Memphis Medical News June 2014 by FW Publishing

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PHYSICIAN SPOTLIGHT PAGE 3

Robert W. Wake, MD ON ROUNDS GTx Sees Better Times Ahead

Biopharmaceutical firm hopes patience, perseverance will pay off Financial losses, layoffs, administrative departures and underperforming clinical results would dampen the enthusiasm of most biopharmaceutical companies, but GTx, the only freestanding biopharmaceutical company in Memphis, said it expects to rise from the ashes created by the recent ﬁrestorm of negative news ... 6

Rural Hospitals Face Threat of Closing Without Medicaid expansion, more shutdowns likely By EMILy KEPLINGER

Just six months ago, the Tennessee Hospital Association warned that rural hospitals would begin to close if Tennessee did not expand its Medicaid program. Now those prophetic words are ringing true as the hospital in Brownsville is scheduled to close this summer. Effective July 31, Community Health Systems is ending both inpatient and emergency services at Haywood Park Community Hospital because it cannot afford to keep operating them. Craig Becker, president of the Tennessee Hospital Association, sees this closing of rural hospitals as an example of what is to follow. “Closing a rural hospital is likely to trigger the departure of physicians, as well as pharmacists,” Becker said. “Patients will experience increased costs as they have to travel for their care. Acute care will likely necessitate the use of an ambulance. Even routine care will be impacted, especially if a patient needs to see a specialist. (CONTINUED ON PAGE 12)

Telemedicine: An Idea Whose Time Has (Finally) Come? Technology can help underserved rural areas receive healthcare Healthcare experts have suggested the time has come to electronically link the skills and knowledge of Memphis’ experienced medical specialists to underserved rural communities that are in desperate need of greater access to such care ... 10

ONLINE: M.MEMPHIS MEDICAL NEWS.COM

HealthcareLeader

Michael W. Nolen Jr. Emergency Mobile Health Care vice president and chief administrative ofﬁcer By BOB PHILLIPS

Smack in the middle of one of the worst winters on record, a call came to Memphis-based Emergency Mobile Health Care LLC to pick up a seriously ill patient in East Tennessee and transport him to a Memphis hospital. “It was January and we had ice and

snow on the ground,” recalled Michael W. Nolen Jr., vice president, chief administrative and compliance officer of EMHC, as the company is most widely known. “The weather was bad all the way. Fortunately, the patient made it, but the trip there and back – with the ice and snow – took 32 hours.” (CONTINUED ON PAGE 8)

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PhysicianSpotlight

Robert W. Wake, MD

Urologist’s loyalty to UT is matched by his devotion to residents, patients By RON COBB

While it’s unlikely that Robert W. Wake, MD, wears orange scrubs in the OR, he’s pretty much orange to the core in most other respects. The urologist grew up in Knoxville and attended the University of Tennessee for both undergraduate and medical school. After receiving his degree in 1985, he did his residency at UT and then joined the faculty. He is now professor and chairman of the Department of Urology at the University of Tennessee Health Science Center. We might also mention, to no one’s surprise, he is a big fan of Tennessee football. “Even in the down times, like now, we remain loyal UT fans,” Wake said of himself and his wife of 29 years, Debbie. Staying in the same state, much less within the same university system, is a bit uncommon for a doctor with his experience, but Wake’s loyalty to UT has rarely been shaken. “A couple of times we have considered opportunities, like everyone does, but I walk by faith, not by sight, and that has allowed me to remain in the place and career that I truly love,” he said. Inspired by his parents and their support, Wake went into healthcare for reasons he can’t specifically pinpoint. “In high school,” he said, “I decided I wanted a career in medicine. It was just something I felt drawn to, despite having no true reason for my interest.” Wake, now a member of UT Methodist Physicians, knew early on that he wanted to do surgery, but he also liked the variety that medicine offers. “Urology was the best combination of a major surgical subspecialty that offered the opportunity to do major open surgeries, endoscopic surgeries, and still have a great deal of medical care that could be offered to patients with a variety of urological problems,” he said. “It also allowed me to care for male and female patients as well as adult and pediatric patients. “I readily admit I’m biased, but if there’s a better surgical subspecialty in medicine, I haven’t found it.” Throw in the opportunity to teach, and Wake has what he feels is the perfect situation. He calls his duties as program director of UTHSC’s urology residency program demanding, but also rewarding. The responsibility of educating future urologists is what motivates him to keep his hand in academia. “It challenges me on a daily basis, which I sincerely welcome,” he said. “Our memphismedicalnews

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residents are like an extended family to me, and most become lifelong friends and peers. “Many people misunderstand what is involved in an academic career. They often believe it means one doesn’t see their own private practice patients and that the residents do all the work while we sit in an office and monitor them from a distance. Nothing could be further from the truth.

“For example, I have an office in Germantown, where I see my private patients two full days and one half-day every week. There are no residents with me on these private office days. I have two and a half days for surgeries each week. One of those days, I spend operating with the residents at our Veterans Hospital, which is part of our training program.” According to UTHSC’s website, Wake has an interest in kidney stone disease in addition to treating and researching prostate cancer and its complications. He is described as one of the first to perform and report on a large series of second-generation targeted cryoablation of the prostate, and one of the first urologists to perform tubeless percutaneous nephrostolithotomy. Wake identifies two particular areas in which advancements have been made related to prostate cancer. “Newer markers coming out to supplement, but not necessarily replace PSA, for screening and to aid the urologists as to when a second biopsy may be indicated after a patient has had a previous negative biopsy,” he said. “Other newer markers may help determine which patients may have an aggressive form of prostate cancer that needs treatment and those with less-aggressive types that may just be followed. So treat-

ment can be individualized for each patient potentially based on these results. “Also, the numerous drugs that have been developed and FDA-approved are currently being used in the treatment of patients with castration-resistant prostate cancer. In fact, new guidelines have been developed on the best way to implement the use of these new drugs in this group of patients.” In terms of listing his rewards and challenges, Wake began with “taking care of my patients and doing my very best to resolve, or at least improve, their problems. Realistic expectations for ourselves and our patients, as well as faith, are critical to successful outcomes. “The biggest frustration has to be the government intrusion into the patientphysician encounter. The use of Electronic Medical Records (EMR) despite potential benefits has certainly been a frustrating endeavor. I’m not against positive change to improve a situation and I embrace new technology, but with the Baptist, Methodist and Regional Medical Center recently implementing three different EMR systems that do not currently communicate effectively and each requiring hours of classroom work to even attempt to learn how to use them, one can see how this may be a tad bit frustrating. But it is the world we live in, and all we can do is embrace the change and move forward.” Five or 10 years from now, Wake says he still hopes to be chairman and program director at UTHSC and “still providing exemplary patient care. Maybe by then I will have mastered the EMR at all the hospitals as well, if they haven’t changed them again.”

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Streetdog Foundation: On a Spiritual Mission to get Temporarily Unwanted Dogs off the Street MEMPHIS on the MEND BY PAMELA HARRIS

Melanie Pafford remembers the exact day the Streetdog Foundation was created. It was August 7, 2009. She had been asked by a friend to help find a lost dog and ended up at Memphis Animal Services to look for Thurman, an American Bulldog. Melanie was unable to locate Thurman, but what she saw that day changed her and her husband’s lives forever. Overall conditions at the shelter were not good, but even worse, there were about 70 dogs lined up on the “Green Mile” meaning that they had only a day or two to be claimed or they would be euthanized. The Paffords describe cage after cage of animals – some wounded, some “cowering in fear.” “The dogs know,” claims Kent, Mel-

anie’s husband. “Nauseated with sorrow,” the Paffords vowed to make it their mission to save as many of these “precious creatures of God’s creation” as they possibly could. Saving these “precious creatures” does not equate to finding homes for stereotypical miniature, fluffy, purebred types. Saving unwanted canines means finding homes for some of the most difficult-to-place animals including pit bulls – the breed with the worst reputation and often the most abused. Streetdog Foundation specializes in helping the “misunderstood” bully breeds. Melanie will tell you that it hasn’t been easy. There have been many times that they’ve housed a dozen or so dogs in their home which obviously requires feeding, bathing and walking. The vet bills alone – to save, restore and rehab these animals – are enough to drive someone into bankruptcy. But she says they are on a spiritual mission and claims that every time she wonders how they’re going to continue, they get a “God Nod,” meaning something good will happen to enable them to move on. Since 2009, they have

tion makes sure that these animals get the medical care they need. They work with area veterinarians to mend the physical wounds, and then proceed to find a forever home so that the emotional wounds can heal as well.

successfully placed about 400 of these “temporarily unwanted” dogs in loving and forever homes. Important Alliances Part of the process of helping stray dogs either find their way home or find a new home involves instructing those who find them what to do. Since the Streetdog Foundation is not a “shelter,” they first try to get the “finder” to keep the dog temporarily while trying to track down the owner. They recommend taking the animal to their local vet to have it scanned for a microchip as one way to expedite that process. Posting fliers with photos is also recommended. Use social media resources such as the Facebook page called Lost and Found Pets of the Midsouth (www.facebook.com/lostandfoundmidsouth). This is where anyone can post a photo of an animal that has either been lost or found and hopefully connect the owner and their pet. The Streetdog Foundation is in the pet rehab business. Many of the dogs they rescue have been neglected, abused and in some cases tortured. Streetdog Founda-

How Big is the Problem? Melanie estimates that they get about 100 emails and calls every day regarding found street dogs. Based on what they have seen and experienced, she and her staff say that there are hundreds of strays wandering the greater Memphis area on any given day. However, Memphis is also a city of dog lovers, and the Streetdog Foundation has 8,800 Facebook “Likes” and over 1,000 Instagram followers. Each week it estimated (by Facebook reports) that they reach more than 14,000 viewers through social media. This represents interest and hope for potential adoptions. How Can You Help? Donate Streetdog Foundation is a 501(c )3 organization. Donations help purchase food, collars, leashes, toys, crates, bedding, and medical care for every rescue. Donations in any amount help the team of volunteers and veterinary professionals provide care. You can pay online using Paypal or send donations to: Streetdog Foundation P O Box 485 Memphis TN 38101 Or go to http://amzn.com/ w/3EGJ06GHRETE7 and check out Streetdog’s online wish list. In addition, they will take new or used items such as: • Crates (any size or type) • Dog beds/fleece pads • Dog Bowls • Dog food (canned and dry) (CONTINUED ON PAGE 16)

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GTx Sees Better Times Ahead Biopharmaceutical ﬁrm hopes patience, perseverance will pay off

Other anticipated news will come in the form of study results in first quarFinancial losses, layoffs, administrater 2015 on GTx’s prostate cancer drug tive departures and underperforming clinCapesaris®, a selective estrogen receptor ical results would dampen the enthusiasm (ER) alpha agonist for the treatment of of most biopharmaceutical companies, men with advanced prostate cancer. but GTx, the only freestanding biopharEnobosarm 3 mg did not meet expecmaceutical company in Memphis, said it tations of a fast track development agreeexpects to rise from the ashes created by ment between GTx and the U.S. Food the recent firestorm of negative news. and Drug Administration in August of last Marc Hanover, inyear. terim CEO and presi“Obviously this was dent and COO of GTx, a major letdown for the Get the current online based the optimism on a company,” Hanover new dosage and applicasaid, “and we had to edition of Memphis tion of one of the compaadjust our expenses to ny’s drugs to be unveiled advance our late-stage Medical News delivered at the American Society programs. Discovery, to your desktop. of Clinical Oncology benchwork and preclini(ASOC) this month. cal is not where value Enobosarm (Ostarine®), is created in biopharpreviously tested in 3 mg maceuticals, and we EMAIL NOTIFICATIONS doses for muscle wasting couldn’t afford to keep in non-small cell lung paying that cost struccancer patients, will have ture.” Mark Hanover data presented for its apBy October, commemphismedical plication in a 9 mg dose for the treatment pany administrators took pay cuts and laid news.com of androgen receptor and estrogen recepoff 60 percent of their 88-person worktor positive metastatic breast cancer at the force. All efforts were turned to studying ASOC meeting. potential for enobosarm in Europe. “On the whole, the studies did not meet primary endpoints as required by study protocols and the FDA,” he said. “For European authorities, one of the studies potentially qualified, so we are You’ve spent thousands on your “image.” pursuing that with the European MediHow about a Professional Portrait to go with it? cines Agency (EMA) — the equivalent of our FDA in Europe. We feel we need additional studies to try to get approved in the U.S. at this time, and we can pursue that later.” In April, Mitchell Steiner, MD, the co-founder of GTx, resigned as CEO. In a statement, he said, “After more than 15 years as CEO, it’s a good time for me to leave my position so that I can spend more time with my family and pursue different opportunities.” Less than two weeks after the April 4 announcement about Dr. Steiner, James Dalton, PhD, the company’s vice president and chief scientific officer, announced his resignation, effective the end of August. He is leaving to become dean of the University of Michigan College of Pharmacy. Professional Portrait “Dr. Dalton is primarily a preclinical PhD, and we are not doing much of the OFFICE EXPENSES: Made by a friend Fixtures & Furnishings: $30k preclinical activities right now. That is the Interior Designer: $250/hr. reason for his departure,” Hanover said. Advertising: $36k/yr. He explained that GTx has a wealth Cleaning Crew: $5k By GINGER PORTER

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of clinical and regulatory expertise in their key officers and that they have enlisted the help of several clinical and industryexperienced MDs in the wake of Steiner’s resignation. Hanover described the past 10 months as “challenging” and extolled a “very patient and understanding shareholder base.” The largest stockholder of GTx is J.R. “Pitt” Hyde, whose personal journey with cancer helped launch the firm in 1997. He is still an investor and chairman of the board, currently serving as a member of the compensation committee and the nominating and corporate governance committees. A bio on the company’s website describes him as “primary advisor to senior management on all matters of strategic importance.” “Dr. Steiner took care of Mr. Hyde during his prostate cancer treatment, as he was head of the University of Tennessee Urology Department back then,” Hanover said. “Some of the research Dr. Steiner was working on then was transferred to GTx via a tech transfer from his lab to us, so we were basically partnering together. Mr. Hyde was our sole financier shortly after the inception of the business.” GTx was a privately held company and gradually attracted other healthcare funds and venture groups. It went public in February 2004. Hanover spoke of the future of the biopharmaceutical industry and lauded American investors for being so devoted, as the research has come to a point where the long years of waiting are about to be rewarded. “The U.S. is a wonderful place for biotech companies to get funded because there is dedicated capital to it. It is now paying off,” he said. “Cancer treatments and rare diseases have drugs coming to the end of their development. Applications are being submitted to the FDA, and it is obviously doing a good job of coordinating with the biopharma space in order to get drugs approved.” Locally, Steve Bares, PhD, MBA, executive director of Memphis Bioworks Foundation, believes there is a great deal of technology and research to support more biopharmaceutical efforts and companies. The foundation is a nonprofit that assists in creating companies, jobs and investments in bioscience by investing in entrepreneurs and building labs/facilities. “There is the ecosystem to support it,” he said. “There is so much opportunity here. There is collaboration in research, with the government, across borders. I’m bullish on it. “What happens if all the current drugs in research stages work and created thousands of jobs in Memphis?” he asked. “And at the endpoint, you are helping somebody.”

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Letter to the Editor

Doctors and Nurses Editor’s note: We originally produced the article “Nurses, Doctors Agree on Rx for Improved Work Environment” with anonymous quotes to open a risk-free dialogue on the issues addressed. In keeping with that parameter, we publish this anonymous letter to the editor. In response to your May article, I would like to specifically address the comments related to surgeons and disruptive behavior. Sadly, very little has changed since 2008, the year this entrenched problem was addressed by the Joint Commission. According to Becker’s Hospital Review, the average operating margin of non-profit hospitals now stands at 2.5 percent – probably less since the statistics were compiled. As a result of a rapidchanging healthcare system and the commercialization of healthcare, rules regarding disruptive behavior, horizontal violence and bullying (a documented recipe for medical error) are not enforced. This is especially true within the closed, non-transparent doors of the operating room (OR), where losing a surgeon means losing money. Although many healthcare organizations seem to have successfully created a culture of collegiality between hospital and medical staffs, the OR – a major source of income and revenue – seems to be the last holdout. It is also a place where errors made while distracted by aberrant behavior can mean the difference between life and death (or errors leading to life-threatening complications) for an asleep and powerless patient – utterly dependent on the presence of a wellfunctioning team. Surgeons’ “run-amok” behavior and “captain of the ship” (rather than team) mentality remain the norm – so much so that most surgical team members fail to recognize it as a negative, potentially dangerous situation. This “abnormal normalcy,” best known as the “normalization of deviance,” – a term coined by NASA after the Challenger explosion – is alive and well in operating rooms across the country. Quality and safety policies touting zero-tolerance for disruptive

behavior, lateral violence, bullying and retaliation seem to be written for the sake of regulatory agencies and frequently unenforced by ineffective management teams. Management team members often fear for their own jobs when the mainstay of the OR – productivity – decreases. Hospitals commonly mitigate risk through termination of nurses who internally and/or externally report abusive physicians, rather than risk losing said revenue-producing surgeon. The decision to get rid of a nurse who dares to speak out is as simple as the decision between trying to contain costs and increase business – or the hospital shutting its doors. When nurses (expense) are denied a voice and physicians (revenue) are allowed to exhibit abusive behavior, the result can be deleterious to patient safety and surgical outcomes. Patients are de-

nied the advocacy of the Registered Nurse, who knows he or she will most likely be fired after speaking up. Thus, the so-called “culture of silence” in the healthcare industry translates to yet another risk for patients in the OR. It coincides with the equally dangerous “culture of fear.” Nurses, when faced with the potential personal cost of reporting risks to patient safety, are caught between the legal, ethical obligations of every state Nurse Practice Act and the Nurses’ Code of Ethics, and the very real personal risk to career, reputation and financial stability. There is more. According to OSHA, none of the 22 federal laws addressing retaliation against whistleblowers mention the wrongful termination of healthcare workers who report threats to patient safety. Most federal whistleblower legislation concerns fraud, waste and abuse – protecting whistleblowers in the financial industry or financial realm of healthcare, but not healthcare workers who report patient safety issues, and certainly not patients. Although several states have passed bills protecting healthcare whistleblowers, once a lawsuit is filed, these statutes often lack the power wielded by hospital attorneys and state judicial systems. Once the nurse is wrongfully termi-

nated – potentially losing the ability to make a living in his or her chosen profession – there are two choices available to fight the “system.” First, there is the Equal Employment Opportunity Commission (EEOC), the federal agency that addresses discrimination related to wrongful retaliatory termination. The other choice – IF one lives in a state with patient safety legislation – involves paying an attorney to fight the hospital system and its high-powered legal team. In doing so, the healthcare professional risks bankrupting financial resources, loss of reputation, ability to obtain employment and precious time fighting a legal battle that, statistically, will probably be lost. Thus, the “culture of silence” is reinforced by the legal system. Sadly, nurses who have seen coworkers terminated for their courage to report a powerful physician are too afraid to speak up within this culture of silence and fear. This begs the question: Who is left to advocate for the patient during “free-for-all” aberrant behavior occurring daily behind the closed doors and windowless, non-transparent walls of the Operating Room? — Memphis Operating Room Nurse Memphis Medical News welcomes letters, but they must be signed and include contact information. Please email your letters to editor@ memphismedicalnews.com

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Healthcare Leader, continued from page 1 The event was the final piece of evidence the 17-year-old company needed to take a major step forward. “We had been discussing adding an airplane for several months, and this convinced us to do it,” Nolen said. So on March 10, less than two months after that treacherous January mission, EMHC became the first locally owned medical transport company in Memphis to offer airborne fixed-wing ambulance service. “We have a plane, our own pilot and our own medical team,” Nolen said. “We can deliver bedside-to-bedside in four hours. We can be airborne 45 minutes after we get a phone call and go 800 miles non-stop. Typical time to complete a mission is four hours.” The two-member team, which consists of a registered nurse and a paramedic, specializes in critical care, burns and trauma. The staff is employed by EMHC. The plane is maintained by an aviation company that keeps everything current with FAA requirements. The aircraft is equipped with a Zoll X Series Cardiac Monitor with transmission capabilities from the air, satellite telephone communications to the hospital and physician while in-flight. Its ventilator is approved for in-flight use and the medical team is able to monitor and infuse unlimited intravenous infusions with stateof-the-art infusion pumps. Also available is a video laryngoscope for intubation and electronic real-time medical records. EMHC, which contracts with hospitals, nursing homes and other medical facilities, also has a fleet of 33 ambulances, some of which can hold additional patients or team members. All the vehicles have EKG transmitting capabilities. The company also has 16 wheelchair transport vehicles, but no helicopters. (“There’s another firm in Memphis that does a wonderful job with medical helicopters,” Nolen said.) Michael Arndt, who served two tours as a medic in Vietnam, and his wife, Bette, founded the company in 1997. Bette’s father was Bert Ferguson, founder of radio station WDIA, the nation’s first AfricanAmerican station. The Arndts, proud that their company is the only locally owned ambulance service, have instilled a strong culture of community involvement. Nolen, who joined the company in 2002 as a driver, is a passionate disciple of the founders. He says EMHC has donated more than $1.5 million to local non-profits and another $5 million-plus in in-kind contributions. The walls of Nolen’s large office are decorated with trinkets, banners, bobble heads, photos, official passes and flags from fund-raising events he and the company have participated in. Nolen came to

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appreciate the importance of giving about the same time he was learning about healthcare – when he was 5 years old. In 1970 his mother was an operating room nurse at St. Joseph Hospital, the 115-year-old downtown hospital that closed in 2000. “That was before they had day care centers, so on weekends my mom took me to work with her,” said Nolen, now 38. “I loved going there. They gave me interesting things to do. I found healthcare fascinating.” As he grew older, he would volunteer for work at the hospital on weekends and during the summer. By the time he was 13, he had worked in every department and even had spent time in the operating room. One summer he worked in the emergency room. “I’d see the ambulances come and go, delivering patients,” he said. “It made an impression on me. I liked the urgency and the people there. Some of the nurses I worked with then I still see at hospitals today.” Not only did Nolen learn about healthcare, he also found a role model: Sister Annette Crone, who ran Saint Joseph.“She was a wonderful woman,” Nolen said. “She and the other sisters had a major positive impact on me.” His dad, who worked at FedEx during the early years, stimulated his interest in planes and air travel. After working for awhile in McDonald’s corporate training and then for Northwest Airlines, Nolen went to work at EMHC. Healthcare had always been beckoning. “I didn’t know a thing about the ambulance business,” he said. “In addition to being a driver, I worked in dispatch, in marketing, as a supervisor ... everything. In 2002 we had four ambulances and 40 staffers.” As the company grew, so did Nolen’s role. The Arndts filled his head with knowledge. He was sent to everything from EMT school to executive management classes. In 2006 the company had 75 employees and 13 units. And Nolen was a director. Two years later he was COO. In 2011 the company moved to its current location at Appling Farms Parkway in Bartlett, less than a mile from I-40 and a quick jump to Memphis’ healthcare facilities as well as the airport. EMHC’s fleet now is composed of Mercedes “sprinter diesel ambulances,” which are expensive but fuel efficient and require less maintenance. The staff has grown to 220. Nolen, too, has grown in stature. But his passion and caring have not diminished. On a recent Monday his office was lined with 220 goody bags. “May is EMT Month,” he explained. “Last night I came in and put these together for our staff. There’s company coffee mugs and some other things.” Those who work with Michael Nolen say that’s a perfect example: Sunday night the company’s vice president comes in by himself to stuff 220 goody bags for the employees. Sister Crone would be proud.

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One of the nation’s best hospitals is right here in Memphis. Baptist Memphis is honored to be the only Mid-South area hospital listed on Becker’s Hospital Review’s 2014 list of “100 Great Hospitals in America.” According to Becker’s, the top hospitals offer some of the greatest medical advancements in U.S. health care, and are also mainstays of their communities. It’s a tribute to the hard work of all our colleagues and physicians and their commitment to providing the best care available.

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Telemedicine: An Idea Whose Time Has (Finally) Come? Technology can help underserved rural areas receive healthcare By JUDY OTTO

Healthcare experts have suggested the time has come to electronically link the skills and knowledge of Memphis’ experienced medical specialists to underserved rural communities that are in desperate need of greater access to such care. The idea is actually not new. The first interactive telemedicine system was launched in 1989 over standard telephone lines. It was designed to remotely diagnose and treat cardiac patients at 12 hospitals in the United States. Since 1998, Memphisbased Interactive Solutions, Inc. (ISI), a leader in the field, has designed, installed and supported more than 1,500 telemedicine units across the country for a wide range of medical specialties and subspecialties, from neurology, emergency medicine and high-risk OB consults to stroke networks, surgery collaboration and more. Brock Slabach, senior vice president of the National Rural Health Association (NRHA), says the need is definitely there and notes that 20 percent of Americans live in rural communities and only 9 percent of the nation’s doctors practice there.

JUNE 2014

The need is exceptionally keen in the Mid-South. Mississippi has the highest stroke prevalence rate in the nation, and Arkansas, Tennessee, Alabama and Louisiana are among those sharing the top six highest rates; Mississippi likewise has the highest infant mortality rate, with Louisiana, Alabama, Tennessee and Arkansas

close behind. Telemedicine has proven it can work – impressively and productively: The University of Arkansas for Medical Sciences (UAMS) has spent $20 million to set up a model telemedicine program and, working in partnership with ISI since 2006, has deployed more than 500

remote/rural sites across the state. It continues to grow and evolve, offering every flavor of telemedicine and subspecialty, and serving those who might otherwise go without healthcare service in any form. The American Telemedicine Association Conference’s credentials as the fastest-growing trade show in the U.S. also demonstrate the increasing fascination with the field. Yet, according to Jason Moore, ISI’s account manager, fewer than 10 percent of Memphis-area specialists are being utilized for telemedicine. Slabach agrees that “although there are some specific niche programs that telemedicine has been used for and continues to be very effective in terms of utilization, the spread of it has not gone as fast and as far as possibly we would have hoped.” While the technology may be marvelous in its design and execution, the concept and operation are relatively simple. Jeremy Johnson, vice president of sales for ISI, described a hub-and-spoke structured network, with typically a convenient desktop terminal at the doctor’s end and a mobile cart that administrators or nurses at each (CONTINUED ON PAGE 18)

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Limited Access

Rural Communities Risk Losing Hometown Healthcare By CINDY SANDERS

At 11:59 p.m. on July 31, Haywood Park Community Hospital will cease inpatient admissions and emergency services. At the stroke of midnight, the Brownsville, Tenn. hospital will become an urgent care clinic, leaving the county’s rural residents to drive close to 30 minutes to hospitals in Covington, Ripley or Jackson. According to a release from the hospital, operated by Community Health Systems, inpatient admissions had dropped from 1,300 in 2009 to less than 250 in 2013. Additionally, the Emergency Room had also seen a sharp decline with 15 or fewer patients per day over the past several months. The release went on to cite changes in guidelines for inpatient admissions and federal reimbursement cuts under the Affordable Care Act that have not been offset by Medicaid expansion in Tennessee as contributing factors to the hospital’s demise. In light of the new reality, Haywood Park CEO Joel Southern said maintaining a full-service hospital was simply not sustainable. Although the latest to make a news splash, Haywood Park isn’t the only hospital that has closed in Tennessee or been reassigned as an outpatient clinic in recent months. Craig Becker, president of the

Tennessee Hospital Association, noted Scott County in East Tennessee has only recently reopened (and without obstetric care) after being shuttered for several months and two others have closed in West Tennessee. Both Humboldt General Hospital and Gibson General Craig Becker Hospital both closed earlier this year, and yet another hospital in Upper East Tennessee is currently on life support. A common theme among the recently departed inpatient facilities and the more than 50 others that have been deemed ‘in danger of closing’ is their rural location. “These rural areas are the most vulnerable,” Becker said, adding it was hard to envision how to adequately service these communities without hospitals. Joellen Edwards, PhD, RN, FAAN, president of the Rural Health Association of Tennessee (RHAT), concurred, noting hospital closures have a ripple effect. “You lose your prenatal care. You Joellen lose your primary care Edwards because they just can’t

make it when the hospital closes.” Edwards, whose research focuses on rural populations, is a professor and associate dean at East Tennessee State University’s College of Nursing. Looking at a number of the threatened hospitals in the state, she said, “Some of these are critical access hospitals, which means there is not another hospital for a minimum of 30 miles – or it could be even further away ... and probably is.” She continued, “In East Tennessee, if you live in our mountains, 30 miles is not an easy drive. Not having a hospital available in minutes … rather than an hour or more away … makes a difference literally to life and death.” In addition to losing access to care, Becker said the economic impact of losing a hospital is a topic that has been glossed over. “These are often some of the best paying jobs in these communities,” he said. Edwards pointed out hospitals are frequently the economic driver in rural towns and are sometimes one of the few jobs in the county that come with health benefits. Losing those jobs only exacerbates the problem of uninsured and under-insured rural populations. “I can guarantee you Brownsville is hurting right now because of losing

those jobs,” Becker said. He added CHS couldn’t be blamed for their decision to cease emergency and inpatient services … it’s simply an economic reality. “It certainly isn’t that the community doesn’t deserve to have a hospital. The reality is now you can’t afford to have one.” Even in communities that don’t close hospitals, Becker said he anticipated seeing service lines that are not typically profitable … such as oncology and obstetrics … dropped. “Cutting services isn’t much of a strategy, but we’re going to see a lot of that,” he surmised. He added lawmakers have, at times, accused the THA of ‘crying wolf’ as the association leaders have discussed the imminent danger to numerous hospitals in the state. “This is the kind of thing we’ve been predicting,” Becker said of the recent closures, adding he wasn’t happy to be proven right. The current closures, however, are feared to be the tip of the iceberg. Fueling the concern is that the federal funding cuts, such as DSH payments, are back loaded. Becker said Tennessee hospitals face $1 billion in cuts in the year 2019 alone. “Even with (Medicaid) expansion, it’s going to be difficult,” he said of the financial stressors hospitals face. “But (CONTINUED ON PAGE 12)

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JUNE 2014

Rural Hospitals, continued from page 1

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“Underserved areas will increase, which is likely to be the beginning of the unraveling of an area’s social fabric. For example, businesses looking to locate to a particular area will consider available medical care, just as they consider school systems, in their decisions. Truly, it will have a wide-spread ripple effect.” But these closings are not merely the result of what has happened in the last six months. For years, rural providers have been warning that failure to expand the public health program would put them in jeopardy. Becker explained, “The choice was left to each state, and Tennessee is one of the states that is not participating in the Obamacare provision of Medicaid expansion. In fact, most of the states that are not participating are in the South, and have large segments of their population in rural areas.” Many rural hospitals operate at a loss because they serve a high number of poor and uninsured patients who can’t always pay for their care. These hospitals, referred to as Disproportionate Share Hospitals (DSH), received reimbursements from the federal government. Because the Affordable Care Act intended for every state to expand Medicaid, thereby reducing the number of uninsured people who can’t pay their bills, the reimbursements for those DSH hospitals have been reduced. According to Kathleen Sebelius, former secretary of the Department of Health and Human Services, Tennessee began losing out on more than $6 million a day on January 1 when the federal government began picking up all the cost for covering people who newly qualified for Medicaid under expanded guidelines -- an offer that goes away at the end of 2016. It then phases down the federal match to a permanent 90 percent in 2020. W. Larry Cash, chief financial officer for the community health group that operates the hospital in Brownsville, says Ten-

nessee’s refusal to expand Medicaid was a “contributing factor” in the move to close the hospital. The 62-bed facility will become an urgent care clinic, treating minor illnesses and non-life-threatening injuries. A document prepared by the Rural Policy Research Institute Health Panel reports that states can opt to expand Medicaid at any time and receive the 100 percent federal match for newly eligible recipients. Arkansas is one of two states (the other is Iowa) that have been granted waivers from the Centers for Medicare and Medicaid Services (CMS) allowing Medicaid recipients with incomes between 100 percent and 138 percent of FPL to purchase health plans through the new marketplaces, using Medicaid payments to cover the costs of premiums. Paul Cunningham, executive vice president of the Arkansas Hospital Association, said, “We have chosen to implement a state-tailored version of the expansion. We are losing financially on the Medicare side, but we hope to balance things out with our private option insurance option. Yet, even in states that opted for Medicaid expansion, such as Arkansas, rural hospitals are still facing difficulties. Case in point, Crittenden Regional Hospital in West Memphis. With or without its Medicaid expansion, the hospital serves a high number of people who cannot pay for their care. Crittenden Regional is trying to address its financial problems by asking local residents to vote for an increase in the local sales tax to help save the hospital. The vote is scheduled for June 24. “Basically, what we’re seeing is just the beginning,” Becker said. “There will be more and more areas without acute care services. Similar situations have already occurred elsewhere in Tennessee, in Jellico and in Scott County. In the latter case, the hospital reopened, but without OB services. The big question is, ‘How do we keep a medical presence in these communities?’ If not a hospital, then what?”

Limited Access, continued from page 11 without expansion, we’ll lose even more hospitals and definitely see more services cut.” He added, “One-third of the hospitals in the state are losing money. I see other hospitals on the border … on the brink.” The Tennessee Plan proposed by Gov. Bill Haslam as an alternative to the Medicaid expansion program rolled out by the federal government, which has been accepted by 26 states plus the District of Columbia so far, is still stalled … although not yet dead. During the 108th General Assembly, however, state lawmakers added another hurdle to getting funding to Tennessee hospitals by passing a bill requiring Haslam to obtain legislative approval before accepting any expansion dollars. Becker, who called himself an eternal optimist, said he still believes the Tennes-

see Plan could pass. Unfortunately, he said it might take having more hospitals close to drive the message home. “Maybe there is going to be some pressure on some of these rural legislators when they realize they are losing part of the social fabric of their communities,” he said. From RHAT’s standpoint, Edwards said, “We have a stance that uninsured people in Tennessee should have an opportunity to be covered just like in Maryland where they chose to expand Medicaid.” Although she said the association doesn’t take a political stance as to which expansion plan is implemented, Edwards concluded, “We in the Rural Health Association do want to see a reasonable expansion of services to people in this state … it’s what they deserve.”

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MedicalEconomics BY BILL APPLING

Pour Over Ice and Shake Well

I enjoy looking at food magazines. One of the magazines I was reading recently was a summer edition that had some nice drink recipes, including Jimmy Buffett’s original Margarita. That interested me because I bartended all through college – and was a good one, if I do say so. I also noticed that almost every drink recipe included instructions to “pour over ice and shake well.” At this point, you may be asking, what does a margarita recipe have to do with healthcare? Hopefully by the time you finish this article you may see some analogy, and possibly even have an “aha moment.” I am blessed that my mom and dad, both in their early 80s, still live in the house they have lived in for years. From my house, I can be there between 15 to 30 minutes depending on traffic and how fast I drive. As their caregiver, it is important for me to be close. Mom has been a patient of Frederick Pelz, MD, for a number of years. She looks forward to her appointment with Dr. Pelz and his nurse, Sandra. Dr. Pelz is board certified in Geriatrics and Internal Medicine and is a physician in Baptist Medical Group. Mom was diagnosed with Alzheimer’s in May, 2013. Like most cases, Alzheimer’s usually comes on gradually and you start

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noticing little things – not thinking too much of it at first. But then you start noticing more. During one of the times I accompanied my mom to Dr. Pelz’s office, both he and his nurse Sandra, told mom and me about Baptist Onecare, MyChart. Of course, like many older Americans, my folks don’t have the internet (nor do they want it). However, this application enables my sister and me access to mom’s health records. Both of us downloaded MyChart to our iPhones, and we now have her information right at hand. MyChart was easy for me to access. Its support line was very helpful when I called. They were able to tell me what I was doing wrong and help me fix it. (Of course, most technical issues like this can be traced to a problem being somewhere between the chair and the keyboard.) There are a lot of things this system can do and I am discovering more useful things as I access it – labs, diagnostic results, consults etc. One thing that got my immediate attention was the segment regarding medications. My parents are just like anyone else’s – they have medicines in their medicine cabinet that have been there a long time. They never throw any of their pills away. One area, safety concerns me the

most. I will periodically look at their medications; the dates, dosages etc. I am able to email Dr. Pelz and he returns my email by the next day. At the beginning of mom’s office exams, we reviewed her medications and were able to address any concerns. (I used the word “we” to include Dr. Pelz, his nurse, and me, son and caregiver.) It really doesn’t matter if you refer to it as Accountable Healthcare or Affordable Healthcare, it can’t be done without information, education and action. As with all caregivers, you worry, you stress, and often you neglect your own health. But keeping up with my mom’s health has helped me be more informed about my own health issues as well. In my opinion, the majority of patients are not purposely non-compliant. They just need the help of a competent bartender who can pour over ice and shake well. And, as I mentioned in the first part of this article, I’m a good bartender and mom enjoys a good margarita. Bill Appling, FACMPE, ACHE, is founder and president of J William Appling, LLC. He is a national speaker, presenter and a published author. He serves as an adjunct professor at the University of Memphis and is on the boards of Hope House and Life Blood. For more information contact Bill at j.william.appling@ outlook.com.

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Hey Doc, What About the New Ones? By TIM NICHOLSON

Last month I sat with my son as he completed an online application for healthcare insurance via the Affordable Care Act Health Exchanges. I wasn’t there because he needed my help. He’s smart and web savvy like most of his generation. I’m just into this subject to be helpful to you. Anyway, he’s off mom and dad’s insurance. He’s paying for his healthcare for the first time ever. He’s making his own decision about healthcare providers. He actually wants to get a physical and develop a relationship with a doctor. But surprise, he finds the whole thing exasperating. It’s not for the reason you might think. No, it’s not the money. His frustration stems from how counter intuitive the process is to the way his generation works. His frustration is an opportunity for someone. It occurred to me that that someone might be you and that social media might be a way to bridge the communication gap, improve this generation’s perception of the healthcare community/ process and drive patients to you. Here’s how: First, 90 percent of those 18 to 24 years of age said they would trust medical information shared by others on their social media networks. A millennial’s network on social media is a group of people that is well trusted, which again, presents an opportunity to connect with them as healthcare professional in a new and authentic way. Be transparent. Share information that’s helpful, and include how to pay for things. They just want to know. Second, more than 80 percent of the millennial generation said that information found via social media affects the way they deal with everything – health, too. Healthcare professionals have an obligation to create educational content to be shared across social media that will help accurately inform this generation about health related issues and squash misleading information. The opinions of others on social media are often trusted but aren’t always accurate, especially when it comes to a subject as sensitive as health. Be present. Listen as much as you “tweet”. Share what you’d want your child to know and dialogue with them if they reach out to you. Hey, their doctor’s voice will cut through the online clutter but they also expect to be heard. Third, 75 percent of the 18 to 24 year olds said social media would affect their choice of a specific doctor or medical facility. This makes social media important as a tool to help accelerate positive and overcome negative word of mouth. It can attract new patients, minimize missed appointments, retain your patients, and win their referrals. Millennials are using social media to discuss memphismedicalnews

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everything in their lives including health and it is up to you to tune in. Fourth, millennials are the most likely group of social media users to trust social media posts and activity by doctors. They see doctors as respected members of society (yeah, really) who are also highly revered for their opinions when they are shared on social media, which is even more reason to help boost your reach as a healthcare provider and use social media to discuss health is-

sues, choosing healthcare plans, meeting providers, and getting well. This may require that you explore some new channels. Think Instagram. This generation is definitely a “show me don’t tell me” community of patients. Hmmm. Now that I think about it, millennials are not the only ones who can relate to these ideas. The percentages may vary but the impact could be more immediate to your business if middle-aged people find you online. But if you’re think-

ing about tomorrow and the new patients coming into the healthcare stream, consider connecting with millennials via social media. Their moms and dads will thank you. Tim C. Nicholson is the President of Bigfish, LLC. His Memphis-based firm connects physicians, clinics and hospitals to patients and one another through healthcare social media solutions, branding initiatives and websites. His column, “Hey Doc”, appears here monthly. Find him on twitter @timbigfish or email tim@gobigfishgo.com

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Streetdog Foundation, Continued from page 4 • • • • •

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Adopt Every Saturday, Streetdog is at a different location with an adoption event! Check the event page on their website (http://streetdogfoundation.com/ events/) to see where you can go meet some of their pups. You can also see some of the pets online at: http://streetdogfoundation.com/adoptable-pets/ Streetdog is serious about responsible adoptions. Their seven page adoption application is available on the website. Foster Fostering dogs saves lives. Melanie says fostering terms are flexible – indefinitely, a month, a week, or a weekend. You just have to let them know what you can do. Currently, Streetdog Foundation has about 115 dogs placed in foster homes. In a testimonial one person said: “Fostering for Streetdog Foundation has been the most refreshing and rewarding experience! They impress me with their focus and care for both pet and foster home. I have never felt forgotten or alone in taking care of my foster dog which could easily happen when trying to manage so many people and pets (all with different needs!). I know how much effort goes into keeping a program like this organized so I am deeply grateful. “ Volunteer Streetdog currently has about 50 to 60 volunteers and would always welcome more. Volunteers are needed to walk some of the kenneled dogs, help out at an adoption event, assist in planning a fundraiser or make home visits to make sure prospective adoptees are going to a good and safe home. There is a volunteer application online at http://streetdogfoundation.com/ volunteer-application/ Nominate your favorite non-profit or charity by emailing me at: pamela@ memphismedicalnews.com.

Memphis Medical News Follow us on Twitter 16

JUNE 2014

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Drowning in a Sea of Change MGMA Tackles Tough Issues to Help Practices Stay Aﬂoat By CINDy SANDERS

Value-based reimbursements, ICD-10 reboot, meaningful use, clinical integration physician alignment, transparency, PQRS, 5010 implementation, e-prescribing, stafﬁng and training, compliance, audits … oh yes … and caring for patients There’s no question the American healthcare system is in the midst of a sea of change as foundational rules are rewritten and a new infrastructure for care delivery is being put in place. While providers, practice managers and administrators are supportive of many of the concepts, it doesn’t make the transition any easier. With wave after wave of change washing over practices, it’s certainly ‘sink or swim’ time. For those trying to navigate the rough waters, the Medical Group Management Association’s extensive resources, advocacy and insights on critical issues help shore up practice managers as they fight to keep afloat. Laura Palmer, FACMPE, a senior industry analyst and subject matter expert for MGMA, said practices across the country are facing unprecedented change. While much of it is tied to the Affordable Care Act, a move to restructure the deliv- Laura Palmer ery and payment system was underway even before the landmark legislation was set in motion but has since been greatly accelerated. Today’s practice managers are being asked to alter ‘business as usual’ on most every front.

be true.” Therefore, she continued, it’s critical to regularly check coverage parameters and limits. Verifying benefits annually used to be pretty common. However, Palmer said that no longer works. “Best practices say we really need to check eligibility and benefits every single visit for every single patient,” she said. Although patient benefits tied to large employers or government entities still aren’t likely to change more than once a year, the same isn’t necessarily true for smaller employers. And, Palmer pointed out, people change jobs much more frequently now so even if a company’s plan hasn’t changed, the patient’s job status might have. Appropriate Staffing True access to care doesn’t mean simply having the coverage in place to allow a patient see a provider. The second part of the equation is having providers available to meet appointment demands within a reasonable time frame. “The days of a doctor’s office being closed for two hours over lunch are long gone,” Palmer said. In fact, she noted, many practices are looking at evening and/or weekend hours, group care settings and adding non-physician extenders to meet demand. From a reimbursement standpoint, practices must see enough patients to keep the doors open. From a quality standpoint, which now ties to reimburse-

ments, it’s critical to meet best practice parameters. Palmer noted evidence-based standards might call for a patient with a specific complaint to be seen within 48 hours. Practices have to figure out how to do that or risk the consequences … both of missing quality benchmarks and of lowered patient satisfaction scores, which also will soon tie into reimbursement rates. “You don’t want patients to go to the Emergency Room because they couldn’t get an appointment,” Palmer said. She added, “Practices need to make sure they have adequate staff coverage and a triaging system in place to ensure patients are getting the right care in the right environment in the right time frame.” Making New Friends “Practices that in the past might have been competitors in a particular community are now having to play nice with each other,” Palmer pointed out of new coverage rules and clinical integration models. Tied to the narrowing network trend, providers are finding payers and plans in-

creasingly dictate referral patterns. Palmer said new payment models, such as the formation of accountable care organizations, also are forcing more collaborations encouraged by both the financial setup and patient need. She added that while this kind of collaboration across care settings is generally viewed as a good move for quality patient care, it is different than traditional practice silos and will take time for providers to adjust to creating more community-based care than has been available in the past. Adjusting to New Payment Models Although the vast majority of reimbursements remain in the fee-for-service world, the switch to a value-based system is already underway. “The practical aspect of how we deliver care is already changing,” Palmer said. Practices have begun investing in changing technology and staffing models before reimbursements have caught up (CONTINUED ON PAGE 18)

Benefits & Eligibility Referencing the ACA impact, Palmer said it’s about much more than just expanding coverage. “It’s really a change in how insurance plans work,” she noted. Keeping up with who covers what, where, with whom and at what point has become increasingly complex as staff members drill down through eligibility requirements and benefits to figure out the bottom line for patients. While access might be expanding as more people join the insurance rolls, Palmer noted there has actually been a trend of narrowing networks. Not every physician or service provider is on every plan level under a payer. Adding to the confusion, not every family member is on the same plan. “We’re starting to see more differentiation, and it’s more difficult for the patient and provider, who needs to know where to send someone for referrals,” she noted. Whereas traditionally a lab company would have been on every plan under a payer, that’s not necessarily true today. A platinum plan might have more options than a gold or silver plan. “It’s a lot more complicated,” Palmer said. “You can’t depend on what you knew in the past to memphismedicalnews

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JUNE 2014

Drowning in a Sea of Change, continued from page 17 to the new way of doing business. Case managers, nutritionists and non-physician providers are being added … even when those services aren’t clearly reimbursable across most payers … because of the value they add to patient care. Currently, Palmer noted, only about 3-5 percent of a practice’s reimbursements are tied to quality metrics. While those numbers have remained pretty steady for the past few years as reported to MGMA, Palmer said she was eager to see if there is a change indicated in this year’s data. Anecdotally, she said MGMA staff members have heard from more practices that contracts are being negotiated with quality metrics in mind. Despite payments lagging a bit behind, Palmer said practices have really embraced the concept of value-based care. “It’s the right thing to do,” she stated. “I think physicians and practices know to really manage care, the best way is to look at total patient care.” ICD-10 Recognizing that not every provider in every setting is on the same page about the latest ICD-10 delay (with a new implementation date of Oct. 1, 2015 as confirmed by CMS in May), Palmer said it cropped up as the number one concern for 2014 in MGMA’s annual Medical Practice Today survey. Chief among worries are cash flow

concerns, vendor issues, testing, and adequate staff training. Palmer noted, “The delay in implementation is going to allow for more testing, and that’s got to be good for everyone.” She added, she thinks it will give vendors the needed extra time to resolve software issues and practices time to get the technology and training in place. However, Palmer acknowledged there would be some practices that once again put ICD-10 on the back burner only to panic again next year instead of using this time to really prepare. Practice Setup “Integration and alignment issues are still a big topic of conversation,” Palmer said. What is the most effective practice model? Should practices merge? Sell to a hospital? Specialize or become multidiscipline? The ‘correct’ answer, she said, truly varies depending on circumstances and location. “Healthcare is local,” Palmer pointed out. “What would work in Maine won’t necessarily work in Arizona.” The MGMA Lifeline MGMA’s resources can serve as a lifeline to practice managers who are treading water as fast as they can. Palmer stressed the organization’s role is not to make decisions for practice managers but to put them in a position to proactively

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i wish you well

peer networking to allow the exchange of information across regions. Where a practice manager might not ask the competing cardiology practice down the street how they are handling benchmarking or succession planning, MGMA membership provides a forum where that manager could talk to cardiology practices outside the market catchment area to find out how they are addressing those issues. Finally, she noted, MGMA offers the tools to allow managers to excel in their careers. “We provide professional development so we grow the next generation of practice managers,” Palmer stated.

Telemedicine, continued from page 10 of the participating rural clinics or hospitals can move from room to room, utilizing specialized technology that ranges from basic video conferencing to add-ons such as a digital stethoscope, an ultrasound machine or an ear, nose and throat scope, for example. “With some of the clinical assessment tools, we can integrate into these consults; it really is the closest thing to being there,” Johnson said. Additionally, as new needs are discovered, e.g. for telestroke or telecardiology, the ISI technology can easily be expanded with additional scopes, pieces, even a computer — to make it as flexible and cost-effective as possible. The video conferencing equipment is versatile enough to do double duty in also offering on-site access to CME credits for the physicians, Moore pointed out. As in so many other contemporary healthcare frustrations, cost seems to be the culprit, Moore said. “A lot of the challenges with telemedicine — and something that’s really starting to change — is the reimbursement for it.” An in-person consultation with a physician is reimbursed at a different rate than a telemedicine visit — which reimburses at “much less,” Moore said. “That’s been the big hesitation, I think, for a lot of people: how can they make enough money doing this to sustain the program?” ISI helps to

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make thoughtful choices based on their own unique set of circumstances. The goal, she said, is to “bring people vetted information – good information from reliable sources – so practice managers can make informed decisions.” She continued, “There isn’t one right answer. The joke around here is if you’ve seen one practice … you’ve seen one practice.” Although new delivery models are building local alliances, there is certainly still a competitive relationship among practices in a given geographic area. Palmer said a key benefit of MGMA is that it provides a safe environment for

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identify available grant sources to fund the equipment and get the program going, but, Moore said, once the grant money is gone they haven’t been able to sustain, due to limited reimbursements. Individual states are now starting to reimburse for many more procedures, he points out — Mississippi is leading the charge as one of 16 states that have open reimbursement for different levels of telemedicine. The House Energy and Commerce Subcommittee on Health is also seeking input on how 21st-century technology can improve healthcare and help patients — through government support of technology adoption and identification of ways the government is currently inhibiting the use of such technologies — good news, indeed, for telemedicine’s future. Slabach agrees that Medicare has already done some work on its telehealth reimbursement policy. “The real issue for Medicare is not that they don’t want to pay for it, necessarily, but that there’s a scarcity of data that shows the effectiveness of telehealth services,” he said. “A lot of research is being done now, however, so we should start seeing some peer-reviewed science coming out that could, with time, change Medicare’s mind on some of their payment policies.” Prices of the technology itself also seem to be improving. “The equipment and the software to run it have really become much more affordable,” Moore said. “A few years ago folks would spend typically $30,000 on a high-definition site; today, sub-$5,000.” Costs will vary, depending on the different subspecialties and the tools required, but outreach through telemedicine may be becoming a venture increasingly worth investigating. “People are looking at this as much more than just a technology decision,” Johnson said. “It’s now an access to care decision. We need to make sure that the hospital logistically is ready to serve potential patients in the most effective way possible.” Go online to: Americantelemed.org or isitn.com.

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Catching Fire: Lean Healthcare Transformations

When you need it.

Joan Wellman pioneered application of Toyota principles in healthcare; helps complex health systems facilitate large-scale change By LyNNE JETER

Last June, healthcare leaders from around the country – Stanford’s Lucile Packard Children’s Hospital, Oregon Health & Science University, UCLA Health, the University of Michigan Health System, and Vancouver Coastal Health – converged on the campus of Nemours Children’s Hospital in Orlando to see lean healthcare transformation in action. As usual, Joan Wellman, president of Seattle-based Joan Wellman & Associates (JWA Consulting), worked quietly and diligently behind the scenes, connecting hospital system administrators with companies in a strategic way to build a more reliable healthcare system using lean manufacturing principles. “A lean transformation is excruciatingly patient-focused,” said Wellman, who pioneered the application of Toyota principles in healthcare and helps complex systems facilitate large-scale lean healthcare transformations. “Every activity in the organization is assessed, relative to whether it adds value for the patient. As waste is removed, more time and resources are paid to the patient. It’s a very smart move to use these principles in a highly competitive environment because if you can do more for your patients with the same resources, you obviously have competitive advantage.” Wellman’s lean transformation journey began in the early 1990s, when she was consulting with Boeing on its lean manufacturing effort. “We were taking executive teams from Boeing to Japan,” explained Wellman. “In the course of two weeks, we took them by Toyota, Honda, Fuji, Xerox and other prize-winning companies to see how their manufacturing processes work. They saw the same principles in action at all these companies.” In 1994, Wellman recalls a Boeing executive, who served on the board of directors of a Seattle hospital, pondering whether lean principles could apply to healthcare. “At that time, none of us were healthcare consultants, but we saw the appeal,” memphismedicalnews

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she recalled. “We took a group of clinicians to Boeing’s final assembly line in Everett, Washington, and trained them in lean principles alongside operators on the line. Then we went back to the hospital and scratched our heads, trying to figure out how to make it palatable to healthcare professionals so the same principles could be applied. We looked at the waste and problems in hospital processes as we would in a lean manufacturing line.” Wellman spent a year at the hospital, better understanding the healthcare sector and the application of lean manufacturing principles to a healthcare setting. In 1996, Wellman became involved in delivering a series of lectures at Seattle Children’s Hospital about concurrently improving patient flow and quality while also reducing costs. In 1998, “it was time to put our big toe in the water,” said Wellman, who established JWA Consulting in 2000. A few years later, her book, Leading the Lean Healthcare Journey: Driving Culture Change to Increase Value (CRC Press), was published with co-authors Pat Hagan and Howard Jeffries, MD. The book chronicles healthcare improvements at Seattle Children’s Hospital, Memorial Care, The Everett Clinic in Washington, and Children’s Hospitals and Clinics of Minnesota. “I don’t see the lean principles movement slowing down at all because of the Affordable Care Act,” said Wellman, whose firm has grown to 22 associates. “I see an increased commitment and attention to building a more reliable system – with better quality, better safety, and better patient flow – at a lower cost. Applying the lean production system to healthcare is one of few models anywhere that simultaneously addresses all of those issues.” A lack of time, attention, and leadership passion are the primary barriers to lean principle implementation in healthcare systems, said Wellman. “Mainly, it’s the lack of time,” she

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JUNE 2014

GrandRounds UTHSC Graduates 672 Healthcare Professionals Last month the University of Tennessee Health Science Center (UTHSC) graduated 672 healthcare professionals. UTHSC Chancellor Steve J. Schwab, MD, presided over the ceremony. UT System President Joe DiPietro conferred the degrees and gave the charge to the graduates. The 672 graduates are from all six of the UT Health Science Center’s colleges. • 185 from the College of Allied Health Sciences; • 74 from the College of Dentistry; • 23 from the College of Graduate Health Sciences; • 157 from the College of Medicine; • 107 from the College of Nursing; • 126 from the College of Pharmacy. This year’s graduating class included 75 African-Americans, 12 Latino-Americans, and 147 graduates who came from out of

state to study at UTHSC. In addition, this graduating class was comprised of 411 women and 261 men. Sixteen of the out-ofstate dentistry graduates were Arkansans who earned their doctoral degrees from the UT College of Dentistry. Arkansas students come to Tennessee to train as dentists because their state has no dental college.

Saint Francis Hospital-Memphis Receives 5th Consecutive “A” For the fifth time, Saint Francis Hospital-Memphis received the top grade from one of the nation’s leading patient safety advocacy organizations. The hospital received an “A” in The Leapfrog Group’s Spring 2014 Hospital Safety Score The Leapfrog Hospital Safety Score rating system is designed to give consumers information they can use to make the best healthcare decisions for themselves or a loved one.

Catching Fire, continued from page 19 said. “Money is not the issue because it’s rare for organizations to look back and say they aren’t getting financial gains from doing this work.” The application of lean principles is also aggressively being used in another segment of the healthcare industry: the design of healthcare facilities around the world, said Wellman, whose firm is becoming well known for its work in what JWA Consulting refers to as Integrated Facility Design, applying lean principles

to the design and construction process. “We just finished up some work in the Netherlands, and helped design a healthcare facility in Saudi Arabia,” she said. “We’re also doing work in Canada and the U.S., whose clinical processes are fairly similar but social systems are quite different. All those factors have to be taken into account. One thing’s for sure: With the healthcare industry facing financial challenges and other market pressures, lean healthcare transformation is catching fire.”

Creating High-Powered Healthcare Improvement Engines Chapter 3 of Leading the Lean Healthcare Journey: Driving Culture Change to Increase Value (CRC Press, 2010), written by Joan Wellman with co-authors Pat Hagan and Howard Jeffries, MD, begs the question: What additional value do consumers in the United States receive for the extraordinary ﬁnancial commitment made to healthcare? “A 2008 Commonwealth Fund Report ranked the United States last in quality of healthcare among 19 comparative, developed nations,” said Wellman, noting the United States spends twice as much per capita on healthcare than other developed nations. “Not a stellar track record for a society paying top dollar.” The chapter, “Creating High-Powered Healthcare Improvement Engines,” provides a blueprint for change through: • Brutally honest leadership • Moving from ‘episodic’ project based improvement to continuous improvement; • Changing the mindset and the management system of the organization vs. just applying lean methods; • Developing lean leaders; and • Developing a long term plan that ensures that this is a pervasive effort. “Although the quantitative evidence demonstrates undeniable success, some of the emotional aspects of staff and clinicians engaging in improving the healthcare system are even more exciting,” said Wellman, after helping an organization through the early years of its lean transformation. “The sense of accomplishment – ‘we can do this!’ – is palpable. Even during the very early days of this organization’s lean transformation, improvement team members frequently expressed their enthusiasm for being engaged in the work. Other team members saw this as one of the most rewarding times of their careers. Still others keep asking, ‘When are we going to do this again?’ Such comments are the reward for the lean leader.”

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GrandRounds Health Choice Announces New Hires Health Choice, LLC, has announced that Ellen Abisch, RN, has joined Health Choice in the newly created position of senior director of Population Health Services, and LaTasha Jones has been named director of Provider Engagement. As director of Population Health, Abisch will be Ellen Abisch responsible for designing, implementing and managing population health and wellness programs for the Health Choice network. Health Choice will use the overarching data from the network of providers and LaTasha Jones payors to identify and prioritize the healthcare needs of the population to work with patients and physicians to improve patients’ health and the quality of care, while also reducing costs. Abisch brings more than 24 years of experience to Health Choice, having served most recently as manager of Benefits and Wellness for ServiceMaster. Prior to that, she was Global Health Promotion manager for General Electric in Schenectady, NY. She holds a Bachelor of Science degree in Nursing from Russell Sage College in Troy, NY, and a Master of Science degree in Nursing

from Adelphi University in Garden City, NY. In her new role as director of Provider Engagement, Jones will direct the implementation of Health Choice’s Valence Healthcare Vision database for the independent MetroCare physician practices. Post-implementation, she will lead the training efforts for physicians and practice staff on the database tools. She and her staff will train and coach the physician practice staff on improving the quality of the data and improving quality of care. She will also work closely with the MetroCare staff, leadership, and governance board on identifying and prioritizing opportunities in quality improvement. Jones has more than 17 years of experience in health information management and managed care. She has worked for Health Choice since 2012, serving most recently as the director of Operations. She has also served in a variety of managed care positions with companies including Accredo Health Group, Memphis Managed Care Corporation, and St. Jude Children’s Research Hospital. She holds a Bachelor of Science degree in Health Information Management from the University of Tennessee, Memphis.

Hospital celebrated the completion of the expansion and renovations of the hospital’s emergency room in May. The entire space within the emergency room has been redesigned to provide a more patient- and family-centered approach to care. The waiting room allows for direct patient access, making emergency staff available to answer any questions. The nurses’ stations in the ER is also open and accessible for patients and family members to walk up to discuss any questions or concerns, or request general information. Additionally, the new space creates a more efficient emergency room by changing patient flow. Nurses and physicians now use direct bedding, which involves taking patients back to a treatment room soon after they check in, so diagnosing and treating patients can begin sooner. The hospital broke ground last April to add 5,050 square feet to the existing facility and renovate the existing space. The new emergency room has an additional six new treatment rooms along with three triage rooms. A second floor above the emergency room will allow for future growth, as the hospital develops and advances the services it offers to meet the community needs.

Methodist Le Bonheur Germantown Celebrates Newly Expanded, Renovated ER

Campbell Clinic Opens Surgery Center in Midtown

Methodist Le Bonheur Germantown

The center, previously known as Midtown Surgery Center, was purchased by Campbell Clinic in October 2013. Located at 255 S. Pauline Street, this 18,000-squarefoot, ambulatory surgery center allows Campbell Clinic, the largest provider of orthopaedic and sports medicine services in the region, to double the size of its outpatient orthopaedic surgery space, adding four new operating rooms under its management and making surgical and block scheduling more convenient for its patients. The clinic has owned and operated Campbell Surgery Center on its Germantown campus since 2002. The Midtown facility operates as Campbell Clinic Surgery Center – Midtown, with the former becoming Campbell Clinic Surgery Center – Germantown. Campbell Clinic currently performs more than 7,400 surgical or block procedures on its Germantown campus annually, in addition to surgical capabilities the company’s surgeons utilize at numerous other area hospitals and medical facilities. The new outpatient surgery center will also further enhance the clinic’s training and research programs and complement other local partner facilities that include The Regional Medical Center at Memphis, Methodist Le Bonheur Hospital, and the Memphis VA Medical Center.

Campbell Clinic opened the doors to its midtown surgery center in April.

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JUNE 2014

GrandRounds SVMIC Declares $7.5 M Dividend State Volunteer Mutual Insurance Company’s Board of Directors has declared a dividend of $7.5 million to be returned to all policyholders renewing in the twelvemonth period following May 15, 2014. This is the seventh consecutive year SVMIC has declared dividends for its physician policyholders. Policyholders will receive the dividend in the form of a credit on the renewal premium. Additionally, rates will remain unchanged for 2014. Since SVMIC’s inception, a total of $335.5 million has been returned to physician policyholders.

Prime Urgent Medical Clinic Joins MedPost Prime Urgent Medical Clinic, located in Cordova, now has a new name: MedPost Urgent Care. The center becomes part of a new and growing national network of urgent care centers launched by Tenet Healthcare, the parent company of Saint Francis Hospital- Bartlett, to provide high-quality, efficient and convenient health services. The MedPost network currently consists of 23 urgent care centers in eight states. The walk-in centers are open seven days a week with extended hours to provide high quality care for residents in their communities. MedPost Urgent Care centers also provide follow-up care and specialty referrals when needed. They are staffed with physician specialists in primary care, internal medicine and emergency medicine, as well as nurse practitioners and other health professionals. The facilities are equipped with X-ray and laboratory capabilities and provide a comprehensive array of services ranging from flu shots and other immunizations to treatment for such things as upper respiratory infections, sinus problems, allergic reactions, fever, ear aches and orthopedic injuries.

UT Medical Group Welcomes Plastic and Reconstructive Surgeon Dr. Uzoma Ben Gbulie has joined the department of plastic surgery at UT Medical Group Inc. and been named assistant professor at the University of Tennessee Health Science Center. Gbulie earned his medical degree at the University of Lagos in Nigeria Dr. Uzoma Ben Gbulie and completed a residency in general surgery at Howard University Hospital in Washington, D.C. He furthered his training with a fellowship in plastic and reconstructive surgery at St. Louis University Hospital in St. Louis, Missouri, followed by a fellowship in craniofacial surgery at the UT Health Science Center and Hopital NeckerEnfants Malades in Paris, France. Gbulie is board certified by the American Board of Plastic Surgery and the American Board of Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.

JUNE 2014

Surgery. He is also a fellow of the American College of Surgeons. He cares for patients at 7945 Wolf River Boulevard in Germantown, where he specializes in aesthetic and reconstructive surgery for the face and body, including facial rejuvenation, body contouring, breast surgery, complex flaps for traumatic wounds, and reconstruction for cancers of the skin, head and neck.

CBU Graduates First Class of Physician Assistants Christian Brothers University (CBU) claimed the distinction of graduating the first class of physician assistants educated in the city of Memphis — 31 students who were admitted into the first cohort of the city’s first PA program. Dr. John Mark Scott, director of Physician Assistant Studies at CBU, says that the program is not only groundbreaking, but is also much needed in the city. The fact that this is the first program in Memphis is innovative in itself, but the PA as well as the BSN programs made CBU competitive in the healthcare market he said. There was a known need for a program of this sort after a survey gauging the need for physician assistants went out to 100 Mid-South physicians. Eighty percent of the physicians responded positively to the survey and most expressed a desire to employ these students upon their graduation. The CBU program, which currently numbers 106 students, is run and taught by Dr. Scott, along with six full-time and six adjunct faculty members. The cohort-based program consists of 110 credit hours offered over 27 months or seven continuous semesters.

West Cancer Center’s Daruka Mahadevan, MD, Presents Findings of Pre-Clinical Study Dr. Daruka Mahadevan, Director of the New Therapeutics Program at the West Cancer Center, presented findings of a pre-clinical study at the recent American Association for Cancer Research (AACR) meeting in San Diego, CA. The study looked at ways of improving Dr. Daruka response rates and duration Mahadevan of responses in patients with prostate cancer before or after they receive chemotherapy. Patients with castrate-resistant prostate cancer (CRPC) or those who failed hormonal therapy have poor survival rates. Androgen receptor (AR) is a cancer causing protein that binds to the male sex hormone, testosterone, and remains an important cause of CRPC progression. Despite recent phase III trials showing a survival advantage for AR inhibitors (e.g. abiraterone and enzalutamide), responses are often short lived, lasting generally less than one year. It has been demonstrated that blocking both the AR and a common cancer causing protein network (PI-3K/mTOR pathway in PTEN deficient prostate cancer) can prevent drug resistance. Greater than 50 percent prostate cancer patients have ac-

tivation of the PI-3K/ PTEN tumor suppressor pathway. We hypothesize that selecting patients based on genetic testing would identify those most likely to benefit and respond to this novel combination therapy. According to Dr. Mahadevan, significantly improving the response rates, duration of responses and overall survival in patients with CRPC with a good quality of life based on mechanistic biology is not incremental but is a big leap in the hope of curing this disease. Dr. Mahadevan and his team in collaboration with Dr. Bradley Somer conducted lab research on 5 different prostate cancer cell lines demonstrating increased anti-cancer activity of Enzalutamide or Abiraterone when combined with a panel of pan PI-3K/ mTor kinase inhibitors. Combination targeting of PI3K/mTOR & AR pathway resulted in significant cell killing. Mouse model studies are currently underway to evaluate the safety & activity of blocking the AR plus PI3K pathways. This study represents a novel therapeutic strategy for patients with CRPC to be evaluated in clinical trials. It will be the first trial of its kind in the U.S. based on this pre-clinical work.

Regional One Health Foundation Launches ONEpulse Magazine Regional One Health Foundation has launched a new semi-annual magazine for donors and friends of the Foundation called ONEpulse. This launch of ONEpulse comes at an exciting time for Regional One Health Foundation. With the February 2014 introduction of the Regional One Health system of health services, (formerly Shelby County Health Care Corporation or The MED), there begins a new vision for an expanded future of healthcare and philanthropy in our region. This new publication will chronicle Regional One Health’s path to becoming a world-class academic medical center through the generosity of the Foundation’s dedicated supporters. ONEpulse is available semi-annually to numerous donors and friends of Regional One Health Foundation.

OrthoOne Announces D1 Sports Training Facility Ground Breaking OrthoOne Sports Medicine & Orthopaedics and D1 Training and Therapy are pleased to announce the ground breaking of a 19,275 square foot D1 Sports Training Facility at 85 Market Center Drive in Collierville. Similar to the 23 other training facilities, this one will be a membership based center that will offer scholastic, adult, family and elite benefits including D1-on-1, bootcamp, rookie (ages 7-11), developmental (ages 1214), prep (ages 15-18), collegiate and pro training as well as physical therapy. Professional athletes associated with the D1 facility will be announced closer to the grand opening. Building of the facility has begun and completion is estimated for September. OrthoOne, currently a D1 Medical Partner, offers D1 therapy at both its Collierville and Olive Branch locations.

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Newlywed. Proud mother. Conquered breast cancer close to home. Just married, Grumeul and Johnny shared a dream of growing old together with her two children. But shortly after taking their vows, a diagnosis of breast cancer threatened their new life together. Grumeul and Johnny decided to fight her disease together, choosing West Cancer Center as their partner. Pioneering leaders in cancer research, the doctors at West unite groundbreaking technology with years of expertise to treat cancer, of all types, at every stage. Perhaps best of all, their world-class resources are here in the Memphis area; this keeps Grumeul and Johnny closer during times of sickness, and through the journey to good health. The fight against cancer is here at home. See Grumeulâ&#x20AC;&#x2122;s remarkable story and those of others who are fighting cancer, and find more information about West Cancer Center at WestCancerCenter.com or by calling 901.683.0055.

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