Nov 14, 2014

Emergency Response Protocols for Suspected Ebola in Urgent Care and Primary Care Settings

 

By Brian B. Rogers1, DO, MPH; David M. Weitzman1,3, MD; Gregory S. Buzard2, PhD; Alexandra Boyd-Rogers

Publisher's Note: Dr. Rogers and his colleagues prepared these protocols to help physicians prepare to respond to suspected cases of Ebola virus. The contents have been edited for style and readability, but have not been reviewed by TMA for scientific accuracy.


I write to you from the "New Hot Zone," just a few miles from the newly famous Dallas Presbyterian Hospital. Like many of you in our field, I have been attempting to put together coherent protocols for addressing the potential Ebola cases that might arrive at our facilities from the often conflicting and scattered breadth of information available online. Making a synthesis of all suggestions by using the best information currently available on the CDC website, I have prepared an updated and comprehensive guide for Urgent and Primary Care Physicians. As a former Public Health Officer, I have chosen a conservative approach to these guidelines, preferring to err on the side of caution where Federal suggestions vary.

This article will cover:

  • How to determine if a patient is a potential Ebola case
  • What to do once you decide a patient might be an Ebola case
  • What to do if the patient requires life-saving procedures
  • What to do in the event of staff exposure
  • How to get the patient into the right hands for specialized and extended care

Determining if Your Patient is a Potential Ebola Threat

Symptoms of Ebola (if your patient has one or more of the following):

  • Fever (prolonged or spiking) greater than 38.0° C (100.4° F)1
  • Headache
  • Generalized Muscle Pain
  • Vomiting
  • Diarrhea
  • Generalized Abdominal Pain
  • Unexplained Bruising or Bleeding2

Risk Assessment:

High-Risk:

  • Patient has had percutaneous, mucosal, or direct skin contact with blood or body fluids (including sweat, saliva, semen, vomit, fecal material, etc.) of a confirmed Ebola victim
  • Patient has processed blood or body fluids of a confirmed Ebola victim
  • Patient has had direct contact with a dead body (as part of funeral rites, embalming, or body handling prior to cremation) of a suspected Ebola case in an outbreak-confirmed country or area

Some/Low-Risk:

  • Being within approximately 1 meter (3 feet) of an active-case Ebola patient
  • Being within an Ebola victim's room or care area for an extended period of time
  • Making direct or brief contact (shaking hands, physical exam) with an Ebola victim

No Known Exposure:

  • Having been in a country or facility with known Ebola patient(s) within 30 days BUT having had no high-risk or low-risk exposure2

If a patient is SYMPTOMATIC (fever OR other symptoms) AND fits into one of the above categories, IMMEDIATELY report the case to your local health department and infection control officer. Follow their directions regarding the immediate isolation and transportation of the patient OR the relay of conditional release/controlled movement* information to the patient.

If a high-risk or low-risk patient is ASYMPTOMATIC (low-grade or no fever AND lacks other symptoms) at presentation, STILL report the case to your local health department for directives regarding the relay of conditional release/controlled movement information to the patient.

If a patient is of the NO KNOWN EXPOSURE category and is ASYMPTOMATIC (NO fever AND lacks other symptoms), provide and discuss written self-monitoring instructions with the patient.

*Persons who are 'conditionally released' should self-monitor for fever and all other symptoms twice daily for a conservative minimum of 21 days beyond the last possible exposure date. They should report all potentially relevant temperature or symptom changes to a public health authority during the monitoring period. 'Controlled movement' involves reporting intended local, national, or international travel to the health authority to receive clearance for the intended travel (commercial travel is prohibited, although the use of local public transportation may be allowed).3

Initial Handling of an Ebola Suspect

Once you (and/or your local public health department) decide that a patient might constitute a potential Person Under Investigation (PUI), you must take immediate measures to protect your other patients, your staff, and yourself.

Isolate the Patient:

  1. IMMEDIATELY isolate the patient in a designated and predetermined room.
  2. Limit staff exposure (to the patient AND isolation room) to the fewest necessary, utilizing original Health Care Providers whenever possible to manage all aspects of patient care.
  3. Post infection-control trained personnel at patient's closed door, to ensure consistent and proper use of Personal Protective Equipment (PPE) by all persons entering the patient's isolation room.
  4. Maintain a log of all persons who enter and exit the patient's room, with evaluation of the proper PPE upon entry and a description of the condition of PPE upon exit4.Using a  coded picture chart of possible PPE will reduce PPE recording times.
  5. Prevent entry of visitors into the patient's room - essential staff ONLY.3
  6. Provide a means of communications if the patient is a care provider for young children (or special needs individuals), in order to prevent panic.
  7. Use caution when approaching a potential Ebola patient, as they may exhibit delirious, erratic, or violent behavior, which could put staff at risk (e.g., flailing, staggering)1.

Protect Yourself and Your Staff:

  1. Utilize a buddy system when donning and doffing Personal Protective Equipment (PPE).
  2. PPE should include SINGLE-USE, DISPOSABLE:
  3. waterproof boot covers (covering to mid-calf)
  4. N95 respirator
  5. full-face shield
  6. surgical hood
  7. waterproof apron (covering full torso to mid-calf)
  8. double gloves (long-cuff, nitrile)
  9. Remove PPE with the greatest of care (as this is the most frequent occasion for self-contamination), utilizing the buddy system to prevent inadvertent exposure, while a separate Containment Monitor observes and documents any potential exposures.
  10. Health Care Providers should perform hand hygiene with Alcohol-Based Hand Rub before and throughout the doffing of PPE.
  11. PPE should be worn during environmental cleaning (utilizing initial HEALTH CARE PROVIDER to limit exposure risk to additional staff), following all guidelines outlined above.4

Conduct a Thorough Interview of the Patient:

  1. Create a timeline for onset of symptoms
  2. Create a detailed and precise travel history (dates, times, places)
  3. Create a thorough and comprehensive 'patient contact list' since the most probable date of symptom onset (remember, a low-grade fever might not have been recognized by the patient for a few days)5

If Immediate Life-Sustaining Procedures MUST* be Performed

* To avoid inadvertent exposure to clinic staff, make an attempt to minimize ANY invasive procedures (including blood-draws) that are not IMMEDIATELY necessary to stabilize the patient 1

The timely transfer of a patient to a designated Ebola-care hospital is preferable to treatment in an Urgent Care or Primary Care setting, due to the superior resources and decontamination protocols in the hospital setting. The CDC indicates the necessity of treatment of other medical conditions (like hypertension and diabetes), as well as the assessment of potential comorbidities/alternate diagnoses; however, the risk of exposure to Urgent and Primary Care staff is greater than at the hospital level, due to the superior sterility of the isolation rooms and lab facilities in the hospital setting (it is unclear if the CDC directive as of October 20, 2014 is directed towards hospitals in particular or towards all potential healthcare points of contact).5

IF, however, medical-stabilizing procedures MUST be performed, the following guidelines should be followed:

  • Use infectious-disease-case-dedicated, preferably disposable, medical equipment
  • Limit the use of needles and other sharps as much as possible and dispose of them in puncture-proof, sealed containers
  • Laboratory testing should be limited to the bare minimum necessary6
  • Limit use of Aerosol-Generating Procedures (AGP) to life-saving functions ONLY* (i.e., open suctioning of airways, endotracheal intubation, cardiopulmonary resuscitation)1, and utilize an N95 respirator and covering head gear
  • Perform frequent gloved-hand disinfection utilizing an alcohol-based hand rub5

If a Health Care Provider (HCP) is Exposed

If PERCUTANEOUS or MUCOCUTANEOUS exposure to blood or body fluids occurs, HEALTH CARE PROVIDER should:

  • Immediately stop working
  • Immediately flush affected skin surfaces with soap and water and/or irrigate affected mucous membranes with copious amounts of water or eyewash solution6
  • Immediately contact the Containment/PPE Monitor for an assessment5
  • Report all exposures to local health department for post-exposure management

Post-Exposure Care:

  • Medical Evaluation
  • Medical Testing (potentially)
  • Fever & Symptom Monitoring/Reporting (2x daily)
  • Work Exclusion (minimum 21 days)6

Due to the exposure issues at Dallas Presbyterian Hospital in early October, it now seems prudent for all Health Care Providers who interact with patients or patient samples to self-monitor for fever and other symptoms for 21 days after the last contact, so that in the event of occult exposure, infected Health Care Providers can receive the earliest diagnosis and treatment (which has proven vital to survival). At the first sign of symptoms, the HEALTH CARE PROVIDER should immediately self-isolate and alert the local health department for monitoring, evaluation, and potential testing.

Responsible Transfer of Patient to Receiving Facility

  • Take transportation direction from the receiving hospital Emergency Department and/or your local or state health department
  • Notify the receiving healthcare facility, so that proper precautions may be prepared in advance of receiving the patient
  • Take note of logistical information from receiving facility, such as where to park (if patient is not to be transported by ambulance, also advise the patient not to mingle with other patients), which entrance to use, etc.1
  • Inform the US Centers for Disease Control and Prevention (CDC), via the 770-488-7100 hotline, or via eocreport@cdc.gov

Reporting Overview

As part of preparation for potential Ebola threats, a short-list of public health reporting contact information is invaluable. I suggest you take the time to find your local contact information, and confirm that it is still OPERATIVE (before you have to use it). Make the information available to all personnel and drill on its use.

Local Health Department:  _________________ 

State Health Department:  _________________ 

Preferred Receiving Facility:  _________________

CDC: eocreport@cdc.gov 770-488-7100

Note from TMA Here are some additional resources to keep handy:

Note:

It is my sincere hope that these plans may be of benefit to my fellow Urgent Care and Primary Care Physicians. I would like to emphasize that the information provided is up-to-date as of the writing of this article, but my expectations are that these suggestions will change often and quickly as the pandemic evolves. We should all strive to keep up with the newest protocol guidelines, as the CDC posts them.

I have chosen the side of caution in deciding which protocol suggestions to include (i.e., a lower fever temperature threshold, the 30-day exposure follow-up criteria over 21-days, the stringent end of exposure reporting), with the expectation that greater vigilance will save more lives.

Our Urgent and Primary Care facilities are in the unique position of being at the frontline to much of the infectious disease presentations in our local communities. Much of our time will necessarily be spent reassuring the "worried well." Let us stay well informed, highly prepared, and calmly vigilant, for the health of our patients and ourselves.

References

1. Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html. Updated October 21, 2014. Accessed October 21, 2014.

2. Case Definition for Ebola Virus Disease (EVD). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/case-definition.html. Updated September 5, 2014. Accessed October 21, 2014.

3. Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease Exposure. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html. Updated August 29, 2014. Accessed October 21, 2014.

4. Guidance on Personal Protective Equipment to be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html. Updated October 21, 2014. Accessed October 21, 2014.

5. When Caring for Suspect or Confirmed Patients with Ebola. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/caring-for-ebola-suspects.html. Updated October 20, 2014. Accessed October 21, 2014.

6. Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S. Hospitals. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html. Updated October 20, 2014. Accessed October 21, 2014.

Additional Resources:

Checklist for Patients Being Evaluated for Ebola Virus Disease (EVD) in the United States. Centers for Disease Control and Prevention Web site. www.cdc.gov/vhf/ebola/pdf/checklist-patients-evaluated-us-evd.pdf. Accessed October 21, 2014.

Tightened Guidance for U.S. Healthcare Workers on Personal Protective Equipment for Ebola. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html. Updated October 21, 2014. Accessed October 21, 2014.

What You Need to Know about Ebola. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/pdf/what-need-to-know-ebola.pdf. Updated October 16, 2014. Accessed October 22, 2014.

Health Care Workers: Could it be Ebola? Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/pdf/could-it-be-ebola.pdf. Accessed October 22, 2014.

Infographic: Facts about Ebola in the U.S. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/pdf/infographic.pdf. Accessed October 22, 2014.

Author Affiliations:

American Academy of Urgent Care Medicine (Rogers, Weitzman); Booz Allen Hamilton (Buzard); DDC Corp (Weitzman)

Corresponding Author:

Brian B. Rogers, DO, MPH, Board of Directors, American Academy of Urgent Care Medicine. (dr.brianrogers@gmail.com)

Author Contributions:

Drafting of the Manuscript: Rogers, Boyd-Rogers

Critical revision of the manuscript: Weitzman, Buzard

Affiliations:1American Academy of Urgent Care Medicine; 2Booz Allen Hamilton; 3DDC Corp.

Address correspondence to: Brian B. Rogers, DO, MPH, Board of Directors, American Academy of Urgent Care Medicine. [dr.brianrogers@gmail.com]

Short Title: Ebola Protocols in Urgent and Primary Care Settings

Abbreviations: CDC - U.S. Centers for Disease Control and Prevention; PPE - Personal Protective Equipment

Funding Source: No funding was secured for this study.

Financial Disclosure: The remaining authors have no financial relationships relevant to this article to disclose.

Conflict of Interest: The authors have no conflict of interest to disclose.

Contributor's Statement:

Brian B. Rogers and Alexandra Boyd-Rogers: Dr. Rogers and Ms. Boyd-Rogers drafted the initial manuscript and approved the final manuscript as submitted.

David M. Weitzman and Gregory S. Buzard: Drs. Weitzman and Buzard reviewed and revised the manuscript, and approved the final manuscript as submitted.

Nov 9, 2014

A "Bright New Day" for VA Health Care?

(DALLAS) - The issue of veterans’ access to timely health care returned to the American Medical Association House of Delegates this weekend in a far more positive light than it enjoyed five months ago.

In June, in the wake of scandals over excessive wait times in the Veterans Affairs Administration (VA) health care system, the AMA House pushed for President Barack Obama and Congress to make it easier for private practice physicians to care for VA patients. The Texas Medical Association was at the forefront of that fight, led by TMA Delegation Vice Chair Asa Lockhart, MD, of Tyler.

The president has replaced his VA secretary with former Procter & Gamble CEO Robert McDonald, and Congress passed the Veterans Access, Choice, and Accountability Act of 2014. That law will pay private health care providers $10 billion to treat veterans who cannot get VA appointments within 30 days or who live more than 40 miles from a VA health care facility. Another $5 billion will help the VA hire new doctors, nurses, and other medical staff.

The AMA House convened this weekend in Dallas for its first meeting since that debate. Secretary McDonald spent an hour telling delegates about changes in his agency and answering physicians’ questions. From May through September, he said. the agency saw a 46-percent increase in care provided by non-VA physicians; more than 1 million veterans saw doctors outside of the VA system.

The secretary also said the VA is working to reduce the hassles many community physicians have experienced in trying provide care to veterans covered by the VA.

“We need you to participate in the program,” he said. “We know you won’t if it’s too much trouble.”

We caught up with Dr. Lockhart after Secretary McDonald’s speech. He was favorably impressed. “I really see the promise of a bright new day for the veterans’ health system,” he said.

Sep 15, 2014

Is This Any Way to Treat a Doctor?






































Our Facebook page is exploding with likes, shares, and comments on our new Doctors Are Under Siege by the Federal Regulatory Barrage flyer. It has garnered rave reviews from physicians around Texas and around the country for accurately portraying the weight of federal demands on a practice today. Please download it, print it out, and share it with your patients and friends in high places. TMA’s lobby team will distribute it on Capitol Hill next week.

Aug 11, 2014

Six Serious Problems with "Value-Based" Purchasing and How to Solve Them

By Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform.

Both patients and healthcare providers could be harmed by the measures of healthcare spending Medicare plans to use in its new Value-Based Payment Modifier for physicians and in the Value-Based Purchasing Program for hospitals.  Serious problems also exist with the spending measures that many commercial health plans are using to define narrow networks and that both Medicare and commercial health plans are using in various "shared savings" payment contracts with physicians, hospitals, and Accountable Care Organizations.

A new report from the Center for Healthcare Quality and Payment Reform - Measuring and Assigning Accountability for Healthcare Spending - explains how the spending measures used in so-called "value-based purchasing" programs can:

  • Inappropriately assign accountability to physicians and hospitals for services they did not deliver and cannot control, while at the same time failing to hold healthcare providers accountable for many of the services they do deliver. 
  • Financially penalize physicians and hospitals who care for patients with complex health problems and who deliver evidence-based services to their patients;
  • Fail to provide physicians, hospitals, and other providers with the kind of actionable information they need to identify opportunities to control healthcare spending without harming patients; and
  • Give patients misleading information about which providers deliver lower-cost, higher quality care.

The report details multiple, serious weaknesses in the simplistic "attribution" methodologies Medicare and other payers are currently using to retrospectively assign accountability to a single physician, hospital, or other provider for all of the spending on all of the healthcare services received by a patient over a period of time, regardless of which providers actually delivered those services.  For example, under current approaches:

  • Most of the spending that is attributed to a physician usually results from services delivered by other providers.
  • Physicians are assigned responsibility for services new patients receive before the physician first met the patient.  
  • Primary care physicians are assigned responsibility for services delivered by specialists to treat serious illnesses such as cancer; and
  • Specialists and hospitals are assigned responsibility for unrelated healthcare problems their patients experience in the future.

The report also describes how the "risk scores" currently used to adjust spending measures fail to recognize important differences in patient needs and can thereby mislabel physicians and hospitals as "inefficient" if they care for patients who have acute illnesses or complex problems.

In addition to documenting the many serious problems with current approaches, Measuring and Assigning Accountability for Healthcare Spending shows how they can be solved.  A detailed methodology is presented for assigning accountability to providers for the services they actually can control or influence.  The methodology also explicitly identifies which services might be changed in order to achieve the same or better outcomes for patients at a lower cost.  In addition, methods are described for comparing providers' performance in treating patients with similar needs rather than trying to use a single, simplistic risk score to "adjust" spending.  The report shows how these improved methodologies can use existing data to produce more valid, reliable, comprehensive, and actionable measures than those currently being used.

Better ways of measuring and assigning accountability for spending are necessary but not sufficient for achieving a higher-value healthcare system.  Even if they use better spending measures, value-based purchasing, pay for performance, and shared savings payment systems do not remove the fundamental barriers to better care that are created by the current fee-for-service system.  Measuring and Assigning Accountability for Healthcare Spending shows how better ways of measuring spending can help payers and providers move more quickly to true payment reforms such as bundled payments, warranties, condition-based payments, and global payments. 

Both the full report and the 7-page Executive Summary are available at no charge on the CHQPR website (www.CHQPR.org).  Comments on the report are welcome.

Jul 14, 2014

Veterans' Needs 'Should Drive Where They Get Their Care'

JUL 14, 2014
On Capitol Hill, lawmakers resume work this week to resolve differences over legislationaimed at alleviating long wait times for medical care at the Department of Veterans Affairs hospitals and clinics after reports that some veterans may have died awaiting appointments and that some VA staff falsified records to cover up excessive wait times.  Five senior VA leaders – including former department secretary Eric Shinseki – have resigned in the past six weeks.

Dr. Kenneth Kizer
Both the House and Senate have passed bills that would allow veterans to seek medical care outside of the VA system if they meet certain conditions, including living more than 40 miles from a VA medical facility.
Dr. Kenneth Kizer, a former VA undersecretary for health, spoke recently with KHN’s Mary Agnes Carey about the issue of the VA contracting with outsideproviders for medical care. Kizer, the founding chief executive officer and president of the National Quality Forum, is now director of the Institute for Population Health Improvement at the University of California, Davis.
An edited transcript of that interview follows.
Q: Both the House and Senate bills include a provision allowing the VA to contract with non–VA medical providers to ease waiting lists.  What are some of the challenges the VA faces in creating new outside networks of providers. 
A: The challenges in creating new networks are the same that everybody faces. Who are the providers? What are their credentials? Can you find the types of providers that you need? What’s the quality of care? How will the information, the exam reports, the consultation reports, how will that information be fed back into the system?  It’s not unlike some of what you’re seeing being played out right now with the health plans which are competing under the Affordable Care Act provisions for the health insurance exchanges. Regardless of who the payer is, you have the same problems.
There are shortages of primary care physicians and mental health professionals everywhere. The VA has done a good job in bolstering the number of mental health providers that it has. But the mental health system in this country is broken. The system just doesn’t work well, so referring veterans out for mental health services may be problematic for a whole host of reasons.
Q: The VA currently has a program that allows it to contract with outside medical providers to make sure veterans receive timely and accessible care.  How would a new contracting program compare to what is currently being done?
A: That’s going to depend on the specific language [that Congress passes]. The VA currently spends about $5 billion a year on what’s called fee-basis care, basically sending people out for services. The need to send veterans out for services that the VA has difficulty sometimes providing is not a new issue. This has been going on for years. The amount of care that’s being provided outside of the VA has increased dramatically in recent years. 
There was a particular program Congress implemented called Project Hero. The VA contracted with some managed care providers – three providers in four geographic areas – to help ease the waiting list issue. Some of the problems they encountered there were the ones we’re talking about—getting into the [providers’] networks and ensuring [that providers] actually were in the network. Sometimes they have availability. You can get an appointment in a short time but they might be a long distance away. Veterans complain, “Yeah, they can get me in next week but I had to drive 100 miles to get there.” 
In that program there was difficulty getting information back to the VA. The private providers would often dictate their reports, which would have to be sent to the plan, which would then fax a copy and send it to the VA and then that had to be scanned into the electronic health record. Sometimes that might take weeks or more. 
Q: What level of reimbursement is needed to encourage non-VA providers to accept these patients?
A: The complaints you hear from private providers is not so much about the rate the VA pays – those rates are often determined locally -- but it’s the difficulty in getting paid.  It’s the contracting rules and cumbersome mess of the payment process that have been more of a barrier to providers often than the amount of payment per se.  It’s just part of government contracting.  Even if substantial amounts of money are appropriated--which it sounds like they will be--if the contracting mechanisms don’t get more facile, then there’s going to be a lot of frustration. 
Many of these private providers are happy to take care of veterans. They feel an obligation and they’re willing to do it for whatever the payment amount is. But it’s just getting it that is so difficult and frustrating for them.
Q: What can lawmakers do to assure the medical care given to these veterans is the highest quality, the most appropriate, the most efficient care?
A: Other than some general verbiage it’s hard for legislation to put those sorts of provisions into law. Certainly going forward if more care is going to be provided in the private sector, the VA needs to focus on a couple of things.
One is ensuring that the quality of care provided by contractors is as good as what’s provided in the VA, which has been an issue in the past. Because VA on quality performance, by and large, does quite well.  The other problem that needs to be addressed is getting the information back into the system. One of the problems with contracting out is that it is promoting more fragmented care, which is a problem. We know that fragmented care leads to bad things.
We need to focus on what the end game is, which is more rapid access to care, on higher quality care and we want integrated services.
Q: Are there veterans who may be best handled by VA personnel and not sent outside the VA system?
A: Every patient should be looked at, and what their needs are should drive where they get their care.  For many of the complicated patients, if they have amputations, they may have chronic medical conditions, if they have mental health issues, you really want as much of that care being provided within the system so that everyone on the team knows what’s going on. 
Someone may need a colonoscopy or some other procedure where you might be able to contract out if the information gets back into the system in a timely manner and if you’re confident in the quality of that exam.
Q: Both the House and Senate bills would sunset the non-VA care provision in two years. What happens then?
A: The access problems aren’t going to go away in two years. You have a backlog that you need to work through, but access is not a new problem in the VA, nor is it a new problem in any of the government-funded programs or in the private sector.  In some cases, there’s this delusion that access is rapid and speedy in the private sector and that’s not necessarily the case, as anyone who’s tried to get care can tell you.


Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.  

Jun 10, 2014

Russ Wins!

(CHICAGO) - We're so very proud of Russ Kridel, MD, of Houston, who won election today to the Board of Trustees of the American Medical Association.

Dr. Kridel is extremely dedicated to physicians and our patients. He ran a great campaign and will be an outstanding board member.

The AMA House of Delegates today also reelected three physicians to the board -- Drs. Barbara McAneny of New Mexico, Steven Permut of Delaware, and Carl Sirio of Pennsylvania -- and chose Jack Resneck Jr., MD, of California as a new board member.

Here is the official AMA news release announcing Dr. Kridel's election:

Houston Physician Elected to AMA Board of Trustees 

CHICAGO, IL - (June 10, 2014) - Today, the American Medical Association (AMA), the nation's largest physician organization, announced the election of Russ Kridel, M.D., a facial plastic surgeon from Houston, Texas, to the Board of Trustees.

"I am honored to be elected to the AMA Board of Trustees," said Dr. Kridel. "I hope to further the AMA's goals of preserving the patient-physician relationship and improving the health of the nation."

Dr. Kridel maintains a practice in Houston, where he is a facial plastic surgeon. He founded the Houston Face Foundation, and uses his surgical skills to help battered women and children who are victims of domestic violence. He also serves as a clinical professor and voluntary director of the Division of Facial Plastic Surgery at the UT Health Science Center in Houston.

Dr. Kridel is the chair of the AMA Council on Science and Public Health, a member of the Governing Council of the AMA Specialty and Service Society and a member of the AMA House of Delegates.

He has a distinguished record as a medical leader, having served as immediate past-president of the Harris County Medical Society. As a medical student, he was elected the national president of the Student American Medical Association. At the state level, Dr. Kridel chaired the professional liability committee of the Texas Medical Association, and served as president of its charitable foundation.

Dr. Kridel attended medical school at the University of Cincinnati College of Medicine, where he was awarded his M.D. He studied at Baylor College of Medicine, in Houston, where he did residencies in General Surgery and in Otolaryngology-Head and Neck Surgery.

Dr. Kridel was nominated by the American Academy of Facial Plastic and Reconstructive Surgery and the Texas Medical Association.

About the AMA

The American Medical Association is the premier national organization dedicated to empowering the nation's physicians to continually provide safer, higher quality, and more efficient care to patients and communities. For more than 165 years the AMA has been unwavering in its commitment to using its unique position and knowledge to shape a healthier future for America.

#AMAmtg Calls for Care for Vets Outside of Troubled VA

Dr. Lockhart

(Chicago) - Led by the delegations from Texas and Florida, the American Medical Association House of Delegates today called on President Barack Obama to "to take immediate action to provide timely access to health care for veterans utilizing the health care sector outside the Veterans Administration (VA) until the VA can provide health care in a timely manner."

Delegates also asked Congress to "act rapidly to enact a bipartisan, long-term solution" to the excessive delays in care that have been documented within the VA system.

"The problems are complex, they are longstanding, and they're not amenable to a quick fix," said Asa Lockhart, MD, an anesthesiologist from Tyler who took the lead on the issue for the Texas physicians. "The only answer is to ask the president to take some sort of immediate action in order for veterans to seek health care outside of the VA system."

David McKalip, MD, a neurosurgeon from St. Petersburg, FL, exhorted his colleagues in the House of Delegates to step up to the challenge. "American veterans are dying and suffering due to delays in care," he said. "Our AMA should ask for the only action that can fix this now."

TMA President Austin King, MD, who traveled to Chicago for the AMA meeting, added his voice to the chorus calling for immediate action.“Our veterans have stepped up and served our country, so physicians want to be able to step in and serve them,” Dr. King said. “It is tragic that our veterans have been forced to wait for the health care they need and deserve, so Texas physicians and our colleagues across the nation want to help care for them until the VA can right the ship.”

The AMA house also encouraged all physicians to participate, when needed, in the care of veterans, and recommended that state and local medical societies across the country create registries of physicians offering to see veterans and to share that registry with community organizations and local VA officials.

"This is a tragedy that needs to stop," said Massachusetts delegate Mario E. Motta, MD.

Jun 9, 2014

Texans Stand for Patients, Texas Docs at #AMAmtg

CHICAGO - From improving access to care for veterans to helping young physicians manage their mountains of student debt, Texas physicians, residents, and medical students lent their voices to important issues at the American Medical Association House of Delegates.

(Column 1) Dr. Henkes; Cynthia Jumper, MD, and Alex Valadka, MD, study
the issues at the Reference Committee on Medical Practice. (Column 2) Mr.
Savage; Colonel Ortega; Dr. Lockhart. (Column 3) Dr. Klawitter,
David Fleeger, MD, Ms. Solnick, Dr. Callas.

In the wake of the revelations of long delays in health care at Veterans Affairs (VA), the Texas and Florida delegations to the house asked AMA to push President Obama for immediate action. In an emergency resolution that was cleared Sunday for debate at the AMA meeting, Texas and Florida asked that AMA “publicly insist (by June 12, 2014) that the President of the United States take immediate action to provide full health coverage financial benefits to ensure that United States veterans can rapidly access the medical care they need outside the VA until the VA can provide promised care.” Texas delegation Vice Chair Asa Lockhart, MD, of Tyler; Irag War veteran Ray Callas, MD, of Beaumont; and Col. Ed Ortega Jr., MD, of San Antonio testified for the resolution Sunday at reference committee.

Many other issues brought the Texans to the microphone, while their colleagues closely studied the reports and resolutions at hand.

  • Delegation chair David Henkes, MD, of San Antonio, testified for a Texas resolution asking AMA to seek changes in a federal law that is imposing new paperwork burdens on private pathology labs.
  • Medical student David Savage of Houston rose to support a call for the AMA to investigate ways to work with private lending institutions to find lower interest rates on the big student loan debt that most graduating physicians carry today.
  • Medical student Rachel Solnick spoke on a public safety issue.
  • Art Klawitter, MD, of Needville, listened to hours of testimony as a member of the Reference Committee on Amendments to AMA Constitution and Bylaws.

Drs. Bailey, Lockhart Win #AMAmtg Elections

Clockwise from lower left: Ms. Hamouie and Ms. Bailey with Romero  Santiago,
UT Southwestern; Dr. Sue Bailey; Dr. Kridel; Dr. Ejesieme; and Dr. Lockhart

CHICAGO - Two Texas physicians secured leadership positions at AMA without opposition; a third must wait until Tuesday’s elections. The House of Delegates unanimously reelected Sue Bailey, MD, of Fort Worth to a fourth term as vice speaker. As one of four candidates running for four available seats on the AMA Council on Medical Service, Asa Lockhart, MD, of Tyler won his post by acclamation. Meanwhile, Russ Kridel, MD, of Houston is among eight candidates seeking the four available spots on the AMA Board of Trustees. We’ll know the outcome Tuesday morning.

Some younger Texans also won elections at the AMA meeting:

  • Nnenna Ejesieme, MD, of The University of Texas (UT) Southwestern Medical Center, is the newly elected chair of Region 3 of the AMA Resident and Fellow Section.
  • Elected to the Medical Student Section Region 3 Executive Council were: Angie Hamouie, UT Medical Branch at Galveston, secretary; and Tennessee Bailey, UT Health Science Center at San Antonio, membership chair.


Jun 7, 2014

AMA Foundation Honors Anu Atluru with National Leadership Award

CHICAGO -- Anu Atluru, a medical student at The University of Texas Southwestern Medical School, is a recipient of the American Medical Association Foundation’s 2014 Leadership Award. This national award recognizes medical students, residents/fellows, and early career physicians for achievements in community service, medical education, and public health.

Ms. Atluru is a second-year medical student who has applied her creative inclination and management consulting experience to expand the innovation ecosystem for rising physicians. She serves as the product track co-director for the Dallas-area Innovating Healthcare Solutions program and leads a team of MD/PhD candidates to develop a medical device for use in complicated cesarean section deliveries.

She is also an elected Administrative Board Member of the Association of American Medical Colleges Organization of Student Representatives. Anu envisions a multi-faceted career as a clinician and an educator. She hopes to drive the creation of novel, impactful technologies and approaches to patient care.

The AMA Foundation honored 15 outstanding individuals with Leadership Awards at its June 6 annual Excellence in Medicine Awards celebration in Chicago. Award recipients will receive special training to develop their skills as future leaders in community affairs and organized medicine.

The Excellence in Medicine Award program is presented in association with Eli Lilly & Co., Novo Nordisk Pharmaceuticals, Inc., PhRMA, and Pfizer Inc.

The AMA Foundation, a nonprofit, is improving the health of Americans through philanthropic support of quality programs in public health and medical education. To join the AMA Foundation in supporting medical heroes like the Excellence in Medicine Award winners, visit www.amafoundation.org.

Jun 2, 2014

Texas Takes Three Candidates, Six Resolutions to AMA House

The Texas Delegation will have plenty of work to do when the American Medical Association House of Delegates convenes in Chicago this month. Actually, it looks like the delegation can put a checkmark in the "done" box for two of its chores.

First, Fort Worth allergist and former TMA president Sue Bailey, MD, is running unopposed for reelection as vice speaker of the house. Also, Tyler anesthesiologist Asa Lockhart, MD, is running for the Council on Medical Service, and there are only four announced candidates for the four seats up for grabs. However, Russ Kridel, MD, of Houston, is one of eight men and women seeking five seats on the AMA Board of Trustees.

The delegation is also carrying six resolutions from the Texas House of Delegates to AMA:

  1. Work to prevent recoupments if an Affordable Care Act marketplace insurer has not notified the physician that a patient is in the last 60 days of the grace period for not paying his or her premiums;
  2. Push for a federal law requiring insurers to provide real-time claims adjudication;
  3. Have the AMA Council on Ethical and Judicial Affairs issue rulings on whether AMA's continued support for parts of ACA violates the AMA Code of Medical Ethics;
  4. Commission a study to compare the federal estimates of direct and indirect costs attributable to the Physician Quality Reporting System, meaningful use, and ICD-10 with the actual time and costs required by physicians to comply with these mandates;
  5. Organize an official protest of the "immediate-use" exception to the United States Pharmacopeia Chapter 797 guidelines on sterile compounding; and
  6. Eliminate the law requiring private sector laboratories to report to Medicare their payment rates for lab tests.

May 5, 2014

AMA help for Medicare claims data release

As reporting about the Centers for Medicare & Medicaid Services’ (CMS) recent release of physician Medicare claims data continues to cycle through the media, a new resource page from the AMA offers the essential information you need to know about the data release.

The physician Medicare claims data, which was made available April 9, includes such information as billed charges, Medicare payments and the number of different Medicare services provided in 2012. Because CMS released only raw data with little context and considerable limitations, it’s easy for patients, reporters and others to draw inaccurate conclusions about individual physicians. The AMA’s new resource page can provide the clarification you need.

Read more.

Mar 12, 2014

Identity Theft

By Martha Leatherman, MD, Past President, Texas Academy of Psychiatry

Did I get your attention? It’s a real problem and affects people throughout the country, but the identity theft I’m talking about is the one you’re likely thinking about. The dictionary defines identity theft as “the fraudulent acquisition and use of a person's private identifying information, usually for financial gain.” I would like to propose another sort of identity theft that has been happening in American medicine for at least the last twenty years. It hasn’t made the news; it hasn’t been defined in our common vernacular; it hasn’t been declared a crime. That is because it has been widely accepted as a reasonable evolution of American medicine. The identity theft I’m talking about is the slow creep of para-professionals into the practice of medicine, and the use of the words “doctor,” and “physician” to mean things other than a professional who has devoted his life to studying medicine and has earned an M.D. or D.O.

The identity of “physician” has been stolen by the bureaucrats, the insurance companies, the legislators, and the special interests. We are now “providers” along with other “providers” such as acupuncturists, midwives, phlebotomists, and nurse aides. Often, these other providers allow patients to call them “Doctor.” Physicians graduate from medical school with tens of thousands of dollars worth of debt, heavy malpractice premiums, and expectations of perfect performance, but are paid not much more than the nurse practitioners they work alongside.

In another life, probably during the days of dinosaurs, physicians administered injections, drew blood, performed EMGs, and took vital signs. Now, many physicians do not even take a history from their patients. Increasingly, nurses and nurse practitioners counsel patients, perform procedures, take histories, write prescriptions, and make “diagnoses.” Nurse aides answer medical questions and perform minor procedures. Patients increasingly feel that they are getting their real medical care from paraprofessionals, and that the actual physician is little more than a figurehead. Physicians are boxed into algorithmic medicine and are required to follow the flowcharts devised by bean counters who are more interested in demographic outcomes than in what is best for an individual patient. Our work is digitized, analyzed, and criticized, but no one has ever captured the art that is medicine, and in trying, they are turning us into technicians.

This is identity theft. The professional identities of thousands of physicians have been stolen, and we have been left with identities we never wanted. The stereotype of a medical school applicant’s answer to “why do you want to be a doctor?” was always “because I want to help people.” It’s a stereotype because it was true of so many of us, and by “helping people,” we meant getting to know them and their families. We meant having our patients bestow on us a level of trust and caring that few are privileged to share with anyone. The television character Marcus Welby, M.D. is an icon because his character represents something that people long for, but now rather than being seen as helping, caring, professionals, we hear patients complain that “the nurse did all the work” and “the doctor spent less than three minutes with me.”

What does this have to do with the Texas Academy of Psychiatry? The Academy, along with our colleagues in the Texas Society of Psychiatric Physicians and other member organizations of the Federation of Texas Psychiatry have consistently worked to protect the professional identity of Texas psychiatrists. From the halls of the Capitol building in Austin to the bowels of regulatory agencies and insurance commissions, members of organized psychiatry work to protect physicians and our patients from expanding scope of practice by non-physicians as well as from the practice of medicine by legislative fiat. The Texas Academy of Psychiatry remains a professional organization of physicians who work together to network, educate, and support each other as we navigate the changing landscape of medical practice today.

We need your support to continue our work. Obviously, we have a lot to do and a lot to learn. Please join us.

This article appeared in the February/March 2014 issue of Texas Psychiatrist. Reprinted with permission.

Mar 3, 2014

DPS Announces Interim Plan to Renew Controlled Substance Permits

On Jan. 1, renewal of controlled substances registration (CSR) permits issued by the Texas Department of Public Safety (DPS) should have become part of physicians' biennial online medical license renewal with the Texas Medical Board (TMB). TMA advocated passage of House Bill 1803 by Rep. Bill Callegari (R-Katy) and Sen. Joan Huffman (R-Houston) to ease the administrative hassle and red tape on physicians when they renew their CSR permits, and to avoid interruptions in patient care and in physicians' practices due to inadvertent expirations.

Under the law, permits valid on Jan. 1 would automatically extend to the date of the physician's next state medical license renewal. At that time, the CSR permit would be valid for two years for a $50 fee.

TMB reports that it had completed the work necessary to implement HB 1803 by Jan. 1, including developing data-sharing capabilities that allow information to flow electronically to DPS for processing. DPS wasn't prepared, however, by Jan. 1 to allow for the two-year permit and to synchronize the expiration of the permit with the physician's license renewal date.

In the past, physicians have had problems when DPS didn't process renewals in a timely manner, before the CSR permit's expiration. When physicians are unable to renew their CSR permits, they can't prescribe medications. A physician's ability to prescribe medications hinges on possession of a valid CSR, which is necessary to obtain a permit from the Drug Enforcement Administration.

Just as critical, a physician whose CSR permit lapses faces (at least) temporary suspension of hospital privileges, as maintaining current certifications is a requirement to retain medical staff privileges in Texas.  

To address concerns among physicians and to ensure DPS is ready to begin processing CSR renewals, TMA has been meeting with department officials and TMB representatives. DPS told TMA in February that it will take at least six weeks to implement necessary changes to its processing system and to verify test data.

As an interim solution, DPS officials say they'll begin synchronizing the CSR expiration date with the TMB expiration date "in the near future." To ensure physicians don't experience any disruption in their controlled substances prescribing authority or place medical staff privileges at risk, DPS has posted the following information on its Controlled Substances Search and Verification System website:  

  • CSRs that currently expire in February 2014 or March 2014 will automatically be renewed by DPS with a temporary one-year expiration date. The renewal will be completed before expiration without the renewal application and associated fee. No action is required by the physician. The information on the Controlled Substances Search and Verification System will be updated.
  • Programming changes are under way at DPS to implement the statutory requirement to synchronize the CSR expiration date with the TMB expiration date.
  • Upon completion of the synchronization, the information on the Controlled Substances Search and Verification System will be updated, and new CSR certificates will be mailed to each affected practitioner.

Visit the DPS Regulatory Services webpage for updates and additional information as it becomes available.

Feb 9, 2014

Call Today! SGR Repeal Closer Than Ever

Late last week the "SGR Repeal and Medicare Provider Payment Modernization Act of 2014" (H.R. 4014/S. 2000), was introduced in the U.S. Senate and House of Representatives. Its author is U.S. Rep. Michael Burgess, MD (R-Lewisville). It features the handiwork of Rep. Kevin Brady (R-The WoodlandsAnd it has the support of key congressional leaders from both parties and in both chambers.

"We may not get this opportunity again," said TMA President Stephen L. Brotherton, MD. "Take action now to support permanent SGR repeal."

The three key congressional committees involved have come to this bipartisan, bicameral agreement in advance of the March 31 deadline when physicians' Medicare payments will be cut by 24.1 percent. It incorporates many Texas Medical Association-supported recommendations to reform the physician payment system and improve care for Texas seniors, military families, and people with disabilities. This legislation would provide physicians with positive annual payment updates of 0.5 percent for five years. (While these updates won't keep up with physicians' cost of providing health care to Medicare patients, the cumulative 2.5-percent update is larger than all of the increases Congress has provided in the past 12 years, combined.) It also includes important medical liability reform protections and significant financing and tools to help us adopt new payment and delivery models.

"Congress is now closer than it ever has been to enacting fiscally prudent legislation that would permanently repeal the SGR, "Dr. Brotherton said. "That will happen only if Washington hears our loud voice. Please contact U.S. Sens. John Cornyn and Ted Cruz and your U.S. representative today."

Physicians can send an email through TMA's Grassroots Action Center, and call lawmakers via the American Medical Association's Physicians Grassroots Network hotline at (800) 833-6354.

Here are the key points to stress:

  • For at least 12 years, members of Congress have told us how serious they are about reforming the Medicare physician payment system. Now that a bipartisan, bicameral policy has been developed, it is time to stop talking about the problem and seize the opportunity to solve it.
  • Congress must vote as soon as possible in support of a fix that will permanently repeal the flawed Medicare SGR formula.
  • Congress must avoid continuing the fiscally irresponsible cycle of short-term patches that contribute to the Medicare's program instability and do nothing to solve the underlying problem.
  • Congress must ensure that practicing physicians lead the development of the alternative payment models and quality incentive programs established in this bill.

"Please call or write today," Dr. Brotherton said. "We may not get this opportunity again."

Jan 22, 2014

Using Photos in the Medical Record? Use Them Right

In some fields of practice, such as dermatology, photographs are a common way to document a patient's condition and response to treatment. These records are no different from narrative records — the photo is meant to document what is necessary to achieve an adequate medical record and should be considered part of that record.

Many of the photographs will be smaller than 8½ x 11; the practice should either tape them to a full-sized sheet of paper or keep them a plastic slip cover, says the Texas Medical Association's Managing Your Medical Records. The photo should have identifying data on the reverse side.

Photos that contain sensitive anatomy should be safeguarded (as every single page of every medical record should be safeguarded).

Many surgeons make videos of surgeries, particularly surgeries performed via scopic equipment such as arthroscopy or laparoscopy. The practice should have a means (digital, disk, or both) to file and catalog the videos. Because the videos are a part of the medical record, a backup system is mandatory.

Some surgeons provide copies of the video to the patient. They should do this only pursuant to a practice-wide policy, developed in consultation with legal counsel and the medical liability insurer.

If you have questions about medical records, check TMA's Medical Records webpage for legal white papers, tips, and more. Or, contact the TMA Knowledge Center at (800) 880-7955 or knowledge@texmed.org.


See more, free Practice E-tips from the Texas Medical Association.