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FOCUS TOPICS GASTROENTEROLOGY • PEDIATRICS • HEALTH LAW

September/October December 2019 2009 >> >> $5 $5

Addressing the Shortage

ON ROUNDS

Communicating the Importance of Childhood Vaccinations

State leaders discuss local impact of proposed Resident Physician Shortage Reduction Act

Pediatrician Brentley J. Silvey, MD, says disease resurgence complicated by antivaxxers The recent measles outbreak in the U.S. linked primarily to unvaccinated children is a troubling reminder of how important vaccines are against preventable diseases ... 3

Friday Law Firm Health Law Update: OCR Caps Reduction

Introduced by Senators Boozman, In August, US Charles Schumer Sen. John Boozman (D-NY) and Bob (R-AR) joined governMenendez (D-NJ), ment and healthcare The Resident Physileaders from across cian Shortage Reducthe state to address the tion Act increases the nationwide shortage number of residency of physician residency positions eligible for positions, and how Graduate Medical The Resident PhysiEducation payments cian Shortage Reunder Medicare for duction Act of 2019 qualifying hospitals, can help. The GME with an aggregate inSummit, co-sponsored crease of 3,000 posiby the University of tions per fiscal year Sen. John Boozman discusses the Resident Physician Shortage Reduction Act. Arkansas for Medical for five years. Of these Sciences and Northpositions, at least 1,500 west Arkansas Council, highlighted the shortage’s economic and per fiscal year must be for residents in a shortage specialty residency patient impact in Arkansas, where the growing number of medical program (i.e., a program in a specialty in which baseline physician school graduates will soon exceed first-year residency slots available. (CONTINUED ON PAGE 6)

On April 30, 2019, the Department of Health and Human Services (HHS)’s Office for Civil Rights (OCR) issued notification that it is lowering the maximum total penalties it may assess against covered entities and business associates for multiple violations of HIPAA Privacy, Security, Breach Notification, and Enforcement Rules (HIPAA Rules) in a single year ... 4

HealthcareLeader

It Takes a Team

Forrest City Medical Center’s, John Ballard, looking to build on service lines and customer service By BECKY GILLETTE

John Ballard, PhD, FACHE, CEO of Forrest City Medical Center, tends to refer to himself as the accidental CEO. After graduating with a degree in computer science from Louisiana State University, he initially had a career as a computer programmer. Then he helped manage his family’s Wharf Master’s restaurant in Natchez, Miss., for 12 years. When the family closed the restaurant, the computer world had changed so much that employers felt he was no longer qualified to get a job in programming.

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PhysicianSpotlight

Communicating the Importance of Childhood Vaccinations

Pediatrician Brentley J. Silvey, MD, says disease resurgence complicated by anti-vaxxers By BECKy GILLETTE

The recent measles outbreak in the U.S. linked primarily to unvaccinated children is a troubling reminder of how important vaccines are against preventable diseases. “Currently, there have been nearly 1,200 cases of measles in 30 states,” said Northwest Arkansas Pediatrics President, Brentley J. Silvey, MD. “This is the highest number since 1992 and the first outbreak since 2000 when measles were declared eliminated in the United States. About 90 percent of the current cases are in people who have not been vaccinated.” Parents can easily be influenced by the anti-vaxxer movement that links childhood vaccinations to sudden infant death syndrome, auto-immune disorders, inflammatory bowel disease, allergies, asthma, ADHD and autism. Some prominent celebrities like Jenny McCarthy and Jim Carrey have posted anti-vaccination messages on social media. All 19 partners at Northwest Arkansas Pediatrics, which is part of the independent physician group Medical Associates of Northwest Arkansas (MANA), are adamant about the importance of vaccines. “For parents who are vaccine hesitant, I try to spend time understanding their concerns and supplying them with science-based information rather than information found on social media,” Silvey said. “Specifically, for the Measles Mumps Rubella vaccine, I stress to parents that it is among the most studied medical product we have.” One exciting development over the past several years is the routine use of the human papillomavirus (HPV) vaccine, also known as Gardisil. Silvey said although the HPV vaccine was introduced only in 2006, the rising vaccine coverage has already resulted in declining rates of cervical cancer in the U.S. This vaccine is recommended for males and females ages 9-12, although the vaccine is now licensed for use in those ages 9-45. Silvey grew up in the small town of Mansfield located near Fort Smith. He decided on medicine as a career at a young age. In junior high he set his sights on a career that would help and serve others. “Plus, I loved science,” Silvey said. “Medicine was a field that met both of those criteria.” Silvey received a Bachelor of Science in Biology from the University of Arkansas, and earned a medical degree at the University of Arkansas for Medical Sciences (UAMS). It wasn’t until his third year of medical school that he decided to specialize in pediatrics. ARKANSASMEDICALNEWS

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“I was on a medical mission trip to Honduras and was naturally drawn to the joy of children no matter what their circumstance,” Silvey said. “After that trip, I tailored more of my rotations toward pediatrics, which solidified my love for it.” Silvey has continued his medical mission work. “Once a year I lead a medical mission team to Haiti with my church, Cross Church,” Silvey said. “This is an exhausting, but very rewarding, trip where we are providing basic medical care to one of the poorest countries in the Western Hemisphere. Thousands of kids and adults who have no access to any medical care are seen in a few days span.” Over the past few years he has been involved with Tim Tebow’s Night to

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Shine, which is a prom for individuals with special needs. Silvey also volunteers weekly through his church in leading Awana games for elementary kids. Awana is an international ministry that works with local volunteers in churches around the world “with Biblical evangelism and discipleship solutions so that today’s children may become tomorrow’s Christian leaders, in every aspect of society and culture.” Silvey, who did his residency at Arkansas Children’s Hospital, has been in private practice for 13 years at Northwest Arkansas Pediatrics in Fayetteville. He is Board Certified by the American Academy of Pediatrics. Silvey was instrumental in the opening and design of the Fayetteville Wellness Clinic to provide a vibrant, safe environment for infant care and preventive medicine for children and their families in 2009. In 2017, he helped coordinate the opening of the Pinnacle Hills Clinic with separated well and acute care. That has

proven to be a very popular option with parents who don’t want their children potentially exposed to a virus while having a routine checkup. Northwest Arkansas Pediatrics is the largest private pediatric group in Arkansas with 19 partners, two locations, and a walk-in clinic open six days a week, including evenings. “As Northwest Arkansas continues to grow due to the multiple corporate headquarters, the area has grown in diversity of cultures,” Silvey said. “It is fun and exciting to take care of this diversity and learn the differences in cultures that contribute to the medical care. We also love the diversity in complexity of our patients ranging from simple runny noses to working closely with the pediatric specialist for the most medically complex kids.” Silvey and his wife, Leslie Silvey, have two daughters: Olivia Grace is in the 8th grade and Annalyse is in the 4th grade. The family’s favorite leisure time activity is spending time out on Beaver Lake.

Opioids: Is Prescribing Making You Nervous? UAMS AR-IMPACT is a weekly FREE interactive televideo consultation service designed to help Arkansas clinicians better manage their chronic pain patients and those who need their opioid dosage reduced. Televideo conferences are held Noon-1 p.m. Wednesdays. The program starts with a brief didactic presentation about an aspect of the care of these patients, followed by a case conference where doctors can present their difficult cases for discussion with their peers and with our panel of subspecialists. To join the conference, visit our website ARimpact.UAMS.edu For questions or to submit a case for our panel, email ARimpact@UAMS.edu To watch previous conferences and still receive CE credit, visit LearnOnDemand.org/lms/arimpact. Provider education: free CE for physicians, pharmacists, nurses, physical therapists and other health care professionals.

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Office for Civil Rights Reduces Annual Penalty Caps for Certain Violations Under HIPAA By LYNDA JOHNSON, TIMOTHY EZELL and AMIE K. ALEXANDER

On April 30, 2019, the Department of Health and Human Services (HHS)’s Office for Civil Rights (OCR) issued notification that it is lowering the maximum total penalties it may assess against covered entities and business associates for multiple violations of HIPAA Privacy, Security, Breach Notification, and Enforcement Rules (HIPAA Rules) in a single year.

The HITECH Penalty Scheme

Under the HIPAA Rules, Congress initially authorized HHS to impose a maximum Civil Money Penalty (CMP) of $100 for each violation, subject to a calendar year cap of $25,000 for all violations of an identical requirement or prohibition. Congress enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act in February 2009 as part of the American Recovery and Reinvestment Act of 2009. The HITECH Act strengthened HIPAA enforcement by increasing minimum and maximum penalties. It also established different categories of HIPAA violations, with increasing penalty tiers based on the level of culpability associated with the violation. The HITECH Act provided four levels of culpability: Culpability Level One – “No Knowledge”: The covered entity did not know (and by exercising reasonable diligence would not have known) that it was violating the HIPAA provision. Culpability Level Two – “Reasonable Cause”: It is established that the HIPAA violation was due to reasonable

cause and not willful neglect. Culpability Level Three – “Willful Neglect – Corrected”: It is established that the violation was due to willful neglect and the violation was corrected within the 30-day period beginning on the first date the person liable for the penalty or damages knew, or by exercising reasonable diligence should have known, that the failure to comply occurred; and Culpability Level Four – “Willful Neglect – Not Corrected”: It is established that the violation was due to willful neglect and the violation was not corrected within the 30-day period beginning on the first date the person liable for the penalty or damages knew, or by exercising reasonable diligence should have known, that the failure to comply occurred.

The Obama Administration’s 2009 Interpretation

HHS issued an Interim Final Rule (IFR) in October 2009 to implement the enhanced penalty visions of the HITECH Act. However, the language of the Act led to differing interpretations of its penalty provisions. At the time of the 2009 IFR, HHS’s view was that the HITECH Act’s penalty provisions were conflicting because they allegedly referenced two levels of penalties for three of the four violation types. Despite the fact that the HITECH Act provided four different annual penalty caps, the IFR concluded that the “most logical reading” of the Act was to apply the highest annual cap of $1.5 million to all violation types. The IFR was adopted by HHS as a Final Rule (the “Enforcement Rule”) without change to the penalty tiers and annual limits on January 25, 2013.

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Chart A: Penalty Tiers Under HHS’s 2009 Interpretation (the Enforcement Rule) Level of Culpability

Minimum Maximum Annual limit penalty/violation penalty/violation

No Knowledge

$100

$50,000

$1,500,000

Reasonable Cause

$1,000

$50,000

$1,500,000

Willful Neglect – Corrected

$10,000

$50,000

$1,500,000

Willful Neglect – Not Corrected

$50,000

$50,000

$1,500,000

Chart B: Penalty Tiers Under HHS’s April 2019 Reinterpretation Level of Culpability

Minimum Maximum Annual limit penalty/violation penalty/violation

No Knowledge

$100

$50,000

$25,000

Reasonable Cause

$1,000

$50,000

$100,000

Willful Neglect – Corrected

$10,000

$50,000

$250,000

Willful Neglect – Not Corrected

$50,000

$50,000

$1,500,000

The Enforcement Rule’s penalty matrix applied the same cumulative annual CMP limit across all four categories of violations based on the level of culpability, as set forth in Chart A. This interpretation maximized HHS’s enforcement authority in order to further what it believed was Congress’s intent to strengthen HIPAA enforcement, but in doing so, ultimately ignored the minimum annual caps provided in the HITECH Act entirely.

The Trump Administration’s 2019 Reinterpretation

HHS will now apply a different cumulative annual CMP limit for each of the four penalty tiers, which it considers the better reading of the HITECH Act. These amounts will be adjusted for inflation and

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are set forth in Chart B. For now, this reinterpretation is only an exercise of OCR’s enforcement discretion. However, the Trump Administration has made clear its plans to undertake future rulemaking in order to formalize the reinterpretation into a final rule. Such action would make it much more difficult for future administrations to move back to the prior, higher penalty enforcement matrix. The lowering of annual CMP limits are certainly more favorable to covered entities and business associates, and more appropriately incentivize covered entities and business associates to act in ways that fall within the lower annual caps, such as taking additional steps to correct willful neglect in a timely manner. Covered entities and business associates should maintain evidence of lack of knowledge, reasonable cause, and timely corrections. Covered entities and business associates should not take this reinterpretation as a sign that OCR is lessening HIPAA enforcement. OCR just wrapped up a record-breaking year for HIPAA financial enforcement and is showing no signs of slowing down. Regardless, if you do find yourself working with OCR after a HIPAA breach incident as a covered entity of business associate, taking steps to show OCR that any violations that may have occurred were done without knowledge despite reasonable diligence may mean the difference between a $25,000 penalty cap versus $1.5 million. Lynda Johnson and Timothy Ezell are both partners at Friday, Eldredge & Clark, LLP.

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GI Update 2019: Proton-Pump Inhibitor (PPI) Therapy is Safe By TERENCE ANGTUACO, MD

Over the past few years, safety issues associated with PPIs have come to the forefront of discussion in the field of Gastroenterology. Many studies on the long-term use of PPIs have reported adverse effects such as fractures, hypomagnesemia, acute and chronic kidney disease, dementia, and Clostridium difficile infection. These have become a source of major concern to both patients and physicians. Some patients discontinued their PPI therapy abruptly or inappropriately, and prescribers withheld or underdosed the treatment of their patients because of this. Up until recently, all the published results were based on retrospective and observational studies. They were unable to establish a definite association and could not prove cause and effect between PPI use and the development of serious adverse events. It is important to determine the long-term safety of this class of drug because many people depend on it, and yet, we do not want to endanger their well-being because of it.

ment of Veteran Affairs national databases and assessed the renal outcomes of 173,321 new PPI users compared to 20,270 new H2RA users over 5 years. PPI users were found to have a 28 percent increased risk of CKD. Antoniou T et al (CMAJ Open. 2015;3(2):E166-171) reported a 2.5-times increased risk of acute kidney injury and 3-times increased risk of acute interstitial nephritis in elderly patients recently

started on PPI’s. This was a populationbased study of 290,592 patients older than 65-years-old. The mechanism for development of CKD may be due to untreated subclinical acute interstitial nephritis that progressed over time. Dementia. Two prospective studies investigated the association of PPI use and the risk of dementia. Haenisch et al (Eur Arch Psychiatry Clin Neurosci.

2015;265(5):419-428) studied 3,076 patients 75 years or older with no history of dementia and found a 38 percent increased risk of dementia in PPI users. Gomm et al (JAMA Neurol 2016;73(4):410-416) studied 73,679 individuals 75 years or older with no history of dementia and found that regular PPI users had a 44 percent increased risk of dementia. On the other hand, there were (CONTINUED ON PAGE 8)

Retrospective Studies on PPI Use and Development of Adverse Events:

Fractures. A meta-analysis of 18 observational studies reported a 33 percent increased risk of fracture at any site, 26 percent higher risk of hip fracture, and 58 percent increase in risk of spine fracture. Both short-term (<1 year) and long-term use of PPI were associated with increased risk of hip fracture. (Zhou B et al, Osteoporos Int. 2016;27(1):339-47). The proposed mechanism is reduced calcium absorption resulting in decreased bone mineral density (BMD). Although a placebo-controlled, double-blind, crossover trial found decreased calcium carbonate absorption after 1 week of Omeprazole treatment (O’Connell M et al, Am J Med 2005;118(7):778-781), there is no evidence to show that PPI are associated with development of osteoporosis. A study on 4,512 patients who received continuous PPI treatment and followed over 10 years, did not show a significant rate of change in BMD (Targownik L et al, Am J Gastroenterol 2012;107(9):1361-69). The association of short-term PPI use with fractures as reported by Zhou B et al in 2016, also lead us to conclude that PPI-associated fractures are unlikely due to osteoporosis. Hypomagnesemia. A meta-analysis of 9 observational studies that included 109,798 patients, reported a 43 percent increased risk of hypomagnesemia (Cheungpasitporn W et al, Ren Fail 2015;37(7):123741). Magnesium level normalized with discontinuation of PPI treatment. In 2011, the U.S. FDA issued a safety warning regarding this association and recommended monitoring of magnesium levels in patients on long-term PPI therapy. Acute and chronic kidney disease (CKD). Xie et al (J Am Soc Nephrol 2016;27(10):3153-63) used the Departarkansasmedicalnews

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Addressing the Shortage, continued from page 1 requirements projections exceed the projected supply of total active physicians, as identified by the Health Resources and Services Administration in a specified report). The current cap stems from a 1997 decision to limit the number of residents a hospital can claim for Medicare GME, and it’s one healthcare leaders say has backfired. By 2032, the American Association of Medical Colleges predicts a nationwide shortage of up to 125,000 physicians. “Twenty years ago, medical organizations felt like we had an over-supply of providers, and actually wanted to reduce that number,” explained Boozman, who’s received bipartisan support for the Act. “As years have gone by it’s changed, and has now become more of a monetary thing – finding the Medicare dollars to increase funding for training.” In Arkansas, Boozman said resolving physician shortages would require public-private partnerships as healthcare leaders work to address the problem of insufficient providers, particularly in specialty areas.

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Cam Patterson, MD, MBA, chancellor at the University of Arkansas for Medical Sciences, said training needs have increased substantially since CMS capped slots on large hospitals like UAMS. “Our ability to support additional residents has been hampered by this cap in federal support for GME physicians in training,” said Patterson, who Cam Patterson, MD, MBA also participated in the Aug. 12 summit. “The result has been a bottleneck for everyone, especially for states with large underserved areas.” That includes Arkansas, where two-thirds of land mass is depopulated and all but two counties are considered medically underserved. The cap severely impacts Arkansas’ ability to train, and retain, young physicians, since the majority of residents settle within 50 miles of where they train: Fewer residents mean fewer providers long-term. Nationally, the US graduates 38,000 physicians, and more than 3,000 are unable to find residency spots. In Arkansas, UAMS graduates up to 174 medical students each year. The Arkansas College of Osteopathic Medicine in Fort Smith and the New York Institute of Technology Osteopathic Medicine in Jonesboro will both graduate their first students in two years, resulting in a total of 439 medical school graduates. However, there are only 277 first-year residency slots in the state. “This is not just an Arkansas issue but a national crisis, and we need to get started on training now to not be paralyzed by a shortage of physicians,” Patterson said. “We want to make sure we have enough residency slots for everyone who wants to practice in Arkansas.” Patterson said it’s not uncommon for a promising undergrad to receive subsidized tuition from a state university and subsidized medical training from UAMS, only to end up in a neighboring state for residency. “This

will only continue if there’s not change,” he said. “We can’t be penny-wise and foolish. If we don’t do something now it will cost us much more 15 years from now.” Boozman said residency slots are especially important in rural states like Arkansas, where provider recruitment and retention are particularly challenging. “When you have people who train here and start to have families here, those factors contribute to them wanting to stay within the region,” he said. “Once we get people here they discover a great quality of life, and it’s easier to retain them.”

NWA Council

Summit organizers from the Northwest Arkansas Council also understand the economic potential of losing physician residents to other states. Established nearly 30 years ago, the group is a forward-thinking nonprofit working to advance quality of life, improve the workforce, create job opportunities, upgrade infrastructure and keep up with growth. “We’re coming up with strategies and plans to address the shortage in northwest Arkansas the best we can, and that might include federal solutions as well as state,” said Council President and CEO Nelson Peacock. He and his colleagues were struck by the potential economic impact of a stronger healthcare infrastructure when the Council’s 2019 “Healthcare in Northwest Arkansas” report Nelson Peacock found the region is losing $950 million annually due to outmigration of people seeking specialty medical services. Conversely, the region could gain $2 billion by 2040 if northwest Arkansas is able to establish itself as a healthcare destination. “Over the last six years, the idea of northwest Arkansas as a healthcare destination has been in our strategic plan,” Peacock said. “The idea behind that report was finding out what it will take: What is the economic impact of not doing anything or taking steps toward it?” To that end, the Council has been working with UAMS and area health systems to identify residency needs, including development of teaching hospitals and a solid rotation paradigm.

“A People Thing”

As the bill awaits action, all three leaders say the time to advocate for more services and providers in Arkansas is now. “It’s difficult to come up with an argument to oppose this, which is why this bill has bipartisan support,” Patterson said. “What’s really needed is for enough people to shake the tree so that it’s considered a priority by our legislature rather than something they’re merely in favor of.” Boozman agreed, and said he’s yet to run into any opponents of The Resident Physician Shortage Reduction Act. “If you need a specialist and you live in an area that doesn’t have enough providers, you know this isn’t a Democrat or Republican thing,” he said. “It’s a people thing, and everyone recognizes that.” arkansasmedicalnews

.com


It Takes a Team, continued from page 1 He went back to school and earned a Masters’ of Business Administration (MBA) from Alcorn State University. A friend recommended he send a resume to the CEO of the Natchez Community Hospital. “The CEO called me and said he had a job for me at a clinic,” Ballard said. “I told him I don’t know anything about healthcare. The CEO said he had eaten at my restaurant, and that had shown him I knew about quality and customer service. He said he could teach me about healthcare, but that he had a customer service problem in that clinic that he needed me to fix.” Ballard took the job and worked hard to help improve the service and reputation of the clinic. It was a job he found challenging and rewarding. Then he decided to go back to school again, this time obtaining a PhD in epidemiology from Walden University. All he learned about technology, customer service and quality orientation in previous jobs are skills he uses every day in his role as a CEO. “My background being as varied as it is, works to my advantage,” he said. “Getting a doctorate in epidemiology has helped me, too, because I can to talk with doctors and nurses at a more clinical level.” Having a clinical perspective is also a bit unusual for a hospital administrator. Many people go to work in hospital

administration after receiving their MBA, but experience managing the clinic was good training for his hospital work. “I have answered calls at a clinic, preauthorized payments, worked to get payments, and worked with patients over payment plans,” said Ballard, who moved to Forrest City in May. “It takes all of us working together to make it effective. Unfortunately, it is about more than quality patient care. There are so many different regulatory agencies, all the managed Medicaid out there, and fighting with insurance companies to get paid. It takes a team of specialists to make everything work smoothly.” Prior to taking his present position, Ballard previously worked as CEO of Kentucky River Medical Center in Jackson, Ky. While there, he had a focus on recruiting vital providers to the area, including a general surgeon, a urologist, a family practitioner, an ENT and four family nurse practitioners. He worked to improve customer satisfaction and emergency department performance. Under his tenure, the serious safety event rate went from 0.97 to zero with no sentinel or serious safety events during the past four years. He has been impressed by the leadership team at Forrest City, in particular the team’s commitment to quality and patient-centered healthcare. “The hospital is poised for growth in the coming years with highly experienced

medical staff and strong community support,” Ballard said. “We don’t have an orthopedic surgeon on staff and a top goal is to recruit one. We don’t need someone with a fellowship in knee replacement. We just need a bread-and-butter orthopedist. We haven’t had an ENT for a while, so we will also be working to recruit one of those.” One of his biggest challenges at Forrest City Medical Center is to combat a patient perception that “bigger is better.” There are larger facilities north in Jonesboro and east in Memphis. Still, Forrest City pulls from the West Memphis market. “A lot of people don’t want to go over the bridge to Memphis,” Ballard said. “For a lot of folks in our area, travel is difficult, so it helps to have local treatment. By staying here, patients are also able to use Arkansas Medicaid instead of having problems using Arkansas Medicaid in Tennessee. People tend to think they can get better care at larger hospitals. Larger hospitals may offer services we don’t offer, but what we do here we do extremely well.” His goals for the hospital are to grow the service lines and capture more of the market share by improving customer service and quality. Ballard feels that healthcare is a calling. It you don’t feel passionate about it, it may not be the career for you. “I look forward to going to work

every day and making it a fun environment for people in which to work,” Ballard said. “What we do is very intense, but we can do our best to make it as pleasant and rewarding as possible. We must have an environment where people feel they can speak their minds, come to me with problems. That allows us to do serious work and at the same time be a close work family. We go through birth, deaths, car wrecks and serious illnesses. You have to build that family atmosphere. That bleeds into your patient care. They pick up on your comradery. It is all about creating that culture that people know that you have their back. As leaders, we have to be willing to roll up our sleeves and help out when things get hectic. We do whatever it takes. All of our clinical leadership is of that mindset.” There is a large population of diabetic patients in the area. Forrest City Medical Center can do in-patient dialysis at the hospital, and has a wound care center with hyperbaric oxygen treatment. They also deliver on average 800 to 900 babies per year. Ballard said Forrest City feels very familiar to his hometown of Natchez. An avid outdoorsman, he is excited about recreational opportunity in the woods of Northeast Arkansas. “Wild turkey hunting is my passion,” Ballard said. “I have hunted all my life and nothing is more challenging than wild

(CONTINUED ON PAGE 8)

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GI Update 2019, continued from page 5 two studies that did not show an association between PPI use and dementia. Lochhead P et al (Gastroenterology 2017;153(4):971979.e4) reported negative results on a prospective analysis of 13,864 middle-aged and older women enrolled in the Nurses’ Health Study II, and Taipale H et al (Am J Gastroenterol 2017 Dec;112(12):1802-08)

It Takes a Team, continued from page 7

turkey. I love to deer hunt and duck hunt, but will drop everything to go turkey hunting. The wild turkey season in Arkansas is only seven days long, so I go to Texas and Oklahoma where there are longer seasons and bigger bag limits. I also love bass fishing. With all the rivers here, I’m going to have to learn to go trout fishing.” Ballard is the youngest of five children, and has four adult children ages 22 to 32. One son and one daughter-in-law are in the U.S. Coast Guard, and a second son is about to enroll. Forrest City Medical Center is a 118bed facility providing complete inpatient, outpatient, surgical, diagnostic and emergency care. It employs about 90 healthcare professionals. Forrest City Medical Center is a subsidiary of Quorum Health, which provides support for operations, accounting, recruiting, legal and regulatory compliance. Quorum Health has 27 hospitals, including two in Arkansas.

reported negative results of an analysis of 70,718 newly diagnosed case of Alzheimer’s disease in the Finnish nationwide health care registry. PPIs are suspected to cause dementia by causing an accumulation of amyloid-B peptides in the brain. This was based on the findings of a study where mice that were treated with Lansoprazole were found to have higher levels of amyloid-B peptides in their brain due to an increase in amyloid synthesis and decrease in amyloid degradation in the brain. Clostridium difficile infection (CDI). A meta-analysis of 42 observational studies revealed an increased risk of both incident and recurrent CDI in patient treated with PPI. All studies were nonrandomized observational studies, and the dose and duration of PPI treatment used were highly variable. The hypothesis of this association is the survival of the toxinsecreting vegetative form of C. difficile in the alkaline gastric pH. (Kwok C et al, Am J Gastroenterol 2012;107(7):1011-1019). All-Cause Mortality Risk Increased. Xie Y et al (BMJ 2019 May;365:l1580) reported results from a retrospective study using data from the U.S. Department of Veterans Affairs to estimate the all-cause and cause-specific mortality among new users of PPIs (n=157,625) and H2RA (n=56,842). Over a median of 10 years of follow-up, there were more deaths among patients taking PPIs (37.92 percent) than among those taking H2RA (35.69 percent). PPI use was associated with excess mortality due to cardiovascular disease,

CKD, and upper GI cancer.

Prospective Randomized Controlled Trial on PPI Safety:

Moayyedi P et al, published the first prospective, double-blind, placebocontrolled randomized trial to evaluate the many long-term safety concerns related to PPI use (Gastroenterology 2019 September;157:682-691). This was a large trial involving 17,598 patients with stable cardiovascular disease and peripheral artery disease. This trial had a median follow-up of 3.01 years. Participants were randomly assigned to receive Pantoprazole 40 mg/day (n=8,791) or placebo (n=8,807). There was no significant difference between the Pantoprazole and placebo groups with regards to the following adverse events: gastric atrophy, C. difficile infection, chronic kidney disease, dementia, pneumonia, fracture, COPD, and diabetes mellitus. Only enteric infections other than C. difficile was more common in the Pantoprazole group (1.4 percent vs. 1.0 percent).

Summary and Recommendations:

Earlier studies and a few recent ones reported various safety concerns regarding the use of PPIs. However, these results were inconclusive because of inherent biases associated with retrospective and observational studies from which they were derived from. The only large, multi-year, prospective, randomized controlled trial looking into the safety of PPIs by Moayyedi P et al, found

that Pantoprazole 40 mg/day is not associated with any adverse events when used for 3 years, with the possible exception of an increased risk of enteric infections. Although this study presented strong evidence that PPI is safe, this conclusion cannot be extrapolated beyond the dose and duration used in this study. There are many questions that are yet to be answered by future studies of various designs. In the meantime, judicious use of PPIs should be practiced. Prescribe PPI only when indicated and give the recommended dose and duration of treatment. When there is a proven indication for PPI therapy, treatment should not be withheld because of concerns of potential long-term harm. Long-term PPI therapy should be given at the lowest effective dose when clinically indicated. PPI dose escalation and continued chronic therapy in those unresponsive to initial empiric therapy should be discouraged. For patients whose symptoms improved on PPIs, and there are no reasons for continued treatment, they should be given a trial of stopping the PPI or use a less potent acid-reducer and see if their symptoms recur. Terence Angtuaco, MD, is a founder of Premier Gastroenterology Associates, a single specialty medical practice. He is board certified in Internal Medicine & Gastroenterology and accepts patients with general digestive disease issues, including laryngopharyngeal reflux disease and chronic liver disease. Visit https:// pgalr.com/

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Another Option to Address Pediatric ADHD NeuroSigma Prepares U.S. Launch of First FDA-Cleared Device By CINDY SANDERS

The Centers for Disease Control and Prevention (CDC) estimate a little more than six million children in the United States have … or have had … AttentionDeficit/Hyperactivity Disorder (ADHD). The latest statistics, pulled from the 2016 National Survey of Children’s Health (NSCH), underscore how prevalent the disorder is with approximately 9.4 percent of children ages two-17 having been diagnosed with ADHD. Currently, treatment options for ADHD typically include behavioral therapy, medication or a combination of the two. While the CDC stated there is no single source of comprehensive data on ADHD treatment, parent reports and claims data provide some insight into therapy preferences. Of those ages two-17 with a diagnosis, the CDC estimates: • About 30 percent treated with medication alone, • About 15 percent received behavioral therapy alone, • About 32 percent received both medication and behavioral therapy, and • About 23 percent of children with ADHD receive neither treatment option. On April 19, the U.S. Food and Drug Administration (FDA) cleared a new treatment option for pediatric ADHD – the Monarch® external Trigeminal Nerve Stimulation (eTNS®) System by NeuroSigma, Inc., a bioelectronics company based in Los Angeles. The Monarch eTNS System, the first medical device cleared to treat pediatric ADHD, is a prescriptiononly device cleared for use in patients ages seven to 12 who are not currently taking prescription ADHD medications. “It provides non-invasive, transcutaneous stimulation of the trigeminal nerve through the forehead,” explained Colin Kealey, MD, vice president of Advanced Development & Medical Affairs for NeuroSigma. Used while children sleep at night, Kealey noted the treatment allows users to go about their normal day without having to interrupt school or play time to take medicine. An electrical patch about the size of a large bandage is applied to the forehead before bedtime. The patch is connected to the handheld Monarch eTNS pulse generator, which is similar in size to a cell phone. “That generator creates a gentle electrical signal that stimulates the trigeminal nerve,” said Kealey. While the FDA release regarding the new device stated the exact mechanism of eTNS still isn’t fully understood, the federal agency pointed out neuroimaging studies have shown eTNS increases activity in certain brain regions.

The Road to FDA Clearance

“We submitted our application for FDA clearance via the de novo pathway in 2018, and that clearance was granted in April 2019,” Kealey said. He added the de arkansasmedicalnews

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common side effects were drowsiness, headache, trouble sleeping, fatigue, increased appetite and teeth clenching. Kealey said the eTNS has been approved in the European Union since 2012. “In all that time, there has never been a serious adverse event with the device that we’re aware of,” he said, adding it has a strong safety profile.

Next Steps

novo pathway is reserved for novel medical devices that are deemed low-to-moderate risk for patients. Even under the best circumstances, it may take years for a novel device to develop the data necessary to obtain marketing authorization from FDA . For NeuroSigma, the trek to FDA clearance began with an open label study enrolling 24 patients. That study yielded positive results that were published in 2015 and set the stage for a larger clinical trial, which was completed in 2017. “Based on those results (from the open label study), the principal investigator at UCLA – Dr. Jim McGough – was awarded a grant from the National Institutes of Health to do a blinded trial, and NeuroSigma provided the devices for that trial,” Kealey said. James McGough, MD, is a professor and child psychiatrist at the Jane & Terry Semel Institute for Neuroscience and Human Behavior at UCLA. The NIH-funded, randomized, double-blinded trial enrolled 62 children with moderate-to-severe ADHD to assess the Monarch eTNS System’s efficacy as a monotherapy to treat the disorder as compared to a placebo device. Kealey said the trial’s primary endpoint was improvement on the ADHD-RS-IV. The ADHD Rating Scale is commonly used to monitor the severity and frequency of symptoms for children diagnosed with the disorder. In addition, the trial also looked at changes to the Clinical Global Impression-1 (CGI1) scale, which measures severity. Trial results were provided to the FDA last year and were published in the April 2019 issue of the Journal of the American Academy of Child and Adolescent Psychiatry. Children were randomized to use the Monarch eTNS or a sham (placebo) device for four weeks while sleeping. Those in the active group of the trial had statistically significant improvement in ADHD symptoms compared to the placebo group. The active group’s average ADHD-RS score decreased from 34.1 points at baseline to 23.4 points (differential of 10.7 points) at the end of four weeks compared to a decrease in the placebo group from 33.7 to 27.5 (a 6.2-point differential). Similarly, between group comparison of the CGI-1 scores also favored the trial’s active group(p = .003). No serious adverse effects were observed with use of the device. The most

“We’re in the process of preparing for launch,” NeuroSigma President and CEO Leon Ekchian, PhD, said of the next steps. He added a pilot rollout will happen later this year, followed by a full market launch in 2020. “What is important in pediatric ADHD is to be able to offer different options to parents,” Ekchian said. “What we’re offering is a non-stimulant, nondrug treatment to improve a child’s ADHD symptoms.” He noted that at any given time, a little more than three million children are taking ADHD medication and that it is common to cycle on and off of drugs. “Our value proposition is we want to

offer parents an alternative to the drugs. Of course, that’s a choice between physicians and parents, but we now have this alternative that has a strong safety profile and limited side effects.” Pointing to the broader field of neuromodulation, Ekchian continued, “We view this as part of a broader treatment paradigm. These approaches have the potential to provide an alternative to the use of medication and offer a more targeted treatment approach.” He said that while at this time the Monarch eTNS is only cleared in the US for pediatric ADHD, NeuroSigma plans to perform additional studies in the future to explore potential use in conditions such as PTSD, epilepsy, depression. However, he added, NeuroSigma is laser-focused on introducing the ADHD application to providers, patients and parents as the company prepares for the national rollout and partnering opportunities outside the US. “We think there’s a really compelling opportunity for our eTNS system because we believe it’s an alternative to medication with positive efficacy and a favorable safety profile,” Ekchian concluded.

GrandRounds Michael Birrer, MD, PhD, Named UAMS Winthrop P. Rockefeller Cancer Institute Director

LITTLE ROCK - Internationally recognized medical oncologist Michael Birrer, MD, PhD, has been named vice chancellor and director of the Winthrop P. Rockefeller Cancer Institute at the University of Arkansas for Medical Sciences (UAMS), succeeding Laura Hutchins, MD. Michael Birrer, MD, PhD He formerly served as director of the O’Neal Comprehensive Cancer Center at the University of Alabama at Birmingham. As director of the UAMS Cancer Institute, Birrer will lead all cancer-related activities. There are about 150 UAMS faculty members engaged in cancer-related research and clinical activities. Brirrer left a professorship at Harvard Medical School in an attempt to help a broader number of patients with cancer. He will also hold the position of Cancer Service Line director. Christopher Westfall, MD, executive vice chancellor and dean of the UAMS College of Medicine said Birrer will help move the Winthrop P. Rockefeller Cancer Institute toward the goal of achieving designation by the National Cancer Institute. NCI Designation is awarded through a highly competitive assessment process during which cancer centers must demonstrate outstanding depth and breadth of high-quality cancer research.

Receiving designation brings substantial benefits, including the ability to access federal research funding and offer clinical trials not available to non-designated centers. It also is expected to result in a $72 million economic impact on Arkansas and create about 1,500 new jobs over five years. Brirrer said that given state support, UAMS and philanthropic support, he estimates a $70 million investment over the next five years in the Cancer Institute, which will strengthen the chance at NCI designation. Birrer completed his MD and PhD in 1982 in the Medical Scientist Training Program at the Albert Einstein College of Medicine in New York. Following a medical internship and residency at Massachusetts General Hospital, Birrer entered the Medical Oncology Fellowship program at the National Cancer Institute in Bethesda, Maryland. After his fellowship, Birrer was appointed senior investigator (with tenure) and established the molecular mechanism section in the Division of Cancer Prevention and Control. In 2008, Birrer was appointed professor of medicine at the Harvard School of Medicine and assumed the position of director for both Gynecologic Medical Oncology at Massachusetts General Hospital and the Gynecologic Oncology Research Program at the Dana Farber/ Harvard Cancer Center. Recognized nationally and internationally as an expert in gynecologic oncology, Birrer’s primary research interest is in characterizing the genomics of gynecologic cancers to improve the clinical management of these diseases. SEPTEMBER/OCTOBER 2019

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GrandRounds American Association of Critical-Care Nurses Recognizes CVICU at ACH with Award for Excellence LITTLE ROCK – The Cardiovascular Intensive Care Unit (CVICU) at Arkansas Children’s Hospital (ACH) has been recognized with a Silver-Level Beacon Award for Excellence by the American Association of Critical-Care Nurses (AACN), distinguishing the unit’s exceptional patient care and healthy work environments. The CVICU, which provides comprehensive surgical and intensive care for Arkansas children with heart disease and defects, becomes the second unit at ACH to receive this national designation. The AACN recognized the ACH Pediatric Intensive Care Unit (PICU), which cares for the state’s most critically ill and injured children, with a Silver-Level Beacon Award in 2018. They are the only intensive care units in the state to be awarded this honor. The Beacon Award for Excellence recognizes unit caregivers who successfully improve patient outcomes and align practices with AACN’s six Healthy Work Environment Standards. Units that achieve this three-year, three-level award with a gold, silver or bronze designation meet national criteria consistent with Magnet Recognition, the Malcolm Baldrige National Quality Award and the National Quality Healthcare Award. The CVICU is a component of the Heart Center at ACH, with two cardiovascular operating rooms, two state-of-theart cardiac catheterization labs, heartlung bypass technology and outpatient services that include regional clinics. The Heart Center at ACH provides comprehensive congenital cardiac care for a lifetime, from fetal echo interpretation before a baby is born to full support for adults with congenital heart disease. The Silver-Level Beacon Award for Excellence earned by Arkansas Children’s Hospital’s CVICU signifies an effective approach to policies, procedures and processes that includes engagement of staff and key stakeholders. The unit has evaluation and improvement strategies in place and good performance measures when compared to relevant benchmarks. The CVICU at ACH earned its SilverLevel Award by meeting the following evidence-based Beacon Award for Excellence criteria: • Leadership Structures and Systems • Appropriate Staffing and Staff Engagement • Effective Communication, Knowledge Management and Learning and Development • Evidence-Based Practice and Processes • Outcome Measurement The other Beacon Award designations are gold and bronze. Gold-level awardees demonstrate an effective and systematic approach to policies, procedures and processes that includes engagement of staff and key stakeholders; fact-based evaluation strategies for

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continuous process improvement; and performance measures that meet or exceed relevant benchmarks. Recipients who earn a bronze-level award are beginning the journey to excellence, which includes developing systematic policies, processes and procedures; identifying opportunities for staff participation; and recognizing the need to develop cycles of evaluation and improvement.

NIH Awards $420,000 to ACRI, UAMS Researcher to Study Chlamydia, Potentially Inform Therapies & Vaccine Development LITTLE ROCK – Research to better understand chlamydia, potentially informing the development of a vaccine for the infection, is underway at Arkansas Children’s Research Institute (ACRI) and the University of Arkansas for Medical Sciences (UAMS) after the National Institutes of Health (NIH) awarded the project $420,000. The National Institute of Allergy and Infectious Diseases, part of NIH, is funding the work of Laxmi Yeruva, PhD, an investigator at ACRI and an associate professor of Pediatrics in the UAMS College of Medicine. She and her team will

use the two-year award to examine interactions between chlamydia and proteins released by cells during infection. They believe building a better understanding of how these Laxmi Yeruva, PhD proteins affect inflammation and tissue damage during infection can lead to novel therapies, possibly even helping vaccine development. Dr. Yeruva’s research has been supported, in part, by funds from the Arkansas Biosciences Institute, the major research component of the Tobacco Settlement Proceeds Act of 2000.

CHI St. Vincent Welcomes Geriatrician Dr. Meaghan Masini to Hot Springs Village Clinic HOT SPRINGS VILLAGE - Dr. Meaghan Masini has joined CHI St. Vincent Primary Care Clinic, located at the West Gate in Hot Springs Village. Dr. Masini specializes in geriatric medicine and help

Dr. Meaghan Masini

ensure residents of the Village continue to have access to the very best in care right in the community where they live. She is now seeing patients at the clinic located at 4417 Highway 7 North. Dr. Masini most recently served as a physician specialist at Kings County Hospital Center in Brooklyn, New York, caring for adult and elderly patients. She was also a faculty teacher and lecturer at SUNY Downstate Medical Center in Brooklyn. Dr. Masini attended medical school at St. George’s University School of Medicine in Grenada, West Indies, where she also obtained her master’s of public health. She completed her residency training in internal medicine and fellowship training in geriatric medicine at SUNY Downstate Medical Center. Dr. Masini has board certifications in geriatrics and internal medicine. CHI St. Vincent’s network of clinics provide care for both adults and children, including wellness checks, preventative medicine, management of chronic conditions like diabetes and robust coordination with the state’s largest and most diverse network of heart specialists with the CHI St. Vincent Heart Institute.

Dr. Randy Esters, North Arkansas College president, and Stephanie Gardner, Pharm.D., Ed.D., University of Arkansas for Medical Sciences (UAMS) provost and chief strategy officer, sign an agreement Monday, Aug. 26, in Little Rock to allow Northark Medical Laboratory Technology (MLT) graduates to transfer to an online program at UAMS to earn a Bachelor of Science degree in Medical Laboratory Sciences (MLS).

North Arkansas College, UAMS Sign New Online Transfer Agreement LITTLE ROCK - North Arkansas College in Harrison has signed an agreement with the University of Arkansas for Medical Sciences (UAMS) that allows Northark Medical Laboratory Technology (MLT) graduates to transfer to a corresponding online Bachelor of Science degree program through UAMS without leaving their hometowns. This is the first 2+2 partnership between the two institutions and the first MLT online bachelor degree option offered in the state. The 2+2 means students attend Northark for two years and then transfer to UAMS for two more years to earn the bachelors’ degree. In addition to providing an online degree that is convenient and accessible, both institutions desire to provide seamless transfers, thereby affording students the opportunity to earn a high-quality degree from both institutions in the most efficient manner possible. Signing the agreement at UAMS was Stephanie Gardner, Pharm.D., Ed.D., UAMS provost and chief strategy officer, and Dr. Randy Esters, president of North Arkansas College. Under the terms of the agreement, any student transferring from Northark to UAMS who has completed courses identified in the MLT 2+2 Degree Plan Checklist, completed required transfer procedures and gained admission to UAMS will receive full transfer credit for previously earned hours in his or her major field of study. The medical laboratory sciences program is in the UAMS College of Health Professions. Northark’s MLT program has experienced a 100% job placement rate for several years, with most students receiving job offers before graduation. This agreement will increase the number of skilled workers to meet the increasing demand. arkansasmedicalnews

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GrandRounds UAMS Partners With Arkansas Blue Cross and Blue Shield to Expand Digital Health Network LITTLE ROCK - A $1 million grant to the University of Arkansas for Medical Sciences (UAMS) from Arkansas Blue Cross and Blue Shield will enable the UAMS Institute for Digital Health & Innovation to advance digital health statewide to provide patients better and more streamlined access to health care. The grant was announced today as leaders from UAMS and Arkansas Blue Cross unveiled a digital health interpretive wall on the first floor of UAMS Medical Center. The interactive display will allow visitors to gain a better understanding of the benefits of digital technology and how it serves as an important tool for not only patient care, but for improved health and wellness The support of Arkansas Blue Cross in the UAMS digital health initiative honors Mahlon O. Maris, MD, for his nearly 50 years as a practicing primary care physician, providing quality care with great compassion in rural Arkansas. Digital health delivers health care through technology such as smart phones, interactive live video, wearable devices and personal computers. It reduces the cost of health care and improves access for patients, especially in a largely rural state like Arkansas. UAMS Chancellor Cam Patterson, M.D., MBA, who has made digital health a key component of his tenure, made the announcement with Curtis Barnett, Arkansas Blue Cross president and CEO, and Curtis Lowery, M.D., director of the UAMS Institute for Digital Health & Innovation. Lowery has nurtured digital health applications in Arkansas over the last 30 years, culminating in creation this year of the Institute for Digital Health & Innovation. The institute already connects many hospitals and clinics across the state through interactive video to provide care for high-risk pregnancy, stroke and other health needs. The first phase of the plan will focus on urgent care. Patients will be able to consult with a medical professional by phone or live video on their phone to determine whether they need immediate care and how to obtain follow-up care. A digital provider will be able to treat significantly more patients and can treat patients throughout the state. Phase Two will develop ways to provide primary care and certain specialized care, such as gynecology, ophthalmology, gastroenterology, oncology and orthopaedics. The services should be available for the public in early 2021, allowing UAMS time to establish the technology infrastructure and training programs necessary for a full digital interprofessional education and health care delivery center. None of that would be possible without the critically important $1 million investment from Arkansas Blue arkansasmedicalnews

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Cross, which has long supported UAMS programs. Since the institute’s inception in February, it has been distributing software and technology to patients so they can take part in live video consultations 24 hours a day, seven days a week with physicians and other health care professionals. At least 6 percent of patients use a digital device to manage health, and 66 percent of millennials are interested in managing their health on mobile devices, according to 2017 surveys. The institute can expand on existing relationships between UAMS and rural hospitals to provide access to medical specialties that aren’t in those communities. Increased access to specialists can reduce health care costs by reducing the need to transfer patients from rural hospitals to larger medical centers such as UAMS where those specialists often are more commonly practicing. These changes will help move toward compensating providers for positive health outcomes rather than the now predominant, fee-for-service model. This will result in fewer hospitalizations, shorter hospital stays and fewer Emergency Department visits. Cost savings are then shared with providers. The Institute for Digital Health & Innovation also provides continuing medical and health education, public health education, and evaluation research through interactive video.

Baptist Health Heart Institute/Arkansas Cardiology Adds Dr. Robin Singh LITTLE ROCK – Robin Singh, MD, has joined Arkansas Cardiology/Baptist Health Heart Institute as a member alongside his father, Dr. Balkrishna Singh. Dr. Robin Singh, a native of Little Rock, graduated from Duke University and earned his medical degree Robin Singh, MD from the University of Arkansas for Medical Sciences. He completed an internal medicine residency at the University of Louisville, followed by fellowship training in cardiovascular disease at the University of South Florida in Tampa where he served as a chief cardiology fellow. Most recently, Dr. Singh finished his clinical cardiac electrophysiology fellowship at Brigham & Women’s Hospital/ Harvard Medical School prior to returning home. He has co-authored several journal publications as well as a book chapter on fluoroless ablation of cardiac arrhythmias. Dr. Singh is board certified in cardiovascular disease, nuclear cardiology, adult comprehensive echocardiography and internal medicine. For more information, call Baptist Health HealthLine at 1-888-BAPTIST or visit baptist-health.com.

GastroArkansas Uses the Bravo PH Wireless Capsule as a Diagnostic Tool Esophageal reflux occurs when stomach acid refluxes or moves back into the esophagus. While some reflux is physiologic and is usually asymptomatic, gastroesophageal reflux disease (GERD) is a condition that occurs when the reflux of stomach contents causes troublesome symptoms and/or complications. GERD is noted for its high prevalence, affecting 10-20% of the U.S. population, as well as its two classic symptoms, heartburn and regurgitation. While an extremely common problem, GERD can be difficult to diagnose as symptoms are often not enough. The presence of reflux symptoms lack direct correlation with increased esophageal acid exposure as well as endoscopic proven esophagitis. It is for these reasons that it is important to confirm the presence of acid reflux in patients with “refractory” GERD symptoms before an escalation of anti-reflux therapy or surgery is considered. Ambulatory pH monitoring is considered the gold standard test for GERD as it correlates symptoms with acid exposure in the esophagus. The test is often used to confirm the diagnosis of GERD in those patients with persistent symptoms despite medication or to monitor the adequacy of treatment. Conventional pH monitoring is a 24 hour study that involves using a nasal-pharyngeal catheter. While sensitive and specific, this procedure has several drawbacks including patient discomfort and catheter displacement. Oftentimes, patients will limit their daily activities and alter their diet which can affect the accuracy of the test therefore leading to erroneous results. In an effort to overcome these limitations and improve upon this cumbersome test, a wireless pH system was designed and developed. The Bravo pH wireless capsule system is designed to be user-friendly and has the added advantage of prolonged (48-96 hours) pH monitoring. The Bravo pH system involves endoscopically attaching a small (pea-sized) capsule to the mucosa of the distal esophagus thus avoiding the inconvenience of wearing a nasal-pharyngeal electrode. The diagnostic yield of the Bravo system has been shown to be comparable to the catheter-based test while at the same time scoring higher marks for tolerability with only a minor impact on diet and daily activities.

About the author: Dr. Craig Davis graduated from the University of the South in Sewanee, TN with a B.S. in Biology, earning his medical degree from the University of Arkansas College of Medicine in 2004. He completed his Residency at the Mayo Clinic in 2007 and received his Master’s Degree in Public Health from the University of Alabama. Dr. Davis is board certified by the American Board of Internal Medicine in Gastroenterology and Internal Medicine, and a member of the American College of Gastroenterology and the Arkansas Medical Society.

The Bravo capsule is placed during a routine EGD. Once the endoscopist identifies and marks the GE junction, the capsule is then placed 6 cm above the GE junction. The patient will then be sent home with a Bravo recorder that will communicate with the capsule. The patient returns the recorder, usually after 48 hours, and the data is then downloaded onto a computer. The capsule typically falls off after 7-10 days and will pass in the stool. The Bravo pH study can answer three basic questions: First, does the patient actually have acid reflux? Second, if the patient has acid reflux, how bad is it? And finally, when does the reflux of acid occur (after eating, at bedtime, predominantly in the upright or supine position)?

Among the data collected to help the physician answer these 3 questions include: the percentage of time the esophagus was exposed to a pH of less than 4 during the 48 hour study period, the total number of reflux episodes and the duration and timing of each reflux event. The relation of acid reflux to meals and whether the patient was in the upright or supine position is also noted. Taken together, these data components can be used to calculate a DeMeester score which is a global measure of esophageal acid exposure. A DeMeester score of greater than 14.72 is indicative of abnormal acid reflux. Using these data points, along with the patient’s symptoms and EGD findings, the physician is now in a position to tailor a more targeted and thus effective treatment plan for the patient.

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GrandRounds CARTI Expands Imaging Services, Opens CARTI Imaging North NORTH LITTLE ROCK – CARTI announced that its newest location, CARTI Imaging North, has opened. Featuring diagnostic radiologist Theodore Hronas, MD, the clinic will offer imaging services, including MRI and CT scans. The clinic is located at 3320 Springhill Drive, Suite B, North Little Rock. Dr. Hronas has been at CARTI Cancer Center Little Rock as a diagnostic radiologist since 2014. He earned his medical degree and completed his residency at the University of Arkansas for Medical sciences. For more information, visit CARTI. com.

OB-GYN Dr. Brock Warford Joins the CHI St. Vincent Hot Springs Women’s Clinic

HOT SPRINGS - Dr. Brock Warford, OB-GYN, has joined the team of leading obstetricians and gynecologists at the CHI St. Vincent Hot Springs Women’s Clinic. Dr. Warford is now seeing patients at the CHI St. Vincent Women’s Clinic at 118 Dr. Brock Women’s Center Lane Warford in Hot Springs. Dr. Warford completed medical school and residency at the University of Arkansas for Medical Sciences in Little Rock. He is a member of the American College of Obstetrics and Gynecology, Arkansas Medical Society and American Chemical Society. With a pledge to give excellent, compassionate and personalized care, the CHI St. Vincent Hot Springs Women’s Clinic offers a wide range of specialized services for women’s health, including pelvic exams, Pap tests and mammograms. For expectant mothers, the OB-GYN team provides assistance with pregnancy, ultrasounds, labor and delivery. To schedule an appointment with Dr. Warford, call 501.609.2229.

NEA Baptist is Among Nation’s Top Performing Hospitals for Treatment of Heart Attack Patients JONESBORO - NEA Baptist has received the American College of Cardiology’s NCDR Chest Pain-MI Registry Platinum Performance Achievement Award for 2019. This is the top tier award of which NEA Baptist is one of only 225 hospitals nationwide to receive the honor. The award recognizes NEA Baptist’s commitment and success in implementing a higher standard of care for heart attack patients and signifies that NEA Baptist has reached an aggressive goal of treating these patients to standard

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levels of care as outlined by the American College of Cardiology/American Heart Association clinical guidelines and recommendations. To receive the Chest Pain-MI Registry Platinum Performance Achievement Award, NEA Baptist has demonstrated sustained achievement in the Chest Pain-MI Registry for eight consecutive quarters and has performed at the top level of standards for specific performance measures. Full participation in the registry engages hospitals in a robust quality improvement process using data to drive improvements in adherence to guideline recommendations and overall quality of care provided to heart attack patients. As a Platinum Performance Award recipient, NEA Baptist has established itself as a leader in setting the national standard for improving quality of care in patients with acute myocardial infarction said Michael C. Kontos, MD, FACC, chair of the NCDR Chest Pain – MI Registry Steering Subcommittee, Virginia Commonwealth University Medical Center. By meeting the award requirements set forth in the registry, NEA Baptist has demonstrated a commitment to providing reliable, comprehensive treatment for heart attack patients based on current clinical guideline recommendations. The Center for Disease Control estimates that over 700,000 Americans suffer a heart attack each year. A heart attack occurs when a blood clot in a coronary artery partially or completely blocks blood flow to the heart muscle. Treatment guidelines include administering aspirin upon arrival and discharge, timely restoration of blood flow to the blocked artery, smoking cessation counseling and cardiac rehabilitation, among others. Chest Pain-MI Registry empowers health care provider teams to consistently treat heart attack patients according to the most current, science-based guidelines and establishes a national standard for understanding and improving the quality, safety and outcomes of care provided for patients with coronary artery disease, specifically high-risk heart attack patients.

CHI St. Vincent partnering with Penn State LITTLE ROCK - Penn Medicine is partnering with an Arkansas hospital to expedite heart surgery research in an area with a particularly high mortality rate for heart disease. The partnership with the Little Rock-based CHI St. Vincent Heart Institute is part of a larger program pairing five medical institutions that have conducted extensive cardiothoracic surgery research with qualified institutions that have conducted little clinical research. The latter hospitals also are located in underserved areas with high prevalence

rates of cardiac disease, stroke, obesity and diabetes. Arkansas has the third-highest mortality rate from heart disease in the United States, according to the U.S. Centers for Disease Control and Prevention. Across the country, heart disease remains the leading cause of death. Cardiac surgeries help address some of the most prominent conditions related to heart disease, including coronary artery disease, congestive heart failure, atrial fibrillation and valvular heart disease. Rapid innovation has led to new approaches and technologies for cardiac surgeries, but health officials say clinical research efforts – which validate these approaches – have not kept pace. Part of that lag is due to clinical trial enrollment challenges. To accelerate research efforts, Penn Medicine’s cardiac surgeons will work with physicians at St. Vincent for the next seven years to conduct clinical research studies that test new products, surgical interventions and cardiovascular practices. Their work will be funded by a grant from the National Institutes of Health and is part of the Cardiothoracic Surgical Trials Network’s Linked Clinical Research Centers project. Dr. Michael Acker, Penn Medicine’s chief of cardiovascular surgery, said clinical trials involving cardiac surgery historically have been difficult to conduct. But Penn Medicine has done so with the support of the NIH’s National Heart, Lung and Blood Institute and the Cardiothoracic Surgical Trials Network.

Mercy Opens Sleep Center in Booneville BOONEVILLE – Mercy has opened a sleep lab in Booneville to conduct studies for patients with a variety of sleep-related disorders. The move from Mercy Hospital Waldron to Mercy Hospital Booneville creates a centralized location for Mercy Sleep Center to serve patients in Logan and Scott counties and surrounding areas, according to Chellie Smith, director of sleep services for Mercy in the Fort Smith region. Mercy sleep centers help people with disorders such as insomnia, restless leg syndrome and sleep apnea, which is characterized by brief interruptions of breathing during sleep. The centers are staffed by seven registered polysomnographic technologists, four of whom also are certified respiratory therapists. Mercy Sleep Center in Booneville provides studies Monday through Thursday nights weekly, with plans to add Fridays. The labs are nationally accredited, offer private rooms, queensize beds with premium mattresses and daytime studies (at the Fort Smith lab only) for those who work the night shift. A primary care physician may rec-

ommend a sleep study for patients who have trouble falling or staying asleep, who snore, pause in breathing or gasp at night, experience daytime sleepiness or have other sleep disruptions. After it’s determined a sleep study is needed, a technician walks patients through an in-depth, one-on-one discussion before they’re wired with sensors. The technician closely monitors patients while they are sleeping. Testing and treatment is determined by a board-certified sleep specialist. Mercy Sleep Centers last year received a three-year national accreditation that demonstrates a commitment to providing the highest level of performance and patient care. The Accreditation Commission for Health Care granted the accreditation, which focuses on clinical care when patients are tested for a variety of sleep disorders. The three centers demonstrated a commitment to providing quality care and services to patients through compliance with the commission’s nationally recognized standards. If you think you could benefit from a sleep study, ask your primary care doctor for a referral to one of the three sleep centers or make an appointment with Dr. Snell or nurse practitioner Paula Brosnan at Mercy Clinic Sleep Medicine

New Physician Joins Conway Regional Wound Healing Center CONWAY - Kelly Crowe, MD, a board certified Emergency Medicine physician, has joined the Conway Regional Wound Healing Center and Healogics, Inc. as the new, full-time outpatient wound care physician. Dr. Crowe holds a Kelly Crowe, MD medical degree from UAMS. She completed a four-year residency in Emergency Medicine at Lincoln Hospital through Weill Cornell Medical College in the Bronx, New York City. She graduated with a Bachelor’s of Science degree in Microbiology from the University of Arkansas at Fayetteville and went on to obtain her Masters of Science degree in Biology. She worked in Emergency Medicine until 2013 and then began practicing in urgent care settings. Dr. Crowe and her husband, John, live in Little Rock with their four daughters. The Conway Regional Wound Healing Center offers state-of-the-art outpatient clinical wound care and hyperbaric medicine. The center specializes in advanced wound care, using a variety of clinical treatments, therapies and support services to treat chronic wounds. The center provides a physician-driven, multi-disciplinary approach to outpatient wound care.

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GrandRounds CARTI Expands Statewide Presence with Ashley County Medical Center to Open CARTI Crossett CROSSETT – CARTI announced that its newest clinic, CARTI Crossett, opened in August featuring medical oncologist Bilal Malik, MD. The clinic offers infusion services, including chemotherapy. Thanks to a partnership with Ashley Bilal Malik, MD County Medical Center, and with Dr. Malik at the helm, the clinic looks forward to bringing the most advanced technologies and expertise to the patients living in and around Ashley County. Dr. Malik has run his own solo practice, South Arkansas Hematology & Oncology Clinic, in Pine Bluff for more than 20 years. He is a member of the American Society of Clinical Oncology, Arkansas Blood and Cancer Society, American Can Society and the Association of Pakistani Physicians in North America. He earned his medical degree from Nishtar Medical College in Pakistan. He completed residencies in pathology at Cooper Medical Center in Camden, New Jersey and The State University of New York in Buffalo, New York, and in internal medicine at St. Clare’s Hospital in New York, New York. He completed a fellowship in hematology and oncology at the University of Alabama in Birmingham, Alabama.

UAMS Joins Consortium to Advance Blending Complementary with Conventional Health Care Methods LITTLE ROCK - The University of Arkansas for Medical Sciences (UAMS) has joined the Academic Consortium for Integrative Medicine & Health as part of its effort to improve evidence-based integrative health research and patient care for Arkansans. Integrative health treats the whole patient by blending conventional and complementary health care methods to create a holistic, patient-focused approach to wellness. This can include cognitive behavioral therapy, acupuncture, massage, yoga, tai chi, chiropractic manipulation, nutrition and other physical and behavioral therapies as complements to traditional health care approaches. The Academic Consortium includes over 70 highly esteemed academic medical centers and health systems from across North America. The Consortium advances the principles and practices of integrative health care by providing its membership with a community of support and a collective voice for influencing change. These efforts include: • Supporting and mentoring academic leaders, faculty and students to advance integrative health care education, research and clinical care. • Disseminating information on rigorous scientific research, educational curricula in integrative health and sustainable models of clinical care.

• Informing health care policy. UAMS’ membership was approved by the Consortium’s Membership Committee and by member institutions. Pearl McElfish, Ph.D., MBA, vice chancellor for the UAMS Northwest Regional Campus in Fayetteville, and Jeanne Wei, M.D., Ph.D., director of the UAMS Donald W. Reynolds Institute on Aging, will serve as UAMS’ representatives for the Academic Consortium. UAMS is already engaged in these goals in several ways. For example, UAMS faculty have published 150 peerreviewed articles on integrative health. At its Northwest Regional Campus, UAMS has received $20 million in extramural research funding to evaluate and implement holistic solutions for the prevention of chronic diseases like obesity, diabetes, hypertension and cancer. UAMS is partnering with Brightwater and Crystal Bridges Museum of American Art for educational programs on culinary medicine and the arts in health. The UAMS Interventional Pain Management Clinic offers a holist approach to speed healing and eliminate dependence on opioids. Additionally, programs like ARIMPACT (Arkansas Improving Multidisciplinary Pain Care and Treatment) enable physicians from across the state to interact directly with UAMS experts in pain management and integrative treatments for pain available for education and case consults. For more information on the Academic Consortium, visit imconsortium.org.

Mercy Hospital NWA Achieves Primary Stroke Center Certification ROGERS - When it comes to treating stroke, it’s important to act quickly and seek care that can help lessen its potentially debilitating effects. It’s also essential to get help at a hospital that provides top-level stroke care. The Joint Commission announced recently that Mercy Hospital Northwest Arkansas has earned certification as a Primary Stroke Center. The certification means Mercy Hospital can display The Joint Commission’s Gold Seal of Approval, a symbol of quality that reflects Mercy’s commitment to providing safe and effective patient care. Mercy has a stroke team on site 24 hours a day, augmented by support from vStroke, Mercy’s virtual stroke program. Mercy Hospital underwent a rigorous onsite review June 12. During the visit, a team of Joint Commission reviewers evaluated compliance with related certification standards including program management and delivering and facilitating clinical care. Joint Commission standards are developed in consultation with health care experts and providers, measurement experts and patients. The reviewers also conducted onsite observations and interviews. Primary Stroke Center Certification recognizes health care organizations committed to fostering continuous quality improvement in patient safety and quality of care, said Mark Pelletier, chief operating officer for Accreditation and Certification Operations and chief nursing executive, The Joint Commission. In addition, The Joint Commission announced that Mercy Bella Vista, a multispecialty facility with a 24-hour Emergency Department, was certified as an Acute Stroke Ready Hospital. The certification signifies the clinic’s expertise in diagnosing and treating stroke. arkansasmedicalnews

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Arkansas Health Network Appoints Dr. Shahid Shafi as Chief Medical Officer & Vice President LITTLE ROCK – The Arkansas Health Network (AHN), a physician-led, clinically integrated network (CIN) serving Arkansas patients, providers, and employers, announced that Dr. Shahid Shafi has been appointed as its new Chief Medical Officer and Vice President. Dr. Shafi’s responsibili- Dr. Shahid Shafi ties will include all aspects of clinical quality improvement, evidence-based medical guidelines and the development of quality metrics across the network in addition to supporting AHN’s other strategic initiatives. AHN is the largest and most successful CIN in the state of Arkansas. The organization currently manages over 95,000 patients across the state of and partners with a growing network of nearly 2000 providers. AHN has repeat successes in programs sponsored by both commercial and governmental payors. Its Medicare ACO in the state earned shared savings both in the 2014 and 2017 performance years. In addition, with the rising cost of healthcare growing as a concern for employers across Arkansas, AHN has partnered with Arkansas Children’s Care Network to provide a unique health care delivery model designed specifically for self-insured employers. It leverages technology and big data to identify high-risk patients and then connects them with registered nurse health coaches to proactively manage their care with an emphasis on preventative, rather than reactive, services. The holistic approach drives positive outcomes for employees and associated lower costs for employers. Dr. Shafi previously served as Medical Director of Baylor Scott & White Quality Alliance ACO in Dallas, Texas and as CEO of Surgical Group of North Texas. He also served as Medical Director of Trauma Surgery for Parkland Memorial Hospital in Dallas as well as Associate Dean for Clinical Affairs for Texas Christian University and the University of North Texas. Dr. Shafi earned his Doctor of Medicine from Aga Khan University in Karachi, Pakistan and received his trauma surgery fellowship from the University of Pennsylvania. He also holds a Master of Public Health degree from Johns Hopkins University and his Master of Business degree from Southern Methodist University.

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GrandRounds CARTI Announces Plan to Build CARTI Cancer Center South Arkansas in El Dorado EL DORADO - CARTI has announced its plan to build CARTI Cancer Center South Arkansas, a comprehensive cancer treatment facility to be located in El Dorado. The cancer center’s planned services will include medical and radiation oncology, an infusion suite, imaging and an onsite lab. The project is currently in preliminary phases and a site has yet to be identified. This will be the fifth comprehensive cancer center in CARTI’s network of cancer treatment locations, bringing its statewide presence to 16 treatment locations in 14 communities. CARTI currently has south Arkansas locations in El Dorado and Crossett, and will open a third location in Magnolia in October. CARTI IN SOUTH ARKANSAS Dr. Balagopalan Nair began seeing patients in El Dorado in 1998. Due to a significant increase in patient volume, Dr. Nair expanded his presence in south Arkansas. Today, Dr. Nair sees more than 60 patients per day. With the help of his medical team, more than 100 cancer patients are served at CARTI El Dorado every Tuesday. Since 1998, Dr. Nair has treated more than 4,000 cancer patients from south Arkansas. In the last 12 months, CARTI has served 1,643 people from south Arkansas.

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Dr. John Brizzolara Joins Ozark Urology Clinic FAYETTEVILLE - John Brizzolara, MD., recently joined Washington Regional Ozark Urology Clinic where he works alongside Mark Jackson, MD, Lindsay Horton, APRN and Tasha Kerr, APRN. Dr. Brizzolara received his medical de- John Brizzolara, gree and completed a MD urology residency at UAMS. He served as staff urologist in the military at Irwin Army Hospital in Ft. Riley, Kansas and Brooke Army Medical Center in Fort Sam Houston, Texas. Dr. Brizzolara has practiced at the Arkansas Urology Associates, Little Rock Veterans Administration Hospital Department of Surgery, and most recently in private practice. He is board certified by the American Board of Urology and a member of the American Urologic Association and American College of Surgeons.

CHI St. Vincent Infirmary Appoints Dr. George Hutchison as Medical Director of Patient Access LITTLE ROCK - CHI St. Vincent Infirmary has promoted longtime Emergency Room Medical Director Dr. George

“Hutch” Hutchison to Medical Director of Patient Access. In his new role, Dr. Hutchison will work to continually improve patient experiences and the efficienDr. George cy of care from entry to Hutchison exit. Dr. Hutchison, who has cared for the community at CHI St. Vincent since 1998, will continue to share his leadership and experience serving patients in the emergency room, but will now focus specifically on improving patient access. A graduate of the University of Texas Southwestern Medical School in Dallas, Dr. Hutchison completed residences in Internal Medicine and Emergency Medicine at the University of Arkansas for Medical Sciences. He is certified by the American Board of Emergency Medicine.

PUBLISHER Pamela Z. Haskins pamela@arkansasmedicalnews.com EDITOR Pepper Jeter editor@arkansasmedicalnews.com ADVERTISING SALES 501.247.9189 pamela@arkansasmedicalnews.com CREATIVE DIRECTOR Susan Graham sgraham@nashvillemedicalnews.com GRAPHIC DESIGNERS Susan Graham, Katy Barrett-Alley CONTRIBUTING WRITERS Becky Gillette, Melanie Kilgore-Hill Lynda Johnson Timothy Ezell Amie K. Alexander Terence Angtuaco, MD, Cindy Sanders All editorial submissions and press releases should be sent to pamela@memphismedicalnews.com Subscription requests can be mailed to the address below or emailed to pamela@memphismedicalnews.com.

Arkansas Medical News is now privately owned by Ziggy Productions, LLC. P O Box 1842 Memphis, TN 38101- 1842 President: Pamela Z. Haskins Vice President: Patrick Rains Reproduction in whole or in part without written permission is prohibited. Arkansas Medical News will assume no responsibility for unsolicited materials. All letters sent to Arkansas Medical News will be considered the newspaper’s property and unconditionally assigned to Arkansas Medical News for publication and copyright purposes.

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GrandRounds Baptist Health Women’s Clinic-Fort Smith Adds Physician FORT SMITH – Anne Bowes, DO, is now taking new patients at Baptist Health Women’s ClinicFort Smith. Dr. Bowes provides prenatal and postpartum care, as well as general wellness exams and surgical procedures for women of all ages. She also specializes in women’s Anne Bowes, DO sexual health and wellness, along with hormone therapy. The Oklahoma City native earned a medical degree from Lincoln Memorial University – DeBusk College of Osteopathic Medicine in Harrogate, Tennessee. She completed her residency in Obstetrics and Gynecology at Oklahoma State University Medical Center in Tulsa, Oklahoma. During that time, Dr. Bowes also spent two years at Baptist Health-Fort Smith, then Sparks Regional Medical Center, as part of her training. While Dr. Bowes had always been passionate about science and health care, it wasn’t until later in life and after she became a mother that she decided to pursue an education to become an obstetrician and gynecologist. In her obstetrics practice, Dr. Bowes takes a patient-centered approach to natural childbirth, low medical interventions and vaginal birth after cesarean section. Dr. Bowes, her husband and young son are excited to return to Fort Smith. In her free time, she enjoys cooking and spending time with her family watching movies and playing games.

Dr. Drew Beasley Joins Baptist Health Spine Center in Little Rock LITTLE ROCK – Baptist Health Spine Center recently welcomed Drew Beasley, MD. Dr. Beasley received his medical degree from the University of Arkansas for Medical Sciences. He obtained a residency in anesthesiology from Drew Beasley, MD the University of Arkansas for Medical Sciences, and became fellowship trained in pain management at The Cleveland Clinic Foundation. Dr. Beasley is board certified by the American Board of Anesthesiology. Baptist Health Spine Center is located at 9101 Kanis Road, Suite 150A, in Little Rock. The center assembles the expertise of neurosurgeons and nonsurgical spine physicians as well as a team of spine therapists. For more information about Dr. Beasley and Baptist Health Spine Center, including how to request appointment, call Baptist Health HealthLine at 1-888-BAPTIST or visit baptist-health.com. arkansasmedicalnews

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2019

ARKANSAS HOSPITAL ASSOCIATION

ANNUAL MEETING & TRADE SHOW

LITTLE ROCK MARRIOTT & STATEHOUSE CONVENTION CENTER

OCTOBER 2-4

JOE THEISMANN The Challenge of Change

BEN NEMTIN New Leadership: Why You Matter

JAKE POORE Improving the Patient Experience to Build Customer Loyalty

SHOSHANA UNGERLEIDER Reimaginging Health Care for the Future

Plus! Sessions on: Health Care Policy: Past and Future Patient and Family Engagement Strategic Communications Data Visualization Legal and Risk Management Accountable Care Organizations

At the Trade Show More than 100 Industry Vendors Photo booth, complete with props! Food truck feast for lunch Emcee is Lisa Fischer For more information, or to register, contact our offices: 419 NATURAL RESOURCES DR, LITTLE ROCK | 501.224.7878 | ARKHOSPITALS.ORG

ANNUAL AWARDS DINNER WITH LIVE MUSIC BY

Rodney Block

Profile for Medical News

September-October 2019 AMN  

Arkansas Medical News September-October 2019

September-October 2019 AMN  

Arkansas Medical News September-October 2019