September 10, 2019

Jennifer Werner, a wound ostomy nurse at Texas Children’s, sees roughly 10 patients and their families each day at our Medical Center campus. With 11 years of wound care experience under her belt, Werner assesses, treats and develops care plans for patients with wounds, ostomy and continence conditions.

“I always put myself in my patient’s shoes and share an understanding of their anxieties,” Werner said. “Sharing my experience can help put a family at ease and help build a strong relationship in the process. After all, care for their child’s wounds should be as gentle and compassionate as care for my own.”

Before becoming a wound ostomy nurse, Werner served as a fitness director for the U.S. Navy. But it was her young daughter who inadvertently inspired her to go back to school to pursue a different career path.

“As the mother of a daughter with spina bifida, Amanda has taught me so much about surgical wounds, pressure injuries and ostomy problems, enough to grow a passion for care,” Werner said. “It has been 11 years since I made the career change and I have never looked back. This is truly a rewarding field.”

While every nurse will tend to a wound at some point in their nursing career, certified wound ostomy nurses demonstrate a higher level of knowledge, skill and expertise in this highly specialized field and often act as educators and consultants to staff nurses and other members of the health care team. Understanding the underlying etiology of wounds, this rare breed of nurses play an integral role in the healing process, and their jobs require ongoing training, lots of patience and a great deal of compassion for their patients.

From our three hospital campuses at the Medical Center, West Campus and The Woodlands, to our inpatient and outpatient clinics for pediatric and women’s health, Texas Children’s wound ostomy nurses use evidence-based practices to assess, treat and care for patients with simple to complex wounds. These include wound debridement (a process that removes dead tissue and contaminants), dressing wounds, treating and preventing pressure ulcers, and caring for patients with continence conditions and ostomies, where proper pouching techniques are necessary to improve outcomes.

In addition to providing direct patient care, our wound ostomy nurses educate patients and their families on how to care for wounds at home and how to prevent infection and further injury. Furthermore, the team also collaborates with our multidisciplinary partners on ways to enhance skin care management and prevent pressure ulcers, especially in high acuity areas of the hospital like our intensive care units.

While every patient is different, and the healing process takes time, the satisfaction of seeing a patient’s wound heal, witnessing their ability to self-manage their condition while maintaining their dignity and self-esteem – and realizing that you played a role in this – makes this nursing specialty extremely rewarding.

“In addition to working in collaboration with an amazing hospital staff, knowing that I helped my patients in some small way to improve their quality of life is what makes this job rewarding,” said MaryAnne Lewis, a wound ostomy continence nurse serving Texas Children’s community hospitals and outpatient nursing clinic in The Woodlands. It often takes a village to heal some of these complex wounds, and the incredible synergy at Texas Children’s makes it possible.”

Lewis uses her more than 30 years of wound/ostomy care experience to help ostomy patients overcome the physical and emotional burdens of their medical condition. She created a support group that offers helpful resources for these patients and opportunities to meet other families facing similar challenges.

“The support group is probably the single best thing I’ve been a part of to promote ostomy care in the past 30 years,” Lewis said. “I can apply and recommend specific pouches for patients but only someone with a similar diagnosis or situation can truly understand what the other person is going through.”

At Texas Children’s Hospital, our seven wound care nurses have over a century of combined nursing experience in wound care, ostomy and continence care with varying levels and areas of certifications.

The Meyer Center for Developmental Pediatrics at Texas Children’s Hospital, Baylor College of Medicine and the Spina Bifida Association recently hosted the Houston Spina Bifida Education Day for patients, families and caregivers. Held at Houston Methodist Hospital, the event showcased newly established, evidence-based national guidelines for the care of individuals living with spina bifida. This is the first time the guidelines, written in part by Texas Children’s and Baylor clinicians and researchers, were shared with such a broad audience.

More than 100 people from across Texas and other states as far as Florida and Indiana attended the event. In addition to unveiling the new guidelines, experts from Texas Children’s presented talks covering a range of health issues faced by individuals living with spina bifida from infancy to adulthood. There also were presentations on related topics such as care coordination, emotional wellness, skin, and bowel-management tips specifically geared toward this group of families.

“Usually, clinical care guidelines are widely shared and disseminated among medical practitioners, not so much the lay public, so this conference not only provided professional guidance, but also much needed peer-to-peer advice,” said Dr. Ellen Fremion, a physician in the Spina Bifida Program at Texas Children’s and one of the organizers of the event. “Moreover, the heartfelt appreciation and deep emotional reactions from the families who attended this conference exemplifies how crucial it is to empower patients, families and caregivers with this kind of information, so they are better equipped to care for themselves and their family members.”

Spina bifida (meaning “split bone”) is the most common permanently disabling birth defect seen among newborns in the United States. It is a type of neural tube defect that occurs when a baby’s neural tube fails to develop or close properly. The symptoms of this condition range from mild to severe, depending on where the spinal cord is affected. Myelomeningocele is the most severe form of spina bifida in which parts of the spinal cord and nerves come through the open part of the spine. This leads to several related problems such as loss of feeling in areas below the opening, weakness or paralysis of the feet or legs, problems with bladder and bowel control. Some affected individuals have additional neurological complications, including a buildup of excess fluid around the brain (hydrocephalus) and diverse cognitive challenges. Multiple environmental (such as folic acid deficiency) and genetic factors are thought to cause this complex condition, although the exact causes are still unclear.

The Meyer Center’s Spina Bifida Program at Texas Children’s is a multidisciplinary program that includes several specialty services: neurosurgery, developmental pediatrics, urology, orthopedics, and physical medicine and rehabilitation. Experts from these specialties offer prenatal evaluations and follow patients from in utero to adulthood.

In 2011, Texas Children’s was among the first centers to perform open fetal surgery to treat spina bifida. Using this procedure, the defect in the fetal spine is accessed and repaired through an incision across the mother’s uterus (womb), and has since been the standard of care for spina bifida. In 2014, Texas Children’s Fetal Center pioneered a novel minimally-invasive fetoscopic procedure, in which the spinal defect is repaired through tiny incisions in the uterus using a small camera. This offers the same improved outcomes as the open fetal surgery but comes with additional benefits and reduced health risks.

“Despite recent advances of in utero repair procedures, surgery is not suitable for all patients and cannot be considered a cure,” said Dr. Jonathan Castillo, clinical director of the Spina Bifida Program at Texas Children’s. “Additionally, these surgeries may not reverse all the function or correct all related impairments. Also, these procedures are specific to myelomeningocele and may not help patients with other forms of spina bifida. Therefore, a deeper understanding of the etiology and biology of this condition is crucial to develop better treatment approaches in spina bifida care.”

In addition to providing cutting-edge clinical services, physicians and researchers at Texas Children’s Spina Bifida Program also are engaged in comprehensive, multidisciplinary research initiatives to find newer and safer medical and surgical interventions that can improve the quality of life for these individuals.

In 2014, a multidisciplinary team of experts at Texas Children’s Spina Bifida Program led by Drs. Heidi Castillo, Jonathan Castillo and Duong Tu, received a federal grant from the U.S. Centers for Disease Control and Prevention (CDC) to develop national standards in spina bifida care at the population level. Texas Children’s was the only funded hospital in Texas to be included in this effort, and, along with Baylor, was among the first institutions in the state to participate in the CDC’s National Spina Bifida Registry that collects medical data from this population to improve outcomes.

“Receiving that grant from the CDC and joining the registry gave us an amazing opportunity to participate in a nation-wide effort to develop better outcomes, interventions and standards of care for individuals with spina bifida,” Castillo said. “Since we are one of the major referral sites for spina bifida in the state of Texas, our team provides the entire spectrum of care to pediatric patients – from prenatal diagnosis, surgical interventions and postnatal care until adulthood – for myriad health issues related to spina bifida. This gives our team access to a wide demographic of participants and allows us to conduct unique in-depth studies and comparisons of the outcome measures of current interventions.”

“These studies have led to important findings that are reflected in the recent clinical care guidelines, and have revealed consistent disparities in the outcomes based on patient’s socioeconomic conditions and ethnicity, a novel observation that is currently under further investigation,” Castillo said. “Our team is excited that recently the CDC granted an extension of this grant for five more years, so we can continue to be at the forefront of comprehensive clinical care and research initiatives that will improve the lives of individuals living with spina bifida.”

August 12, 2019

Let’s say you had a business and every three months it was guaranteed to lose 100 customers.
(Whoa!)
You operated this way because you couldn’t figure out how to prevent this from happening.
(Oh.)
And then one day someone showed you how to predict which of your customers might leave in the next three months – so that you can keep them.
(Yay!)

The happy ending in the above scenario is now happening at Texas Children’s Health Plan. The solution is a cloud-based software platform called Predictive Analytics.
Three Health Plan departments – Finance, Business Analysis and Member Engagement – are working together to meet members’ needs through this new capability.

How does it work?

Di Miao, senior decision support analyst, explains that hundreds of data points are fed to a machine learning model to determine the likelihood of a member leaving the plan. These might include location of residence, number of missed appointments, number of providers, etc.

All of those variables are entered into a system that produces a likelihood of which members may leave. That list of members is then given to the Member Engagement team.

“When we know a member has a high likelihood of leaving, we work hard to prevent that by providing them VIP status at member events or taking extra steps to meet their needs,” said Alejandra Lima, marketing event planner. “It isn’t a perfect science but at the very least we have an idea of who might not be as satisfied with our services as we would want them to be.”

Time will tell

As is the case with most new efforts, time will tell how well the project works. However, the potential is very promising.

“I’m so excited about this project,” said Miao. “It really does have so much potential to help us care for members better. Often times when you work in positions like ours and you build the model or pull the data, you never fully understand the impact.”

But in this particular case the impact is clearer.

Miao worked alongside Kyle Stringer, senior decision support analyst, and Sadhana Sharma Luetel, data architect, to create the model.

“The old way of doing things is that you have a theory or an idea and then you use data to prove it. But when there is more data, more computing power, and more mature machine learning techniques you can take that data and then use it to discover interesting patterns or new ideas,” Miao said. “That is a better way of working and a better way of taking care of our families.”

The Next Step

The team agrees that adding more manpower to the process is the next step. “It takes time and attention to cull through the names each month and choose who to focus on. Then – maybe most importantly – it takes time to keep up with those families, follow them and determine if they actually left or not.

Adding at least a part-time staff member to the efforts is the next steps to seeing the potential of the project all the way through.

Want to know more about the predictive analytics program or think your department can help? Contact Di Miao at dxmiao@texaschildrens.org or Alejandra Lima at axlima@texaschildrens.org.

August 6, 2019

This past year, Texas Children’s Motion Analysis and Human Performance Laboratory, located at Texas Children’s Hospital The Woodlands, was awarded a prestigious accreditation from the Commission for Motion Laboratory Accreditation (CMLA) – an independent body established to enhance and standardize the clinical care of people with movement disorders.

The lab is now one of only 14 accredited labs in the nation and one of only three in Texas.

“This was an incredible accomplishment for our entire team and a major milestone for the entire Texas Children’s system,” said Dr. Eric Dugan, director of Texas Children’s Motion Analysis and Human Performance program.

Watch a video about the Motion Analysis Lab.

CMLA accreditation is a rigorous, often lengthy process and requires top-to-bottom documentation of everything a motion analysis lab does, how it’s done and the level of quality achieved. This includes evaluation of personnel, administrative structure, clinical and technical data collection methods, quality assurance procedures, and institutional policies. This data is then reviewed by a panel of CMLA experts in orthopedic surgery, physical medicine and rehabilitation, physical therapy, biomechanics, and other related disciplines.

“In early discussions with the CMLA, their estimated timetable for us, from the lab going online to accreditation, was about five years,” said Dugan. “We did it in 18 months, and were one of the fastest ever to receive accreditation.”

Every day, Texas Children’s is getting bigger and better. That’s because our leadership and world-class health care experts are always looking for ways to improve processes, to forge new paths in research, and to ensure an unmatched level of quality care for our patients. And it’s evident in our outcomes and in measures like our recent U.S. News & World Report rankings.

The CMLA accreditation was certainly a factor in the Division of Orthopedics rising five spots to become the No. 10 pediatric program in the country.

“There are so many things that go into the U.S. News rankings, but CMLA accreditation had a positive effect on our position because it helps us ensure we’re offering a full capacity of care for patients with movement disorders,” Dugan said.

Helping remove barriers

The Motion Analysis and Human Performance Laboratory provides the platform for an integrated approach to patient care. The foundational service for the lab is for neuromuscular or clinical gait patients with some form of neuromuscular disorder, such as cerebral palsy or spina bifida. However, lab capabilities are already being expanded to include a comprehensive sports medicine component. Two programs in early phases of implementation are running analysis – to determine any deficits in strength and mobility, or to identify mechanical issues that could lead to chronic injuries – and concussion management, which helps children avoid returning to play too early and experiencing another brain injury and also any possible musculoskeletal injuries that could result from concussion-related changes to postural control.

Clinical gait patients come to the lab as part of pre-surgical or pre-treatment planning to help multidisciplinary care teams determine the best path forward. The evaluation process is intensive and begins with a physical exam with a physical therapist (PT). In this approximately one-hour session, the PT assesses muscle tone, strength, range of motion and other functional measures to get a clear picture of the patient’s condition. A series of 2-D videos and photos are then taken to document standing posture and foot alignment. Patients are then “markered up” head to toe with 70 reflective spheres adhered at specific points on the body. This allows the team in the lab – typically a PT, PT tech and a biomechanist (human motion expert) – to capture a full biomechanical picture of the patient. These experts then work with colleagues in surgery and physical medicine and rehabilitation to analyze the data and develop a treatment plan that fits the needs of each individual patient – patients just like Hannah Deverse.

Hannah was born at 32 weeks, so her parents had been told to expect some developmental delays. However, when Hannah turned one, she still couldn’t sit up or crawl. Her body was stiff and she screamed in discomfort. A neurologist diagnosed her with cerebral palsy.

Over the course of her life, Hannah would need surgeries to alleviate tightness, improve flexion and correct structural deformities. But more than a decade ago, awareness and technology weren’t far along and her parents often felt they were flying in the dark.

“When you have to make difficult decisions about treatment without knowledge, you can feel lost,” said Jessica Deverse, Hannah’s mother. “That was how we felt before we experienced Texas Children’s motion lab. We had two surgeries before the lab was available and two after. We were much more confident with data from the lab. We were presented with multiple options and never felt pressured to do any of them. When we did make a decision, the team answered every single question we had, and we had a clear picture of what the process would be, from beginning to end.”

The data gathered in their initial lab session at Texas Children’s helped experts in pain management determine that Hannah would benefit from a special intrathecal pump to alleviate tightness in her body.

“Have you ever tried to stretch and you just couldn’t reach your toes? It was like that but all over my body for my whole life,” Hannah said. “After I got the pump, I felt like I was walking on clouds. I’d never felt that way before. I asked, ‘Is this how it’s supposed to feel?” because my whole life my body had been so tight.”

Lab analysis also allowed Hannah’s care team to make integral decisions about surgery. Initially it was thought she would need surgery on both knees. But because of the pump helping to control spasticity, the team changed course and decided to operate on only one knee, a surgery performed by Dr. Jeffrey Shilt, chief surgical officer at Texas Children’s Hospital The Woodlands and Texas Children’s chief of Community Surgery, and co-medical director of the Motion Analysis Lab.

“It’s really important that parents know just how much more confident you can feel about making a surgery or treatment decision after seeing and reviewing the data with the team from the motion lab,” Jessica said. “As parents we are often faced with making decisions that will impact the future wellbeing of our children. When you have a child with a disability, the weight of some decisions can be overwhelming because it has drastic lifelong implications. I wish everyone faced with these decisions had this information and this team to work with.”

When Hannah was a baby, her parents were told that she may never walk. Hannah’s proven detractors wrong. Today, she’s 16 years old and has her sights set on getting her driver’s license.

“I’m the only person in my group of friends who doesn’t have a license yet, which is hard on me!” she said. “But I know I’ll get there.”

July 15, 2019

Texas Children’s Hospital is seeking an innovative solution to at-home hospital care for patients who are discharged from the health care setting but are still healing. Instead of providing patients with a binder of instructions, Texas Children’s Cancer & Hematology Center is working with a group of college and graduate students to create an interactive video game that encourages positive health habits in the home. The effort is part of the Healthcare Games Showdown™, which is going on throughout July and is being hosted by the world-renowned Texas Medical Center Innovation Institute.

“Leveraging game design to encourage healthy behaviors in the home is a great way to engage children and promote positive health outcomes,” said Business Development & Innovation Manager for Women’s Services Haley Jackson. “We are excited to learn from this innovative project!”

Jackson, Quinn Franklin, Assistant Director of the Psychosocial Division of the Cancer and Hematology Centers; and Dr. Monica Gramatges, Co-Director of the Center’s Survivorship Program, are advising the TCH student team with the support of Senior Vice President Myra Davis, Chief Quality Officer Dr. Eric Williams, Vice President Jackie Ward and Texas Children’s Cancer and Hematology Centers Director, Dr. Susan Blaney.

The group is working with a team of four digital media and computer science students – Jacqueline Nguyen of the University of Texas Dallas, Carlos Puerta of the University of Houston, David Musick of the University of Houston and Jonathan Nelson of Huntington University – to develop a prototype for an augmented reality game that focuses on the importance of hand washing and oral hygiene.

The concept for the game revolves around an animated world that can be unlocked by patients, families and/or caregivers when they complete a handwashing or oral hygiene activity. Players will be sent alerts on their smart phone device when it’s time for an action to be completed. Each time the player completes a task, their animated universe becomes more complex and elaborate.

“Health care video gaming allows us to foster playfulness and learning through a medium that our patients are naturally drawn to,” Franklin said.

During the development period, patients will be viewing the game and providing feedback as it is created. Marty McMahon, our Texas Children’s Gaming Activity Coordinator funded through a collaboration with Child’s Play, is also supporting this effort as a technical mentor for the students.

A live-stream following the progress of all three teams participating in the Healthcare Gaming Showdown is being hosted weekly by comedian and voice-over actor, Scott Gibbs, together with Ink Rose and Kevin Wu. Click here to learn more about the games and how to tune in to the live-stream.

“At Texas Children’s Hospital, our mission is to create a healthier future for children,” Davis said. “Using augmented reality and video games is an excellent means with which to continue our mission.”

July 9, 2019

Dozens of patients and their families recently attended the 2nd Annual Complex Care Clinic Resource Fair, held at Texas Children’s Meyer Building. The event is one of several the clinic hosts throughout the year in an effort to build a community for families with children who have ongoing complex care needs.

“Medically complex children are the sun around which their entire family orbits, and it can be frustrating to see how alone and isolated these families feel,” said Amanda Harris, a medical social worker at the clinic and one of the event’s organizers. “Aside from providing helpful resources, we wanted to create an opportunity to just let these families – including siblings and grandparents – be around other people who are facing similar situations and to see that there are other people just like them.”

There were activities, such as face-painting, and canvases were set up for families and patients to create original artwork for display in the clinic. Children also had an opportunity to pet and interact with ponies that were provided by SIRE (Self-improvement through Riding Education), a local occupational therapy group that specializes in equine therapy.

There were numerous community partners present, including a school advocacy group to answer parents’ questions and offer advice on how to make requests for special accommodations at school, as well as the Deaf-Blind Multihandicapped Association of Texas, a group that advocates and intervenes for patients with co-occurring symptoms to help improve their quality of life.

Families also had access to internal resources, such as Texas Children’s Medical-Legal Partnership, a collaboration between Texas Children’s Hospital and Houston Volunteer Lawyers that provides low-income patient families with free legal advice and representation. There were also representatives present from Texas Children’s Autism Center and Developmental Pediatrics to talk about resources and services available, as there is often overlap between these patient populations.

About Texas Children’s Complex Care Clinic

The dedicated team of experts in the Complex Care Clinic provides comprehensive, high-quality care for nearly 1,200 of Texas Children’s most medically complex patients. These patients include:

  • Former premature infants
  • Children with complex seizure disorders
  • Patients with technology needs, such as tracheostomies or gastrostomy tubes
  • Congenital heart disease patients
  • Patients suffering from rare genetic or neuromuscular disorders

“There are so many wonderful stories people hear about the miracles that happen every day in our pediatric or neonatal intensive care units, but a lot of people might not realize those stories don’t always end when the patient is discharged,” said Dr. Heather Moore, clinic chief. “For the patients we see, that’s just the beginning of the journey, and they’re going to need ongoing, highly coordinated care.”

The clinic – located at the Texas Medical Center campus and West Campus – is a true one-stop shop for patients and families, functioning as the primary care physician (PCP) office for well visits and touch point visits for proactive preventive care. The clinic also provides all urgent care needs. In an effort to reduce emergency room visits and hospitalizations among this vulnerable population, experts are available to assist families 24/7, and calls go directly to an on-call physician or nurse practitioner.

The full team includes:

  • Four physician PCPs and three nurse practitioner PCPs
  • Two masters-level medical social workers who remove barriers around transportation needs, housing, food insecurity, guardianship issues, transitioning to adult care, as well as providing assistance in instances of child or domestic abuse
  • Masters-level clinical dietitians embedded within the clinic who manage tube feeding regimens and oral feeding diets, while also assisting clinic providers to ensure access for patients who need enteral supplies and feeding therapies
  • Four clinical nurses, who triage patients for medical needs via triage line, change gastrostomy tubes and place nasogastric tubes, administer immunizations, suction and escort to the Emergency Center if necessary
  • A child and adolescent psychiatrist, providing both behavioral health and family therapy
  • A care coordination team comprising six nursing coordinators and six patient navigators (an administrative support role) that interfaces with specialists, therapists, insurance carriers, and medical supply and home nursing companies, and others to help streamline care and remove gaps or redundancies

There are plans to add new staff in the near future, including additional PCPs, a dedicated hospitalist and Physical Medicine and Rehabilitation doctors. A planned expansion to The Woodlands is also in the preliminary phases.

“Many of our patients have special transport needs and it takes a tremendous amount of effort to get around,” said Moore. “We’re trying to provide everything our families need in one place that’s closer to home, while also reducing any gaps in care. Our goal is to provide the most comprehensive care available and to make life easier for them.”

This month’s installment of Medically Speaking features Texas Children’s orthopedic surgeon, Dr. John Heydemann, discussing the rising prevalence of obesity in American adolescents and the increased level of difficulty it creates in the treatment of pediatric orthopedic injuries or deformities.

To clearly relate the two, he highlights four specific treatment areas or conditions that are often exacerbated by, or that can contribute to, obesity. These are:

  • Trauma, including increased fracture rates, higher risk of loss of reduction and increased risk of complications
  • Blount’s disease, a growth disorder of the shin bone that causes the lower leg to be angled inward
  • Slipped capital femoral epiphysis, a hip condition that occurs in adolescents and teens
  • Back pain, potentially due to children leading more sedentary lifestyles

Learn more about the services provided and conditions treated by Texas Children’s Division of Orthopedics.

Fighting obesity at Texas Children’s

In addition to contributing to or complicating the treatment of orthopedic injuries, obesity drives significant health outcomes in Texas Children’s patients. Obesity is one of the biggest drivers of preventable chronic diseases and in childhood can lead to high blood pressure and cholesterol, increased risk of type 2 diabetes, asthma and sleep apnea, and joint problems, not to mention the associated psychological ramifications, such as anxiety and depression.

But obesity it a health problem Texas Children’s Hospital is attacking head on.

This year, Texas Children’s included a system-wide BMI goal as part of our Fiscal Year 2019 care quality objectives. The target was to record BMI for 85 percent of the patient population, ages 2 to 19. In addition to recording BMI, an additional target was set to refer or implement counseling and/or education for more than 40 percent of patients with BMI greater than the 85th percentile.

So far this year, Texas Children’s is exceeding those goals. Through March 2019, we’d recorded BMI for more than 87 percent of our patients, and more than 73 percent of those with BMI in the 85th percentile or higher have been referred to or received the resources they need to combat obesity.

About Medically Speaking

Medically Speaking, a video series from Texas Children’s Service Line Marketing, features some of the brightest minds from several Texas Children’s specialty and subspecialty areas. The series is meant to be a helpful educational resource for parents and a convenient way for physicians and other caregivers to stay up-to-date on the latest in pediatric medicine. Viewers can watch talks on a variety of interesting topics, including advancements in surgery, breakthroughs in research, new clinical trials, and novel and back-practice treatments for specific conditions.

Don’t miss future Medically Speaking episodes featured here on Connect, or view additional episodes now.

PLEASE NOTE:
This presentation is not intended to present medical advice or individual treatment recommendations, and does not supplant the practitioner’s independent clinical judgment. Practitioners are advised to consider the management of each patient in view of the clinical information. All content is shared for informational purposes only, and reflects the thoughts and opinions of the original author. No physician-patient relationship is being created by the use of this presentation. The presentation sets out recommendations based upon similar circumstances and is provided as an educational tool. The presenters are not attorneys, and to the extent this presentation provides commentary on current laws and regulations affecting health care activities, it is not intended as legal advice.