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Medical Ophthalmic Coding Specialist

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In its bold upward thrust to become one of the vital biggest medical institution techniques within the nation, providence health & functions struck a deal in 2011 to declare a Seattle-enviornment rival, Swedish health.

windfall delivered 5 sanatorium campuses in the system, together with Swedish-Cherry Hill, an establishment with a storied historical past and a budding attractiveness as a worldwide center for neuroscience analysis, remedy and medical trials.

just a couple of years later, windfall and Swedish had overhauled the style Cherry Hill’s neuroscience software processes the company of drugs, enriching the nonprofit institution and its superstar surgeons.

a gradual churn of excessive-chance sufferers undergoing invasive brain and spine processes allowed Cherry Hill to generate half one thousand million bucks in net working revenue in 2015 — a 39 p.c increase from just three years prior. It additionally had the maximum Medicare reimbursements per inpatient consult with of any U.S. clinic with at least 150 beds.

by means of these metrics, providence’s acquisition of Cherry Hill has been a rousing success story.

but the aggressive pursuit of extra sufferers, more surgeries and extra dollars has undermined providence’s values — rooted in the nonprofit’s founding as a humble home where nuns served the terrible — and placed patient care in jeopardy, a Seattle instances investigation has found.

The times spent a year analyzing greater than 10,000 pages of statistics in four states, examining federal and state databases containing hundreds of thousands of statistics, and interviewing more than one hundred people, including more than 30 latest and former Cherry Hill scientific staffers.

among the many findings:

  • The doctors in the neuroscience unit are incentivized to pursue a excessive-volume approach with contracts that compensate them for enormous patient numbers and sophisticated surgical options. Of the six appropriate-producing brain and backbone surgeons in Washington state in 2015, 5 have been a part of Cherry Hill’s neuroscience crew, averaging $67 million in billed expenses.

  • The health center touts its superstar surgeons to attract patients from lots of of miles away, but six current and former staffers said those medical doctors will sometimes do little within the working room as soon as the affected person is beneath anesthesia. instead, the surgeons will go away much less-experienced docs receiving really good working towards to address ingredients of a surgery. That enables the simple surgeons to be in another working room — a tradition referred to as “concurrent surgery” — to hold high volumes. It is not prohibited however can look at various the limits of Medicare guidelines.

  • sanatorium leaders recruited one doctor from an additional institution as he dealt with an interior investigation and allegations that he had excessive prices of complications and can have performed unnecessary surgical procedures. At Cherry Hill, greater allegations of patient care problems emerged concerning the medical professional, but directors promoted him to a true leadership place.

  • Cherry Hill patients have passed through surgical procedures which are extra invasive than available alternatives. That’s particularly the case in the treatment of aneurysm patients, where statistics reveal a reported spike in a strategy that requires opening a patient’s cranium and dealing on the brain as an alternative of employing a much less-invasive technique that doesn't require a craniotomy.

  • The expanded quantity of patients has left medical staffers from the working room to the intensive-care unit with large caseloads, dividing the attention of ICU nurses who would otherwise deliver one-on-one affected person care. A loophole in a Washington state legislations designed to boost affected person defense has forced some nurses at Cherry Hill to be on duty for 20 hours in a day.

  • There are signals that the high-extent mannequin is taking a toll on patient care. In benchmarks tracked with the aid of the federal executive, Cherry Hill became flagged for having excessive rates of blood clots, collapsed lungs and critical surgical problems. State statistics demonstrate an increase in different difficulty indicators over the last a number of years, including aneurysm sufferers with high numbers of strokes.

  • There is not any doubt that the surgeons at Cherry Hill have automatically stronger and saved lives, and the data The Seattle times analyzed suggests simplest a partial graphic of what’s going on inner the power. but the most troubling findings within the instances’ investigation came from the medical doctors and other scientific staff contributors who have witnessed the adjustments inner Cherry Hill’s Swedish Neuroscience Institute (SNI).

    interior information received by The instances, and interviews with present and former staffers, show an array of concerns communicated without delay to the establishment’s precise directors. The complaints encompass express warnings about insufficient patient care, inappropriate surgical procedures, negative documentation, an absence of accountability for postoperative complications and dubious selections that resulted in affected person harm and loss of life.

    these objections have been mostly suppressed by means of a management crew that has been accused of brushing aside clear issues, based on the information and interviews. as an alternative, medical staffers who've spoken out about their considerations suggested dealing with intimidation and retribution. One memo referred to these issues as a cause that greater than 60 workforce participants had departed the ability in the span of two years.

    “This toxic, repressive atmosphere has already negatively impacted the ability of the SNI community to supply the nice care (to) their patients that they deserve,” wrote one neurosurgeon, Dr. Charles Cobbs, in a memo to Swedish CEO Tony Armada final 12 months.

    In an emailed observation, Armada touted Swedish’s unwavering dedication to high fine affected person care. He pointed out SNI and Swedish work to ensure that caregivers have a safe and respectful working environment.

    “To maintain a subculture of protection, every and each caregiver is supported and empowered to lift protection considerations,” Armada referred to in his commentary. “Any concerns about high-quality of care are addressed instantly and entirely reviewed with oversight from clinical committees, senior leadership and third-birthday celebration consultants, when needed.”

    windfall and Swedish officers declined repeated requests to be interviewed for this story. In January, a providence spokeswoman emailed to claim that the institution become launching an investigation into an allegation that a Seattle times reporter had improperly obtained medical records in violation of federal legal guidelines retaining patient privateness.

    The most effective affected person statistics acquired by using The times got here from the sufferers themselves, similar to Jeff Sproles, a Marine Corps veteran who shared his Cherry Hill information with a reporter. Sproles checked in for surgery at Cherry Hill in September 2013 to tackle a spine problem. He recalled his medical professional — Rod Oskouian, probably the most state’s most energetic mind or spine surgeons — asserting that his fusion surgery was so primary that he may do it along with his eyes closed.

    Ken Lambert / The Seattle instances

    Jeff Sproles, of Moses Lake, turns into emotional while speaking about his severe put up-surgery issues.

    however when Sproles lower back domestic from surgery, he had issue breathing and swallowing. He back to the hospital and later realized the surgeon had reduce too deep into his throat, Sproles stated. He spent months convalescing and obligatory a peg tube to feed himself via his stomach.

    A reporter contacted Sproles closing December to ask if he was certain that Oskouian, who didn't reply to interview requests for this story, had carried out his surgery. Sproles changed into greatly surprised — Oskouian had been his doctor, and he in no way regarded that the surgical procedure had been finished by any one else. Sproles contacted Swedish and requested his finished clinical file.

    He reviewed his facts in tears. They reveal that one other doctor, a fellow, played a huge role in his case. It’s uncertain from the information how a whole lot time Oskouian himself spent in the working room or which tactics he performed.

    “Who do I flip to?” Sproles asked. “there's nobody to go to, to claim, ‘This isn’t right, this isn’t fair.’ ”

    inside conflict

    because the Swedish Neuroscience Institute was shifting towards a high-quantity apply, providence recruited Dr. Johnny Delashaw, a star surgeon regular around the West Coast as a true producer. in exactly the first 16 months after his arrival in Seattle, state information exhibit Delashaw handled 661 inpatient situations totaling greater than $86 million in billed prices for the health facility — more than another mind or spine surgeon in the state.

    but over that same time, Delashaw confronted forty nine interior complaints from alarmed group of workers individuals involved concerning the satisfactory of his affected person care and alleging unprofessional conduct, inner statistics show.

    Delashaw, in an emailed statement, highlighted his credentials as some of the leading experts on the remedy of complicated tumors and aneurysms. He mentioned he and his colleagues were doing fantastic work that may “exchange the realm” by assisting treatment paralysis. He recounted the increase at SNI has confronted resistance by way of some group of workers participants who haven't embraced the changes.

    “Some have turn into disgruntled and a few of these health care suppliers have left,” Delashaw wrote. “When there is a metamorphosis in culture it is ordinary for individuals to whinge through the nameless complaint device” at the sanatorium.

    those complaints are “vetted and handled effectively as vital,” he wrote.

    The interior clash between Delashaw’s growing to be construction and the perceived disruption came as providence and Swedish directors searched at the end of 2014 for brand new SNI leadership.

    providence CEO Rod Hochman, who oversees the equipment’s 50 hospitals in seven western states, referred to as a meeting of about 15 correct choice-makers, including medical institution directors and the neighborhood of SNI neurosurgeons. Hochman, a doctor himself who prior to now really good in rheumatology and internal medication, had led Swedish health earlier than the merger expanded him to guide providence.

    Hochman’s group gathered on the sixth floor of Cherry Hill’s James Tower, in house run with the aid of a nonprofit affiliate.

    some of the surgeons had been looking forward to directors to conduct a country wide search for a new SNI chief, however they realized at the assembly that directors have been now looking to appoint someone from inside, based on 4 people who attended the assembly, speakme separately and on situation of anonymity due to worry of retribution. one of the crucial surgeons recommended they take a vote to decide the way to approach the issue.

    Hochman ended the discussion. “here is now not a democracy,” he referred to, in accordance with the americans in attendance. He observed they'd appoint somebody internally.

    To nobody’s shock, Delashaw become the man. Swedish wrote in an emailed statement that Delashaw’s merchandising came with the assist of his neurosurgery colleagues.

    Dr. Eric Vallieres, the pinnacle of Swedish’s inside committee on surgical pleasant, stepped down from his place in protest. Vallieres wrote a January 2015 memo, acquired by The times, telling Swedish and providence management that he couldn’t do the job when directors were merchandising “an individual that has shown very little respect for the lifestyle of defense and connected procedures.”

    The “variety of bad reports submitted by means of so a variety of people is, in my judgment, a significant indicator of deficiencies in an effort to no longer make him a very good leader for Neurosurgery,” Vallieres wrote. He declined to remark.

    regardless of the considerations aired about Delashaw, the hospital’s administrators moved ahead with a plan to revamp surgical contracts in a way that would incentivize the excessive-quantity method in which Delashaw excelled.

    in the past, the SNI surgeons pooled a component of their pay and redistributed it among every different. It turned into a equipment designed to motivate docs to circulate along sufferers to their friends when they thought a co-worker might possibly be a far better specialist to deal with the affected person’s manner. In some surgical settings, all revenue is pooled this fashion.

    The revised contracts at Cherry Hill’s SNI software ended the pooling system, based on facts and interviews. Surgeons could be paid basically completely on their production, as measured by way of Relative cost gadgets, or RVUs. RVUs are a part of a Medicare compensation formulation that assigns a price to every system.

    Volumes had been rising among SNI’s excellent surgeons in 2013 and 2014, and they persisted rising below Delashaw’s stewardship and the new contracts, in accordance with state facts that track particulars of every inpatient hospital discuss with in the state. among the many institute’s brain and backbone surgeons, the usual billing per case additionally jumped.

    there has been a dramatic shift in surgical extent at the Swedish Neuroscience Institute (SNI), primarily based at Swedish's Cherry Hill campus. 5 of the proper six high-greenback mind and spine surgeons within the state are now a part of SNI.

    supply: Seattle times analysis of the state's comprehensive hospital summary Reporting gadget (CHARS) records

    Emily M. Eng / The Seattle instances

    by means of 2015, 5 docs at SNI ranked among the state’s right six brain and spine surgeons, as measured by using the entire billed expenses for sufferers during which the medical doctors have been listed as the attending medical professional. The right two docs — Delashaw and Oskouian — each and every passed $seventy five million in billed expenses, almost $25 million more than the state’s nearest mind and backbone surgeon outdoor of the SNI group.

    knowing the business

    Neurosurgeons address a number existence-threatening scientific issues, excising a brain tumor in one case and then responding to a burst aneurysm the subsequent. along with really expert orthopedic surgeons, they may also additionally tackle invasive processes of the spine.

    It’s a excessive-stakes job that can involve patients near to dying. because of this, neurosurgeons are more likely to face malpractice claims than every other medical specialty. research posted within the New England Journal of medication shows that one in five neurosurgeons will face a malpractice declare in a given year.

    all through Delashaw’s final 14 years at Oregon fitness & Science institution, 12 diverse complaints named him as a defendant, with allegations that blanketed an operation on the wrong part of the backbone and a surgery for a tumor that became out to be a benign cyst. those situations and three others later resulted in settlements, despite the fact court records don’t describe the terms. Six of the instances seem to had been dropped or ended in Delashaw’s prefer. accessible court docket records do not point out how the 12th case turned into resolved.

    Delashaw, in his emailed commentary, noted he wasn’t privy to 12 lawsuits however observed “none resulted in any findings of culpability or breach in the ordinary of care.”

    officers on the university of California, Irvine, saw Delashaw as a possible asset. interior memos from 2011 show that institution officers in particular outlined that Delashaw become somebody who “has mastered many of the knowledge quintessential to be aware the ‘company’ of fitness care.” The memo also mentioned his potential to build an incredible referral network and lead the Irvine branch to national prominence.

    “There are distinctive chances that he will encourage more advantageous productivity from other school participants in order that the quantity of revenue generated with the aid of the branch will make it a leader inside the institution,” Dr. John Kusske, then the interim chair of the department of Neurological surgical procedure, wrote in one message.

    UC Irvine provided Delashaw a earnings of $900,000, plus the probability to earn tons more, in accordance with college records. The deal would pay Delashaw in keeping with his RVUs, the Medicare metric that assigns a price to every technique. And he could be paid more if his department’s RVUs also grew.

    Delashaw begun the UC Irvine job in March of 2012 and automatically made alterations. inside months, one colleague, Dr. Mark Linskey, filed a complaint that accused Delashaw of slicing his compensation while hoarding patients for himself and another doctor, in line with facts.

    Delashaw later defined, as a part of his testimony in Linskey’s case, that he had concluded some of his friends weren’t doing sufficient work to assist their salaries.

    “i wanted all my faculty — as I said to them repeatedly — I want them to be wealthy,” Delashaw testified, based on information in the case. “however to be able to be rich, you must work and you've got to do scientific quantity or you must produce other styles of monetary assist.”

    other allegations from the case established on patient care. In information filed through the school as a part of a lawsuit Linskey is pursuing, Linskey mentioned that a gaggle of neurosurgery residents had come to aid him with an enormous mind-tumor case however had been redirected to support Delashaw, who turned into operating three working rooms simultaneously. Two professors who reviewed concerns in the Linskey dispute mentioned in an August 2015 private memo to the school’s chancellor that that they had “heard stressful testimony about incidents concerning patient care that if true could have resulted in serious legal responsibility for the school.”

    based on a public-facts request filed by way of The Seattle instances, the university refused to liberate tons of of files involving Dr. Delashaw. an individual with direct skills of the case supplied to the instances, on the condition of anonymity, files that encompass the testimony from inner school hearings stemming from Linskey’s grievance.

    The facts demonstrate that Dr. Scott Goodwin, the chair of the branch of Radiological Sciences at UC Irvine, testified that docs in his branch had flagged more than forty Delashaw circumstances that concerned them. The flagged instances included surgeries that had been potentially useless and others that worried huge problems for the affected person.

    The doctors had additionally viewed scans of Delashaw sufferers who had gone through brain-tumor surgical procedure “where so little of the tumor changed into removed you couldn’t inform the change pre- and postoperatively,” Goodwin observed. He declined to comment for this story.

    Dr. Hamid Djalilian, a surgeon, described how Delashaw pressed to do a manner in opposition t a affected person’s desires in one case, in keeping with statistics. Djalilian additionally stated in his testimony that Delashaw’s complication price changed into “greater than anyone else I’ve ever considered in my existence.” Djalilian declined to comment, referring questions to a UC Irvine spokesman.

    a further doctor, who had been a resident under Delashaw, testified that Delashaw wanted to cast off a patient whose family wasn’t coming to get him, in response to the statistics. The affected person changed into an undocumented immigrant, so Delashaw suggested residents to name U.S. immigration officials, stated the former resident, Dr. Alexa Reeves Smith. Smith, who declined remark for this story, testified that she didn’t at the beginning make the call however finally did after Delashaw ordered it. She spoke of Delashaw later denied making the demand.

    Delashaw wrote in his commentary to The Seattle times that he couldn't discuss the immigrant case as a result of privacy rights but pointed out there changed into a a hit scientific influence. He talked about the other accusations towards him all over his time at Irvine will also be blamed on expert jealousy.

    “everybody doesn't all the time respect growth and success. the former neurosurgery chair and the chairman of radiology had been sad with and resentful of their success, all too human frailties, because it had no longer been finished earlier than my arrival,” he wrote.

    Delashaw confronted scrutiny past the turmoil at UC Irvine. In April 2013, the board of administrators of the American association of Neurological Surgeons voted to censure Delashaw for questionable testimony he gave in a malpractice case the place he turned into serving as an expert witness, based on the association. The firm declined to deliver details about the case, together with what Delashaw had stated.

    The complications weren’t adequate to tarnish Delashaw’s attractiveness as a high-extent megastar. before the year was out, windfall lured Delashaw away from UC Irvine to return to Seattle.

    settling on a method

    No count number where he has practiced medication, one problem in selected has been a flashpoint for Delashaw’s sufferers and colleagues: the remedy of aneurysms.

    brain aneurysms are sacs that develop over time and protrude from arteries in the head like a slowly inflating balloon. Blood circulate into the sac puts power on the aneurysm partitions, that may finally cause the sac to burst, causing a doubtlessly deadly rush of blood into the brain.

    Surgeons customarily deal with aneurysms in a single of two approaches:

  • In a “coiling” technique, a doctor makes an incision the size of an eyelash into the affected person’s groin. A tiny catheter is then fed into the incision to follow the patient’s arteries to the aneurysm ballooning in the head. once there, the doctor feeds slim metal coils during the catheter and into the aneurysm, filling it and closing it off from the rest of the artery.

  • In a “clipping” process, a surgeon cuts into the scalp, peels it lower back and saws out a palm-sized component of the skull. The dura membrane covering the mind is opened so the surgeon can push brain tissue apart until the aneurysm is found. The surgeon locations a metallic clip over the bottom of the aneurysm, cutting off blood movement to the sac. The patient’s head is then put again collectively, with metal plates and screws securing the skull and sutures securing the dura and scalp.

  • Cerebral aneurysm

    An aneurysm is a balloon-like bulge that types due to weak point in an artery wall. as the aneurysm grows, the partitions become thinner and greater liable to rupture, inflicting a potentially fatal rush of blood into the brain.

    Aneurysm coiling procedure

    typical sanatorium reside after easy coiling manner: 1-2 days

    Full recuperation: 5-7 days

  • First, a flexible catheter is inserted into the femoral artery in the thigh. it is guided throughout the arteries, previous the coronary heart and up into the mind.

  • A coil is fed during the catheter into the aneurysm.

  • The coil twists and wraps unless the aneurysm is filled. The catheter is eliminated.

  • Blood clots across the coil, sealing off the movement of blood.

  • Aneurysm clipping manner

    common sanatorium reside after easy clipping manner: 4-6 days

    Full recovery: a few weeks to months

  • An incision is made in the course of the scalp, exposing the skull.

  • A portion of the cranium is eliminated to reveal the brain.

  • medical doctors work in the course of the brain tissue to attain the aneurysm, placing a metal clip to dam blood from flowing into it.

  • Sources: American Stroke affiliation, American heart affiliation

    Emily M. Eng / The Seattle instances

    docs might also select a way according to elements including the vicinity, measurement and shape of the aneurysm. Coiling has grown in popularity as a result of research — such because the foreign Subarachnoid Aneurysm Trial — indicating that the less-invasive option can be more advantageous for sufferers. And patients regularly decide upon coiling since it avoids having a part of their cranium eliminated.

    Delashaw, besides the fact that children, specializes in the clipping manner.

    In his testimony from the UC Irvine case, Goodwin expressed subject that Delashaw had recommended the power into performing the greater invasive clipping procedure at an surprisingly excessive cost.

    A Seattle times analysis of affected person records indicates dramatic shifts in aneurysm remedy as Delashaw moved between jobs. earlier than his 2012 arrival at UC Irvine, the school’s medical center performed clipping surgery in exactly about 13 p.c of situations. After Delashaw’s arrival, 62 percent of aneurysm sufferers undergoing treatment at Irvine received a clip — the maximum fee among California hospitals who had as a minimum 20 aneurysm instances, according to state facts analyzed by way of The times.

    When Delashaw moved to the Cherry Hill clinic in Seattle, that campus jumped from 36 percent of instances getting a clip in 2012 to fifty seven percent in 2014. The statewide regular remained under forty percent all through that same time.

    Delashaw wrote in his remark that he has “a countrywide referral observe and wherever i'm going, complex vascular sufferers observe. It become natural and expected to peer a rise in vascular surgeries with my arrival in Seattle.”

    Dr. Joe Eskridge, an interventional neuro-radiologist who really good in coiling techniques all through his eleven years on the Cherry Hill campus, spoke of earlier than Delashaw arrived he worked with Dr. David Newell, who had dealt with lots of the aneurysm clippings.

    Eskridge talked about he and Newell regularly discussed aneurysms to assess no matter if the patient would have more suitable outcomes with a clip or coil technique. Newell would come over to Eskridge’s office or lab, bringing pictures to consult with him. every now and then, Newell and Eskridge would both focus on the alternatives with the affected person.

    “Delashaw on no account did that,” stated Eskridge, who observed he turned into compelled out of Swedish after complaining about a special surgeon’s degree of care.

    Dr. Michael Myint, the vice president of excellent and affected person safeguard at Swedish, referred to medical staffers are at present setting up plans to increase how the organization evaluates and chooses the most suitable treatment alternatives for aneurysm patients.

    “we're continuing to work on supplying superior practices around this,” Myint observed.

    From the time Delashaw arrived at Cherry Hill in October 2013 through the conclusion of 2015, 9 percent of the aneurysm patients handled at Cherry Hill developed an ischemic stroke throughout their live, in comparison with four % in any respect different hospitals within the state. When looking at just clipping strategies, Cherry Hill’s stroke fee was twice that of different hospitals — 14 percent to 7 percent.

    in a single of the Oregon court cases, a forty-year-old firefighter named Erik Rosendahl alleged that Delashaw rushed him into surgery in 2011 for an unruptured aneurysm and certainly not provided him the coiling alternative. Rosendahl’s aneurysm ruptured all through the surgery, according to his case file, and has left him with actual, psychological, cognitive and speech impairments. That lawsuit became settled. Rosendahl, via his attorney, declined to comment or divulge the terms.

    Tonia McLinn, 49, had been having occasional headaches and blurry imaginative and prescient for a number of years. She realized she had an unruptured aneurysm and changed into spoke of Cherry Hill in the care of Dr. Delashaw.

    McLinn, who made the trip to Seattle from her domestic in Alaska, said Delashaw defined the clipping method and confirmed one of the clips all over a quick meeting.

    After her surgery, McLinn skilled problems that protected swelling and an infection. She needed an extra surgical procedure in Alaska to remove the flap of bone that had been cut away for the aneurysm surgery. A year later, surgeons put a plate in her head to cover the outlet in her cranium.

    McLinn still offers with ache, and her household says her personality has changed. She’s paranoid, anxious, has short-time period memory loss and has panic assaults in random public places.

    “My head is deformed. It’s uneven, and it’s substantive,” McLinn talked about. “I hate searching in the mirror.”

    McLinn pointed out she doesn’t recollect Delashaw ever mentioning that there was a much less-invasive medicine. She observed she by no means knew about the coiling choice unless months after her surgical procedure, when a different medical professional asked her why she had chosen the clipping system. medical data exhibit her aneurysm became small and located in the ophthalmic phase of the interior carotid artery, where analysis suggests coiling is an alternative.

    turning out to be the numbers

    Surgeons with production-based mostly contracts can increase their income via adding more degrees to a surgery. That’s primarily genuine when it involves spine instances.

    for instance, a common method to alleviate back complications is a spinal decompression, wherein a surgeon will eradicate a portion of the vertebra to provide more space to the spinal twine or surrounding nerves.

    Doing the system on one vertebra can complete 15.37 RVUs. Doing an extra stage of the vertebra can add a modest 3.47 RVUs.

    but a surgeon can dramatically extend their numbers by way of adding a fusion, which makes use of hardware to give the backbone extra stability. Fusing two vertebrae would complete 23.fifty three RVUs. A surgeon can add 6.43 RVUs for every further vertebra and even more by using adding extra contraptions.

    All those RVUs equate to more reimbursements for the medical institution and, under the Swedish contracts, more funds for the doctors. And, with the aid of backbone cases, Cherry Hill has drawn more Medicare spending for every inpatient seek advice from than some other sanatorium within the nation that has as a minimum a hundred and fifty beds.

    A transforming into body of analysis suggests that, even though profitable, spinal-fusion surgical procedure isn't the best option for lumbar stenosis, a standard situation of degenerative spinal alterations, when the patient doesn’t also have a displaced vertebra, spoke of Dr. Richard Deyo, who researches spine surgeries at OHSU.

    Swedish noticed a rise within the number of lumbar-fusion surgeries in 2014 when the patient had a first-rate prognosis of lumbar stenosis and did not also have a displaced vertebra. Delashaw and Oskouian ranked tops in the state that 12 months among brain and backbone experts, with 24 cases every.

    a regular neurosurgeon performs about 9,400 RVUs per 12 months, in accordance with the clinical community administration affiliation, a firm used through Swedish and other hospitals to display screen compensation ranges. files received by the times exhibit Delashaw and Oskouian have every handed 27,000 annual RVUs in fresh years.

    When he testified in the UC Irvine case, Delashaw boasted that his RVU prowess dwarfed the output of his colleagues in the yr before he joined the institution.

    “Yeah, the complete department’s bad,” he pointed out. “I did 35,000 work RVUs myself that yr.”

    across the nation, the median neurosurgeon earns about $772,000 a year, based on data compiled by MGMA. once a neurosurgeon makes $1.four million, they've reached the desirable 10 p.c of their friends.

    In 2014, Delashaw nearly broke $2 million in compensation, based on windfall’s tax filings as a nonprofit. (Public records reveal Delashaw is also the biggest recipient of Oregon public pension funds, at $663,354 per yr, from his previous work in that state). Oskouian earned greater than $2.three million, the tax information display.

    With a push from the federal govt, the fitness-care business in contemporary years has been transferring to a model that compensates hospitals in accordance with productive and valuable care, instead of lucrative usual extent, noted John Romley, an economist concentrated on health policy on the university of Southern California.

    there is proof that physicians respond to extent incentives by means of including greater procedures — perhaps needless ones — to a affected person’s visit, Romley mentioned.

    Simultaneous surgeries

    To control their caseloads, Cherry Hill’s proper medical doctors will run distinct working rooms at a time, in response to six existing and former staffers.

    Concurrent surgeries aren’t prohibited by means of legislation. Medicare allows for simultaneous surgeries if the attending doctor is current throughout “important” parts of each and every system.

    It’s a common apply to have residents and fellows perform basic tasks, like stitching up a affected person, when the surgery is essentially finished. Fellows may also additionally take on larger projects while the attending doctor supervises.

    After The Boston Globe posted a story in 2015 that explored an issue over concurrent surgeries at Massachusetts standard clinic, the American college of Surgeons developed instructions stating that doctors might delivery a 2nd surgery when the key parts of the primary surgery were completed.

    “In familiar, the patient’s fundamental attending surgeon may still be within the operating suite or should still be instantly accessible for the whole surgical process,” the college wrote in its up to date Statements on concepts.

    At Swedish, surgeries are often scheduled to run on the identical time, the six present and former staffers said. four workers expressed difficulty that Delashaw would handiest be within the room for only 15 minutes right through a surgery.

    one of Delashaw’s former fellows, Dr. Peter Bouz, talked about Delashaw became clear about which ingredients of the circumstances had been crucial parts that the man couldn't deal with alone. For an aneurysm clipping, the fellow could open the scalp and remove a part of the skull, but Delashaw would should be there for inserting the clip on the aneurysm, Bouz spoke of.

    For other situations, such because the removing of portions of a patient’s vertebrae in a laminectomy, Bouz observed the procedure changed into elementary enough that there changed into no crucial portion. He talked about Delashaw would come to assess to be sure it had been achieved as it should be. Bouz stated that the fellows had completed their residency and were now certified to work on their personal but had come to Swedish for specialized working towards.

    4 current and former staffers who asked to remain nameless expressed difficulty that the OR would have to pause to look ahead to Delashaw in the core of the surgery, with the patient’s physique spread out and under anesthesia. Bouz referred to there were times when there turned into a pause however that it might usually ultimate no greater than quarter-hour. one more former fellow, Dr. Prashant Kelkar, mentioned Delashaw all the time got here in a timely vogue.

    Three of the employees who requested to stay nameless expressed subject that Delashaw can be off in a hospital while simultaneously having distinct instances within the OR. Bouz spoke of that could take place best when one case was starting and an additional was ending.

    Delashaw wrote in his remark that his surgeries are staggered so the attending surgeon is available for the essential components of the operations. He said the follow is standard at hospitals and that Cherry Hill information suggests no measurable difference between effects for patients with medical doctors who run varied rooms and those that don’t.

    “As I have remarked earlier than, not all team of workers are in choose of change and will categorical concern when it is distinctive. i will be able to guarantee you that quality is their no 1 precedence and we've excellent statistics to lower back us up,” he wrote.

    Consent types that Swedish patients signal consist of small print announcing that their attending health professional may additionally use acquaintances “to perform and/or support with half or all of my system(s),” in accordance with a replica of the kind from 2014.

    Sproles, the affected person who didn’t know that Oskouian’s assistant had performed such a big role in his surgery, doesn’t have a replica of this kind of kind however suspects he likely signed one. He observed what bothers him is that when he met with Oskouian, the doctor made it sound like he stands out as the one dealing with the process.

    In his postoperative note, however, Oskouian used the word “we” to explain the steps of the techniques that were used. at the conclusion of his abstract, he wrote that his assistant “helped perform the exposure, the diskectomy, in addition to placed native bone into the cage, as well as did the fusion at C4-C5, C5-C6 and placement of the hardware.”

    Such practices get away consideration when every thing goes as deliberate. but the elevated caseloads at Cherry Hill have coincided with an increase in some indicators that indicate patient care is declining.

    In 2011 and 2012, state statistics display, simply 0.1 p.c of Cherry Hill neuro or spine sufferers who had been admitted electively developed complications with unintentional cuts or different concerns from surgical procedure during their live, based on a instances evaluation of state facts. That has climbed every 12 months, to 2.6 p.c in 2015.

    Myint, the affected person-defense chief at Swedish, pointed out the state facts is dependent upon the reliability of scientific coding, which has its flaws. He pointed to data Swedish uses internally that suggests Cherry Hill cranial and spine instances frequently performing improved than national expectations in contemporary months. Swedish said a affected person in 2016 was 31 % less prone to die whereas present process a craniotomy at Cherry Hill than the country wide expectation.

    Myint said Swedish is all the time monitoring benchmarks and dealing to improve them, and he stated that the company’s purpose is to be within the suitable 10 percentile of hospitals when it comes to great metrics.

    among 10 patient defense symptoms published via the federal govt, Cherry Hill ranked beneath countrywide degrees in three areas within the statistics throughout the core of 2015: blood clots after surgery, collapsed lungs and severe issues.

    just one different hospital within the state — Tacoma regular — was also at the back of on three country wide benchmarks.

    stress on body of workers

    To give protection to patient protection, lawmakers authorised a state legislations in 2003 prohibiting hospitals from requiring nurses to work time beyond regulation apart from in unexpected emergencies. Jenae Knapp, a Cherry Hill nurse who represents her co-workers as the co-chair of Swedish’s multi-campus Joint Oversight Staffing Committee, mentioned hospitals can take advantage of that exception with the aid of summoning on-name nurses for circumstances that aren’t basically emergencies.

    It’s generally a problem at Cherry Hill, Knapp noted, the place the high affected person volumes and the exodus of workforce has strained the purchasable materials.

    It’s no longer unusual to peer some nurses who guide Cherry Hill’s operating-room work 20 hours in a 24-hour period, Knapp mentioned, despite analysis displaying that lengthy shifts can result in more errors.

    “If the caregivers are fully spent, they’re not going to be able to focus on you,” Knapp mentioned.

    meanwhile, post-op areas have additionally been overwhelmed. within the ICU, Knapp pointed out, patients who would usually get one-on-one care are watched by nurses with a 2nd patient. cost nurses, tasked with administrative responsibilities, at the moment are forced to take on patients as smartly, she stated.

    With the ICU full of sufferers and missing nurses, patients linger in the post-op restoration room for hours once they should still be within the ICU, Knapp pointed out.

    Cobbs, the neurosurgeon, protected in his memo that staff members believed Delashaw had decimated the ICU infrastructure and failed “to safely body of workers the unit with trained providers.” other internal memos obtained by using the instances say Delashaw exacerbated the condition with a caustic demeanor that created a poisonous and antagonistic atmosphere.

    “basic considerations together with admire for others, affected person safeguard, appropriate surgical procedure, and exceptional of care were rebuffed via the management, in principally Dr. Delashaw,” Cobbs wrote. He declined to remark.

    Delashaw stated some surgeons have expressed anxiety as a result of they see new friends as competitors.

    “while I predict excellence and unswerving commitment to their desires i'm not a bully and haven't produced an intimidating ambiance,” Delashaw wrote in his commentary.

    Early last 12 months, facts reveal an anonymous whistleblower contacted the state department of fitness outlining a variety of concerns at Cherry Hill — inappropriate surgeries, raises in problems and infection rates, fellows who were doing unsupervised surgical procedures, and team of workers complaints that had been ignored. After a two-day investigation, the DOH investigator said the allegations had been “not substantiated because of lack of proof.”

    however power internal Swedish persisted to mount through 2016. Dr. Ralph Pascualy, then the chief govt of physicians at Swedish, confronted Hochman, the chief of windfall, about Delashaw’s issues in a November memo obtained by The instances.

    Pascualy wrote that the Cherry Hill neurosurgeons felt intimidated to carry up what they considered to be Delashaw’s unsafe practices and errors right through the standard morbidity and mortality conference, a standard gathering at hospitals around the nation designed to be an open discussion for peers to supply remarks on circumstances to improve future great.

    He told Hochman that he heard reports of Delashaw making choices that resulted in tremendous affected person damage and dying.

    “you're perceived as giving him special privilege and honor when he is held in extraordinarily low regard with the aid of every different health care provider on the medical team of workers,” Pascualy wrote. “It has created a notion that what actually concerns at Swedish is giant RVU creation devoid of situation for the means through which it's completed.” Pascualy declined to comment.

    Ten surgeons and body of workers members joined collectively for a gathering with hospital management in October, with some making desperate pleas, according to minutes from the meeting acquired through The instances. The surgeons reiterated considerations to Armada, the Swedish CEO, and two different directors.

    The minutes demonstrate the group warned that a Seattle times reporter had been calling workforce contributors. They feared that a news article might damage the institution’s attractiveness.

    They were clear of their message: the entire problems that had been not noted had been poised to burst into the open. Swedish’s proud culture of defense became at risk. Delashaw obligatory to go.

    To today, Delashaw is still in charge.

    greater coverage

    These experiences are only the beginning of their volume of Care sequence. examine greater in their ongoing investigation.

    About their analysis

    click here for particulars on databases used for this report.

    Did you discover this story advantageous? aid watchdog journalism at the Seattle times by subscribing.


  • Design: Frank Mina
  • development: Thomas Wilburn

  • a way to become a licensed Coding expert | Real Questions and Pass4sure dumps

    What do I need to do to be a certified coding specialist?

    Step 1: Pursue a Postsecondary schooling in clinical Billing and Coding

    Many coding positions are seeking individuals with an affiliate's diploma in clinical billing and coding. courses deliver knowledge in medical terminology, compensation methods, pathophysiology and time-honored coding programs, including CPT and ICD-9. students are also taught the details of the medical insurance Portability and Accountability Act (HIPAA) as smartly.

    Step 2: benefit Work journey

    whereas work journey isn't a requirement to become certified, obtaining 2-3 years of labor event is additionally extremely suggested. Hospitals, clinics, physicians' workplaces and assurance agencies are general work environments for clinical coders. people enrolled in a level program even have the opportunity to join an internship to benefit hands-on practising and some informed work journey.

    Step three: Pursue Certification

    The AHIMA oversees the certification examination for aspiring coding consultants. It presents a couple of certification designations, together with the certified Coding professional (CCS) and the certified Coding professional-surgeon-based (CCS-P). The CCS is geared towards health center-primarily based coding authorities. both tests encompass two materials, including distinctive-option questions and affected person-case situations for scientific coding. each the CCS and the CCS-P tests look at various on ICD-9 and CPT coding systems. The CCS-P also contains testing on the Healthcare standard technique Coding system (HCPCS).

    Step four: Take continuing training lessons and Renew Certification

    The BLS pronounced that fitness counsel technicians (which consist of certified coding technicians) need to regularly renew their certification and take carrying on with schooling courses. The AHIMA offers seminars, conferences and webinars that supply really helpful experiences for certified coding specialists and meet these necessities. CCSs and CCS-Ps need to complete at least 30 carrying on with education devices (CEUs) like these each certification cycle, as well as pay a renewal payment. CEUs are accomplished through college courses.

    Step 5: trust Pursuing a Bachelor's diploma

    Coding consultants trying to pursue promotional alternatives may wish a bachelor's degree in health administration or a connected box, so coding consultants should still maintain that choice open to them in the event that they wish to strengthen.

    licensed coding consultants have affiliate's levels and certification. They use medical application classes whereas overseeing and updating affected person information, and they earn a median annual income of $37,110.

    medical coding gives hope for Canadian Valley know-how center graduate | Real Questions and Pass4sure dumps

    Elaine Simpson is using the education she received in medical coding at Canadian Valley Technology Center as a springboard to realize her dream of one day becoming a medical doctor. [PHOTO PROVIDED]

    Elaine Simpson is the use of the schooling she got in scientific coding at Canadian Valley expertise core as a springboard to recognise her dream of one day becoming a medical medical professional. [PHOTO PROVIDED]

    YUKON — well-nigh two years in the past, Elaine Simpson's mailbox offered hope.

    The optimism got here from a booklet showcasing classes for adults. Simpson, 31, of Mustang, referred to she had needed an honest job to make ends meet after having these days given birth to her 2d newborn. She had accomplished some faculty fitness classes, however she turned into no longer desperate to work 12-hour shifts in common direct affected person care. She study a course description in Canadian Valley technology center's adult and carrying on with training brochure highlighting the “enterprise aspect” of the fitness care trade. She dug deeper. “I came across scientific coding,” she noted. “It sounded best. I figured there become plenty I may learn and nonetheless be a stay-at-domestic mother.” there were openings in Canadian Valley expertise middle's daytime medical Coding expert software on the Cowan Campus in Yukon, so she attended category full-time.

    In 13 months, Simpson had achieved the path and passed the licensed skilled Coder (CPC) exam. She earned a CPC-A credential, which capacity she turned into identified as an apprentice. After working within the field for just about two years, she utilized for removing of the “A,” and is now a completely credentialed CPC. “My ultimate day on Oct. 30 (2016), I received a call for my first job,” Simpson mentioned. “I started working the very next week.” After five months working as a clinical coder for a medical equipment company, she found a related job with enhanced pay on the Oklahoma metropolis Indian clinic. each and every yr, the sanatorium serves nearly 20,000 individuals representing more than 200 tribes.

    “i'm on the Chickasaw Nation (tribal registry) roll, so I believe this is the appropriate region for me at this time,” she observed. “every little thing I learned at Canadian Valley so far as coding and scientific terminology and the anatomy and physiology, i am placing to use.”

    The subsequent chapter

    Simpson observed her new profession has inspired her to proceed dreaming and upgrading her advantage. “I enrolled in faculty the day prior to this,” she talked about. “when I went earlier than, I wasn't in fact inquisitive about it. I actually have loads of goals in mind.” She has chosen pre-med as her predominant and plans to become a scientific doctor. “i really like the incontrovertible fact that i'm getting to comprehend the company side of how all of this works, as a result of my dream is to open up my own apply at some point,” Simpson noted. “I feel like this will all play a task in helping me make my goals come real.”

    deciding on a coding profession

    clinical coding education offers entry-stage prevalent administrative scientific workplace potential through the more challenging clinical insurance and coding capabilities. a hit assurance and coding knowledge are the important thing to the persevered success of the scientific apply as these avenues give the money move for the business to continue, referred to Christi Walker, Canadian Valley technology core's medical coding specialist teacher.

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    Specialty physicians driving EHR design, workflows at Cerner | real questions and Pass4sure dumps

    For the past several years, specialty physicians have called attention to the deficiencies of EHR systems tailored to primary care, acknowledging that one size does not fit all when it comes to EHR design. The same can likewise be said of EHR design within specialty medicine itself. “As an obstetrician, I’ve just got different things I do than a neurologist, which is different from internal medicine doctor is going to do, which is different than an orthopedist,” Dr. Jeff Wall, OB/GYN and Physician Executive for Cerner, told at HIMSS13.

    Depending on their area of practice, specialty physicians prefer certain workflows and functionalities. An orthopedist finds more value in X-rays than other practitioners based on the care he provides, offers Dr. Wall as an example of these nuances. In light of this variation among specialists, specialty EHR systems need to reflect how these providers interact with patients and document their patient encounters.

    In his role at Cerner, Dr. Wall has undertaken the challenge of providing a specialty EHR solution that is able to meet the needs of as many as 20 different types of specialists, from cardiology and surgery to neurology and ophthalmology. And he has done so by placing a high value on the input of these very physicians.

    “The Physician Experience Initiative started at the beginning of 2012,” explains Dr. Wall. “We’re developing what they call playbooks, and each of those playbooks looks at the way the desktop software — there are 600 decision points that affect physician usage of the software — they look at each one of those decision points as providing the best answer for how the software should be set for that particular type of physician.”

    And while specialty physicians share a number of similarities in terms of their workflows, this vetting process highlights the subtleties that distinguish one specialist’s workflow from another. It’s a process that Dr. Wall and his team at Cerner believe will be a trend for the EHR vendor community going forward as physicians come to have a larger say into how a system is designed and customized to fit their clinical needs:

    It’s a natural evolution based on the fact that there are a lot of angry docs out there going, “Really, this was designed by engineers. Nobody asked my opinion, and you’re telling me I got to use it.” One thing we’re doing to address that is that they actually have a team of user-interface and usability designers so that whenever they have some new functionality, it actually gets mocked up and goes through extensive rounds of usability testing before the engineers ever write a single line of code. By the time they get to where we’re coding it, they get a design that doctors have signed off on.

    Because software design is an ongoing process, Dr. Wall suggests that they can expect from EHR vendors more tools geared toward allowing healthcare organizations and providers to analyze how they are using their systems and identify areas where improvements can be made either through EHR optimization or user training.

    With the attention of EHR vendors expanding to now include specialty physicians and non-primary care workflows, the EHR systems themselves must become more adaptable and agile in accommodating the needs of an array of providers. As the experience at Cerner has shown, the solution can be found not in creating wholly-new EHR software but in presenting information to different subsets of users that aligns with their clinical care.

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    Arleo Eye Associates | real questions and Pass4sure dumps

    For more than 20 years Arleo Eye Associates has been providing Ithaca and the Finger Lakes region with state-of-the-art eye care and ophthalmology services.


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    Our dedicated staff of expert eye care professionals includes board certified physicians, led by Dr. Robert J. Arleo; doctors of optometry; technicians, billing, and coding specialists certified by the Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO); and a New York State licensed optician.

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    AI can deliver specialty-level diagnosis in primary care setting | real questions and Pass4sure dumps

    A system designed by a University of Iowa ophthalmologist that uses artificial intelligence (AI) to detect diabetic retinopathy without a person interpreting the results earned Food and Drug Administration (FDA) authorization in April, following a clinical trial in primary care offices. Results of that study were published Aug. 28 online in Nature Digital Medicine, offering the first look at data that led to FDA clearance for IDx-DR, the first medical device that uses AI for the autonomous detection of diabetic retinopathy.

    The clinical trial, which also was the first study to prospectively assess the safety of an autonomous AI system in patient care, compared the performance of IDx-DR to the gold standard diagnostic for diabetic retinopathy, which is the leading cause of vision loss in adults and one of the most severe complications for the 30.3 million Americans living with diabetes.

    IDx-DR exceeded all pre-specified superiority endpoints in sensitivity, the ability to correctly identify a patient with disease; specificity, the ability to correctly classify a person as disease-free; and imageability, or the capability to produce quality images of the retina and determine the severity of the disease.

    “The AI system’s primary role is to identify those people with diabetes who are likely to have diabetic retinopathy that requires further evaluation by an eye-care provider. The study results demonstrate the safety of autonomous AI systems to bring specialty-level diagnostics to a primary care setting, with the potential to increase access and lower cost,” says Michael Abràmoff, MD, PhD, the Robert C. Watzke Professor of Ophthalmology and Visual Sciences with UI Health Care and principal investigator on the study. He is founder and president of IDx, the company that created the IDx-DR system and funded the study.

    Early detection may prevent vision loss

    More than 24,000 people in the U.S. lose their sight to diabetic retinopathy each year. Early detection and treatment can reduce the risk of blindness by 95 percent, but less than 50 percent of patients with diabetes schedule regular exams with an eye-care specialist.

    In the study, 900 adult patients with diabetes–but no history of diabetic retinopathy–were examined at 10 primary care sites across the U.S. Retinal images of the patients were obtained using a robotic camera, with an AI assisting the operator in getting good quality images. Once the four images were complete, the diagnostic AI then made a clinical diagnosis in 20 seconds. The diagnostic AI detects disease just as expert clinicians do, by having detectors for the lesions characteristic for diabetic retinopathy, including microaneurysms, hemorrhages, and lipoprotein exudates.

    Camera operators in the study were existing staff of the primary care clinics, but not physicians or trained photographers.

    “This was much more than just a study testing an algorithm on an image. They wanted to test it in the places where it will be used, by the people who will use it, and they compared it to the highest standard in the world,” says Abràmoff, who also holds faculty appointments in the UI College of Engineering.

    AI measured against gold standard

    Study participants also had retinal images taken at each of the primary care clinics using specialized widefield and 3D imaging equipment without AI operated by experienced retinal photographers certified by the Wisconsin Fundus Photograph Reading Center (FPRC)–the gold standard in grading the severity of diabetic retinopathy.

    Complete diagnostic data accomplished by both the AI system and FPRC readers was available for 819 of the original 900 study participants. FPRC readers identified 198 participants with more than mild diabetic retinopathy who should be further examined by a specialist; the AI was able to correctly identify 173 of the 198 participants with disease, resulting in a sensitivity of 87 percent. Among the 621 disease-free participants identified by FPRC readers, AI identified 556 participants, for a specificity of 90 percent. The AI had a 96 percent imageability rate: of the 852 participants who had an FPRC diagnosis, 819 had an AI system diagnostic output.

    In June, following FDA clearance, providers at the Diabetes and Endocrinology Center at UI Health Care-Iowa River Landing in Coralville, Iowa, were the first in the nation to begin using IDx-DR to screen patients.

    “We are hoping to do this also for early detection of diseases like glaucoma and macular degeneration. They are working on those algorithms already. The goal is to get these specialty diagnostics into primary care and retail, which is where the patients are,” Abràmoff says.

    IDx is working with the American Medical Association to ensure that there is clear coding guidance for billing of IDx-DR. Providers, physicians, and suppliers should contact their third-party payers for specific and current information on their coding, coverage, and payment policies. IDx is a licensed distributor of the robotic camera used in the study.

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    Alfresco [1 Certification Exam(s) ]
    Altiris [3 Certification Exam(s) ]
    Amazon [2 Certification Exam(s) ]
    American-College [2 Certification Exam(s) ]
    Android [4 Certification Exam(s) ]
    APA [1 Certification Exam(s) ]
    APC [2 Certification Exam(s) ]
    APICS [2 Certification Exam(s) ]
    Apple [69 Certification Exam(s) ]
    AppSense [1 Certification Exam(s) ]
    APTUSC [1 Certification Exam(s) ]
    Arizona-Education [1 Certification Exam(s) ]
    ARM [1 Certification Exam(s) ]
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    ASIS [2 Certification Exam(s) ]
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    ASTQB [8 Certification Exam(s) ]
    Autodesk [2 Certification Exam(s) ]
    Avaya [96 Certification Exam(s) ]
    AXELOS [1 Certification Exam(s) ]
    Axis [1 Certification Exam(s) ]
    Banking [1 Certification Exam(s) ]
    BEA [5 Certification Exam(s) ]
    BICSI [2 Certification Exam(s) ]
    BlackBerry [17 Certification Exam(s) ]
    BlueCoat [2 Certification Exam(s) ]
    Brocade [4 Certification Exam(s) ]
    Business-Objects [11 Certification Exam(s) ]
    Business-Tests [4 Certification Exam(s) ]
    CA-Technologies [21 Certification Exam(s) ]
    Certification-Board [10 Certification Exam(s) ]
    Certiport [3 Certification Exam(s) ]
    CheckPoint [41 Certification Exam(s) ]
    CIDQ [1 Certification Exam(s) ]
    CIPS [4 Certification Exam(s) ]
    Cisco [318 Certification Exam(s) ]
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    College-Board [2 Certification Exam(s) ]
    CompTIA [76 Certification Exam(s) ]
    ComputerAssociates [6 Certification Exam(s) ]
    Consultant [2 Certification Exam(s) ]
    Counselor [4 Certification Exam(s) ]
    CPP-Institue [2 Certification Exam(s) ]
    CPP-Institute [1 Certification Exam(s) ]
    CSP [1 Certification Exam(s) ]
    CWNA [1 Certification Exam(s) ]
    CWNP [13 Certification Exam(s) ]
    Dassault [2 Certification Exam(s) ]
    DELL [9 Certification Exam(s) ]
    DMI [1 Certification Exam(s) ]
    DRI [1 Certification Exam(s) ]
    ECCouncil [21 Certification Exam(s) ]
    ECDL [1 Certification Exam(s) ]
    EMC [129 Certification Exam(s) ]
    Enterasys [13 Certification Exam(s) ]
    Ericsson [5 Certification Exam(s) ]
    ESPA [1 Certification Exam(s) ]
    Esri [2 Certification Exam(s) ]
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    FCTC [2 Certification Exam(s) ]
    Filemaker [9 Certification Exam(s) ]
    Financial [36 Certification Exam(s) ]
    Food [4 Certification Exam(s) ]
    Fortinet [13 Certification Exam(s) ]
    Foundry [6 Certification Exam(s) ]
    FSMTB [1 Certification Exam(s) ]
    Fujitsu [2 Certification Exam(s) ]
    GAQM [9 Certification Exam(s) ]
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    GIAC [15 Certification Exam(s) ]
    Google [4 Certification Exam(s) ]
    GuidanceSoftware [2 Certification Exam(s) ]
    H3C [1 Certification Exam(s) ]
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    Hitachi [30 Certification Exam(s) ]
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    Hyperion [10 Certification Exam(s) ]
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    ICAI [1 Certification Exam(s) ]
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    IEEE [1 Certification Exam(s) ]
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    IIA [3 Certification Exam(s) ]
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    Intel [2 Certification Exam(s) ]
    IQN [1 Certification Exam(s) ]
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    ISACA [4 Certification Exam(s) ]
    ISC2 [6 Certification Exam(s) ]
    ISEB [24 Certification Exam(s) ]
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    iSQI [7 Certification Exam(s) ]
    ITEC [1 Certification Exam(s) ]
    Juniper [64 Certification Exam(s) ]
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    Legato [5 Certification Exam(s) ]
    Liferay [1 Certification Exam(s) ]
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    Lotus [66 Certification Exam(s) ]
    LPI [24 Certification Exam(s) ]
    LSI [3 Certification Exam(s) ]
    Magento [3 Certification Exam(s) ]
    Maintenance [2 Certification Exam(s) ]
    McAfee [8 Certification Exam(s) ]
    McData [3 Certification Exam(s) ]
    Medical [69 Certification Exam(s) ]
    Microsoft [374 Certification Exam(s) ]
    Mile2 [3 Certification Exam(s) ]
    Military [1 Certification Exam(s) ]
    Misc [1 Certification Exam(s) ]
    Motorola [7 Certification Exam(s) ]
    mySQL [4 Certification Exam(s) ]
    NBSTSA [1 Certification Exam(s) ]
    NCEES [2 Certification Exam(s) ]
    NCIDQ [1 Certification Exam(s) ]
    NCLEX [2 Certification Exam(s) ]
    Network-General [12 Certification Exam(s) ]
    NetworkAppliance [39 Certification Exam(s) ]
    NI [1 Certification Exam(s) ]
    NIELIT [1 Certification Exam(s) ]
    Nokia [6 Certification Exam(s) ]
    Nortel [130 Certification Exam(s) ]
    Novell [37 Certification Exam(s) ]
    OMG [10 Certification Exam(s) ]
    Oracle [279 Certification Exam(s) ]
    P&C [2 Certification Exam(s) ]
    Palo-Alto [4 Certification Exam(s) ]
    PARCC [1 Certification Exam(s) ]
    PayPal [1 Certification Exam(s) ]
    Pegasystems [12 Certification Exam(s) ]
    PEOPLECERT [4 Certification Exam(s) ]
    PMI [15 Certification Exam(s) ]
    Polycom [2 Certification Exam(s) ]
    PostgreSQL-CE [1 Certification Exam(s) ]
    Prince2 [6 Certification Exam(s) ]
    PRMIA [1 Certification Exam(s) ]
    PsychCorp [1 Certification Exam(s) ]
    PTCB [2 Certification Exam(s) ]
    QAI [1 Certification Exam(s) ]
    QlikView [1 Certification Exam(s) ]
    Quality-Assurance [7 Certification Exam(s) ]
    RACC [1 Certification Exam(s) ]
    Real-Estate [1 Certification Exam(s) ]
    RedHat [8 Certification Exam(s) ]
    RES [5 Certification Exam(s) ]
    Riverbed [8 Certification Exam(s) ]
    RSA [15 Certification Exam(s) ]
    Sair [8 Certification Exam(s) ]
    Salesforce [5 Certification Exam(s) ]
    SANS [1 Certification Exam(s) ]
    SAP [98 Certification Exam(s) ]
    SASInstitute [15 Certification Exam(s) ]
    SAT [1 Certification Exam(s) ]
    SCO [10 Certification Exam(s) ]
    SCP [6 Certification Exam(s) ]
    SDI [3 Certification Exam(s) ]
    See-Beyond [1 Certification Exam(s) ]
    Siemens [1 Certification Exam(s) ]
    Snia [7 Certification Exam(s) ]
    SOA [15 Certification Exam(s) ]
    Social-Work-Board [4 Certification Exam(s) ]
    SpringSource [1 Certification Exam(s) ]
    SUN [63 Certification Exam(s) ]
    SUSE [1 Certification Exam(s) ]
    Sybase [17 Certification Exam(s) ]
    Symantec [134 Certification Exam(s) ]
    Teacher-Certification [4 Certification Exam(s) ]
    The-Open-Group [8 Certification Exam(s) ]
    TIA [3 Certification Exam(s) ]
    Tibco [18 Certification Exam(s) ]
    Trainers [3 Certification Exam(s) ]
    Trend [1 Certification Exam(s) ]
    TruSecure [1 Certification Exam(s) ]
    USMLE [1 Certification Exam(s) ]
    VCE [6 Certification Exam(s) ]
    Veeam [2 Certification Exam(s) ]
    Veritas [33 Certification Exam(s) ]
    Vmware [58 Certification Exam(s) ]
    Wonderlic [2 Certification Exam(s) ]
    Worldatwork [2 Certification Exam(s) ]
    XML-Master [3 Certification Exam(s) ]
    Zend [6 Certification Exam(s) ]

    References :

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