February Edition 2020
Inside This Issue
Changes Coming for Prescribers to The Texas Prescription Drug Monitoring Program By Mark S. Armstrong, JD Polsinelli, PC
Ascension Texas Names Timothy Brierty as Regional Hospital President See pg. 10
INDEX Mental Health...................... pg.3 Oncology Research......... pg.4 Financial Forecast ............ pg.8 Healthy Heart..................... pg.12
Safely Managing Pain for Aging Well See pg. 13
I
n response to the opioid epidemic, many states, including Texas, created prescription drug monitoring programs to monitor high-risk patients and provider behaviors. The Texas Prescription Drug Monitoring Program (“PMP”) is managed by the Texas State Board of Pharmacy and is the only statewide electronic database that currently collects, manages, and stores outpatient prescription data for all Schedule II through Schedule V controlled substances dispensed by a Texas pharmacy. PMP helps inform prescribing practices and addresses prescription drug misuse, diversion, and overdose. In addition, PMP assists prescribers and pharmacists to avoid potentially life-threatening drug interactions, decide when to make referrals to specialty treatment providers, and identify individuals obtaining controlled substances from multiple health care providers and pharmacies. PMP can also be used to verify a practitioner’s
own records and prescribing history, as well as to inquire about patients.
required to access PMP, with respect to a patient, before prescribing or dispensing opioids, benzodiazepines, barbiturates or carisoprodol; provided, however, that neither a prescriber nor a pharmacist is required to access PMP if the patient has been diagnosed with cancer or if the patient is receiving hospice care. Prescribers or pharmacists may access PMP with respect to a patient before prescribing or dispensing any controlled substance. After the effective date, a prescriber or pharmacist in Texas who fails to access PMP with respect to the patient prior to prescribing or dispensing opioids, benzodiazepines, barbiturates or carisoprodol may be subject to disciplinary action by the regulatory agency that issued a license, certification or registration to the individual who committed the violation (i.e. Texas Medical Board, Texas State Board of Dental Examiners, Texas Board of Nursing, Texas State Board of Pharmacy).
Effective March 1, 2020, prescribers and pharmacists will be required to access the Texas Prescription Drug Monitoring Program (PMP)...before prescribing or dispensing opioids... Texas-licensed pharmacies are presently required to report all dispensed controlled substances records to PMP no later than the next business day after the prescription is filled. If the pharmacy does not dispense a controlled substance prescription during a period of seven consecutive days, then the pharmacy must submit a zero report indicating that the pharmacy did not dispense any controlled substances during that period. Effective March 1, 2020, prescribers and pharmacists will be
see Monitoring Program... page 14
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Mental Health Drug Shows Promise for Treating Cognitive Problems and Inflammation In Gulf War Illness By Mary Leigh Meyer
T he compou nd, monosod iu m l u m i n o l , s h ow n t o i m p r o ve cognitive and mood function and reduce inflammation in a Gulf War illness model
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ulf War illness, or GWI, previously called Gulf War syndrome, is a collection of medically unexplained chronic symptoms that one-third of veterans who served in the first Gulf War experience even now, nearly 30 years later. This condition is characterized by central nervous system impairments—including cognitive and memory problems, mood dysfunction, sleep disorders and chronic fatigue—and systemic symptoms such as gastrointestinal problems and hypersensitive skin. With such a wide variety of symptoms, historically, experts have been unable to find a treatment for the illness. However, Ashok Shetty, PhD, professor with the Department of Molecular and Cellular Medicine at the Texas A&M College of
Medicine and associate director of the Institute for Regenerative Medicine, and his research team took a significant step forward with regard to treating this mysterious illness. Their findings, a result of a study funded by the Department of Defense, were recently published in Redox Biology. Modeling Gulf War illness During the war, veterans were exposed to multiple chemicals. Although the exact cause of Gulf War illness is unknown, it is generally understood that the combination of pyridostigmine bromide (an anti-nerve agent used as a pretreatment to protect troops from an attack with nerve gas agent), DEET (a mosquito repellant) and permethrin (a pesticide sprayed on clothes to keep rodents and insects away) played a significant role. “In our study, after administering the chemicals, the models presented Gulf War illness symptoms that closely resembled the symptoms veterans experience every day,” Shetty said. “They have memory problems,
concentration issues and depressive-like behavior. Furthermore, the models experienced similar systemic problems and the blood samples showed elevated levels of proinflammatory cytokines.” A previous study by Shetty showed proinflammatory cytokines— which, when in too great of a quantity can eventually deteriorate brain tissue and cause cognitive and mood problems—can be used as a reliable biomarker to determine the progression of the brain inflammation. Oxidative stress, free radicals and Gulf War illness Another previous study by Shetty
showed that the brain experiences increased oxidative stress and inflammation when suffering from Gulf War illness. Oxidative stress, or an accumulation of free radicals, can happen for a number of reasons. “Most GWI-related chemicals are acetylcholinesterase inhibitors, which are known to induce hyperexcitability in neurons and cause inflammation,” Shetty explained. “These hyperexcited neurons are caused by an excess of free radicals.” see Mental Health...page 13
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Oncology Research Blood Cancer Breakthroughs: Targeted Therapies Take the Lead in the Future of Treatment By Jason Melear, M.D., Texas Oncology– Austin Midtown
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plashed across the cover of TIME magazine on May 28, 2001, an oral therapy for cancer was introduced to the public as a revolutionary targeted cancer treatment unlike anything on the market at the time. It was deemed the leukemia “miracle pill.” As an oncologist specializing in hematology, this was an exciting development. It also garnered the attention of my patients, their families, and the public, and marked the beginning of a promising chapter in the treatment of patients with blood cancers. Nearly two decades later, targeted therapy sits squarely at the forefront of cancer care. Targeted therapy is different from conventional
cancer treatments like chemotherapy and radiation therapy in that it is designed to treat only the cancer cells, minimizing damage to normal, healthy cells. Today, we continue to see incredible advancements in the area of targeted therapies leading to better chances of good outcomes and minimized side effects for patients with blood cancers, including Hodgkin and non-Hodgkin lymphoma, acute myeloid (AML), and chronic myelogenous leukemia (CML). To put the future of blood cancer treatment into context, look no further than improvements in therapies for CML. Once deemed a highly challenging cancer to eradicate, CML is one example of a cancer that has responded well to targeted therapy. By attacking cancer cells and minimizing damage to healthy cells, patients experience fewer side effects from treatment, live longer, and have greater quality of life.
Below are several of the latest treatment options making it possible to target and eliminate cancer cells in patients with blood cancer. Chimeric Antigen Receptor – T Cell (CAR-T) CAR-T is a breakthrough treatment that has shown promising results in patients with blood cancers. A type of immunotherapy, CAR-T therapy uses the body’s immune system to fight cancer. Genetically engineered immune T cells can recognize certain proteins on cancer cells. To target the cancerous cells, white blood cells are extracted, modified, and replicated
from those proteins on the cancerous cells, then injected into the patient so they can recognize and attack the cancer. This is a highly targeted therapy for eligible patients, and oncologists and hematologists are keeping a close eye on further developments in CAR-T. Monoclonal Antibodies Antibodies are proteins that are considered a form of immunotherapy. Administered through a vein, antibodies for cancer treatment can be used on their own or in combination see Oncology Research...page 14
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First-of-Its-Kind Master’s in Design in Health Launches at UT Austin
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he School of Design and Creative Technologies and the Design Institute for Health at The University of Texas at Austin are advancing the role of design with the creation of the Master of Arts in Design in Health. It is the only degree of its kind in the nation and brings together expert designers with health design specialists to teach the latest methods for health’s most complex problems. The one-year degree program focusing on the application of human-centered design in health is offered jointly through the School of Design and Creative Technologies in the College of Fine Arts and Dell Medical School’s Design Institute for Health. Applications are now open until May 2020. The program will start August 2020. “The Design in Health master’s degree was uniquely constructed so that Dell Med students and innovative professionals could work collaboratively to solve real-world problems that impact
the health and health care of millions of Americans every day,” said Doreen Lorenzo, assistant dean of the School of Design and Creative Technologies. “Learners explore the many facets of design to creatively design solutions that revolutionize the way people get and stay healthy.” As Dell Med charts a revolutionary path to health — one that shifts the focus beyond clinical care to include all the ways people get and stay healthy within their communities — it presents the unique opportunity to reshape the U.S. health care system through human-centered design. The Design Institute for Health is leading the charge by addressing critically important health factors across the spectrum of conditions in which people are born, grow, live, work and age, and taking a systems design approach to encouraging collaborations across sectors that were not designed to work together. The M.A. in Design in Health
teaches learners how to become a force of innovation by using human-centered design methodologies. Students will learn: • Design research methods to better understand the needs of people who are seeking health, receiving care and delivering care. • Ideation and creation skills to generate new approaches for better care systems. • How to prototype, test and iterate solutions based on measuring impact and results that matter to patients. • Techniques to craft compelling and persuasive experiences, stories and systems that can be used
widely to distribute innovations across systems of health “This new breed of health leaders will wield a creative, problem-solving mindset and design skills that enable them to not only see the places where the health system is broken, but also to take action to fix it,” said Stacey Chang, executive director of the Design Institute for Health. “When they put their design skills to work, the health system of the future will put people first. Our health care system is intrinsically flawed, and we need a new generation of care providers and design thinkers who can creatively solve health care’s most wicked problems from the inside.”
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Financial Forecast Physician Practices: Here’s what to expect in 2020 By Reed Tinsley, CPA,CVA,CFP,CHBC
MS (Medicare) issued its Final Rule – This final rule updates payment policies, payment rates, and other provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2020. Here’s a sneak peek at a few of the changes that physician practices can expect in 2020: Coding • There are 273 additions to ICD
services in accordance with Stats law and State scope of practice rules that are specific for the State in which the services are furnished to the extent that those rules describe the required relationship between physician and PAs including its collaborative nature and describe a form of relationship between physicians and PAs collaborative nature and describe a form of supervision for Medicare’ purposes.
10 CM, 21 deletions, and 30 revision including revisions to atrial fibrillation, diseases of lymphatic system, pressure ulcers and congenital diseases effective October 1, 2019. • There are also 394 changes to CPT, 248 new codes , 71 deleted and 75 revised including 6 new codes for on line digital visits, long term EEG, self measured blood pressure. Recommendation: Study your new CPT and ICD coding books! Medicare Physician Fee Schedule CMS proposed increasing physician payment rates by 0.14 percent in 2020. After applying the budget neutrality adjustment required by law, CMS estimated the 2020 Physician Fee Schedule conversion factor is $36.09, up from $36.04 in 2019. Scope of Practice • CMS is finalizing the “Physician Supervision for Physician Assistant (PA) Services” proposal, implementing CMS’ reinterpretation of Medicare law that requires physician supervision for PAs’ professional services. • Federal Regulations require that PAs must furnish their professional
Medical Record Documentation Final rule contains a proposal to reduce burden by implementing a general policy that will allow all Physicians, Physician Assistants (PAs), Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), Certified Midwives(CNMs) and Certified Registered Nurse Anesthetists (CRNAs), each of whom are recognized as Advanced Practice Registered Nurses (APRNs): • To review and verify by signing and dating documentation in medical records without having to redocument notes the medical record includes. This principle apples to all Medicare covered services that each of whom are professional disciplines furnish and are paid under the MPFS. • In addition to physicians, residents , nurses and medical students, this provision includes PA and APRN students or other members of the medical teams, as individuals who are allowed to make notes in a patient’s medical record, can review and verify by physicians and APRNS, rather than redocumenting notes.
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Bridgemoor Transitional Care Adds New Pulmonary Program in Round Rock
Ascension Texas Names Timothy Brierty as Regional Hospital President Brierty to Oversee Three Ascension Seton Hospitals
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imothy Brierty, LFACHE, has accepted the role of regional hospital president at Ascension Texas, overseeing three Ascension Seton hospitals, effective immediately. Brierty previously served as Chief Operating Officer of Dell Seton Medical Center at the University of Texas. As regional hospital president, Brierty will have leadership responsibilities for Dell Seton Medical Center at the University of Texas, Ascension Seton Shoal
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Creek and Ascension Seton Medical Center Austin. For each of these sites of care, he will oversee day-to-day operations, serve as a leader who articulates the hospital’s mission and vision to the public community, and lead the development of strategies and policies for each hospital. “We are incredibly fortunate to have Tim serving on the executive team at Ascension Seton, as he see Ascension...page 14
ridgemoor Transitional Care in Round Rock is broadening its list of patient services with the addition of an advanced care pulmonary program. In partnership with Respiratory Health Services, Bridgemoor is now able to provide around-the-clock, therapeutic treatment for individuals with complex respiratory problems. The program offers a variety of services for numerous diagnoses. Among them are ventilator weaning, 24/7 registered nursing, an on-site nurse practitioner, high-flow oxygen, as well as an on-site lab and pharmacy dispensing system. “We’re thrilled to add the advanced pulmonary program to our highly skilled, clinical patient care services,” Mark Fritz, president of Bridgemoor Transitional Care, said. “In adding this layer of respiratory therapy, we demonstrate our continued commitment to helping our patients transition back home and to their everyday lives—no matter the nature
of care required.” Bridgemoor’s innovative model of care serves as a bridge between the hospital and home, helping to reduce the likelihood of a patient returning to the hospital. This practice can reduce total care costs as the patient recovers under the care of a physician-led team. Respiratory Health Services co-created the original model of respiratory care for the post-acute industry in 1991. The company is recognized as superior in the industry, based on its vast experience in respiratory care, management expertise, credentials and dedication to excellent patient care. Bridgemoor, the first skilled nursing transitional care facility in Round Rock accredited by The Joint Commission, is a 70-bed facility with a Five-Star Quality Rating by the Centers for Medicare and Medicaid Services (CMS). It’s located at 16219 Ranch Road 620 N.
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Healthy Heart Get Familiar with Signs of a Heart Attack Or Stroke By American Heart Association
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February 2020
ost people realize getting medical help quickly is crucial in response to a heart attack or stroke. But it’s important to know the signs so you can act. “It is an emergency. People need to call 911,” said Dr. Erin Michos, associate director of preventive cardiology at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease in Baltimore. Emergency medical responders can begin evaluating a potential heart attack or stroke, and start treatment before arriving at a hospital, she said.
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anyone, even young women,” Michos said. The sooner medical treatment begins, the better the chances of preventing heart damage. But people shouldn’t try to drive to the hospital. “A heart attack can trigger a dangerous heart rhythm. You don’t want to be in a car if this is happening,” said Michos, who suggests chewing an aspirin while waiting for the ambulance. For heart patients who have nitroglycerin tablets, take one, she said. Just like a heart attack, a stroke is an emergency. Quick help increases the likelihood of saving
Heart disease is the nation’s leading killer, and every 40 seconds someone has a heart attack. A common symptom is chest pressure or pain that may feel like tightness or squeezing, which can spread out to the arms. Other possible heart attack symptoms are shortness of breath, nausea, indigestion or pain in the jaw or back. If these symptoms come on suddenly and last at least 15 minutes, despite sitting down and resting, it’s a “red flag” that a coronary artery blockage may be restricting blood flow to the heart, Michos said. Women more often experience symptoms other than chest pain, wait longer before seeking help and attribute symptoms to other causes, Michos said. Young, seemingly healthy women without known heart disease risk factors might experience an uncommon form of heart attack caused by a tearing in the coronary artery wall. This is known as SCAD, or spontaneous coronary artery dissection. “Heart attack can happen to
brain tissue. An ischemic stroke is the most common type and is caused by a clot that blocks blood flow to the brain. The clot-busting drug alteplase typically delivered through an IV may reduce the likelihood of permanent disability if it’s administered within three hours. “Earlier is better. This is a really narrow time frame,” Michos said. “Three hours goes by really fast.” A less common type is a hemorrhagic stroke, caused when a blood vessel in the brain ruptures. The acronym FAST can help identify stroke symptoms. The “F” stands for face drooping; “A” for arm weakness, “S” for speech difficulty; and “T” for time to call 911. An updated version is BE-FAST that adds “B” to signify balance problems and “E” for eyes to represent sudden vision changes or vision loss. To help keep a cardiovascular emergency from happening, adopt a heart healthy lifestyle and know your
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Austin Medical Times
Age Well Live Well fall than their peers taking overthe-counter medications for painrelief3. There is a variety of opioid medications such as OxyContin, Vicodin, Fentanyl and Morphine that can have different side effects and affect balance and coordination. Talk with your health care provider about possible side effects and any concerns you might have to help you decide what medications are right for you. One way to reduce possible adverse side effects of opioid use is to have a complete medication review. A medication review can help identify if there might be contraindications between the items you are taking. This
is useful if you see multiple health care providers who might not be in direct communication with each other or if you take multiple prescriptions, medications or supplements. To get a medication review, take a detailed list of prescriptions, over-the-counter medications, and supplements to a nurse or pharmacist. Area Agencies on Aging provide services and supports for people 60 and older, their family members and caregivers. Some Area Agencies on Aging provide medication review services and other community health and wellness programs. To find out if your local Area Agency on Aging provides medication review services, call 800252-9240. If you are concerned you or a
loved one might have a substance use issue, the Texas Health and Human Services Outreach, Screening, Assessment and Referral Centers can help. Located in the 11 local mental health authorities of Texas, OSAR centers provide screenings and assessments, referrals to treatment providers, recovery support services and intervention, and prevention programs. To find an OSAR center, call 877-541-7905. Healthy aging is viable for many Texans with the right information, resources and supports. Making informed decisions about pain management can allow more older adults to live and age well while reaching their fullest potential.
different doses for several weeks. They measured the levels of oxidative stress, inflammation and cognitive function. Oxidative stress and inflammation can be quantitatively assessed through various markers in the body. However, cognitive function cannot. To decrease the subjectivity of measuring cognitive function, the team used three tests. First, they tested the hippocampus via the object location test. This test investigates the ability to discern minor changes in the environment. The second test, called the pattern separation test, measures ability to distinguish similar, but not identical experiences. For the third test, the researchers conducted a depression test to measure the amount of depressive-like behavior in the models. Monosodium luminol’s impact All three of these tests measured common cognitive issues veterans with
Gulf War illness experience: problems with working memory, memory recall and depression. As expected, the models had difficulty with all three tests. However, the models that received the drug tested close to normal levels of cognitive function with all of these tests. Similarly, the monosodium luminol brought the elevated oxidative stress and inflammation levels back within normal range. “We measured the oxidative stress markers in the blood and they were normalized,” Shetty said. The drug helped both the cognitive and systemic symptoms in the models of Gulf War illness. “When you have inflamed conditions in the hippocampus, neurogenesis—the production of new neurons—goes down,” Shetty said. “We know people with depression and Gulf War illness have very low levels of neurogenesis. Low levels of
neurogenesis are related to depression, problems in making new memory and cognition.” Shetty said neurogenesis actually increased in the models after taking this drug. The next step Presently, the drug is not approved by the U.S. Food and Drug Administration (FDA), but there is a pharmaceutical company conducting the required tests to get approval for monosodium luminol to be administered in the United States. Furthermore, the Department of Defense is backing several studies with this drug. “From what we can tell right now, this drug does not seem to have any side effects,” Shetty said. “Theoretically, if this drug gets approved for use in the United States, this drug would need to be taken every day to maintain that redox homeostasis and, hopefully, be a solution for many of our veterans suffering from this illness.”
Safely Managing Pain for Aging Well
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bout three quarters of older adults live with chronic pain1 making everyday activities such as grocery shopping and meal preparation difficult or overwhelming. To help manage chronic pain, doctors might prescribe opioids. However, taking opioids can have serious side effects for older adults such as an increased risk of falling. The Healthcare Cost and Utilization Project showed the rate of opioid-related hospitalizations for older adults increased 34 percent2 between 2010 and 2015. Older adults prescribed opioids are four to five times more likely to experience a
Mental Health
Continued from page 3 Free radicals are uncharged molecules with an unpaired electron. Therefore, Shetty looked toward an existing drug known to balance out the free radicals by bringing the body back to normal levels as a solution. Although not FDA-approved in the United States, monosodium luminol has been tested for use with cancer patients in Europe and Russia. “The drug is a redox balancing drug, as it can donate and receive electrons. In other words, it maintains redox homeostasis, or an equilibrium of free radicals,” Shetty said. “When a shift in the balance of free radicals occurs, oxidative stress happens.” Measuring the cognitive function During the study, the research team administered the drug at
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Monitoring Program Continued from page 1
Individuals who are provided access to PMP and who are subject to the new requirements regarding accessing PMP prior to prescribing or dispensing opioids, benzodiazepines, barbiturates or carisoprodol include, but are not limited to: • Physicians • Dentists • Podiatrists • Optometrists
• Advance Practice Nurses • Physician Assistants • Pharmacists Prescribers and pharmacists are further permitted to designate an unlimited number of delegates to access patient prescription data and generate reports on their behalf. Every individual is required to register with PMP as a separate user, however all delegate queries are attributed to the prescriber or pharmacist for whom they
generate the report. Eligible prescriber delegates include nurses, medical residents, administrative staff, etc. Pharmacists may only delegate this responsibility to pharmacy technicians. Prescribers, and their delegates, who are not currently registered with PMP, should do so prior to March 1, 2020, so that they are positioned to access PMP, with respect to a patient, before prescribing opioids, benzodiazepines, barbiturates or carisoprodol.
Oncology Research most frequently in older adults and grows slowly, making it difficult to treat with treatments like conventional chemotherapy and radiation therapy. Oral targeted therapies have been successful in not only minimizing side effects but also providing better chances for good outcomes compared to chemotherapy. The use of oral therapy has also been successful in patients with AML. Whereas previously the standard treatment was intense chemotherapy, now less aggressive therapy in conjunction with
oral agents may be used. A combination of conventional and targeted therapies are options for patients who may not be eligible for immunotherapies like CAR-T and targeted oral agents. As an oncologist specializing in blood cancer, it is gratifying to see the tremendous progress made since that 2001 breakthrough and to guide my patients through these new treatment regimens – offering them better chances for good outcomes.
Ascension
Continued from page 10 has proven to be a compassionate and effective leader,” said Christann Vasquez, Chief Operating Officer of Ascension Texas. “I look forward to his continued engagement and commitment as Regional Hospital President, and I am confident he will continue to support the growth of our health system in this new role.” Brierty has an extensive background as a healthcare executive with more than 27 years’ experience. He joined Ascension Seton in October 2018 as Chief Operating Officer at Dell Seton Medical Center. While in this role, the hospital has exceeded goals for patient satisfaction scores, and the leadership team has been working
to re-engineer AIM for Excellence to continuously improve the quality indicators for safe and excellent care of patients. Prior to joining Ascension Seton, Brierty began his career at The George Washington Hospital in Washington, D.C. followed by progressive administrative leadership roles for more than 20 years with the McKenna Health System in New Braunfels, Texas. He served as the CEO of the McKenna Health System for 10 years. Brierty transitioned his career to the University Healthcare System (UHS) in San Antonio where he served as the CEO for the University Hospital. UHS owns and
operates University Hospital, a Level I trauma, academic tertiary facility to include transplant services. He was responsible for the overall operational and financial accountability with oversight of operational effectiveness and performance, growth and strategic development as well as strengthening community partnerships. Brierty earned a master’s degree in Healthcare Administration from The George Washington University in Washington, D.C. He currently serves on the boards of HeartGift Foundation and The Mission of Divine Mercy.
American College of Cardiology and AHA. The recommendations emphasize a healthy diet and physical activity and to involve patients in health decisions.
“A healthy lifestyle is the foundation for all preventive efforts,” she said. “We encourage patients to be really engaged and be champions of their health.”
Healthy Heart
Continued from page 12 numbers for risk factors such as high blood pressure and diabetes. Michos was among the experts who wrote prevention guidelines issued last year by the February 2020
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Continued from page 4
with chemotherapy to target cancerous cells while preserving the healthy cells. Antibodies essentially latch onto cancer cells and kill them at the source. This form of treatment has shown to be less harsh on the patient’s body and with fewer side effects than treatments like conventional chemotherapy and radiation. Oral Therapy (Targeted Agents) Another type of targeted therapy is in the form of a pill taken orally to target cancers like chronic lymphocytic leukemia (CLL). This cancer occurs
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Austin Medical Times
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Page 15
February 2020
Austin Medical Times
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