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FOCUS TOPICS PEDIATRICS • ENDOCRINOLOGY • HEALTHCARE IT • AUTISM SPECTRUM DISORDER

September 2018 >> $5 ON ROUNDS

Thinking Outside the Box: Reaching Into Their World

Specialists Advise on How to Connect with Autistic Children By SUZANNE BOYD

Physician’s Son Delivers a New Facet to Practice For years one Memphis practice was solely internal medicine. That all changed recently thanks to a young man who not only is the son of one the doctors but also happens to be a pediatrician.

Profile on page 3.

Medicaid’s Growth Boosts Accessibility Of Diabetes Meds A new study reports that low-income individuals with diabetes are better able to afford their medications and manage their disease in states that expanded Medicaid.

According to estimates from the Centers for Disease Control and Prevention’s Autism and Developmental Monitoring Network, one in every 68 children has been diagnosed with an Autism Spectrum Disorder (ASD). In 2014, that number was one in 64 in Tennessee. Children with ASD are hospitalized more often than other children, making it highly likely that healthcare providers will come across patients with autistic conditions in their ER, hospital or clinic. Providers are having to learn how to provide proper (and sometimes creative) care to these special patients. Because children process information from the world around them much differently than adults, they have distinct needs for managing the effects of stress and trauma. While this is true for all children, it is especially true for children with autism. They may have difficulty developing language skills and understanding what others say to them. Additionally, they might also

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HealthcareLeader

Report on page 5.

Regional One IT Director Focuses on Underserved

New Barriers Deter Exciting Promise Of Precision Medicine Precision Medicine offers the promise of dispensing medicine in the most effective and precise manner possible. However, integrating the discipline into practice is often anything but an exact science.

By JUDY OTTO

Conveying vital healthcare information quickly, understandably and effectively is one way to make a positive difference in delivering appropriate healthcare. Daniel Thomas, Regional One’s IT Director-Clinical and Ancillary Applications, has made it his continuing

Story on page 7.

ONLINE: MEMPHIS MEDICAL NEWS.COM

have difficulty with nonverbal communication. And while some children may have a specific diagnosis, all children are still equally different. Therefore, a trip to the hospital or doctor can be extremely stressful for a person on the autism spectrum and it can be hard for providers to know the best way to interact with autistic patients and their parents. Fortunately, healthcare professionals are recognizing that providing quality care for children with ASD involves identifying unique needs and challenges. The medical team at Le Bonheur Children’s Hospital, trained in working specifically with children and their families, has recognized an opportunity to better serve patients with special needs with a multi-disciplinary team working to change how staff identifies and works with children with autism.  Jessica Kellough, director of Child Life at Le Bonheur, has served more than eight years on the inpatient

Fourteen specialties. On-site pharmacy and imaging. Online scheduling and same-day appointments. Publication: Memphis Medical News Size: 7.75"x1.25"

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mission to improve healthcare services to an underserved patient population by supporting clinical and ancillary areas of care delivery. A Mississippi resident since age 6, Thomas is an Ole Miss graduate who later earned a Master’s in health administration (with leadership focus) from Capella University. His IT (CONTINUED ON PAGE 8)

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PhysicianSpotlight

Son Brings New Dimension to Father’s Practice After Many Years, It’s No Longer Just Internal Medicine By LAWRENCE BUSER

When Dr. Jeremy Avila completed his four-year dual residency in pediatrics and internal medicine at the University of Missouri-Kansas City last year, he was eager for the opportunity to return to Memphis to begin practicing with his father. Equally happy was his proud father, Dr. Reuben Avila, an internist at Cresthaven Internal Medicine who says it’s “a joy” having his son join the practice, although there was an initial period of concern over the pediatric part. “Dr. (Derene) Akins and I have been in practice quite a number of years and we just do internal medicine, no pediatrics,” declared the senior Dr. Avila. “We were concerned it might be too disruptive for our adult patients who are used to just other adults in the office. So we thought, ‘Let’s just see how he does the first year.’ Jeremy was in another CMPM office and when it became apparent he didn’t have a lot of babies (as patients) we thought, ‘Well, this could work. We could bring him in.’ “All the patients have been very receptive, and they’re excited for us as well. That’s been encouraging.” Young Dr. Avila sees his dual specialties as complementing one another. “I thought medicine was incredibly interesting and pediatrics was a lot of fun, and I didn’t want to have to choose between them,” he says. “I believe if you look at all of life on a spectrum, so I’m in charge from when they’re born until they are in their 80s and 90s. I don’t see pediatrics and internal medicine as two distinct entities as much as it’s a lot of the same entities, they just look different.” For example, asthma or heart conditions in children may need lifetime attention for patients as their bodies change with age. “Having been trained in pediatrics and internal medicine, there’s no awkward transition from pediatrics to adults,” says Dr. Avila, who sometimes sees entire families for office visits. “It gets a little interesting when you have four people in the room, ages 4 to 45. I don’t know if I have any three-generation families yet, but that will be interesting someday. It can be pretty fun.” Despite being in the early stage of his career, Dr. Avila has noticed changes, such as the increase in specialized medications that weren’t available just 10 years ago. Another change is not so much in medicine as in the patients of today and their expectations of their doctor. “The baby boomers and the people who are a little bit older have certain expectations of their doctors whereas the younger generation – the millennials – has much different expectations,” says Dr. Avila. “Serving both groups in memphismedicalnews

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The Doctors Avila – Jeremy and his dad, Reuben

a way that’s meaningful can present a challenge. Whereas older patients value loyalty to their doctor, younger patients value accessibility. And the internet and all of its information and misinformation proves more of a challenge with younger patients, especially regarding things like vaccines.” Dr. Avila, not that far removed from the millennial generation himself, is an avid practitioner of the internet, including Facebook and the office web portal. “The portal allows patients to message me directly,” he says. “I probably have 10 conversations going on every day on the portal with patients, either explaining test results or carrying out a treatment plan just to save them an office visit. Sometimes you can type clearer than you can talk on the phone. I’m trying to go completely paperless. My father’s still on paper, but our working together has gone well so far.” There are seven doctors at their Cresthaven location on Great Oaks Road in Germantown, four upstairs and three downstairs, so the doctors Avila are not in constant contact during the day. “We don’t necessarily see each other, though we pass in the hall an awful lot,” says the senior Dr. Avila. “At the end of the day, though, we talk an awful lot and at lunch we’ll talk and debrief. Our cases kind of bounce off of each other because he’s got fresh ideas and I’ve got old ideas. It’s fun to have him there. It’s actually a joy.” Dr. Avila never actually encouraged his son to go into medicine, but preferred instead to “let him choose his own path. He’s an independent man.” After being home-schooled until high school with his three siblings by his mother, Leslie, a pharmacist, young Dr. Avila attended Wheaton College near Chicago (as did his father) and majored in biology (just like his father) and attended the University of Tennessee College of

Medicine (where his father did his residency). “He never really pushed me to go into medicine,” says young Dr. Avila. “I just remember dad always talking about how much he loved his job.” The senior Dr. Avila attended medical school at Temple University in his

hometown of Philadelphia and was eager to head south. “We had some friends who were southerners and I always said when I get a chance I’m moving South. I didn’t want to stay in the North. Too much snow and too many Yankees.” His son did his residency at the University of Missouri School of Medicine in Kansas City, and though he recalls only shoveling the driveway once, he was happy to return to Memphis. He and wife Stephanie, a Nebraska native whom he met at Wheaton, have two daughters, ages 4 and 3. Dr. Avila was a competitive soccer player in his earlier years, but his main link to soccer these days is following Liverpool in the English Premier League. “I splintered my tibia one year playing soccer for Bellevue Baptist and watched the championship game on crutches,” he recalls, adding that the team’s victory eased the pain a bit. “Then the next year I did the same thing to my other leg playing basketball. Then I tore my PCL in college and in med school I tore both ACL’s, so my sporting days are over.” So far he has received rave reviews in his practice.

The MidSouth MGMA Invites MEDICAL PRACTICE MANAGERS To Join Our Organization in 2018.

Our Fall Luncheons are Back!

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Attention Medical Practice Managers! Please join us for our upcoming educational & networking luncheons:

SEPTEMBER 20TH SPEAKER: Dr. Kennard Brown, EVC/COO UTHSC

OCTOBER 18TH SPEAKER: Cato Johnson, Chief of

Staff, Methodist LeBonheur Healthcare

NOVEMBER 15TH SPEAKER: Officer Terry Donald,

Shelby County Office of Preparedness

All luncheons are held at the Memphis Racquet Club & begin at 11:30 am. PLEASE RSVP AT MIDSOUTHMGMA.ORG

SEPTEMBER 2018

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Thinking Outside the Box: Reaching Into Their World, continued from page 1 Neuroscience unit where she gained experience working with children with autism. “I am not an expert in working with children with autism, but I have learned the questions to ask to learn more about each child, while also working alongside their family to best meet each child’s needs,” she said. “We have found that we are most successful in creating a positive experience when we are able to create a plan and follow through with that plan to reduce their stressors and increase their coping.”    As a child life specialist, Rachel Ryan works on the pediatric floor for Ayers Children’s Medical Center at Jackson-Madison County General Hospital to help reduce the stress and anxiety of hospitalized children by providing play and social interaction; teaching and distraction during medical procedures; and assesses emotional and developmental needs of children. “I am a one-person program which has been in existence at this hospital for almost 13 years,” said Ryan. “As a child life specialist, the primary goal is to help reduce the stress and anxiety of hospitalized children and their families. We do this in a number of ways such as play, preparation, pain management, coping strategies and through family support.” Both child life specialists agree that using first person language can be helpful. “This involves referring to them as a child with autism rather than defining them by their diagnosis, such as autistic child,” said Kellough. “Choosing words that put the person first helps us make sure we are

The Specialists Jessica Kellough is a certified child life specialist and serves as director of Child Life at Le Bonheur Children’s Medical Center. A graduate of Tennessee Tech, she has been at Le Bonheur for 12 years. She is an adjunct faculty member at the University of Memphis where she teaches courses related to Child Life and is currently pursuing a Master of Professional Studies with a concentration in Strategic Leadership. Rachel Ryan has served as the certified child life specialist at Ayers Children’s Medical Center of Jackson-Madison County General Hospital since 2007. A certified bereavement counselor, she serves on the Perinatal Hospice Team. Before beginning her career as a child life specialist, Ryan interned with the Child Life program at Le Bonheur Children’s Hospital and is a member of the Association of Child Life Professionals. She has served as an adjunct instructor at Union University and the University of Tennessee at Martin.

focusing on them as a person to meet their individualized needs.” Although patients at the Ayers Children’s Center are short-term stays, Ryan has found that during this quick hospitalization one of the best ways to gain information is by asking the parent or guardian general questions such as: What are the child’s special interests? What does the child like to do? What are their dislikes? How do you communicate best with your

child? Are there any specific triggers we should be aware of? What do we need to know about your child to take the best care of them? This gives the medical staff a better idea of how to approach the child which will result in better outcomes for the patient. The more comfortable and prepared patients are, the more compliant they are. Another Child Life technique used for all children is “soft language.”

UTHSC Contributed $4 Billion to State’s Economy in 2017 The University of Tennessee Health Science Center contributed approximately $4 billion to the Tennessee economy in Fiscal Year 2017, according to a study released last month that designed to gauge the university’s total economic impact on the state. The 2017 Economic Impact Report was done by Cyril F. Chang, PhD, professor of economics at the Fogelman College of Business and Economics at the University of Memphis. The report, the first for UTHSC since 2011, includes the university’s direct and indirect economic contributions to the economy and confirms that UTHSC’s statewide financial impact continues to grow. “As a major employer and purchaser of goods and services, UTHSC contributes substantively to the economic well-being of the communities it serves by creating jobs, stimulating economic activities, and supporting public programs through tax revenues generated directly and indirectly by the economic benefits derived from the presence of UTHSC,” the 2017 report states. By contrast, the previous report done by the Methodist Le Bonheur Center for Healthcare Economics and the Sparks Bureau of Business and Economic Research at the University of Memphis found UTH4

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SC’s economic contribution to the state amounted to more than $2.3 billion. For the 2017 report, UTHSC’s approximately $4 billion economic impact was estimated using a model that has been employed by more than 500 universities, government agencies, and nonprofit organizations to estimate the impact of investments and economic activities on their communities. It includes not just the impact or market value of total sales and jobs supported by the main Memphis campus and campuses in Chattanooga, Knoxville, and Nashville, but the affiliate organizations and community-based social service organizations and foundations that affect the people of Tennessee, the inpatient care revenues earned by local hospitals as a result of the services provided by UTHSC’s clinical faculty, as well as federal, state, and local taxes. The total direct impact of the four campuses was $2.2 billion. The indirect effect (firms that supply goods and services to UTHSC) was $719.3 million, and the induced effect (increased sales from household spending of income earned as a result of UTHSC) was $1.1 billion. UTHSC received $146.8 million in state appropriations, or 28.6 percent of the university’s operating budget for FY 2017. “When compared to the total estimated economic

impact of $4 billion, the economic contributions of Tennessee’s flagship public medical school to the state economy exceeded state appropriations for university operation by a factor of 27 to 1,” the report said. In 2017, UTHSC and its affiliated organizations supported 32,333 jobs in Tennessee. The main Memphis campus, generated approximately $3 billion or 74 percent of the total economic impact of the university, Knoxville, $668 million or 16.8 percent, Chattanooga $368 million or 9.2 percent, and Nashville $1.8 million. Of the total number of jobs generated, 23,914 were in the Memphis area (74 percent), while 5,420 were in Knoxville (16.8 percent), 2,984 were in Chattanooga (9.2 percent); and 15 were in Nashville. The economic contributions of the university and its affiliated organizations made it possible for taxing authorities to collect $358.7 million in federal taxes and $148 million in state and local taxes to support various public service programs. The top 10 industries most affected by UTHSC and its affiliates included other institutions of higher education, real estate owners and firms, hospitals, physician offices, full-service and limited-service restaurants, wholesale trade establishments, and local government enterprises.

“For example, avoiding using terms such as ‘put to sleep’ as a child might associate that with putting an animal to sleep, rather than the induction of anesthesia,” said Ryan. “Patience is especially key when working with children. Procedures and even conversations can take longer. Allowing extra time for a patient with autism to process what you said and then respond is important.” Environment can play an important part in stress for an autistic patient. Kellough suggests being aware of stimulation: loud sounds, many people talking, and lighting. Waiting areas may be too stimulating, so if possible move the patient to an area where there is lower stimulation, such as a private exam room while waiting. A variety of activities can also be offered for normalization and distraction during hospital stays. “Two of which we are most proud is music therapy and pet therapy,” said Ryan. “We have witnessed firsthand the positive outcomes these can make.” “Children with autism benefit from routine and schedules, so anything that moves away from their routine may increase their stress and anxiety,” Kellough said. “Adjust appointments to avoid wait times, such as scheduling appointment at the beginning of the day. “Provide sensory items that promote a calming environment, if possible.  We have autism coping kits that include items like a weighted lap pad, a light spinner, bubbles, vibrating tube, pop tubes, noise canceling headphones and other manipulatives.  Some of the items are single-use and some are reusable.  One of these kits could easily be pulled together for $25 to $50 and will be worth the investment after its first use.” Communication is key in all that is done but sometimes minimal verbal language is best. Kellough also recommends using pictures to support verbal communication. “It is important to explain what you are doing no matter how small of a task or transition you may think it is. Pictures can support verbal communication and be used to explain the steps of a process such as having blood drawn,” she said. “Allow for repetition of the information, as this is how children with autism best learn.” Provide appropriate choices.  Choices promote a sense of control for both children and their caregivers.  Allowing children and their caregivers to feel like they are active participants in their care is a quick way to promote coping.  The key element is to provide choices that are appropriate while not providing unrealistic choices. If it is not something they are allowed a choice, don’t provide the option.    While it is always best if staff can plan ahead and create a plan to best meet an autistic patient’s needs, sometimes there is no time to plan ahead. “Make time to meet their needs. Even if you are not able to invest in-depth time to assess their needs, asking what is stressful and what they love to do are quick ways to get to know each child’s individual needs,” said Kellough. “The three to five minutes it takes to ask these questions will be worth the time in the long run.” memphismedicalnews

.com


PHOTO BY JONATHAN BACHMAN/GETTY IMAGES

CONSOLIDATED MEDICAL PRACTICES OF MEMPHIS Salutes This Father And Son Team: REUBEN AVILA, MD

Dr. Reuben Avila has been in practice in Memphis since 1981. Dr. Avila graduated from Temple University School of Medicine in 1978 and then completed his residency in internal medicine at the University of Tennessee. He is certified by the American Board of Internal Medicine. To refer patients to him, please call 901.821.8300.

A woman hands an insulin pen to Sen. Bill Cassidy (R-La.) during a town hall meeting on Feb. 23, 2017, in Thibodaux, La. She was expressing concern about the rising cost of the medication.

Medicaid Expansion Making Diabetes Meds More Accessible to Poor, According to Study By KAISER HEALTH NEWS

Low-income people with diabetes are better able to afford their medications and manage their disease in states that expanded Medicaid under the Affordable Care Act, a new study suggests. The Health Affairs study, released last month, found a roughly 40 percent increase in the number of prescriptions filled for diabetes drugs in Medicaid programs of the 30 states (including Washington, D.C.) that expanded eligibility in 2014 and 2015, compared with prior years. By contrast, states, such as Tennessee, that did not embrace the Medicaid expansion saw no notable increase. “Gaining Medicaid insurance would have significantly reduced out-of-pocket spending for insulin for previously uninsured patients, thereby facilitating uptake of the medication,” the Health Affairs study reported. Diabetes, characterized by abnormally high blood sugar, is a chronic disease that requires expensive and ongoing medical care. More than 114 million adults in the U.S. have diabetes or pre-diabetes, making the disease one of the country’s most formidable health challenges. “In the long run, preventing diabetic complications not only saves lives, but it improves public health and saves public money,” said Dr. Michael Bush, an endocrinologist in Beverly Hills, California, and president of the California chapter of the American Association of Clinical Endocrinologists. Bush and other experts said the Health Affairs study shows that the Medicaid expansion can help patients manage memphismedicalnews

.com

their health and also limit unnecessary spending. An analysis by the Centers for Disease Control and Prevention cited by the study shows that each diabetic patient who is treated for the condition can lead to a $6,394 reduction in health care costs (in 2017 dollars) because of fewer hospital admissions. In California, roughly 3.9 million people gained coverage when the state expanded eligibility for Medi-Cal, the state’s version of the federal Medicaid program. In all, about 13.5 million people — more than one-third of Californians — are enrolled in Medi-Cal. By 2016, about 12 million people had enrolled in Medicaid nationwide as a result of the expansion, according to the Kaiser Family Foundation. The foundation estimates that more than 2 million people who live in non-participating states would have qualified for Medicaid had their states chosen to expand. (Kaiser Health News is an editorially independent program of the foundation.) “It’s not particularly surprising that extending Medicaid opened up this door for lots of other people to be able to fill prescriptions and be able to take advantage of managing a chronic disease like diabetes,” said Flojaune Cofer, director of state policy and research at Public Health Advocates, a nonprofit organization based in Davis, Calif., that seeks to eliminate health inequalities in California. But Michael Cannon, director of health policy studies at the libertarian Cato Institute, said the Medicaid expansion may not mean good news for everyone. Medicaid pays a fraction of a drug’s

JEREMY AVILA, MD

Dr. Avila practices Pediatric Internal Medicine specializing in teens and young adults. He graduated from the UTHSC College of Medicine in 2013 and completed his residency in internal medicine and pediatrics from UMKC. To refer patients to Dr. Avila, please call 901.757.5333.

We address the health care needs of those in the Shelby County region and surrounding areas by providing outstanding and compassionate care. Derene E Akins, MD Derene Reuben EW.Akins, Avila, MD MD Reuben W. Avila, Robert Burns, MDMD

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For more information visit our website: MedicalOfMemphis.com or call 901.751.0405

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SEPTEMBER 2018

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Medicaid Expansion Making Diabetes Meds More Accessible, continued from page 5 list price, which leads pharmaceutical companies to hike prices for everyone, he said. That, in turn, could drive up everyone’s premium costs or lead those with private insurance to pay more out-of-pocket. “You have to look at not just the immediate effects of a policy, but all of the effects of a policy,” Cannon said. “As prices rise, fewer people will be able to afford diabetic medications.” Bottom of Form Last year, nearly 900,000 Californians with Medi-Cal were known to have diabetes, according to state figures. One of them is James Warden, 62, a retired rancher near Fresno who said he was forced to stop working because of a back injury several years ago. Warden enrolled in Medi-Cal in 2016 and was diagnosed with diabetes last year after a urinary condition landed him in the hospital, he said. Without the coverage, he said, he wouldn’t have the insulin his body needs. “Medi-Cal saved me,” he said. “I wouldn’t have the money to be able to pay, or go to the doctor or anything.” The researchers found that people in groups with a higher prevalence of diabetes before the ACA became law, such as those ages 55–59, showed larger increases in filling their diabetes prescriptions after the Medicaid expansions. The price of insulin, a staple medication for many diabetes patients, rose almost 200 percent from 2002 to 2013, according to the study. And nearly 40 percent of insulin users who responded to the American Diabetes Association’s 2018 insulin affordability survey reported that they had faced a price increase in the past year. As a result of the price hikes, many said, they took less of the medication, missed doses or switched to a cheaper drug. In states that didn’t expand Medicaid after 2014, such as Texas and Florida, the number of diabetes prescriptions filled remained relatively flat, the study found. In these states, low-income and uninsured diabetics must rely on a “patchwork of options” to get insulin and other medications to treat their disease, according to the American Diabetes Association. Patients may need to seek help through drug company patient assistance programs or chari-

Is the missing

About Kaiser Health News Kaiser Health News (KHN) is a nonprofit news service committed to in-depth coverage of healthcare policy and politics. It reports on how the healthcare system — hospitals, doctors, nurses, insurers, governments, consumers — works. In addition to its website, its stories are published by news organizations throughout the country. The KHN site also features daily summaries of major healthcare news. KHN is an editorially independent program of the Kaiser Family Foundation, a nonprofit organization based in Menlo Park, California dedicated to filling the need for trusted information on national health issues. KHN’s coverage is supported in part by The John A. Hartford Foundation

ties, the group said. The study also showed a surge in filled prescriptions for newer, pricier diabetes drugs that have fewer side effects and control diabetes more effectively. And there was an increase in prescriptions for metformin, a generic drug that is often used as a first line of treatment for new Type 2 diabetes patients.

Maryland Board Selects Memphis Physician to Join Investigative Team Frederick M. Azar, MD, chief of staff at Campbell Clinic Orthopaedics, has been selected to serve on the commission that will investigate the culture of the football program at the University of Maryland following the death of a football player during the opening weeks of fall practice. The University System of Maryland Board of Regents announced the appointment of Azar and four other additional members to a commission created to investigate the death of offensive lineman Jordan McNair and “the culture of the football program” at Maryland. McNair suffered heatstroke during a May 29 workout. Head coach DJ Durkin was placed on paid administrative leave on Aug. 11 after an ESPN report detailed allegations of a toxic culture within the

piece in

your office?

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John Pantall, Microsoft Certified 901.466.6358

football program that was based on fear and intimidation. The new appointees will join three previously named members: retired U.S. District Court judges Ben Legg and Alex Williams, and former federal prosecutor Charlie Scheeler. In addition to Dr. Azar, a sports medicine doctor who also serves as professor and director of the Sports Medicine Fellowship program in the University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, the new appointees include: Bonnie Bernstein, founder of Walk Swiftly Productions; sports journalist at ESPN, ABC and CBS for nearly 20 years; and alumna of the University of Maryland, College Park, where she was an Academic All-American gymnast.

Robert L. Ehrlich Jr., former Maryland governor and former captain of the Princeton University football team. C. Thomas McMillen, former United States Congressman; current president and CEO of the LEAD1 Association (which represents the athletic directors and programs of the Football Bowl Subdivision); former co-chair of the President’s Council on Fitness, Sports and Nutrition; former member of the USM board of regents; and alumnus of the University of Maryland, College Park, where he was an All-American and Academic All-American basketball player. Doug Williams, Washington Redskins senior vice president of player personnel; Super Bowl-winning quarterback; and former head football coach at Morehouse College and Grambling State University.

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The rise in metformin prescriptions suggests the federal health law also led to more people being diagnosed with the disease, the authors said. The study, conducted by University of Southern California pharmaceutical and health economists, was based on an analysis of filled prescriptions before and after

the state Medicaid expansions began in 2014. The number of states that expanded Medicaid has since grown to 33 states and Washington, D.C. The prescriptions analyzed cover the period from 2008 to 2015. About 15 percent of retail pharmacies did not share their information, and the data did not include prescriptions filled by health clinics or via mail-order, which could have led to underestimates of the total effect, the authors said. Bush, the Beverly Hills endocrinologist, acknowledged that providing diabetes drugs to Medicaid patients is costly to taxpayers. But he said it is money well spent. “This is clearly a disease where if you take care of it now, you can prevent complications that occur later,” he said. This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation. KHN’s coverage of these topics is supported by California Health Care Foundation and Laura and John Arnold Foundation.

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Practicing with Precision:

Barriers, Resources to Integrating Precision Medicine By CINDY SANDERS

Precision Medicine. The very name neatly sums up providers’ universal hope to dispense medicine in the most efficient, effective, precise manner possible to the benefit of a patient based on that person’s individual profile. Yet, integrating the discipline into practice is often anything but an exact science. A number of barriers – from a barrage of new discoveries to difficulties with authorization and reimbursement – have hindered physicians as they seek to offer patients the best option to treat a range of conditions and illnesses. The American Medical Association (AMA) has taken a leadership role in working with stakeholders, from researchers and colleagues to payers and policymakers, to address a number of key issues cited by physicians on the frontlines of care. Already critical to the delivery of patient-centered care in a variety of specialty areas including oncology and rare disease, the discipline is only anticipated to grow as new discoveries come online daily. To enable that growth, the AMA has recognized physicians need readily available resources to learn about the rapidly changing field and its impact on patient care. The national organization has developed a number of educational resources, including the “Precision Medicine for Your Practice” series, which includes online modules to enhance awareness of physicians and healthcare providers of the different ways genetic testing can be incorporated to improve health outcomes for patients. According to the national organization, “The modules – developed by the AMA in partnership with Scripps Translational Science Institute and The Jackson Laboratory – cover specific topics in genomics and precision medicine, including expanded carrier screening, prenatal cell-free DNA screening, somatic cancer panel testing, cardiogenomics, neurogenomics and pharmacogenomics. The modules offer CME free of charge and can be found on the AMA’s website.” Currently, those modules are available

online at education.ama-assn.org/precision-medicine.html. However, the AMA is updating its Education Hub so the address will likely change as that transition occurs but should be searchable in the association’s new education section. The AMA is also supporting continued research as a formal partner in the National Institutes of Health “All of Us” research program, which is building a large research cohort for precision medicine. The goal of the initiative is to better understand genomic influences and how they interact with lifestyle and the environment. More information on the large-scale project is available at allofus.nih.gov. While precision medicine holds great promise for the future, current payment systems have proven to be a significant barrier to clinical integration. Additionally, more work is needed on the clinical decision-support front to assist providers in identifying and deploying appropriate testing. On a related note, the AMA said there is a widespread shortage of medical geneticists and other clinicians with specialized knowledge to help drive broad clinical integration. “The AMA is working on several fronts to address these barriers. For example, the AMA has advanced several priorities to expand coverage and payment and access, as well as educational initiatives and support for research and clinical validation,” the organization responded to the Birmingham Medical News in a statement. While efforts to ensure coverage and payment for clinically validated precision medicine continue, the AMA noted, “An ongoing challenge has been the rapidly evolving coverage and payment policies of government and commercial health insurers that have not necessarily kept pace with innovation and clinical validation in genetics and genomics. There are some commercial insurers that are imposing either prior authorization requirements or other utilization management policies due to their fixed capacity to keep pace with the change, which impacts and challenges patient access and clinical integration.” At the beginning of 2017, the AMA joined with 16 other organizations repre-

senting the continuum of care to release the Prior Authorization and Utilization Management Reform Principles, calling for an array of improvements in utilization management including addressing the key issues of clinical validity, transparency, fairness, timely access, continuity of care, alternatives and exemptions. “The release of these principles spurred important conversations between provider and health plan organizations on the need for prior authorization reform. An important initial outcome of those discussions was the January 2018 release of the Consensus Statement on Improving the Prior Authorization Process,” stated the AMA. The consensus statement from six national organizations representing physicians, hospitals, pharmacists, practice managers and payers reflected an agreement between providers and payers to meaningful address the process impacting the delivery of cutting-edge care. With the shortage of medical geneticists and specialized clinicians deploying precision medicine … and with those who do possess that specialized knowledge and skill set often clustered at major academic centers . . . the AMA has focused on increasing access to genetic and genomic consultations through the utilization of telehealth and e-consults. Strong supporters of using technology to expand access and knowledge, the organization hailed a proposal to allow the Medicare program to cover

inter-professional e-consults beginning Jan. 1, 2019. “This is very important news for physicians and patients who will be able to obtain patient-specific medical genetic consultations more rapidly and without constraints of geography, while ensuring care coordination and care delivery by the primary care provider,” the AMA stated. “With all of this optimism and promise, consistent coverage policies that reflect the evidence base remain a critical factor in the successful implementation of precision medicine, as well as the infrastructure to support widespread clinical decisionsupport for the right patient, right test at the right time,” noted the AMA. Although excited about forward movement in terms of expanding access through e-consults and the work to address prior authorization impediments, the national physician group said additional challenges remain, including concerns over affordability and accessibility. A growing concern is the potential impact of efforts that could limit the number of clinical laboratories offering testing due to payment cuts. “The AMA is committed to addressing these challenges though advocacy efforts, investing in a number of educational initiatives, as well as promoting continued discovery and innovation through the All of Us campaign.” Additional information and links to resources to assist in implementing precision medicine at the practice level are online at MemphisMedicalNews.com.

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Regional One IT Director Focuses on Underserved, continued from page 1 career took its turn toward healthcare shortly after college, when he was offered a job improving electronic health records (EHR) workflow at a healthcare IT group. “At one point I wanted to be a doctor,” he recalled, “so this was the next best thing.” The thread of designing, documenting and implementing EHR workflow best practices to ultimately improve patient care remained consistent throughout Thomas’ subsequent career at SergeMD, Inc., in Memphis and Delta Health Alliance in Stoneville, Mississippi. It’s what brought him to Regional One in February 2018, to fill a vacant position directing the acute clinical and ancillary IT applications that impact in-patient care. He said an increasing workload, changing technology and added personnel at the analyst level were the factors that influenced the hospital’s decision to recruit Thomas. “Sometimes a lot of the management will trickle up and become a little overwhelming,” he said. “But they (Regional One) did a good job of managing it for the period it wasn’t filled.” The position offered Thomas the opportunity to make a difference in a population he had focused on during the previous 6½ years of his career. “I’m very interested in the underserved, the uninsured, the underinsured,” he said. “That’s something that this orga-

nization has a big part in, in the community.” Since February, Thomas has tackled some significant internal systems upgrades: “things required for clinical care that have been by the metrics successful”— although he qualifies the claim with a reminder that “success in an IT world is somewhat based on perception; it’s almost impossible to measure because it’s all opinion.” That opinion — and a shared perception of the metrics — depends on a great deal of trust building between business users and information technology. Trust grows from committed relationship-building, he believes — something he has applied to addressing his toughest challenge: taking over an existing team consisting of 14 analysts in two reporting groups. A new boss “from outside” must also work to earn his team’s respect and trust, he said. Strategically, his goal is to continue to serve the end users. “We’re always looking to find new and improved ways to use technology to improve patient care that also fall within budgetary constraints,” he said. “Any opportunity we can find to improve care and reduce cost is a real win for everybody. Because this organization is a non-profit, the less (money) that IT uses, the more can go to direct patient care.” Communication, which he identifies

as the most common root that IT problem healthcare businesses and institutions face, can pose a challenge, either with translating and understanding the need that’s communicated to information technology or information technology communicating the response and the opportunity back to the user. “In order to succeed in leadership in IT,” he said, “you have to be able to translate. Clinical teams have acronyms, IT people have acronyms, and there’s a period of time where you all have to agree that you’re not going to use three-letter words!” Avoiding confusing ambiguities and translating “that intimidating geek talk” into something everyone understands is essential, he stressed. In a world where technology evolves rapidly, keeping up can also be a challenge — not only because major updates appear on an almost yearly basis, but also because government regulations drive many upgrades, and they’re non-negotiable and time-sensitive. That evolution, however, has also brought healthcare IT from a point when systems didn’t talk to each other to today’s level of interoperability, which has been dramatically improved by vendors over the past seven years, he explained. Security concerns, too, have made comforting strides, Thomas said. “There’s so much energy put into security, espe-

cially cyber security, these days. I’ve really been impressed with the amount of prevention I’ve seen over the last couple of years, especially in healthcare.” Today’s breaches, he said, often arise from human error — a laptop carelessly left in a car, a thumb drive lost — rather than malicious mischief by a determined hacker. Of his own accomplishments, Thomas reflected, “I’d like to think I’ve had a real impact in the area of healthcare where people are delivering care for the underserved; I’ve spent a lot of time improving access to quality healthcare in places where it just didn’t exist before, and it all led me to bring what I’ve learned to Regional One to see if I could make the same kind of impact here, working with a bigger team that shares the passion and purpose.” Thomas enjoys spending his free time with his children ages 8 and 11, or perfecting the golf skills he’s been honing since age 3 — above-average skills that helped his high school team win a state championship. He encourages IT healthcare leaders to pursue clearer understanding: “As IT people, we’re a bit removed from the bedside aspect of care, so we have to be very focused on the needs of those end users. Try to be the ears instead of the mouth, listening to their needs and working diligently to resolve them.”   

Who’s INCHARGE in 2019? A POWERFUL ECONOMIC DRIVER, Memphis’ diverse healthcare offerings impact the industry on a local, regional and national basis. Knowing who is ‘in charge’ is important to fostering relationships and partnerships to keep this vital industry moving forward. Each December, Memphis Medical News provides a definitive list of leaders in the annual InCharge Healthcare issue, which is formatted as a glossy, four-color magazine.

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InCharge showcases a wide range of difference-makers, including: 

Hospital, health system and large practice leaders

Top researchers and academic leaders

Go-to healthcare advisors including the top healthcare attorneys, bankers, accountants and consultants

Key healthcare investors and entrepreneurs

And other leaders … including some working behind the scenes … who continue to grow Memphis’ multi-billion dollar industry.

Want to nominate a Memphis healthcare leader for a listing? Interested in advertising in the next InCharge? Talk to the publisher: Pamela Harris 501.247.9189 or pamela@memphismedicalnews.com.

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GrandRounds UTHSC Names Associate Vice Chancellor Student Affairs Darrylinn Todd, EdD, has been named associate vice chancellor of Student Affairs and Enrollment Services at the University of Tennessee Health Science Center (UTHSC). In this role, she will provide executive leadership for and oversee several Darrylinn Todd administrative units that provide centralized campus support activities and services to students. Todd will also assume an active role in the campus-wide wellness efforts in collaboration with the Office of Student Academic Support Services and Inclusion, UTHSC colleges, and the Memphis community. She brings more than 20 years of higher education experience. She has held a number of academic leadership positions and previously served as executive administrator at the University of Tennessee Health Science Center, the senior director of  Online Learning at DePaul University and vice president of Academic and Student Affairs at Malcolm X College-City Colleges of Chicago. During her tenure as vice president she was instrumental in managing academic and student affairs initiatives and health care programs in an urban setting. In this role, she provided leadership and management of a broad range of student services to assist students in achieving their academic and life goals.  A native of Chicago, Todd earned a Bachelor of Arts degree in education from the University of Northern Colorado, a Master of Arts in Education from Oakland University, and an MBA and doctoral degree from Northern Illinois University.   

UTHSC Professor Receives DOD Prostate Cancer Research Grant Jay Fowke, PhD, MPH, chief of the Division of Epidemiology and professor in the Department of Preventive Medicine at the University of Tennessee Health Science Center (UTHSC), has been awarded an $843,694 grant from the Department of Defense for his research project Jay Fowke entitled, “Prostate Tissue Gene Expression Patterns Predict Prostate Tissue Inflammation, Aggressive Prostate Cancer, and a Poorer Prognosis Among Black and White Men.” The project focuses on the overarching challenge of distinguishing aggressive from indolent disease in men newly diagnosed with prostate cancer, with an emphasis on data science and analytics, population science, and tumor and microenvironment biology. “Prostate cancer is a disease that develops over a long period of time, and we don’t really understand what that process is of going from normal prostate cells and tissue to cancer,” Dr. Fowke said. “What we do know is that there are some established risk factors for prostate cancer, such as age and family history.” In addition to these established risk factors, Dr. Fowke’s research also explores a racial disparity component; specifically, the fact that African-American

men are more likely to develop and die from prostate cancer than Caucasian, Hispanic/Latin, and Asian men. “We know that black men, for some reason, are more likely to develop and die from prostate cancer than other groups of men and we have almost no idea why that is the case,” Dr. Fowke said. “We don’t think it’s entirely genetic, although there could be some sort of inherited component to that, but there could also be a cultural, lifestyle component to that, and the two could interact in ways we don’t understand right now.” Dr. Fowke’s work attempts to look at the environmental, non-genetic components of prostate cancer risk and then combine it with the established genetic components as a method to tease out how the seemingly disparate two talk to each other to advance prostate cancer across all groups of men. “We’re trying to understand why these differences exist across races. Is it just a genetic factor that drives this or is it some combination of cultural, lifestyle effects with genetic factors that pair to advance prostate cancer in, this case, African–American men.” Dr. Fowke said. “We think that one part of what drives prostate cancer is what we generally refer to as inflammation,” Dr. Fowke said. “Sometimes, the immune system should turn on and it then should turn off. When it does not turn off, or does not turn off in the right way, it sometimes creates an inflammatory event that is not curtailed and can cause tissue damage

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BlueCross Names Director of Corporate Governance BlueCross BlueShield of Tennessee has promoted Jill Langston to director of corporate governance and corporate secretary. Langston will manage and coordinate the business of the board of directors, who help ensure the company maintains responsible and trustworthy performance as it delivers Jill Langston peace of mind through better health to customers and communities. Langston has been with BlueCross for more than 20 years, and has served for the last 13 years as corporate governance analyst and assistant corporate secretary. In this role, she worked directly with the board of directors and supported the director of corporate governance and corporate secretary.

VA Memphis to Hold Information Fair in Holly Springs

Saint Francis Physical Therapist Earns Certification Saint Francis Hospital-Bartlett physical therapist Joann Igharas has achieved certification from the American Board of Physical Therapy Specialists (ABPTS) as a Board Certified Orthopedic Clinical Specialist. This recognizes Joann for Joann Igharas her advanced clinical knowledge, skill and experience unique to treating patients with orthopedic conditions. Igharas has worked as a physical therapist for 26 years, including the past eight years at Saint Francis HospitalBartlett. Before becoming eligible to take the certification exam, a clinician must have at least 2,000 hours of clinical practice experience.

on its own. The immune system could be sending cells into the prostate tissue to address something, but it doesn’t turn off. It stays and persists at a low-level state, which can cause damage and advance cancer development.” From collected circumstantial data, Dr. Fowke believes those events happen more readily in African-American men than other groups of men, as they are more likely to develop other inflammatory diseases such as cardiovascular disease and diabetes.

Recipients of the Methodist Healthcare Foundation’s 2018 Living Awards Benefit are (from left) Deborah Jones, Dr. Hollis H. Halford, III, Dr. James M. West, and Dr. James C. Fleming.

Methodist Healthcare Foundation Presents 2018 Living Awards The Methodist Healthcare Foundation held its 36th annual Living Awards Benefit at The Peabody last month to honor “individuals and organizations who exemplify the faith-based, healing mission of Methodist Le Bonheur Healthcare through their efforts to improve the health of their community locally and beyond.” This year’s honorees are: James C. Fleming, M.D. , medical director, Hamilton Eye Institute Ambulatory Surgery Center - Physician Inspiration in Faith and Health Hollis H. Halford, III, M.D., managing partner and president, Memphis Radiological Professional Corporation – Physician Inspiration in Faith and Health Deborah J. Jones, philanthropist and community volunteer – Individual Inspiration in Faith and Health James M. West, M.D., partner, Memphis Anesthesia Group, and director of Transplant Anesthesia, Methodist Le Bonheur Healthcare - Physician Inspiration in Faith and Health The award is the highest honor Methodist Le Bonheur Healthcare bestows.

VA Memphis to will hold an Information Fair in Holly Springs , Mississippi, on September 12 from 10 am to 2 pm at the Eddie L. Smith Multipurpose Center at 235 North Memphis Street. Veterans and their family members, caregivers and others in the Holly Springs area are invited. VA representatives with Women’s Health, Homeless Services, Eligibility, Home Based Primary Care, Suicide Prevention, Transition Care Management (formerly OEF/OIF/OND), My HealtheVet, Customer Service, the Vet Center, Voluntary Services, and Mississippi VA Regional Office will be on site to answer questions and assist Veterans.

Follow us on to begin receiving West TN Medical News in print or on your tablet or smartphone @memphismednews for updates and breaking news www.WestTNMedicalNews.com

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GrandRounds Lee Schwartzberg Presents Phase III Findings West Cancer Center’s Executive Director, Lee Schwartzberg, MD, FACP presented key findings from a phase III study to the Multinational Association of Supportive Care in Cancer (MASCC) during its annual meeting held in Vienna, Austria. He Lee Schwartzberg was lead investigator for the study titled “Eflapegrastim is Safe and Effective in Reducing Severe Neutropenia in Patients Receiving Myelosuppressive Chemotherapy in a Phase 3 Randomized, Controlled Trial Compared to Pegfilgrastim.” The objective was to demonstrate the non-inferiority (NI) of eflapegrastim to pegfilgrastim, with findings that concluded eflapegrastim was safe and well-tolerated with a similar safety profile to pegfilgrastim. This is good news for patients receiving chemotherapy, who many times deal with Neutropenia, a low level of neutrophils (a type of white blood cell). While all white blood cells help fight infection, neutrophils in particular help destroy harmful bacteria and fungi that can be a serious concern for cancer patients. The time between chemotherapy treatments can be prolonged for a person with severe neutropenia, so reducing the duration (DSN) can positively impact a patient’s treatment. In summary, the patients who received eflapegrastim had a mean DSN of .19 or .478 days vs. .34 or .668 days for pegfilgrastim. Dr. Schwartzberg hosted an international conference call on Friday, June 29th  to discuss the study’s outcome. Just one more example of the tremendous impact our physicians at West Cancer Center are having on cancer research that impact patients globally.    ​ Those interested in viewing the presentation and listening to the webinar, should visit  http://investor.sppirx. com/events-and-presentations

St. Jude Earns an ‘Exceptional’ Ranking The National Cancer Institute has awarded St. Jude Children’s Research Hospital the highest possible rank of “exceptional” for the second time in a row as well as giving it the best numerical score in the hospital’s history during the renewal of the hospital’s $30 million Comprehensive Cancer Center grant. St. Jude  is the first and only NCIdesignated Comprehensive Cancer Center  that  is devoted solely to children. The designation and accompany-

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ing grant funds must be renewed every five years. St. Jude first earned an “exceptional” score in 2013.  St. Jude has had the designation as an NCI Cancer Center since 1977, and first achieved comprehensive cancer center status in 2008. A comprehensive cancer center must possess a deep and broad research-based portfolio that extends from the laboratory to the clinic, and must include population-based science. Centers must also be actively engaged in professional and public cancer education and outreach.

Paper Published by UTHSC Cancer Researcher Notes Critical Role of STAT3 A paper authored by Lawrence M. Pfeffer, PhD, a professor in the Department of Pathology and director of the Center for Cancer Research at the University of Tennessee Health Science Center (UTHSC) has been published in the journal Oncotarget, entitled “The critical role that STAT3 plays in glioma-initiating cells: STAT3 addiction in glioma.” The paper notes the critical role

that proteins play in Glioblastoma tumor growth. Despite advances in surgery and therapy, Glioblastoma (GBM) remains the most common and deadliest brain cancer in adults. Research shows that Glioblastoma tumor recurrence and therapeutic resistance has been attributed to Glioma-Initiating Cells (GICs) within the tumor that display several characteristics of neural stem cells. “With a median patient survival rate between 10 to 15 months, identifying pathways critical for GIC function is essential for developing new strategies to target these cells and improve survival for Glioblastoma patients,” Pfeffer said.  In previous studies, Pfeiffer’s lab reported that Signal Transducer and Activator of Transcription (STAT) proteins are involved in many cellular functions including activation in various cancers. STAT3 proteins in particular play a critical role in promoting GBM tumor growth and the growth of new blood vessels in the body, inhibit immune responses, and promotes tumor invasion and metastasis.

“In this study, we showed that regulation and/or deletion of this particular protein, STAT3, markedly inhibited tumor formation and growth in various pro-tumorigenic pathways,” Pfeffer said. “Moreover, we discovered that certain STAT3 modification sites are vital and fundamental for GIC formation.” To study this specific protein’s function, Dr. Pfeffer’s lab developed a system that can be manipulated to reduce STAT3 protein expression in Glioma-Initiating Cells. The goal is to determine in certain tumorigenic pathways  whether non-modifiable amino acids introduced at specific STAT3 sites play distinct roles in Glioma-Initiating Cell function in vitro and in vivo.

PUBLISHER Pamela Z. Haskins pamela@memphismedicalnews.com EDITOR Bob Phillips editor@memphismedicalnews.com ADVERTISING INFORMATION 501.247.9189 Pamela Z. Haskins CREATIVE DIRECTOR Susan Graham sgraham@nashvillemedicalnews.com GRAPHIC DESIGNERS Susan Graham, Katy Barrett-Alley CONTRIBUTING WRITERS Suzanne Boyd, Lawrence Buser Judy Otto, Cindy Sanders, PHOTOGRAPHER Greg Campbell

Researchers John D. Boughter, left, and Max Fletcher

UTHSC Scientists Win Grant to Study Taste-Behavior Link Two scientists from the University of Tennessee Health Science Center (UTHSC) – John D. Boughter, Jr., PhD, and Max Fletcher, PhD – have received a five-year $2.27 million grant through the National Institutes of Health for their project entitled “Spatial taste coding in mouse gustatory cortex.” Their work explores how an important sensory system is organized in the brain and how it works to modify behavioral patterns. Dietary decisions play a vital role in the progression of a number of human conditions (obesity, diabetes, anorexia, hypertension, coronary artery disease, etc.), and arguably the most important factor regulating these decisions is the sense of taste. “The general idea is that it’s a project to map sensory representation in the cortex,” said Boughter, associate professor of Anatomy and Neurobiology at UTHSC. The duo is accomplishing this aim by using a cutting-edge brain imaging technique called two-photon imaging with animal models, recording a mouse’s brain activity as it tastes and feeds. The part of the brain the two researchers are focusing on, the gustatory cortex, is extremely difficult to access. Located on the lateral surface of the brain, the gustatory cortex is a region where the sense of taste and its reactive neurons are stored. What’s more, Boughter and Fletcher are on the forefront of this research, as at the time of their grant submission, only one other paper had been published on the topic.

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rong still st . . . 7 Da y 4

be your center of excellence. We can provide the highest quality of care in the nation. And we’ve been recognized for it. West Cancer Center is 1 of 36 practices given the highest-level rating by the National Committee for Quality Assurance, and 1 of 27 cancer centers in the country accredited by the National Comprehensive Cancer Network. All so we can create better outcomes, and better quality of life. At West Cancer Center, we can.

901.683.0055 • westcancercenter.org

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