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Risk Assessment

Diagnostic Services

Committed to the healing of the mind, body and spirit, Loma Linda University Medical Center (LLUMC) understands that early detection of prostate cancer is critical to your well-being. LLUMC provides the following diagnostic procedures:

Causes & Risk Factors

To-date, the cause of prostate cancer is unknown. As the causes of this condition continue to be investigated, the medical community has identified risk factors contributing to prostate cancer's development:

Screenings

Screening tests identify prostate cancer at its earliest stages. When prostate cancer is discovered before symptoms develop, our male patients can be treated most effectively and may result in a better chance of recovery. At LLUMC, the prostate-specific antigen (PSA) blood test is a screening tool used to detect prostate cancer in men with or without symptoms. The PSA blood test:

A patient with normal PSA levels does not entirely exclude the possibility of contracting prostate cancer. In conjunction with the PSA, a digital rectal exam (DRE) is strongly encouraged to:

Fill out the Contact Us form to receive a free risk assessment booklet and learn about Loma Linda University Medical Center’s free PSA screening events.


Prostate Cancer

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Definition

Prostate cancer is cancer that starts in the prostate gland. The prostate is a small, walnut-sized structure that makes up part of a man's reproductive system. It wraps around the urethra, the tube that carries urine out of the body.

Alternative Names

Cancer - prostate

Causes

The cause of prostate cancer is unknown. Some studies have shown a relationship between high dietary fat intake and increased testosterone levels.

There is no known association with an enlarged prostate or benign prostatic hyperplasia (BPH).

Prostate cancer is the third most common cause of death from cancer in men of all ages and is the most common cause of death from cancer in men over age 75. Prostate cancer is rarely found in men younger than 40.

People who are at higher risk include:

The lowest number of cases occurs in Japanese men and those who do not eat meat (vegetarians).

Symptoms

Thanks to PSA testing, most prostate cancers are now found before they cause symptoms. Although most of the symptoms listed below can occur with prostate cancer, they are more likely to be associated with noncancerous conditions.

Other symptoms that may occur with this disease:

Exams and Tests

A rectal exam will often show an enlarged prostate with a hard, irregular surface.

A number of tests may be done to diagnose prostate cancer:

Prostate biopsy is the only test that can confirm the diagnosis.

The following tests may be done to determine whether the cancer has spread:

Health care providers use a system called staging to describe how far the cancer has grown. Tumor size, and how far the cancer has spread outside of the prostate determine the stage. Identifying the correct stage may help the doctor recommend the best treatment.

There are several different ways to stage tumors, including:

The grade of a tumor describes how aggressive a cancer might be. The more tumor cells differ from normal tissue, the faster these cells are likely to grow. The grading system for prostate cancer is called the Gleason grade or score. Higher scores are usually faster growing cancers.

Treatment

The appropriate treatment for prostate cancer is not clear. Treatment options vary based on the stage of the tumor. In the early stages, talk to your doctor about several options including surgery, radiation therapy, or, in older patients, monitoring the cancer without active treatment.

Prostate cancer that has spread may be treated with drugs to reduce testosterone levels, surgery to remove the testes, or chemotherapy.

Surgery, radiation therapy, and hormonal therapy can interfere with sexual desire or performance on either a temporary or permanent basis. Discuss your concerns with your health care provider.

SURGERY

Surgery is usually only recommended after a thorough evaluation and discussion of all treatment options. A man considering surgery should be aware of the benefits and risks of the procedure.

RADIATION THERAPY

Radiation therapy is used primarily to treat stage A, B, or C prostate cancers. Whether radiation is as good as prostate removal is unclear. The decision about which treatment to choose can be difficult. In patients whose health makes surgery too risky, radiation therapy is often the preferred alternative. Radiation therapy to the prostate gland is either external or internal:

MEDICATIONS

Medicines can be used to adjust the levels of testosterone. This is called hormonal manipulation. Because prostate tumors require testosterone to grow, reducing the testosterone level often works very well at preventing further growth and spread of the cancer. Hormone manipulation is mainly used to relieve symptoms in men whose cancer has spread. It may also be done by surgically removing the testes.

The drugs Lupron and Zoladex are also being used to treat advanced prostate cancer. These medicines block the production of testosterone. The procedure is often called chemical castration, because it has the same result as surgical removal of the testes. However, unlike surgery, it is reversible. The drugs must be given by injection, usually every 3 - 6 months. Possible side effects include nausea and vomiting, hot flashes, anemia, lethargy, osteoporosis, reduced sexual desire, and impotence.

Other medications used for hormonal therapy include androgen-blocking drugs (such as flutamide), which prevent testosterone from attaching to prostate cells. Possible side effects include erectile dysfunction, loss of sexual desire, liver problems, diarrhea, and enlarged breasts.

Chemotherapy is often used to treat prostate cancers that are resistant to hormonal treatments. An oncology specialist will usually recommend a single drug or a combination of drugs. Chemotherapy medications that may be used to treat prostate cancer include:

After the first round of chemotherapy, most men receive further doses on an outpatient basis at a clinic or physician's office. Side effects depend on the drug, how often you take it, and for how long. Some of the side effects for the most commonly used prostate cancer chemotherapy drugs include:

MONITORING

You will be closely watched to make sure the cancer does not spread. This involves routine doctor check-ups. Monitoring may include:

Support Groups

You can ease the stress of illness by joining a support group whose members share common experiences and problems. See: Support group - prostate cancer

Outlook (Prognosis)

The outcome varies greatly. This is mainly because the disease is found in older men, who may have a variety of other diseases or conditions such as heart or respiratory disease, or disabilities. The outcome is also affected by the stage and grade of the disease when you are diagnosed.

Possible Complications

Impotence is a potential complication after prostate removal or radiation therapy. Recent improvements in surgical procedures have made this complication less common. Urinary incontinence is another possible complication. Medications can have side effects, including hot flashes and loss of sexual desire.

When to Contact a Medical Professional

Call for an appointment with your health care provider if you are a man over age 40 who has:

Discuss the advantages and disadvantages to PSA screening with your health care provider.

Prevention

There is no known way to prevent prostate cancer. Following a vegetarian, low-fat diet or one that is similar to the traditional Japanese diet may lower your risk. Early identification (as opposed to prevention) is now possible by screening men over age 40 each year with a digital rectal examination (DRE) and PSA blood test.

There is a debate, however, as to whether PSA testing should be done in all men. There are several potential downsides to PSA testing. The first is that a high PSA level does not always mean that a patient has prostate cancer. The second is that health care providers are detecting and treating some very early-stage prostate cancers that may never have caused the patient any harm. The decision about whether to use a PSA testing to screen for prostate cancer should be based on a discussion between the patient and his health care provider.

References

Andriole GL, Crawford ED, Grubb RI 3rd, Buys SS, Chia D, Church TR, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009;360:1310-1319.

Babaian RJ, Donnelly B, Bahn D, Baust JG, Dineen M, Ellis D, et al. Best practice statement on cryosurgery for the treatment of localized prostate cancer. J Urol. 2008;180:1993-2004.

NCCN Clinical Practice Guidelines in Oncology: Prostate cancer. V.2.2009. Accessed June 2009.

Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360:1320-1328.

Walsh PC, DeWeese TL, et al. Clinical practice: localized prostate cancer. N Engl J Med. 2007;357(26):2696-2705.

Wilt TJ, MacDonald R, et al. Systematic review: comparative effectiveness and harms of treatments for clinically localized prostate cancer. Ann Intern Med. 2008;148(6):435-448.


Review Date: 8/10/2009
Reviewed By: Reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc. Also reviewed by Scott Miller, MD, Urologist, private
practice, Atlanta, Georgia.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2010 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

Proton Therapy

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Definition

Proton radiation treatment differs from standard radiation therapy. If given in sufficient doses, conventional radiation therapy techniques will control many cancers.

Because of the physician's inability to adequately conform the irradiation pattern to the cancer, healthy tissues may be damaged with radiation. Consequently, a less-than-desired dose frequently is used to reduce damage to healthy tissues and avoid subsequent unacceptable side effects. The characteristics of proton beam therapy enable the physician to deliver full or higher doses while sparing surrounding healthy tissues and organs.

Much research and many hundreds of millions of dollars of federal funding went into developing the technology to accelerate protons. Much of that work was done at the U.S. Department of Energy's Fermi National Accelerator Laboratory (Fermilab). Fermilab physicists and engineers built the proton accelerator that exists at Loma Linda University Medical Center today.

Using high-energy protons for medical treatment was first proposed in 1946. Protons were first used to treat patients with certain cancers less than 10 years later. Research and laboratory applications increased rapidly in the next three decades. It was not until the opening of the hospital-based proton treatment facility at Loma Linda University Medical Center in 1990, however, that the full benefits of proton treatment could be offered to patients with a wide variety of cancers.

The synchrotron was invented in the 1950s to produce higher-energy particles for studying subnuclear matter. Loma Linda University Medical Center's accelerator is the world's smallest variable-energy proton synchrotron. It is designed to deliver a beam of energy sufficient to reach the deepest tumors in patients. Proton treatment is notably valuable for treating localized, isolated, solid tumors before they spread to other tissues and to the rest of the body.

Proton Technology

Each proton begins its journey at an injector located within an electric field. In the field, hydrogen atoms are separated into negatively charged electrons and positively charged protons. The protons are then sent through a vacuum tube within a pre-accelerator. This process boosts their energy to two million electron volts.

The protons continue in the vacuum tube and begin their high-speed journey in the synchrotron. They travel around the synchrotron about 10 million times per second. Each time they circulate, a radiofrequency cavity within the ring delivers a boost of energy. This increases the protons' energy to between 70 and 250 million electron volts. The voltage achieved is enough to place them at any depth within the patient's body.

After leaving the synchrotron, the protons move through a beam transport system, continuing in the vacuum tube through a series of steering and focusing magnets that guide them to the four treatment rooms. (A fifth room, used for beam calibration and basic research, contains three additional beam lines.) One treatment room has a stationary beam with two branches. One branch is for irradiating eye tumors and the other branch is for central nervous system tumors and tumors of the head and neck. The other three treatment rooms have gantries. Gantries are wheels 35 feet in diameter and weighing approximately 90 tons, which revolve around the patient to direct the beam precisely to where it is needed. From the patient's perspective, however, all that is visible is a revolving, cone-shaped aiming device.

Each treatment room has a guidance system to direct the beam that treats the patient. The guidance system monitors the beam until it enters the patient and positions the Bragg peak to conform to the size and shape of the tumor and the immediate volume at risk for tumor spread, according to a plan designed by the physician. Field sizes to accommodate regional spread of tumors can be as large as 40 by 40 centimeters.

The beam delivery system, or nozzle, is the last device the protons travel through before entering the patient's body. The nozzle shapes and spreads out the proton beam in three dimensions. When calculating the number of protons to be delivered to the designated volume and the velocity and shape of the proton beam, radiation oncologists take into account the location and shape of the target and the tissue density and depth through which the protons must travel to reach their target. After leaving the nozzle, the protons enter the patient's body.

The entire proton facility is controlled by computers that are equipped with safety measures to ensure that patients receive proton radiation treatments as prescribed. Three host computers control the accelerator and beam transport system. A second set of computers, located in each treatment room, controls the beam guidance system and all other treatment room systems. These computers verify patient identification, set operational parameters for each patient's treatment plan, and direct the host computers to deliver a specified beam.

All this is done at Loma Linda to make in as rigorous and safe a manner as possible. In this way, the superior benefits of proton therapy can be offered to more patients with different types of cancers.

Advantages of Proton Therapy

Although still a relatively newer cancer treatment, proton radiation therapy has already shown promise in the treatment of prostate cancer. And with early detection, proton radiation treatment carries a series of advantages that is unrivaled to what other prostate cancer treatments have to offer.

What is Prostate Cancer Proton Therapy?

Proton therapy for prostate cancer is a treatment option that involves using a focused ray of proton particles to kill diseased, cancerous tissues. Capable of delivering precise and higher doses of radiation, proton therapy treatment for prostate cancer targets cancer cells while significantly reducing the damage of healthy tissue surrounding the prostate. This fact puts prostate cancer proton radiation treatment ahead of chemotherapy with chemo being known to damage or kill the body's healthy cells.

Benefits of Proton Prostate Cancer Treatment

Proton therapy for prostate cancer treatment essentially improves the quality of life for prostate cancer patients and survivors by offering a number of compelling benefits. Additionally, prostate cancer proton radiation therapy doesn't require any recovery time and poses a minimal risk of impotency. In fact, men are generally able to continue their sexual activity while undergoing this prostate cancer therapy. Proton therapy for prostate cancer differs from other popular cancer treatment options in that it is

References
http://www.protons.com

Robotic Surgery

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Definition

Robotic surgery is a technique in which a surgeon performs surgery using a computer that remotely controls very small instruments attached to a robot.

Alternative Names

Robot-assisted surgery; Robotic-assisted laparoscopic surgery; Laparoscopic surgery with robotic assistance

Description

This procedure is done under general anesthesia (you are asleep and pain-free). The surgeon sits at a computer station nearby and directs the movements of a robot. Small instruments are attached to the robot's arms.

The surgeon first inserts these instruments into your body through small surgical cuts. Under the surgeon’s direction, the robot matches the doctor’s hand movements to perform the procedure using the tiny instruments.

A thin tube with a camera attached to the end of it (endoscope) allows the surgeon to view highly magnified three-dimensional images of your body on a monitor in real time.

Why the Procedure Is Performed

Robotic surgery is a type of procedure that is similar to laparoscopic surgery. It also can be performed through smaller surgical cuts than traditional open surgery. The small, precise movements that are possible with this type of surgery give it some advantages over standard endoscopic techniques.

Sometimes robotic-assisted laparoscopy can allow a surgeon to perform a less-invasive procedure that was once only possible with more invasive open surgery. Once it is placed in the abdomen, a robotic arm is easier for the surgeon to use than the instruments in endoscopic surgery.

The robot reduces the surgeon’s movements (for example, moving 1/2 inch for every 1 inch the surgeon moves), which reduces some of the hand tremors and movements that might otherwise make the surgery less precise. Also, robotic instruments can access hard-to-reach areas of your body more easily through smaller incisions compared to traditional open and laparoscopic surgery.

During robotic surgery, the surgeon can more easily see the area being operated on. The surgeon is also in a much more comfortable position and can move in a more natural way than during endoscopy. However, robotic surgery can take longer to perform, due to the amount of time required to set up the robot. In addition, the robot is expensive to use and may not be available in many hospitals.

Robotic surgery may be used for a number of different procedures, including:

Robotic surgery cannot be used for some complex procedures. For example, it is not appropriate for certain types of heart surgery that require greater ability to manipulate instruments in the patient’s chest.

Risks

The risks for any anesthesia are:

The risks for any surgery are:

Robotic surgery may have fewer risks than open and laparoscopic surgery.

Before the Procedure

You cannot have any food or fluid for 8 hours before the surgery. If you are having certain types of abdominal surgery, your surgeon may recommend that you cleanse your bowels with an enema or laxative the day before surgery.

Stop taking aspirin, blood thinners such as warfarin (Coumadin) or Plavix, anti-inflammatory medications, vitamins, or other supplements 10 days before the procedure.

After the Procedure

You will be taken to a recovery room after the procedure. Depending on the type of surgery performed, you may have to stay in the hospital overnight or for a couple of days.

You should be able to walk within a day after the procedure, depending on what type of procedure was done. Avoid heavy lifting or straining until your doctor gives you the okay. Your doctor may advise you not to drive for at least a week.

Recovery

Because the surgical cuts are typically smaller than with traditional open surgery, robotic surgery may lead to:

References

Eichel L, McDougall EM, Clayman RV. Basics of laparoscopic urologic surgery. In: Wein AJ. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 7.

Gomez G. Emerging technology in surgery: Informatics, electronics, robotics. In: Townsend CM, Beauchamp RD, Evers BM. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa:Saunders Elsevier;2007:chap 19.

Lanfranco AR, Castellanos AE, Desai JP, Meyeres WC. Robotic surgery: A current perspective. Ann Surg. 2004;239:14-21.

Oleynikov D. Robotic surgery. Surg Clin N Am. 2008;88:1121-1130.


Review Date: 2/3/2009
Reviewed By: Robert A. Cowles, MD, Assistant Professor of Surgery, Columbia University College of Physicians and Surgeons, New York, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2010 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

Privacy Policy

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THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Who Will Follow This Notice?
The entities listed below and their affiliated clinics and institutes of care (“We”) will follow the terms of this Notice and will only use or disclose your health information as is described in this Notice. We are an organized health care arrangement and for purposes of our privacy practices, are considered one single entity, the Loma Linda University Adventist Health Sciences Center Organized Health Care Arrangement ("LLUAHSC Organized Health Care Arrangement” or “LLUAHSC OHCA”). A detailed listing of the affiliated clinics and institutes of care affected by this Notice is provided on page 10 in a section titled “Entities That Are Included in the LLUAHSC Organized Health Care Arrangement”.

LOMA LINDA UNIVERSITY
LOMA LINDA UNIVERSITY HEALTH CARE
LOMA LINDA UNIVERSITY FACULTY PRACTICE PLAN
LOMA LINDA UNIVERSITY MEDICAL CENTER
LOMA LINDA UNIVERSITY CHILDREN’S HOSPITAL
LOMA LINDA UNIVERSITY EAST CAMPUS
LOMA LINDA UNIVERSITY BEHAVIORAL MEDICINE CENTER

The terms “use” and “disclosure” will be referenced frequently throughout this Notice. As you read this Notice, understand that “use” applies only to activities within our entity and “disclosure” applies to activities such as releasing, transferring, or providing access to information about you to other parties outside our entity.

I. Your Health Information
We know that health information about you is personal and we are committed to protecting the privacy of your information. As a patient, the care and treatment you receive is recorded in a health record. So that we can best meet your health care needs, we may share your record with the health care providers involved in your care for treatment and payment purposes.

For any other reason besides treatment and payment, we can not share your information without your written permission unless the law specifically permits or requires that we do so. For example, in most circumstances, laws pertaining to mental health and substance abuse related services require that we obtain your written permission.

II. Your Health Information Rights
Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you. You have the following rights regarding health information we maintain about you:

Right of Access to Inspect and Copy
• You have the right to inspect and obtain a copy of information in your health and billing record with the exception of items limited and/or prohibited by law. You must submit your request in writing to the department/address listed in the “Contact Information” section of this Notice. If you request a copy of your health information, a fee for the costs of copying may apply.

In limited circumstances, we may deny your request to access your health information. If you are denied access to health information you may request in some instances that the denial be reviewed. In this case, we will conduct an independent review and comply with the outcome of the review.

• Mental Health and Substance Abuse Records:
A provider can lawfully deny access to the patient of the patient’s mental health records/substance abuse records when the provider determines that there is a substantial risk of harm to the patient in seeing or receiving a copy.

A provider may choose to furnish a summary report in lieu of permitting inspection or providing copies of the record.

Right to Request an Amendment to Your Record
• You have the right to request an amendment to your record if you feel that health information we have about you is incorrect or incomplete. You have the right to request an amendment for as long as the information is kept by or for an entity within the LLUAHSC OHCA. To request an amendment, you must submit your request in writing to the department/address listed in the “Contact Information” section on page 9 of this Notice. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

o Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
o Is not part of the health information kept by or for us;
o Is not part of the information which you would be permitted to inspect and copy; or
o Is accurate and complete

Even if we deny your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the addendum to be made part of your health record, then we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

Right to an Accounting of Disclosures

• You have the right to request a list (called an Accounting of Disclosures) of certain disclosures that we made about you. All disclosures that are required to be listed by law will appear on the Accounting of Disclosures list. The items that typically would be listed on an Accounting of Disclosures list are indicated in the section titled “How We May Use and Disclose Health Information About You”. To request an Accounting of Disclosures, you must submit your request to the department/address listed in the “Contact Information” section on page 9. The first request for an accounting in any 12 month period is provided to you free of charge. Any subsequent requests within that 12 month period may be subject to reasonable fees allowed by law.

Right to Request Restrictions
• You have the right to request a restriction on certain uses and disclosures of your information for treatment, payment or health care operations. For example, you might request that we not share information with your insurance company about a procedure that you had. You must submit your request for this type of restriction in writing. However, we are not required to agree to your request.

• You have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, while a patient, you can request we not discuss your course of treatment with a particular family member in attendance. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or as is otherwise required by law. You can speak directly with your health care provider concerning your request for these types of restrictions. Your health care provider may require that you submit your request in writing.

• You have the right to request a restriction on the use and disclosure of your health information for the facility directory. When you are an inpatient in our facility, we may provide your location in the facility and your general condition to someone who calls and asks for you by name. If you tell us your religious affiliation, we may provide your name, location in the facility, general condition and religious affiliation to members of the clergy. Unless you notify us that you object we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. You can request a restriction on the use and disclosure of your health information for the facility directory by “opting out” or requesting that we do not include any or all of your information in the facility directory. To “opt out” of the facility directory, you must make your request in writing through the Admitting or Registration desk.

Right to Confidential Communications

• You have the right to request communications of your health information by alternative means or at alternative locations. We will accommodate reasonable requests. You must submit your request for confidential communications directly to your health care provider.

Right to Notice

• You have the right to adequate notice of how we use and disclose your health information. The Notice (or Notice of Privacy Practices) must also advise you of your rights and our legal duties with respect to your health information. You have the right to receive a paper copy of the Notice upon request. A copy of the Notice currently in effect will be available through your health care provider.

III. How We May Use and Disclose Health Information About You

We can only disclose information in your record 1) with your permission or 2) if federal, state or local law tells us that we can or must disclose information in your record. We can or must disclose information in your record for the purposes listed in this section. When a federal, state or local law tells us that we can or must disclose information in your record, in certain cases, we will list these disclosures in a report if requested. Page 3, under the section titled “Right to an Accounting of Disclosures” explains how you can request a list of the people who received your information. The disclosures described below that will typically be listed on an Accounting of Disclosures are noted with the statement “Included in an Accounting of Disclosures”.

1) We May Use or Disclose Your Health Information for Treatment.

For example: We may use or disclose health information about you to doctors, nurses,
technicians, students, or other hospital personnel who are involved in taking care of you. Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, then physician will know how you are responding to treatment. We may also provide your treating physician or a subsequent health care provider with copies of
various reports that should assist him or her in treating you.

2) We May Use or Disclose Your Health Information for Payment.

For example: We may use or disclose health information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a surgical procedure you had so your health plan will pay us or reimburse you for the surgery. We may also inform your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

3) We May Use or Disclose Your Health Information for Health Care Operations.

For example: Members of the medical and clinical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide. We may also use or disclose information to doctors, nurses, technicians, students, and other hospital personnel for review and learning purposes and as necessary to conduct our business operations, to administer the policies and processes of our health staff and to comply with the laws
that govern health care. Other examples of how we may use or disclose your health information for health care operations include using or disclosing information for compliance and audit activities, customer service initiatives and the coordination or provision of spiritual care services.

4) We May Use or Disclose Your Health Information for Purposes Other Than Treatment, Payment and Health Care Operations

Facility Directory
Unless you notify us that you object we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you, specifically, by name. See page 3 under “Right to Request Restrictions” for information on what to do if you object to your information being in the facility directory.

Notification:
We may use or disclose information regarding your location and general condition to notify or assist in notifying a family member, personal representative, or another person responsible for your care. See page 3 under “Right to Request Restrictions” for information on what to do if you object to the notification of certain family members.

Communication With Family:
Health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. See “Right to Request Restrictions” for information on what to do if you object to our communication with family members involved in your care.

Disaster Relief Purposes
In the event of a disaster, we may use information or disclose information to an authorized private or public entity to the extent that it is necessary to respond to the emergency situation.

Research:
We may use or disclose information to researchers when their research has been approved by an Institutional Review Board (IRB) or Privacy Board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. We may also use or disclose information about you to people preparing to conduct a research project, for example, to help them look for patients with specific health needs, so long as the health information they review does not leave the facility. Your physician or other caregiver may discuss the possibility of enrolling you in a clinical trial. Disclosures made outside our institution for an IRB/Privacy Board approved research activity where your individual permission is not given, are Included in an

Accounting of Disclosures.
Funeral Directors:
Consistent with applicable law, we may use or disclose health information to funeral directors to carry out their duties. Included in an Accounting of Disclosures

Organ and Tissue Procurement Organizations:
Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs and/or tissues for the purpose of tissue donation and transplant. Included in an Accounting of

Disclosures
Appointment Reminders:
We may use or disclose health information to contact you as a reminder that you have an appointment for treatment or health care.

Treatment Alternatives:
We may use or disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Products and Services:
We may use and disclose health information to tell you about our health-related products or services that may be of interest to you.

Fund Raising:
We may contact you as part of a fund-raising effort.

Medical Staff Administration:
The Medical Staff is responsible for insuring appropriate conduct of physicians and other licensed health professionals in the provision of patient care and safety within our facilities. It is sometimes necessary for the Medical Staff administrators and committees to conduct an internal review of patient records to insure quality care by the professionals privileged to practice in our facilities.

Food and Drug Administration (FDA):
We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement. Included in an Accounting of Disclosures

Workers Compensation:
We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law. Included in an Accounting of Disclosures

Public Health:
As required by law, we may disclose your health information to public health or legal authorities for activities that include the following:

• To prevent or control disease, injury or disability;
• To report births and deaths;
• To report the abuse or neglect of children, elders and dependent adults;
• To report reactions to medications or problems with products;
• To notify people of recalls of products they may be using;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Disclosures made for public health activities are Included in an Accounting of Disclosures.

Health Oversight Activities:
We may disclose health information to a health oversight agency for activities authorized by law. Health oversight agencies include the Department of Health Services (DHS) and the Department of Health and Human Services (HHS). Oversight activities include, for example, audits, investigations, inspections and licensure. Included in an Accounting of Disclosures

Correctional Institution:
Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law Enforcement:
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Included in an Accounting of Disclosures

Lawsuits and Disputes:
If you are involved in a lawsuit or dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request by that person, (e.g., notice to consumer), which would give you an opportunity to obtain an order protecting the information requested. Included in an Accounting of Disclosures

As Required by Law:
We will disclose health information about you when required to do so by federal, state or local law. Included in an Accounting of Disclosures

To Avert a Serious Threat to Health or Safety:
We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. Included in an Accounting of Disclosures

Other Uses of Health Information

Business associates:
There are some services provided in our entity through contracts with business associates. An example is a transcription service we may use for transcribing physician dictation of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Other uses and disclosures
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. Disclosure made with your written permission will not be included on the Accounting of Disclosures as you will already have record of these. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or disclosure of your health information for the purposes covered by your written authorization, except if we have already acted in reliance on your permission. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

IV. Our Responsibilities

This LLUAHSC OHCA is required to:
• maintain the privacy of your health information
• provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• abide by the terms of this notice

V. Other Important Information

Changes to this Notice
We reserve the right to change the terms of this notice and to make the new provisions effective for health information we maintain. We will post a copy of the current notice at each affiliated site and on our website. The notice will contain on the first page, in the top right-hand corner, the effective date.

For More Information or to Report a Problem
If you believe your privacy rights have been violated, you may file a complaint. To file a
complaint, contact the Patient Relations representative listed in the Contact Information section on page 9. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. Our Patient Relations representative can provide you with the appropriate address upon request.

Privacy Complaint Telephone Line 909-558-8282

Entities That Are Included in the LLUAHSC Organized Health Care Arrangement

Loma Linda University Medical Center (to include but not limited to)
Loma Linda University Medical Center – East Campus
Community Medical Center
Outpatient Rehabilitation Center
Cancer Institute
Diabetes Treatment Center
LLU Kidney Center
Home Health Care (includes Mountain View Pharmacy, Family Care Services, Loma Linda Medical Supplies and
Respiratory Home Care)
International Heart Institute
LLU Rehabilitation Institute
Transplant Institute
Proton Treatment Center

Loma Linda University Children’s Hospital

Loma Linda University Behavioral Medicine Center

Loma Linda University Health Care

Loma Linda University Faculty Practice Plan
Faculty Physicians and Surgeons of Loma Linda University School of Medicine:
Dermatology
Neurosurgery
PM&R/Pain
Psychiatry
Pediatrics
OB/GYN
Orthopedics
Ophthalmology
Faculty Medical Group of Loma Linda University School of Medicine:
Emergency Medicine
Transplant
Loma Linda University Anesthesiology Medical Group, Inc.
Loma Linda University Cardiology Medical Group, Inc.
Loma Linda University Family Medical Group, Inc.
Loma Linda University Neurology Associates Medical Group, Inc.
Loma Linda University Pathology Medical Group, Inc.
Loma Linda University Physicians Medical Group, Inc.
Loma Linda University Preventive Medicine Medical Group, Inc.
Loma Linda University Radiation Medicine
Loma Linda University Radiology Medical Group, Inc.
Loma Linda University Surgery Medical Group, Inc.
Loma Linda University Urology Medical Group, Inc.

Loma Linda University (to include but not limited to)
University Clinics:
SACHS Clinic
Center for Health Promotion (CHP)
Marriage & Family Therapy
Department of Psychology
School of Dentistry
School:
Allied Health Professions
Public Health
Dentistry
Medicine
Nursing
Graduate School
Pharmacy