 8

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BOARD OF DIRECTORS

OFFICERSK. Ashok Kumar, MD, PresidentJayesh B. Shah, MD, Vice PresidentLeah Hanselka Jacobson, MD, TreasurerMaria M. Tiamson-Beato, MD, SecretaryJames L. Humphreys, MD, President-electGabriel Ortiz, MD, Immediate Past President

DIRECTORSJosie Ann Cigarroa, MD, MemberChelsea I. Clinton, MD, MemberJohn Robert Holcomb, MD, MemberLuci Katherine Leykum, MD, MemberCarmen Perez, MD, MemberOscar Gilberto Ramirez, MD, MemberAdam V. Ratner, MD, MemberBernard T. Swift, Jr., DO, MPH, MemberMiguel A. Vazquez, MD, MemberFrancisco Gonzalez-Scarano, MD,

Medical School RepresentativeCarlos Alberto Rosende, MD,

Medical School RepresentativeCarlayne E. Jackson, MD,

Medical School RepresentativeLuke Carroll, Medical Student RepresentativeCindy Comfort, BCMS Alliance PresidentNora Olvera Garza, MD, Board of Censors ChairRajaram Bala, MD, Board of Mediations ChairGeorge F. "Rick" Evans Jr., General Counsel

CEO/EXECUTIVE DIRECTORStephen C. Fitzer

CHIEF OPERATING OFFICERMelody Newsom

DIRECTOR OF COMMUNICATIONSSusan A. Merkner

COMMUNICATIONS/PUBLICATIONS COMMITTEEFred H. Olin, MD, ChairEstrella M.C. deForster, MD, MemberJay S. Ellis Jr., MD, MemberDiana H. Henderson, MD, MemberJeffrey J. Meffert, MD, MemberSumeru “Sam” Mehta, MD, MemberRajam S. Ramamurthy, MD, MemberJohn C. Sparks Sr., MD, MemberChittamuru V. Surendranath, MD, MemberJ.J. Waller Jr., MD, MemberJason Ming Zhao, MD, Member

Owning a home is an essential part of the American Dream; it

is one's proudest possession and a reflection of one's character.

Ever since I started my leadership role at the Bexar County

Medical Society, I always wanted us to have our own building,

regularly bringing the issue up in our BCMS meetings. Many

of the leaders in the BCMS have the same desire that we need a

place of our own. There are always pros and cons for anything we

do in life.

I firmly believe that there are a lot more positives than negatives

in pursuing this dream. The course of living in a rented space

from one lease to another never did run smoothly, and while we

spend all that money on rent there is no accumulation of equity

for the society. Furthermore, we are one of the oldest medical so-

cieties in the country, and the first medical society to be chartered

in the state of Texas, and while many of our far younger sister so-

cieties in the state have their own building, we still do not.

It is high time that we build a home for BCMS.

I am delighted to let you all know that the idea took shape last

year, and we started looking at the opportunities to find a place

which is convenient to the membership and also embody our ideals.

At the same time we do not have to spend an arm and a leg.

We surveyed the membership about selecting a desirable loca-

tion. We also formed a group of BCMS members under the lead-

ership of Dr. Buddy Swift, who has extensive experience in

building. He and the BCMS leadership and staff under the guid-

ance of Steve Fitzer, and with the help of our general counsel Rick

Evans, started our efforts to find a great place for us to build a

structure or buy an existing building.

Finally, I have some good news to share with you. We found a

piece of land ideal for constructing our future home. The plan is

to build an office which will not only meet our own needs as a

medical society, but also build extra office space for rental which

will be a source of ongoing revenue for the society. This will be

one small step toward self-reliance and sustainability.

According to the current estimates we need a lot more money

than we have in the bank. That means we need to raise additional

funds to fulfill our dreams of owning our own home for our med-

ical society. We need to use our resources, we need to get a mort-

gage, and we need to raise more funds.

In the most recent board meeting we brainstormed as to how to

achieve this goal of raising the necessary funds. I was so thrilled to

see overwhelming enthusiasm from all of our BCMS board mem-

bers (even among the quietest members), and we discussed many

creative ideas long past our usual meeting time. We came up with

many ideas which I will be sharing with you. In the meantime, I

plead with you to share your own thoughts and ideas with me.

Certainly we need help from our friends in the community,

and we have plans to approach them. However, there was a strong

sentiment among members that we should first raise money from

among ourselves before we ask for donations from others.

I heard so many passionate testimonials from long-time members

about how they came to the society's rescue when the medical so-

ciety needed help before. I request all of you to show your support

and commitment once again, both emotionally and financially.

The board has come up with a plan to ask $75 from each mem-

ber for each of the years 2015 and 2016 to help fund the cost of

the building.

In addition to your contributions, we need your ideas to raise

more funds. I would be most grateful if you would contact me

with your advice. I am going to form a fundraising committee,

and if you are willing to volunteer, please call or write to me (ku-

[email protected]).

We deserve a building of our own. Let us work hard to make

that a reality. True hope is swift, and I firmly hope and believe

that you will be proud of our own BCMS building.

Kaparaboyna Ashok Kumar, MD, FRCS, FAAFP, is the 2014

president of the Bexar County Medical Society.

PRESIDENT’SMESSAGE


A new home for BCMSBy K. Ashok Kumar, MD, FRCS, FAAFP2014 BCMS President

He that has a house to put's head in has a good headpiece. ~William Shakespeare, King Lear


MEDICINE & THE LAW

Texas Medical Liability Trust (TMLT) has received more than100 cyber liability claims from policyholders since adding cyberliability coverage to all policies in December 2011. The majorityof these claims involved breaches of electronic protected healthinformation (ePHI) stored on unencrypted computers and mobiledevices that were either stolen or lost. These incidents were allpossible violations of Health Insurance Portability and Account-ability Act (HIPAA) privacy laws.

Among the more sinister cyber claims reported to TMLT wasa cyber extortion claim involving more than 6,000 electronicallystored patient records.

A CYBER EXTORTION CLAIMA physician arrived at his practice and was unable to access his

electronic patient records. A cyber criminal had hacked the prac-tice’s servers and installed “ransomware” to encrypt the medicalrecords and deny access to them. The hacker left a message de-manding several thousand dollars before he would decrypt thefiles and permit access to the records.

The physician immediately notified the FBI Cyber Crime Di-vision and local police about the data breach. He contacted theTMLT claim department to initiate coverage under his cyber lia-bility policy. The physician also hired an attorney to assist withreporting the breach to the U.S. Department of Health andHuman Services (HHS).

HHS enforces the breach notice provisions of the Health In-formation Technology for Economic and Clinical Health(HITECH) Act. Under HITECH, healthcare providers are re-quired to report a breach of unsecured PHI to HHS if the breachinvolved the impermissible use or disclosure of PHI of more than500 individuals. Notification is to include the affected patientsand local media. HHS also places a press release about the breachon its website. Providers are required to report the breach to HHSwithin 60 days after its discovery.

The physician’s attorney hired a forensic computer specialist torecover the inaccessible patient records. A media release vendorand a fraud detection/credit monitoring vendor were hired. Thephysician incurred expenses for a call center to answer patients’

questions. These direct costs did not include the potential damageto the physician’s reputation resulting from the media reports andpatient notifications.

The physician received a letter from the Office of Civil Rights(OCR) notifying him of their investigation of the breach. (OCRis responsible for enforcing federal privacy laws.)

“Please be advised that the U.S. Department of Healthand Human Services (HHS), Office for Civil Rights(OCR) received your breach notification report on …,2013, pursuant to the HITECH Breach NotificationRule, 45 C.F.R. § 164.408 and § 164.414.

“Per the notification, you reported to OCR that …[the clinic] might not be in compliance with the FederalStandards for Privacy of Individually Identifiable HealthInformation and/or the Security Standards for the Pro-tection of Electronic Protected Health Information (45C.F.R Parts 160 and l64, Subparts A, C, D, and E, thePrivacy and Security Rules). Specifically, you reported abreach of approximately 6,300 patients’ protected healthinformation by a hacker that infected your network andencrypted your medical records. The hacker then de-manded money in return for allowing access into yourmedical records. These allegations could reflect violationsof 45 C.F.R. §§164.502(a), 164.530(c), 164.404,164.406, 164.308(a)(1)(ii)(A), 164.308(a)(1)(ii)(B),164.308(a)(5)(ii)(B), 164.308(a)(6)(ii), 164.308(a)

Do you know your cyber liability risks?By John Southrey, CIC, CRM

MEDICINE & THE LAW

visit us at www.bcms.org 11

(7)(ii)(A), 164.308(a)(7)(ii)(B), 164.312(a)(1), and164.312(c)(1), respectively.

“Covered entities must cooperate with OCR during acomplaint investigation (45 C.F.R §160.310(b)) andpermit OCR access to its facilities, records and other in-formation during normal business hours or at any time,without notice, if exigent circumstances exist (45 C.F.R.§160.310(c)).

“If we are unable to resolve this matter voluntarily, andif OCR’s investigation results in a finding that [theclinic] is not complying with the Privacy and SecurityRules, HHS may initiate formal enforcement action,which may result in the imposition of civil money penal-ties … We have enclosed a separate fact sheet explainingthe penalty provisions under the Privacy and SecurityRules. The fact sheet also explains that certain violationsof the Privacy and Security Rules may be subject to crim-inal penalties, which the U.S. Department of Justice isresponsible for enforcing.

“Under the Freedom of Information Act, we may berequired to release this letter and other informationabout this case upon request by the public.”

Also attached to this letter was a “data request” consisting of athree-page matrix of checklists that cited numerous potentialcompliance failures. The physician had only 14 days from the dateof the letter to provide the requested information, including doc-umentation of his “internal investigation and corrective action re-garding the incident” and proof that a HIPAA Security Rule riskanalysis was done.

The physician is still dealing with this matter and will be forquite some time. It is not clear what corrective actions the OCRwill require of the physician’s practice. In the interim, he has re-tained new IT staff and implemented new privacy and securityprotections.

The ransom demand was never paid, and the forensic computerspecialists were unable to restore all of the medical records fromthe original server. The physician paid and incurred expenses forthis claim that exceeded the $50,000 limit of his TMLT cyber li-ability coverage.

FINES, PENALTIES CAN BE SERIOUSAs of Sept. 23, 2013, all healthcare providers were required to

comply (there are a few exceptions) with the expanded privacyprotections mandated in the HIPAA Omnibus Final Rule. TheOmnibus Rule is a comprehensive update of the regulations en-acted under the HIPAA Privacy and Security Rules that expandedthe rights of patients and tightened federal breach notification re-quirements. The Privacy Rule applies to all forms of PHI (oral orrecorded in any form or medium) and the Security Rule appliesonly to ePHI.

Under the Security Rule, covered entities are required to imple-

ment suitable administrative, physical and technical safeguards toensure the confidentiality, integrity and security of patients’ ePHI.They also must conduct an analysis of the risks and vulnerabilitiesof their ePHI. The OCR expects organizations to have reasonableand appropriate safeguards in place to protect patients’ ePHI — es-pecially if that information is accessible over the Internet.

Providers are becoming increasingly exposed to unauthorized ac-cess, acquisition, use and disclosures of unsecured PHI/ePHI thatcould result in costly violations. Breach vulnerabilities are abundantin healthcare. A workforce that is untrained about privacy and se-curity protocols; storage of unencrypted ePHI especially on portabledevices; ongoing hacking and virus attacks, and privacy breachesby disgruntled employees represent several possible exposures. It iswidely recognized that healthcare IT lags other industries in em-ploying adequate privacy and security practices.

In 2012, OCR director Leon Rodriguez stated that healthcareproviders need to get their HIPAA policies and procedures inworking order or they will face more audits and increased civilmonetary fines.

Two recent data breach examples involving ePHI are repre-sentative of the OCR’s call-to-action.

1. In 2012, Phoenix Cardiac Surgery of Phoenix and Prescott,Ariz., agreed to pay HHS a $100,000 settlement and take correc-tive action to employ policies and procedures to safeguard thePHI of its patients.

The OCR’s investigation found the practice was posting clinicaland surgical appointments for its patients on an Internet-based cal-endar that was publicly accessible. The OCR also found PhoenixCardiac Surgery had implemented few policies and procedures tocomply with HIPAA Privacy and Security Rules and had only lim-ited safeguards in place to protect their patients’ ePHI.

Rodriguez highlighted this case as a warning. “We hope thathealthcare providers pay careful attention to this resolution agree-ment and understand that the HIPAA Privacy and Security Ruleshave been in place for many years, and OCR expects full compli-ance no matter the size of a covered entity.”

2. For the first time, the OCR pursued a HIPAA breach of lessthan 500 patient records. The Hospice of North Idaho (HONI)reported to HHS that an unencrypted laptop computer contain-ing the ePHI of 441 patients had been stolen in June 2010.

In 2012, HONI agreed to pay a $50,000 settlement to HHSbecause HONI did not conduct a security risk analysis to safe-guard the ePHI of their patients and they did not have policies orprocedures in place to address mobile device security, as requiredby the HIPAA Security Rule.

Once again, Rodriquez used this case to admonish the healthcarecommunity. “This action sends a strong message to the healthcareindustry that, regardless of size, covered entities must take actionand will be held accountable for safeguarding their patients’ healthinformation. Encryption is an easy method for making lost infor-mation unusable, unreadable and undecipherable.”

Continued on page 12


With penalties and random audits expected to escalate, it is imper-ative for healthcare providers to carefully identify their risks and vul-nerabilities to a data breach and to employ privacy and securitypolicies and procedures to safeguard all PHI.

On Sept. 1, 2012, Texas House Bill 300 (HB 300) became effec-tive, and it significantly revised the Texas Medical Records PrivacyAct for covered entities who store PHI. HB 300 increased a provider’scyber liability exposure by adding more stringent safeguards thanthose found in HIPAA and HITECH.

A CLEAR MESSAGEProviders must dedicate sufficient attention, resources, staff train-

ing, and systems to comply with state and federal laws to minimizetheir risk of violations and reputational harm. It appears assertive en-forcement of data breaches by the OCR will fall hard, particularly onhealthcare providers who have clearly failed to address and remedyprivacy and security issues. The liabilities and potential assessment ofcivil penalties associated with such failures can inflict heavy time andfinancial burdens.

All covered entities should review their HIPAA policies and proce-dures, conduct a risk assessment, update their notice of privacy prac-tices, and generally ensure they are in compliance. Specifically,physicians should: • update their HIPAA privacy notices;• conduct a HIPAA security risk analysis;• revise HIPAA employee training to comply with the 2013 changes

required by the Omnibus Rule, HB 300, and by Senate Bills 1609and 1610;

• revise Business Associate Agreements to include the language re-quired under the HIPAA Omnibus Rule and HB 300 to obtainwritten assurances that your business associates will similarly pro-tect patients’ PHI;

• implement technical safeguards such as encryption to all ePHI storedon portable devices or that is electronically transmitted; and

• develop breach notification policies and procedures and a responseplan for staff.

Cyber liability insurance policies are available from TMLT andother sources.

John Southrey, CIC, CRM, is manager of consultingservices at Texas Medical Liability Trust. He may bereached at [email protected].

This information is provided on behalf of a valued BCMS Circle ofFriends sponsor at the platinum level, but it is not an endorsement. Do-nations from Circle of Friends sponsors help keep down the cost of duesand allow BCMS to continue to provide quality service to its members.The society continues its pledge to you and only will involve itself in serv-ices and programs that benefit you, the member, and your patients.

MEDICINE & THE LAW

Continued from page 11

RESOURCES• HHS guidance: www.hhs.gov/ocr/privacy

• National Institute of Standards and Technologiesinformation: www.csrc.nist.gov

• Mobile Devices: Know the RISKS. Take theSTEPS. PROTECT and SECURE Health

Information: www.HealthIT.gov/mobiledevices

• Understanding Your Cyber Liability Coverage:http://resources.tmlt.org/PDFs/cyber-liability-brochure-2013.pdf

• U.S. Department of Health and Human Services,Breaches Affecting 500 or More Individuals:www.hhsgov/ocr/privacy/hipaa/administrative/breachnotificationrule/breachtool.html

• American Medical Association, The Health Insur-ance Portability and Accountability Act (HIPAA)omnibus final rule summary: www.amaassn.org/resources/doc/washington/hipaa-omnibus-final-rule-summary.pdf

• HHS’ Office for Civil Rights (OCR) has devel-oped an array of tools to educate consumers andhealthcare providers about the HIPAA Privacyand Security Rules, including a video titled TheHIPAA Security Rule for small providers to helpthem establish basic safeguards and to complywith the Security Rule’s requirements:www.youtube.com/user/USGovHHSOCR

The OCR has also developed three modules for providers about compliance that are available at Medscape.org:

• Patient Privacy: A Guide for Providerswww.medscape.org/viewarticle/781892?src=ocr

• HIPAA and You: Building a Culture of Compliancewww.medscape.org/viewarticle/762170?src=ocr

• Examining Compliance with the HIPAA Privacy Rulewww.medscape.org/viewarticle/763251?src=ocr


MEDICINE & THE LAW

The integration of the electronic health record (EHR) intomedical practices has great potential to advance both the practiceof good medicine and patient safety. However, there are alwaysunanticipated consequences when new technologies are adopted— and the EHR is no exception. Real and potential liability risksare beginning to be recognized, and it is important for physiciansto become familiar with them.

Doctors are responsible for information to which they have rea-sonable access — and there is increased access to e-health datafrom outside the practice that is accessed from the practice EHRor website or through Health Information Exchanges, e.g., hos-pital charts, consultants’ reports, lab results and radiology reports,and community medication histories. EHR metadata documentswhat was reviewed. If patient injury results from a failure to accessor make use of available patient information, the physician maybe held liable.

CAPABILITIES, BENEFITSE-prescribing is being adopted rapidly, driven by federal finan-

cial incentives, and is currently used by more than 50 percent ofoffice practices. Potential capabilities and benefits include: • Most electronic prescriptions are transmitted via a Surescripts

network (which has data on more than 70 percent of pa-tients) to all chain pharmacies, 60 percent of independentpharmacies and most insurance formularies.

• EHRs have an e-prescribing module, which is a required ca-pability under the federal financial incentives for “MeaningfulUse” of EHRs. E-prescribing provides electronic routing topharmacies, quick access to drug formulary and eligibility in-formation, and the patient’s prescription history.

• Standalone e-prescribing software also is available at no costfrom Allscripts and the National ePrescribing Patient SafetyInitiative (NEPSI).

• Most e-prescribing programs check for drug interactions,dosage errors, medication allergies and patient-specific med-ication factors.

• Office prescription renewal requests can be synchronized withmost e-prescribing systems.

• E-prescribing encourages patients to fill prescriptions (cur-rently 30 percent do not), because the prescription is sent to

the pharmacy electronically and is ready to be picked upwhen they arrive.

• Costs are lowered by flagging generic and “on-formulary”drugs.

However, practices are exposed to community medication his-tories through e-prescribing. For example, Dr. A renews a med-ication, and his e-prescribing program sends an alert advising himthat the medication could interact with another drug the patientis taking. He has not prescribed that drug, so his office staff willhave to contact the patient to identify who has prescribed it, andthen Dr. A will have to contact Dr. X to “negotiate” which drugwill be discontinued or changed. If failure to take action resultsin patient injury from a drug interaction, Dr. A may be liable.

Drug-drug interaction lists generate frequent, annoying anddisruptive alerts, and doctors may develop “alert fatigue” and ig-nore, override or disable them. If it can be shown that followingan alert would have prevented an adverse patient event (this willbe documented in the metadata), the physician may be found li-able for failing to follow it.

Doctors may copy information from a prior note or the historyand physical (H&P) and paste it into a new note or H&P (knownas “cloning”), making changes where appropriate. This works wellfor the past history but is risky for the physical examination,which may change. This may result in irrelevant over-documen-tation, and the patient may appear to have more or less complexproblems since the prior encounter. By substituting a word proces-

Electronic healthrecords pose malpractice risksBy David B. Troxel, MD


MEDICINE & THE LAW

sor for the physician’s thoughtful review and analysis, the narrativedocumentation of daily events and the patient’s progress may belost, thereby compromising the record of the patient’s course. Thequality of notes and documentation may be further compromisedby the use of templates.

The computer may become a barrier between the doctor andthe patient. When the doctor fills in a computer template, it maydivert attention from the patient, limit interactive conversationand restrict creative thinking. This may depersonalize and weakenthe doctor-patient relationship. The computer’s location in theoffice is an important ergonomic consideration; i.e., the locationof electrical outlets shouldn’t force you to sit with your back tothe patient.

DEPOSITION QUESTIONSMany EHRs autopopulate fields in the H&P (from data de-

rived from data fields in a prior H&P) and in procedure notes(from personalized or packaged templates). While over-documen-tation may facilitate billing, entering erroneous or outdated in-formation may increase liability. For example, an internist wasdeposed and his EHR was the medical record. Some of the au-topopulated fields contained obviously wrong information. Atdeposition, the plaintiff ’s attorney asked these questions:

“So is the information in this record accurate or not?”“Do you bother looking at your records?”“If these ‘autopopulated’ fields are incorrect, can we trust any-

thing in this record?”“Do you deliver the same level of care as you do in record-

keeping?”EHRs are certified for compliance with Meaningful Use re-

quirements, e.g., computerized provider order entry (CPOE),e-prescribing, Clinical Decision Support (CDS), and patientconnectivity through patient portals. Patients must be providedwith clinically relevant, disease-specific educational and drugsafety materials through these portals. Providers are responsiblefor the content, which creates risk. Some EHRs have patientquestionnaires that use an algorithm to interview the patientthrough these portals. The questionnaires may address — andmemorialize in the record — issues that physicians are not pre-pared to pursue (depression, substance abuse, sexually transmit-ted disease, etc.) Lack of or incomplete follow-up can createpotential liability — and provide a clear record for the plaintiff ’sattorney to follow.

Vendor contracts may attempt to shift liability resulting fromfaulty software design or CDS data onto the physician. Malprac-tice policies may exclude coverage for product liability and in-demnification of third parties. Read all contracts carefully.

Electronic discovery: Lawyers may request printed copies of theEHR and also copies in native format, which shows how the datawas used. (Were CDS alerts and prompts followed or overridden?)They also will request the metadata, which includes logon and lo-goff times, what was reviewed and for how long, what changes or

additions were made, and when the changes were made. Smart-phone and e-mail records are also discoverable. All physician in-teractions with the EHR are time-tracked and discoverable.

Templates with drop-down menus facilitate data entry. How-ever, drop-down menus are usually integrated with other auto-mated features. An entry error (accidentally selecting themedication above or below the one desired on the menu) may beperpetuated elsewhere in the HER — and it may be overlooked,resulting in a new potential for error. Erroneous information, onceentered into the EHR, is easily perpetuated and disseminated.

CHECK PRESCRIBING INFORMATIONEHRs provide e-prescribing drug information and CDS data-

bases (required by Meaningful Use). Clinicians should know thesource of the medication and CDS information in their EHRs,because it may be in conflict with the clinical standards of care orpractice guidelines for their specialty and with the information inU.S. Food and Drug Administration (FDA)–approved drug labelsor drug alerts.

Computer-assisted documentation uses point-and-click lists,drop-down menus, auto-fill, templates and canned text to bypassnatural language and produce structured progress notes. Thesecontain redundant, formulaic information, making it easy to over-look significant clinical information that is lost in a sea of normalor irrelevant findings. Communication with on-call and consult-ing physicians may be compromised, and abnormal lab and im-aging test results may be missed.

CDS provides alerts, warnings and reminders for medicationand chronic disease management and preventive care, but physi-cians may have to justify departures from these guidelines (docu-mented in the EHR’s native format) if an adverse event occurs.Always document why a prompt was overridden.

David B. Troxel, MD, is medical director, boardof governors, for The Doctors Company.

The guidelines suggested here are not rules, do notconstitute legal advice, and do not ensure a successful

outcome. The ultimate decision regarding the appropriateness of anytreatment must be made by each healthcare provider in light of allcircumstances prevailing in the individual situation and in accor-dance with the laws of the jurisdiction in which the care is rendered.Reprinted with permission. ©2014 The Doctors Company(www.thedoctors.com).

This information is provided on behalf of a valued BCMS Circleof Friends sponsor at the silver level, but it is not an endorsement.Donations from Circle of Friends sponsors help keep down the costof dues and allow BCMS to continue to provide quality service toits members. The society continues its pledge to you and only willinvolve itself in services and programs that benefit you, the member,and your patients.


MEDICINE & THE LAW

Having lived in Texas all of my life, I was eager to spend timein the Windy City during my forensic psychiatry fellowship train-ing many years ago. And while my enthusiasm for new learningwas robust, running as fast as I could in a top-ranked program, Icarried a hole in me. I missed our great big skies, our climate (yes,this is true), our friendly people, and the air of independence thatcan only be called Texan.

After serving on the Texas Medical Board for the past sevenyears, I have concluded to more than a reasonable degree of med-ical certainty: I am a prouder Texan than before.

Fairly soon after Gov. Rick Perry appointed me to the board,Dr. Roberta Kalafut asked me to chair the licensure committee.Sitting at the head of our conference table, I caught a glimpse intohow great our state really was. On the heels of tort reform, licen-sure was a busy place. New license applications (averaging 2.7Kper year) had increased by more than a third (to an average ofmore than 4K per year).

Since then, those figures have not let up. In fact, there has beenyet another notable increase in applications received over the pasttwo years, and our projected figure of new license applicationsthis year will exceed 5K.

TAKING CARE OF PATIENTSIn the trenches, I recall hearing a physician mention that mov-

ing to Texas would decrease his malpractice premiums by almost$100K. Another physician, whose application had been flaggedfor excessive suits that proved frivolous, told me that he wasthankful for having the opportunity to practice medicine in ourstate and focus on patient care.

There are many cases just like these, where doctors simply wantto do what they spent most of their life preparing for – takinggood care of patients. Indeed, thousands of new citizens are look-ing for opportunity in our great state. A recent (Forbes) study

showed that four cities in Texas sat atop the list of our nation’sbest cities for good jobs. Facts speak for themselves.

In licensure, it is our duty to accredit medical schools, resi-dency programs and fellowships programs in the state (althoughwe honor and depend upon the Accreditation Council for Grad-uate Medical Education (ACGME) processes). Herein lies themost important discovery that I’ve made serving on the board:We have some of the finest medical centers and training pro-grams on this planet.

Despite my appraisal (and I do not stand alone on this), ourmedical centers and training programs probably won’t ever receivethe recognition that they deserve simply because they exist inTexas. This incongruence is eerily akin to the vibes that I some-times pick up on when sitting in a Federation of State MedicalBoards conference room with other state medical board represen-tatives, where I steadfastly represent our sovereign rights as a stateagency while the scent of federalism – fighting words, no less –permeates the air.

On a positive note, I come away from that debate knowing thatothers respect us. After all, our state board has been a trailblazerin keeping abreast of the changes in medicine and creating policythat protects the public and encourages the growth of medicine.

Lastly, I have been fortunate to work with an array of excellentclinicians who oversee the training of our young doctors. The

A view from inside the TexasMedical BoardLicensure committee assists physicians, organized medicineBy Michael R. Arambula, MD, PharmD


MEDICINE & THE LAW

stakeholder meetings we held last year allowed us to hear of the

subtle changes that had commenced in the evaluation of ouryoung physicians per the national accrediting bodies. More im-portantly, we (licensure) have adjusted our analyses of new appli-cants who carry training concerns so as to avoid unnecessarydisciplinary action against them.

POSITIVE MEMORIESI harbor countless memories from my interactions with physi-

cians during medical board proceedings. Naturally, there arememories that I would rather forget. A very low feeling still per-vades my air space when board counsel describes the harsh con-ditions of a disciplinary order to a physician; more so when aphysician has gambled away an entire medical career running a“pill mill.”

Alternatively, I carry mostly positive memories. The image of aphysician suddenly breaking down in tears when his case was dis-missed comes to mind. The gratitude that a previously impairedphysician expressed to me for stepping into his life so that hecould change the path he was on also comes to mind. So too dothe remarks I heard during a break that one physician could cracktheir chests. Sentiments like these give me confidence that whatwe strive for is to do the right thing.

I must give a “shout-out” to the Texas Medical Board staff. Sim-

ply said, they are superb. Still, there is a rumor that something must be wrong with

those who serve on the Texas Medical Board. If that rumormeans that my service can help people who reside in this greatstate that I will never meet, that my service can help physicianswho have difficulty helping themselves, that my service can pro-vide opportunities for physicians to come to Texas and practicemedicine, that my service can adapt to the training needs ofour future medical professionals, that my service can sustainthe sovereignty of our great state in the arena of medicine, andthat my service allows me to get up in the morning and lookforward to the good fight that all of us (board members) engagein, then I wholeheartedly embrace that something must bewrong with me and furthermore, that I would do it again in aheartbeat.

Michael R. Arambula, MD, PharmD, is vicepresident of the Texas Medical Board and chairmanof the licensure committee. He carries board certifi-cations in general and forensic psychiatry and an ad-

junct faculty appointment at UTHSCSA. He is a long-timemember of BCMS.


MEDICINE & THE LAW

In many situations, texting is the fastest and most efficient wayof sending information, and reports show that texting amongphysicians is widespread and that they are texting clinical infor-mation.

Physicians who text each other clinical information risk expos-ing themselves to the privacy and security violations of the HealthInsurance Portability and Accountability Act (HIPAA). Seeing theneed for an answer that supports a physician’s desire to commu-nicate and collaborate quickly while still mitigating the risk ofHIPAA violations, Bexar County Medical Society partnered withDocbookMD, a secure messaging app for physicians that com-bines the ease and mobility of texting within a HIPAA-secureframework.

DocbookMD, available for iOS, Android and PC/Mac, wascreated and developed by the Austin husband-and-wife team ofTim Gueramy, MD, and Tracey Haas, DO, MPH – both TexasMedical Association members.

“DocbookMD allows you to look up another doctor at thepoint of care. You can then either call the physician or send a textmessage with room numbers, medical record numbers, even at-tach photos of wounds, X-rays and EKGs,” said Dr. Gueramy, anorthopaedic surgeon. “All of this is sent securely and in a way thatmeets HIPAA requirements.”

The app allows physicians to: • Have a simple communication solution, in and out of the of-

fice;• Coordinate across the full care team, including nurses, PAs

and office staff;• Access an up-to-date, extensive physician directory;• Send fast, HIPAA-secure messages; and • Attach high-resolution images, including X-rays and EKGs.

All BCMS member physicians have free access to Doc-bookMD, and their non-physician staff and care team membersalso can download the app to communicate securely with themember physicians, through a simple invitation process that keepsphysicians in control of their accessibility. Nurses, PAs and staffmembers can send messages to any physician who has invitedthem to be a part of their care team, as well as to other membersof their team.

Reports from physicians -- across all specialties and settingsaround Texas -- have been overwhelmingly positive about the po-tential of DocbookMD. Wichita Falls otolaryngologist Jed Grisel,MD, has been using DocbookMD for the past year, and says ithelps him coordinate with primary care physicians and other spe-cialists alike. For instance, he and his colleagues at Head and Neck

‘HIPAA-secure’ doesn’t have to mean complicated

Special to San Antonio Medicine


MEDICINE & THE LAW

Surgical Associates work with a dermatologist who removes skincancers from patients. After having the cancer removed, patientssometimes need to return to have the area reconstructed.

"Using DocbookMD, the dermatologist can send me an imageof the skin defect prior to the surgery I'll be performing. It reallyhelps to have that picture in advance because I can begin planninghow I'll reconstruct the defect. Bypassing the need for an extrapatient visit, I'm ready to go, and care is coordinated in a HIPAA-compliant way," Grisel said.

Hospitals and large groups, including Memorial HermannPhysician Network in Houston, also are deploying an enterpriseversion of the DocbookMD HIPAA-secure platform.

Docbook Enterprise offers additional integration and admin-istrative capabilities, such as allowing doctors to get answeringservice messages and radiology reports, such as stat X-rays, CTsand MRIs, directly on their mobile device, and provides the abilityto securely connect physicians in a hospital setting not only toone another, but to other physicians in the local medical commu-nity as well.

This ability to connect physicians to colleagues and healthcareresources within an entire region is what sets Docbook Enterpriseapart from other communication platforms. Most enterprise tech-

nologies use a closed network that al-lows physicians within a hospital orgroup to communicate securely onlywith colleagues and staff who are insidethat organization, but DocbookMD'sguiding vision has always been to breakdown the barriers that prevent physi-cians from sharing critical communi-cations with all of those involved in their patients' care.

DocbookMD is a benefit of your BCMS and TMA member-ship, and you can start taking advantage of it immediately!Across the country, DocbookMD is offered as a free benefitthrough more than 300 county/state medical societies and isnow used by more than 25,000 physicians in 40 states, includingmore than 8,500 Texas physicians.

To begin using DocbookMD, download the app to youriPhone, Android or tablet and follow the registration instructions.For more information or help getting registered, contact BCMSat (210) 301-4391, and be sure to view the video tutorials on howto use the app at docbookmd.com/videos.

DR. JED GRISEL

BCMS NEWS

Bexar County Medical Society (BCMS) officially entered intoa sister cities agreement with medical professionals in the state ofNuevo Leon, Mexico, effective June 20.

The sister cities agreement is the third between BCMS, the pro-fessional organization for San Antonio physicians, and medicalprofessionals elsewhere in the world. BCMS established a sistercities relationship with Kumamoto, Japan, in 1992, and withChennai, India, in 2008. Through the programs, BCMS mem-ber-physicians visit their international counterparts, touring med-ical facilities, comparing healthcare services, and exploringhistorical and cultural landmarks. BCMS members also hostgroups of medical delegates from Japan and India -- and nowMexico – to share the Alamo City’s medical, cultural and historicalaccomplishments.

Roberto San Martin, MD, 2014 chairman of the BCMS In-ternational Relations Committee, said the medical sister citiesagreements enable physicians and other healthcare personnel toshare best practices with international colleagues.

“San Antonio, in some ways, is the northern border of Mexico,”said Dr. San Martin, a board-certified ophthalmologist who hasbeen in clinical practice for 35 years. “Many of our physiciansstudied in Mexico, and many San Antonio residents also havelived there. Our culture is identical. We have a shared languageand heritage.”

Representatives from BCMS and the Colegio de Médicos Ciru-janos del Estado de Nuevo León, A.C., marked the new agree-ment at a signing ceremony June 20 in Monterrey, Nuevo Leon.

Attending on behalf of BCMS were Dr. San Martin; Dr. Ger-aldo Ortega, 2001 BCMS president, and his daughter, Karen; Dr.Hugo Casteneda; John Dauer and Yolanda Perez, RN.

Representing the state of Nuevo Leon were Dr. Fernando R.García García, 2012-14 president of the Colegio de MédicosCirujanos del Estado de Nuevo León, A.C. The colegio represents

3,000 physicians in the northern Mexico state.San Antonio representatives presented a ceremonial proclama-

tion signed by Mayor Julian Castro.Shahrzad “Sherry” Dowlatshahi, chief of protocol and head of

international relations in the City of San Antonio’s Intergovern-mental Relations Department, called the agreement momentous.

“We are thrilled to see an excellent example of cooperationamong sister cities,” Dowlatshahi said. “The role that BCMS isplaying in our sister city relationships by entering meaningful re-lationships with sister medical societies in Kumamoto, Japan;Chennai, India, and now Monterrey, Mexico, is important tohighlight.”

The City of San Antonio has sister city agreements with ninecities. In addition to Kumamoto and Chennai, they include twocities in Mexico -- Monterrey, Nuevo Leon, and Guadalajara,Jalisco; two in the Canary Islands of Spain – Las Palmas and SantaCruz de Tenerife; as well as Gwangiu, South Korea; Kaohsiung,Taiwan, ROC; and Wuxi, Jiangsu Province, China.

Sister Cities International is an initiative started in 1956 byPresident Dwight D. Eisenhower to develop economic, culturaland technical exchanges between U.S. cities, counties and stateswith corresponding communities worldwide.

BCMS and its medical sister cities agree to have groups of del-egates visit their respective cities in alternate years. A group of 16Japanese visitors came to San Antonio in August 2012 and are ex-pected this month, and 13 BCMS delegates visited Kumamotoin September 2013. The first BCMS delegation to Chennai vis-ited India in January 2012.

Dr. San Martin said the Monterrey trip was successful. “Ourcolleagues were most gracious, very professional and excited forthe opportunity to engage with their sister medical society. Ourmission was well received. They were impressed with our presen-tation, friendship and, of course, our ability to speak in Spanish.”

BCMS establishes sister cities agreementwith Nuevo Leon physicians

BCMS representatives and Nuevo Leon healthcare professionals signed a medical sister cities agreement June 20 in Monterrey.


SAVETHE DATE

Sept. 18: BCMS FoundationGolf Tournament, QuarryGolf Club. Register atwww.bcms.org.

Sept. 24: BCMS Fall GeneralMembership Meeting,Hiltonat the Airport. CME and leg-islative updates.

Sept. 28: Siclovia, AlamoPlaza. www.siclovia.org.

Oct. 9-10: Texas Health Literacy Conference,La Quinta Inn and SuitesMedical Center. www.healthcollaborative.net.

Oct. 16: BCMS Auto Show,BCMS office parking lot. Buf-fet and cocktails; new modelvehicles; family and friendswelcome.

BCMS NEWS

NOTEWORTYBCMS life member Charles R. Bauer,

MD, was one of four gold-level recipientsof the 2014 TMA Awards for Excellence inAcademic Medicine at the May TexMedmeeting in Fort Worth. The award recog-

nizes academic physicians who are consummate teachers,role models and medical professionals.

IN MEMORIAMSamuel B. Bashour, MD, FACS,

died June 14, 2014, at age 94. A sur-geon, Dr. Bashour was a BCMS mem-ber and a member of the TMA 50Year Club.Jack Leigh Eidson, MD, died June

15, 2014. Dr. Eidson, 93, was aBCMS member.James R. “Dick” O’Neill, MD,

died May 25, 2014, at age 96. Dr.O’Neill, a cardiologist, was a BCMSlife member.

LEGISLATIVE AND ADVOCACY NEWS

Members of the BCMS Legislative and Socioeconomics Committee welcomed U.S. Rep. Lamar Smith (Texas Congressional District 25)on April 22 for a meeting to discuss the recent SGR patch and to hear from the congressman about other issues of interest to physicians.

A group of BCMS physicians attended a TEXPAC dinner at Paesano'sRestaurant in support of State Sen. Donna Campbell, MD (District 25),on June 20.

For information, contact BCMS Chief Governmental and Community Relations Officer

Mary E. Nava, MBA, [email protected].


BCMS NEWS

FINANCIAL AIDSOUGHT FORLECTURE

Dr. Alain Touwaide will present a lectureon “The Archaeology of Health in the An-cient Mediterranean World” at 7:30 p.m.Oct. 20 in Chapman Hall at Trinity Univer-sity. The event is free and open to the public.

Dr. Touwaide is a science historian whospecializes in the history of medicinal plantsin the cultures that flourished around theMediterranean Sea from antiquity to the 17thcentury CE. His lecture is sponsored by theSouthwest Texas Archeological Society(SWTAS), a branch of the Archeological In-stitute of America.

Financial support is being sought to coverthe approximate cost of $2,000 for expenses.Contributions of all sizes are appreciated bythe SWTAS, which is a 501(c)(3) organiza-tion. Contributions can be sent to AIASWTAS. The check should be mailed to:Laura Childs, 2858 Burning Log, San Anto-nio, TX 78247. The check should stipulateTouwaide Lecture.

NEW MEMBER WELCOME PARTYBCMS members, guests and Circle of Friends sponsors filled the Argyle Club June 3

for the annual new member mix and mingle, which featured complimentary beveragesand buffet. Live entertainment, including a set by Rick Cavender, and door prizes wereincluded.

Dr. Marvin Eng (left) visits withBCMS President K. Ashok Kumar atthe new member mix and mingle.

Aisha Ross (left) and Dr. Kimberly Crittendenchat on the porch of the Argyle Club at the NewMember Welcome.


As the most preferred and trusted healthcare provider in San An-tonio, the Methodist Healthcare System has been recognized by thecommunity for its outstanding team of nurses, medical professionalsand physicians for more than 50 years. Since opening its first hos-pital in 1963, Methodist Healthcare has expanded its vision ofworld-class healthcare to residents in San Antonio and the 26 sur-rounding counties and to patients from around the world.

Methodist Healthcare is the fifth-largest healthcare system in thecountry and the largest healthcare provider in South and CentralTexas, with 27 facilities, including nine acute-care hospitals servingmore than 90,000 inpatients and 390,000 outpatients annually.

The system’s ownership structure is a 50/50 co-ownership be-tween not-for-profit Methodist Healthcare Ministries and investor-owned Hospital Corporation of America (HCA), a truly uniquebusiness model for health systems in the country. MethodistHealthcare Ministries is a private, faith-based, not-for-profit or-ganization dedicated to providing medical and health-relatedhuman services to low-income families and the uninsured in SouthTexas. Methodist Healthcare Ministries is second only to the gov-ernment in providing healthcare to the indigent population in a26-county area. HCA, based in Tennessee, is the nation’s leadingprovider of healthcare services, composed of 163 hospitals and 105freestanding surgery centers in 20 states and England.

MISSION, VISIONOur mission is “serving humanity to honor God by providing

exceptional and cost effective healthcare accessible to all.” Our vi-sion is to be a world-class healthcare provider, continually raisingthe standards of performance excellence and advancing the health

status of the community.Led by a culture of Methodist Excellence, the more than 8,000

staff and volunteers, combined with a medical staff of more than2,500, dedicate themselves to continuous quality improvement bycommitting to live by the Methodist Excellence mission, visionand values.

Methodist Excellence is the foundation of all aspects of thehealthcare system; from the hiring process to the strategic planningprocess. This commitment to quality and process improvementenables us to provide better service and outcomes to our patientsand that is what drives us to be nothing less than excellent.

Our journey to excellence is based on the National MalcolmBaldrige Quality Award criteria. The Baldrige Award was estab-lished by Congress in 1987, envisioned as a standard of excellencethat would help U.S. organizations achieve world-class quality. Theaward is based on seven key areas.

In the healthcare industry, we are all facing the same cost pressures.Whether a hospital or a physician, we must provide high-qualitycare at a lower cost. Our journey to excellence has provided a wayfor us to address this issue in collaboration with our physicians.

PHYSICIAN INVOLVEMENTFor the last five years, we at Methodist Healthcare have worked

through teams of doctors, nurses and other clinical staff organizedby service lines to improve care. Physicians’ involvement is criticalto our journey. Each clinical service line is co-managed by a physi-cian leader and an administrative leader. Working together, theseteams have created protocols that have resulted in efficiencies ofphysician and staff time, cost savings and patient-flow.

CARE SYSTEM PROFILES

EDITOR’S NOTE: This is the ninth article in a planned series of Care System Profiles, highlightingvarious healthcare providers in Bexar County in the pages of San Antonio Medicine. The goal of the seriesis to inform BCMS members about the relationships that exist within and among various local institutions.Articles will focus on what distinguishes one system from another, and what is unique about each organi-zation. Representatives of local healthcare delivery systems are being invited to submit an article describingtheir institutional initiatives for publication in the series. Organizations are featured in the order in whichtheir articles are submitted and approved. Members of the BCMS Communications/Publications Com-mittee review articles before publication, and content may be edited for format, style and clarity. For guide-lines and more information, email [email protected].

Methodist Healthcare SystemA journey to excellence in which best practices save lives

By Kenneth Davis, MD, Chief Medical Officer, Methodist Healthcare


Using the Baldrige template has allowed us to learn from suc-cesses achieved in other industries. It has encouraged us to embrace

new approaches, challenged us to learn a new language, and helpedus grow by sharing our experiences with others.

Working closely with our physician leaders, Methodist Health-care has been recognized with several quality awards. In 2012,Methodist Hospital and its affiliated campuses received one of onlytwo gold awards presented by the Texas Medical FoundationHealth Quality Institute for distinguished efforts in healthcarequality improvements. This was quite an achievement as the com-petitive field included 214 hospitals throughout the state.

In 2013, Methodist Hospital received the Bill Aston QualityAward for innovations in quality, based on the Methodist HospitalCardio-Hospitalist Program and clinical outcomes.

Methodist Healthcare recently received the Texas Award for Per-formance Excellence (TAPE) from the Quality Texas Foundation,representing the highest level of quality an organization can achievein the state of Texas. This award is based on the Malcolm Baldrigecriteria. Methodist Healthcare is the first healthcare system inSouth Texas to receive the TAPE award since the inception of theaward in 1994.

MILESTONES REACHEDExcellence is a journey, not a destination. Here are a few of the

many milestones that Methodist Healthcare has reached along ourjourney: • Evidenced Based Care Measures (Composite Core Measures)

are in the top 10 percent of the nation, for those care inter-ventions known to improve patient mortality and complica-tions.

• The Methodist Healthcare in-hospital mortality rate is only50 percent of what is expected given the severity of illness lev-els of system patients. For Methodist this translates into 530fewer patients dying each year than should be expected givenpatients’ risk factors.

• The Patient Safety Indicator (PSI) 90 is a composite score ofseveral in-hospital patient complications. Methodist Health-care scores significantly lower (better) at 0.46 than the nationalaverage of 0.6, indicating a much lower hospital complicationrate than most hospitals.

• Methodist Healthcare’s quality initiatives include a reductionin hospital acquired conditions (infections, etc.) and a reduc-tion in heart failure readmissions.

Methodist Excellence recognizes that best practices save lives.When people see real results — patients receiving better care, doctorsusing their time more effectively, and staff experiencing increased jobsatisfaction — their commitment to excellence grows stronger andleads to continuous quality improvement throughout the system.

Our goal is not just to be the best in San Antonio, but to be thebest in the nation. Achieving this lofty goal requires a close collab-

orative working relationship with our physicians.

Kenneth Davis, MD, has served as the chief med-ical officer for San Antonio’s Methodist Healthcaresince 2008. Prior to joining Methodist, he served for16 years as the chief medical officer at North Missis-sippi Health Services, winner of the Malcolm

Baldrige National Quality Award in 2006 and again in 2012. Dr.Davis was in private practice specializing in internal medicine and geri-atrics for 20 years. He is a fellow in the American College of Physicians.

CARE SYSTEM PROFILES

METHODIST HEALTHCAREMethodist Hospital and its campuses:

Methodist Children’s Hospital

Methodist Heart Hospital

Methodist Specialty and Transplant Hospital

Metropolitan Methodist Hospital

Methodist Texsan Hospital

Northeast Methodist Hospital

Methodist Ambulatory Surgery Hospital

Methodist Stone Oak Hospital

EXPANSION DETAILS• Largest-ever expansion of Methodist Hospital and

Methodist Children’s Hospital and the biggest expendi-

ture in the hospital system’s history

• Addition of nearly 500,000 square feet, increasing their

footprint in the medical center nearly 40 percent

• New adult patient tower with beds for general acute

care and critical care

• New six-story tower for pediatric patients

• Nine-story parking garage with underground access to

surgical services

• Both hospitals will have new entrances

• Conversion of 90 percent of patient rooms at both hos-

pitals to private rooms

• Increase of number of beds in the newborn intensive care

unit from 78 to 94

• Expansion of emergency departments in both hospitals

• Upgrades in the hospitals’ cancer and heart services,

labor and delivery unit, general surgery and neurosurgery

areas and pediatric services

• Expected completion in 2017


BCMS FOUNDATION

The Bexar County Medical Society Foundation resumed its edu-cational mission in May, led by the Foundation’s executive directorSteve Fitzer, Foundation manager Lisa Robertson and Gerardo Or-

tega, MD, the Foundation’s acting president. The Foundation will return to its goals of raising scholarship

money for graduating high school seniors who are planning to enterthe field of medicine, whether as physicians, nurses or in other alliedhealth positions. This is the original purpose under which the Foun-dation was created when it was granted an endowment by the thenMethodist Foundation, said Fitzer, BCMS executive director/CEO.

“BCMS is excited about this philanthropic effort and plans tobegin offering scholarships in the spring of 2015,” Fitzer said. “Thegenerosity of BCMS physicians together with its sponsors make thisentire effort possible, benefitting not only students but also patientsas these future medical workers contribute through clinics, hospitals,

surgery centers, physicians’ offices and the like. In addition, the Foun-dation enables great social events that unite the medical community.”

Foundation board members include Douglas Browne, Cindy

Comfort, Steve Fitzer, Gigi Gross, Jim Kelso, K. Ashok Kumar, MD,Monty LaPierre, Jesse Moss, MD, John Nava, MD, Gerardo Ortega,MD, Sharvari Parghi, MD, Lee Rodgers, MD, Shirley Sanders,Reema Shroff, Rebecca Waller and Tolbert Wilkinson, MD.

The Foundation’s first event is a golf tournament Sept. 18 at theQuarry Golf Club.

A Valentine’s Day Gala is planned for February 2015.BCMS and the Foundation welcome participation from sponsors

and volunteers to help create scholarship opportunities for San An-tonio’s future medical workforce.For information, contact Lisa Robertson at

[email protected].

BCMS Foundation resumes its mission:creating scholarships


BUSINESS OFMEDICINE

Quality is a resounding buzzword in the industry today. A sim-

ple Google search for “quality of care” can result in more than 4.4

million hits. Search results include everything from Medicare to

Medicaid, and scholarly articles attempting to define what quality

of care really means. The Affordable Care Act’s National Quality

Strategy is not the first, and won’t be the last, attempt at defining

quality and its impact on the healthcare community.

From a physician’s standpoint, the definition of quality also

varies. No matter how you define quality, it is crucial to under-

stand that quality does affect your bottom line. Furthermore, a

newer and vaguer aspect of quality will affect your practice’s costs

– patient satisfaction. The Texas Medical Association (TMA) em-

phasizes physicians need to become more aware of the importance

of quality of care and patient satisfaction measures. Medicare is

now providing incentive payments (an additional 0.5 percent

through 2014) based on quality reporting through the Physician

Quality Reporting System (PQRS).

Beginning in 2015, penalties will be assessed to eligible profes-

sionals who are not “successful reporters.” These professionals will

be paid 1.5 percent less than the Medicare Physician Fee Schedule

(PFS) amount for 2015 services. Under the PQRS the types of

quality measures will vary yearly, and are based on specialty and

reporting method used. The Centers for Medicare and Medicaid

Services (CMS) state focus areas include patient safety, clinical ef-

fectiveness, population/community health, efficiency and cost re-

duction, person/caregiver centered experience and outcomes.

PATIENT ‘SATISFACTION’One aspect of quality often discussed nowadays is patient “sat-

isfaction.” For example, a hospital website states, “Our definition

of quality reflects our commitment to excellence and combines

patient outcomes and patient satisfaction.” What really consti-

tutes patient satisfaction is debatable. Does it mean you need Star-

bucks coffee provided in your waiting room? Does your practice

need an app for scheduling appointments? Do you provide free

wi-fi? Dr. Lawrence “Rusty” Hofmann, in a Feb. 21, 2014, blog

in the Huffington Post, argues these operational and administra-

tive goals are a mistake . Should patient satisfaction be based on

how well you are able to manage the patients’ chronic condition?

There is no concrete right or wrong answer.

In an attempt to balance this issue of patient satisfaction and

define quality of care, physician practices can turn to the Con-

sumer Assessment of Healthcare Providers and Systems Clinician

and Group Surveys (CG-CAHPS) for answers. The goal of these

surveys is to focus on patient experience with care, such as how

well providers communicate with patients; are patients able to re-

ceive timely appointments; how helpful/courteous is the office

staff. Under Medicare’s PQRS, CAHPS surveys are required and

provided at no cost to group practices of 100 or more physicians.

This requirement directly links potential incentive payments to

patient experience/satisfaction. For smaller practice groups of 25

to 99 physicians, patient feedback is optional for the PQRS qual-

ity data, and CMS does not cover the cost. In addition to affecting

Medicare reimbursements, some accreditation agencies also may

require assessment of patient satisfaction.

Our evolving industry continues to focus on quality of care

which is difficult to define. The increasing trend toward patient

satisfaction is flooding the Internet with strategies to “boost your

patient satisfaction.” This trend will lead some to question:

Should your Medicare reimbursement be linked with the conven-

ience of your parking garage?

Pamela C. Smith, PhD, is an associate

professor of accounting at the University of

Texas at San Antonio. She teaches in the un-

dergraduate and graduate tax program, as

well as the MBA program, business of

healthcare track.

QUALITYand your bottom line

By Pamela C. Smith, PhD


PHYSICIANAS PATIENT

as

The economics of serious illnessBy Jay Ellis, MD

EDITOR’S NOTE: This is the fifth in a series of arti-cles written by San Antonio anesthesiologist Jay Ellis,MD, a member of the BCMS Communications/Publica-tions Committee. The series, published monthly in SanAntonio Medicine, examines the physical, emotional, fi-nancial and spiritual burden of life-threatening illness

PhysicianPatient

What does it cost to get sick? It costs a lot. Here is a break-down of just some of our expenses during the first six monthsof my illness.

MEDICAL COSTSThere is a commonly accepted belief that medical costs are the

primary cause of bankruptcy in the United States. Whether ornot that statement is true depends on how you define the causeof bankruptcy. It is true that medical bills and serious illness area major factor in bankruptcies for many people. Whether or notthey are the primary cause in the majority of cases depends onhow you define your terms. I don’t want to debate the issue, butlet’s say that if your finances are precarious, a major illness willpush you over the edge. Why? Let’s review my costs.

From September 2013 through February 2014, my private in-surance paid just under $120,000for my care. Tricare paid another$8,000. The table published hereshows approximate costs for vari-ous items. Chemotherapy seemsvery expensive (and from my per-sonal experience, worth everypenny), but the bulk of the costis for two drugs. Insurance paysaround $5,000 for rituximab and$3,000 for pegfilgastrim. Thehospital payment for a three-daystay in the ICU and two days onthe rehab floor was just under$20,000. One would think thatwith all that money flowing out Iwould be off the hook. Not true.

Since I was unlucky enough to get ill at the end of one year andthe beginning of another, I had to meet two sets of deductiblelimits. I guess the moral of that story is don’t get sick in Decemberunless you can be out of the hospital by New Year’s Eve. My shareafter the $120,000 was $14,000. In truth, I paid a fraction of thisbecause I also have Tricare insurance, which paid once I met myannual $3,000 cap. I also have other advantages such as a flexiblespending account. It is also true that my treating physicians ex-tended professional courtesy on several occasions despite my pleasto send a bill. We live in a great medical community.

It is easy to see how serious illness could devastate the financialreserves of some people. Medical bills alone can be overwhelming,especially if you have a high deductible policy and you happen tohave an illness that covers two calendar years. In that situationyou could end up paying $10,000 before insurance pays a dime.


I remember waiting for my chemotherapy appointment and see-ing the faces of people emerging from the financial counselor’s of-fice. Having a life-threatening illness and facing bankruptcy atthe same time seems an unbelievably cruel predicament.

MISSING WORKWorking half-time does not result in half the pay. As every busi-

ness owner knows, you work most of the month to pay expensesand taxes. The last week of the month represents your profit, andif you miss that week, there is no profit. I watched my paycheckgradually dwindle in size until it reached a nadir of $236 for onemonth. It reminded me of my days pumping gas in high school.This is when disability insurance proves critical. I have friendswho don't have disability insurance because it is too expensive. Itis expensive, but not having it may prove catastrophic.

When I became ill, I spoke to people in my group who faceddisability. David Davis was a great source of advice. He told methat waiting too long to file for disability is a serious mistake. In-surance companies base your replacement income on your currentearnings. The definition of the time period used in the earningscalculation is specified in the disability policy. He advised me tofile right away when I was first diagnosed, which I did. I claimeddisability from the day of my first chemotherapy. It would proveto be a wise decision. With all disability policies there is a waitingperiod. I had three policies, two with a three-month waiting pe-riod and one with a six-month waiting period. My first paymentsfrom the three-month policies would coincidentally begin themonth I had to stay home.

I heard horror stories of insurance companies denying payment,or reducing payment because of problems proving income. Myinsurance carriers were helpful and empathetic. They tried to

make the application process easy, but they do require a mountainof paperwork. I had to produce five years of income tax returns,with all schedules. I had to produce productivity data for 12months from my practice. Fortunately my group, Tejas Anesthe-sia, was invaluable. They produced reports without any effort onmy part, and all I had to do was stand at Kinko's for one hourcopying tax returns.

It was fortunate that I was still well enough to accomplish thesetasks. I asked my wife, Merrill, what she would have done had Inot been able to do this, and she gave the right answer. She wouldspeak to our administrator John Spiekerman. If she had problemswith insurance she would talk to my office manager Marta Reyna.Those were good answers, but I still made sure she understoodwhere I kept all the insurance documents and contact phonenumbers. Another advantage I have is a military pension. It really

is a form of disability insurance, in that it pays throughout thelifetime of the veteran, whether you are employed or not. Wenever had a time when there wasn't at least some money comingin. I wouldn't want to live on my military pension, but it helpedkeep us afloat in those months before the disability insurance pay-ments kicked in.

Personal savings are essential to weather a serious illness. Thelight bill, the mortgage payment, the car payment, the medicalinsurance payment and any other expenses you might have stillcome when you are ill. Merrill and I put away a considerableamount in savings, one year’s living expenses. We didn't do thisbecause we thought one of us might become ill. We did it becauseI was afraid that after retirement, the U.S. military might call meback, and we would have to exist on my Air Force salary. Havinga cash cushion kept us from having to worry about money whilewe were also worrying about my illness.


PHYSICIANAS PATIENT

Tejas Anesthesia staff include(seated from left) Jennifer Villanueva,Darla Herlitz, Heidi Barrera and(standing from left) Jo Ann Morris andMarta Reyna. Courtesy photo


PHYSICIANAS PATIENT

SAVING YOUR PRACTICEEven with disability insurance, personal savings and the luxury

of a military pension, I still wondered if I would have a practiceto which I could return. I realized that though I was sick, otherpeople’s lives would go on. My patients would still need care, myreferring doctors would still need help, and the surgeons I workedwith in the operating room would still need coverage. It was atthis time that I began to fully appreciate what a wise choice I madein joining Tejas Anesthesia. My partners in my pain practice, JimGrowney, Tim Orihel and Arnold DeLeon, saw all my patientsand made sure that they had uninterrupted care. My office staffwas instrumental in explaining my predicament to my patients,and my patients’ loyalty was overwhelming. I cannot count howmany other members of Tejas Anesthesia offered to back me upif I wanted to take call or provide relief if I got tired while in theOR. Before I became deathly ill, Vanessa Weems, who does ourscheduling, would offer me stipend work if extra shifts becameavailable. Without their support I would have had to rebuild mypractice from scratch, hustling like a new grad, except now I’m

58 years old and recovering from a serious illness. That is not apretty picture.

When I was in the military, young doctors would often ask mefor advice while looking for a job. I told them the two least im-portant questions to ask are, “How much money will I make, andhow much call will I take?” The most important questions to askare, “Would I let these doctors take care of my family, and if Idrop my wallet and turn my back would there be any money leftin it?” If you can say yes to both of these questions most other is-sues will work themselves out. In truth, I didn’t save my practice –my partners and my group did. I will be forever grateful for theirsupport. I challenge everyone to perform this thought experiment:How will my organization react if I become ill and I am gone forseveral months? I challenge every organization to ask the question:How will we support our members if they become incapacitated?

In retrospect, I realize that we were quite blessed to get throughthe financial part of this illness so well. As a physician, I havemany advantages not available to the average person. While Iwould like to say that I made a great financial plan that saved us,



PHYSICIANAS PATIENT

the truth is many of the decisions I made were never done with the thought there would come a time I couldn’t work.Like many doctors, I considered myself invincible, dare I say, indestructible. I will never hold that belief again.

NEXT: Recovery.

Tejas Anesthesia physicians include(from left) Dr. Timothy S. Orihel, Dr.Jay Ellis, Dr. Arnold DeLeon and Dr.James L. Growney. Courtesy photo


HASA

Coordinating high-quality care with HITBy Vince Fonseca, MD, MPH, FACPM

A previous column described various quality and clinical per-

formance reports that can be done using HASAFacts to support

Accountable Care Organizations (ACOs). There are 33 clinical

quality reports to be done for the ACO’s aggregate population of

at least 5,000 patients. ACOs were created by the 2010 Patient

Protection and Affordable Care Act (ACA) to improve care and

lower the rate of cost increases in Medicare. The same ACO ap-

proach can be applied to any provider’s panel of patients to im-

prove health by improving care and also provide better value (the

“triple aim” of healthcare). The key to these aims is better coor-

dination of the delivery of higher-value services and decrease

lower-value services.

Patients see a variety of providers, both outpatient and inpa-

tient, and sharing timely clinical information between providers,

especially the primary care provider, is critical to effective care co-

ordination and better outcomes. HASA is able to provide some

of the services so that providers participating in the care of the

patient are able to get this integrated information more quickly

and completely.

FOUR KEY TECHNOLOGIESA recent article in the American Journal of Accountable Care1,

“Four Key Technologies for Physician-led Accountable Care Organ-

izations,” describes what HIT features best support physicians

as they work to improve quality of the care they provide to their

patients. EHRs are not enough because they don’t yet easily

allow sharing of patient information. A system of HIT services

is needed (e.g., HASA services) to securely share patient infor-

mation so that care can be coordinated based on the individual

needs of each patient.

The first area of innovation is risk stratification so that a per-

sonalized care plan can be made for the patient and then kept cur-

rent. A previous column covered risk stratification using the

comorbid conditions found in a patient’s records to provide a

stratification of clinical complexity. Psychosocial complexity is

also important, and gathering patient-generated health data on

personal barriers to better health allows for stratification.

The second area the authors describe is that of “advanced net-

work management” to allow for better coordination across con-

sultants, inpatient and postacute providers. Near real-time sharing

of clinical information is available using HASAProviderAssist be-

tween outpatient and inpatient providers.

The third innovation area is to alert providers of emergency de-

partment visits and hospital admissions, discharges and transfers

(ADTs). An ED visit or unplanned hospitalization indicates that

there is an opportunity to review and perhaps improve the care

plan. A discharge summary from an ED visit or hospitalization is

helpful to the outpatient provider when providing post-discharge

services and adjusting care plans. ED and ADT alerts are available

in HASAFacts, and discharge summaries are in ProviderAssist.

The fourth innovation area is “patient outreach and engage-

ment.” MyHASA is the patient portal that allows patients to view

their clinical information that comes from multiple providers and

EHRs. Patient portals have been shown to improve patient en-

gagement, especially when they are not tethered to just one EHR.

MyHASA also allows for patients to have proxies and thus engage

the family and other caregivers.

With HASA services developed in conjunction with providers

and organizations, BCMS members will be better situated to im-

prove care provided to their patients and to meet quality and cost

benchmarks.

1http://www.ajmc.com/publications/ajac/2014/2014-1-vol2-

n1/four-key-technologies-for-physician-led-accountable-care-or-

ganizations/2#sthash.CXT53nkG.dpuf

Vince Fonseca, MD, MPH, FACPM, is the

director of medical informatics at Intellica

Corp., and the medical advisor for Healthcare

Access San Antonio (HASA), the local Health

Information Exchange (HIE) provider au-

thorized by the state of Texas to create a com-

munity-based, regionwide HIE in Bexar County and 22 surrounding

counties. Visit www.hasatx.org.


UTHSCSADEAN’S MESSAGE

In the United States, about 2.3 million adults and a half millionchildren – including more than 200,000 Texans – have epilepsy.One hundred fifty thousand new cases are identified annually, ap-proximately a third in children; most cases of epilepsy – abouttwo-thirds – are idiopathic. Although epilepsy is not usuallythought of as a fatal disease, certainly not in the majority of indi-viduals, it is estimated that 50,000 people a year die from seizuresand related causes, an issue that has received increased recognition,as many of these deaths appear to be from seemingly unrelatedcauses such as automobile accidents. While with treatment mostindividuals can have a productive life, in some circumstancesepilepsy can result in poor school performance, inability to workand drive, and in an uncertain economic future.

The South Texas Comprehensive Epilepsy Center (STCEC) atthe UT School of Medicine opened in 1995 in collaboration withthe University Health System (UHS). It is one of the largestepilepsy programs in the state and the only Level IV comprehen-sive epilepsy treatment center for adults and children in Centraland South Texas. This is the highest accreditation awarded by theNational Association of Epilepsy Centers (NAEC), and it is givento epilepsy centers that deliver state-of-the-art care to adults andchildren, particularly those whose seizures are not fully controlledby medications.

MULTIDISCIPLINARY TEAMDr. Charles Akos Szabo, a neurologist who trained at the Cleve-

land Clinic Foundation’s epilepsy program, leads the center andcares for patients at UHS and at the UT Medicine Medical Artsand Research Center (MARC) “Comprehensive epilepsy care re-quires a multidisciplinary team, including epilepsy specialists,neurosurgeons, psychologists, psychiatrists and neuropsycholo-gists,” says Dr. Szabo. “My goal was to bring them all together tocreate a state-of-the-art center for adults and children withepilepsy – both for medical and surgical treatment.” Dr. LolaMorgan, a fellowship-trained epilepsy specialist, is the co-directorof the clinical program of the STCEC, and oversees the inpatientservice at UHS, monitors the quality of care, and directs the clin-ical neurophysiology fellowship program.

Dr. Jose Cavazos, who trained at Duke University, is also a clin-ical neurophysiologist and heads the associated Epilepsy Center

of Excellence at the Audie Murphy VA Hospital. Dr. Linda Leary,who trained at Columbia University in New York, focuses on pe-diatric epilepsy patients for UT Kids. Other key neurologists onthe epilepsy team are Drs. Kameel Karkar and Octavian Lie, whoare also fellowship trained in epilepsy. All of these neurologistswork very closely with two of the UT neurosurgeons who focuson epilepsy: Drs. Alexander Papanastassiou, who undertook anepilepsy surgery fellowship at Yale University, and Jean-LouisCaron, who was trained at the Montreal Neurological Institute,one of the pioneer centers for epilepsy surgery.

With more than 5,000 patient encounters a year, our programalso includes outreach clinics in South Texas; these have recentlyexpanded from a single one in Harlingen, to four now, includingDel Rio, Laredo and Eagle Pass. These clinics are part of a part-nership between the STCEC and the Epilepsy Foundation, andare supported by state and federal grants to bring much-neededepilepsy specialists to the area for both the insured and uninsured.

The center’s clinical and laboratory research, focused aroundimproving the lives of people with epilepsy, involves collaborationswith scientists at the Health Science Center’s Graduate School ofBiomedical Sciences, the Research Imaging Institute, and South-west Foundation for Biomedical Research. Funding comes fromthe National Institutes of Health and the Veterans Administra-tion. The center’s most recent publication is an article by Dr.Cavazos on the effectiveness of combining anti-seizure medica-tions, published in JAMA online.

Although the center treats many forms of epilepsy, one of thecrucial areas in which our program distinguishes itself is in theavailability of surgical treatment. Approximately 25 epilepsy sur-geries are performed each year for epilepsy, and 30 vagal nervestimulators are implanted or replaced annually.

Resective surgery for epilepsy is indicated for medically refrac-tory seizures that originate in a single region of the brain. Thegoal of the surgery is to remove or ablate, as precisely as possible,the tissue responsible for the initiation of the seizure withoutharming the rest of the brain. Epilepsies that are candidates forsurgical treatment often include those associated with tumors,blood vessel abnormalities, scar tissue or developmental abnor-malities of the brain. A distinguishing feature of our program isthat surgery can be performed in many areas of the brain, not just

SOUTH TEXAS EPILEPSY CENTER:Advancing and extending care

By Francisco González-Scarano, MD


UTHSCSADEAN’S MESSAGE

the temporal lobe, which is the most common area for surgicalresection in epilepsy. There are also other surgical options avail-able to patients when indicated. These include neurostimulation,hemispherectomy and corpus callostomy.

Pre-surgical evaluation is an understandably elaborate process,and several tests are performed before any recommendation forsurgery is considered. Video-EEG monitoring, magnetic reso-nance imaging (MRI), single photon positron emission comput-erized tomography (SPECT), and positron emission tomography(PET) are used to help locate the seizure onset zone. MRIs canreveal structural abnormalities that can cause seizures, such as tu-mors, cerebral or vascular malformations, or scar tissue. PET scansare used to measure the metabolism of glucose or blood flow, in-dicating the health of brain regions in patients when they are nothaving seizures. Potential risks to surgery are determined withneuropsychological testing, the intracarotid amobarbital proce-dure, as well as functional neuroimaging. A neuropsychologicalassessment is also done to assess memory and language areas.These tests are carried out before and after epilepsy surgery toevaluate potential risks posed by the surgery and cognitive out-come. The intracarotid amobarbital procedure (IAP) is performedin concert with a neuroradiologist, who by injecting one carotidartery with amobarbital causes half of the brain to fall asleep andidentifies the hemisphere responsible for language function. Func-tional PET and MRI are also important for the mapping ofmotor, sensory and language areas. The IAP and functional neu-roimaging studies are crucial for the surgeon to plan for the safetyof the patient during surgery.

In the pre-surgical evaluation, candidates are admitted to theepilepsy monitoring unit (EMU) at University Hospital for a 24-hour video observation that records any visible evidence of a seizurein conjunction with electroencephalography (EEG). With almost400 admissions per year for video-EEG monitoring, some patientscan be identified as potential epilepsy surgery candidates, which isideal for those for whom 100 percent of the seizures originate fromone focus. The new Sky Tower at UHS includes a new monitoringunit that includes 10 adult and four pediatric beds. The SPECTscanning is performed in the same unit by administering a short-acting radioactive tracer during a seizure. This helps to further de-fine the seizure focus, which has a high metabolic rate andconcomitant increase in blood flow relative to a control state.

The assessments are presented to our multidisciplinary team ofepileptologists, neurosurgeons, neuroimaging specialists, psychi-atrists and neuropsychologists, and the intervention most benefi-cial to the patient is then crafted. In the final steps, the patient isexamined by the neurosurgeon, who will also discuss the risks andbenefits of the proposed surgery.

The STCEC has adopted newer and less invasive tools for eval-uating and treating epilepsies amenable to surgical treatment.

Stereotactic EEG (s-EEG) is one method for mapping whereseizures originate, used by relatively few centers in the UnitedStates. S-EEG uses up to eight depth electrodes with sensors tomonitor brain activity on each side of the brain. These are placedthrough tiny burr holes, obviating the need for a craniotomy andplacement of a more complex surface grid. This method also al-lows for sensors to record in areas that are very difficult to accessvia craniotomy, such as the recesses areas between the two brainhemispheres, or deeper structures, such as the insula. Anotherpromising treatment adopted by the neurosurgeons at the STCECis an ablation therapy using a stereotactically guided laser that alsoavoids a craniotomy. Administered through a small burr hole andguided by an MRI, the technique has proven effective with muchless risk to the patient and much faster recovery times.

Outcomes have been very positive; one study tracking 130 casesreported that 83 percent of temporal lobe resections result in Class1/2 outcomes, meaning that the patients are seizure free or haverare seizures after one year. In the extratemporal resections, 64 per-cent of cases were Class 1/2. This lower rate for the extratemporalgroup is attributed to the need to preserve some areas of the epilep-togenic focus in order to maintain critical neurological functions.

EFFECTIVE SURGICAL TOOLA vagal nerve stimulator is another effective surgical tool as well,

and requires little postoperative care other than regular neurolog-ical follow-up for programming the device. A similar device willbe adopted by the STCEC team using electrodes implanted intothe brain to sense the beginning of a seizure and automaticallyblock its evolution with a small current. The system is type oftherapy is referred to as responsive neurostimulation.

There are many members of this multi-disciplinary team: neu-rologists, neurosurgeons, psychiatrists/psychologists and otherspecialists, nurses, nurse-case managers, social workers and others.They function as a unit to improve the quality of life in patientswho have few or no alternatives. The significance and impact ofthe work they have done to advance the broad categories ofepilepsy treatment – and the patients who can now access thiscare -- cannot be understated. My congratulations to them all.

To learn more or refer a patient, please contact UT Medicineat 210-450-9700 or email [email protected].

Dr. Francisco González-Scarano is deanof the School of Medicine, vice presidentfor medical affairs, professor of neurology,and the John P. Howe III, MD, Distin-guished Chair in Health Policy at the Uni-versity of Texas Health Science Center atSan Antonio. His email address [email protected].


BOOK REVIEW

I recently had the pleasure of reading two really engrossing nov-els. If the quality of a piece of fiction can be rated by one’s eager-ness to get back to reading when interrupted, both of these rankvery high.

The first, “Red Sparrow” by JasonMatthews, is a current-day spy thrillerwhich centers around two young intelli-gence operatives, Nathan Nash of theCIA, who is in Moscow on his first as-signment, and Dominika VassileyevnaEgorov, the beautiful niece of a high-ranking official in the SVR, Russia’s For-eign Intelligence Service. An envious rival

had cut her promising ballet career short by a bit of sabotage, andshe’s recruited by her uncle to be a counterspy. As part of hertraining she is sent to the “Sparrow School,” where young peopleof both genders are taught to sexually seduce potential sources ofinformation. Her first assignment is to try to recruit Nate Nash.

The story develops as she is delegated to find a “mole” in theSVR. It turns out that the mole’s handler is our boy Nate, whois disliked by the Moscow chief of station, and is demoted toHelsinki … but his mole is high enough in the SVR that he pe-riodically travels, and their relationship continues. Dominika issent to Finland, and the story accelerates. There are the usual insand outs, twists and turns of this genre. For example, there is theexpected “boy meets girl” plot line, but it doesn’t develop as onemight expect. We encounter only one real-life personage: Presi-dent Vladimir Putin. He is just as lovable in this book as he seemsto be in real life.

Every chapter contains a reference to food, somehow, and as abonus there are rudimentary recipes for the mentioned dishes atthe end of each chapter. These little items were actually really in-teresting.

The second book is “The Cuckoo’s Call-ing” by Robert Galbraith, who isn’t RobertGalbraith at all, but J.K. Rowling, the au-thor of the Harry Potter series, writingunder a pseudonym. This is a London-based detective story of the “noir” variety,featuring a somewhat down-and-out, debt-

laden former member of the British military’s criminal investiga-tive branch, who lost a leg in Afghanistan. The protagonist,whose name is Cormoran Strike, and whose lack of business hashim down to sleeping in his office, engages a temporary recep-tionist, the recently betrothed Robin Ellacott. As one sort of ex-pects, Robin becomes his sidekick. The story takes off when, onRobin’s first day, a new client shows up and asks Strike to inves-tigate whether the death three months earlier of his adoptive sister,Lula Landry, a supermodel, was really suicide, as determined bythe police, or if it could have been murder.

The story delves into the realms of high fashion, the aristocracy,addiction, adoption, shelters for the homeless, racial politics, popmusic, paparazzi and, of course, police activities. Just like “RedSparrow,” it has convoluted convolutions, surprising relationships,unexpected findings and interesting characters. The Londonstreets that Strike traverses are accurately described, and when Iwent looking for the location of his office, I found the building,and it even had the street-level bar mentioned in the book.(Google Maps comes through again!)

In summary, this is a first-rate mystery, with believable charac-ters and an unexpected resolution, set in a variant of the real worldthat may, just may, be real indeed.

Now, for the brief mention. On the rec-ommendation of friends, I read “If theDevil Had a Wife” by Frank Mills. It’s atrue, well-documented story about corrup-tion in Orange, Texas, the University ofTexas at Austin, the ultimate dysfunctionalfamily, multiple murders by poison, em-bezzlement, forgery, theft, etc., etc. I triedto write a real review of it. I couldn’t figureout how to encapsulate the complexity.Read it. You won’t be disappointed. Be aware that it’s not a newbook, and you might have to search it out somewhere. The SanAntonio Public Library has a copy or two, I know. Just bewarned: I couldn’t put it down.

Fred H. Olin, MD, is a semi-retired orthopaedist andchair of the BCMS Communications/PublicationsCommittee.

Short reviews of two excellent books... and a brief mention of a third

Reviewed by Fred H. Olin, MD


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Aspect Wealth Management(HHH Gold Sponsor)We believe wealth is more thanmoney, which is why we improveand simplify the lives of ourclients, granting them greatersatisfaction,confidence, andfreedom to achieve more in life.Jeffrey Allison [email protected] what you deserve… Maxi-mize your Social Security benefit!

Frost Leasing(HHH Gold Sponsor)As one the largest Texas-basedbanks, Frost has helped Texans

with their financial needs since1868, offering award-winningcustomer service and a range ofbanking, investment, insuranceservices to individuals and businesses.Laura Elrod Eckhardt 210-220-4135laura.eckhardt@frostbank.comwww.frostbank.comCommercial leasing for a doctor’sbusiness equipment and vehicle.

Platinum Wealth Solutions ofTexas LLC(HH Silver Sponsor)Comprehensive financial plan-ning firm who assists medicalprofessionals to protect theirincome, their wealth, their practice and legacy.Tom Valenti 210-998-5023 [email protected] Eric Gonzalez: 210-998-5032 ericgonzalez@jhnetwork.comwww.platinumwealthsolutionsof-texas.comUnderstanding the uniqueness inthe financial life as a physician.

Retirement Solutions(HH Silver Sponsor)Committed to providing compre-hensive, reliable consultation tohelp you navigate the complexworld of retirement planning.Robert C. Cadena 210-342-2900robert@retirementsolutions.wswww.retirementsolutions.ws

Bold Wealth Management(H Bronze Sponsor)Comprehensive Investment Advisory and Retirement Plan-ning Services for Businesses and Individuals.Richard A. Poligala, 210-998-5787richard.poligala@natplan.comwww.boldfinancialgroup.comComplimentary no-obligation retirement plan review to BCMS members

• GOLF

TPC San Antonio(H Bronze Sponsor)18-hole championship golfcourses designed by two ofgolf's most innovative architects,Pete Dye and Greg Norman.Matt Flory, 210-491-5816www.tpcsanantonio.com

continued from page 37


• HEALTHCARECONSULTING

TNT Healthcare Consulting LLC(H Bronze Sponsor)We want physicians to concen-trate on what they were trainedto do, treating patients.Tom Tidwell, CMPE 210-861-1258 [email protected] TNT healthcare consultantsevaluate your practice and im-prove efficiency and cost.

• HOSPITALS/HEALTHCARESERVICES

SOUTH TEXAS SINUS INSTITUTE(HHH Gold Sponsor)The South Texas Sinus Institute isa state of the art facility dedi-cated to in-office BalloonSinuplasty using the unique Painless Sinuplasty AnestheticLinked Method.Sue Musgrove210-225-5666stsisue@gmail.comwww.southtexassinusinstitute.com.We will offer convenient sameday or lunch appointments toBCMS members.

Warm Springs Medical CenterWarm Springs Thousand OaksWarm Springs Westover Hills(HHH Gold Sponsor)Our mission is to serve peoplewith disabilities by providingcompassionate,expert care during the rehabilitation process& support recovery througheducation & research.Central referral Line 210-592-5350Joint Commission COE

Elite Care 24 Hour EmergencyCenter(HH Silver Sponsor)We are a fully equipped emer-gency room open 24 hours aday and 7 days a week, staffedby experienced emergencyphysicians. We provide thesame level of emergency medical care that you would receive in a hospital ER.

Clemente Sanchez [email protected] Clark 210-771-0141rclark@elitecaremarketing.comwww.elitecareemergency.comGet seen by an experiencedphysician within 10 minutes.

Select Rehabilitation of San Antonio (HH Silver Sponsor)At Select Rehabilitation Hospitalof San Antonio, we providespecialized rehabilitation programs and services for individuals with medical, physicaland functional challenges. Miranda [email protected]://sanantonio-rehab.com/Offers patients a higher degreeof excellence in medical rehabilitation.

Southwest General Hospital(HH Silver Sponsor)Southwest General Hospital is a327-bed, state-of-the-art hospi-tal located in San Antonio, Texas.Southwest General offers com-prehensive healthcare services.Craig Desmond, 210-921-3521Elizabeth Luna, 210-921-3521www.swgeneralhospital.com

• HUMAN RESOURCES

Employer Flexible(HHH Gold Sponsor)Employer Flexible doesn’t simplylessen the burden of HR adminis-tration. We provide HR solutionsto help you sleep at night andget everyone in the practice on the same page.John Seybold 210-447-6518jseybold@employerflexible.comwww.employerflexible.comBCMS members get a free HR assessment valued at $2,500.

Pinnacle Workforce Corp HR. Services (H Bronze Sponsor)Dan [email protected]

�• INFORMATION

TECHNOLOGY

Allison Royce Business Technologies(H Bronze Sponsor)Business Technology Provider, specializing in HIPAA CompliantManaged IT Services and IT Sup-port since 1993.Jeff Tuttle,[email protected]

PitCrew IT Services(H Bronze Sponsor)Provides reliability for your business computers or network, enabling you to operatesmoothly.Eric Murcia, [email protected]

• INSURANCE

Frost Insurance(HHH Gold Sponsor)As one the largest Texas-basedbanks, Frost has helped Texanswith their financial needs since1868, offering award-winningcustomer service and a range ofbanking, investment, insuranceservices to individuals and businesses.Bob Farish [email protected] and personal insurancetailored to meet your uniqueneeds.

Humana(HHH Gold Sponsor)Humana is a leading health andwell-being company focused onmaking it easy for people toachieve their best health withclinical excellence through coor-dinated care.Donnie [email protected]

Nationwide Insurance Joel Gonzales Agency(H Bronze Sponsor)What matters to you, matters to us!Joel Gonzales 210-314-7514 [email protected] www.nationwide.com/jgonzales

Texas Drug Card(H Bronze Sponsor)The Texas Drug Card program is a FREE statewide Rx assistanceprogram available to all residents.Todd Walker [email protected]://texasdrugcard.com/index.php

�• INSURANCE/MEDICALMALPRACTICE

Texas Medical Liability Trust(HHHH Platinum Sponsor)Texas Medical Liability Trust is aphysician-owned health care liability claim trust, providing malpractice insurance productsto the physicians of Texas. Currently, we protect more than14,000 doctors in all specialtieswho practice in all areas of the state. TMLT is endorsed bythe Texas Medical Association,the Texas Academy of FamilyPhysicians, the Dallas, Harris, Tarrant, and Travis County Medical Societies. Patty Spann, [email protected] Partner of theBexar County Medical Society.

Medical ProtectiveMedical Malpractice Insurance(HHH Gold Sponsor)Medical Protective, the nation'soldest and only AAA-ratedprovider of healthcaremalpractice insurance. Thomas Mohler [email protected]

Texas Medical Association Insurance Trust(HHH Gold Sponsor)Created and endorsed by theTexas Medical Association (TMA), the Texas Medical Association In-surance Trust (TMAIT) helpsphysicians, their families, andtheir employees get the insur-





ance coverage they need.James Prescott, [email protected] Isgitt 512-370-1776www.tmait.orgWe offer BCMS members a freeinsurance portfolio review.

The Bank of San Antonio Insurance Group, Inc.(HHH Gold Sponsor)We specialize in insurance andbanking products for physiciangroups and individual physicians.Our local insurance professionalsare one of the few agents in thestate that specialize in Medical Malpractice and all lines of insur-ance for the medical community. Katy Brooks, CIC, 210-807-5593katy.brooks@bosainsurance.comwww.thebankofsa.comServing the medical community.

API/ProAssurance Medical Malpractice Insurance(HH Silver Sponsor)ProAssurance is about YOU —and, more specifically, treatingyou fairly when it comes to pro-fessional liability insurance andrelated products and services.Paul Schneider, MBA, [email protected]

The Doctors CompanyMedical malpractice insurance(HH Silver Sponsor)Kirsten Baze [email protected]

• INTERNET/TELECOMMUNICATIONS

Time Warner Cable Business Class(HH Silver Sponsor)When you partner with TimeWarner Cable Business Class, youget the advantage of enter-prise-class technology and communications that are highlyreliable, flexible and pricedspecifically for the medical community.Rick Garza, [email protected]

Time Warner Cable BusinessClass offers custom pricing forBCMS Members.

�• MARKETING SERVICES

Phiskal LLC Marketing and Promotion(H Bronze Sponsor)A leading edge marketing anddevelopment firm using propri-etary Artificial Intelligence en-gines to enhance your presencewith websites, apps & databaseapplications.Sundeep Sadheura [email protected]://PHISKAL.COM/

�• MEDICAL BILLING &COLLECTIONS SERVICES

Commercial & Medical CreditServices(H Bronze Sponsor)A bonded and fully insured San Antonio-based collectionagency.Henry Miranda [email protected] us the solution for your ac-count receivables.

DataMED(HHH Gold Sponsor)Providing your practice with thelatest compliance solutions, con-centrating on healthcare regula-tions affecting Medical Billingand Coding changes allowingyou and your staff to continuedelivering excellent Patient Care.Anita Allen (210) [email protected] members receive a discounted rate for our billingservices.

PriMedicus Consulting Inc.(H Bronze Sponsor)A physician-founded and builtcompany, dedication to yoursuccess. Sally Combest MD. 877-634-5666s.combest@primedicusconsult-ing.comwww.primedicusconsulting.comPriMedicus Consulting for theHealth of Your Practice.

URGENT CARE BILLING SOLUTIONS, LLC(H Bronze Sponsor)UCBS provides superior practicemanagement services and rev-enue optimization services to thehealthcare community in a virtualoffice environment. ANN DeGrassi.CMIS 210-878-4052 adegrassi@ucbillingsolutions.comwww.urgentcarebillingsolutions.net

��• MEDICAL SUPPLIES& EQUIPMENT

Henry Schein Medical(HHHH Platinum Sponsor)From alcohol pads and band aidsto EKG’s and Ultrasounds, we arethe largest worldwide distributorof medical supplies, equipment,vaccines, and pharmaceuticalsserving office based practition-ers in 20 countries. Recognizedas one of the world’s most ethi-cal companies by Ethisphere.Tom Rosol [email protected]/medicalBCMS members receive GPO dis-counts of 15%-50%.

McKesson Medical-Surgical(H Bronze Sponsor)MCKESSON is a leading distributor of Medical Supplies and Equipment.Karan Cook [email protected]

�• PAYMENT SYSTEMS/CARD PROCESSING

�Heartland Payment Systems(HH Silver Sponsor)Sherry Willis [email protected]

• PUBLICATIONMANAGEMENT FIRM �Traveling Blender(H Bronze Sponsor)Publication Management FirmJanis Maxymof, [email protected]% discount on display advertis-ing in magazine for members.

�• PRINTING SERVICES

SmithPrint(H Bronze Sponsor)SmithPrint offers custom print-ing, branding, graphic design,signage and more!

Robert Upton [email protected]://www.smithprint.net/New customers: 10% discount onprint materials at SmithPrint.

• REAL ESTATE/COMMERCIAL

Cano and Company CommercialReal Estate(HH Silver Sponsor)Experienced and respected com-mercial real estate representation.We specialize in office leasing,property acquisition, and com-mercial real estate investment. Dennis Cano, Agent 210-731-6613 [email protected] commercial real estatesolutions for your practice andinvestments.

Newmark Grubb Knight Frank(H Bronze Sponsor)Commercial Real EstateDarian Padua [email protected]

Stream Realty Partners(H Bronze Sponsor)Carolyn Hinchey Shaw [email protected]

• REAL ESTATE/RESIDENTIAL

SA Luxury Realty(HH Silver Sponsor)Effective real estate transactions(Buy, Sell, Lease, Syndicate,etc..) within the shortest timepossible and for maximum results!Matin Tabbakh 210-772-7777matin@saluxuryrealty.comwww.saluxuryrealty.comAccredited Luxury Home Special-ist. Call us today.

Becky Aranibar Realty GroupKeller Williams(H Bronze Sponsor)Offering Real Estate Services to the San Antonio Medical Community.Carlo G. Aranibar, MBA, [email protected] free comparative mar-ket analysis to determine yourhome's value.



�• REAL ESTATE/INVESTMENTS

Texas Premier Capital(HH Silver Sponsor)A real estate development company offering and managingreal estate investment funds inthe South Texas area.H.B. Newman [email protected] Carter 210-367-7909rick@texaspremiercapital.comwww.texaspremiercapital.com

��• REGULATORYCOMPLIANCE

Hildebrand Regulatory Compliance(H Bronze Sponsor)HEDIS, Accreditation, PCMH,ICD10Patricia Hildebrand, 432-352-6143Pati.Hildebrand@Hildebrand-Healthcare.comwww.hildebrandhealthcare.com

• RESEARCH STUDIES/BIOTECHNOLOGY

�

ICON Development Solutions(HHHH Platinum Sponsor)We are a respected clinical re-search organization that has anextensive reputable history in di-abetes research. Dependingupon the current studies, ICONmay establish working relation-ships with local physicians.Your expertise may be invaluableto our efforts to identify subjectsDr. Dennis Ruff [email protected] out how ICON can help yourPractice.

• STAFFING SERVICES

Favorite Healthcare Staffing(HHHH Platinum Sponsor)Serving the Texas healthcare

community since 1981, FavoriteHealthcare Staffing is proud tobe the exclusive provider ofstaffing services for the BCMS. Inaddition to traditional staffingsolutions, Favorite offers a com-prehensive range of staffingservices to help members improve cost control, increaseefficiency, and protect their revenue cycle!Brian Cleary, [email protected]/pub-lic/medicalsocieties/bexar_county/bexarcounty_index.aspxFavorite Healthcare Staffing offers preferred pricing for BCMS members.

�• TITLE COMPANIES

Alamo Title Company(HH Silver Sponsor)Corina Cashion [email protected]

• TRANSCRIPT SERVICES

Med MT, Inc.(H Bronze Sponsor)Narrative transcription is physi-cians’ preferred way to createpatient documents and populate electronic medicalrecords.Ray Branson [email protected] Med MT solution allowsphysicians to keep practicing justthe way they like.

As of July 15, 2014

For more information, call210-301-4366,

emailAugust.Trevino@

bcms.org, or visit

www.bcms.org.



Gunn Acura11911 IH-10 West

Cavender Audi15447 IH-10 West

BMW of San Antonio8434 Airport Blvd.

Cavender Buick17811 San Pedro Ave.(281 N @ Loop 1604)

Batchelor Cadillac11001 IH-10 at Huebner

Cavendar Cadillac801 Broadway

Tom Benson Chevrolet9400 San Pedro Ave.

Ancira Chrysler10807 IH-10 West

Ingram Park Auto Center7000 NW Loop 410

Ancira Dodge10807 IH-10 West


Ancira Elite Motorcars10835 IH-10 West

Northside Ford12300 San Pedro Ave.

Cavender GMC17811 San Pedro Ave.

*Fernandez Honda8015 IH-35 South

Gunn Honda14610 IH-10 West(@ Loop 1604)

*Gunn Infiniti

12150 IH-10 West

Ancira Jeep10807 IH-10 West


Ancira Kia6125 Bandera Road

*North Park Lexus611 Lockhill Selma

*North Park

Lincoln/ Mercury9207 San Pedro Ave.


Mercedes-Benzof Boerne

31445 IH-10 W, Boerne

Mercedes-Benzof San Antonio

9600 San Pedro Ave.

*Mini Cooper

The BMW Center8434 Airport Blvd.

Ingram Park Nissan7000 NW Loop 410

Porsche Center9455 IH-10 West

Ancira Ram10807 IH-10 West


North Park Subaru9807 San Pedro Ave.

Cavender Toyota5730 NW Loop 410

*Ancira Volkswagen5125 Bandera Rd.

*The Volvo Center1326 NE Loop 410


The Audi Q7 is defying gravity — salesgravity, that is. Despite being close to its re-placement date, the Q7 continues to sellstrongly. Audi moved 15,978 Q7s in theUnited States in 2013, an impressive 4,970units (45 percent) more than in 2012, andthat momentum is not abating: Sales for thefirst quarter of 2014 are tracking at more than40 percent above those strong 2013 levels.

As you might imagine, it’s typical for salesof any car or light truck to drop as it nearsthe end of its life cycle and rare for sales togrow. I credit ongoing incremental improve-ments and the availability of a diesel engineoption for the Q7’s continuing popularity,but really, the diesel optionshould probably get most of thecredit. Diesel models now makeup about 40 percent of Q7 sales,and that percentage has grownevery year since the TDI wasfirst offered in 2009.

TORQUE PROVIDESMUSCLE

The TDI version of the Q7— TDI stands for turbo directinjection — is increasingly fa-vored because its modern cleandiesel engine combines gooddrivability with impressive fuelefficiency. Producing an OK240 HP and OMG 406 ft-lbs oftorque, the TDI feels as strongas the 333 HP gasoline-powered

Q7 3.0T Premium Plus model, which seemsodd given the fact that the TDI gives up 93HP to the 3.0T. The reason the TDI feels somuscular is torque, a much more importantcontributor to off-the-line oomph thanhorsepower. Since all diesels have signifi-cantly more torque than similarly-sized gaso-line engines, they feel stronger than theyreally are. (For the record, the gas versions ofthe Q7 actually accelerate slightly faster thanthe diesel.)

Another advantage of diesels is that theytypically give owners better fuel economythan their EPA numbers would suggest.That’s especially nice given the fact that hy-

brid vehicles generally do worse than theEPA cycle predicts. When you consider thata Q7 TDI (19 mpg city/28 mpg highway)can take you over 700 miles once you fill its26.4-gallon tank, is it any wonder more cus-tomers are choosing diesel Q7s over theirgasoline-powered siblings?

The exterior design of the Q7 is aerody-namic and attractive, particularly with largerwheels. As I’ve written previously, on onehand, the Q7 incorporates edgy design ele-ments such as an aggressive, almost angry,front end highlighted by a big grille and an-gled headlights. Yet its sides and profile are astudy in soft curves and gentle contours that

AUTO REVIEW

Defying gravity: Audi Q7’s diesel engine combinesgood drivability, fuel efficiencyBy Steve Schutz, MD


reassure the eye. While merging edgy andsoft in one vehicle seems contradictory, itworks in this case.

Still, this popular SUV has been on themarket for six years, so it’s time for a new de-sign. While Audi has done a Lexus-esque jobof keeping the Q7 fresh with new color com-binations, wheel design updates, and the ad-dition of cool LED lighting, I’m lookingforward to seeing an all new Q7. Audi hasnot announced when it will appear, but UK’sCar magazine says they expect it to be re-leased sometime in late 2014 or early 2015.

The Q7 drives more like a car than mostother big SUVs, and that’s saying somethingwith the very nice Mercedes GL, BMW X5and Lexus GX available to cross shoppers. Intown, the Q maneuvers and parks easily; ontwisty roads, it turns confidently, and on thehighway, it cruises serenely. Having said that,I’d say the Q7 TDI is most at home on the

highway, particularly at speeds greater than75 or 80 mph.

USEFUL EXTRASNaturally, the Q7’s interior is well

trimmed-out, as all Audis are these days. I es-pecially like the gauges with their brightwhite numbers and red accents.

The Q7 TDI has a starting price of justunder $53K, and the version I drove with thePremium Plus package stickered at over $60K.That package includes such useful extras asnavigation, parking-assist sensors with rearviewcamera, panoramic sunroof, HID headlights,and LED running lights and turn signals.

The extra-lux Prestige package addsabout $12,000 to the price of the Q7 andadds adaptive headlights and cruise control,lane-departure warning, and many otherfeatures too numerous to list here. And, ofcourse, there are numerous other trim

packages and stand-alone options to choosefrom if you so desire.

Audi is defying gravity with the Q7 TDI,and after driving one for a week, I can seewhy it continues to sell strongly, eventhough it’s approaching the end of its lifecycle. It has good looks, a top-shelf interior,and the classic diesel benefits of greattorque and fuel efficiency.

Steve Schutz, MD, is aboard-certified gastroenterol-ogist who lived in San Anto-nio in the 1990s when he wasstationed here in the U.S. AirForce. He has been writingauto reviews for San Antonio

Medicine since 1995.For more information on the BCMS

Auto Program, call Phil Hornbeak at 301-4367 or visit www.bcms.org.

AUTO REVIEW


san antonio medicine august 2014

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