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Your Middle TN Source for Professional Healthcare News


Kiffany Peggs, MD


Walking in a Patient’s Shoes So much of medical school and residency is focused on identifying disease and prescribing a course of action to address the diagnosis … but what happens when the ‘right’ answer doesn’t mesh with the real world? ... 5

LHC Travels to D.C. for Annual Delegation This month, Leadership Health Care (LHC) – an initiative of the Nashville Health Care Council – will lead its annual delegation to the nation’s capital ... 10

Tennessee Kidney Foundation: Supporting Those Fighting Kidney Disease Kidney disease impacts 30 million Americans. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the overall prevalence of chronic kidney disease (CKD) in the general U.S. population is 14 percent ... 14

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March 2018 >> $5

Assessing and Addressing Detriments to Health in Nashville By MELANIE KILGORE-HILL

Nashville is on the move … in more ways than one. Efforts to address social detriments and improve livability are happening citywide with hopes of producing a healthier Nashville for years to come.

Nashville WalknBike

There’s an unmistakable correlation between obesity rates and miles traveled in a vehicle, but the city of Nashville is working to change that. Nashville WalknBike was established in 2015 to kick start conversations and actions needed to encourage healthier means of transportation. The result was a longterm Metro Public Works strategic plan (CONTINUED ON PAGE 4)

Password Protected

Simple Steps to Enhance Cybersecurity By CINDY SANDERS

From U.S. elections to national healthcare providers and payers, the news is filled with examples of massive organizations with massive IT departments that still got hacked. So how do much smaller healthcare companies and medical practices avoid the same fate? Scott Augenbaum, who recently retired after 29 years with the Federal Bureau of Investigation, said there is any number of best practices … most of which cost little or nothing … that healthcare practices should put in place to maximize protection.

“I’ve dealt with thousands of cybercrimes in my career,” noted Augenbaum, who spent the last 14 years working exclusively in this arena. “When a large healthcare organization has an issue, they are able to throw a lot of money at the problem … but not the smaller companies, and when the smaller companies have a breach, it can be devastating.”

First, the Bad News

He added most healthcare practices that are victims of cybercrime have five points in common: 1) They believe they are too small to attract (CONTINUED ON PAGE 12)

For more topic-driven information by subject matter experts, check out our blog:




Dr. Kiffany Peggs: Changing Expectations Geriatrician Focuses on Whole Person Care of the Elderly, Disabled A Patient Advocate


When Kiffany Peggs, MD, decided to specialize in geriatrics, a corporate job was nowhere near her radar. Today, the medical director for Long-Term Services and Support at UnitedHealthcare Community Plan of Tennessee is finding joy in serving more than 10,000 elderly and disabled individuals who might otherwise fall through the cracks.

Finding Her Way

A classically trained concert violist, Peggs received undergraduate degrees in both chemistry and biology from the University of Tennessee - Knoxville before continuing her education in medicine at the University of Tennessee Health Science Center in her hometown of Memphis. In 2008, she landed in Nashville for a residency at Vanderbilt University Medical Center (VUMC), where she remained for a fellowship in geriatrics. “During medical school, I especially loved care of the elderly and vulnerable,” Peggs said. “They always touched my heart.” After her fellowship, the geriatrician worked for the Department of Veterans Affairs Tennessee Valley Healthcare System and served as director of the Geriatric Evaluation and Management Unit. She also worked as medical director of Geriatrics Consult Service at VUMC before making

the switch to UnitedHealthcare in 2016. “A friend of mine who moved to UHC reached out and said he found the perfect position for me,” Peggs said. “I was in a robust clinical practice and had no intention of leaving, but I kept meeting more people and learning what the program is about. In the end, I had no problem saying ‘yes’ because the people I’d work with really understood the problems I’d been seeing in the community, and I knew I could make a difference for thousands of patients.”

In private practice, Peggs could do little to remedy everyday problems facing her elderly patients. Today, she works as a member advocate to ensure patients receive help with everything from food and housing to utility bills and medications. “Patients often need help with the most basic needs, like shelter and bills,” said Peggs. “We can help people catch up on their rent or mortgage and help them transition from a nursing home when they may not even own towels or furniture.” While UnitedHealthcare helps fund many of these needs, Peggs and her colleagues also look for resources to address everything from home repairs to meal delivery. “When people go hungry, they can’t take their pills, and making a doctor’s appointment and exercising aren’t going to happen either, ” she said. “We want to identify people with basic needs and give them the safety and support they deserve.” Under Peggs’ leadership, UnitedHealth’s Population Health team has provided assistance with everything from rotten floorboards to bed bug infestations and behavioral health services. “Our care coordinators are trained to reach out, and between us we’ll find the right person,” said Peggs, who sometimes meets multiple times a day to find solutions for one

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person. “We’re going to find community resources and make sure we’re leaving you better than we found you,” Peggs said. Additionally, UnitedHealth’s Population Health Team recently rolled out a CHOICES program to identify those who want to lose weight or stop smoking, while their Community First program is providing job opportunities to those with intellectual and developmental disabilities.

Changing Minds & Expectations

Compassion for those she serves is evident. As an organization, UnitedHealth no longer refers to customers, members or patients, but instead to “people we serve.” “We’re trying to change the entire model of care to the whole person care model, which means looking at everything affecting a person’s health and seeing how we can make life better,” Peggs said. “It’s a more inclusive way to practice medicine, as opposed to the old way in which you just tell someone what to do.” That whole person care model also means redefining barriers of care and dismissing the notion of non-compliance. “If you tell me to take a medication, I may not be doing it because I can’t remember, not because I’m non-compliant,” Peggs said. “Providers should be asking, ‘How do we help you?’ That will bring in a new wave of care innovation and help us better serve this population.” A lifelong learner, Peggs recently completed the MBA program at Vanderbilt University’s Owen Graduate School of Business. She’s also a proud mother to two-year-old Robert and fourmonth-old Josette.

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MARCH 2018

Emily Evans, OD, clinical optometrist and dry eye specialist at Loden Vision Centers, discusses Ocular Surface Disease and its prevalence, treatment options, and need for timely intervention in her piece “Dry Eye Diagnosis and Earlier Treatment May Improve Quality of Life.” Richard Wild, MD, FACEP, chief medical officer for the Centers for Medicare and Medicaid Services for Region IV, discusses “10 Things to Do and Know” when it comes to fastapproaching MIPS reporting deadlines.



Driving Community Outcomes

i2i, LifePoint Take Leadership Role in Tackling Social Determinants By MELANIE KILGORE-HILL

As market needs continue to stretch the bounds of electronic health record system capabilities, healthcare companies are finding innovative ways to address social determinants of health common in the most at-risk populations.

i2i Population Health

Science is the driving force behind i2i Population Health, a national leader of population health management technology. Since its founding as i2i Systems in 2000, the company has grown to serve more than 300 clients in 35 states. And while their technology is cutting edge, President Justin Neece said data extraction is just the beginning for the Franklin-based company. “We go through a Justin Neece data analytics process that stratifies patient-level data sets against 150-plus clinical quality measures across 16 national and regional programs such as accountable care organizations, patientcentered medical home, and meaningful use,” Neece said. Patient advocates or care mangers then coordinate care from a clinical level, focusing on patients whose risk factors might include smoking, obesity or chronic diseases. For tobacco users, assistance might come in the form of smoking cessation classes or support groups, while dietary education is often offered for obese patients. Since i2i’s software looks at zip codes by urban markets and classifies populations into food deserts – neighborhoods where fresh, affordable food is scarce – some clients are now bringing food trucks onsite to offer the underserved affordable, fresh food that otherwise might be unavailable. Patients also receive dietary education and tips on how to prepare healthy meals.

Zip Codes & Social Determinants

The company also uses geo tracking to identify social determinants surrounding transportation and housing. “Our clients identify zip codes that look at poverty levels and marry that (data) to show unemployment rates, transportation means, and those who frequently no-show to doctor’s appointments,” Neece said. As a result, clients sometimes offer free van rides from certain zip codes on specific days to provide access to appointments and group education sessions with a whole-health view. On average, i2i clients see a 22 percent increase in establishing contact with patients who fall into these social detriment cohorts. “If you’re an urban medical system with 50,000 patients or more, nashvillemedicalnews


a 22 percent increase in the underserved is a significant improvement,” Neece said.

Growing with the Industry

While the majority of i2i’s 70,000 users represent ambulatory medical sites, the company is now working with payers, as well. BlueCross BlueShield of Tennessee and Amerigroup of Tennessee are among those now using i2i’s service to improve outcomes for Medicaid patients. “Now we’re merging clinical data sets with administrative and claims data on the payer side to optimize cost of care,” Neece said. “It’s not just about driving costs down; it is also improving the quality of care and removing the burden from clinicians’ workflow to drive community outcomes.”

LifePoint Health

Another local company making changes nationwide is LifePoint Health. Chief Medical Officer Rusty Holman,

MD, said the Brentwood-based healthcare company began addressing social determinants seven years ago after being selected to participate in the Centers for Medicare and MedicDr. Rusty Holman aid Services’ Partnership for Patients Initiative as a Hospital Engagement Network. “One of their goals was to find more meaningful ways to engage patients and families,” Holman said. “That was the beginning of our modern quality journey.”

Thinking Outside the Box

While addressing patient safety and readmission rates, LifePoint leaders found the answer to improved patient health lay beyond a hospital’s walls. “We found it was more difficult to make improvements as quickly or effi-

ciently for readmissions as we could in the world of patient safety, which happens within the hospital,” Holman said. That’s because many factors related to readmission are connected to social determinants of health, affordability of care, access to primary care and necessary resources to promote wellness. “Sometimes patients are making the choice between buying groceries or buying their medications,” Holman said. “Housing and nutrition, daily habits and health literacy all are very important factors in determining whether or not someone continues to do well after leaving the hospital, or whether they decline and come back to the Emergency Department.”

Community Coalitions

To that end, LifePoint now oversees more than 30 structured community coalitions across the country … each uniquely different based on community resources (CONTINUED ON PAGE 4)

Better Collaboration Required to Address Social Determinants The last few decades have seen some amazing advances in medical science. However, as organizations like the Centers for Disease Control and Prevention (CDC) point out, genes, biology and health behaviors together only account for about 25 percent of population health predilection. The remaining factors are conditions and By JULIE environment in GOLDBERG, PhD which people are born, grow, live, work, and age … typically referred to as social determinants of health (SDOH). A person’s health is affected by these many factors that extend beyond healthcare alone. For instance, inequitable access to care means that at-risk populations can – and usually do – end up sicker with higher medical costs in the end because of how long it typically takes them to find a source of care. Thanks in large part to better data, there is a much greater understanding of how socioeconomic status, education levels and environmental conditions affect population health. By considering these underlying societal factors and improving access to basic social services available in local communities, there are now some creative efforts underway by government, private sector and nonprofit organizations to “level the playing field” for access to care and services.

Initiatives like the federal government’s Healthy People 2020 - along with efforts in many states and local communities – are making progress to address and reduce inequities. Over the last 30 years, the organization has encouraged collaboration, empowered individuals to make informed health decisions and contributed better data by measuring the impact of prevention activities. The CDC and nonprofits such as The Health Research & Educational Trust (an affiliate of the American Hospital Association) are laying the groundwork by creating guidelines for cultivating community partnerships that can address and improve SDOH. Even as pressure grows for providers to bear greater financial risk for outcomes and many hospitals in the U.S. screen patients for social needs, these screenings are still inconsistent. A recent Deloitte study revealed nearly three-quarters of surveyed hospitals simply don’t have the adequate resources to address patients’ social needs. And even the best care may not lower readmission rates in communities with deep SDOH inequities, underscoring that additional spending alone on healthcare services is not in and of itself a pathway to better health outcomes. Providers and health plans are realizing more and more the critical role information technology plays in addressing overall community health and how data from EMRs, HEDIS and other sources can illuminate social determinants of health for specific populations and communities, giving providers better opportunities to support patient care teams by connecting their

patients and members with local services. Many providers and health plans are partnering with third-party organizations to start communicating across the board and ultimately match patient needs to appropriate community services. Centauri Health Solutions helps to address SDOH with a fully integrated, proprietary platform that provides quick access to a database of more than 200,000 local services and programs. By uncovering social service needs and tracking the referral workflow, case managers can better achieve the intersection point between patients and the services they need. As the American healthcare system approaches 20 percent of the gross domestic product, one thing is clear: meaningful improvement to the effects of SDOH will require sustained collaboration among government agencies, healthcare providers, health plans, and the many organizations filling the needs within communities. Rapidly evolving technology solutions will remain a key element to bring everything together, helping to make healthcare more efficient and accessible to all. Nashville-based Julie Goldberg, PhD, is a product development specialist who applies behavioral research to health technology for Centauri Health Solutions, Inc. She is the author of more than 50 peer-reviewed articles and professional presentations on the psychology of medical decision-making and health outcomes. Goldberg earned her doctorate in social psychology from the University of California, Berkley and her undergraduate degree in sociology and master’s degree in counseling psychology from the University of Pennsylvania. For more information, go online to

MARCH 2018



Assessing and Addressing Detriments to Health in Nashville, continued from page 1

for sidewalks and bikeways to improve outcomes in a city with higher-thanaverage fatalities for walkers and bikers. “We have the highest concentrations of healthcare companies and workers in the U.S., but extremely poor health overall,” said Transportation and Sustainability Manager Mary Beth Ikard with the Nashville Mayor’s Office. “We felt like we needed to take a look at that and make Mary Beth Ikard sure it’s on par with best practices and consistent with the transit plan the city recently adopted.” The commitment is a sizeable one, with $30 million earmarked for sidewalks and bikeways in Mayor Megan Barry’s first year in office. Since then, an additional $5 million has been set aside for the project, and full implementation will require roughly $41 million. On May 1, Mayor Barry is seeking voters’ approval of a transit funding referendum touted as making the city even more conducive to pedestrians and bikes.

(PSN). The PSN will serve as the foundation for the development of the five-year strategic project list. A scoring card helps officials look at each neighborhood objectively based on social detriments such as obesity, safety, health disparities and chronic disease. “We look more strongly at investing in an area where we know we can achieve health goals,” Ikard said, noting the number of carless households also factors into the equation. “Walking is free, and the annual transportation cost for a biker is $700 a year instead of $9,000 or more for a vehicle,” she continued. “For people on limited incomes, walking, biking, and mass transit are the most affordable modes.”

Priority Sidewalk Network


The multi-faceted WalknBike strategic plan was finalized in 2017 and includes changes ranging from new sidewalks and sidewalk repairs to safer bikes lanes and repurposed public space. City leaders are now meeting with council members to establish a Priority Sidewalk Network

Linking Transportation & Lifestyle

“We’re trying to have really informed discussions and engage the community in conversations about these trade-offs … with an understanding that as a growing city, we’ll have to think about how to accommodate transportation means that take up less space than cars and give people health, affordability, and better quality of life,” Ikard said. In 2015, NashvilleHealth was launched as a citywide effort to support a cross-sector of activities surrounding the improvement of overall well being. Three years later, the group is hard at work addressing a variety of social determinants impacting Nashvillians.

Mazzetti+GBA Helps Bring Clean Water to Puerto Rico Mazzetti+GBA believes in building healthier environments to make the world a better place – whether that environment is a hospital in a small Tennessee town or a community clinic in rural Burundi. To carry out that vision in limited-resources settings around the world, the Nashville-based company, which is a global provider of MEP engineering design and technology consulting focused primarily on healthcare and mission critical markets, started the Sextant Foundation. The nonprofit aims to bring health to the world’s people by building environmentally sustainable, affordable healthcare infrastructure where it’s most critically needed. This past November, Sextant volunteer engineers travelled to Puerto Rico after Hurricane Maria’s devastating impact to help assess the community-based water systems around the island with the Department of Health and EPA and to aid other organizations responding to the disaster. Gilbert Duggins and Casey Hester, two engineers from Mazzetti’s Nashville office, were part of that group. Duggins explained his first role in Puerto Rico – “Initially, my mission was to interface with the EPA team, managing the assessment of Non-PRASA water services (PRASA is the water authority that provides water to most urban areas in Puerto Rico). The 230-plus, community-based sites represent somewhere between 5 to 15 percent of the public water service to residents on the island.” The Mazetti team helped prioritize the needs for EPA, FEMA and Non-Government Organizations (NGOs) that would begin restoring the water services. Not surprisingly, the team’s responsibilities and roles changed frequently over the 10 days spent in Puerto Rico. As Duggins noted, “You must be open-minded about what you are going to do. Situations change almost hourly so your mission can and will change. If you aren’t flexible, you may miss a real opportunity to change someone’s life.”



MARCH 2018

“Our city is rich in healthcare capital and experience, but we suffer from serious health inequities among our citizens,” said former U.S. Senator Bill Frist, MD, who helped launch the iniDr. Bill Frist tiative. “NashvilleHealth is bringing together public health, business, government and academia to align resources and move the needle on the shared goal of better population health.”

Infant Mortality

NashvilleHealth has joined forces with more than 70 groups to address infant mortality in Nashville. The Nashville Infant Vitality Collaborative (NIVC) is led by Metro Health Department and Meharry with a goal of making Nashville the best place for babies to be born. “We’re excited to be a part of the NIVC effort, where we seek to address key influencers on infant health,” said NashCaroline Young villeHealth Executive Director Caroline Young, who serves on the NIVC leadership committee. Because 25 percent of infant deaths are sleep related and considered preventable, NashvilleHealth is launching an infant safe sleep public awareness campaign for parents and caregivers. “Nashville partners are working hard to educate about safe sleep, and we’re excited to help amplify that message,” added Young.

Tobacco Reduction

According to the Centers for Disease Control and Prevention, the current rate of tobacco use among adults in Tennessee is 22.1 percent, noticeably higher than the

U.S. rate of 15.1 percent. With a national ranking of 43, Tennessee is among the states with the highest prevalence of smoking adults. Cigarette smoking and exposure to secondhand smoke account for deaths of 11,400 Tennesseans annually, while productivity losses caused by smoking each year equal an estimated $3.6 billion in Tennessee, according to the Campaign for Tobacco Free Kids. Additionally, the organization estimates another $2.67 billion in annual healthcare cost in Tennessee directly caused by smoking. As administrator of the Tobacco-Free Tennessee Coalition, NashvilleHealth is convening more than 25 organizations across the state to strengthen tobacco policies. They also recently supported media efforts related to the state’s “Quittin’ Time” smoking cessation campaign. “If the Tennessee smoking rate dropped to the national smoking rate, then there would be 365,000 fewer people smoking in the state … ultimately giving those people about two million additional years of life,” Frist stated.

Conversations on Health

At the beginning of March, the group partnered with the Metro Public Health Department to launch a speaker series called All In: Conversations on Health in Nashville. The March 2 presentation – which was open to business, community and health leaders – highlighted the correlation between zip codes and overall health. A more detailed report on the inaugural meeting will be featured in the April edition of Nashville Medical News. Young said each presentation would be followed up by small group discussions to continue conversations sparked at the lectureship. A second event is being planned for fall 2018. “We want to bridge Nashville’s health and business worlds so there’s greater networking and awareness of resources we can put toward making our city a great place to live and work,” Young said.

Driving Community, continued from page 3 and needs and comprised of leaders from local organizations. “A common theme we see across all communities is that resources and agencies traditionally have their own missions and purposes but work independently of one another as opposed to working together,” Holman said. LifePoint coalitions are helping to shift that paradigm. In Tennessee, Livingston Regional Hospital’s coalition was established to reduce readmissions when data suggested many return trips to the hospital were preventable. Members also recognized a need for increased education around medications and reconciling long-term prescriptions with drugs prescribed during a hospital stay. In Lake Havasu City, Ariz., hospital readmission rates fell to under seven percent when the local hospital teamed up with paramedics and home health providers to keep people healthier at home. In rural Selma, Ala., a local cab company

joined a group of healthcare providers to help get patients without access to transportation to their medical appointments. Other hospitals have engaged churches, pharmacists, local employers, and support groups to help solve their communities’ health challenges, reduce barriers to care, and make medical services, medication and equipment more affordable.

A New Focus

“One of the biggest revelations for us as we try to address more complex problems in healthcare is that it’s more important than ever to work with partners and view things as a community,” Holman said. “These are community issues rather than healthcare system issues, and that perspective means a great deal in terms of our ability to improve the wellness of a community in general. It’s been very gratifying.” nashvillemedicalnews


Walking in a Patient’s Shoes

Social Determinant Simulation Gives Students, Residents Invaluable Insights By CINDY SANDERS

So much of medical school and residency is focused on identifying disease and prescribing a course of action to address the diagnosis … but what happens when the ‘right’ answer doesn’t mesh with the real world? Helping students and young physicians truly provide patient-centered care was the driving force behind the launch of a unique simulation program created by the University of Tennessee College of Medicine - Chattanooga in cooperation with Erlanger Medical Center. “Walking in our Patient’s Shoes” flips the script by having young medical professionals try to follow ‘doctor’s orders’ while navigating a host of issues ranging from a lack of transportation and funds to unsafe environments and food deserts. Spearheaded by Mukta Panda, MD, MACP, FRCP-London, assistant dean of Medical Student Education and a professor in the Department of Medicine at UT, and facilitated by Erlanger chaplains Greg Daniel, BCC, and Jeremy Lambert, BCC, the popular program started with Dr. Mukta Panda residents in 2011 and was expanded to include medical students in 2014. “A patient with diabetes: you write a prescription, tell them to eat nutritious foods and get 30 minutes of exercise daily … but to a patient living on food stamps who has no transportation and lives in a zip code where it’s not safe outside of the house, that feels impossible,” said Panda. “I found it was really difficult for me to articulate that the patient population we saw really needed a lot more than just writing a prescription or doing a procedure.” Putting providers in patients’ shoes drives home the impact social determinants play on compliance in a way that didactic lectures hadn’t been able to achieve previously. Many medical students and residents, noted Panda, hadn’t personally experienced the types of tough choices faced by a lot of patients seen in clinical practice. The interactive learning experience also helped meet a number of goals for both the university and hospital including fostering holistic, patientcentered care; providing future physicians with enhanced knowledge and tools to improve population health; and addressing key hospital metrics including readmissions and length of stay, which are significantly impacted by adherence to a medical plan. “We took actual patient scenarios, and we flipped the roles,” explained Panda. She added students were given a budget, the exact clinical scenario a de-identified patient presented with prior to admission, and the discharge instructions provided nashvillemedicalnews


to that patient. Other useful details were found in the patient’s social history. “We wanted to teach them a social history taken on a patient is more than just ‘Do you smoke or drink? We also talked to them about spiritual support because spiritual support is one of the important components of holistic care,” Panda continued. Working in teams, the students had to navigate the four weeks of time between discharge and the follow-up appointment, while meeting all the requirements of daily life alongside some unexpected surprises. “Do you pay the rent or the babysitter so you can go to work? Do you not take your insulin this month because the car broke down?” Panda said of the real-world scenarios the teams faced.

She explained the interactive exercise was facilitated by discussions about community resources that might be available to help patients address barriers and rethinking how providers could lay out a treatment plan that more realistically mirrored a patient’s specific circumstances. Other professionals, including a lawyer from Legal Aid, have been worked into the scenarios over the years, as well. “You do not work alone as a physician,” said Panda. “It is truly patientcentered care, and you are the pivot. It’s a partnership between you and the patient and the patient’s family, nurses, pharmacist, chaplain, social worker and all the other care providers that might be involved in the care,” she enumerated. While the foundational seminars are comprised of 60- to 90-minute sessions, Panda said the lessons learned are applied daily. The teams also meet each weekday for about 15 minutes at the end of their interdisciplinary rounds to discuss action plans and coordinated care. “The learning from this seminar is reinforced every day,” said Panda. “It’s become a part of the culture.” Not only has the course continuously received overwhelmingly positive responses from participants, but the impact of the seminar also was evident in an informal research format. Using a control group of young medical professionals in Middle Tennessee who had not taken the seminar or had involvement in the interdisciplinary rounds, Panda said the Chattanooga stu-

dents and residents had significantly higher empathy scores. ”They’ve changed the way they actually see their patients and take their patient’s histories,” she said of those completing the course. A vocal advocate for holistic care, Panda said it’s equally important to look at a patient’s spirituality and how that impacts patient care and satisfaction. When patients are seen as spiritual beings in a human body, she continued, the shift in perception has also been shown to enhance physician engagement while decreasing burnout. “The programs we are talking about are all about the human connection and looking at that person as a human being and not just as a patient with diabetes,” Panda said. “In today’s healthcare environment, one of the important aspects of our vocation as healthcare providers is to reignite the joy of medicine … and that will only happen if we reignite the reason we went into medicine in the first place,” she concluded. The unique University of Tennessee College of Medicine – Chattanooga program was recently featured as part the Tennessee Center for Patient Safety Leadership Summit, which highlighted successful initiatives fostering an organizational culture of excellence, quality and patient safety. The TCPS, a department of the Tennessee Hospital Association, develops and shares hospital and health system success stories and promotes best practices.

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MARCH 2018



Field of Vision

News of Note in Ophthalmology Gene Therapy Approved for Inherited Blindness

Last December, the Food and Drug Administration unanimously approved a new gene therapy to treat a rare cause of inherited blindness. Delivered via subretinal injection, the treatment is designated for adults and children with confirmed biallelic RPE65 mutation-associated retinal dystrophy, which can lead to blindness. Luxturna (voretigene neparvovec-rzyl) by Spark Therapeutics delivers a normal copy of the RPE65 gene directly to retinal cells, which then begin producing the normal protein that converts light into an electrical signal in the retina and restores vision loss. Luxturna uses a naturally occurring adeno-associated virus, which has been modified using recombinant DNA techniques, to deliver the normal RPE65 gene to the retinal cells. At the announcement, FDA Commissioner Scott Gottlieb, MD, said “Today’s approval marks another first in the field of gene therapy — both in how the therapy works and in expanding the use of gene therapy beyond the treatment of cancer to the treatment of vision loss — and this milestone reinforces the potential of this breakthrough approach in treating a widerange of challenging diseases. The culmi-

nation of decades of research has resulted in three gene therapy approvals this year for patients with serious and rare diseases. I believe gene therapy will become a mainstay in treating, and maybe curing, many of our most devastating and intractable illnesses.” While this specific RPE65 mutation impacts between 1,000 to 2,000 patients in the United States, there is a broad spectrum of inherited retinal dystrophies that result from mutation to any of the more than 220 genes associated with various conditions. The hope is additional gene therapies will be developed to address other forms of inherited vision loss. Gottlieb stated, “We’re at a turning point when it comes to this novel form of therapy and at the FDA, we’re focused on establishing the right policy framework to capitalize on this scientific opening.” Luxturna received Orphan Drug designation, and the therapy was approved under Priority Review and Breakthrough Therapy status, which are designed to get novel treatments through the pipeline more rapidly. For patients with confirmed biallelic RPE65 mutation-associated retinal dystrophy, a cause of Leber congenital amaurosis (LCA), vision loss typically starts in infancy and progressing to com-

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plete blindness. With Luxturna, billions of modified viruses are injected into both eyes. The FDA approval noted Luxturna should only be given to patients who still have viable retinal cells as determined by a treating physician. Efficacy of the therapy was demonstrated among patients ages 4 to 44 with the primary evidence coming from a Phase 3 study that utilized an obstacle course bathed in varying light levels to measure improvement over baseline in the ability to navigate the course in those receiving active treatment. Data from the first randomized, controlled, Phase 3 study showed that 27 of 29 treated patients (93 percent) experienced meaningful improvements in their vision, enough that they could navigate a maze in low to moderate light. They also showed improvement in light sensitivity and peripheral vision, which are two visual deficits these patients experience. While treatment didn’t restore normal vision, patients were able to see shapes and light, which allowed them to get navigate without a cane or a guide dog. Although it is unclear how long the treatment will last, most patients had maintained their improvement at the two-year mark. Eye redness, cataract, increased intraocular pressure and retinal tear were the most common adverse reactions with the treatment. With the Luxturna approval, Peter Marks, MD, PhD, director of the FDA’s Center for Biologics Evaluation and Research, noted, ““Patients with biallelic RPE65 mutation-associated retinal dystrophy now have a chance for improved vision where little hope previously existed.”

Local Ophthalmologist Runs for Senate Seat

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Local physician and eye surgeon Rolando Toyos, MD, announced his candidacy for U.S. Senate last fall as part of the Republican field running to replace Sen. Bob Corker’s open seat.. Toyos – who founded the Toyos Clinics in Nashville, Franklin, Memphis Dr. Rolando Toyos and Southaven, Miss., alongside his wife and business partner Melissa Toyos, MD – earned his undergraduate and master’s degrees from the University of California, Berkley and his medical degree from the University of Illinois. He completed his internship in internal medicine at Illinois Masonic Hospital in Chicago and his ophthalmology residency at Northwestern University and Chicago Children’s Hospital. The son of Hispanic immigrants, Toyos spent time as a high school teacher prior to medical school, winning the

National Teaching Award from Columbia University for his science curriculum development for at-risk students. With his background in medicine, research and entrepreneurship, Toyos has penned several blogs regarding his vision for healthcare system reform and thoughts on the expansion of HSAs to address access issues.

Visionworks Announces New Springhill Location

In late February, Mark Lynn, OD, & Associates PLLC announced the opening of the newest Visionworks location in Springhill at Crossings Circle. Lynn owns and/or operates more than 90 Visionworks locations in offices in Kentucky, Georgia, Missouri, Tennessee, Mississippi and Indiana. “Nashville and the surrounding area has been a great market for us so far, and we’re looking forward to servicing more patients in this area.” said Lynn. This newest center joins 11 others located throughout Middle Tennessee including sites in Cool Springs, Gallatin, Hendersonville, Mount Juliet, Murfreesboro and Nashville.

Vanderbilt Focuses on Eye Care for Ebola Survivors

Last month, Vanderbilt Eye Institute (VEI), Vanderbilt University School of Medicine (VUSM) and Vanderbilt Institute for Global Health announced a new initiative with partners in Liberia to strengthen medical education and increases access to ophthalmology services. In the aftermath of the West African Ebola epidemic that killed more than 11,000 people, a significant number of survivors have faced eye inflammation and vision loss caused by the virus. Currently, survivors with vision issues have limited access to specialists and treatments that could reduce swelling and might suppress viral growth. In an effort to meet that need, Vanderbilt is partnering with the Liberian College of Physicians and Surgeons to develop a new, fully accredited ophthalmology residency training program and to build institutional, as well as research, capacity at the University of Liberia’s A.M. Dogliotti College of Medicine in the capital city of Monrovia. “This grant will provide critical ophthalmic training in an underdeveloped part of the world that has proven to be highly vulnerable to the devastating effects of eye disease,” noted Paul Sternberg Jr., MD, director of VEI and chief medical officer for Vanderbilt University Medical Center (VUMC) The program will be supported by a PEER grant (Partnership for Enhanced Engagement in Research), which is implemented by the National Academies of Science, Engineering and Medicine. nashvillemedicalnews


BlephEx: Advanced, Office-Based Procedure for Chronic Eyelid Irritation & Dry Eye A breakthrough technology, BlephEX® is now available to treat chronic dry eyes and eyelid infection (blepharitis). Wang Vision 3D Cataract & LASIK Center was among the first in the state to introduce the treatment system, which has corporate offices in nearby Franklin. Blepharitis is a common condition affecting the By MING WANG, eyelids. Symptoms MD, PhD of blepharitis may include redness, irritation, itching, crusting, matting, dry eye, and foreign body sensation affecting the eyelids or the eyes. It can lead to fluctuation and intermittent blurred vision. Epidemiology research has indicated that 86 percent of people with dry eye have concurrent blepharitis. Over 25 million people in the United States are affected by the condition. There are many different causes of blepharitis, but all result in irritation and a mild chronic infection of the eyelids. Blepharitis is generally caused by excess bacterial flora along the eyelids with the

most common offender being Staphylococcus aureus. Small parasitic mites called demodex can also lead to this condition. Infestation of and waste products from infectious bacteria and ocular mites can cause blockage of the eyelid follicles and glands, resulting in a chronic inflammatory response. The mild chronic infection leads to scurf or crusting along the eyelids. Because the eyelids can be difficult to clean, the bacteria create a biofilm, similar to plaque on teeth. This biofilm creates a safe harbor for the organisms, which can lead to chronic inflammation and result in a destruction of the delicate eyelid structures. Long term, this destroys the integrity of the meibomian glands – oil glands that vertically line the eyelids – leading to poor tear production and chronic dry eye. Traditional treatments for blepharitis include at home therapies targeted at cleaning the eyelid margin with gentle cleansers such as OcuSoft cleansers, or baby shampoo. Patients are directed to apply a small amount and gently massage along the eyelids for about 15 seconds, one to two times daily. Patients generally see improvements in treatment of the condition if they are diligent about completing the home therapy. Much like dental flossing, the benefits can be significant, but it

does take dedication and habit forming. Recent advancements in treatment condition indicate office treatments have more effect than at home remedies, as complete cleaning and patient compliance can be a significant issue. The in-office cleaning procedure called BlephEx is a new and effective treatment for blepharitis. With BlephEx, trained office staff can eliminate the buildup of bacteria and parasites along the eyelids, using a small, sterile sponge that is first soaked in a gentle eyelid cleanser. The eyelids are then microexfoliated by a special instrument that rotates at 3,000 times per minute to debride the biofilm. The treatment is fast, taking about six to eight minutes. It is non-invasive and painless, with most patients simply report a tickling sensation along the eyelids. Patients can resume all normal activities immediately following the treatment. Side effects are very mild and could include mild redness or irritation of the eyelids, which would last less than 24 hours. For most, no side effects occur and relief is obtained almost instantaneously. An initial treatment will often provide significant relief that can be equal to several weeks of diligent home therapy. Results will last differently depending on severity of the condition. Similar to dental hygiene, buildup

will reoccur. In-office treatments are recommended every three to six months, followed with regular at home treatments to maintain the surface and control the condition. This treatment can often be a very beneficial solution for patients suffering from chronic eyelid irritation or dry eye. Often, these patients have exhausted a significant amount of over-the-counter and prescription treatments without finding sufficient relief. The deep cleaning of the eyelids can help the get the production of tears into a healthy equilibrium, and many patients see significant improvement not realized with other treatments. The procedure is not covered by insurance, but the cost is low in comparison to many alternative treatment options, and patients generally report the benefits worth the out of pocket expenses. Dr. Ming Wang, Harvard & MIT (MD, magna cum laude); PhD (laser physics), is the CEO of Aier-USA, director of Wang Vision 3D Cataract & LASIK Center, and one of the few laser eye surgeons to hold a doctorate degree in laser physics. He has performed more than 55,000 procedures, including on over 4,000 on doctors. For more information, email drwang@ or go online to

It’s time to get back to your bucket list. F

or more than 45 years, NHC has provided quality, rehabilitative care to people of all ages. With skilled therapists and decades of experience providing compassionate post-surgical care in locations close to home, you can get back to what’s important to you. So what’s first on your list?

Discover NHC and get back to life. Visit to learn more about our rehabilitative care services, to explore our full range of services and to find the NHC nearest you. To learn more about our homecare services, visit ©2017 NHC 23664




MARCH 2018



Something to Smile About

Meharry Launches Mobile Dentistry Clinic

In February, Meharry Medical College launched a mobile dentistry clinic to bring critical dental services to patients living in underserved areas across the state. With the announcement, Meharry became the first academic institution in the state of Tennessee to own and operate a mobile dentistry unit. “Tennessee is facing a serious oral health crisis,” said Meharry Medical College President and CEO James E.K. Hildreth, PhD, MD. “According to HRSA,

only 29 percent of our state’s dental health needs are met because there is a shortage of dentists. This makes it difficult for Tennesseans to receive even the most basic dental services. By launching this Dr. James Hildreth mobile dentistry clinic, we are further delivering on our mission of serving the underserved by providing care to those who need it right in their own hometowns.”

Students and faculty of the Meharry School of Dentistry and members of the Meharry Board of Trustees joined Hildreth at a recent ribbon-cutting ceremony to celebrate the launch of the mobile clinic. Hildreth expressed gratitude to the United Methodist Church, which helped fund the purchase of the clinic with a $300,000 grant, and to the Elgin Children’s Foundation of Knoxville, which sold the mobile clinic to Meharry and shares the college’s mission to provide dental care to the underserved. The mobile clinic will be staffed by

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MARCH 2018

third-year dental students with faculty oversight. It is fully equipped with four dental chairs, a portable x-ray machine and office space. All treatments and exams typically given at a dental practice will be available to patients at the mobile clinic at reduced rates. The clinic also will accept most forms of insurance. The clinic is already travelling to facilities across Tennessee to provide on-site care to children who are in state custody. In coming months, Meharry will also unroll a schedule of clinic stops at churches and senior centers in communities across the state with a shortage of local dentists. Specifically, Meharry will focus its outreach on communities in Appalachia in East Tennessee where the population faces the largest disparities in the nation when it comes to oral health. “Poor oral health has been directly linked to some of the most vexing diseases in our nation, including heart failure, diabetes, strokes and even premature, low-birth weights,” said Cherae FarmerDixon, DDS, dean of Meharry’s School of Dentistry. “With the mobile health clinic, our students can now meet patients right where they are and provide critical dental services that they desperately need. We also Dr. Cherae will be partnering with Farmer-Dixon area dental practices to ensure that those who visit in the mobile clinic have options for follow-up treatment should they need it.” Farmer-Dixon said service on the mobile clinic would prepare students well for their future careers. Many of Meharry’s dental students will practice in communities similar to those the mobile clinic will be visiting. Of its alumni, more than 83 percent of Meharry School of Dentistry graduates practice in underserved areas and nearly 18 percent of all dental alumni set up practice in Tennessee.

UTHSC Helps Kids Keep Smiling

Last month, the College of Dentistry at the University of Tennessee Health Science Center participated in the American Dental Association’s annual “Give Kids a Smile Day.” Partnering with Freedom Preparatory Academy Charter School in Memphis, the College of Dentistry provided 1,105 procedures to more than 80 children valued at $22,188. Give Kids a Smile Day was launched in 2003 by the American Dental Association to provide free dental services to children through the help of volunteers. The UTHSC College of Dentistry has participated in the national event for five years. “This event is a win-win for both the College of Dentistry and the community,” said John Seeberg, DMD, associate dean for Clinical and Extramural Affairs. “Our students are able to receive credit toward their degree for the dental procedures performed, and we are able to provide a much needed service to children in our community.” nashvillemedicalnews


DOJ Formalizes New Approach to Frivolous Qui Tam Actions Last month we reported that Michael Granston, director of the Civil Fraud Section of the Department of Justice (DOJ), made comments during a November 2017 healthcare compliance conference suggesting that in cases where the DOJ has determined allegations in a qui tam (or By J. MATTHEW “whistleblower”) KROPLIN lawsuit lack merit, the government might more aggressively exercise its statutory authority – rarely used in the past – to dismiss such cases. In a formal memorandum released on Jan. 10, 2018, Director Granston put those & ADAM W. words to action. OVERSTREET In his memo, Granston acknowledges that although the DOJ has seen “record increases” over the last few years in qui tam actions filed under the

False Claims Act, it has “sparingly” utilized its authority to dismiss those lawsuits following its decision not to intervene. As a result, the government has “expend[ed] significant resources” in continuing to monitor these cases. In light of that, the memo encourages prosecutors to more carefully consider the prospect of dismissing qui tam lawsuits where the government opts not to intervene (which, as explained last month, occurs in approximately 75 percent of these cases). The memo then identifies seven factors that prosecutors should consider when evaluating whether to seek dismissal: Curbing meritless qui tam lawsuits – where the complaint is “facially lacking in merit” because of a defective legal theory or frivolous factual allegations; Preventing parasitic or opportunistic qui tam lawsuits – where the lawsuit duplicates a pre-existing investigation and adds no useful information to the investigation; Preventing interference with agency policies and programs – where an agency has determined that a qui tam lawsuit threatens to interfere with the agency’s policies or the administration of its program and has recommended dismissal to avoid these effects; Controlling litigation brought on behalf of the government – when necessary to protect the DOJ’s litigation prerogatives;

Safeguarding classified information and national security interests – particularly in cases involving intelligence agencies or military procurement contracts; Preserving government resources – when the government’s costs are likely to exceed any expected gain, such as when the estimated government losses are less than the anticipated burden imposed on taxpayers by continued governmental participation even when the relator advances the litigation; and Addressing egregious procedural errors – where there are problems with the relator’s lawsuit that frustrate the government’s efforts to conduct a proper investigation, such as when the relator fails to serve the qui tam complaint or disclose material facts to the government. The memo goes on to provide other practical guidance to prosecutors and, among other things, advises that the seven factors are not exhaustive, and there may be other factors that could be considered in determining whether to dismiss a case. The memo reminds prosecutors that they can seek partial – as opposed to wholesale – dismissal of qui tam complaints and also instructs prosecutors to “consider advising relators of perceived deficiencies in their cases, as well as the prospect of dismissal” so that relators could consider dismissing the lawsuit on their own. According

to the memo, since January 2012, relators have dismissed over 700 qui tam lawsuits voluntarily after learning that the DOJ was declining to intervene. The Granston memo is significant because it marks the first time in the DOJ’s history that it has issued written guidance on this matter. As a result, healthcare providers who find themselves defending a meritless qui tam action now have a blueprint – through the DOJ’s seven guideposts – in arguing for its dismissal. Although the practical impact of the memo remains to be seen, at the very least it reflects the DOJ’s willingness to dismiss burdensome and frivolous whistleblower lawsuits. In the end, it might turn out that the memo will not result in many more dismissals by the DOJ itself, but rather in more voluntary dismissals by relators who learn of the “perceived deficiencies in their cases” and the “prospect of dismissal.” Either scenario would be welcome news to healthcare companies that spend millions of dollars every year defending meritless whistleblower lawsuits. J. Matthew Kroplin is a partner in Burr & Forman’s Nashville office, practicing in the firm’s healthcare and business litigation sections. Adam W. Overstreet is counsel in Burr & Forman’s Birmingham office, practicing in the firm’s healthcare section, and is a former Assistant United States Attorney.

The Administrative Viewpoint By CINDY SANDERS

What keeps practice administrators up at night? The list is long as practices strive to deliver the highest quality of care while making enough money to keep the doors open and complying with a long, complex list of regulations. MIPS remains a chief concern for many as practices move to the new quality payment program for Medicare enrollees. The Merit-based Incentive Payment System is the next evolution in the move away from fee-for-service and towards a valuebased system of care. Joy Testa, practice manager for Nashville Family Foot Care, PLLC, said the physicians in her practice recognize the value in federal programs that Joy Testa shift the focus towards quality metrics. “We’ve always been on board for all of these processes, but it’s a lot of work,” she said. Ironically, she added the team has to keep watch to make sure keeping up with new regulations doesn’t inadvertently wind up taking time away from patients. Testa, who also serves as president of the Nashville Medical Group Managenashvillemedicalnews


ment Association (NMGMA), said her practice reported for a 90-day period for 2017. “We’ve done two of the three portions,” she said, adding the third portion on quality is in process through their clinical EMR system. “We won’t have a payment reduction,” she noted. With today’s tight margins, she continued, “We want to be cognizant of the fact that we don’t want to lose any revenue opportunities.” From the quality standpoint, Testa said the practice welcomes the clinical decision support embedded in their eClinicalWorks EMR system. For example, she noted, every diabetic patient should receive patient education so it’s nice to have that extra reminder pop up on the dashboard. “These are things that are relevant to the patient and relevant to their care,” she pointed out. For Kathi Carney, CPC, CPMA, CPC-I, a billing and coding specialist and member of the NMGMA Board, payment issues stemming from prior authorizations and third party payers have become increasingly frequent. “In line with that has Kathi Carney been the ever-changing payment structure,” she noted. “How do you continue to make your practice thrive

when reimbursement rates are going down and costs continue to increase? How do you stay on top of changing regulations and keep the staff informed?” she questioned. Like Testa, she relies on the automation of an electronic health system to pull key data for reporting and said she couldn’t imagine how difficult and time intensive it would be to capture required data without an EMR. “There are a lot of choices to decide what works best for your practice,” she pointed out. “Often, it requires a consultant to come in and drill down to see what’s best.” Despite Carney’s professional focus on the revenue cycle, she was quick to say that practices can’t always worry solely about the money aspect but must strike a balance between patient experience and revenue. “Ultimately it comes back to your patient, patient care and patient experience … but really it’s all tied together,” she said. “You want to be respectful of your patient’s time, and it costs a lot more to be inefficient. The best patient care at the lowest cost … that’s the ultimate goal.” Another issue practice managers face is the sheer breadth of their job description. “Practice managers wear so many hats these days,” said Testa. It’s one of the reasons she finds organizations like NMGMA so valuable. With a motto of ‘meet, learn,

grow,’ Testa said the organization delivers on all three. “If you’re having a rough day, you have someone to talk to who understands,” she noted of the relationships built through the monthly meetings. The educational component is another huge factor for attendees. In upcoming meetings, NMGMA will welcome speakers from the Office of the Inspector General to discuss compliance issues and from Palmetto GBA, the state’s new Medicare Administrative Contractor. Participation also helps practice managers grow their careers by earning continuing education credits towards board certification from the national organization. “It’s hard to get away from the office, especially when you have a small practice,” Testa said from experience. “But once you are away and have a minute to yourself, you hear something useful and are able to bring that back to the practice. That’s what stood out to me when I first started coming to NMGMA.” Carney agreed, saying it was important for administrators to become involved in their local and national specialty organizations, including NMGMA. “You have to keep your finger on the pulse somehow, and I think one of the best ways is to stay involved with your professional community.” MARCH 2018



NMGMATen Minute Takeaway Best Practices for the Hiring Process By CINDY SANDERS


The second Tuesday of each month, practice managers and healthcare industry service providers gather for the monthly Nashville Medical Group Management Association (NMGMA) meeting. In February, Concept Technology Founder and President James Fields discussed building a balanced company culture that begins with smart hiring. For Fields, he said company decisions had to balance the needs of clients, the team, and business. “If James Fields one of those is going to take a substantive hit, then it’s probably the wrong thing to do,” he said. Building a great corporate culture, Fields continued, starts with the right people. “The culture of any company is the grand total of everything that’s said,

every action taken,” he noted, adding that if you have the right people onboard, then 80 percent of your problems are already solved. Smart Hires For Concept Technologies, the hiring process has become a science. Starting with a large group of source candidates from a job posting, applicants are narrowed down through a brief, basic online technology quiz. From those candidates, around three dozen might be invited to come to the office for a more in-depth technical exam that still takes only about 10 minutes. In addition to the skills assessment, Fields said the team observes whether or not the candidate arrived on time, was engaging, and dressed appropriately. Narrowing the field again, about a dozen might receive a first interview and just over half be invited back for a second interview and advanced technical evaluation. There are several key elements of


Last month, the American College of Healthcare Executives of Middle Tennessee presented “The Healthcare Leader’s Role in Preparing for the Unthinkable” in collaboration with the Middle Tennessee chapter of the Organization of Nursing Executives (MT-ONE). The event, held at the Tennessee Hospital Association’s headquarters in Brentwood, drew a record turnout of leaders despite inclement weather. In light of recent disasters and national events, this program turned out to be extremely timely. John Morris, MD, associate chief of staff for Vanderbilt Health Systems, discussed ways that healthcare leaders could prepare for disaster management and mass casualty events. He addressed many areas of concern, including the importance of business continuity, avoiding disruption, supply chain concerns, and even tapping into different forms of transportation – such as utilizing Uber and Lyft – to get adequate staff to work. Morris also emphasized the importance of documentation in crisis management, discussing cost, probability, solution implementation, and rationale documentation. Chris Clarke, senior vice president of Clinical Services for the Tennessee Center for Patient Safety, which is a department of the THA, served as panel moderator and led a dynamic conversation about action in the face of adversity. Susan Peach, CEO of Sumner Regional Medical Center, offered a personal recollection of the terrifying events that unfolded during an active shooter incident last spring and 10


MARCH 2018

shared some surprising revelations as a result of that incident. The group explored free services from the local police department available to all healthcare leaders to evaluate facilities for safety and points of vulnerability to increase security and safe guard against a future event. HCA’s Michael Wargo further contributed to the discussion with his knowledge about best practices and policies regarding perimeter security. He brought a wealth of information about situational awareness and behavioral patterns to watch for when a potentially volatile situation could erupt. Wargo covered scenarios surrounding active shooters as a result of domestic violence, as well as the importance of addressing the needs of family members during stressful events to reduce mass panic.  A “sympathy and sandwich committee” is essential to communicate with the members of the community that will naturally want updates regarding anyone caught in the crossfire of a mass casualty, natural disaster, or active shooter situation. John Benitz, MD, MPH, medical director of the Tennessee Department of Health for Emergency Preparedness, shared excellent resources for healthcare leaders in terms of financing a disaster plan.  He revealed grant opportunities and healthcare coalitions to help pay for improvements for a safer work environment.  He also guided the group to the CDC for ultimate best practices for healthcare leaders during a disaster. The next meeting, scheduled for March 22, will focus on the opioid epidemic. For more information, go online to

smart hiring, Fields said. The first is to know your numbers – they often process more than 300 applications before hiring one superstar team member. Next, he continued, “We require a little work at every stage of the interview.” His third tip, as you move through to a smaller group of candidates, is to keep them longer than an hour. “Anyone can keep their game face on for an hour,” he pointed out. The team also conducts group interviews as the candidate pool narrows down. “The purpose of the group interview isn’t to vet skills, it’s to vet culture fit,” Fields noted. Finally, the candidate is assessed for HCV – humility, curiosity, and vulnerability. “We need people to lean in and actively participate in business,” he said, adding the curious person might come to the table and question processes in an effort to find ways to work better whereas a critic only comes to the table to shoot down options. Best First Day After going through all the work to find the right person, Fields said companies too often drop the ball when it comes to onboarding. “New hires are confused by how you work. Take time to explain to them,” he said, adding effective onboarding equals greater productivity and longevity. Excited about joining the team, how often have new employees walked into an office where they instantly felt awkward and unsure? A new job is much like the

first day at a new school where everyone else already knows each other and the routine. To integrate new team members from the start, Fields said his company has a welcome banner to greet the new employee, has their desk already outfitted with the items that will be needed, business cards are ready, an account list is printed out, and lunch plans with colleagues have been set. “These are all things you have to do anyway, just do it before the person’s first day,” he advised of setting a welcoming tone and reinforcing a positive corporate culture.

NMGMA in March The next meeting – scheduled for 11:30 am-1 pm on Tuesday, March 13 at KraftCPAs – features a presentation on “Why Social Engineering Succeeds” by an expert with Sword and Shield. For more information or to register, go online to Practice managers interested in attending a luncheon to learn more about the organization and educational topics, should email NMGMA President Joy Testa at joytesta@ to register for their first meeting as a guest.

LHC Travels to D.C. for Annual Delegation By MOLLY VICE

This month, Leadership Health Care (LHC) – an initiative of the Nashville Health Care Council – will lead its annual delegation to the nation’s capital. The event, now in its 16th year, offers an exclusive opportunity for LHC members to hear directly from members of Congress, Administration officials and national thought leaders on the most pressing topics in healthcare policy, federal healthcare spending and reform implementation, among other issues. The 2018 delegation will begin on Monday, March 12 with keynote speakers Dan Diamond, reporter for Politico, who will deliver the opening keynote address, and Chris Stirewalt, politics editor for Fox News, who will give the dinner keynote address that evening. Other confirmed speakers include Andrew Bremberg, assistant to the president and director of the White House Domestic Policy Council, U.S. Congressman Jim Cooper (D-TN),

U.S. Congressman Marsha Blackburn (R-TN) and Wilson Compton, MD, MPE, deputy director of the National Institute on Drug Abuse. These speakers, along with others, will discuss topics such as the administration’s view on healthcare, how health policy is influencing business strategies, the role of healthcare information technology and the national opioid crisis. LHC is designed to nurture the talents of emerging healthcare leaders with unique educational programs and networking opportunities like the annual delegation to Washington, D.C. Nearly 900 up-and-coming healthcare industry leaders from 330 companies are members of LHC. The April edition of Nashville Medical News will include a recap of the 2018 event. Molly Vice is director of Leadership Health Care, an initiative of the Nashville Health Care Council. To learn more, visit www.



Making Sense of MACRA Develop a Plan to Address Updates for 2018 Reporting The Medicare Access and Chip Reauthorization Act (MACRA) was signed into law in 2016. Less than a year later, clinicians were expected to begin reporting. During the transition year (2017), the Centers for Medicare and Medicaid Services (CMS) allowed eligible clinicians to “pick their pace” for reporting into the quality payment program (QPP). Now, for 2018, cli- By JESSICA BENSON nicians must provide a full year of reporting on these measures. To add another layer of complexity, CMS has released new changes and updates for this year. An action plan put in place sooner, & DANIELLE rather than later, TRIBOUT can help ensure proper reporting.

Changes for 2018

Small Practice Relief For small practices (groups of 15 or fewer clinicians), changes for 2018 could bring about some relief from the previous reporting requirements. • The virtual group option is now available, giving solo practitioners and small practices the choice to form or join a group to participate in the Merit-based Incentive Payment System (MIPS) with others. • The low-volume threshold has been extended to exclude individual MIPSeligible clinicians or groups with less than or equal to: ° $90,000 in Medicare Part B allowed charges, or ° 200 Medicare Part B beneficiaries. Five bonus points will automatically be added to the final score of small practices. Practice Management Tip: Whether your practice has decided to report as a group or as individual clinicians, be sure to check all clinician eligibility through the MIPS Participation Status ( site to confirm if the clinicians in your practice are required to submit data to MIPS each year.

Performance Category Updates As CMS moves towards full implementation of the QPP, many of the transition-year policies have been extended to allow for gradual implementation and further prepare clinicians for full implenashvillemedicalnews


mentation in 2019. • The cost performance category is being introduced and will hold a weight of 10 percent of the MIPS final score. For the current reporting year, no action is required by clinicians — CMS will calculate cost measure performance. Look for further guidance on reporting in 2019 to be released towards the end of this year. • With the introduction of the cost performance category, the MIPS score is now comprised of the following: ° Quality - 50 percent ° Cost - 10 percent ° Improvement activities - 15 percent ° Advancing Care Information (ACI) - 25 percent • The ACI category carries the same weight of composite score as it did in the 2017 transition year, and the requirements to achieve the base score in the ACI category remain the same. However, there are additional ways to earn bonus points in this area during the 2018 performance year. ° Practices can earn a 10 percent bonus to their ACI score by exclusively using 2015 Certified Electronic Health Record Technology (CEHRT). ° Reporting to any single public health agency or clinical data registry can result in a 10 percent boost in the performance score, up from the 5 percent available in 2017.

° Lack of control over the availability of CEHRT Practice Management Tip: Clinicians who qualify can apply for a hardship exemption by visiting qpp. Applications may still be submitted for reporting year 2017 through March 31, 2018. Applications for 2018 will be available once the 2017 submission period has closed.

Exclusions Clinicians who may not meet the requirements for reporting ePrescribing and Health Information Exchange (HIE) measures can still qualify for the 2017 exclusion established by CMS. • The ePrescribing measure requires reporting when at least one permissible prescription written by a MIPS-eligible clinician is queried for a drug formulary and transmitted electronically using CEHRT. ° If an eligible clinician writes fewer than 100 permissible prescriptions during the performance year, they are excluded from the ePrescribing measure. However, if the clinician is participating in MIPS as part of a group, the group must qualify the same way to be eligible for this exclusion. • For the HIE measure, a MIPSeligible clinician who transitions or refers

a patient to another health provider or setting of care must (1) use CEHRT to create a summary of care record and (2) electronically submit the summary to the receiving provider. ° If an eligible clinician transfers patients to another setting or refers patients to other providers fewer than 100 times during the performance period, they are excluded from the HIE measure. However, if the clinician is participating in MIPS as part of a group, the group must qualify the same way to be eligible for this exclusion.

Action Plan 2018

For many eligible clinicians, 2018 will be the first year of full reporting. To ensure the highest incentive potentials, it’s essential for practices to develop an action plan to meet CMS requirements. Some proactive steps to consider for 2018: • Determine the level of MIPS eligibility and ensure clinicians do not fall under the low-volume threshold. • Review performance categories. ° Narrow down the quality measures that clinicians are frequently reporting. (Clinicians must report on six measures.) • Review current improvement activities. (More than 100 activities in nine sub(CONTINUED ON PAGE 12)

Practice Management Tip: There is no specific information available to the public related to CEHRT requirements for the 2019 performance year and beyond. However, one could surmise that it may become required in the future. Thus, it is recommended that practice administrators and clinicians proactively consult with their technology teams to map out a course for 2015 CEHRT integration. These types of transitions can be more difficult to schedule (and end up being costlier) when performed after a requirement is announced.

Hardships & Exemptions For the 2017 transition year, CMS allowed for the exemptions of extreme and uncontrollable circumstances, including natural disasters and public health emergencies. Unfortunately, numerous clinicians were affected in 2017. As a result, CMS has extended the application for both the transition year and the 2018 reporting year. • In 2018, clinicians in FEMA-registered disaster areas may submit a hardship application for the re-weighting of all three performance categories (quality, cost, and improvement activities). • MIPS-eligible clinicians may also submit a hardship exemption to be considered for re-weighting of the ACI performance category. Eligibility for this exemption includes: ° Insufficient internet connectivity MARCH 2018



Password Protected, continued from page 1 the attention of cyberthieves. Augenbaum noted, “Nobody ever expects to be a victim.” He added that many healthcare providers believe larger health systems or insurers are at greater risk than a small practice or payer … but security is often easier to breach at smaller organizations. 2) They don’t think they have anything of value to hackers. “I don’t hear this as much in the practices but do from insurers and consultants. Even without patient records, they have financial records and emails,” he noted. 3) A mistaken belief that law enforcement can fix it. “When the bad guys steal your stuff and you call law enforcement, law enforcement doesn’t get your stuff back,” he said of the impossibility of recovering data after it’s gone. 4) “The chances of us putting the bad guys in jail are tougher than getting your stuff back,” he said, adding that most bad actors are overseas. While points one through four are depressing, Augenbaum said the last common trait is the hardest for him. “Why does it make me depressed? Because 90-95 percent of what I have dealt with could have been prevented without spending money on technical solutions.”

Learn More at AAHAM Scott Augenbaum is one of the expert speakers slated for the upcoming American Association of Healthcare Administrative Management one-day educational meeting in Nashville. The Music City AAHAM 2018 Conference is set for April 18 at the Envision Conference Center in Brentwood. For more information, go online to and click on the Events section.

steps, he continued, cost almost nothing but go a long way in protecting a medical practice or healthcare company.

Password Protected

So what does a strong password look like? Augenbaum said, for starters, it isn’t a common word. “A good password is 12 characters, upper/lowercase, has a special

symbol and number with no dictionary words,” he explained. To come up with a great, seemingly random password, think in terms of ‘pass phrases’ with a hint that can be written down without tipping off the password to a random viewer. For example, your hint might be ‘my child’s latest accolade.’ The actual phrase from which the password is derived is: ‘Tommy came in first at the state swim meet in backstroke.’ And, the actual password is: Tci1@Tssmib! Another option is to pick a special number and character that you use at the beginning and end of most passwords and just change the center part. Perhaps you always use the number four and the # symbol. Your hint is how you feel about your patients. Your actual pass phrase is ‘We love helping our patients feel great,’ and your password is #4wLhopfG4#. The idea, he continued, is to create hints and phrases that mean something to you but would be difficult for anyone else to decipher. Taking a few simple, inexpensive steps, Augenbaum concluded, can certainly avoid a lot of time, effort, heartache and money by making it much harder for cyberthieves.

Some (Slightly) Better News

While companies buy a lot of tech products that are supposed to keep them safe, there is no real silver bullet, cautioned Augenbaum. “People are now HIPAA compliant, HITRUST compliant, PCI compliant … but being compliant is completely different than being secure.” He continued, “Most organizations are not doing the basic things … they’re not doing the fundamentals. All the bad guys need to do today is steal your password – that’s it. It really comes down to securing that password.” The ways to steal passwords vary and are becoming more sophisticated. A practice administrator might receive an email that appears to be from someone they know and trust that has a document, usually in a PDF format, to be accessed. To look at it, the person must log in with their Microsoft 365 credential. “They enter it and nothing happens,” said Augenbaum. Instead, a pop-up appears saying that didn’t work so please enter Gmail credentials to access. “Now a bad guy sitting in Africa has both your Microsoft 365 and your Gmail credentials.” Since most people use the same password or slight variation of a password for everything, having that information realistically opens the entire organization to the hackers. But … here’s the good news … it’s relatively easy to avoid catastrophe. First, said Augenbaum, “You need to be your own human firewall. Think before you click.” Second, he continued, “Have separate passwords for mission critical platforms – anything bad guys can use to weaponize against you.” Create a strong password (see below), use two-factor authentication, and back up the most important information you have so that if ransomware is deployed, you have a copy of your critical information. Those five 12


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More Simple Steps to Improve Security With March Madness in the air, retired FBI agent Scott Augenbaum shared his own ‘Sweet 16’ when it comes to a winning cybersecurity strategy. • Think before you click on a link or open an attachment, become a human firewall and question every email. • Intrusion Detection Systems are a must but they will not stop everything as virus writers write in excess of 50,000 new viruses a day. • Separate passwords for mission critical accounts. • Strong passwords need to be longer than twelve characters in length with capital and lower case letters, numbers and a special symbol and NO dictionary words. Think passphrase instead of password.  • Updated operating systems are a must, as Microsoft doesn’t support XP anymore. • Patch your system, Microsoft updates, java and adobe. • Multifactor authentication is a must on Facebook, LinkedIn, Outlook 365, Gmail, LogMeIn, VPNs and financial accounts when offered. www. • Consider a separate computer for critical business functions. If you can access your client records on a computer that is used for Facebook and personal web surfing you are putting yourself at risk. If you are gaining remote access to your company and you are using a home computer that you share with your kids, you are putting your organization at great risk. • Do not surf the Internet as the Administrator on a computer. If you purchase a computer and you are the only user, chances are you are the administrator. Go to the control panel and create a new profile and give it administrator access and change your profile to regular user. • Back up your mission critical files on a daily basis. There have been numerous cases of ransomware that turns a company’s critical data into useless information unless you send $500 in bitcoin to a bad guy in Eastern Europe. • Have a plan for your organization, cyberplanner.pdf • Practice smart online banking • Don’t store your password in the browser; it’s the same as leaving your keys in the car for ease and convenience.   • If you can access your information in the cloud and all you have is a password, be prepared for the info to be stolen. Use multifactor. • Once the bad guys get your stuff … it’s usually too late. • You need to have a strong password for your smart phone and if you are using an Android, consider an intrusion security suite.

Making Sense of MACRA, continued from 11 categories are available.) • Review data from transition-year reporting. If not available, review meaningful use and PQRS reporting data from years prior to 2017. • Decide whether to report as an individual, group, or virtual group. • Identify a reporting mechanism. ° Qualified Clinical Data Registry/ Qualified Registry ° CEHRT – Certified Electronic Health Record Technology 2014 or 2015 editions are allowed, but bonus points will only be given for use of the 2015 edition. ° Claims (available only to individual clinicians) ° CMS Web Interface (available only for groups of 25 or more) As clinicians are working on reporting for 2018, it is imperative that practices and facilities continue to educate personnel on the changes handed down from CMS, as additional alterations are expected in the months and years to come.

Feedback & Comments

Even though the compliance process can feel cumbersome, CMS is considering feedback and comments from clinicians, advisors, and vendors relating to the practicality of reporting requirements under these new rules. The changes relating to small practice relief, performance category adjustments, and hardship exclusions are just a few examples of how feedback is impacting the QPP. There’s no time better than now to have an internal conversation about your reporting requirements to ensure you have a plan in place for 2018. Make sure you have an educated team and the appropriate tools and procedures in place to achieve the maximum possible score for your clinicians and practice. Jessica Benson, CPA, a supervisor on the KraftCPAs healthcare industry team, has more than nine years of experience in public accounting. Danielle Tribout, CPC, CPMA, CEMC, a coding and compliance consultant with Kraft Healthcare Consulting, has more than 12 years of experience in the healthcare industry. For more information, go online to

Practice Management Best Practices March 29 • 8-9:30 am KraftCPAs Nashville Office A panel of experts will discuss the healthcare landscape in 2018, providing practical solutions to help effectively manage a medical practice in an increasingly complex environment. Topics will include operational, revenue and financial management, as well as other pertinent challenges facing the industry. Come prepared with questions! For more information or register, go online to: www.



MSOs Give Physicians Time to Do What They Do Best – Care for Patients A long-standing concern for physicians in private practice is the amount of time they must spend away from patients tending to the business side of their practice, and that concern has only grown larger in recent years as complex EMRs were installed and reimbursement procedures By ANDREW grew ever more MCDONALD complicated. In some cases, practices have lagged behind in such areas as strategic planning and billing and collections because they could not make the necessary investments in technology. And looming on the horizon is perhaps the biggest time and technology challenge of all: managing the clinical data needed to participate in value-based care. As a result, more and more practices are turning to Medical Services Organizations (MSOs), which perform the “back office” functions for physician practices on an outsourced basis. Outsourcers have long been available to physician practices for specific functions. A practice might contract with one company to do its accounting, another to manage its technology and a third to handle billing and coding. Increasingly, the favored solution is a fully integrated MSO, which not only performs the traditional outsourced func-

tions outlined above but can also provide an EMR system, negotiate with payors, and provide access to a clinical data system that will meet the requirements of value-based care. An advantage of a onestop shop is that all of the MSO’s systems “talk to each other,” eliminating the inefficiencies and hiccups that occur in trying to tie together the variety of systems that are deployed when tasks are outsourced to multiple vendors. MSOs also provide physician practices with access to sophisticated technology they might not be able to afford on their own. “One example is data analytics,” said Tammy Wolcott, CEO of W Squared, an LBMC company that provides finance and accounting services for LBMC’s MSO. “A physician practice that we work with was, for the first time, able to get detailed analytics on the profitability of the various services they offered. That allowed them to strategically plan in a way they never could before and make informed decisions on how they could grow.” And with the increasing deployment of value-based reimbursement, physician practices will need to provide detailed information about treatments and outcomes in order to be reimbursed. Systems that generate this data are very sophisticated and, as a result, often costly. Contracting with an MSO can provide cost-effective access to a clinical data system. “As practices go down the road towards value-based reimbursement, the cost of these clinical data systems will likely be greater than most practices are willing to invest,” said Doug Shirley, an LBMC

director working with the MSO. Access to expertise and purchasing power are other potential advantages of using an MSO. A truly full-service MSO provides such expertise-based services as negotiating with payors and group purchasing, which provides savings on supplies and equipment that are available to organizations such as MSOs that can negotiate on behalf of a large group of providers. Additionally, other services offered by full-scale MSOs include: • Revenue cycle management, • Procurement, • Coding/Compliance program, • Physician compensation modeling, • Physician and Mid-level credentialing, • Professional employer organization health benefits, • Human resources consulting, • Valuation, • Tax, and • Cybersecurity. Another factor driving the rise of MSOs is the plateauing of the full-employment model by hospitals, health systems and other healthcare organizations. For a long time, the ranks of hospital-employed physicians grew as doctors sought to free themselves of the administrative burden of running a practice. More recently, the

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trend towards employment has flattened, and we now are entering a period in which these organizations are conducting those difficult contractual renewal discussions that could lead to more shared risk on the financial front. Physicians wishing to regain some autonomy and independence might be facing additional financial risk in exchange for those. While employing physicians helps shore up competition and physician shortage issues, hospitals are finding that because of reimbursement cuts, they may not be able to afford the current full-employment model. A return to a fully independent private practice – or perhaps in a joint venture with the hospital – means those physicians will need to set up their own businesses. An MSO might well make more sense than the large capital investment physicians would need to create their own back office functions. And with physicians in short supply, it only makes sense for them to spend the maximum amount of time possible doing what they do best – taking care of patients. MSOs help make that possible. Andrew McDonald, FACHE, is practice leader of LBMC Physician Business Solutions, LLC and LBMC Healthcare Consulting. For more information, email or go online to


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Mark Your Calendar Meharry Medical College Celebrates Annual Oral Health Day

March 10 • Doors open at 7 am Meharry Medical College Henry A. Moses PhD Alumni Hall On Saturday, March 10, Meharry Medical College will provide free dental services – including cleanings, extractions and fillings – to hundreds of uninsured Middle Tennesseans at its annual Oral Health Day event, which is sponsored by the Meharry Chapter of the American Student Dental Association. Patients must be 18 years old to receive treatment and will be seen on a first come, first served basis by registering onsite at the Henry A. Moses PhD Alumni Hall. No insurance or ID is required. For more information, go online to

American College of Foot & Ankle Surgeons

March 22-25 • Gaylord Opryland Hotel More than 1,800 foot and ankle surgeons from around the nation will gather in Nashville for the 76th Annual Scientific Conference of ACFAS. For nashvillemedicalnews


more information, go online to acfas. org or follow the conference on Twitter, #ACFAS2018.

Matthew Walker Breakfast Celebration Featuring Dr. Henry Foster

April 12 • 7:30-9 am Meharry Medical College Cal Turner Center As Matthew Walker Comprehensive Health Center continues its 50th anniversary celebration, join Tennessee Health Care Hall of Famer Dr. Henry Foster for a gala breakfast event honoring the center and its legendary namesake. For more information or to register, go online to






Music City SCALE Symposium

May 10-12 • Music City Center The educational conference and symposium features the latest information in aesthetic medicine for physicians and clinicians. For more information or to register, go online to






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MARCH 2018




Tennessee Kidney Foundation: Supporting Those Fighting Kidney Disease By CINDY SANDERS

Kidney disease impacts 30 million Americans. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the overall prevalence of chronic kidney disease (CKD) in the general U.S. population is 14 percent. “People don’t talk about kidneys the way they do other organs like the heart and lungs, but almost everyone knows someone impacted by kidney disease,” said Heather Corum Powell, CEO of the Tennessee Kidney Foundation (TKF). “The rate of kidney disease increases 10-15 percent every year,” she continued, noting diabetes, hypertension, and aging are all risk factors for developing CKD. The Tennessee Kidney Foundation is there to support patients and providers through a variety of educational resources and funding mechanisms to ensure patients receive the lifesaving care needed. “We serve a 40-county area throughout Middle Heather Corum Powell Tennessee. Our mission is to empower and support those at risk or affected by kidney disease,” Powell said. She added the organization considers all its programs to be preventative – whether that is primary, secondary or tertiary prevention. On the primary prevention front, TKF provides education about maintaining kidney health through exercise, maintaining stable blood pressure, exercise, healthy diet, and avoidance of sugary drinks. Health screenings are a key component of secondary prevention with TKF volunteers setting up at health fairs, churches and community gatherings across the region. After completing an intake form, individuals move to the next station for a blood pressure check and height and weight measurements. Next, participants stop at the urinalysis station. “We have a dipstick testing machine that tells us in about 30 seconds if someone has normal, abnormal, or very abnormal urinalysis results,” explained. Powell. The last station is a one-on-one conversation with a physician or nurse to discuss results and holistic measures to maintain or improve kidney health. Powell said about 20 percent of people who go through TKF screenings have abnormal or very abnormal results. “We’re not a referral organization, but we want to make sure you get follow-up care within a certain amount of time,” she said, not14


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ing the clinicians stress the importance of seeing a primary care physician for additional testing and monitoring. Primary and secondary prevention are so important, said Powell, because kidney disease rarely makes itself known

in the early stages. “It’s called the silent disease because it’s very asymptomatic. People often don’t know they have it until it’s too late, and their kidneys are failing,” she said, adding 90 percent of people who have kidney disease don’t realize it. For those who have progressed to the point where their kidney disease is evident, Powell said TKD offers a number of supports as part of their tertiary prevention plan, including transportation services. “We actually pay 100 percent of transportation costs for dialysis and transplant patients,” she said. “The cost of transportation to get back and forth for those who can’t drive themselves is just astronomical.”

She added transportation is often the biggest barrier to care for dialysis patients. For someone on hemodialysis, it’s pretty standard to have three treatments per week for a total of 12-14 treatments monthly. With an average transportation cost of $10, it quickly adds up … often to a point that is unsustainable for the patient. “When people can’t afford their treatment, what happens is they sacrifice that treatment. Dialysis is life or death. Thinking about someone who doesn’t know if they can stay alive because they cant afford to get to their treatment is something we just can’t let happen,” she stated. To combat that problem, TKF works with MTA’s Access Ride program in Davidson County, buying about 1,500 tickets per month. In surrounding counties, the team works with other solution providers including transport companies. “This year we’ll provide about 46,000 trips,” Powell said. TKF also helps address other social needs. With the amount of time required for dialysis, many patients with kidney failure are unable to work full time. The organization has a grant application mechanism to assist with utilities, rent, medication costs or food in emergency situations.

Spring is always a key time to drive awareness about the disease and services offered by TKD. March is Kidney Awareness Month and that leads right into April, which is Organ Donation Month. “The only treatments for kidney failure are dialysis and transplant. Of all the people in the country who need a transplant, 90 percent need kidneys. It’s amazing to be able to give the gift of life while you’re still living,” she said of the unique opportunity to be a kidney donor. Just as TKD hopes to increase kidney education among individuals, Powell said it’s equally important to raise awareness with clinicians. “We’d like for providers who have patients who present with hypertension or diabetes to bring kidney health into the conversation early and often,” she said. “Kidney disease – if it’s caught early – is maintainable, and prevention is doable. But once you get to kidney failure, there’s really no going back.” For Powell, the mission is personal. “My mom was diagnosed with kidney disease over 30 years ago. She’s one of those unique people who never progressed to dialysis or transplant,” said Powell, noting medication and lifestyle modifications have kept her mother stable. “Now 67 years old, she’s atypical … but that’s how I know the importance of these early detection programs. If she hadn’t been told of her kidney disease early on, I don’t know if we’d still have her today.”

Landmark Vanderbilt Studies Find IV Saline Less Beneficial Than Balanced Fluids for Patient Survival Vanderbilt University Medical Center is encouraging its medical providers to stop using saline as intravenous fluid therapy for most patients, a change provoked by two companion landmark studies released today that are anticipated to improve patients’ survival and decrease kidney complications. Saline, used in medicine for more than a century, contains high concentrations of sodium chloride, which is similar to table salt. Vanderbilt researchers found that patients do better if, instead, they are given balanced fluids that closely resemble the liquid part of blood. “Our results suggest that using primarily balanced fluids should prevent death or severe kidney dysfunction for hundreds of Vanderbilt patients and tens of thousands of patients across the country each year,” said study author Matthew Semler, MD, MSc, assistant professor of Medicine at Vanderbilt University School of Medicine.

“Because balanced fluids and saline are similar in cost, the finding of better patient outcomes with balanced fluids in two large trials has prompted a change in practice at Vanderbilt toward using primarily balanced fluids for intravenous fluid therapy.” The Vanderbilt research, published today in the New England Journal of Medicine, examined over 15,000 intensive care patients and over 13,000 emergency department patients who were assigned to receive saline or balanced fluids if they required intravenous fluid. In both studies, the incidence of serious kidney problems or death was about 1 percent lower in the balanced fluids group compared to the saline group. “The difference, while small for individual patients, is significant on a population level. Each year in the United States, millions of patients receive intravenous fluids,” said study author Wesley Self, MD, MPH, associate professor of Emer-

gency Medicine. “When we say a 1 percent reduction that means thousands and thousands of patients would be better off,” he said. The authors estimate this change may lead to at least 100,000 fewer patients suffering death or kidney damage each year in the US. “Doctors have been giving patients IV fluids for over a hundred years and saline has been the most common fluid patients have been getting,” said study author Todd Rice, MD, MSc, associate professor of Medicine. “With the number of patients treated at Vanderbilt every year, the use of balanced fluids in patients could result in hundreds or even thousands of fewer patients in our community dying or developing kidney failure. After these results became available, medical care at Vanderbilt changed so that doctors now preferentially use balanced fluids,” he said. nashvillemedicalnews



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