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FOCUS TOPICS

ORTHOPEDICS • ENT • HEALTHCARE REAL ESTATE • BIG DATA ANALYSIS

April 2009 2018 >> $5 December ON ROUNDS Doctor’s Writing Skill Finally Proved To Be An Important Talent Dr. Phillip Lieberman never got the journalism prize he wanted, but his writing talent has proven to be a valuable asset for his career as a specialist in Phillip Lieberman allergies and immunology.

Profile on page 3.

Continuing Demand For More Facilities Fuels Area’s Growth As the MidSouth’s need for healthcare continues to increase, so does the need for more facilities, Matt Weathersby bringing about more construction projects.

Suggestion Concerning Cataract Procedures Draws Concerns Question Raised: Is Monitored Anesthesia Care Always Needed? By MADELINE PATTERSON SMITH

A suggestion from one of the nation’s largest for-profit managed healthcare companies concerning the use of anesthesia providers during cataract procedures has drawn the attention of Memphis-area healthcare professionals. Anthem, Inc., part of the Blue Cross and Blue Shield Association – formerly WellPoint Health Networks – updated its cataract surgery guideline in February saying “administration of monitored anesthesia care or general anesthesia for cataract surgery is considered not medically necessary.” The policy lists five exceptions – children less than 18 years of age, patients unable to cooperate (e.g. dementia), patients who are unable to lie flat, patients who have reactions to anesthesia and anticipation of a complex surgery. Typically performed on an outpatient basis, cataract surgery begins with an incision in the eye with a laser, ultrasound probe or blade. The ophthalmologist uses a microscope to remove the protein deposits and insert a new artificial lens for improved vision. Patients are usually conscious, but receive a numbing shot to keep the eye (CONTINUED ON PAGE 10)

HealthcareLeader

Family Lessons Guide OsteoRemedies’ CEO

Story on page 6.

Expert Examines Healthcare Data’s Difficult Challenge

By SUZANNE BOYD

Those dealing with healthcare data know it can be diverse and complicated. An expert gives five reasons healthcare data is difficult to measure.

Hard work and family are at the heart of Chris Hughes’ work ethic as he serves as Chief Executive Officer for OsteoRemedies. When Hughes was growing up in Medina, Ohio, his parents instilled a strong sense of family, a demanding work ethic and the importance of treating everyone with respect. The loss of his wife, Kim, in 2016 at 43, only accentuated the importance of those qualities and fueled this drive to lead his Memphis-based medical device company that provides orthopedic surgeons solutions to complex disorders while offering revision and infection remedies. For Hughes, college was a must; the challenge was how to pay for it.

Article on page 7.

(CONTINUED ON PAGE 12)

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PhysicianSpotlight

Asthmatic Found Career Treating Asthma Dr. Phillip Lieberman’s Early Interest in Writing Has Served Him Well By LAWRENCE BUSER

As a student at Central High School in Memphis, Phillip Lieberman was the sports editor of the student newspaper, The Warrior, and had serious designs on becoming a sportswriter. He applied for a Grantland Rice Fellowship in Journalism, named for the legendary Murfreesboro-born sportswriter, a prestigious prize that perhaps would have launched his career in sports. “I didn’t get it, though, and that shifted my career away from journalism and toward medicine,” said Dr. Phillip Lieberman, a specialist in allergies and immunology for nearly 50 years. “And writing has been part of what I’ve enjoyed doing in my medical career. I’ve had somewhere near 300 publications now.” His enviable fallback career from sports writing to medicine is actually not as unlikely as it might seem. “I’m the first one in my family to go into medicine, but it had always been in the back of my mind,” Dr. Lieberman said. “I grew up next door in the 1940s to a medical student, Hugh Murray, at UT College of Medicine in an apartment at 244 South Cleveland. He took an interest in me, and he was one of the kindest people I ever met. “I would help him study anatomy. He would bring a box of bones, and I would pull one out and have the identification in front of me. I would quiz him daily on his knowledge of the anatomy. That got me interested in medicine at a very early age.” The other factor that influenced his career path in medicine was being an asthma sufferer himself. “It creates an empathy with patients that couldn’t occur otherwise because you’ve actually experienced the same symptoms,” Dr. Lieberman said. “You can have sympathy regardless, but it’s hard to have empathy without having experienced the same problems at some time.” Asthma is a chronic disease that inflames the airways and leads to coughing, wheezing, shortness of breath, rapid breathing and chest tightness. According to the Centers for Disease Control and

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Prevention, some 25 million Americans have asthma, and it’s the leading chronic disease in children. There is no cure for asthma, but it can be managed with proper treatment and management. It remains one of the country’s most common and costly diseases. Roughly 10 people die every day from asthma. Allergies occur when the body’s immune system overreacts to a foreign substance called an allergen. The sub-

stance might be something you eat, inhale, inject or touch, and cause coughing, sneezing, itchy eyes, a runny nose or a scratchy throat. An estimated 50 million people are affected by allergies, according to the CDC. In severe cases, it might cause rashes, low blood pressure, hives, breathing problems, asthma attacks or even death. Like asthma, there is no cure for allergies, but they can be managed. But take a deep breath. Not all the news with asthma and allergies is bad. Since he began his career in 1971, Dr. Lieberman has witnessed – and been a part of – tremendous strides in the treatment of patients with asthma and allergies. ‘There have been incredible, astonishing advances,” said Dr. Lieberman, former president of both the American Academy of Allergy, Asthma and Immunology, and the American Association of Certified Allergists. “The tools that we have now have increased in efficacy so dramatically that the vast majority of asthmatics are well controlled. Whereas when I started there were a very significant number of asthmatics where that control was unachievable.” He attributes the advances to two things: basic science research which has helped physicians better understand the basic pathophysiology of the disease and the pharmaceutical industry taking advan-

tage of that research to develop drugs that target that underlying pathogenesis. “For example, we’ve now learned which chemicals the body produces that that create an internal milieu that fosters the development of asthma and makes it more severe,” Dr. Lieberman said. “Because of that, we’re learning about the basic science underlying the disease, and that has allowed the drug companies to create monoclonal antibodies that directly target those chemicals. “We can now inactivate those chemicals that produce the disease using these antibodies, and that has been a game changer for severe asthmatics.” Being a specialist in asthma and allergies in Memphis means never running out of patients. Memphis traditionally ranks near the top in annual worst cities to live in for asthma and allergy sufferers, a ranking conducted by the Asthma and Allergy Foundation of America. “Memphis is allergen rich,” Dr. Lieberman noted. “We have rich and dense flora that produces pollen in great abundance and that produces more symptoms.” His practice, Allergy & Asthma Care, has five doctors and three nurse practitioners, with locations in Germantown, Collierville, Southaven, Bartlett and Jackson, Tenn. (CONTINUED ON PAGE 4)

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Being a Friendly City Not Always a Good Thing When it comes to friendly environments in which conditions for asthma and allergies can flourish, Memphis is about as friendly as they come. In fact, the most recent annual rankings of Asthma and Allergy Foundation of America (AAFA) for cities that are the best and the worst for asthma sufferers places Memphis at the head of the class in the worst-cities category. “Although Memphis’ air quality is average, almost all other factors are not delivering good results,” the AAFA survey says. “For example, the city’s asthma occurrence rate, as well as asthma death rate, is pretty high, while the number of asthma specialists is considerably low. On top of that, the pollen score, just like the poverty rate, is very high.” Other cities that made the top five worst list include Philadelphia, Detroit and Oklahoma City, and Richmond, Virginia. Each city is on the list because of low air quality, a high level of pollen, no strong public smoking restrictions and – with the exception of Richmond – a high poverty rate. The best city to live in for asthma sufferers is San Francisco, according to the experts at AAFA. That’s not only because of its clean air quality, tough smoking laws and low pollen, but also because the city has an Asthma Task Force that helps pre-

vent asthma and improve the quality of life for those with the pulmonary condition. Other cities in the top five best on the survey include Boise, Idaho; Seattle, San Jose, California, and Abilene, Texas, because of their favorable air quality, low pollen, low poverty rates, required levels of healthcare, and smoking regulations. Also, even though San Jose’s air quality is considered average, the city is participating in a Spare the Air program that allows implementation of environmentally friendly projects to improve local air quality. The AAFA surveyors note that while asthma is a chronic condition that cannot be completely cured, it can be managed with a prudent lifestyle and favorable living location. But rather than immediately pack up and move from Memphis to San Francisco (which some might find appealing regardless of the asthma factors), they simply note that you must pay closer attention to your asthma management and plan activities more carefully with your chronic condition in mind. If it’s any consolation, the AAFA’s most recent allergy rankings survey placed Memphis only as second worst. Top prize went to Jackson, Mississippi.

Asthmatic Found Career, continued from page 3 Dr. Lieberman began his career as head of the allergy section at the University of Tennessee Medical School’s Department of Medicine, going straight from his fellowship to chair of the section. After 10 years, he went into private practice, first at the 920 Madison building, then a move to Cordova and another move to his present location on Wolf River Boulevard in Germantown. “I’ve been very fortunate to have some great associates and nurse practitioners over the years,” he said. His view of the future in the field of asthma and allergies is mostly positive, though not entirely so. “The area of science and the improvement of our ability to care for patients has a very optimistic future,” said Dr. Lieberman. “The gains we’ve made are minor miracles, and I think we are going to gain even further in the future. We have a group of very dedicated scientists who keep carrying us forward at an increasingly rapid rate. That part is going to be good.” But he sees nagging problems of healthcare costs and bureaucracy as problems that continue to hinder patient care. “Socioeconomic factors, the bureaucracy involved and the difficulties in overcoming costs are going to continue to give us trouble, I’m afraid, for quite a long time,” he said. “It’s very difficult because of the nature of our society to institute the

new therapies that we have available. “We now need the equivalent of a fulltime person just to be able to go through all the hoops required to obtain some of the agents that we now use to treat our patients. The costs have exploded and therefore the controls have increased, so it’s a real challenge now to be able to offer the ability we have to care for these patients. I’m less optimistic about our ability to control costs, but I’m very optimistic about our ability to develop more and better drugs.”  He and wife Barbara have been married nearly 50 years. They have three well-educated sons – Ryan, a lawyer and MBA; Lee, a CPA and MBA; and Jay, an allergist like his father.   During his internal medicine residency, Dr. Lieberman and roommate Walter Allison dated and then married the Broz twins – Barbara and Martha from Doniphan, a small town in the Missouri Bootheel.  Three decades later, the two couples traveled to the Graceland Wedding Chapel in Las Vegas to renew their vows.  ”We did it because we both had very small home weddings without any bridal gowns or parties,” Dr. Lieberman recalled. “We decided our wives really deserved to have a more ceremonial bride hood.”    

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Dramatic Growth of Medical Facilities Continues Across Mid-South Renovations, Expansions Abound Throughout the Memphis Area By BETH SIMKANIN 

From eastern Arkansas to Germantown, Tennessee, the growth of medical development continues dramatically throughout the Mid-South in an effort to meet an ever-growing demand. The explosion of medical facility renovations and expansions contributes to much of the development in the Memphis Medical District, but despite challenges such as land scarcity and population growth, medical development is not expected to slow down anytime soon in areas such as Germantown and DeSoto County, according to healthcare officials closely involved in the effort. Nearly all development projects in the Medical District are expansions or renovations. Examples of this include the $275 million Methodist University Hospital Tower modernization and expansion, now halfway completed; the 10-year expansion and modernization at the University of Tennessee Health Science Center (UTHSC), now in its second phase; and the $1 billion capital expansion at St. Jude Children’s Research Hospital, now well underway.

Outside Memphis in areas such as Crittenden County, Arkansas; DeSoto County, Mississippi; and even nearby Germantown, new medical facilities will emerge within the next several years. “There is still a lot of momentum and future growth in the Mid-South area,” said Matt Weathersby, principal of Cushman and Wakefield Commercial Advisors, a commercial real estate services firm. Additionally, Richard Kelley, vice president of corporate facilities management at Methodist Le BonMatt Weathersby heur Healthcare, revealed the healthcare corporation has 50 active construction and development projects in progress in the metropolitan area.

Memphis Medical District

The majority of medical development inside the Medical District continues to be facility expansions with additional renova-

tions to existing facilities. “There is a lot of on-campus renovation taking place in the Medical District,” Weathersby said. “Those buildings are older and are in need of modernization.” Kelley projected that the Methodist University Hospital Tower expansion and modernization will be completed in the first quarter of 2019. Construction began in 2016 to a 450,000-square-foot tower with nine floors, which will consolidate all of the services at West Cancer Center, which have been housed in different locations. The Methodist Transplant Institute will be housed there also. After the tower is completed, the existing hospital will undergo a 65,000-square-foot renovation. Kelley said an older hospital building at the corner of Union Avenue and Bellevue, which will be empty after the expansion, will be demolished and become the hospital’s main entrance. Additionally, Le Bonheur Children’s Hospital will undergo a $23 million, 37,280-square-foot operating room expansion and will renovate its sterile processing department inside the hospital. The Memphis VA Medical Center will begin construction on a parking garage in

the fall, which, according to Sheena House, chief of engineering service, will add 184 parking spaces for patients. Upon completion of the renovations to the hospital’s lobby and front entrance in February, the VA began the renovation of its existing corridors and walk-through areas. House said the hospital will undergo more renovations to its clinical laboratory, physical therapy pool and spinal cord patient restrooms over the next two years. “Most of our construction projects have been renovations because our buildings are older and it’s time to modernize to make services more efficient,” she said. Construction and development continues at UTHSC with renovation of three of the campus’s oldest buildings, including one that has been vacant for 20 years. In what is known on campus as the historical quadrangle, the $70 million renovation will create a new general administration building, new College of Nursing building and a building for basic sciences such as physiology. According to Ken Brown, Ph.D., executive vice chancellor and COO of

(CONTINUED ON PAGE 8)

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5 Reasons Healthcare Data Is Unique and Difficult to Measure By DAN LeSUEUR

Those of us who work with data tend to think in very structured, linear terms. We like B to follow A and C to follow B, not just some of the time, but all the time. Healthcare data isn’t that way. It’s both diverse and complex making linear analysis useless. There are several characteristics of healthcare data that make it unique. Here are five, in particular:

1. Possibility of multiple places

Healthcare data tends to reside in multiple places. From different source systems, like EMRs or HR software, to different departments, like radiology or pharmacy. The data comes from all over the organization. Aggregating this data into a single, central system, such as an enterprise data warehouse (EDW), makes this data accessible and actionable. Healthcare data also occurs in different formats (e.g., text, numeric, paper, digital, pictures, videos, multimedia, etc.). Radiology uses images, old medical records exist in paper format, and today’s EMRs can hold hundreds of rows of textual and numerical data. Sometimes the same data exists in

different systems and in different formats. Such is the case with claims data versus clinical data. A patient’s broken arm looks like an image in the medical record, but appears as ICD-9 code 813.8 in the claims data. And it looks like the future holds even more sources of data, like patient-generated tracking from devices like fitness monitors and blood pressure sensors.

2. Structured and unstructured

Electronic medical record software has provided a platform for consistent data capture, but the reality is data capture is anything but consistent. For years, documenting clinical facts and findings on paper has trained an industry to capture data in whatever way is most convenient for the care provider with little regard for how this data could eventually be aggregated and analyzed. EMRs attempt to standardize the data capture process, but care providers are reluctant to adopt a one-size-fits-all approach to documentation. Thus, unstructured data capture is often allowed to appease the frustrated EMR users and avoid hindering the care delivery process. As a result, much of the data captured in this manner is difficult to

About the Writer Dan LeSueur has been developing and implementing the core products and services of Health Catalyst since 2011. He started as a data architect, moved into a technical director role and is now a Vice President of Client and Technical Operations. Prior to joining Health Catalyst, he owned a management consultancy for five years that assisted ambulatory practices in the implementation of electronic health records and datadriven management methodologies.

aggregate and analyze in any consistent manner. As EMR products improve, as users become trained to standard workflows, and as care providers become more accustomed to entering data in structured fields as designed, we will have more and better data for analytics. An example of the above phenomenon is found in a recent initiative to reduce unnecessary C-sections at a large health system in the Northwest. The first task for the team was to understand how the indications for C-section were documented in the EMR. It turned out that there were only two options to choose from: 1) fetal indication and 2) maternal indication.

Because these were the only two options, delivering clinicians would often choose to document the true indication for C-section in a free text form, while others did not document it at all. Well, this was not conducive to understanding the root cause of unnecessary C-sections. So, the team worked with ananalyst to modify the list of available options in the EMR so that more detail could be added. After making this slight modification to the data capture process, the team gained tremendous insight, and identified opportunities to standardize care delivery and reduce unnecessary C-sections.

(CONTINUED ON PAGE 9)

  

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Growth of Medical Facilities Continues Across Mid-South, continued from page 6 UTHSC, the design of an additional $47 million dental building is complete. The new building will connect to the existing College of Dentistry building and will contain additional faculty offices, classrooms and a new dental clinic for adults with special needs. Additionally, Brown said, a $10 million gross anatomy lab is in the early stage of design and will be housed on the fourth floor of the university’s general education building. Recently, St. Jude announced the development of a $412 million, 625,000-square-foot advanced research center, which is one of the largest developments in the hospital’s history, according to John Curran, director of design and construction for St. Jude. The center will contain six floors and will house new stateof-the-art laboratories focusing on immunology, neurobiology, cell and molecular biology, gene editJohn Curran ing, metabolomics, microscopy, epigenetics, genomics, immunotherapy and RNA biology. An older, existing building will be excavated this month to make room for the center, Curran said. Departments from that building have been moved into newly

gency rooms, two operating rooms, one endoscopy suite and eight cancer infusion rooms. Additionally, the hospital will have diagnostic imaging, lab services and inpatient and outpatient surgery. The new hospital is near Interstate 40, which, Welton said, is easier to access than the previous location of the county hospital, which closed in 2014. “The community hasn’t had a local hospital in three and a half years, and they have a need for basic healthcare services,” Welton said. “Residents have had to drive to Memphis or Forrest City, and it has been disruptive to the community.”

DeSoto County, Mississippi

UTHSC Center for Healthcare Improvement

renovated buildings on the St. Jude campus or to other locations.

Germantown

According to Cushman and Wakefield’s Weathersby, the demand for medical facilities continues to be high in Germantown, where there is a significant healthcare presence, but with land availability scarce for new construction, developers will have to be creative. “There is still much interest along the Wolf River corridor in Germantown, but the challenge is a scarcity of land,” he said. “The area is well positioned with three Mid-South hospitals close to the area. Because the land is scarce, we have clients now looking into rehabbing office build-

ings.” Despite the challenge, construction will begin on a 120,000-square-foot expansion project for Campbell Clinic in June. The three-story building will be constructed adjacent to its current location on five acres. The new building, which will include outpatient orthopedic space, an expanded physical therapy area, imaging suites and an ambulatory surgery center with eight operating rooms, is a $30 million expansion, which according to the city of Germantown will add 185 new jobs to the area in three years. Construction is scheduled to be complete in the fall of next year. Weathersby said the Campbell Clinic expansion will be the first new medical construction project along Wolf River Boulevard in two years.

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Baptist Memorial Health Care’s recent development efforts have been targeted outside of Memphis. The healthcare corporation began construction on a $43 million, 52,000-square-foot hospital last year. Brian Welton, administrator and CEO for Baptist Memorial Hospital – Crittenden, said the hospital will have 11 inpatient rooms, 10 emerBrian Welton

Baptist is in the process of a $19 million, 20,000-square-foot expansion to its emergency room at its hospital in Southaven. According to Phyllis Chambers, DNP, director of emergency services for Baptist Memorial Hospital – DeSoto, the expansion is to meet the growing patient volume. “We have seen a rapid increase in volume in the ER between 5 to 7 percent each month,” Chambers said. “In December last year we saw the most ER visits ever, over 6,000 people. The new expansion will speed up wait times, and we will be able to see 7,000 more patients a year.” The ER will have a total of seven triage rooms and 55 patient rooms when the expansion is complete, which is expected to be in July. Baptist will begin renovation to 9,000 square feet of the existing ER after the expansion is complete. When finished, the entire ER will be 42,000 square feet. Additionally, to meet the growing patient demand in DeSoto County, Methodist is planning to build a medical office building in Southaven, which will contain physician offices, according to Richard Kelley.

Suburbs’ Growth

Weatherbsy sees future medical development expanding east toward Fayette County in Tennessee and continuing south in DeSoto County. “Some areas to look out for future development are along the I-40 corridor and possibly in Olive Branch,” he said. “There is still land available in those areas to develop.”

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5 Reasons, continued from page 7 3. Inconsistent definitions

Oftentimes, healthcare data can have inconsistent or variable definitions. For example, one group of clinicians may define a cohort of asthmatic patients differently than another group of clinicians. Ask two clinicians what criteria are necessary to identify someone as a diabetic and you may get three different answers. There may just not be a level of consensus about a particular treatment or cohort definition. Also, even when there is consensus, the consenting experts are constantly discovering newly agreed-upon knowledge. As we learn more about how the body works, our understanding continues to change of what is important, what to measure, how and when to measure it, and the goals to target. For example, this year most clinicians agree that a diabetes diagnosis is an Hg A1c value above 7, but next year it’s possible the agreement will be something different. There are best practices established in the industry, but there’s always ongoing discussion in the way those things are defined. Which means you’re trying to create order out of chaos and hit a target that’s not only moving, but seems to be moving in a way you can’t predict.

4. Complex data

Claims data has been around for years and thus it has been standardized and scrubbed. But this type of data is incomplete. Clinical data from sources like EMRs give a more complete picture of the patient’s story. While developing standard processes that improve quality is one of the goals in healthcare, the number of data variables involved makes it far more challenging. You’re not working with a finite number of identical parts to create identical outcomes. Instead, you’re looking at an amalgam of individual systems that are so complex we don’t even begin to profess we understand how they work together (that is to say, the human body). Managing the data related to each of those systems (which is often being captured in disparate applications), and turning it into something usable across a population, requires a far more sophisticated set of tools than is needed for other industries like manufacturing.

5. Changing Regulatory Requirements

Regulatory and reporting requirements also continue to increase and evolve. CMS needs quality reports around measures like readmissions, and healthcare reform means more transparent quality and pricing information for the public. The shift to value- based purchasing models will only add to the reporting burden for healthcare organizations. Complexity Is Growing Healthcare data will not get simpler in the future. If anything, this list will grow. Healthcare faces unique challenges and with that comes unique data challenges. Because healthcare data is so uniquely complex, it’s clear that traditional approaches to managing data will not memphismedicalnews

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CONSOLIDATED MEDICAL PRACTICES OF MEMPHIS

work in healthcare. A different approach is needed that can handle the multiple sources, the structured and unstructured data, the inconsistency, the variability, and the complexity within an ever-changing regulatory environment. The solution for this unpredictable change and complexity is an agile approach, tuned for healthcare. As with a professional athlete, the ability to change directions on a dime when the environment around you is in constant flux is a valuable attribute to have. If I start out from point A in direct route to point B and the location of point B suddenly changes or an obstacle arises, I certainly wouldn’t want to have to retrace my steps back to point A, redefine my coordinates, and set off on the new course. Rather, I need to take one step at a time, reevaluate, and pivot inflight when necessary. Agility Compensates Those are the core issues with healthcare data, and they are very real. Understanding that, and the fact that some of those issues will never change, the question becomes how you work within those limitations to deliver better information to those who need it. The generally accepted method of aggregating data from disparate source systems so it can be analyzed is to create an enterprise data warehouse (EDW). It is a method common across many industries. Just as a physical warehouse is used to store all sorts of goods in bulk until they’re needed, an EDW houses data from across the enterprise in a single place. Yet how you aggregate that data can have a huge impact on your ability to gain maximum value from it. The early-binding methods that are prevalent in manufacturing, retail, and financial services don’t work very well in healthcare, because they depend on making business rule decisions before you know what you want to do with it. It would be expensive to warehouse goods with the thought in mind that you would store everything you could ever want in the future. So you’re paying for all the storage space and the overhead that comes along with it. But you’re not using it. Traditionally other industries look ahead at what business questions they’ll want to answer. They know exactly what information they’ll need. Their data warehouses, then, store everything they need in the way that they need it. Healthcare is not like those industries where business rules and definitions are fixed for long periods of time. The volatility of healthcare data means a rule set today may not be a best practice tomorrow. The industry is filled with instances of EDW projects that never deliver results or even come close to completion because the rules and definitions keep changing. A better approach is to use a LateBinding™ Data Warehouse. With this schema, data is brought into the EDW from the source applications as-is, and placed into a source data mart. When you need to turn it into information, it is then transformed into exactly what the analysis requires.

(CONTINUED ON PAGE 10)

SALUTES DR. RAZA HASHMI

Dr. Raza Hashmi graduated from King Edward Medical College, Lahore Pakistan in 2002. He completed his internal medicine residency training from Weiss Memorial Hospital Chicago, IL, in 2007, where he received the Best Resident of the Year award. This was followed by additional fellowship training in geriatric medicine at University of Illinois at Chicago. He practiced as a hospitalist from 2009-2015 and completed his Rheumatology fellowship training at University of Louisville, KY in June 2017. He has recently joined Consolidated Medical Practices of Memphis and has started his rheumatology practice. Dr. Hashmi is board certified in both internal medicine and geriatric medicine. He is board eligible in Rheumatology. He is a member of the American College of Rheumatology and American College of Physicians. In addition to Rheumatoid arthritis, Dr. Hashmi has a special interest in psoriatic arthritis, Systemic Lupus Erythematosus, gout and osteoporosis. Dr. Hashmi also has expertise in treating other autoimmune diseases such as Sjögren’s syndrome, ankylosing spondylitis, vasculitis, scleroderma. He is proficient in performing joint injection for osteoarthritis as well as treatment of Carpel tunnel syndrome.

We address the health care needs of those in the He is accepting new patients to his practice. For referShelby County region rals, please call our office at 901-259-0090. and surrounding areas by We address the health care providing outstanding needs of those in the and compassionate Shelby County regioncare. and surrounding areas by providing outstanding Shannon Riedley Malone, MD Derene Akins, MD andE compassionate care. Reuben W. Avila, MD

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Cataract Procedures, continued from page 1

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comfortable. Often, anesthesia providers give a systemic medication to relax the patient, who must remain perfectly still during the procedure. “We are putting you [the patient] in a twilight state, not normally under general anesthesia,” says Subba Gollamudi, MD, ophthalmologist at Eye Specialty Group in Memphis. He adds that psychologically, a lot of patients have anxiety about the procedure, which is understandable since a blade or laser is making an incision in the eye. The National Eye Institute says that more than half of all Americans either have a cataract or have had cataract surgery by the time they are 80 years old. Nationally, Anthem has come under fire for this new guideline, which is not currently impacting Memphis patients as Anthem has no market presence in Tennessee. However, area ophthalmologists and anesthesiologists are concerned that the guideline could be used by Blue Cross Blue Shield or other insurers. “Monitored anesthesia care” or “MAC” as Anthem calls it in its updated guideline, is generally provided by certified registered nurse anesthetists (CRNA) or anesthesiologists before, during and after the cataract surgery. Anthem cites a 1999 study by Rosenfeld and colleagues in which 1,006 participants were tracked for intervention by the anesthesia professional during surgery. The results concluded that 376 patients required intervention, and the number of those needing more than one type of intervention were 548. Examples of intervention from anesthesia professionals range from hand-holding, to more serious needs such as treatment for cardiac arrhythmias or hypertension. Furthermore, a pre-surgery EKG did not predict intervention by an anesthesia professional, nor did a review of underlying medical conditions, meaning it is very challenging to know in advance of cataract surgery which patients might need additional care during the operation. The American Society of Anesthesiologists Statement on Anesthetic Care During Interventional Pain Procedures of Adults (2016) quoted by Anthem in their guideline states that physicians must weigh the benefit of anesthesia during procedures with the potential risk factors. Additionally, “for most patients who require supplemental sedation, the physician performing the interventional pain procedure(s) can provide moderate (conscious) sedation as part of the procedure. For a limited number of patients, a second provider may be required to manage moderate or deep sedation…” according to the updated guidelines. Anthem concludes that “there is no one definitive approach to anesthesia for cataract surgery” but as mentioned above, the policy states MAC is not medically necessary (unless a patient falls into one of the

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five exception criteria). Eric Callan, CRNA, DNAP, CEO LifeLinc Corporation says that the new policy takes the ophthalmologist away from the surgery, which is performed through a microscope, to check vital signs, resulting in poor patient care. “Even though it’s light sedation, different people react differently to medication so it’s just not prudent to have someone unmonitored,” says Callan. Dr. Gollamudi, who works closely with Callan, describes the surgery in this way: “Anesthesia professionals are monitoring everything else while I take care of the eyeball.” The majority of patients undergoing cataract surgery are over 65, so they are insured by Medicare, which covers anesthesia care during the procedure. However, Gollamudi adds that the surgery has improved so much that younger patients with mild-to-moderate cloudy vision are opting to undergo cataract surgery because they see such improvement with minimal downtime. Under Anthem’s change, these younger patients would likely not qualify for MAC during surgery. Kourtney Houser, MD, Assistant Professor of ophthalmology at the University of Tennessee Health Science Center’s Hamilton Eye Institute said the surgery is on average 10 to 20 minutes long, but “it’s a high intensity procedure that requires the patient to be very still and cooperate. Most patients don’t know how they’re going to react to manipulation of the eye [before surgery].” She also adds that many patients have other health conditions like high blood pressure or are on dialysis, while others feel claustrophobic, complicating the surgery and anesthesia care. “We understand healthcare is ratcheting down on costs across the market,” says Callan, “but jeopardizing patient safety is not an area that should be skimped on.”

5 Reasons,

continued from page 9 If there is a change to the business rules or definitions, such as what constitutes an at-risk patient, that change can be applied within the application data mart rather than having to transform and reload all the data from the source. That is how Late-Binding™ supports the discovery process so important to healthcare. When frontline business users enter into a clinical analysis of the data, you want them to start free of any pre- conceived data models. Late-Binding™ allows you to aggregate data quickly and develop business rules on the fly so users can develop hypotheses, use the data to prove them right or wrong, and continue the discovery process until they are able to make scientific, evidencebased decisions. Health Catalyst is a mission-driven data warehousing, analytics and outcomesimprovement company that helps healthcare organizations of all sizes improve clinical, financial, and operational outcomes needed to improve population health and accountable care. Printed with permission from Health Catalyst. memphismedicalnews

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Family Lessons Guide OsteoRemedies’ CEO, continued from page 1 “My choices were either to go to West Point or find a school with an ROTC program. Either way, I could serve my country and get my education paid for,” said Hughes. “In doing my research on ROTC programs, I discovered not all included room and board. I also was looking for a good business school. The University of Tampa was the answer. It offered an ROTC program that would give me a full ride, had a great business school and I could be on the golf team.” After college, Hughes spent four years active duty in the Army. When faced with the choice of making the military a career and then starting a new career at the age of 42 or leaving as a Captain, Hughes chose civilian life. Through a military program that placed junior officers into corporate America, Hughes entered the medical field as a sales manager in the medical sales industry. Four years later, Hughes found himself at a crossroad in his career, needing to decide between sales or marketing. Having a degree in marketing, it was an easy choice. Orthopedics and Memphis seemed to offer the best opportunity. For the next ten years Hughes worked in marketing medical devices for Wright Medical Group, Smith and Nephew, then Medtronic. “I had always wanted to lead my own company so when Paradigm Spine offered me the opportunity to be President, I couldn’t say no, even though the job was in New York City and Memphis was my home. It was one of the greatest experiences I had in my medical device career, even though it meant a weekly commute to New York. After four years, I swapped my weekly airplane commute for one by car to Nashville to run a medical device distribution company there” said Hughes. “While working in Nashville, I was approached by colleagues in the industry who had some intellectual property and interest in developing a business plan to start a company with this unique technology. When they asked what it would take for me to run the company, my only request was that the company be based in Memphis. My six years of commuting was over when OsteoRemedies was founded in 2013.” Aside from it being his home, Memphis brought a lot to the table in terms of

Is the missing

being the global headquarters for OsteoRemedies. “Memphis is a great choice for any medical device start-up. It is centrally located and home to FedEx,” said Hughes. “Add to that there are 20-some medical device start-ups here and the more than 4000 medical device industry employees which means a plethora of expertise here.” First on Hughes’ CEO agenda was to find distributors for a product that was not yet ready for sale. Hughes went to a medical device conference and signed up ten distributors. Three months later he set up a booth at the annual meeting of the American Academy of Orthopedic Surgeons to announce the launch of OsteoRemedies Remedy® Spacer System that could be used in infected knee and hip surgeries. The company since has added shoulder applications and continues to expand its portfolio, recently announcing a fifth product line. Having a positive cash flow and being profitable quickly was a key element of Hughes’ initial business plan. His plan also included rejecting investment or venture capital. To this end, Hughes wanted to keep the firm lean. “One philosophy when developing the business plan came from challenges I had faced in the past with hiring too many people and having a facility with too much space,” he said. “We only hire someone when we need them full time.” Initially, OsteoRemedies and Chris Hughes were one and the same – he was the only employee. After six months he hired an office manager to help with logistics. In 2014, when the first product launched, he hired a customer service representative. Since then the staff has grown by just three permanent employees – the Chief Operating Officer, one person in marketing and another in R&D. All other duties are fulfilled by 1099 contract personnel. “We only hire the best and I am very proud of the team we have built,” said Hughes. “Marketing and R&D came out of the growth we have had. Our COO, Eric Stookey, is former president of Wright Medical Group and a known leader in the ortho space. He changed the trajectory of this company when he came in 2015.” With 80 distributors across the United States, OsteoRemedies focuses on being

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the premier choice of orthopedic surgeons for complex infection and revision procedures. “We are capturing about 20 percent of the market for patients eligible for the type of devices we offer,” said Hughes. “While we have room to grow, we are very comfortable in our niche. We see ourselves as complementing the bag of products offered by the orthopedic distribution companies we use.” Hughes says OsteoRemedies relies on feedback from surgeons when it comes to research and development of new products. “We are constantly looking at new products,” he said. “We are the only company in the market with a modular hip spacer system and an acetabular cup, used in the complete revision of a two-stage infected hip revision. That product came about based on gaining insight from some of the top surgeons experts, who were not choosing our system.” With a philosophy on growth and a mantra of never fast enough and never enough, Hughes is pleased that OsteoRemedies’ growth has exceeded expectations every

month, quarter and year. “Either I underestimated our potential, or we have just done better than we anticipated,” he said. In developing his work ethic and management style, Hughes said he had the greatest example growing up: his parents. “They treated everyone with respect and they worked hard,” he said. “It’s a simple leadership style that is built on the fact that everyone is an individual and should be treated with respect. I believe no one works for me, they work with me. Servant leadership was what I was taught as a young marketing person and something I believe in every day.” That servant’s heart is also evident in Hughes’ personal life. Family is of the utmost importance to him and never more so than since the loss of his wife. “Family has always been important to me, but now more than ever with my children. Being able to take care of them is of paramount importance. I view my business as another way to do that,” said Hughes. “My family is what keeps me focused and drives me more than ever.”

Tennessee Legislature Approves PhysicianFriendly MOC Bill The Tennessee Medical Association reports in a recent news release that its “physician members are praising a new law that will ease the costly, burdensome and in many cases mandatory requirements for doctors to maintain specialty board certification.” The Tennessee General Assembly unanimously approved the measure after a two-year effort by TMA to persuade state lawmakers to take action on what has become a hot button issue for physicians across the U.S. The Tennessee Senate last month passed bill SB1824 by a vote of 33-0 after the House unanimously passed the companion bill a week earlier. Sen. Richard Briggs, MD (R-Knoxville) sponsored the Senate bill while House Republican Caucus Chairman Ryan Williams (R-Cookeville) led the effort in the larger chamber. According to the TMA, the largest professional organization for doctors in Tennessee, Sen. Briggs and Rep. Williams worked with TMA in 2017 to pass another law that prevents MOC from being required for state licensure. That same bill created a task force to study MOC as it relates to hospital hiring practices, admitting privileges and insurance networks. Legislators who served on the task force returned to session in 2018 ready to give Tennessee physicians some relief and ensure the arbitrary MOC process no longer interferes with Tennesseans’ access to care. Nita W. Shumaker, MD, TMA president, said, “TMA’s goal, after years of complaints from our member physicians about MOC testing requirements, was

simply to give doctors options for maintaining and improving their professional competency. Doctors should not be forced by hospitals or insurance companies to participate in an arbitrary certification process that has not been shown to improve quality of care. “This bill gives much-needed relief for doctors who may choose Continuing Medical Education or other forms of ongoing learning. Thanks to Sen. Briggs, Rep. Williams and the other members of our state legislature, Tennessee is now one of few states developing real solutions to this national issue.” The new law carries two important provisions for doctors who have pleaded for relief from the MOC requirements levied by the American Board of Medical Specialties, insurance companies, hospitals and health systems. It prohibits health insurance companies from excluding physicians from health plan networks based solely on a physician’s MOC status. It allows the medical staff at each hospital to determine whether to require MOC or accept other forms of competency measures (such as Continuing Medical Education) for credentialing and/or admitting privileges. Hospitals requiring MOC must adopt bylaws making it a stipulation for work or network participation. TMA expects the state’s new MOC laws, coupled with a favorable medical liability climate and other qualities that help Tennessee rank among the best states in which to practice medicine, will improve the state’s efforts to recruit and retain the best physicians. memphismedicalnews

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GrandRounds Ericka Liggins Promoted at Methodist Le Bonheur Ericka Liggins has been named clinical director of the Cardiovascular and Medical Intensive Care Units at Methodist Le Bonheur Germantown Hospital. She previously held the role of nurse educator for a number of departments. Erika Liggins Liggins received a Bachelor of Science degree in natural science from Christian Brothers University and a Master of Science in the Nurse Executive Leadership Program at the University of Memphis. Liggins is a member of the Tennessee Nurses Association, American Association of Critical Care Nurses (AACN), and Sigma Theta Tau. She currently serves as secretary for the Local Greater Memphis Chapter of AACN.

UTHSC Names Director of Regional Biocontainment Laboratory Colleen Jonsson, PhD, has been selected by t he University of Tennessee Health Science Center (UTHSC) as its new director of the Regional Biocontainment Laboratory (RBL). The facility is dedicated to creating networks of collaborators to identify and solve Colleen Jonsson problems in infectious disease research. “By converging disciplines, we

can create synergy around a topic, which hopefully leads to new perspectives and solutions,” said Jonsson, who joined UTHSC in 2017. Jonsson comes to UTHSC from the University of Tennessee-Knoxville, where she was the director of the National Institute for Mathematical and Biological Synthesis and Beaman Distinguished Professor of Microbiology. Previously, she served as director of the Center for Predictive Medicine for Biodefense and Emerging Infectious Diseases, among other roles at the University of Louisville. She said she hopes to use her experience to propel the UTHSC RBL and the campus forward. She has spent nearly 30 years studying highly pathogenic human viruses and an additional eight years studying plant infectious agents. Her work is represented in more than 100 publications and six patents. The 30,315-square-foot RBL, constructed in 2009, enables research on pathogens responsible for naturally occurring common and emerging infectious diseases, such as multidrugresistant tuberculosis, streptococci, influenza, West Nile, Zika, and equine encephalitic infections. The goal of the RBL is to enable drug discovery and translation of new antivirals, vaccines, and therapeutics to protect the general population from infectious diseases and bioterrorism. Jonsson is hoping a new UTHSC institute focused on infectious disease research and the development of new treatments will enhance enthusiasm for drug discovery and development on campus.

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UT Regional One Physicians Welcome Three New Doctors Three physicians have joined the staff at UT Regional One Physicians – Dr. Mark Brady, an emergency medicine physician, and neurologists Drs. Jesus Martinez and Andrew Wilner. Dr. Brady will also be an assistant professor in the Emergency Medicine Department at University of Tennessee Health Science Center (UTHSC). He received his medical degree from Brown University Medical School in Providence, Rhode Island. He comFrom left, Drs. Andrew Wilner, Jesus Martinez and Mark Brady. pleted his emergency medicine residency at Yale-New Haven Hospital in New Haven, Connecticut. Dr. Martinez will serve as a neurologist at Regional One Health and also has taken a position as an instructor in the Department of Neurology UTHSC. He received his medical degree from University of El Salvador School of Medicine. He completed his internal medicine internship at Greenwich Hospital in Connecticut and his neurology residency at North Shore University Hospital at Manhasset in New York. Dr. Martinez is board certified in Epilepsy, Neurology and Clinical Neurophysiology. Dr. Wilner is a neurologist at Regional One Health and an associate professor in the Department of Neurology at UTHSC. Dr. Wilner earned his medical degree from Brown University Medical School in Providence, Rhode Island. He completed an internal medicine residency at Los Angeles County-University of Southern California Medical Center and a neurology residency at McGill University Affiliated Hospitals in Canada. Dr. Wilner is the author of three nonfiction medical books: Bullets and Brains, Epilepsy in Clinical Practice, and Epilepsy: 199 Answers, 3rd Edition.

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GrandRounds Dr. Ryan McGaughey Joins Mays & Schnapp Pain Clinic Dr. Ryan McGaughey has joined the staff of Mays & Schnapp Pain Clinic and Rehabilitation Center. In addition to expanding the capacity for new cases at the clinic, Dr. McGaughey is also committed to the clinic’s comprehensive treatment philosophy Ryan to fight chronic pain. McGaughey Originally from Milan, Tennessee, Dr. McGaughey graduated with honors from University of Tennessee College of Medicine in 2012. He completed an anesthesia residency at University of Mississippi Medical Center, where he served as Chief Resident before completing a pain management fellowship at the same institution. 

Dr. Alan Blanton Heads UTHSC Dental Sleep Medicine Center Dr. Alan Blanton, who was diagnosed with moderate obstructive sleep apnea, 11 years ago, today is director of the William F. Slagle Center for Dental Sleep Medicine and Orofacial Pain in the College of Dentistry at the University of Tennessee Health Alan Blanton Science Center. The diagnosis eventually drew Dr. Blanton away from his private practice in Collierville. He is certified by the American Board of Dental Sleep Medicine, the certification arm of the American Academy of Dental Sleep Medicine, a sister organization of the American Academy of Sleep Medicine. The center, which opened in 2017, offers Oral Appliance Therapy for the treatment of obstructive sleep apnea and orofacial pain. “Obstructive sleep apnea is one of the most underdiagnosed medical conditions in the United States,” Dr. Blanton said. “Estimates are that 25 to 30 million or more individuals in the adult population suffer from sleep apnea, and more

than 90 percent of them are undiagnosed and untreated.” Oral appliance therapy uses customfitted oral appliances that are attached to the teeth to hold the lower jaw in a slightly forward position, stabilizing it and lifting tissues up to prevent the airway collapse from occurring. Worn only during sleep, an oral appliance fits like a sports mouth guard or an orthodontic retainer. The patient is fitted with the device that best suits the mouth shape and the breathing issue. Follow-up visits ensure it sits properly and is relieving the problem.

UTHSC Selects Director of Center for Sickle Cell Disease Kenneth Ataga, MD, has been named director of the University of Tennessee Health Science Center’s new Center for Sickle Cell Disease in the College of Medicine. He will begin his new role July 1. In addition, Dr. Ataga will serve as a professor of internal medicine, Kenneth Ataga director of the section of Non Malignant Hematology in the Division of Hematology/Oncology, and the director of the Memphis Consortium for Sickle Cell Disease and Non Malignant Hematology Research. He also is the Methodist Endowed Chair in Sickle Cell Anemia. The UTHSC Center for Sickle Cell Disease is a collaborative effort among UTHSC, West Cancer Center, UT-Methodist University Hospital and Regional One Health Dr. Ataga comes to UTHSC from the University of North Carolina at Chapel Hill (UNC) School of Medicine, where he was a professor in the Division of Hematology/Oncology and director of the UNC Comprehensive Sickle Cell Program. Dr. Ataga received his Bachelor of Medicine and Bachelor of Surgery degrees from the University of Benin School of Medicine in Benin City, Nigeria. He completed his residency in internal medicine at State University of New York Health Science Center, now Upstate Medical University,

in Syracuse, New York, followed by fellowship training in Hematology/Oncology at the University of North Carolina at Chapel Hill. His research focuses on the development of new treatments for sickle cell disease and its complications. Dr Ataga’s team is also interested in understanding the pathophysiology of chronic kidney disease and pulmonary hypertension in sickle cell disease. In addition, Dr. Ataga and his colleagues are evaluating the contribution of coagulation and platelet activation to the pathophysiology of sickle cell disease. Dr. Ataga’s interest in sickle cell disease began in Nigeria, where the disease is prevalent.

University Clinical Health Announces Telehealth Implementation University Clinical Health’s (UCH) has announced a telehealth implementation plan which includes establishing a telemedicine network as early as this month. As a multi-specialty physician group which also includes primary care, UCH has sufficient infrastructure and reach to provide specialist services to areas of rural Tennessee.  The network will initially include Memphis-based dermatologists, rheumatologists, hematologists, and behavioral health providers treating patients at

family medicine clinics in rural West Tennessee via video conferencing software which utilize high resolution cameras. UCH’s electronic health system will allow for seamless integration of the patient’s health record between sites and will allow for real time updates from site-to-site via a fully integrated electronic health record (“EHR”).  This will later expand to include additional specialists from the group which encompasses 130 physicians and covers 18 specialty areas. Additionally, UCH plans to partner with other Tennessee-based healthcare organizations to provide telemedicine services across the state.  Patient populations in provider shortage areas soon will have access to qualified healthcare professionals via UCH’s physician network according to a recent UCH news release.

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Updates to Telemedicine and Telehealth in Tennessee By Ann E. Lundy and Shannon E. Hoffert Tennessee defines telehealth as the use of real-time, interactive video, video communications, electronic technology, or store and forward telemedicine services by a healthcare services provider to deliver healthcare to a patient within the scope of the practice of the healthcare provider when: (1) the provider is located at a “qualified site” other than where the patient is located; and (2) the patient is located at a “qualified site.”1 A “qualified site” means a medical office, a hospital, a rural health clinic, a federally qualified health center, a mental health facility, and a school staffed by a healthcare provider. Qualified site does not include the patient’s home unless authorized by the insurance company. Also, “Telehealth” does not include phone, e-mailed or faxed communications; therefore, phone calls, e-mails and faxes are not subject to telehealth restrictions.

information to a third-party. • Written consent from the patient to use telehealth after being informed of the risks, benefits, and alternatives.

Medical Records. Any physician

conducting a patient encounter via telemedicine must so document in the patient record and must state the technology used. The physician should have appropriate patient records or be able to obtain such information during the telemedicine encounter. On December 28, 2017, CMS issued a memo specifying and clarifying that healthcare providers may not issue orders via text messaging. Communicating patient information via a secure platform is permitted.

SOME TAKE CREDIT. WE TAKE INITIATIVE. Ann E. Lundy 901.680.7367 Ann.Lundy@ butlersnow.com

Shannon E. Hoffert 901.680.7352 Shannon.Hoffert@ butlersnow.com

direct referral for an in-person visit, request additional information, or recommend the patient be evaluated by the patient’s primary care physician or other local provider.

Patient Privacy. Tennessee does not have a law specifically addressing privacy in telemedicine, but does have privacy regulations for licensed healthcare professionals requiring a privacy policy, and disclosure consent requirements that would apply in the context of telemedicine.

Informed Consent. As is true with inperson medical visits, evidence documenting appropriate patient informed consent for the use of telemedicine technologies must be obReimbursement. Tennessee law requires tained. Appropriate informed consent should, commercial insurance companies and at a minimum, include the following terms: Telehealth Standard of Care: Providers TennCare payors to cover telehealth services • Identification of the patient, the physimust exercise the same standard of care as to the same extent that they cover in-person cian and the physician’s credentials. they would through an in-person visit. visits as long as the patient is at a “qualified The provider should verify the patient’s site.” The catch is that the insurers do identity by using government issued Licensure. The practice of medicine occurs not have to pay the same amount as they photo identification and/or a facilitator. where the patient is located. Tennessee would for an in-person visit. That is, there The provider should disclose his or her requires full medical board licensure if the is no payment parity--only coverage parity.2 name, current and primary practice loThis provision applies to TennCare MCOs patient is located in Tennessee. Former cation, medical degree and recognized (any insurer that agree to insure TennCare “special telemedicine” licenses are no longer specialty area, if any. patients), such as BCBST’s Blue Care valid. Effective July 1, 2018, Tennessee will • Types of transmissions permitted using program. In Tennessee, the law requires join 22 other states as a member in the telemedicine technology (i.e. prescrippayors to cover telehealth services, but not Interstate Medical Licensure Compact. tion refills, appointment scheduling, when the patient is at home. This does not States that are in the Compact can rely upon patient education) restrict commercial payors from deciding to information submitted by the physician to • The patient agrees that the physician pay for remote monitoring at home if they so his or her primary state in order to expedite determines whether the condition bechoose. Blue Cross Blue Shield of Tennessee the licensing process. ing diagnosed and/or treated is appronot pay if the patient is at home because Some legal teams are more concerned withwill priate for a telemedicine encounter Physician-Patient Relationship. it is not considered to be an appropriate Detailsthan on security measures with Tennessee does not require an in-person taking •credit initiative. At taken Butler Snow,originating site. the use of telemedicine technologies, visit in order to establish a physician-patient such asapproach encrypting data, password relationship. The patient encounter can our teamwork For additional information concerning allows us to proanticipate tected screen savers occur with or without a patient facilitator, Telehealth, including questions concerning • Hold harmless clause for information but a facilitator is required when the patient GLEPPIRKIWERHXSČRHGVIEXMZIWSPYXMSRW prescribing and CMS payment coverage, lost due to technical failures is a minor. If the information transmitted contact Ann Lundy with Butler Snow LLP • Requirement for express patient conduring the visit is not sufficient (e.g. bad After all, we measure our success by yours.at Ann.Lundy@ButlerSnow.com or at (901) sent to forward patient-identifiable connection), then the provider must request 680-7367. This article provides a few recent updates to the current legislative trends in Tennessee regarding telehealth:

1 Tenn. Code Ann. Sec. 56-7-1002. 2 Tenn. Code Ann. §56-7-1002.

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