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PHYSICIAN SPOTLIGHT PAGE 3

Robert A. Mericle, MD ON ROUNDS Stroke Risks in Women New guidelines address risk factors unique to women ... 5

A New View on Stroke Research Everyone wants to build a better mousetrap … but building it over and over again isn’t very efficient. Finding a way to keep the ‘mousetrap’ infrastructure in place while adding new features based on a collective body of knowledge is fundamentally the basis of the new National Institutes of Health Stroke Trials Network ... 6

Beating the Odds: Medical Breakthroughs Decrease Stroke Risk for AFib Patients By MELANIE KILGORE-HILL

Stroke is the fourth leading cause of death in the United States and the leading cause of disability. Fortunately, innovations in technology and medicine are making prevention more attainable than ever before in high-risk patient groups.

AFib & Stroke Risk

Christopher Ellis, MD, cardiac electrophysiologist at Vanderbilt Heart and Vascular Institute, said atrial fibrillation makes patients five times more likely to have a stroke. In AFib, which affects an estimated 3 million Americans, the irregular heartbeat makes it harder for the upper and lower chambers to work together, leading to an increased likelihood that blood will pool and clots form. “When it comes to AFib management, the most important thing in my mind is how I can prevent stroke,” said Ellis, who specializes in invasive atrial fibrillation therapies. “A lot of people think if you have a history of AFib but aren’t currently in AFib, you don’t need treatment, but it doesn’t take long for it to flip in and throw a clot. The risk of stroke is the same for patients with intermittent or chronic AFib.” (CONTINUED ON PAGE 4)

A Look at the State’s CON Program

A Master Plan

Last year, members of the 108th Regular Session of the Tennessee Legislature voted unanimously to extend the life of the Health Services and Development Agency through June 30, 2017. This action ensured the state’s certificate of need (CON) program would continue, uninterrupted, into its 44th year ... 8

Healthcare’s Evolving Delivery Needs Change the Design Process By CINDy SANDERS

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Long before the ribbon is cut … before the very first rendering is unveiled … the real work of today’s healthcare design typically begins in a boardroom with a list of thought-provoking questions and a notepad. While ‘form follows function’ has been a design staple for many years, the architectural commandment has traditionally focused on crafting the optimal space within a single facility to meet a client’s needs. Yet, the changing healthcare delivery landscape means architects now must consider not only what happens inside the four walls of a healthcare structure but also how that facility must interact and function within the larger community. (CONTINUED ON PAGE 9)

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Deep Brain Stimulation for Parkinson’s Disease By Hong Yu, M.D., Assistant Professor of Neurological Surgery

Parkinson’s disease is the second most common neurodegenerative disease, affecting approximately 4 million people worldwide. The motor symptoms of Parkinson’s disease, including tremor, rigidity, and bradykinesia, can make simple tasks impossible to perform. Parkinson’s disease is caused by the progressive loss of dopamine producing neurons in the substantia nigra, which disrupts the normal balance of circuits that are necessary for the production of movement. Dopamine replacement is the main medical therapy for Parkinson’s disease. Unfortunately, as the disease progresses, the effectiveness of medications often declines and side effects become more disruptive. It is estimated that 28% of Parkinson’s patients suffer from debilitating motor symptoms despite optimal medical therapy. Deep brain stimulation (DBS) is a surgical therapy where electrical current is applied to targeted locations in the brain through implanted electrodes. These electrodes are connected to a programmable internal pulse generator (IPG) buried under the skin. High frequency electrical stimulation at precise locations in the brain is thought to restore the balance of the circuits that are disrupted in Parkinson’s disease. DBS is reversible and adjustable, thus providing a safe and adaptable treatment method for a progressive disease. Preoperative medication responsiveness is the best predictor of DBS efficacy. In general, the motor symptoms that improve with dopamine replacement therapy will be alleviated by DBS. The ideal DBS candidate is disabled from Parkinson’s without medications but can function independently with medications. DBS can extend the period of time that the patient is on medications and reduce unpredictable off-medication periods. Contraindications to DBS include dementia, inadequately treated psychiatric illness, extensive brain atrophy, and concurrent medical conditions that preclude safe surgery. Patients should not undergo DBS implantation if they anticipate needing future MRI scans of the body. The specific symptoms treated by DBS depend on the location of the implant, which is carefully selected for each patient by a neurologist and neurosurgeon. Cognitive and psychiatric factors are also considered as different target locations can have varying impact. Therefore a team approach to DBS therapy is critical to achieving a successful outcome. The surgical procedure for the implantation of the DBS unit involves the following basic steps: 1) image-guided target localization, 2) physiologic target confirmation using microelectrode recordings (MERs) and test stimulations, and 3) implantation of final DBS lead and connection to the IPG. Traditionally, image-guided target localization

begins with the identification of visible landmarks on brain imaging. Next, the target of choice is located by measuring known distances relative to those landmarks. Unfortunately, this indirect method does not account for individual anatomic variability. Improved technology in magnetic resonance imaging (MRI) allows direct visualization of deep brain regions, which can help account for some individual variation. After selecting the target point, an entry point is selected such that the trajectory avoids vessels, which reduces the incidence of bleeding complications. The translation of the target coordinates from the image space to the patient’s physical space is traditionally performed using a rigid frame that locks the patient’s skull to the operating table. More recently, frameless systems have been developed with equivalent accuracy and improved patient comfort. Physiologic target confirmation is performed in the operating room with the patient awake. Intraoperative physiologic mapping consists of MERs, test stimulations, or both. MER can discern different brain areas based on characteristic neuronal electrical firing patterns. Identification of areas where neuronal signals correlate to movements in specific areas of the body can help refine the stimulation target even further. Test stimulation provides the final confirmation of the optimal target location. Clinical efficacy, side effects, and therapeutic window are noted for each test stimulation area. After the desired physiologic target has been determined, the actual DBS electrode is inserted into that final target. The electrode is then connected to an extension wire, which is tunneled under the skin and connected to the IPG, which is generally implanted over the chest wall. General complications of DBS surgery include intracranial hemorrhage, lead migration, skin erosion, and infection. The risk of intracranial hemorrhage is <3%, causing permanent deficits in <1% of cases. Infection occurs in <10% of cases, which usually requires hardware removal as well as antibiotic therapy. Stimulation-induced adverse effects can be reduced by changing stimulation parameters or turning the DBS off. While DBS is not a cure for Parkinson’s disease, it has become an important part of our armamentarium. The goal of DBS is to control the motor symptoms of Parkinson’s disease and improve patients’ quality of life. Prospective randomized controlled trials demonstrate that DBS is the standard of care for appropriately selected patients with Parkinson’s disease. REFERENCES:

1. Lang AE. When and how should treatment be started in Parkinson disease? Neurology. 2009;72(7 Suppl):S39‐43. 2. Weaver FM, et al. Bilateral Deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA. 2009;301(1):63‐73. 3. Yu H, Neimat JS. The Treatment of Movement Disorders by Deep Brain Stimulation. Neurotherapeutics 2008;5(1): 26-36.

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PhysicianSpotlight

Robert A. Mericle, MD — Brain Repair Using New Solutions to Tackle Complex Neuro Issues By KELLy PRICE

Robert A. Mericle, MD, likes to get into a patient’s head and fix things. The neurosurgeon specializes in treating brain aneurysms, brain and spinal arteriovenous malformation (AVMs), brain tumors, trigeminal neuralgia, Moyamoya disease, carotid stenosis, and stroke, among other neurological issues. Although Mericle is internationally recognized as a leader in performing minimally invasive treatments of brain aneurysms and AVM through needle stick using liquid embolic agents, to his patients, he is simply known as “Dr. Miracle.” His two favorite procedures, he said, involve eliminating the severe pain of trigeminal neuralgia, which has been likened to being hit in the head with a cattle prod, and performing brain bypasses to prevent strokes for sufferers of Moyamoya disease. Moyamoya disease is a rare and progressive cerebrovascular disorder caused by blocked arteries at the base of the brain in the area of the basal ganglia. It is characterized by a narrowing of the internal carotid artery, middle cerebral artery, and anterior cerebral artery, leading to irreversible blockage of the main blood vessels to the brain as they enter into the skull. Moyamoya disease was first described in Japan in the 1960s. Since then, cases have been reported in individuals in the United States, Europe, Australia, and Africa. The singsong name, which means “puff of smoke” in Japanese, is used to describe the way the tangle of tiny vessels that are formed to compensate for the blockage look when imaging the brain. The disease primarily affects children, but it can also occur in adults, often striking in the third to fourth decades of life. Children with Moyamoya present with symptoms of stroke, such as weakness of an arm or leg, or seizures. Adults tend to present with ischemic or hemorrhagic stroke. Mericle explained treatment starts with blood thinning therapy, usually aspirin, to help the blood travel through the narrowed intracranial vessels. Surgery is indicated if there are worsening symptoms. An extracranial to intracranial (EC-IC) bypass that provides a direct and immediate supply of fresh blood to the

affected area is the preferred treatment whenever possible. An expert in the procedure, Mericle is president of Nashville Neurosurgery Group PLC, located at Medical Plaza One on the campus of Saint Thomas Midtown Hospital. Prior to going into private practice, he performed the majority of EC-IC bypass operations done at Vanderbilt University Medical Center and Monroe Carell Jr. Children’s Hospital over the past decade. Mericle and partner Arthur Ulm, MD, who are both nationally recognized leaders in the treatment of trigeminal neuralgia and have extensive experience performing surgery for hemifacial spasm, were principals with HW Neurological Institute, which merged with Tennessee Brain and Spine last year to form the Nashville Neurosurgery Group. A past

president of the Tennessee Neurosurgical Society, Mericle is a Fellow of the American Association of Neurological Surgeons. Growing up in a tiny town outside Barlettsville, Okla., where not one of the 3,000 residents had gone to college, it’s doubtful Mericle could have foreseen the path his career would take. However, he recalled, “I knew I wanted a progressive career, like the eye doctor I went to in Barlettsville, and that college was necessary for that.” He enrolled at the University of Oklahoma, graduating in the top 3 percent of a class of 25,000 students, and was named to Phi Beta Kappa … just one of many accolades he has received throughout his education and the course of his practice. In high school science classes, Mericle was always fascinated by the way the brain interprets information from sound and light waves and decided he wanted to pursue that line of investigation. After graduating from Oklahoma summa cum laude with a BA in psychology and BS in zoology, Mericle applied to medical school. He was accepted to Vanderbilt University School of Medicine and awarded the prestigious Canby Robinson Scholarship – a four-year, full-tuition merit scholarship. After graduation from Vanderbilt, Mericle continued with a general surgery internship and neurosurgery residency at the University of Florida with a two-year neuroendovascular fellowship at the State University of New York in Buffalo. Upon completing his residency at Florida, he served as chief of Endovascular Neurosurgery Service and program director for the university’s fellowship program in his specialty.

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In 2004, Mericle received a call from George Allen, MD, who was chair of Neurosurgery at Vanderbilt at that time. Allen, who remembered Mericle from his student days in medical school, offered him an opportunity to return to Nashville to help build the academic medical center’s cerebrovascular and endovascular neurosurgery program. “I was glad to return to Vanderbilt,” Mericle said. “My wife and I love Nashville.” Since his return 10 years ago, Mericle has treated thousands of neurosurgery patients and has taught dozens of physicians from around the country. Widely published, he has contributed to more than 100 books and medical journals on neurology topics. When Mericle ponders the changes that have occurred in neurosurgery since he started his training, he is most aware of the rapid growth of the use of technology. “We used to have to get to the brain by going though the cranium and opening up the skull. Now we have five or six ways to treat an aneurysm that are so much less invasive and less difficult for the patient,” he observed. “I can use 600 milligram thread to bypass a blockage and sew the two sections together to an artery in the scalp,” he continued of advances in the field, adding this provides an increased blood flow expansion allowing the vessel to actually grow and get stronger. When he isn’t busy repairing brains, he loves spending time with his family. Mericle’s wife is in her last year of training as a medical pharmacist, and the couple has three children, ages 19, 17 and 11.

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Beating the Odds: Medical Breakthroughs Decrease Risks, continued from page 1 According to national research, AFib is responsible for approximately 25 percent of all ischemic strokes, and AFib resulting in cardioembolic stroke is associated with a mortality rate of 30 percent at one year.

Stroke Risk Factors

Ellis said the most current risk predictor for stroke is the CHA2DS2-VASc score. A modification to the earlier CHADS 2 score, the newer iteration adds three additional risk factors. Patients are assigned points for each risk factor, with a maximum score of 9. Factoring into the equation are Congestive heart failure, Dr. Christopher Ellis Hypertension (consistently above 140/90 mmHG), Age (≥ 75), Diabetes and prior Stroke (or TIA or thromboembolism) plus Vascular disease, Age (65-74) and Sex (gender). The score is calculated by allotting one point to each item except stroke and age. Prior stroke, TIA or thromboembolism is weighted at two points, and age is either scored at one point from 65-74 or two points at age 75 and above.

Medication & Stroke Prevention

While a score of zero indicates low risk for patients, scoring a single point moves a person into the moderate risk category. For these patients, physicians often prescribe a daily aspirin regimen. A score of two to three could be a medical therapy ring toss, Ellis said, with some physicians opting for aspirin and others a prescription blood thinner. “Blood thinners like warfarin are proven more effective head-to-head against aspirin but require blood tests and dietary restrictions,” Ellis noted. While warfarin is among the most widely prescribed drugs in the U.S., the anticoagulant also puts patients at increased risk of internal bleeding, mandating frequent monitoring. However, a new class of blood thinners – novel oral anticoagulants (NOACs) – are promising better results with less complications. The U.S. Food and Drug Administration recently approved three new oral anticoagulants – dabigatran, rivaroxaban and apixaban – for stroke prevention in patients with atrial fibrillation. These new anticoagulants do not require strict and frequent lab monitoring, or dietary restrictions, and incur fewer drug interactions than warfarin. Dosing may be adjusted based on kidney function. Still, lack of a specific reversal agent and clinical data regarding their long-term safety could keep warfarin in the game for years to come. “There are two ways to get off blood thinners,” Ellis continued. “Your risk for stroke changes, or something bad happens while on blood thinners.”

Surgical Treatment

Bleeding, bone breaks or stroke make some warfarin patients ideal can4

MARCH 2014

didates for procedural treatment to lower stroke risk. Two novel procedures, now available at Vanderbilt, focus on closing the left atrial appendage (LAA), to eliminate the risk of bleeding. “When we find a clot in patients who’ve had a stroke and AFib, it’s almost always in the left atrial appendage,” Ellis explained. “If we can shut the appendage off, we can typically prevent stroke without the bleeding risks associated with blood thinners.” Anatomy of the LAA holds clues, as well. Cardiologists have identified four consistent shapes of left atrial appendages, and Ellis said identifying structural consistencies in stroke patients could help predict the best candidates for procedural treatment.

LARIAT™ Suture Delivery Device

Ellis was the first … and currently only … cardiologist to use the LARIAT™ Suture Delivery Device at Vanderbilt Heart, and he has seen positive results since debuting the procedure in July. Performed under general anesthesia, the LARIAT procedure places one catheter under the patient’s rib cage with another guiding it into place. The catheter is sent to the heart’s LAA and places and tightens a loop stitch around the base of the appendage, sealing it off from the rest of the heart

and blocking clots from traveling to the brain. LARIAT patients typically spend two days in the hospital for follow-up.

AtriCure® AtriClip PRO

A second option available to patients is the AtriCure® AtriClip PRO, offered at Vanderbilt as part of a sixsite clinical trial. Working through a small incision, surgeons use a barrette-like device to clamp off the LAA. “First we look at the size and shape of an appendage, and if it’s too big or pointing the wrong way for the LARIAT, we use the AtriClip,” Ellis said. The procedure is more invasive than the LARIAT and typically requires three to four days of hospitalization.

Watchman™ LAA Closure Device

A third option cardiologists hope to see widely available soon is the Watchman™ Left Atrial Appendage Closure Device, now in its final stage of FDA approval. In 2011, Saint Thomas Heart at Baptist Hospital (now Saint Thomas Midtown) became the first hospital in Tennessee to implant the Watchman as part of a clinical trial. The device is introduced into the heart via a catheter through a vein in the upper leg or groin and captures clots

that might form in that area of the heart. “The concept of closing the appendage has been around for many years but was only done during major heart surgery,” Ellis said. “Now it’s a stand-alone procedure with minimally invasive complications.”

Reveal® Insertable Cardiac Monitor

According to Christopher Conley, MD, cardiologist with Centennial Heart at Skyline, the cause for stroke goes unidentified in 30 percent of patients. He and other cardiologists nationwide are using the Reveal Insertable Cardiac Monitor by Medtronic as part of a stroke workup to help detect irregular heart rhythm. Smaller than a pack of gum, the monitor is inserted just beneath the skin in Dr. Christopher Conley the upper chest area. “When someone is hospitalized and no source is found, neurologists are asking for long-term heart rhythm monitoring to try to find undetectable AFib,” Conley explained. “It’s the same technology we’ve used for years to look for other conditions like unexplained fainting but going in a new direction.”

When Seconds Count to treat them up to eight hours is a huge lifesaving opportunity.” In 2013, TriStar Skyline Specialized services also include a Medical Center became the first 12-bed Neuro ICU, a dedicated hospital in Tennessee to receive stroke unit and a 41-bed inpatient Advanced Certification for Comrehab center. The Rehab Center prehensive Stroke Centers from at TriStar Skyline, which is accredthe Joint Commission and The ited by the Commission on AccredAmerican Heart Association/ itation of Rehabilitation Facilities, American Stroke Association. starts working with patients from They are now one of 59 hospitals day one. Their average length of nationwide to receive the certifistay for stroke patients from admiscation including Vanderbilt Unision through rehab is 17.7 days. versity Hospital and Knoxville’s The hospital also provides adFort Sanders Regional Medical vanced continuing education for Center and UT Medical Center. ICU, neurology and emergency Complex Stroke Centers are recstaff, and holds multi-disciplinary ognized as industry leaders and neurovascular conferences to reare responsible for setting the naview complex cases. Working tional agenda in highly specialized closely with patients and their stroke care. families to offer stroke and brain “Stroke is the leading cause Steve Johnson, 54, recovers at TriStar Skyline after experiencing a stroke. aneurysm support groups and to of disability, and Skyline really Johnson is exercising on a new piece of equipment used for stroke rehabilitation promote stroke awareness within called ICare. The support at the top helps lift the patient to exercise on an wanted to push forward with elliptical-type machine. the community is another priority. decreasing that,” said Michelle “From the community standBertotti, RN, unit director for point, education is key,” Bertotti Neuroscience and Neurointensive Care day or night. That distinction means TriSsaid. “We want people to know warning at TriStar Skyline Medical Center. “Imtar Skyline’s interventional radiologists are signs of stroke, the importance of calling mediate intervention able to administer IV tPA, the enzyme that 911, and not ignoring symptoms.” is essential because dissolves blood clots, four to eight hours Bertotti noted TriStar Skyline also is time loss is brain loss.” following stroke rather than the standard pursuing Level 2 trauma status, which she The hospital provides three-hour window available at most hosexpects to significantly increase the number 24/7 comprehensive pitals. of patients admitted with brain injury. stroke care including “What we look at is a very detailed “As we plan to grow our neuroscience neurology, neurosurstroke scale that includes when symptoms program overall, trauma will definitely be gery and radiology so started,” Bertotti explained. “We have opa piece of that that and our technology and Michelle patients receive the portunities for patients who may not be a equipment will grow as we begin taking in Bertotti same specialized care match at other hospitals … and being able a higher volume of patients,” Bertotti said. By MELANIE KILGORE-HILL

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Stroke Notes By MELANIE KILGORE-HILL

Stroke Care: Most Have Access, Few Get Recommended Treatment Four out of five people in the United States live within an hour’s drive of a hospital equipped to treat acute stroke — yet very few get recommended treatment, according to research presented at the American Stroke Association’s International Stroke Conference 2014. Of the more than 370,000 Medicare stroke claims for 2011 that researchers examined: • Only 4 percent received tPA, a drug that can reduce disability if given intravenously within three to four hours after the first stroke symptoms. • Only 0.5 percent had endovascular therapy to reopen clogged arteries. The study found that within an hour’s driving time: • 81% had access to a hospital capable of administering tPA. • 66% had access to a primary stroke center. • 56% had access to a hospital capable of performing endovascular therapy.

air:

Within an hour by

• 97% percent could reach a tPA-capable hospital. • 91% could reach a stroke center. • 85% could reach a hospital capable of performing endovascular therapy. In 2011, 60 percent of U.S. hospitals didn’t administer tPA. These hospitals discharged about 1 in 5 of all stroke patients. Stroke Campaign Focuses on the Need for Speed When someone is having a stroke, they need help FAST. The American Stroke Association hopes its new campaign will help people remember the signs of stroke and act quickly. Experts also encourage individuals to note the time symptoms first appear so that tPA, if appropriate, could be administered. Face: Ask the person to smile. Does one side of their face droop? Arms: Ask the person to raise both arms. Does one arm drift downward?

AHA Addresses Stroke Risks in Women, Presents New Guidelines BY MELANIE KILGORE-HILL The American Stroke Association estimates 425,000 women suffer a stroke each year … 55,000 more than men. Although stroke has fallen to the fourth leading cause of death overall, it remains the third leading cause of death in women. “If you are a woman, you share many of the same risk factors for stroke with men, but your risk is also influenced by hormones, reproductive health, pregnancy, childbirth and other sex-related factors,” said Cheryl Bushnell, MD, MHS, author of the new scientific statement published in the American Heart Association journal Stroke. In fact, she added, preeclampsia doubles the risk for stroke and quadruples the risk for high blood pressure later in life. For the first time ever, the American Heart Association has set guidelines geared to primary care providers, including OBGYNs, for preventing stroke in women. The recommendations take into account risk factors unique to women, and the AHA has crafted evidence-based actions to address to address them, including: • Women with a history of high blood pressure before pregnancy should be considered for low-dose aspirin and/or calcium supplement therapy to lower preeclampsia risks. • All women with a history of preeclampsia should be regularly evaluated and treated for cardiovascular risk factors such as high blood pressure, obesity, smoking and high cholesterol. Screening for risk factors should start within one year after delivery. • Pregnant women with moderately high blood pressure (150-159 mmHg/100109 mmHg) may be considered for blood pressure medication, whereas expectant mothers with severe high blood pressure (160/110 mmHg or above) should be treated. • Women should be screened for high blood pressure before taking birth control pills because the combination raises stroke risks. • Women who have migraine headaches with aura should stop smoking to avoid higher stroke risks. • Women past age 75 should be screened for atrial ﬁbrillation risks due to its link to higher stroke risk. Preeclampsia and eclampsia during pregnancy increase the risk for stroke long after child-bearing years. Additionally, high blood pressure, migraine with aura, AFib, diabetes, depression and emotional stress are stroke risk factors that tend to be stronger or more common in women than in men. Bushnell, an associate professor of Neurology and director of the Stroke Center at Wake Forest Baptist Medical Center, said additional studies are needed to create a female-specific score to identify and stratify stroke risk in women.

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Speech: Ask the person to repeat a simple phrase. Is their speech slurred or strange? Time: If you observe any of these signs, call 9-1-1 immediately. Video Game Teaches Kids Stroke Symptoms Children improved their understanding of stroke symptoms and what to do if they witness a stroke after playing a 15-minute stroke education video game, according to new research reported in the American Heart Association journal Stroke. “We need to educate the public, including children, about stroke, because often it’s the witness that makes that 9-1-1 call … not the stroke victim. Sometimes, these witnesses are young children,” said Olajide Williams, MD, MS, lead author and associate professor of neurology at Columbia University in New York City. Williams and a team Dr. Olajide Williams of researchers tested 210

children (9- and 10-year-olds) from low-income homes in the Bronx, New York to measure whether or not they could identify stroke and knew to call 9-1-1 if they witnessed a stroke. The same children were tested again after playing an educational video game, Stroke Hero. Finally, the group was given remote access to the video game and encouraged to play at home. Re-testing of 198 of the children happened seven weeks later. Researchers found: • Children were 33 percent more likely to recognize stroke from a hypothetical scenario and call 9-1-1 after they played the video game. They retained the knowledge when they were re-tested seven weeks later. • Children who continued to play the game remotely were 18 percent more likely to recognize the stroke symptom of sudden imbalance than were the children who played the video game only once. • 90 percent of the children studied reported they liked playing Stroke Hero. The video game involves navigating a clot-busting spaceship within an artery, and shooting down blood clots with a clotbusting drug.

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A New View on Stroke Research By CINDY SANDERS

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MARCH 2014

Everyone wants to build a better mousetrap … but building it over and over again isn’t very efficient. Finding a way to keep the ‘mousetrap’ infrastructure in place while adding new features based on a collective body of knowledge is fundamentally the basis of the new National Institutes of Health Stroke Trials Network. Funded and managed by the National Institute of Neurological Disorders and Stroke (NINDS), NIH StrokeNet is focused on the three prongs of stroke research — prevention, treatment and recovery. The new structure utilizes a network of academic medical centers across the country working with nearby satellite facilities to coordinate and streamline stroke research by centralizing approval and review, while creating a comprehensive data-sharing system. The network also is expected to lessen the time required to set up clinical trials since the infrastructure will already be in place, thereby making research more efficient and less costly. Scott Janis, PhD, program director in the Office of Clinical Research at NINDS and the scientific director for NIH StrokeNet, explained, “We identified 25 geographically distributed regional centers and identified over 200 hospitals that will be part of the network. Many are Dr. Scott Janis primary stroke centers, but many are community hospitals aligned with the regional stroke participant.” The 25 lead sites were chosen based on a demonstration of past experience in stroke research and recruitment, including the ability to enroll underrepresented populations. Each center has been granted five-year funding with $200,000 in research costs and $50,000 for training stroke clinical researchers per year over the first three years. The completion of milestones will drive additional funding. The University of Cincinnati has been named the national clinical coordinating center. With the new structure in place, Janis said it should be possible to more rapidly add studies to the pipeline. NIH StrokeNet also creates a central institutional review board and has a built-in master trial agreement to further expedite launching new trials. Janis also noted the network calls on a truly intraprofessional team of providers and researchers — from first responders and emergency room physicians to the specialists caring for patients acutely all the way through to ambulatory rehabilitative therapists. By having a coordinated team across the continuum of care, including pediatric specialists in the 25 regional centers, the hope is that stroke patients will be rapidly identified and more easily followed throughout their journey. “This network fosters communication in a collaborative way,” he said. “We can’t control when someone has a stroke, but we

can control our ability to identify them for a potential study.” Previously, the model for stroke clinical trials happened in a stand-alone manner. A large team, often over multiple centers across the country, had to be assembled, and the infrastructure set up for each trial. Then, once completed, the entire team had to be disassembled only to start the process all over again for the next study. The cumbersome method led to delays in patient recruitment and repeated costs to initialize new projects. Sometimes those delays caused a stroke trial to go much longer than initially anticipated, costing millions of dollars more than the original estimate. “That effort in building and tearing down, building and tearing down, doesn’t efficiently allow us to ask the questions to move the science forward,” Janis said. Drug research to control stroke risk factors has improved to the point that Janis said sometimes the medicine had moved on by the time a stroke trial that had undergone delays managed to wind down. “You really want to get to answers more rapidly,” he noted. Janis said the tipping point to change the way stroke research occurred across the country came about in a couple of different ways. First, stroke experts identified key research priorities during a NINDS strategic planning meeting two years ago and stressed the need for an orchestrated effort. Second, Janis said NINDS already had honed their ability to manage a coordinated effort through SPOTRIAS (Specialized Programs of Translational Research in Acute Stroke). “The idea behind the network is to take what we already know how to do and do it in a more efficient way,” Janis said. NINDS has a long history of overseeing successful stroke clinical trials, including the first treatment for acute stroke, announced in 1995. Although sometimes slow, research translated from bench to bedside still has been so successful that mortality rates from stroke have declined significantly over the past decade. While still a leading cause of disability, stroke recently moved from the third leading cause of death in the United States to the fourth. Janis noted funding still would be available to researchers outside the network when appropriate. However, he added, the goal would be to collaborate with the network and to coordinate trials through the new mechanisms now in place. “We want to be able to use this infrastructure we’re investing in to be our frontline sites for stroke trials,” he stated. In the Southeast, lead research sites include Emory University School of Medicine in Atlanta, Medical University of South Carolina in Charleston, Miller School of Medicine at the University of Miami, and Vanderbilt University Medical Center in Nashville. Providers and researchers can learn more about the network and clinical trials through the new website at nihstrokenet.org. nashvillemedicalnews

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Recent Debuts

Cutting the Ribbon on Some of Middle Tennessee’s Newest Healthcare Construction Projects filled with healthcare history. The White Avenue A number of new faproperty began serving cilities have debuted in the children with polio and first quarter of 2014 with mental illness in 1930 more on the way. Below is after the Nashville Junior a snapshot of just a few of League quickly outgrew the construction projects their original nine-bed around Middle Tennessee Home for Crippled that recently have been Children at Ninth and completed. Monroe, which had opened seven years earCenterstone lier in 1923. The campus Behavioral health again expanded in 1956 not-for-profit Centerstone with the opening of the recently opened the doors Mental Health Guidon their latest project. The Designers of Centerstone’s new outpatient facility removed large provider desks that ance Center, which was new $6 million outpatient might inhibit patient engagement and created more natural conversational areas. renamed the Dede Walfacility on the grounds lace Center in 1970 to of the Dede Wallace Campus on White honor Junior League volunteer and menNickle, LLC of Nashville and built by Avenue was designed to provide the full tal health advocate Louise “Dede” Bullard Orion Building Corporation, the 18,000 continuum of services for all ages. In adWallace. square-foot facility includes 37 clinician dition to behavioral health services, the With a nod to its storied past, bricks offices for counselors, psychiatrists and new facility includes primary care through from the original building serve as pavers nurses plus space for specialty programs, United Medical Clinic as part of Centerto create garden areas and outline the old group therapy and play therapy areas. stone’s partnership with Unity to help facility’s footprint. However, the facility Large windows and bright interiors help care for medically underserved patients utilizes thoroughly modern design theointegrate nature and sunlight into the fathrough integrated care clinics. ries including removing large desks becility. Designed by InForm Smallwood + tween providers and patients to create an The new construction stands on a site By CINDY SANDERS

environment conducive to more natural conversation. “We are very excited to open this innovative new healthcare facility and explore a clinical model that connects primary care and behavioral health providers under one roof,” Centerstone CEO Bob Vero, PhD, said last month at the facility’s grand opening. “Being able to continue our legacy on this important property that is deeply rooted in Nashville’s history is incredibly inspiring. We look forward to advancing the treatment and prevention of mental illness and addiction from this new location, and working to ensure the health and wellbeing of our clients’ minds and bodies.” Vanderbilt Heart & Vascular Institute Just in time for ‘Heart Month,’ Vanderbilt Heart and Vascular Institute moved all of its key procedure areas to its new home on the fifth floor of the Critical Care tower, which connects to Vanderbilt University Hospital. Designed by Nashville architectural firm Earl Swensson Associates (ESa), the (CONTINUED ON PAGE 10)

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MARCH 2014

Building or Expanding Health Facilities in Tennessee? There’s an ‘App’ for That A Look at the State’s CON Program By CINDy SANDERS

History of Tennessee’s Program

Melanie M. Hill, executive director for the Tennessee HSDA, noted the state has relied on a CON program to drive the orderly creation and expansion of health facilities and services since 1973, a year prior to a federal mandate for such programs. In Tennessee, the Health Facilities Commission adM. ministered the CON pro- Melanie Hill gram until 2002 and was the predecessor to the current agency. Hill joined the Health Facilities Commission in 1998 and was named to the director’s post

in 2001. The following year, the Tennessee Legislature passed the Health Services and Planning Act of 2002, which created HSDA. “Our sole responsibility is the certificate of need program and related activities,” Hill said, adding that includes providing technical assistance and collecting data on certain medical equipment including MRIs, PET scanners, CT scanners and linear accelerators, among others. “There is a requirement in the statute that the equipment be registered with the agency and that owners report usage data annually.” After establishing CON programs nationwide through the 1974 National Health Planning and Resources Development Act, the law was repealed in 1987, eliminating federal funding assistance for state planning offices. However, CON programs remain in place across much of the country. “There are 36 states plus the District of Columbia that have certificate of need programs,” Hill stated. She added each state is different with some having more stringent requirements than others. According to the American Health Planning Association’s website, there are

30 coverage areas for which state programs might choose to require a CON. On one end of the spectrum, Vermont requires an application be made for all 30 of those options from acute hospital beds and air ambulances to medical office buildings and ultrasound. On the opposite end of the spectrum, Ohio requires an approved CON only when adding skilled nursing/long-term care beds for projects exceeding $2 million in cost. With 20 service and equipment areas covered by CON regulations, Tennessee falls a little right of the middle.

Application Trends

The economy and uncertainty over the Affordable Care Act have impacted the number of CON applications being filed in the state. Hill said, “We used to average 100-120 applications annually.” Now, she continued, “We’re probably looking more in the range of five full applications a month.” She added, “In 2008, we dropped from 121 applications to 56 in 2009.” After rebounding slightly to 62 CON applications in 2012, the number dipped down to 51 last year.

What Requires a CON? As outlined by Tennessee code, certain facilities, services and actions trigger the need for an approved certiﬁcate of need before proceeding. Visit Tennessee.gov/hsda for more information.

Facilities

Addition of Services

Actions

Threshold: A modiﬁcation, expansion or renovation in excess of $5 million for a hospital or $2 million for other healthcare facilities.

• Burn Unit

In addition to the cost triggers listed under facilities, the following actions also require CON approval. Go online for details.

• Hospital • Nursing Home • Recuperation Center • Ambulatory Surgery Center • Mental Health Hospital • Intellectual Disability Institutional Habilitation Facility • Home Care Organization (Home Health & Hospice) • Outpatient Diagnostic Center • Rehabilitation Facility • Residential Hospice • Nonresidential Substitution-based Treatment Center for Opiate Addiction • Birthing Center

• NICU • Open Heart Surgery • Positron Emission Tomography • Swing Beds • Home Health • Psychiatric (Inpatient) • Rehabilitation (Inpatient) • Hospital-based Alcohol & Drug Treatment (for adolescents under a program of care exceeding 28 days) • Extracorporeal Lithotripsy

• Change to the bed makeup of a healthcare institution. • Change in location or replacement of existing or certiﬁed facilities providing healthcare services, major medical equipment, or healthcare institutions. • Change of parent ofﬁce of a home health or hospice agency from one county to another county.

• Cardiac Catheterization

• Acquisition of major medical equipment with a cost in excess of $2 million.

• Linear Accelerator

• Discontinuation of obstetrics.

• Hospice

• Closure of any hospital that has been designated a critical access hospital or the elimination of any services for which a certiﬁcate of need is required in those hospitals.

• MRI

• Opiate Addiction Treatment (provided through a facility licensed as a nonresidential substitution-based treatment center)

Prior Approval or Notification Additionally, there are some actions that require individuals to notify or seek prior approval from the Tennessee HSDA even though a formal CON is not required. Details are available on the HSDA website.

Gaining Approval for a CON

At the heart of the approval process is the need to meet three criteria: • Answering a healthcare need, • Proving a plan is economically feasible, and • Showing how the plan contributes to the orderly development of adequate and effective healthcare facilities and services. Actually, Hill noted, “Most applications are approved. It’s a fairly strenuous process so you really have to have your information together by the time you file.” Prior to filing an application, Hill said her agency could provide technical assistance to help navigate the process, important background information regarding utilization for those considering adding equipment or services, and insight into needs outlined in the state health plan. Although applications are assessed against the state health plan, which outlines the numbers that would indicate a community might need to add a facility or service line, Hill was quick to add there are valid reasons to override those numbers … or lack thereof. “That’s why it is guidance and not set in stone,” she said of the health plan. Hill added, “I hope we’re never strictly ‘just numbers.’ There are certainly circumstances in each community that are unique to that community.” For example, she said population figures alone might not warrant the addition of a second MRI in a community. However, she continued, if the owner of the current MRI doesn’t accept many insurance plans, or doesn’t participate in TennCare, or has excessive wait times for appointments, then circumstances could demonstrate a need for a second MRI operator in that area. Hill added the monthly CON meetings are open and transparent … and highly participatory. She said those for and against an application are welcome to come to the meeting and are given an opportunity to speak. She added that when an application is controversial, her team has even held town hall meetings to allow residents to voice concerns. She noted this extra step isn’t requested very often, though. Ultimately, an 11-member board decides the fate of a CON application. There are three consumer appointees – one each from the speaker of the house, governor and lieutenant governor. Three more board members are state officials with the comptroller, commissioner for Commerce and Insurance and the director of TennCare each designating an appointee. The remaining five board members are chosen by the governor with one each being selected to represent home health, surgery centers, nursing homes, hospitals and physicians. While the related associations often provide a list of possible appointees, the selection is at the governor’s discretion. (CONTINUED ON PAGE 10)

MARCH 2014

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Healthcare Helps Fuel Nashville’s Booming Real Estate Market … But Buyers Need Guidance By SAM SARBACKER

The national media has declared Nashville the new “It” city, crediting the area’s unparalleled music scene, rising culinary environment, and compelling Southern culture as primary factors for the region’s growth. Evidence of the city’s prosperity can be seen in local headlines, which constantly feature stories about this new development or that multistory building groundbreaking. Nashville’s skyline is evolving as the real estate industry works to meet the demand for an influx of new businesses and residents. According to the Nashville Area Metropolitan Planning Organization, the greater Nashville region is poised to grow to over 2.6 million people over the next 25 years. As the country’s economy continues to flounder, Nashville is fortunate to be picking up steam locally. One of the main aspects contributing to the city’s booming economy is the

healthcare industry. The Nashville Health Care Council recently conducted an economic impact study which reveals that $30 billion flows into Nashville’s economy from the healthcare sector alone. A focal point of growth within the healthcare industry is the substantial rise in outpatient care facility development. It is estimated that by 2019, the amount of outpatient care in America will see an increase of 22 percent. The rising demand for outpatient facilities will put pressure on healthcare providers to move quickly to secure property in order to meet their growth needs. Critical to the success of delivering these projects will be healthcare providers engaging development experts to assist them in meeting their goals. No one is more aware of the real estate frenzy than those who are currently listing properties for sale. In the current market, sellers naturally feel more emboldened to seek prices that are higher than market value, and can be more hard-

fisted on key purchase agreement terms. Being approached by a physician in lieu of a developer can give the seller an opportunity to push the limits further than if they were dealing with someone who works in the industry – an advantage that can cost a physician thousands of dollars and leave them with a subpar property. Additionally, physicians might be drawn to a specific property because it appears on the surface to be a great deal. There is a litany of reasons that could lead to a listing being significantly below market value, and the old saying — “if sounds too good to be true, then it probably is” — certainly applies to real estate. Flood plains, wetlands, inadequate zoning, onerous easements, use restrictions, endangered species, underground fuel storage tanks, and … believe or not even live bombs on the property due to prior use as a WWII training area … can all be factors behind that “great deal” that can dupe an unsuspecting buyer. Physi-

cians could enter into a literal minefield of issues if purchasing a property without performing the proper due diligence. A thorough vetting by experienced professionals could ensure you don’t get stuck with a property that is unsuitable for your needs. You should be excited about the real estate windfall and subsequent economic boom that is taking place in Nashville. If you are considering an investment in a healthcare property, however, be sure to seek proper assistance in order to get the best available real estate to suit your growth needs. Sam Sarbacker is a LEEP AP, EDACcertified project manager for OGA, a Nashville-based real estate services and development company specializing in outpatient healthcare facilities. The company’s projects span the country and include cancer centers, medical office buildings, urgent care facilities, orthopaedic offices, behavioral health facilities and others. www.oman-gibson. com.

A Master Plan, continued from page 1 Jim Easter, MArch, FAAMA, senior vice president and director of planning for Hart Freeland Roberts (HFR) Design, said his firm has invested in the belief that the design process is changing and evolving. Recently, Brandon Harvey, MArch, CDT, joined HFR as an intern Jim Easter architect/planner to focus on the connections between health facilities and the broader community. Harvey holds both a bachelor’s degree in urban planning and a master’s degree Brandon in architecture from the Harvey University of Tennessee – Knoxville. “Brandon has joined us to help define, with our architects and our firm, how healthcare facilities will be developed as part of the urban fabric of a community … not just as stand-alone facilities,” Easter explained. With an emphasis on preventive care and population health, new reimbursement models that pull together providers across the continuum, a focus on patient engagement, enhanced technology needs, increased connectivity and changing demographics, Easter said the expectation is that clinics, medical office buildings, outpatient facilities and acute care hospitals will increasingly need to partner with each other and plug into the communities they serve. As a result of health reform, Easter said there is an increased need to deliver spaces very tailored to the specific clinical services provided and supportive of the push to streamline processes and increase efficiency. nashvillemedicalnews

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One example has been HFR’s work over the past year in analyzing the effect of the Affordable Care Act on emergency services. Working with Todd Warden, MD, the founder and president of Emergenuity, the design team has used performance metrics to create the physical plant to support streamlined clinical pathways. As Easter explained, the idea is to ‘batch’ consumers into appropriate areas of care so that a senior presenting with stroke symptoms, a parent with a sick child, and an adult with substance abuse issues access the ED in different ways. “We make sure people are in the right pathway for the right reasons. What this system is designed to do is to allow care to be delivered quickly, efficiently and in the most appropriate manner,” he said. So how does that knowledge fit in the larger context of community? Harvey noted, “We’ve defined a lot of urban dynamics. One of those urban dynamics is public policy and how that affects planning and design. The Affordable Care Act is a forcible vehicle for pushing the healthcare industry in the direction of patientcentered care rather than merely patient volumes-for-profit.” That, he continued, changes how you envision accessing care and designing and locating spaces to fill needs within a community. A project in Carthage, Ill. underscored the need to think about delivering services differently. Harvey noted it became clear some services needed to be decentralized to better serve patients. Breaking memory care out of the critical access hospital allowed the design team to deinstitutionalize the feel of the new facilities to care for early Alzheimer’s and other dementia patients. The result is 10-bed residential cottages that feel and function much more like a home than a hospital

Brains before bricks ... designing modern health facilities requires a great deal of due diligence before the first architectural drawings are even conceived.

with places for walking, reading, exercising and visiting with family. “The healthcare industry needs to follow urban trends,” Harvey said. “Now we live in a microwave society where everything is about convenience. It’s changing the dynamics of the way healthcare can and should be delivered in the future.” Harvey added more suburbanites are beginning to move back into urban areas, leading to the creation of a lot of mixed used developments. Perhaps that means accessing healthcare in the same place consumers access retail outlets and dining venues. Perhaps, as in Dallas, it means creating a major light rail transportation connection point actually on the hospital property. Designing for a ‘big picture’ world has forced the creative process to shift and expand. “In the old days, you’d sit down and design an office building or sit down and design a hospital,” Easter said. “Now, it’s not that simple. We’re doing a full analysis.” When working with a hospital campus or health system, Easter noted the first step in the process is to assemble a group of professionals including those with ex-

pertise in strategic alignment, architecture, engineering, finance, urban planning and market analysis to assess how the current alignment does or does not meet the needs of the community. Steps include: • Assessing the current situation. • Determining a strategic direction based on market need and workload requirements. • Assessing current facility conditions and future facility needs. “Most of our hospitals are way too big in spaces that are not well defined,” Easter noted. • Creating a composite redevelopment of an area-wide plan, which Easter said is taking what you know and redistributing it to meet population needs. • Scheduling and pricing that redistribution. • Building consensus with stakeholders and seeking specific design input. However, Easter and Harvey said this is actually a recurrent step integrated from start to finish. • Developing a phased implementation plan. • Measuring the overall economic development impact factors and considering regional implications. • Considering the full continuum of care including patient transitions from inpatient to step-down or home-based care and how technology impacts those moves. As for when the design process begins, Easter said time constraints demand incremental decisions be made along the way with heavy design lifting occurring about halfway through the steps. “We still believe form follows function, and you can’t begin to design a building until you first know what the function is going to be and how process improvements enhance the design,” Easter concluded. MARCH 2014

Recent Debuts, continued from page 7

The new Wallace Health Sciences Complex South at Vol State greatly expands instructional space and adds stateof-the-art labs.

MARCH 2014

Coming Soon

new space incorporates the latest evidence-based trends to meet the needs of providers, patients, staff and families. David C. Miller, AIA, EDAC, principal on the project for ESa, noted the radial lounge takes an innovative approach to make patients more comfortable during cath lab recovery. To reduce anxiety and encourage immediate ambulation, a recliner in a spa-like environment replaces the typical bed. The post-anesthesia care unit Vanderbilt Heart & Vascular Institute Radial Lounge (PACU) was designed to facilitate of space over two stories. close observation by clinicians while still Connected to Wallace Health Sciallowing privacy. Miller pointed out the ences Complex North, the new building PACU has separate rooms for individual allows programming to be spread out patients rather than curtained-off spaces. between the two sides of the complex to Decentralized nurse work areas allow for allow for more instructional space overall. better patient observation. Programs now located in Wallace South The hybrid operating rooms, Miller include ophthalmic technology, sleep dicontinued, were designed with the latest agnostics technology, emergency medical recommended square footage to accomtechnician, diagnostic medical sonogramodate the most advanced technology phy and medical laboratory technology. of today. Yet, flexibility was key to being The new facility marks the first time the able to meet the needs of tomorrow. sleep diagnostic and medical laboratory “We feel that the success of the space programming and labs have been fully is that the physician flow is fluid in the housed on campus. cardiac procedure area,” said Miller. “In The EMT labs have two rooms for creating an environment to deliver the latuse with SimMan patient simulators and est procedures and technologies, we have a control room for faculty members to to also be responsive for advancements change simulations as students practice. that will come in the next few years … The sonography lab houses six beds with and we designed this fifth floor unit to be high definition monitors and top-of-theprepared for the future.” line GE ultrasound equipment. A Biolyte electrolyte analyzer and Genesys UV/ Volunteer State Health VIS spectrophotometers are among the Sciences Complex new equipment in the medical lab. Last month, Volunteer State Com“Students majoring in health science munity College in Gallatin officially cut careers will encounter cutting-edge techthe ribbon on the brand new Wallace nology in their workplaces. They need to Health Sciences Complex South. The $10 be proficient in the use of this technology, million, state-of-the-art educational faciland the only way they can gain those skills ity features more than 28,000 square feet is by hands-on experience,” noted Jerry Faulkner, PhD, president of Vol State, during the ribbon-cutting ceremony. Moody-Nolan and Street Dixon Rick, both of Nashville, served as architects on the project with Hardaway Construction, also of Nashville, overseeing the build. Groundbreaking was held in 2012 and completed in time for the start of 2014 classes.

A number of other Middle Tennessee projects are in various stages of planning, development and execution. The Lentz Public Health Center on Charlotte Pike is scheduled to open this summer. Saint Thomas West broke ground last spring on a $110 million, four-year expansion and modernization project. The centerpiece is an inpatient tower Lentz Public Health Center featuring 155,000 square feet of space. Additionally, renovations are expanding the square footage of critical care rooms and more than a dozen operating rooms. Architect for the multi-phase project is Freeman White, and Turner Construction has Saint Thomas expansion rendering been named construction manager. The renovations and new construction are expected to be complete in 2017. ESa is designing the new Monroe Carell Jr. Children’s Hospital Vanderbilt at Williamson Medical Center, which broke ground at the end of 2013. The $65 million expansion project is expected to open in early 2015. On the main campus, the Monroe Carell Jr. Children’s Hospital at Vanderbilt is moving forward with expansion plans to boost the pediatric facility to nearly a million square feet of inpatient space. A four-ﬂoor tower is being built on top of the hospital’s southeast façade at the corner of Children’s Way and Medical Center Drive. At approximately 40,000 square feet of patient care space per ﬂoor, the new project should add more than 150,000 square feet of space. Construction is anticipated to begin next year.

Building or Expanding, continued from page 8 The Big Picture

Although various groups have looked to limit or abolish the CON process, particularly during years when HSDA is under sunset review, there are many staunch supporters of the system. The Tennessee Hospital Association listed keeping the CON program running in its current format among its top legislative priorities last year. “In Tennessee, we’ve had a CON program for 40 years. It’s a very stable process, and it’s one the healthcare industry understands,” Hill said. “I think it’s a growth management tool, and also it’s a cost savings tool.” Hill said perhaps one of the most important functions of her agency is to help ensure quality programming is available in Tennessee. The impact of the CON

process on cardiovascular surgery outcomes has been the focus of a number of studies. Hill said, “A 2002 report from the University of Iowa College of Medicine showed states without CON programs for open heart surgery had a 21 percent higher mortality rate.” Similarly, she continued, when the Pennsylvania CON law expired, the state saw an influx of open heart surgery programs … quickly growing from 35 to 62. “They saw morbidity and mortality increase,” Hill said. “Any time you see that dramatic growth, you are decreasing volume for surgeons.” Less volume … less experience, she pointed out. Hill concluded, “You still have people who say the CON process is anti-competitive, but it’s really not … it provides a level playing field.” nashvillemedicalnews

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HealthcareEnterprise

Building the Healthcare Infrastructure Turner Construction Brings Facilities to Life By CINDY SANDERS

As the leading builder of healthcare and medical research facilities in the nation, chances are you are familiar with a Turner Construction Company project. From the Ronald Reagan UCLA Medical Center in Los Angeles to the Yale University Health Services Center in Connecticut, Turner projects literally crisscross the country. Closer to home, Turner was the builder in charge of the Middle Tennessee Medical Center replacement facility (now Saint Thomas Rutherford Hospital) and is working on HCA’s new downtown building project. After building the original hospital back in the 1970s, Turner has been named construction manager of the $110 million Saint Thomas West expansion and modernization plan, and the company also has worked on various building projects at Vanderbilt University Medical Center for more than three decades. Founded in New York in 1902, Turner has a number of international offices, as well as more than 40 North American offices across 24 states and two Canadian provinces. The company, which has a global staff of 5,200 employees, has an annual construction volume of $9 billion. Of that total, a little more than 20 percent … close to $2.1 billion last year … is in healthcare construction. The company’s Nashville office oversees much of the builder’s medical construction work nationwide. The Trends “Over the last 10 years, certainly I would say technology is the driving trendchanger in healthcare,” said Howard Allums, a vice president in the healthcare practice who is based out of Nashville. The demand for electronic health records and hybrid ORs, plus a focus Howard on specialty procedures, Allums has helped fuel the need for increasingly complex building and engineering configurations. Flexibility is another request by many clients. “A lot of people say, ‘I want a 50year building,’” Allums noted. Of course, he continued, it’s hard to predict exactly what will happen over the next five decades, but universal rooms that can be reconfigured to meet multiple needs are one solution. “They can spend more money on the up front side but save money in the long run,” he added of clients who invest in flexible spaces. Chip Cogswell, vice president and national healthcare director who is based in Atlanta, concurred, noting another phrase being used is ‘acuity adaptable rooms.’ Traditionally, an ICU Chip Cogswell nashvillemedicalnews

.com

Saint Thomas Rutherford

and standard inpatient room would be built differently to meet very specific equipment needs. “Now, hospitals aren’t sure what the census will look like so they want rooms that will do both,” Cogswell said. “There’s no question with healthcare reform and other activities, we are seeing a lot more outpatient facilities,” he continued of the incentive to keep people out of the hospital. The various building trends noted by Turner’s healthcare team dovetail neatly. As more care is delivered in the outpatient setting, the acuity level of patients in hospitals is rising thus fueling the demand for increased technology capabilities and more flexibility of inpatient spaces. The Process Timing is everything … particularly in a healthcare world focused on cost and efficiency. When it comes to bringing in the construction team, Cogswell said sooner is much better than later. “In a perfect world, we would tell a client we’d like to be at the table the day after they pick an architect,” Cogswell said. Allums added the benefit often shows up in the form of significant cost savings. The T-Cost Modeling System, which Turner has developed over the last decade, allows clients to immediately see the impact of materials and design decisions before designs are finalized. “It allows us at a very, very early stage to help a client understand the impact of their decisions,” Allums said. “We can construct a model of that hospital from a budget standpoint.” The analytical system shows not only the cost of materials – for example an exterior finish of brick, concrete panels, stone or glass tiles – but also how that decision impacts energy costs and long-term operations and maintenance. Something as simple as a flooring decision can have a major impact. Cogswell pointed out choosing between PVC or terrazzo tiles might seem like an easy choice from an immediate perspective, but that view could alter when considering costs over time. The inclination, he noted, is to say, “‘Let’s go with the cheapest one from a first cost standpoint,’ but then they have to wax it every week.” When a client realizes

a different material might offer a three-year payback, the decision could change … particularly considering the lifespan of many healthcare facilities. A little later in the process … but typically still before the first brick is laid … architects provide a model of the building design so that Turner’s experts can add in materials and mechanical and electrical specifications to create a three-dimensional model of the project. Building Information Modeling (BIM) means building twice, once on the computer and then in the field, but like the T-Cost Modeling System, it can save clients money in the long run.

Allums said equipment costs and communications systems are areas that are often under-budgeted and too often cause sticker shock well into the building process. “If clients miss those costs, the only place they have to make up those numbers is out of the construction budget.” It’s a key reason why Turner’s Medical Equipment Planning and Management service, also headquartered out of Nashville, is a win/win for the builder and client. “There are not very many companies that I know of in the construction business that offer this kind of service,” Cogswell said. Having spent more than two decades in healthcare program management before joining Turner two years ago, Cogswell added he is all too familiar with the problems caused by having to go back to a board and ask for more money to offset cost overruns. “Our real value proposition,” he said of Turner’s breadth of experience, “is we offer predictability of outcome. The owner can march forward with confidence.” While the majority of the healthcare group is located in Nashville, Allums and Cogswell said most every office has a local healthcare champion to help oversee this important sector of Turner’s work.

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MARCH 2014

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 pro- Bond Oman duction. That is about a 30 percent increase over 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 seeing more facilities completely finished but designed from the outset with the ability to blow out a wall for future outward expansion. 12

MARCH 2014

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 York-based Taylor helps spread the word about the best available information and latest credible research to help those Ellen Taylor creating healing spaces. “The Center for Health Design is a nonprofit 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 incorporated 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.”

2014 Healthcare Design Conference With a theme of “better care through better design,” the annual Healthcare Design (HCD) Conference is scheduled for Nov. 15-18, 2014 at the San Diego Convention Center in San Diego, Calif. The premier event devoted to how the design of responsibly built environments directly impacts the safety, operation, clinical outcomes, and ﬁnancial success of healthcare facilities, the conference attracts architects, interior designers, top hospital and practice administrators, facility managers, healthcare construction professionals and researchers. For more information on the 2014 agenda or to register, go online to healthcaredesignmagazine. com/conference.

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GrandRounds Let’s Give Them Something to Talk About! Awards, Honors, Recognitions

Sumner Regional Medical Center Chief Nursing Officer Anne Melton was honored by her colleagues from across the state during the annual Tennessee Organization of Nurse Executives (TONE) meeting where she was awarded the annual Excellence in Nursing Leadership Award. Melton came to SRMC in 2006 as nursing director, was named vice president of Clinical Services in 2008 and named CNO the following year. ReviveHealth has won The Holmes Report 2014 In2 SABRE Award for “Most Innovative – Content Creation/Syndication” for its LinkedIn native ad campaign to drive brand awareness. The inaugural In2 SABRE Awards were Anne Melton (center), pictured with leaders of TONE. created to recognize and showcase innovative work in the emerging areas of social and digital media. Alzheimer’s Foundation of America has named Nancy Pertl of Mental Health America of Middle Tennessee as the national Alzheimer’s Dementia Care Professional of the Year. Pertl has been the coordinator of Alzheimer’s and Aging programs for 12 years. Throughout her tenure, she has taught emergency department personnel to distinguish between dementia and delirium, created and copyrighted a 4-series training for family caregivers, made weekly in-home visits to train caregivers one-on-one, and led numerous support groups. Michael L. Kirshner, LPC/MHSP, director of Business Development for the Mental Health Cooperative (MHC) was awarded the 2014 President’s Leadership Scholarship sponsored by Argosy University in partnership with the Center for Nonprofit Management in Nashville. The full tuition scholarship is only awarded once per year to a candidate with a high degree of leadership potential. Kirshner will be pursuing his MBA.

When you need it.

Wishes Granted

Patrick Grohar, MD, PhD, assistant professor of Pediatric Hematology at Monroe Carell Jr. Children’s Hospital at Vanderbilt, has been awarded a $250,000 Reach Award from Alex’s Lemonade Stand Foundation to support Ewing sarcoma research. Grohar’s work aims to develop new approaches to target the gene, EWS-FLI1, which causes Ewing sarcoma tumors to grow and spread throughout the body. The BlueCross BlueShield of Tennessee Health Foundation is providing $3 million in support of the Governor’s Foundation for Health and Wellness and its Healthier Tennessee initiative. The grant will provide $1 million per year in funding for three years. The Healthier Tennessee initiative strives to increase the number of Tennesseans who are physically active for at least 30 minutes five times a week, promote a healthy diet, and reduce the number of people who use tobacco. Vanderbilt University’s AIDS Clinical Trials Unit (ACTU) has received a sevenyear grant renewal from the National Institutes of Health (NIH). The ACTU will receive approximately $1.4 million this year to continue studies aimed at improving treat- BlueCross officials present a check to Gov. Bill Haslam. Pictured (Lment and ultimately devel- R) Scott Pierce, Chelsea Johnson, Bill Gracey, Gov. Haslam, Calvin oping a vaccine to prevent Anderson and Dawn Weber. HIV infection.

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Recent Certifications, Accreditations & Commendations

Three directors at TriStar StoneCrest Medical Center earned a Certificate in Healthcare Leadership from Union University - Center for Excellence in Health Care Practice. Amy Higgins, director of medical-surgical services; Jeff Johnson, director of physical medicine; and Dawn Warren, director of imaging and Sarah Cannon services, recently completed the 2013 TriStar Health Leadership Academy, a 12-month program offered through the TriStar Healthcare Educational Institute at Union University, Hendersonville. The American Society of Hypertension (ASH) has recognized the Vanderbilt Hypertension Clinic as an ASH Designated Comprehensive Hypertension Center. Cheryl Laffer, MD, PhD, professor of Medicine, directs the Hypertension Service within the Division of Clinical Pharmacology. The clinic is now one of eight ASH Comprehensive Hypertension Centers in the United States. Giselle Krieger, RN, BSN, MS, CPHRM, vice president of Risk Management at Capella Healthcare, has earned the designation of Certified Professional in Healthcare Risk Management (CPHRM). Administered through the American Hospital Association, a professional is required to have at least 3,000 hours of risk management experience to even qualify to sit for the exam. TriStar Summit Medical Center’s Breast Center has been granted a three-year, full accreditation designation by the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons. TriStar Summit is the latest facility in Middle Tennessee to earn this elite designation. nashvillemedicalnews

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MARCH 2014

GrandRounds Middle Tennessee’s Primary Source for Professional Healthcare News

Cigarran Resigns from Healthways Board Last month, Healthways, Inc. announced Thomas G. Cigarran had resigned from the board of directors of the company he co-founded, effective Feb. 14, 2014. Cigarran, 72, helped launch the company in 1981 and served as its CEO Thomas G. from 1989 to 2003 before Cigarran retiring to serve as chairman until 2010, when he became chairman emeritus. In a letter to John Ballantine, current board chair, Cigarran said he was “no longer willing to continue as a director and watch this company fail to meet its potential and the reasonable expectations of its shareholders.” He added Healthways is well positioned to become a great company, but Cigarran said he did not think this could be accomplished “without changes in company focus and direction.” Ballantine released a statement thanking Cigarran for his years of service and expressing surprise at the decision. The statement continued, “Our governance guidelines require directors to tender their resignation upon age 72, but given his extensive history with the company, the board had asked Tom to stand for election again this year. The board is surprised that he has chosen not to continue to work with his fellow directors to enhance shareholder value in the rapidly evolving healthcare industry, especially given the market adoption of the company’s well-being improvement solutions.” Ballantine added Healthways has just executed a very successful year of customer retention and new sales and reiterated the board’s support of embattled CEO Ben Leedle and the Healthways management team. North Tide Capital, which owns 11 percent of the Franklinbased company, has objected to Leedle’s leadership and strategic direction for the company and vowed to present its own slate of directors this spring.

Vanderbilt Scientists Contribute to Finding that Could Lead to RSV Vaccine Vanderbilt University scientists have contributed to a major finding, reported last month in the journal Nature, which could lead to the first effective vaccine against respiratory syncytial virus (RSV), a significant cause of infant mortality. The virus, which worldwide causes nearly 7 percent of all deaths among children ages one month to one year and is the leading cause of hospitalizations among children under two, has been notoriously resistant to vaccine-design strategies. The Vanderbilt scientists and other researchers analyzed in an animal model a new method developed at The Scripps Research Institute (TSRI) in La Jolla, Calif., for

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MARCH 2014

designing artificial proteins capable of stimulating an immune response against RSV. “This project is the first work in which a protein that was designed on a computer has been shown to work as a vaccine candidate for a human pathogen,” said Vanderbilt’s James Crowe, MD, Ann Scott Carell Professor and a leading RSV researcher. The TSRI scientists developed a new software app, “Fold from Loops,” to design proteins that folded around their functional fragments more naturally in a way that mimicked the viral epitope and which could serve as a key component of an effective vaccine. In rhesus macaque monkeys, whose immune systems are quite similar to humans,’ the designer “immunogen” proteins showed great promise. After five immunizations, 12 of 16 monkeys were producing robust amounts of antibodies that could neutralize RSV in the lab dish.

Collaboration Improves Efficiency in Pharmacogenetic Testing Nashville-based Common Cents Systems, Inc. (ApolloLIMS) and Translational Software have successfully collaborated to improve Pharmacogenetic (PGx) testing and reporting processes. This strategic collaboration combines Apollo’s platform for operational excellence with Translational Software’s PGx decision support system to enable customers to improve turnaround time, decrease errors, and make test results more relevant for clinicians. The ApolloLIMS Lab Automation component gives the lab automated programmatic processes that intelligently send and receive data directly with the laboratory testing equipment without requiring data entry by the operator. By combining that with the Apollo eXchange HL7 Interface engine, the companies have been successful in creating a bi-directional seamless integration from the pre-analytic, analytic, and post-analytic phases.

LBMC Launches Tennessee Health Reform Online Resource While some questions have been answered, many more remain when it comes to healthcare reform. Lattimore Black Morgan & Cain, PC and the LBMC Family of Companies, one of the Southeast’s largest accounting and business consulting firms, recently developed and launched a Tennessee Healthcare Reform website to provide the latest healthcare reform information in a consolidated site at TNHealthcareReform.com.

Centerre Names Maxhimer COO Nashville-based, Centerre Healthcare Corporation has announced the appointment of Terry Maxhimer as chief operating officer. Maxhimer brings more than two decades of inpatient rehabilitation hospital experience, which has focused on leading clinical Terry Maxhimer and organizational excellence. His background includes an empha-

sis on positive partner relationships through healthcare joint venture partnerships. In the COO role, Maxhimer will lead the operations of the company’s freestanding inpatient rehabilitation hospitals.

PhyMed Promotes Two PhyMed Healthcare Group, an anesthesia practice management company based in Nashville, recently announced two key appointments at Anesthesia Medical Group (AMG), which serves Saint Thomas and Centennial Medical Centers and is the flagship operation of PhyMed. Michael Morgan has been named COO of AMG. He was formerly PhyMed’s chief business development officer and will continue to serve in that capacity. Before joining PhyMed, Morgan was CFO and COO of FOAA Anesthesia Services in Washington, DC. Tammy Myers has been named director of operations. Most recently she served as PhyMed’s director of integration and has served as AMG’s CFO. Myers has more than 20 years experience working at AMG.

Cogent Names Halasyamani CMO Brentwood-based Cogent Healthcare recently named Lakshmi Halasyamani, MD, chief medical officer. The hospitalist fills the executive role left open when company founder and former CMO Ron Greeno, MD, moved to a new position overseeing strategy and innovation. Halasyamani received her undergraduate degree from Saint Louis University and her medical degree from Harvard. She had been an attending physician at St. Joseph Mercy in Ann Arbor, Mich. Since 2000 and was named CMO in 2011. .

LifePoint Adds Two VPs Brentwood-based LifePoint Hospitals® recently announced the addition of two new vice presidents. Chip Staton has joined the company as vice president of the company’s newly established Enterprise Program Management Office. He comes to LifePoint from Deloitte, where he led the project management office responsible for ensuring the firm’s comChip Staton pliance with the federal government’s contractor regulations. A certified public accountant in Texas, Staton received his bachelor’s degree in Accounting in from Texas A&M University. Jennifer C. Peters has joined the company as vice president and chief operations counsel. Most recently, she served as general counsel, secretary and chief compliance officer for Simplex Healthcare. Peters received her undergraduate degree from Buffalo State UniverJennifer C. sity, her master’s in HealthPeters care and Finance Management from the Johns Hopkins School of Hygiene and Public Health, and her law degree with a concentration in health law from the University of Maryland.

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GrandRounds Van Donkelaar Takes on Financial Role for Two Capella-Saint Thomas Partner Hospitals Rodney A. Van Donkelaar has been named senior chief financial officer for River Park Hospital in McMinnville, Tenn. and Highlands Medical Center in Sparta, Tenn. The two hospitals are both part of the Capella-Saint Thomas Upper Cumberland health A. Van system, which also includes Rodney Donkelaar DeKalb Community Hospital in Smithville, and Stones River Hospital in Woodbury. Most recently, Van Donkelaar served as CFO for Grandview Medical Center in Jasper, Tenn. Originally from Michigan, Van Donkelaar earned his degree in Business Administration Accounting from Davenport University in Grand Rapids.

Cumberland Adds Two Partners Two principals at Cumberland Consulting Group have been promoted to partners. Mike Penich joined Cumberland in 2004, shortly after the company’s inception, and specializes in project management, systems analysis and design. He received his bachelor’s degree in Operations Management & Information Systems from Northern Illinois University Mike Penich and is a certified Project Management Professional (PMP). Greg Varner, a registered nurse with more than 22 years of experience in clinical healthcare delivery, has a successful track record as a consulting executive in healthcare IT. He earned his bachelor’s degree from the University of Tennessee at Chattanooga. Greg Varner Both are members of the Project Management Institute and the Healthcare Information & Management Systems Society.

Capella Announces Promotions Capella Healthcare recently announced the promotions of three senior leaders to executive management positions and four others to its senior management team. Promoted to executive vice president are: Neil Kunkel, EVP, chief legal and administrative officer, Andy Slusser, EVP, chief development officer, and Denise Warren, EVP, chief financial officer. Promoted to senior vice president positions are: Mark Medley, SVP, president – Hospital Operations, Carolyn Schneider, SVP – Human Resources, Alan Smith, SVP, chief information officer, and Lori Wooten, SVP, chief financial officer – Hospital Operations. nashvillemedicalnews

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Ardent Appoints Adams VP of Reimbursement Ardent Health Services recently announced the appointment of Jim Adams as vice president of reimbursement. With nearly 20 years of experience, Adams brings a broad background in healthcare reimbursement with experience in both health sysJim Adams tems and national business consultancies. Most recently, he served as direc-

tor of strategic reimbursement for the healthcare practice of Wipfli, LLP, a top 25 accounting and business consulting firm. Previously, he was a senior consultant with Ernst & Young where he specialized in Medicare and Medicaid reimbursement. A certified public accountant, Adams is a graduate of the University of South Alabama.

White Joins Clearwater Compliance as VP Communications veteran Andrea White has joined Nashville-based Clearwa-

ter Compliance as vice president of marketing. . Most recently, White worked with Walgreens, leading innovations project management initiatives for the Take Care Health Em- Andrea White ployer Solutions Group. The Nashville native, received her undergraduate degree from Georgetown University and earned her MBA at the University of Virginia Darden School of Business.

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