Medical News of Arkansas April 2014

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PHYSICIAN SPOTLIGHT PAGE 3

Elylem Ocal, MD

Arkansas joins other states narrowing healthcare peer review privileges for the Patient Safety and Quality Improvement Act of 2005

By LYNNE JETER

ON ROUNDS Diabetic Wound Care Saves Lives, Limbs and Money for the Healthcare System One of the most common mistakes primary care providers make with diabetic patients with a foot wound is to clean the ulcer, remove all the infected tissue, bandage it and then send the patient out of the office on foot ... 4

Preparing for ICD-10 Conversion Part 2 Practice management consultant shares the ‘4 Ts’ for physicians to consider Even though ICD-10 conversion has been anticipated for many years industry-wide, most physician practices haven’t had the resources or the inclination to start preparing before now ... 5

Two new peer review laws in Arkansas should make it easier for doctors to focus on the practice of medicine instead of peer review concerns.

“Peer review is such an important part of medicine … the more steps taken to make it objective for the provider who’s on the line, the better the decisions will be made,” said Janet Pulliam, a healthcare attorney with Watts, Donovan & Tilley PA in Little Rock, who frequently represents providers. “It’s important for people on peer review committees to know that Arkansas has public policy that supports this kind of objectivity.”

Sponsored by Sen. Cecile Bledsoe (RRogers), Senate Bill (SB) 790 improves the quality of healthcare and ensures that peer review committees for medical professional associations are afforded confidentiality, while SB 887 establishes

the Arkansas Peer Review Objectiveness Act. Both bills were approved during the 2013 legislative session.

In SB 887, Bledsoe noted the General Assembly found the peer review process “well established as the most important and effective means of monitoring quality and improving care within an institution,” and that “peer review is essential to preserving the highest standards of medical practice.”

“However, peer review that’s not conducted fairly results in harm to both patients and physicians by limiting access to care and patient choice, and it’s necessary to balance carefully the rights of patients who benefit by peer review with the rights of those who may be harmed by improper peer review,” she said.

Comparing the bills, Pulliam noted that SB 790 doesn’t require clinic practices (CONTINUED ON PAGE 10)

Genomically Directed Medicine Using Genetic Profile to Tailor Better Drug Treatment

BY BECKY GILLETTE

The concept of individual genetic testing to tailor the best type of medicine and treatment for patients is no longer just theoretical. Precision or personalized medicine using genetic testing for diagnosis and treatment of patients is now available and being used often in Arkansas.

“The take home message is that the time is now,” said Bradley Schaefer, MD, division chief of the University of Arkansas for Medical Sciences (UAMS) Medical Genetics Division, who also practices at the Arkansas Children’s Hospital. “It is amazing what can be done. This technology has moved out of the research lab and can be applied in clinics to help people. It is unbelievable what it does for children we see who in (CONTINUED ON PAGE 12) COURTESY OF UAMS/TIM TAYLOR

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PhysicianSpotlight

Elylem Ocal, MD

Assistant Professor of Neurosurgery, UAMS/Arkansas Children’s Hospital

BY LYNNE JETER

It doesn’t take long for Elylem Ocal’s personality to sparkle. The self-deprecatingly funny pediatric neurosurgeon from Istanbul admittedly has “a mix of Canadian–Arkansan English, with a Turkish accent.”

“This’ll never go away,” she joked.

“I make funny mistakes still, and my staff in the office teaches me one new word or phrase every week,” said Ocal, who also speaks Spanish.

She’s quick to admit she likes her first name – Elylem, means action of deed, usually in reference to a rebellious figure.

“I’m an action figure,” she joked, admitting that as the older of two daughters born to Tahsin, a government employee, and Adalet, a sales manager, she was very adventurous. “I liked to make experiments, which usually ended in accidents.

I call it ‘scientific curiosity,’ which helped me a lot in my career.”

Ocal’s youngest aunt, Sehnaz, cared for her while her parents worked.

“She’s like a sister,” she said, recalling that Sehnaz “taught me my first English words.”

An elementary schoolteacher, Mrs. Cakir, also influenced Ocal.

“She gave me a strong foundation and … always pushed me to my limits, sometimes too much,” said Ocal. “She always wanted to see me as doctor in a white coat. She was there for my graduation from medical school! It was a dream fulfilled to see her there, looking at me proudly.”

However, before medical school, Ocal considered other interests.

“As a teenager, I wanted to go in poli-

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tics, study international relations, or be a businesswoman,” she said. “My dream was to become the first female prime minister of Turkey.”

Ocal graduated at the top of her class at the Marmara University School of Medicine in 1999. As the first physician in the family, her relatives urged her to consider specializing in family or internal medicine.

“Everyone was so excited to have a doctor in the family,” she said. “They weren’t happy with my choice of neurosurgery! I love children and thought about becoming a pediatrician for a while, but the brain and entire nervous system was exciting to explore, challenging to understand. It was a puzzle waiting to be solved. Even with the invention of new technologies and better understanding of its function and structure, the brain and entire nervous system is still a mystery. It amazes me every day. That’s why I chose neurosurgery. Combined with

my love for children and passion for their wellbeing, I decided to do pediatric neurosurgery. I find it very fulfilling when a child smiles back at you after undergoing surgery.”

Ocal completed her internship and residency requirements at the Cerrahpasa School of Medicine at Istanbul University in 2004, followed by specialized training at Yale University School of Medicine, and a clinical fellowship in pediatric neurosurgery from British Columbia Children’s Hospital in Vancouver, Canada, that ended in 2011. “This is one of the well-respected places to train for pediatric neurosurgery,” said Ocal. “My mentors – Drs. Steinbok, Cochrane and Singhal – helped me define my path as a pediatric neurosurgeon.”

Ocal has a special interest in spina bifida and brain tumors, rare conditions that are challenging to treat.

“We still have a limited understanding of their genetic basis, etiology and pathologies,” she said. “These patients may need a lot of care, multiple treatments and/or surgeries. It takes a team to deal with these conditions, including the patient, parents, multiple medical disciplines and professionals. You have to push the limits most of the time and I like to do that!”

Ocal’s decision to relocate to Arkansas required little consideration.

“As one of the best children’s hospitals in the nation, Arkansas Children’s Hospital seemed a place that would provide me with opportunities as a new attending taking her first job,” she said. “It has more than enough amenities to serve a large population of patients with diverse clinical conditions to treat, research to do,

well-known mentors and experienced colleagues from every discipline. Most importantly, the passionate staff gives hope, care and love. Although Little Rock is the littlest place I’ve ever lived in, I found everything that I was looking for, including very good, welcoming people.”

Ocal, a Turkish folk dancer who’s done the international dance festival circuit and is now learning salsa dancing, recently discovered fishing and horse riding as new outdoor hobbies.

“Recently I did ice fishing and dog sledding, which was cold but fun,” said Ocal, who swims regularly, practices yoga, and is a certified Level 3 wine expert. “My next big thing will be duck hunting … and, of course, Razorback games!”

Of her “bucket list” items, Ocal wants to teach pediatric neurosurgery in developing and underdeveloped countries (“I always wanted to join Doctors Without Borders, but they don’t want neurosurgeons,” she noted), take a trip to the North Pole, watch aurora borealis with a hot cup of tea in hand, and skydive, “if I can find enough courage,” she said.

“It was difficult to be away from home, family and friends in Turkey,” said Ocal, whose mother lives with her six months every year. They often visit Evrim, a political analyst in Washington DC, and her family, including Mavi and Liam. “However, I like to explore new things, new cultures and new places. I’m also very adaptable. Every place I’ve lived was a new adventure. I met valuable people, friends, and colleagues from different backgrounds, cultures, religions, and languages. This gave me a better understanding and wider perspective of our world. I am truly blessed.”

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Diabetic Wound Care Saves Lives, Limbs and Money for the Healthcare System

BY BECKY GILLETTE

One of the most common mistakes primary care providers make with diabetic patients with a foot wound is to clean the ulcer, remove all the infected tissue, bandage it and then send the patient out of the office on foot.

If it is a weight-bearing wound, it will not heal unless it is treated with a special cast or brace to allow weight bearing, said Ruth Thomas, MD, an orthopedic surgeon who is director of the University of Arkansas for Medical Sciences (UAMS) Center for Foot and Ankle Surgery.

“For weight bearDr. Ruth ing ulcers, you must to Thomas find a way to get the patient’s weight off the foot whether it is by using a cast or brace, or a wheelchair to get all of the weight off the foot,” Thomas said. “The standards have been around for years that after you clean the wound and remove the dead tissue, the ulcer on the foot can’t bear weight. Even though it is a standard of care, a lot of our general practitioners don’t realize it. They

will do the wound care and turn around and let the patient walk out of the office in a shoe. When that happens, whatever they have done is essentially neutralized.”

Thomas said there is nothing extraordinarily new on the horizon for wound care. There is no drug out there to cure all wounds.

“We use a lot of topical agents to try to encourage a clean environment in the wound, but none of them have been shown to be miracle drugs,” she said. “They can assist, but they are not a sure cure.

“VAC therapy or negative pressure wound therapy can be very effective in healing wounds. It is certainly a therapy that has been shown to improve or speed up wound healing. It is basically a sponge that is applied to the wound, and then a little slit or hole is put in the covering of the sponge before applying a dressing that is not permeable. Then you cut a hole in it and attach suctions. The suction will pull all of the fluid out of the wound. It stimulates healing while drawing away unhealthy things like bacteria. So it can be effective even in wounds that are infected.”

Biological skin equivalents are skin replacements made out of viable cells

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taken from different sources such as pigs or humans. Biological skin substitutes can be put over clean wounds and the wound will epithelialize.

“The wound has to be healthy and the patient in good health or skin replacement therapies will not work,” Thomas said.

Researchers are finding simple soap products can cleanse wounds as well as more expensive products sold by commercial companies that have silver or other added special agents.

“No one has shown any of those are better than standard debridement and routine wound care,” Thomas said.

Thomas recommends healthcare providers take time to talk to diabetic patients about basic rules such as not walking barefoot, wearing closed shoes instead of open toe sandals, and not cutting their own toenails. See a physician at the first sign of any trouble with your feet.

“Management needs to be started quickly,” Thomas said. “You get in trouble with diabetics where there are little cuts in the skin, bacteria enters, the foot becomes infected, and can quickly deteriorate.”

Angela Driskill, MD, a wound care specialist at Baptist Health Medical Center-North Little Rock, agrees about the importance for diabetics to be instructed on foot care.

As the occurrence of all diabetic associated comorbidities rise in each individual patient, the Dr. Angela importance of nightly Driskill self-foot examination rises.

“The patient who has retinopathy and neuropathy will have more difficulty performing a nightly foot exam, and yet the importance of the nightly exam increases exponentially as the co-morbidities take their toll,” she said. “Teaching patients to examine their feet is almost as important as teaching them to check their blood sugar.”

As diabetes soars to epidemic proportions in the U.S., diabetic foot ulcers (DFU) have increasingly become a costly problem. In 2013 the Diabetes Association reported that 25.8 million Americans have diabetes, representing nearly ten percent of the population and 25 percent of seniors.

“Patients with diabetes have a 25 percent risk of developing a DFU in their lifetime,” Driskell said. “Of those who present with a DFU, 50 percent will be infected. Of the infected ulcers, 65 percent will have underlying osteomyelitis. It is well documented that osteomyelitis carries with it a high risk for lower extremity amputation. Once the lower extremity is amputated, that patient has a five-year mortality risk of 50 percent. Those statistics show the significant economic, physi-

cal and emotional impact to patients from a single diabetic foot ulcer.”

Driskell recommends the monofilament exam for pedal neuropathy be performed.

“Your monofilament exam may save your patient’s life,” she said. “As a quick reminder, the monofilament exam is done with a 10 g filament. The great toe, and then the first, third and fifth metatarsals are tested. Enough pressure is applied to slightly bend the filament and this pressure is held for two-three seconds. The test is positive if the patient fails to detect pressure at any single point.

“Once it is established that the patient’s foot is insensate at any of these points, custom fit insoles and diabetic shoes are indicated to prevent ulceration.

A diabetic shoe should be properly fit and if there is any structural abnormality a custom orthotic or insole needs to be made.”

Driskell said it is unfortunate that often patients order shoes online or purchase shoes from a retailer who does not have anyone trained in pedorthics. Typically the diabetic patient will need to have a larger toe box and adequate room for the toes, which often are deformed.

“If there is any mechanical abnormality, the insole will need to custom fit to offload this abnormality,” she said.

“Someone who specializes in pedorthics should assist your patient in obtaining the appropriate shoe.

“Even with good care of their feet, more than five percent of diabetics will develop an ulcer each year. When this happens, the basics of ulcer care should be started. This entails five basic steps: 1. Removing the offending callous and any dead tissue.

2. Clean the area and get a culture.

3. Treat infection: topically if localized, systemically if there is cellulitis.

4. Offload the ulcer.

5. Maintain a clean moist wound environment to promote healing.”

If the wound has not healed by 50 percent of the surface area in four weeks, the patient may need more advanced wound care.

Healing the patient’s wound is essential to the patient’s quality of life, and greatly lessens the financial burden on the healthcare system. The average cost of healing a DFU has been estimated at $26,000 with the cost of care of a diabetic who underwent amputation was estimated to be greater than $200,000.

Driskell said another important point is that healing a DFU often means the patient can stay in his or her own home and remain independent, whereas an amputation often leads to placement in a skilled nursing facility or extensive home care.

“Financially, it is much better for the healthcare system and for the health of the individual to have advanced wound care to accomplish healing of the wound,” Driskell said. medicalnewsofarkansas

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Preparing for ICD-10 Conversion Part 2 Practice management consultant shares the ‘4 Ts’ for physicians to consider “The group will need to meet Medicare has announced regularly,” she said. “Someone that testing will occur the week of Editor’s note: The Medishould create and be the March 3-7. A couple of fiscal intermediaries are requiring cal News series, “Preparing keeper of a work plan providers to register to participate in the testing. At this for ICD-10 Conversion,” that lists tasks, dates point, there’s no indication of another testing period, so if began last month with and who’s responsible. practices or clearinghouses miss that testing, there may not “8 Steps” for physicians We recommend keepbe another opportunity before October 1. to take now. This month, ing a single work plan implementing the “4 Ts” so that everyone can – Jennifer O’Brien, MSOD, Practice Management is the focus recommendation to see the progress, looming Consultant, KarenZupko & Associates Inc. facilitate a smooth transition. dates, and the specifics of the shared responsibility.”

Even though ICD-10 conversion has been anticipated for many years industryTesting: Communicate physician, biller, and clinical assistant, wide, most physician practices haven’t with your EMR, Practice and representatives from other functions had the resources or the inclination to Management Software (PMS) in the practice that have diagnosis coding start preparing before now. vendor, clearinghouse and as part of their work, such as a surgery It’s not too late to bring those pracbiggest payors concerning scheduler or ancillary service provider,” tices up to speed, said Jennifer O’Brien, if, when and how testing of said O’Brien. “The practice manager or MSOD, a practice management consulclaims with ICD-10 will be administrator, someone who has an untant with KarenZupko & Associates Inc. done. derstanding of the whole practice, should “Time is of the essence, however,” she “Medicare has announced that testalso be included. This will require true said. “Physician practices need to undering will occur the week of March 3-7. A teamwork. No one person should be shoulstand the enormity of this mandated trancouple of fiscal intermediaries are requirdering the bulk of the conversion for two sition that will affect their bottom line.” ing providers to register to participate in reasons: it’s too much and it’s too risky. If O’Brien recommends applying the the testing. At this point, there’s no indicaone person is doing almost everything and “4 Ts.” tion of another testing period, so if pracwins the lottery in July, the conversion will tices or clearinghouses miss that testing, fall apart.”

Team: Establish a work there may not be another opportunity Place a year-at-a-glance calendar in group for ICD-10 conversion. before October 1. That’s just Medicare; a common staff area so all employees may “The group should be a cross seccommunicate with other big payors to see the deadlines and target dates, sugtion of the practice, including at least one find out about their testing.” gested O’Brien.

BY LYNNE JETER

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Training: Make time for training sessions, both selfand instructor-led.

Self-training exercises are available to all physicians, such as running a report of the 25 to 75 most frequently used ICD-9 codes and then crosswalking those to ICD10.

“I have a client who’s pregnant with her first, and due in April,” said O’Brien.

“She’s already started on this process to teach herself how she’ll need to code and document differently and is planning on implementing necessary changes before she goes on maternity leave, so that when she returns in the summer, she’s not having to learn and prepare for ICD-10, in addition to adjusting to her new work-life balance.”

Specialty societies, state medical societies, hospitals, software vendors and consulting firms also provide ICD-10 training sessions for physicians and staff.

“Sign up for those sessions, go to them, listen and learn,” he said. “For most physicians, the dread associated with attending coding training is akin to that of having a root canal. It’s not going to be fun; it may be barely tolerable. Thing is, it’s not optional. In the past, when physicians considered coding training, it’s (CONTINUED ON PAGE 6)

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Predicting the ICD-10 Conversion Outcome Some pundits liken it to Y2K issue; others call underestimating change ‘dangerous’

BY LYNNE JETER

Controversy has swirled about a recent New York Times article stating that “some healthcare executives say predictions of a fiasco next Oct. 1 will prove as erroneous as those that said civilization would collapse on Jan. 1, 2000 ... the socalled Y2K issue.”

“It’s not going to be a shock to the industry to confront this,” Christopher G. Chute, professor of biomedical informatics at the Mayo Clinic, told the NYT. “We’ve literally had seven or eight years to anticipate it.”

Underestimating the conversion to ICD-10 is dangerous, say practice management experts.

“When you’re in a roomful of payors hearing them talk about how they’re worried, it scares me,” said Shelly Bangert, director of revenue cycle management for Hawthorn Physician Services Corporation, one of the nation’s leading healthcare revenue cycle Shelly management compaBangert nies. “Bigger payers are still expecting hiccups, and they’ve been working on this conversion for several years. We want to make sure practices are prepared.”

The cost of preparing the new system by the original implementation date of Oct. 1, 2013, has already been financially draining for some providers, who had sunk hundreds of thousands of dollars into meeting that deadline.

“Some hospitals had teams ready to go, consultants in place,” said Bangert.

“Then when the start date was postponed a year, everything was put on hold and money was lost. The payors were saying

the same thing, but they were losing millions trying to convert dozens of systems – antiquated, those inherited from buyouts, and new and upcoming systems – into one that would work with ICD-10 codes.”

Practice management consultants also expressed concern about the American Medical Association’s recent ICD-10 readiness survey that ended Jan. 31, saying it’s irresponsible of the national group to take such a step nine months out, and will only put physicians in a greater state of denial and therefore less prepared for the new conversion date.

“Some will run smoothly,” said Bangert. “Others will be total catastrophes. When you have a payor who’s just as worried about underpaying as overpaying, and reconciling and going through millions of provider contracts manually to make sure they’re all updated is overwhelming. That worries me. It won’t be a piece of cake. Some practices may go out of business as a result.”

Risk Assessment

Hospital informatics folks and administrators may have done a thorough job of preparing on behalf of the hospital but the situation physician practices face is different, said Jennifer O’Brien, MSOD, a consultant with KarenZupko & Associates Inc., a Chicago-based firm that has been specializing in physician practice management for 29 years.

“If everything isn’t perfectly in place for the conversion to ICD-10, it’s not reduced reimbursement rates (that) practices are facing; it’s zero reimbursement,” said O’Brien. “Reimbursement rates for physician services aren’t directly attached to diagnosis codes, but rather to CPT codes.

Diagnosis codes provide the justification for those CPT codes. It’s an all-or-nothing thing. We’re not talking about a risk

of reduced reimbursement on a claim-byclaim basis; the risk is zero reimbursement because the ICD-10 code isn’t accurate and specific to justify the CPT code.”

Decidedly, overall reimbursement flow will be slower, said O’Brien.

“Hospitals and larger healthcare organizations have larger IT and administrative support structures, profit margins, cash flow, established credit lines and longer revenue cycles than physician practices,” she said. “If a physician practice averages 45 days (from the date of service) in accounts receivable (before payment) and a hospital averages 105, the practice is going to feel it in the reimbursement by November 15, 2014, whereas the hospital payment cycle doesn’t have it receiving payments for early October services until later.”

Unfortunately, most practices haven’t been preparing well enough for the conversion date.

“One large, Midwestern specialty

practice client of ours has been preparing for the transition since 2011,” said O’Brien. “They’ve been doing bilingual coding (both ICD-9 and ICD-10 for some time) and still, they’ve bolstered their line of credit to cover six months of operating expenses and minimal physician salaries in anticipation of October 1, 2014.”

Regardless of physicians’ preparation for ICD-10 conversion, or lack of, the looming Oct. 1 coding change date will signal one of the most significant challenges the medical industry has faced, said Bangert.

“Likening it to Y2K is a risky over simplification” said O’Brien. “Y2K applied to two digits in the year fields of four digits, and while it had global implications in every industry and system, it was that contained. In other words, there was some analysis, hypothesis and possibly software changes to prepare, but that along with crossed fingers could be, and in fact was, enough. Not the case with ICD-10.”

Preparing for ICD-10, continued from page 5 been for the opportunity to improve their existing CPT and ICD-9 coding, which they’ve been doing for decades. They already have a base fund of knowledge and experience with those two coding systems.

This is completely new to everyone. Basic training on how to use the system – look up, differentiate, assign and document codes – is essential for every physician.

Everyone is starting at a base of zero.”

Tools: Identify all practice tools, processes and systems that use diagnosis codes.

“They’ll all need to be converted to ICD-10, and folks will need to be introduced to and trained in their use,” said

O’Brien. “At one of the early meetings, have your work team brainstorm to create a list of all affected tools, processes and systems. For example, if the practice contracts with an outside lab, which includes diagnosis codes in its orders form, the lab will likely issue a new form. Creating the list is just to understand the scope and delegate specific assignments so that everything can get done by October 1.”

The following list may facilitate tool identification: Billing system Charge tickets Claims/clearinghouse

St. Vincent is Arkansas’ beSt hospital

When the experts at U.S. News & World Report reviewed all 108 hospitals in Arkansas, including 22 in central Arkansas, they ranked St. Vincent as the No. 1 hospital in the state and listed us as “high-performing” in eight clinical specialties – more than twice as many as any other Arkansas hospital.

For 125 years, the Sisters of Charity of Nazareth have taught us that the patient comes first. We made the Sisters proud with the state’s only Magnet® recognition for nursing excellence and this high ranking from U.S. News & World Report.

A major thank-you to all our associates for their unwavering commitment to our healing ministry. We are also blessed to work every day with truly world-class physicians. Our associates and physicians make us No. 1.

Specialties Recognized Cancer Cardiology & Heart Surgery Gastroenterology & GI Surgery Geriatrics Nephrology Neurology & Neurosurgery Orthopaedics Urology See the complete rankings for yourself at health.usnews.com/best-hospitals

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Eligibility EMR discreet data templates ASC Encounter forms Orders (imaging, lab, therapy) Payment posting Patient information/history Prior authorization Referrals (incoming, outgoing) Registration

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Clinical trials/studies

Scheduling Subcontracted services Surgery scheduling Tumor/disease registry Voice recognition templates

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Success.

After beating liver cancer, UAMS has Carroll Martindale back in the swing of things.

I

n 2010, Carroll Martindale should have been waiting for a tee time at his favorite golf course. Instead, he was waiting for something entirely more important: a new liver.

After being diagnosed with liver cancer, Carroll was told he was a candidate for a transplant. While waiting for a donor, he underwent life-prolonging chemotherapy and radiation treatment at the UAMS Winthrop P. Rockefeller Cancer Institute, Arkansas’ official cancer research and treatment facility.

Three years later, the call came and Carroll returned to UAMS for a successful liver transplant.

Today, he is healthy, back on the course and thankful that the best things in life are worth waiting for.

Visit cancer.uams.edu or call: 501-526-2272

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Prescription Monitoring Program Making Major Progress Combating Illicit Drug Use

BY BECKY GILLETTE

Misuse of prescription drugs is second only to marijuana as the nation’s top illicit drug problem, and in some previous studies Arkansas ranked first in the nation in the percentage of youths aged 12 to 17 abusing prescription pain relievers, according to the National Survey on Drug Use and Health. In 2008, Arkansas ranked the second highest nationally in overall drug overdose deaths with 5.1 per 100,000 deaths resulting from nonmedical use of opioid pain relievers.

The state’s new Arkansas Prescription Monitoring Program (PMP) instituted in March 2013 is already making a big difference addressing that public health problem by reducing doctor shopping and pharmacy shopping, going from one doctor or pharmacy to another to get prescriptions filled for the same type of medication.

The number of flagrant doctor shoppers in the state had decreased 60 percent from the beginning of March 2013 through the end of the year.

Dr. Denise Robertson

“That is absolutely fantastic,” said Denise Robertson, PD, administrator of the Arkansas PMP. “The system is running well and our users are pulling information and communicating it to each other. PMP data is unique and provides an important tool for identifying questionable activity

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with respect to prescription drugs, such as doctor and pharmacy shopping, prescription fraud, and problematic prescribing.

The incorporation of information from the Arkansas PMP into current healthcare practice can be instrumental in reducing the devastating effects of prescription drug abuse in Arkansas.”

At nearly a year into the program, there were 9.6 million prescription records in the database. Controlled substance prescription data is collected from both in-state pharmacies and from out-of-state pharmacies that are licensed to deliver prescriptions to Arkansas residents. Pharmacies uploaded six months of back data before March 1, so there are now about a year and a half of records.

By January there had been about 400,000 reports requested by pharmacists and prescribers.

“That is a lot,” Robertson said. “They are using it. In addition to preventing people from getting multiple prescriptions that are not justified, the good thing about the program is that users can see other practitioners involved, and can get them involved in patient care and referral to treatment, if needed. The feedback we are getting is that people find the automated system easy to use and very helpful. Physicians are using it in their drug treatment programs, and they love it. They can see the patterns of usage in their patient, seeing how consistent they are in refilling prescriptions.”

Feedback from users is that the system is very easy to use. Software used by pharmacies can automatically upload the information into the database so no extra, time consuming steps are needed to comply. A report is created weekly.

In addition to reducing problematic use, the PMP can also verify legitimate use.

Robertson said it takes suspicion away from a person who really needs the medication so they don’t have to be worried about getting their pain meds. And physicians can feel assured they are writing a prescription for a

legitimate purpose.

Arkansas chose a software company that already operated PMPs in 22 other states.

“They are very knowledgeable in doing PMPs already,” Robertson said. “The program combines information from different pharmacies and pulls people together by names, alias, birthdates and addresses.

When a prescription comes in, a pharmacist looks into the system and sees prior fillings and prescriptions for that person so the pharmacist can make an informed decision if it is the proper time to fill the prescription, if there are duplications, and if there are potential drug interactions. The pharmacist brings up the information before filling the prescription.”

The program can reveal people who are consistently running out of pills early, and asking for a refill before it is time. It also shows if the patient has visited another practitioner for the same type of medication.

The program also provides recommendations for physicians on dealing with patients who may be abusing prescription drugs through resources links such as www. samshsa.gov. Also, the website www.arkansaspmp.com has signage pharmacies and clinics can put up at their intake and outtake windows stating, “We participate in the prescription monitoring program.”

The PMP is also an effective tool for emergency room physicians designed to reduce prescription drug abuse. These physicians frequently see patients about whom they have little previous information.

Jim Myatt, PD, branch chief, Pharmacy Services, Arkansas Department of Health, said a number of groups in the state came together to get the PMP legislation passed in 2011. “I have to give credit to State Drug Director Fran Flener, who convened a group that came together in 2010 to try to address the prescription drug abuse problem,” Myatt said. “The legislation had been tried previously a couple of times without success. She brought together a big group of interested parties, got consensus and the legislation passed due to her efforts.”

Flener said while the program is user friendly, during the 2015 legislative session there will be efforts to improve the legislation. Any dispensers or prescribers with complaints or suggestions for improvement should contact the PMP advisory committee.

While participation in the program is mandatory in some states, it is voluntary in Arkansas. Flener is hoping that a lot more subscribers and prescribers will sign up to increase the reach and effectiveness of the program.

“We’re trying to get more people aware that the program is there and to use it,” she said. medicalnewsofarkansas

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Help Patients Reduce Stroke Risk: Find Their Barriers to Better Health

BY BECKY GILLETTE

Primary care providers (PCPs) should never underestimate the amount of influence they can have in encouraging patients to take steps to reduce their stroke risk. For the best results, in addition to talking to patients about lifestyle changes to decrease their stroke risk, it is important to refer patients to resources that can help them lose weight, quit smoking and exercise, said Margaret Tremwel, MD, a neurologist with the Sparks Regional Medical Center Vascular Neurology and Memory Disorders Clinic in Fort Smith.

“Absolutely healthcare providers can get through to patients,” Tremwel said.

“As part of routine office visits, we certainly need to help patients look at ways to address their barriers about diet and exercise.”

One example of a barrier for stopping smoking might be other members of their household who smoke. In cases like that, Tremwel advises the patient that it can’t be just one person who quits; it needs to be the entire family that quits.

Tremwel also often tries to get through to patients by telling them that they should know a stroke doesn’t usually kill them, but leaves them in a nursing home unable to do basic functions like going to the bathroom alone.

“That is why you do what you can to reduce stroke risk,” she said. “Regarding diet, instead of telling people to adhere to a particular diet, I tell them to look at their demons. Don’t try to do everything at once. If you have several bad things you are eating, first cut out the donuts, and then the fried foods. Then, the first thing you know, you are eating a healthy diet.”

She also advises people that making lifestyle improvements like exercise can be easier with a group. Refer patients to local fitness programs at a YMCA or gym.

Tremwel highly recommends a new program in Fort Smith called the Healthy Congregation Ministry. This program provides nurses in many different denominations with educational materials, a blood pressure cuff and glucose monitoring sticks. The program also includes fun group exercise programs and classes on topics like heart healthy cooking.

The program has been modeled after similar faith-based health promotion programs in Memphis, Tenn., and in Mississippi.

“Some people respond more to a faith-based approach,” she said. “These wellness programs can be included as part of Bible studies, retreats and educational events.”

Tremwel said it is also important to get across the message to patients that the incidence of stroke is increasing in the U.S. and Arkansas in people under 65.

The Arkansas Department of Health (ADH) is also a good resource for patient tools to prevent heart attack and strokes. medicalnewsofarkansas

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Appathurai Balamurugan, MD, MPH, medical director, ADH Chronic Disease Prevention and Control Branch, said that PCPs need to be aware that Arkansas consistently ranks first or second in the country in stroke deaths, with stroke being the fourth leading cause of death in Arkansas.

“Every year about 1,800 people die due to stroke in Arkansas,” Balamurugan

said. “The number one risk factor is hypertension. It is one of the biggest challenges for the state both from a medical perspective and a public health perspective. About 35 percent of Arkansans have been diagnosed with hypertension, and a significant portion of adults who have it have not been diagnosed. Even of those diagnosed, only 50 percent have their blood pressure under

control. So this is a big problem for Arkansas. If we want to really bring down stroke deaths in Arkansas, prevention with blood pressure control is critical.”

There are some excellent and inexpensive medications for hypertension control including $4 generics. Balamurugan, a family physician who also works at the UAMS Family Medical Center one day (CONTINUED ON PAGE 10)

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Peer Review Law Changes, continued from page 1 to have peer review committees. “But for those who choose to do so, it protects the proceedings and communications as privileged without having to involve an attorney in every detail of the proceedings,” she explained.

SB 887 “is especially important now that more clinics are owned by hospitals,” said Pulliam.

For myriad public policy reasons, physicians would rather be monitored by their peers, said Pulliam.

“Yet at the same time, there’s some kind of hesitancy among physicians to report one another,” she said, noting that 1986 federal legislation established a national reporting databank which, after going through the peer review process that provides due process to a physician, is publicly accessible. It also encouraged realistic and thorough peer reviews by creating immunity for peer review participants.

Since then, various trends have affected the peer review process. Hospitals The American Health Lawyers Association (AHLA) recently published the second edition of the Peer Review Hearing Guidebook to address medical staff peer review and credentialing issues, including medical staff hearings.

The guidebook provides alternative approaches to various issues; its authors present “best practices” that reconcile the various points of view that may be found in healthcare law.

The AHLA will host a twopart program May 1-2, “Health Care Arbitration and Peer Review Hearings” at the Tremont Chicago Hotel in Chicago to qualify participants to serve as both an arbitrator and a hearing officer for the AHLA Dispute Resolution Service. Participants will receive a complimentary copy of the guidebook, edited by Allan Adelman and Ann O’Connell.

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have had two major rushes on physician practices acquisitions – in the 1990s and now. (Hospital-owned clinics are subject to Joint Commission review, not the employment of physicians.)

Also, until recently, the attorney who represented the hospital typically represented the peer review committee.

“Now we’re start- Janet Pulliam ing to see that sometimes those interests are competing or different,” said Pulliam.

For the most part, physicians haven’t kept pace with peer review process changes primarily because they spend an extraordinary amount of time keeping up with their profession, especially specialists and subspecialists. As a result, physicians often delegate public policy issues to others, said Pulliam.

“There’s a general awareness among providers and healthcare attorneys of the need for adequate protection in peer review meetings,” she said. “Traditionally, in Arkansas at least, the hearing officers have often been attorneys or physicians with close ties to hospital administration. In and of itself, that’s not a bad thing. But there’s certainly the appearance on the part of the provider in a peer review hearing that the hearing officer, if representing the hospital, might not be objective.”

Pulliam said she’s often hired after providers have completed one or two steps of the peer review process before the final hearing, She’s now being retained much earlier in the process.

“There seems to be more awareness on the part of the provider of a potential problem,” she said.

The Catalyst The federal Patient Safety and Quality Improvement Act of 2005 (PSQIA) was the impetus for the bill introductions at the state level. Passage of the PSQIA was geared toward decreasing the occurrence of medical error and improving the quality of healthcare via voluntary reporting by clinicians and healthcare practitioners of patient safety and quality information – without fear of the potential legal ramifications of disclosure.

Because of its state law counterparts, practitioners were unlikely to take advantage of the new federal law and voluntarily report patient safety and quality information. States were given the responsibility to consider how interpretations of peer review privilege laws would interact with the creation of a voluntary reporting system designed specifically to address patient safety issues, while also creating a stronger incentive for practitioners to report their patient safety data in accordance with the PSQIA. In December 2009, Eric Scott Bell, a healthcare attorney at Rose Law Firm in Little Rock, wrote in Arkansas Law Review’s “Make Way: Why Arkansas and the States Should Narrow Health Care Peer Review Privileges for the Patient Safety and Quality Improvement Act of 2005,” that Arkansas “should reduce its state statutory healthcare quality assurance and privilege to the furthest extent necessary to instigate reporting by healthcare practitioners.”

“The (PSQIA) provides a self-interest incentive for practitioners to report patient safety data to PSOs, envisioning a data system that could instigate muchneeded change in the U.S. healthcare system,” he wrote, noting that medical errors represent the eighth-leading cause of death in the United States. “But Arkansas’s peer review privilege undermines the effectiveness of this incentive because it provides the same amount of legal protection as the PSQIA without imposing or implementing the PSQIA reporting requirements. Without incentive, the businesses that provide healthcare will not report patient safety and quality information. The pervasiveness of medical error in the U.S. compelled Congress to act by passing the PSQIA, and now Arkansas must act by narrowing its peer review privilege and removing the only significant obstacle to the PSQIA’s vision of significantly improving the U.S. healthcare system.”

The American Bar Association Health Law Section has actively supported public policies to make peer review hearings equally objective to the hospital and to the provider.

“That’s a delicate, important balance,” said Pulliam. “It’s going to become even more so as more physicians become

employed by hospitals.”

Help Patients Reduce Stroke Risk, continued from page 9 a week, said clinicians need to make sure they work with patients ensuring that they take the medication, and that they have a prescription for a 60- to 90-day supply so the medication doesn’t run out. One of the common reasons for non-compliance is patients running out of medications and not being able to get through to the physician’s office for a refill or not making an effort to get prescriptions refilled.

Medication reminders like pill dispensers have been shown to increase medication compliance. And these days when most people have a cell phone, patients might consider a smart phone app medication reminder.

Balamurugan recommends that PCPs advise their patients to purchase a blood pressure monitor and monitor their blood pressure at least once per day. Studies have shown that checking blood pressure regularly increases medication compliance.

Patients often think they need to make big lifestyle changes to achieve a significant decrease in blood pressure. But even as little as a five millimeter decrease in blood pressure reduces stroke deaths 10

to 15 percent. Losing weight and increasing physical activity, cumulatively, can result in a five to ten point drop in blood pressure.

“Empower them with that,” Balamurugan said. “Also, I tell my patients to avoid canned foods, which are loaded with salt, and use frozen foods instead. Avoid salty foods like chips and sodas. Patients are surprised to learn sodas have salt in them, but indeed they do. Reducing salt intake can decrease blood pressure five to ten millimeters. The average American consumes 3.5 grams of salt per day, which is nearly double the recommended two grams per day. There are numerous studies showing reducing salt intake reduces blood pressure and reduces stroke deaths.”

Another major risk factor is smoking.

It is hard to bring the blood pressure of smokers into a normal range. Smokers can be referred to the Arkansas Tobacco Quitline at 1-800-QUIT-NOW (1-800784-8669) for free counseling and smoking cessation aids.

The American Heart Association and American Academy of Family Physicians have good patient educational materials

available that Balamurugan recommends.

“Additionally, many of the clinics have now started providing high-risk case management for individuals who are non compliant and don’t show up for regular office visits,” he said. “Clinics usually use a case manager or nurse call to make sure they keep appointments, and are keeping up with taking medications. With the emergence of patient centered medical homes, many are using the case management model for hypertension control, as well.”

Balamurugan also recommends the Million Heart Initiative, promoting the ABCS program (aspirin therapy, blood pressure control, cholesterol management and smoking cessation).

“Definitely aspirin plays a big role in stroke prevention,” he said.

Another way the ADH is involved is through the Arkansas Stroke Registry which is housed at ADH, and working with hospitals in improving care and ensuring that quality care is provided to patients from the time they enter the hospital to discharge and is based on the standards of care.

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Developing & Designing Effective Ambulatory Facilities

By CINDY SANDERS

The recession took a heavy toll on healthcare construction projects across the nation. However, as the economy has begun to improve, projects are beginning to move forward again.

Experts in healthcare real estate development and evidence-based design recently shared their insights with Medical News regarding the current state of healthcare construction projects in the ambulatory setting.

Real Estate Development

After seeing a number of plans put on hold over the last few years, Bond Oman, chief executive officer of OGA, a national full-service real estate development and project management firm based in Nashville, said there has been an increase in activity lately. While dialysis projects have remained fairly steady throughout, he said, the improved financial environment has resulted in an uptick in ambulatory surgery centers, urgent care centers and behavioral health facilities, among other sectors.

Oman said OGA presently has 21 projects in various stages of production. That is about a 30 percent increase over Bond Oman what the company was doing during the recession and quickly approaching pre-recession numbers, according to Oman. The company’s current portfolio includes work crossing the United States from California to Texas, Ohio to Florida.

One trend Oman said he is seeing nationwide is an emphasis on building smarter. He noted clients are trying to be more efficient by using basic green design to lower ongoing costs and keeping the building footprint as tight as possible.

“With the health systems we are working with, we haven’t done a total gold or silver building,” he said, referring to Leadership in Energy and Environmental Design (LEED) status. However, Oman added, many employ green design when it comes to choosing lighting, insulation, windows, paint, and other elements that increase energy efficiency. In most cases, developers are still trying to strike a balance between the cost of adding green elements and the payoff in reduced monthly costs.

As a whole, Oman said he thinks facilities are being built a little smaller on the front end but with room for growth. “We are designing a large number of our buildings for expansion,” he noted. Rather than creating facilities with shell space to be finished off later, Oman said he is really seemedicalnewsofarkansas

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When you need it.

ing more facilities completely finished but designed from the outset with the ability to blow out a wall for future outward expansion.

What might be surprising to some is how quickly pricing has rebounded. Oman noted those considering developing healthcare properties aren’t going to find any real deals. “The cost of doing business is getting back to where it was pre-recession,” he noted. “I’d say we’re definitely going to see an increase in cost because the economy is doing better … not doing great but definitely doing a little better each year.”

Oman noted landowners who survived the recession are holding firm on real estate prices. Many municipalities that dialed back or waived impact fees to try to entice developers a few years ago have reinstated, and in many cases increased, those fees. He said prices are also inching up for mechanical, electrical and plumbing.

In general, Oman said healthcare development doesn’t tend to be speculative in nature. “It’s a different animal than a lot of the other real estate sectors,” he said, noting a demonstrated patient base and service need must be present before most in the medical industry will consider building. He added that while some markets — including Dallas, Denver, Houston and Nashville — are “on fire” right now, there is still a feeling of cautiousness across most of the nation. Still, projects that were halted a few years ago are beginning to get the green light again.

An Evidence-Based Design Aesthetic

Where facilities are sprouting up, more and more of them are relying on research to inform design decisions.

Ellen Taylor, AIA, MBA, EDAC, an architect for more than 25 years, began volunteering with the Center for Health Design (CHD) before she began working with the organization in 2008. As director of research, the New Yorkbased Taylor helps spread the word about the best available information and latest credible research to help those creating healing spaces.

“The Center for Health Design is a non- Ellen Taylor profit based in California that looks at how the built environment can affect health outcomes … whether for the patient or staff,” she noted, adding CHD accomplishes this goal through research, education and advocacy.

While elements of evidence-based design (EBD) have intuitively been incor-

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(CONTINUED ON PAGE 12)

MARCH/APRIL 2014

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Genomically Directed Medicine Using Genetic Profile, continued from page 1 the past we would never have known what was going on. It happens almost every day in my clinics now.”

Although commonly referred to as genetic or precision medicine, Schaefer prefers the term “genomically directed medicine” better because it is more specific about using genetic information to direct treatment.

The concept is what has been known intuitively for a long time: people are different. Some people are more sensitive to certain medications, and other are less sensitive.

Some patients won’t be helped by a medicine that is a lifeline to others.

Arkansas has more people working in the area of precision medicine than most states with Dr. Bradley Schaefer eight or nine researchers including clinical geneticists and molecular geneticists working at UAMS. “We are moving out ahead,” Schaefer said. “We are being pretty proactive on this and setting up these really novel programs.”

Progress in the field has meant today’s genetic testing is far less expensive than in the past. The federally funded human genome product that sequenced the whole genetic code completed in 2001 took 13 years and cost $13 billion.

“Now we can do the same thing for $15,000 to $20,000 and get it done in about six months,” Schaefer said. “The positive side is that it is absolutely fascinating, the whole idea of knowing what is going on with genetic material and using it to improve treatments and health. The other side of the coin is that the information could be pretty darn scary. What if I find I have colon cancer risk? Could this information be used against me by insurers and employers? We don’t jump into tests without covering all the aspects of it with a patient.”

Genetic tests are not always covered by insurance.

“The tests are relatively expensive,” Schaefer said. “We have to work with each patient to learn if it is going to be covered and if not, do they still want it. Third party payers are just starting to learn about it. It is like other technologies like laptop computers. Prices will continue to get less expensive.”

Often people have a specific medical question in mind when undergoing genetic testing, and then there are those who are medically curious. One practical application is finding out how your specific gene type reacts to medications. The FDA currently has 155 medications that have been studied for how genetics will influence the drug.

The applications are of particular interest in psychiatry. A precision psychiatry program being established at the UAMS Psychiatric Research Institute (PRI) involves a multi-disciplinary team Dr. Jeffrey that includes Schaefer, JefClothier frey Clothier, MD, medi12

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MARCH/APRIL 2014

cal director, UAMS Psychiatric Research Institute, Jennifer Hunt, MD, chair of the UAMS Department of Pathology, William Bellamy, MD, and Charles Sailey, MD, of the laboratory medicine molecular pathology group, and Elvin Price, MD, UAMS Pharmacy School.

“The central dilemma of psychiatry is selecting a treatment for the individual patient,” Clothier said. “The diagnostic schemes of DSM IV and now DSM 5 are silent about causation of these syndromes.

The assumption that all patients with a particular DSM diagnosis have the same pathophysiology is certainly no more correct than the premise that all patients with a cough have the same pathophysiology.”

It is readily apparent that there are several contributors to depressive illness. This may explain why so many patients fail to respond to the initial treatment provided.

“At the current time, the majority of treatments for depressive illness are biological in nature,” Clothier said. “In general, one third of patients respond to the initial medication trial, another one third respond partially, and a full one third have little to no response. Said another way, two thirds of patients with significant depressive syndromes fail to respond completely to the initial medication. Many patients will fail multiple trials of medications.”

Precision psychiatry attempts to identify factors that may predict treatment response, clinical course, and side effects of treatment.

Previous attempts to do so were primarily based on clinical\behavioral subtypes of depression, melancholic depression vs. reactive depression for instance.

“This was somewhat useful, but still created a situation where a patient may not have received a full response to the treatment,” Clothier said. “Even before the complete human genome was sequenced, researchers found markers that related to treatment response. Some markers are related to the stress response such as the dexamethasone suppression test. Others have studied functional imaging to identify predictors of treatment response.”

There are dozens of studies that have identified candidate genes for predicting treatment response. At PRI they have begun to harvest some of this research.

“Over the past two to three years, we have used a commercially available genotyping service that looks at 11 gene markers and found that it was helpful in explaining a number of patients’ failure to respond and selecting specific changes in their regimen,” Clothier said. “However, the genes selected are a minority of the genes that have been identified in replicated studies. For this reason, we have selected a group of 40 genes from the literature that we believe are actionable.

In other words, we believe knowledge of the individual’s genotype on these genes will inform and influence the treatment of the patient. The gene array is being built

and tested and until it is ready for clinical use, we will rely on the limited commercially available products when necessary.”

Clothier said the information provided by the individual’s genotype is not diagnostic or deterministic of outcome. It provides part of the biologic context of the patient’s suffering. Psychotherapy such as cognitive and behavioral therapy is still important.

“Other markers such as markers of the immune system and fMRI will likely be the next step in precision psychiatry as we move forward to extend biomarker evaluation to other conditions,” Clothier said. “I would expect that we will likely be able to find genotypes related to severe side effects for specific medications that will avoid the trial and error approach.”

There are only a couple of commercially available genetic testing products. The PRI uses one that costs about $700. Some insurance companies have paid for it while others decline payment as ‘experimental.’

“Another product has a different set of genes and prices at $3,800,” Clothier said.

“I have not been convinced that this is a price point where I can say it is cost effective. Both services provide a genotyping of the principle enzymes related to medication metabolism. This can be useful information for a variety of non-psychiatric conditions.

Our current plan is to provide a separate genotyping for more of the genes related to drug absorption, distribution, metabolism and elimination.”

Developing & Designing, continued from page 11 porated in healing spaces for centuries, the formalized concept is relatively new. Taylor said a landmark 1984 study by Roger Ulrich, PhD — which found surgical patients with a view of nature had a reduced length of stay, required reduced levels of narcotics and had fewer complications — really captured people’s attention and launched the EBD movement. Since 2009, CHD has offered the Evidence-Based Design Accreditation (EDAC) to those who have proven their expertise in the field.

Although launched in the acute setting, Taylor said an increased awareness of how design impacts outcomes and a focus in the Affordable Care Act on engaging patients and keeping them out of the hospital have combined to create a recognition that EDB has an important role in outpatient settings, as well.

Another major trend for ambulatory spaces, she said, is the notion of flexibility and adaptability. It isn’t uncommon for one specialty to utilize a space two days a week with another specialty using it the rest of the time. “There’s this real need to be nimble,” Taylor said. “You can’t have a room that’s just designed for one purpose.”

Taylor added the concept of the patient-centered medical home has really had an impact on facility design, as well. It is increasingly common to see outpatient clinics and facilities, particularly community health centers, include larger multipurpose rooms that could be used for a support group, to teach a health class or to hold neighborhood meetings.

When working on safety net facility design in California, Taylor noted a center added a walking trail behind the facility so that a physician could prescribe ‘four loops’ to a patient in need of physical activity. To make it truly useful, a playground was installed in the center of the trail so parents could easily keep an eye on children, who coincidentally were also engaging in fun, physical activity playing outside. Similarly, some facilities have begun hosting a farmer’s market or have created a community garden and offer cooking classes to demonstrate the benefits of making simple, nutritious meals.

Along the same vein, Taylor said it is becoming increasingly common for outpatient settings to be embedded in retail locations. Vanderbilt One Hundred Oaks in Nashville is an example of having mixed health and retail venues under one roof.

Storefronts featuring supplies a patient needs to support a prescribed treatment sit next to national retailers featuring clothing or home goods. “It’s that concept of the one-stop-shop … if you can make it easier, you’ll have better compliance,” Taylor said.

The Mayo Clinic, she continued, offers another example of innovative, flexible design. “They started realizing not everyone needed to disrobe for every appointment with physicians,” Taylor said. To address this, ‘Jack and Jill’ rooms were created — two offices with an exam room in between them. One patient could meet with his physician in the office, while another patient was using the exam room … or a patient

might begin in the physician’s office and then move to the exam room to complete the appointment. “You have a more efficient flow,” Taylor pointed out. “You are freeing up that valuable exam space.”

In addition to efficiency, however, Adelante Healthcare in Arizona is also studying whether or not the setup might also reduce stress levels and lead to increased patient satisfaction. Is it easier to pay attention and be more engaged in a conversation with a physician when fully clothed in an office compared to sitting on an exam table in a cold room while wearing a thin gown?

Does the setting change patient behavior?

Does the setup change outcomes? Finding quantifiable answers to those types of questions is key to EBD. Adelante is also studying other design tweaks that might shift the traditional power concept between physician and patient. Something as simple as having patients and physicians sit side-by-side and share a computer screen while discussing treatment options or giving a patient the ability to choose what they wish to view on a video monitor while waiting to see a provider can shift the perception of power.

“That’s creating much more equality in care,” Taylor said. “There is a cultural awareness that needs to happen from a physician side, but then the design needs to accommodate that, as well.”

Taylor concluded, “Ultimately what we hope is that the design of the built environment is one tool in the toolkit to improve outcomes and improve health overall.” medicalnewsofarkansas

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GrandRounds UAMS Programs Receive More Than $450,000 in Grants The University of Arkansas for Medical Sciences’ (UAMS) Center for Dental Education, the planned internal medicine residency program in northwest Arkansas and the physician assistant program were among UAMS programs that received grants totaling more than $450,000 from the Blue & You Foundation and its parent company, Arkansas Blue Cross and Blue Shield.

The Blue & You Foundation awarded more than $350,000 in grants to UAMS programs including $150,000 to the Center for Dental Education and $95,000 to the physician assistant program, both in the UAMS College of Health Professions. A $77,500 grant was presented to the UAMS Northwest regional campus and area hospitals creating an internal medicine residency program to expand the number of resident physicians being trained in that part of the state. A $29,722 grant was awarded to the Safety Baby Showers program at UAMS South in Magnolia that has provided infant safety training and safety equipment to new or expectant parents in south Arkansas.

The Center for Dental Education also received $100,000 in support from Arkansas Blue Cross and Blue Shield.

Together the $450,000 in grants and support from the two organizations will allow for continued development or expansion of education, patient care and outreach programs at UAMS. The $95,000 grant to the physician assistant program will continue development for the program established in 2011, including raising awareness of the physician assistant profession among Arkansas physicians and preparing them to host students while they gain further clinical experience.

The first class of 26 physician assistant students started the 28-month master’s degree program in 2013. Physician Assistants are licensed medical providers who work with the supervision of a physician. They take patient medical histories, conduct physical exams, order diagnostic tests, diagnose medical conditions, write prescriptions and manage acute illness and chronic disease with the supervision of a physician.

The internal medicine residency program in northwest Arkansas, which hopes to admit its first group of eight physicians in July 2015, is continuing to move through the accreditation process. The three-year program will have a total of 24 residents, admitting eight each year, who will see patients at five hospital systems in the region — Mercy Rogers, Mercy Fort Smith, the Springdale-based Northwest Health System, the Sparks Health System in Fort Smith and the Veterans Health Care System of the Ozarks — as the physicians serve a

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post-medical school residency.

Funding to the residency program is for equipment and resources to coordinate the conferences and continuing education fees associated with providing CME credit to physicians who will be preceptors supervising the resident physicians at the hospitals.

The grant to the three-year-old Safety Baby Showers program, based at UAMS South in Magnolia, will cover program costs for a year of safety classes that have reached about 200 new or expectant parents a year in Ouachita and Columbia counties. Participants learn about motor vehicle injury prevention, safe sleep practices for infants, infant CPR and choke-safety, and home safety.

Healthcare Industry Solutions Developer SOAPware to Hold 2014 User Meeting in Orlando SOAPware, Inc. is pleased to announce the SOAPware User Meeting, in Orlando, Florida. The meeting will be held at the beautiful Rosen Plaza Hotel the evening of June 19th through June 21st, 2014. Attendees will receive unprecedented access to the SOAPware staff, partners, and 3rd party integrators through presentations and breakout sessions covering topics such as ICD10, Meaningful Use, and much more!

This venue is a perfect opportunity to immerse yourself in the SOAPware experience, meet and collaborate with other users, and get one-on-one time with many of the SOAPware staff.

Training Workshop: Due to the overwhelming demand for training during the SUM in 2012, a special preconference training workshop has been designed for Thursday, June 19th, prior to the SUM event kickoff later that evening. There is a separate charge for this Training Workshop, and seating is limited, so sign up today.

Personal Training Sessions: Additionally, many of our users asked for personalized, One-on-One Training Sessions tailored to address their specific clinic workflows One-on-One Training Sessions will be offered on Friday and Saturday of the this year’s SUM! Classroom training sessions are sold in one-hour increments and reservations are required. Seating is limited, so sign up early to guarantee getting the most out of your SUM 2014 experience.

For more information, or to register for the event, visit: http://usergroup. soapware.com/

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.

Baptist Health First to Partner With DOD to Provide LifeSaving eICU® Care Services to Fort Leonard Wood Hospital Baptist Health is the first civilian healthcare provider to partner with the Department of Defense to provide remote high tech intensive care coverage for General Leonard Wood Army Community Hospital in Fort Leonard Wood, Mo. Through this first ever civilian-military eICU pilot program, the Army hospital will provide its patients with an additional team of critical care specialists who will watch over their active duty military, family members and retiree patients 24/7. Baptist Health was awarded the five-year eICU care contract in August 2013 and services began at the 65 inpatient bed Missouri hospital in early January.

Each critical-care room with eICU technology is equipped with a camera, microphone, and speaker that enable staff in the control center to communicate with caregivers and the patient in real time. The two-way video and “cockpit-like sensors” of this advanced telemedicine technology enables the eICU care staff to detect even the slightest change in the patient’s condition and communicate more effectively with the bedside team. This model reduces the time between problem identification and enhances the quality of direct care intervention.

The hardware at General Leonard Wood Army Community Hospital includes four mounted cameras in their intensive care unit rooms and two additional mobile carts for use in the emergency room and inpatient medical surgical ward. The system is projected to save the Army hospital $1.7 million the first year, plus an additional $2 million each following year, according to Wiley.

By simply pressing a button the physicians, nurses or support staff at General Leonard Wood Army Community Hospital will be instantly joined by Baptist Health’s experienced critical care team to collaborate and treat their patients. The eICU care team includes certified physician intensivists and nurses who specialize in critical care and are highly trained to execute predefined plans; monitor lab, heart, blood pressure and oxygen saturations; or intervene in emergencies when a patient’s attending physician cannot be immediately present.

Staffed round-the-clock, every day of the year, the Baptist Health eICU care command center and its staff help hospitals like General Leonard Wood Army Community Hospital provide state-of-the-art intensive care to its sickest patients. The addition of eICU care will allow the hospital to keep sicker patients who must previously had to be transferred for various intensive care, said Wiley.

Nationwide, hospitals using eICU technology with critical care specialists have seen reductions in complications, reductions in mortality, and better outcomes for patients.

With the addition of eICU care at General Leonard Wood Army Community Hospital, Baptist Health now supports seven of its own hospitals, 10 community hospitals throughout Arkansas, and the first ever military base Army hospital located across our state borders.

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GrandRounds Northwest Medical CenterSpringdale Joins UAMSLed Program to Provide Emergency Stroke Care

ceived stroke consults through AR SAVES and 518 patients have received t-PA. Forty other Arkansas hospitals are participating in the AR SAVES program.

Northwest Medical Center-Springdale has partnered with the University of Arkansas for Medical Sciences (UAMS) to provide life-saving emergency care for stroke patients in the region.

Called AR SAVES (Arkansas Stroke Assistance through Virtual Emergency Support), the program uses a highspeed video communications system to help provide immediate, life-saving treatments to stroke patients 24 hours a day. The real-time video communication enables a stroke neurologist to evaluate whether emergency room physicians should use a powerful blood thinner within the critical 4.5-hour period following the first signs of stroke.

The AR SAVES program is a partnership between the UAMS Center for Distance Health, the state Department of Human Services, Sparks Regional Health System in Fort Smith, Northwest Medical Center-Springdale and 40 other Arkansas hospitals.

Arkansas, which ranks first in the nation in stroke death rates, had 1,560 stroke-related deaths in 2011, according to the national Centers for Disease Control and Prevention. The nationwide direct and indirect cost of medical and institutional care of permanently disabled stroke victims was $73.7 billion in 2010, according to the American Heart Association’s 2012 Heart Disease and Stroke Statistics.

Stroke patients are at high risk of death or permanent disability, but certain patients can be helped with the blood-clot dissolving agent tissue plasminogen activator (t-PA) if given within 4.5 hours of the stroke.

Since the program began Nov. 1, 2008, more than 2,038 patients have re-

UAMS College of Pharmacy Dean Named President of National Council UAMS College of Pharmacy Dean Stephanie Gardner, Pharm. D., Ed. D., has been elected to serve as president of the Accreditation Council for Pharmacy Education (ACPE) for the 2014-2015 term.

Elections took place in February during the ACPE Board of Directors Dr. Stephanie Gardner meeting in San Antonio, Texas.

Gardner became dean of the college in May 2003 and before her appointment as dean, she served for 13 years as a member of the college’s faculty. She recently served as a Fellow of the American Council on Education.

The American Association of Colleges of Pharmacy appointed her to the ACPE Board of Directors.

In 1989, Gardner earned her doctorate in pharmacy from the University of North Carolina. She held a research fellowship in cardiovascular pharmacology at Case Western Reserve University in Cleveland from 1989-1991. In 2001, Gardner earned a doctorate in education from the University of Arkansas at Little Rock.

The ACPE is an independent, national agency for the accreditation of professional degree programs in pharmacy and providers of continuing pharmacy education. The council also offers evaluation and certification of professional degree programs internationally.

WRMC Medical Complex Satellite ER Construction to Begin M&A Jones Construction submitted the successful bid for conversion of the WRMC Medical Complex Urgent Care Clinic into a Satellite Emergency Room. Work on the project has begun and is expected to be completed this spring. As reported earlier, the building was constructed to comply with healthcare code and only minor modifications are needed to prepare for installation of cardiac monitoring equipment and relocation of the CT scanner. The satellite emergency room will be licensed by the Arkansas Department of Health and provide 24/7 access to physician led medical care. Officials at the Arkansas Department of Health granted the verbal approval necessary for renovations to begin. Upon clarification of procedural questions final written approval will be granted.

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Terry Watson, Cromwell Architects Engineers; Gary Paxson, WRHS Chief Information Officer; and Robert Bateman, Cromwell Architects Engineers, review final plans for the WRMC Medical Complex Satellite Emergency Room.

Dr. Anthony Lamkin Joins St. Bernards Wound Care Center Dr. Anthony Lamkin has joined the medical staff at St. Bernards Wound Healing Center on a fulltime basis as medical director.

Originally from Jonesboro, he is a member of the American Academy of Family Physicians and is Dr. Anthony Lamkin certified as a wound care specialist by the American Academy of Wound Management. Lamkin is one of 11 physicians in Arkansas who hold certification as wound care specialists. He is also board certified in Undersea and Hyperbaric Medicine through the American Board of Preventive Medicine.

Lamkin earned his medical degree from the University of Arkansas for Medical Sciences and completed a residency in family practice at the Area Health Education Center Northwest, where he served as chief resident.

He formerly worked in emergency medicine and wound care in Batesville and worked part-time at St. Bernards Wound Healing Center for the last two years.

St. Bernards Wound Healing Center takes a multidisciplinary approach to healing complex wounds. Individualized treatment programs are developed using wound care pathways proven successful at centers nationwide.

Arkansas Urology Announces Acquisition of Epoch Health Brand Arkansas Urology, the state’s leading urology clinic, has acquired the Epoch Health brand, which created and launched the state’s first physician-run testosterone therapy clinic.

The Epoch Health brand pioneered the concept of a physician-run testosterone therapy clinic.

Arkansas Urology has also opened its first Epoch Health clinic. The clinic, located on E. McCain Blvd. in North Little Rock, provides comprehensive men’s healthcare. The site was formerly an Encore Health clinic.

Epoch Health created a physicianrun clinic model designed to help men as young as 29 enjoy an enhanced quality of life through proper health screenings, treatments and lifestyle modifications, specifically focusing on symptoms of low testosterone.

The medical term for low testosterone, or “Low T,” is hypogonadism, a disease in which the body is unable to produce normal amounts of testosterone.

Only within the past several years has the medical community acknowledged the prevalence and negative impact of Low T in men. Epoch Health focuses on each patient’s specific healthcare needs by conducting a thorough evaluation that precisely tests testosterone levels and a host of other potential symptom-causing conditions during initial and ongoing visits.

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ARKANSAS MUTUAL Industry Experience

37 years

5 years

Arkansas Experience

24 years

5 years

A.M. Best Rating

A (Excellent)

Not rated

A.M. Best Rating History

A (Excellent) or better for 30 consecutive years

None

Operations

Managed 100% in-house with some of the lowest expenses in the country

Managed pursuant to a contractual agreement with an affiliated entity that is partially owned by management of Arkansas Mutual and outside investors

Percentage of premium spent on operating expenses

14%

54%

Surplus as regards policyholders

$464.0M

$2.5M

Total dividends returned to Arkansas physicians

$12.6M

$0

Dividends returned to Arkansas physicians in the last three years (2010, 2011, 2012)

$6.6M

$0

Overall percentage of premiums returned to policyholders in the form of dividends in the last three years

9%

0%

This chart contains information extracted from the December 31, 2012 Statutory Annual Statements of each company and from other publicly available sources.

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