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FOCUS TOPICS RURAL HEALTH • EMERGENCY MEDICINE/TRAUMA

Your Middle TN Source for Professional Healthcare News

PHYSICIAN SPOTLIGHT PAGE 3

Lisa Piercey,

MD, MBA, FAAP

ON ROUNDS

Being Responsive to First Responders “Firemen, policemen, and EMTs – they all unfortunately experience more trauma in a month than most people do in their life,” said Michael Genovese, MD, JD, chief medical officer of Acadia Healthcare ... 7

Health Care Council Hosts Eyles, Kahn for Policy Discussion At the end of February, the Nashville Health Care Council hosted a lively discussion on healthcare policy with the leaders of two of the most influential industry advocacy groups in Washington, D.C ... 11

Addressing the GAPs in Alzheimer’s Trials, Treatment The Global Alzheimer’s Platform (GAP) Foundation, an organization dedicated to improving Alzheimer’s clinical trials in the quest of a cure, has just wrapped the GAP-NET Site Optimization Conference in Nashville ... 12

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Maintaining a Medical Presence in Rural Tennessee THA Searches for Solutions as Another Hospital Closes By CINDY SANDERS

In the last few years, nearly 10 percent of Tennessee hospitals have closed their doors, leaving communities without easy access to emergency services and inpatient care. On March 1, Cumberland River Hospital in Celina, Tenn., became the 10th rural hospital and 12th overall to cease operations since 2012. “ Re a s o n s for these closings included declining volumes, difficulties in the recruitment of healthcare providers, the burden of uncompensated care, and limited financial resources and capital, as well as a reimbursement model that is inpatient-focused and

largely not aligned with prevention and chronic care needs,” noted Craig Becker, president and CEO of the Tennessee Hospital Association. Becker added recent conversations regarding federal healthcare reform could signal even more challenges to rural hospitals when it comes to financial viability. “There are certainly more rural hospitals in Tennessee at risk for closure, and it is unfortunate that more of them likely will shutter in 2019. THA’s work at the federal level to establish regulatory ‘glide-paths’ for rural hospitals to transition to alternative models of care – and at the state level with the Rural Transformation program

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When Every Minute Matters Updates in Trauma Care By MELANIE KILGORE-HILL

According to the Centers for Disease Control and Prevention, trauma is the leading cause of death in the first half of life spanning ages 1-44. Nationwide, 27.6 million people were treated in an emergency department for injuries in 2015. In Tennessee, more than 30,000 patients are treated in designated trauma centers each year.

Behind the Statistics

“The number of trauma injuries is significant but doesn’t capture the number of people who have permanent disabilities or injuries during the most productive years of their lives,” said Roger Nagy, MD, FACS, trauma medical director and surgeon at TriStar Skyline Medical Center.

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Innovative Technology Enables Earlier and More Accurate Diagnosis of Lung Cancer Lung cancer is a growing problem in the U.S. and is the leading cancer killer of both men and women. Most lung cancer diagnoses come at an advanced-stage when patients become symptomatic, resulting in five-year survival rates that are under 20 percent. Early detection of lung cancer is critical to improving survival but can be challenging. An innovation that holds promise to fight lung cancer is now in use at TriStar Centennial Medical by Susan Center. Used to view Garwood, MD the inside of the lungs and obtain a tissue Pulmonary sample for biopsy, the and Advanced Auris Health Monarch Bronchoscopy Platform enables earlier Lung Cancer and more accurate Specialist diagnosis of small and hard-to-reach nodules TriStar Medical Group Centennial in the periphery of the lung. TriStar Thoracic Surgical Centennial is the Associates first in the state of Tennessee and among the first in the U.S. to utilize the new technology, which was recently approved by the U.S. Food and Drug Administration (FDA). The technology integrates the latest advancements in robotics, software, data science and endoscopy. The Monarch™ Platform provides improved reach, vision and control for bronchoscopic procedures. Combining traditional endoscopic views into the lung with computer-assisted navigation based on 3-D models of the patient’s own lung anatomy, the technology provides physicians with continuous bronchoscope vision throughout the entire procedure. Endoscopies rely on a physician’s steady hands operating a long camera as it is manually fed into, and manipulated within, a patient’s body. The new robotic system helps doctors navigate the twists and turns in the lungs. The flexible robotic bronchoscope, which contains a tiny camera, navigates the small tubes in a patient’s lungs by direct physician guidance. The physician directs the procedure with a remote that looks a lot like an Xbox controller to navigate the flexible robotic endoscope to the periphery of the lung. When at the desired location, biopsies can be performed to extract a tissue sample under direct visualization, which can increase accuracy and decrease risk of complications. There are a variety of diagnostic options currently available for lung cancer, but all have limitations in accuracy, safety, and invasiveness. These limitations can lead to missed cancers due to

non-diagnostic biopsies, and side effects such as pneumothorax and hemorrhage, which may increase health care costs and extend hospital stays. The ability to use complementary technology with this platform allows simultaneous lymph node evaluation for staging or radiation marker placement to guide treatment all in one anesthetic event. Prior to having the Monarch Platform, pulmonologists were much more limited in the types of patients we could evaluate and the nodules we could reach. Now with 360-degree visualization in the airways, and a nested scope design that allows one scope to stay planted while the second ventures on to the exact spot being

targeted, navigating complex s-curves in the lungs is no longer problematic. The Monarch Platform enhances our ability to evaluate and diagnose lung cancer at an earlier stage. We are excited about the promise of this technology to shorten the time from the discovery of a lung nodule to the treatment of a lung cancer. Earlier diagnosis saves lives in an otherwise deadly disease. As exciting as this new technology is, this may be just the beginning. Now that we have the tools to reach farther into the lung and biopsy with extreme precision, the hope is this will be a gateway to delivering targeted therapies for treating lung cancer, as well. For more information about robotic assisted bronchoscopy and to refer a patient to a lung cancer specialist for evaluation, please call (615) 342-7345.

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PHYSICIAN SPOTLIGHT

State of Health

Dr. Lisa Piercey Navigates New Role as Tennessee Health Commissioner By MELANIE KILGORE-HILL

struggling to support hospitals.” Time and again, those challenges pointed back to social determinants of health, which led Piercey to a newfound interest in the public health arena. “Loud and clear I realized the significance of social determinants that didn’t change regardless of whether someone has an insurance card in their pocket or a hospital in their community,” Piercey said. “Exposure to that reality and public policies made this opportunity very attractive,” she added of accepting her latest challenge overseeing TDH.

In January, Lisa Piercey, MD, MBA, FAAP, FACHE, was selected as commissioner for the Tennessee Department of Health. The pediatrician is drawing on a decade of leadership experience in rural healthcare and public policy as she works to improve outcomes for the state’s 6.7 million residents.

Tennessee Roots

A native of Gibson County, Piercey grew up in the small community of Trenton, Tenn., the daughter of a farmer and small business owner. An affinity for math and science led to an interest in medicine. After receiving a bachelor’s degree in chemistry from Lipscomb University in Nashville, she headed to Johnson City where she earned her medical degree from East Tennessee State University’s James H. Quillen College of Medicine.

Addressing Child Abuse

Piercey remained at ETSU to complete her pediatric residency program and was soon introduced to the heart-wrenching field of child abuse pediatrics. “Child abuse is an unusual specialty and not something anyone wakes up and says, ‘I want to do that,’” said Piercey, who was introduced to the work by a mentor in East Tennessee. “It was so disturbing, but I went back week after week and finally acknowledged that this is a huge need that people aren’t lining up to fill. My faith is very important to me, and I wanted to be a good steward of the skills I was blessed with,” she explained. The formalization of child abuse as a subspecialty is relatively new, and Piercey is one of a handful of specialized practitioners in the state.

Making a Difference

more patients out of the emergency room while providing them with earlier and more appropriate levels of care.

Challenges of Rural Health

Piercey also oversaw rural hospital operations and witnessed firsthand the sustainability challenges and social determinants facing smaller communities. “Working with rural hospitals started out as personal affinity because I grew up around them,” said Piercey. “I wanted to understand what they’re going through, populations they serve, and the business aspect of why these communities are

Appointed to office by newly elected Governor Bill Lee, Piercey stepped into her role Feb. 2, and was immediately impressed by the high level of performers leading the state’s healthcare efforts. “I wasn’t fully aware of the incredible skill set and expertise of virtually every professional here,” she said. “I was welcomed with open arms.” Piercey’s first month as commissioner has been spent learning the ropes and working alongside Gov. Lee on improving public health for Tennesseans. “Instead of trying to make it bigger or different, we’re focusing on what we can affect from the public health standpoint that really drives down costs,” she said of addressing factors contributing to chronic disease including obesity, inactivity and smoking. “So much of healthcare focuses on treatment instead of prevention, which is a

fundamental flaw in our system. Prevention is a longer-term play, but we need to convince communities and decision-makers that it’s an investment that will pay off exponentially more than treatment only,” she continued. Piercey acknowledged that changing minds is a process, particularly among rural hospitals already struggling to keep doors open. That’s because the need to fill beds and pay bills often trumps the bigger goal of population health. But even in rural America, providers are beginning to realize advantages of moving toward value-based care. It’s just one area Piercey hopes to improve in her time with the Tennessee Department of Health. “Right now, I’m praying about priorities and talking to the governor about priorities,” said Piercey. “I’ve realized very quickly that services provided by the Department are a lot more complex and diverse than anyone realizes; and in order to make good decisions, I need a thorough understanding of what services are covered and where our strong suits and gaps are.” She also hopes to incorporate community and faith-based organizations in outreach efforts and utilize her telehealth experience to bring more innovation and technology partners to the table. “I like to think collaboratively, and there are more avenues where we can leverage technology and innovation to provide better services and enhance access for Tennesseans,” she stated.

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A Head for Business

After finishing training, Piercey returned to West Tennessee. While in private practice in Jackson, she became fascinated by the intersection of medicine and business and went on to pursue her Master’s of Business Administration from Bethel University. “For physicians, having the capability for business is a critical skill set, because you really can’t be in healthcare without dealing with finance and economics, population health, and sustainability of a medical practice,” she said. “It’s just part of the world we live in.” Piercey spent the next decade honing those skills as executive vice president of system services for West Tennessee Healthcare. She spearheaded patientcentered measures that saved millions of dollars of medical costs, focusing on chronic disease and behavioral health. Efforts included increased collaboration with non-profit entities, specialized training for medical professionals, treatment for pregnant women with substance abuse, and telemedicine services for behavioral health patients. Those efforts ultimately kept nashvillemedicalnews

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Maintaining a Medical Presence in Rural Tennessee, continued from page 1

passed by the General Assembly in 2018 – is critical to stabilizing and ensuring the future of rural healthcare.” Bill Jolley, senior vice president of rural health issues for THA, agreed the Tennessee Ru r a l Hospital Transformation Act, signed into law last year by former Gov. Bill Haslam, was a first step to address the changing healthcare landscape. “It provided a mechanism to provide support to those rural Bill Jolley hospitals that are really in dire straits,” Jolley said. He explained the law makes funding available for the state to contract with consultants and professional firms with expertise in hospital turnaround strategies to assess strategic partnerships ranging from joining forces with other hospitals in contiguous geographic regions to partnering with a larger tertiary facility to improve economies of scale and overall financial viability. THA worked closely with legislators on the plan, which is under the oversight of the Tennessee Department of Community and Economic Development. Jolley said

the legislation allows for potentially $3 million over three years to create such transformation plans. While funding must be reauthorized annually, the first $1 million has been approved for work in 2019. He added the expectation is that some hospitals would ultimately need to transition to new delivery models. “The hope would be they could sustain themselves in their current state … but if that’s not possible, then at a minimum maintaining a medical presence in these communities. There are some innovative ways of delivery care in rural Tennessee and across the country.” Jolley pointed to Johnson County Community Hospital, part of Ballad Health, in Mountain City, Tenn., as an example of rethinking the traditional delivery model. The critical access hospital has a 24/7 emergency department, two inpatient beds for either general care or to stabilize a patient before transferring to a larger facility, and a host of outpatient services focused on primary care, prevention and chronic care management. Not surprisingly, communities have fought hard to keep local hospitals, even when swimming against the tide of

AMA Honors Alexander’s Service By CINDY SANDERS

Last month, the American Medical Association (AMA) presented U.S. Senator Lamar Alexander (R-Tenn.) with the Dr. Nathan Davis Award for Outstanding Government Service. “During a career dedicated to public service, Sen. Alexander has been a consensusbuilder, leader, and bipartisan workhorse Sen. Lamar Alexander on a range of public health issues, leaving a lasting impression in Tennessee, Washington and across our country,” said AMA Board Chair Jack Resneck, Jr., MD. “He has forged strong relationships and leveraged them to pass vital legislation that is confronting the opioid abuse epidemic and providing physicians with the tools they need to treat their patients.” A former governor, university president and U.S. Secretary of Education, Alexander has been widely recognized for his bipartisan approach to legislating. As chair of the Senate Health, Education, Labor & Pensions (HELP) committee, Alexander has spearheaded a number of significant healthcare bills, including the “21st Century Cures Act,” which included provisions to accelerate medical product development and expedite getting other healthcare innovations into the marketplace to benefit patients. Additionally, he has championed comprehensive mental health legislation, and the “SUPPORT for Patients and Communities Act” – a legislative package to address opioid use disorders. He worked closely with Sen. Patty 4

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Murray (D-Wash.), who serves as Ranking Member on the HELP committee, to engage key stakeholders in discussions to gain a more comprehensive picture of the opioid epidemic. The AMA specifically lauded Alexander’s efforts to pass the comprehensive SUPPORT legislation (H.R. 6) while protecting states’ ability to work directly with physicians on use of their prescription drug monitoring program (PDMP) databases, protecting patient privacy, and prioritizing new research for the treatment of pain and opioid use disorder.   Alexander, who was presented the award during the recent AMA National Advocacy Conference, told Nashville Medical News, “I am grateful for this very generous award, but I really should be thanking the American Medical Association for what they do to care for people who need help. I’m going to do all I can over the next two years to create an environment for patients that produces a better experience and a better outcome at a lower cost. I hope the American Medical Association will help with that, because we all know we’re more likely to succeed in that if we remember that doctors need to be in a better working environment with less administrative burden so they could spend more time caring for their patients.” Alexander was nominated by the Tennessee Medical Association and was one of eight honorees chosen this year to receive the Dr. Nathan Davis Award for Outstanding Government Service. The award, named after the founding father of the AMA, recognizes elected and career officials in federal, state or municipal service whose contributions have promoted the art and science of medicine and the betterment of public health. 

mounting financial losses. “We’re seeing it now all throughout the state with communities desperately trying to keep their hospitals open,” said Becker. “It’s a real hard pill to swallow to give up a full-service hospital. It’s part of the social fabric of the community,” he added of the role hospitals play beyond care delivery. Becker said a hospital closure causes a ripple effect. Not only is there the loss of high-paying jobs, but it also makes it more difficult to attract new businesses to the area. Craig Becker “Typically, the hospital ranks in the top three employers in a community, and sometimes as the top employer,” noted Jolley. “The population left behind that doesn’t leave these communities tend to be the elderly and the uninsured,” continued Becker. He said the Rural Hospital Transformation Act allows for the assessment of the most appropriate level of care to meet the needs of the population. “It gives them another road to keep a medical presence in that community,” he added. Telemedicine offers another opportunity to link rural communities to providers and specialists. Increased broadband access and greater acceptance by insurers have opened the door to expand the technology. “It provides an opportunity for some of our urban-based practices to partner with rural communities by linking through telemedicine,” said Jolley. Although Gov. Bill Lee has expressed

opposition to traditional Medicaid expansion under the Affordable Care Act, he has signaled his desire to focus on strengthening rural communities. Similarly, Becker said national lawmakers are increasingly cognizant of the rural healthcare crisis across the country. “Awareness … that’s the first step, and then you look at how to fix it,” he noted. Becker added not every rural hospital in Tennessee is failing. Some, in fact, are doing quite well. He pointed to Henry County Medical Center and Hardin Medical Center in West Tennessee as examples of stand-alone hospitals that have served their counties continuously for nearly seven decades. Backed by the power of TriStar Health, Cheatham County in Middle Tennessee is served by TriStar Ashland City Medical Center, a 12-bed critical access hospital that has won national recognition for quality and leadership. Becker also applauded Maury Regional Health in Columbia, Tenn., for stepping in to offer robust communitybased services in nearby counties that have lost hospitals. “They probably have the prototype of how to handle regional care,” he noted. While there is excitement about the building momentum to address rural access to care, both Becker and Jolley said a sustained focus is critical. Tennessee is second only to Texas in the number of rural hospital closures, and there are several more Tennessee hospitals currently hanging on by a thread. “It’s a lot more than a critical condition, and it’s not going to get any better until we address it,” concluded Becker.

State Hospitals Recognized as Part of National Decrease in HACs Two federal government agencies charged with reporting patient safety and quality of care data recently recognized the 88 hospitals participating in the Tennessee Hospital Association’s Hospital Improvement and Innovation Network (HIIN) as part of a nationwide effort to save lives and healthcare dollars. The Tennessee facilities and national counterparts helped prevent 20,500 hospital deaths and saved $7.7 billion in healthcare costs from 2014 to 2017, according to new data released by the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS). AHRQ’s preliminary analysis estimates hospital-acquired conditions (HACs) were reduced by 910,000 from 2014 to 2017. The estimated rate of HACs dropped 13 percent.  Under the leadership of the Tennessee Center for Patient Safety, a division of THA, 88 facilities are participating in the CMS Partnership for Patients’ HIIN through the American Hospital Association’s Health Research Education Trust. Maury Regional, Nashville General, NorthCrest Medical Center, Sumner Regional, TriStar Skyline, TriStar Summit, Vanderbilt University Medical Center and Williamson Medical Center in the Nashville MSA are all part of the HIIN. While there is strong participation from Tennessee’s urban centers, many of the hospitals setting the standard for best practices and innovative programming are rural facilities located all across the state. “Tennessee hospitals are working together through this collaborative program to share best practices and continue to strive to make their facilities the safest places for care,” said THA President & CEO Craig Becker. “Tennesseans should be very comfortable knowing their local hospitals are working hard to provide the best possible care.”  Go online to NashvilleMedicalNews.com for a link to the full AHRQ report and more information on the THA HIIN, including access to best practice success stories from several of the participating Tennessee hospitals.

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I N T R O D U CI N G

Lisa Morgan, MD Rhonda Halcomb, MD Kimberly Hunt, MD Carol McCullough, MD Jennifer Bell, MD Hannah M. Dudney, MD Stephen M. Staggs, MD Nicole Heidemann, MD Sa Cara Shaw, MD Katherine Haney, MD Jeffrey Draughn, MD

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Small Towns, Big Fight for Continued Access to Care

Rural Hospitals Face Death by a Thousand Cuts By CINDY SANDERS

More than 60 million Americans – nearly one in five residents – live in rural communities. While these small towns and wide swaths of farmland are an integral part of the American fabric, the nation has seen the rural population drop from 54.4 percent in 1910 to 19.3 percent a century later, according to the U.S. Census Bureau. As Americans have migrated to urban areas and urban clusters, it has become increasingly difficult to sustain services, particularly access to healthcare, in many of these rural communities. Although a little more than 80 percent of the country lives in urban areas and the clusters surrounding them, the actual land urbanites use is only 3 percent of the country’s total. The remaining 19.3 percent of the population is spread across 97 percent of the nation’s landscape. In a service industry where ‘minutes matter,’ closure of a rural hospital facility likely means adding significant time to get to the next closest medical facility. By the beginning of this year, the National Rural Health Association (NRHA) counted 95 rural hospital

closures since 2010 and identified nearly 700 other facilities as being vulnerable for closing. “Everything that NHRA works on can be boiled down to one thing … and that’s access,” stated Diane R. Calmus, regulatory counsel for the NRHA. T he reasons for the closures are Diane R. Calmus multifactorial. “It would be really easy if there was a silver bullet to solve the issues, but this has been the result of a whole lot of small cuts,” said Calmus. “A lot of cuts that have happened in D.C. have impacted rural hospitals in a way that haven’t impacted urban counterparts with a different payer mix,” she continued. In its #SaveRuralHospitals action center, the NRHA noted, “The rate of closure has steadily increased since sequestration began and bad debt cuts began to hit rural hospitals, resulting in a rate six times higher in 2015 compared to 2010.” Rural hospitals often lack the

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specialty services that bring in higher reimbursement to offset losses on general inpatient care and surgeries. Add to that, Calmus continued, “Rural Americans tend to be older, sicker, poorer than their urban counterparts.” She continued, “We know from MedPAC that at least since 2016, Medicare margins have been, on average, negative. By definition, rural hospitals are providing that frontline care, and that’s where negative margins are even worse.” Calmus said the bad debt cuts have been particularly hard for rural hospitals for a couple of key reasons. Prior to the Affordable Care Act, hospitals could write off a significant portion of their bad debt. However, since ACA was supposed to expand health insurance to everyone, the theory was bad debt would drop dramatically. Therefore, a bad debt cut was put in place. When Medicaid expansion was overruled by the Supreme Court, it left a coverage gap for a lot of Americans, which has been disproportionately felt by rural hospitals with a smaller patient census to offset uninsured care. Even when serving patients with insurance, rural hospitals often have been left with bad debt since paying a $5,000 deductible is nearly impossible for many people. The very nature of frontline care means that rural hospitals often stabilize a patient before sending that individual to an urban counterpart for more specialized treatment. Rural hospitals have found their services fall into the ‘deductible’ part of patient care, whereas insurance has kicked in by the time the patient is transferred to the larger urban center for continued services. “We’ve seen a 50 percent increase in bad debt at rural hospitals that we haven’t seen at urban hospitals,” noted Calmus. Sequestration is another area where federal cuts have made it increasingly difficult for some rural hospitals to keep their doors open. “Critical Access Hospitals were paid 101 percent the cost of providing care. That was cut by 2 percent by the sequester. If you do the notso-difficult math, they are not being paid the cost of care,” Calmus said of the cost deficit faced by CAH-designated facilities. The ‘death by a thousand cuts’ reality has taken a steep toll on rural hospitals across the country. “From 2018, 46 percent of rural hospitals were operating at a loss. That’s up from 44 percent in 2017 and 40 percent the year before that,” outlined Calmus. Yet another threat to access is a lack of providers. “Recruitment and retention of physicians is always an issue for rural hospitals,” said Calmus. This is particularly true for a number of specialties. “Between 2004 and 2014, we’ve seen more than 200 rural communities lose their hospitalbased obstetrics. Now, the majority of

rural counties don’t actually have a place to deliver a baby,” she continued. Coinciding with the decrease in obstetric services has been an increase in precipitous deliveries with more rural babies delivered at home, in ERs, or in the back of an ambulance or in a car en route to a larger facility. On a more positive note, Calmus said, “340B is one of the bright spots in rural healthcare.” In addition to keeping the doors open, she said a number of hospitals are using the 340B money in innovative ways to improve care delivery … and, she stressed, the 340B money isn’t paid for by taxpayers. “The threats to 340B are frequent. We ‘re working constantly to educate legislators and the administration on how well hospitals are using this money,” she admitted. Happily, there are plenty of success stories to share. “Rural hospitals are uniquely positioned to know their patients in a way doctors in urban communities can’t,” she pointed out. Calmus noted one hospital in Kansas kept seeing a family in the emergency room because they had an infestation of bed bugs. Using just a few 340B dollars took care of the problem at a fraction of the cost of an ER visit. Similarly, another patient was having a hard time controlling his diabetes. Tapping into resources to pay his electric bill meant his insulin could be properly refrigerated and therefore more effective. Calmus said rural hospitals have become incubators for innovative practice. “In so many ways, it’s the rural hospitals who are figuring out how to do more with less,” she pointed out, adding that work mirrors the national call to deliver high-value care in the most cost-effective manner possible. Despite the many ongoing threats to the nation’s rural healthcare facilities, Calmus said there is much to be excited about, as well. “Rural America is a great place to practice medicine in the cradleto-grave model so many providers say they want to practice.”

Mark Your Calendars 42nd Annual Rural Health Conference May 7-10 Atlanta, GA The annual conference will be held in nearby Atlanta this spring. For details on registration, housing and the 2019 agenda, go online to ruralhealthweb.org/events.

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Being Responsive to First Responders Program Focuses on Resiliency in the Face of Trauma By CINDY SANDERS

sustain healthy habits, down the stairs to escape, the police and • Social – the creation of firemen were running up the stairs into the “Firemen, policemen, and healthy social networks that foster path of danger.’â€? EMTs – they all unfortunately communication and connectedness, With that image in mind, Genovese experience more trauma in a and said a variance on a quote from President month than most people do in • Spiritual – the strengthening of John F. Kennedy, itself a paraphrase of a their life,â€? said Michael Genovese, core values, beliefs and principles, Bible verse, has become a driver for his MD, JD, chief medical officer of which will vary by individual. work with first responders. “To those from Acadia Healthcare. “Many first A recent three-day training whom much is expected, much should be responders are part of a culture was held in Martin, Tenn., and given,â€? he said of supporting all who put where historically you didn’t talk brought together first responder themselves on the front lines of trauma and about this stuff ‌ you ‘suck it up’ representatives from across the state. tragedy. “If we’re going to expect that from and move on,â€? he continued. “When we do the train-the-trainer them, we darn well better provide them the However, humans cannot model, the reach is exponential,â€? best medical care possible.â€? ‘unsee’ what they have already Genovese said of creating the witnessed, noted the behavioral pathway for participants to return health specialist who also serves to their communities and share the as medical director of the Officer lessons learned. “The Tennessee Safety and Wellness Committee group was fantastic. They were of the FBI National Academy passionate about it, and they were Associates (FBINAA). “Last year, engaged.â€? With completion of last 2018, was the third year in a row month’s training, nearly 300 first that more officers died by suicide responders have now attended the For information on future than in the line of duty,â€? said Dr. Michael Genovese (R) discusses the pathology of trauma during a recent program nationwide. programming or to inquire resiliency training for Tennessee first responders. Genovese. “People frequently ask me why about setting up a training Research has established I’m so invested with first responders. for first responders and/ repeated trauma actually causes injury go to the cardiologist. If you broke a leg, Every generation has a sentinel moment. or emergency department to the brain. “Your neuropathways are you’d go to the orthopaedist. If you have For me, it was 9/11,â€? explained Genovese. personnel, please contact: shaped in part by your environment and an injury to your brain, you should be Growing up in New York, he said he had Joseph Collins • 920.973.7310 • your experiences. Your brain gets trained just as open to going to get treatment for many friends in the Twin Towers on Sept. jvcpublicsafetyconsultants@ to think in the context of your experiences. that,â€? Genovese stated. “The earlier you 11, 2001. “Of those who made it out, I was gmail.com It’s a normal reaction to an abnormal intervene, the better your chances for full struck by them saying, ‘As we were running stress,â€? Genovese explained of the lasting recovery,â€? he added. changes that can occur to the amygdala, Asking for help, however, requires hippocampus and prefrontal cortex. culture change ‌ both among those in Yet, he continued, research out of the need of help and their supervisors. Fear University of Pennsylvania and several exists that seeking treatment could cost a other sites has also shown the protective career. Although it is a legitimate concern, properties of resiliency. “People who had the training program teaches participants it more resilience were not as negatively is possible to heal from PTSI and continue impacted by adverse events,â€? he said, to be highly effective in the field. Through adding those with higher resiliency were the trainings, Genovese has encouraged more likely to bounce back faster and to supervisors to create a formalized pathway have post-traumatic growth instead of postback to service so that individuals aren’t traumatic stress injury (PTSI). punished for trying to improve their mental Recognizing it isn’t possible to health. change the nature of first responders’ Warning signs that a first responder jobs, Genovese said the hope is to lessen might need help include changes in the impact of trauma by improving the mood, sleep, energy or appetite, and/or response to it. The Comprehensive Officer withdrawal from social situations and peers. Resilience Train-the-Trainer Program in Genovese added most people are not going partnership with the FBINAA was born to say they are depressed or anxious, but out of this desire to provide first responders they might mention a recurrent, unwanted with tools to address their continued memory or exhibit a heightened startle proximity to trauma and to help colleagues response or become more negative in Talk to your KraftCPAs advisor about how our and supervisors recognize warning signs of thinking or mood. An individual struggling PTSI. ‌ possibly without realizing it ‌ might healthcare team can help alleviate your tax reform “I see this as engaging in preventive have nightmares and flashbacks of pains so you can get back to what matters most: medicine,â€? said Genovese. “We’re trying to particularly traumatic situations and begin effectuate change.â€? avoiding triggers that serve as a reminder providing excellent patient care. Genovese said it’s important to of the event. “Your world gets smaller and acknowledge a post-traumatic stress is an smaller,â€? Genovese noted. injury, not a weakness. During the trainings, While it could be one incident that he discusses the biology of trauma to triggers PTSI, Genovese said it’s more underscore that message. It’s also vital to often the result of cumulative trauma built build resiliency by giving responders the up over time. “It’s almost like you’re filling tools to effectively address the pressure and up a bottle of water; and at some point, it trauma that comes with the job in order to begins to overflow,â€? he explained. View our tax reform resources at kraftcpas.com/tax-reform prevent injury. The training sessions present 12 But if injury does occur, first responders modules focused on four domains: 3UDFWLFH0DQDJHPHQW‡5HLPEXUVHPHQW‡2SHUDWLRQV‡&RPSOLDQFH should be allowed and encouraged to seek • Mental – the ability to effectively cope, ‡NUDIWKHDOWKFDUHFRP assistance. “If you had chest pain, you’d • Physical – the ability to adopt and

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When Every Minute Matters, continued from page 1

The north Nashville hospital treated more than 3,200 trauma patients in 2018. In 2019, the hospital achieved elite verification as a Level II American College of Surgeons Verified Trauma Center. Nagy said ACS verification represents a level of commitment beyond state standards, which vary nationally.

Becoming a Trauma Center

“The state Department of Health has set standards that are in the best interest of the patient, but the ACS represents an expert panel from around the nation setting another layer to ensure best practices are in place and that data is being reviewed at

multiple levels,” Nagy explained. “It’s helpful to have someone from the outside come in with suggestions from places we haven’t seen and identify areas where we may have blind spots.” Verified trauma centers must meet criteria that ensure trauma care capability and institutional Dr. Roger Nagy perfor mance, as outlined in national guidelines put forth by the American College of Surgeons’ Committee on Trauma in its

current Resources for Optimal Care of the Injured Patient manual. Nagy understands all too well the complexity of the review process. TriStar Skyline was actually denied its first state designation in 2015 following a year of provisional status. While the state had reviewed existing centers, Nagy said building a trauma center from the ground up proved to be a different experience for all involved. The Tennessee Department of Health (TDH) extended the provisional status for a second year and provided the hospital with a list of questions about possible deficiencies. Reviewing the notes, the hospital team spent the next year collecting data to meet all requirements and

received their official designation as a Level II Trauma Center from TDH in 2016. Nagy said the experience brought the department together and made them better clinically. “The bottom line is it’s a lot of work to demonstrate the care you’re providing, which is why designation and ACS verification is so significant,” he said. Skyline also was the state’s first Comprehensive Stroke Center and is complemented by fellowship-trained orthopaedic traumatologists, often found only at university medical centers. Their team of trauma surgeons also includes oral and maxillofacial specialists. “There aren’t a lot of facial surgeons who specialize in trauma, so we’re very fortunate to have them as partners,” Nagy said. TriStar Skyline operates at over 90 percent capacity and saw a 128 percent increase in admissions from 2015 to 2018. Construction of a three-story addition to the existing hospital is now underway to expand emergency room services and add 60 beds, with a focus on critical and intensive care. The hospital also will break ground on a third helipad and parking lot for 475 additional spaces in 2019.

Level 1 Trauma Care

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Vanderbilt University Medical Center is Middle Tennessee’s only statedesignated Level I trauma center and an ACS verified Level 1 Trauma Center. Oscar D. Guillamondegui, MD, MPH, trauma medical director at VUMC, said the teaching hospital takes a unique approach toward trauma care. “Our focus is Dr. Oscar on education of the Guillamondegui surgical disease of trauma and emergency management of resuscitation and critical care,” said Guillamondegui, pointing to VUMC’s role in training all levels of medical providers, from EMS personnel to nurses and resident physicians. “It’s not as simple as doing general surgery, because trauma patients come in with medical conditions and baggage prior to trauma. No one wakes up and says, ‘I want to get hit by a car today.’ That means no one is prepared for the disease of trauma.”

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Hospital residents soon learn the acute process of managing aspects of patient care beyond traumatic injury. VUMC trains eight chief residents in trauma and more than 20 surgery residents each year and treats roughly 6,000 patients – nearly 20 a day. And while the science of trauma isn’t new, the evolution of training is. Vanderbilt now works alongside the U.S. military as a civilian trauma center to share best practices. In fact, VUMC collaborations during recent conflicts have helped shed light on a number of key findings, including the importance of whole blood resuscitation. “That’s changed the entire focus of what we do, from initial management of trauma patients to ICU management and hospital care,” Guillamondegui said. “As a medical community we used to think of transfusions (CONTINUED ON PAGE 9)

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Violence in U.S. Emergency Departments on the Rise ACEP Survey Highlights Growing Risk By CINDY SANDERS

Publisher’s Note: Just as we were going to press with this issue of Medical News, yet another act of violence grabbed national headlines when a physician and an emergency department staff member were shot at a VA Medical Center in Florida. By their very nature, emergency departments are high-stakes settings filled with vulnerable patients and frightened families. Increasingly, they are also high-risk settings for healthcare providers, staff and patients. Last fall, the American College of Emergency Physicians released data and insights into the rising violence in U.S. Emergency Departments. In a poll of more than 3,500 emergency physicians nationwide, nearly seven in 10 said ED violence is increasing, and nearly eight in 10 said the violence harms patient care. “More needs to be done,” said ACEP President Vidor Friedman, MD, FACEP, in presenting the survey results during the organization’s annual meeting. “Violence in emergency departments is not only affecting medical staff, it is affecting patients,” he continued. Findings from the poll, included: • 47 percent of emergency physicians reported having been physically assaulted at work, with 60 percent of those assaults occurring in the past year. • 71 percent personally witnessed others being assaulted during their shifts. • 77 percent said patient care was being affected with 51 percent of those saying that patients also have been physically harmed. • 50 percent believe the majority of attacks are from people seeking drugs or under the influence of drugs or alcohol. While 70 percent of those surveyed said hospital administration or hospital security did respond to the incident, only 21 percent said hospital security arrested the assailant or enlisted law enforcement to do so; 6 percent said hospital administration advised them to press charges; and 3 percent said hospital security pressed charges. The other 70 percent said response to the assault resulted in a behavioral flag being added to a patient’s chart or ‘other’ measure. The vast majority of physicians said patients were responsible for the attack, but 28 percent reported being assaulted by a patient’s family member or friend (results totaled more than 100 percent because some respondents had been attacked more than once). 83 percent of emergency physician respondents said a patient has threatened to return to harm them or their emergency staff. The most common types of assault are being hit, slapped, spit upon, punched, kicked or scratched. In addition, to physical attacks, 80 percent of male and 96 percent of female emergency physicians report having a patient or visitor make inappropriate nashvillemedicalnews

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(L-R) Drs. Terry Kowalenko, Vidor Friedman and Leigh Vinocur present survey findings at an ACEP meeting.

comments or unwanted advances. 34 percent believe a lack of punitive consequence is the biggest contributing factor to the issue, and another 32 percent said behavioral health patients are driving the increases in violence (and 41 percent think the majority of attacks are from psychiatric patients). “Just in hospitals and healthcare in general, people are at their most vulnerable, and family members are at their most worried. The ER is the worst-case scenario for most, so it is this extremely volatile experience,” said Leigh Vinocur, MD, FACEP, past chair of ACEP’s Emergency Department Violence Committee and a national spokesperson for the organization. She added that when most people think about doctors and nurses being harmed or killed, they think of those practicing in war-torn counties. “Yet, here in the United States, it’s possible for your ER physician to become a victim of violence.” The reasons for increasing violence are multifactorial. “I always say the emergency department is a microcosm of society – gun violence, domestic violence, homelessness, psychiatric issues. As there is an increase in violence in society, it’s going to spill over into the emergency department,” noted Vinocur, a board-certified emergency physician with more than 25 years of experience. Add overcrowding and boarding into the mix of heightened emotions, and Vinocur said it isn’t surprising to see tempers flare. While nearly half the physicians surveyed have been physically assaulted and more than 70 percent have witnessed someone else be assaulted, Vinocur said the numbers climb even higher when verbal abuse is added to equation. And while this poll was conducted among emergency physicians, she said nurses are often on the front lines of the potential danger. “The person who is more hands-on with the patient is susceptible to even more abuse,” she pointed out. “If you look at the Bureau of Labor Statistics, being a healthcare professional is one of the most dangerous professions … and it’s very underreported,” Vinocur said, noting those in healthcare chose the profession to help people and often don’t

report incidences because they recognize patients are under stress and don’t want to stigmatize them. Even while being mindful the situation might cause patients and family members to act in ways they normally wouldn’t, Vinocur said she believes hospitals are trying to get in front of bad behaviors that could quickly escalate. “Hospitals and health systems realize it’s the safety of their employees and also the safety of their patients,” she said. Of increasing concern, however, are freestanding EDs and urgent care centers. While most hospitals have guards, Vinocur pointed out, “In these ambulatory settings where you are siloed and there’s no security, you are even more vulnerable … and a lot of healthcare is moving to ambulatory settings.” To offset the disturbing trend in violence, Vinocur said there are a number of concrete

steps facilities and health systems could take to improve safety. Additional security is one key step whether that is in the form of more guards or more cameras on site. When adding security cameras, it’s beneficial to have the devices visible so that individuals are aware their actions are being recorded. Improved visitor screening is another crucial step. In some areas, particularly large urban areas, metal detectors help screen for weapons. In addition, Vinocur said staff should be trained to ask patients if there is anyone who shouldn’t be allowed in to see them to help curb potential domestic violence interactions. “Training people to deescalate situations, too, is important … teaching hospital staff to recognize the signs of someone who is escalating as they are starting to get more and more agitated,” she said. Vinocur noted clinicians could also play a vital role in easing agitation through clear communication with patients and family members to keep them up to speed. While it’s easy for physicians to get distracted because they are so busy, she said it’s crucial to be aware of how stressful the situation is for patients and their families and why it’s so important to foster engagement. “Tensions run high,” Vinocur concluded. “Open communication can help allay fears and help mitigate out-of-control feelings. It can help ameliorate the very emotional experience of healthcare.” And a calmer emergency department is ultimately a safer one.

Every Minute Matters, continued from page 8 as bad, but we now know that more blood given faster improves outcomes. And we have a massive transfusion protocol where we deliver large parcels of blood to the operating room – almost equivalent to the blood volume in one human – and we watch patients get better immediately.” VUMC also is driving research behind traumatic brain injuries and the lifelong impact of head injuries. “Trauma has longterm effects that are cognitive in terms of missed brain injuries,” Guillamondegui said. “A lot of patients have long-term emotional or cognitive dysfunction that no one will ever relate to trauma because of a clear CT scan.” He said he expects those effects to be a major area of study over the next few years, as researchers work to better understand the long-term cognitive outcomes of trauma. “As a teaching hospital, we’re constantly looking at trauma outcomes and research,” Guillamondegui said. “We’re very introspective, so we’re always looking back to make sure what we’ve done is best for our patients. That means care changes based on outcomes over time, which allow us to deliver state-of-the-art care.”

Tennessee Trauma Centers There are 12 designated trauma centers and four comprehensive regional pediatric centers in the state. Half of the trauma centers are designated as Level 1, with Vanderbilt University Medical Center serving Middle Tennessee. Knoxville, Memphis, Chattanooga, Johnson City and Kingsport also have Level 1 centers. Tennessee has two Level 2 centers – TriStar Skyline in Nashville and Bristol Regional in the TriCities. The state has four Level 3 centers, all clustered in Middle Tennessee: TriStar Summit Medical Center in Hermitage, TriStar Horizon Medical Center in Dickson, Sumner Regional Medical Center in Gallatin, and TriStar StoneCrest Medical Center in Smyrna.

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NMGMATen Minute Takeaway 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. During the February meeting Charles Henson, managing partner with Nashville Computer, discussed cyberattacks Charles Henson and the best ways to prevent data loss. Henson said rich patient data made healthcare practices a hot commodity for the criminal underground on the Dark Web, which is a place where you can literally buy anything from identities and malicious software to drugs and guns. He noted the encrypted content that exists on darknets cannot be accessed by

traditional search engines. “The only way to get there is through a Tor Browser … but don’t do it,” he cautioned. Simply accessing the Dark Web opens an individual up to hacking. If there is concern that stolen information might be on the Dark Web, Henson said it was best to hire experienced cyber security professionals to investigate. The way information finds its way to the Dark Web, he noted, is typically through human error and human nature. Poor password choice is one of the biggest issues. Henson told the audience a list of 1.4 billion user names and passwords were recently found on the Dark Web in plain text. From that cache, 9.2 million people use ‘123456’ as a password. Another popular password is ‘password.’ Cyber security, he noted, starts with strong password protection. Additionally, he said, passwords need to be completely changed once breached. “Hackers have tools to add millions of numbers at the ends of passwords so if you were Apollo12, don’t become Apollo13,” Henson said.

Ransomware remains popular, and the attacks have become much more targeted. Once information has been hijacked, it’s a no-win situation. One Atlanta physician refused to pay ransom, so the hackers released data on a significant number of his patients. However, even if ransom is paid, the bad guys still have the information to shop it on the Dark Web. Another ploy that is gaining in popularity is for a ‘boss’ to request private information, such as HR data, or money be sent to him or her quickly. Employees want to do the right thing, but Henson said it’s critical to have smart policies in place. For example, he said a sound workplace policy should be: “One - I will never ask you to send sensitive information in an unencrypted format. And two – if I should ever ask for such information, you should talk to me on the phone prior to doing it.” Prevention, stressed Henson, is the best protection. He noted the FBI has said “95 percent of all breaches they work could have been prevented if the employee hadn’t clicked

on something, downloaded something, or had been educated on a policy.” Henson suggested having your IT team do a little proactive spear phishing to see if your staff falls for some of the most common ploys. If they do, then use it as a teachable moment and to review company procedures. Simple steps individuals should take include thinking twice before clicking on a link in an email, hovering the mouse over the sender’s name to see the actual email address rather than the visible alias, being wary of any requests for personal information, looking for grammatical errors or random capitalizations, and recognizing that a promise of something that seems ‘too good to be true’ probably is just that. Other proactive steps a company or practice should take include having a password policy that locks someone out after three failed login attempts, using two-factor authentication, backing up files regularly, installing a spam filter to block at least some of the bad actors, and considering cyber insurance.

Education through Innovation

VUSN Makes $23.6M Investment in Technology, Training By MELANIE KILGORE-HILL

1,290-square-foot space, which seamlessly captures audio and highthe new Simulation and quality video during the training encounter, Skills Lab is nearly three streams live to faculty and students watching times as large and fills the A $23.6 million the simulation in real time, and records it for new building’s third floor. investment has made playback during the debrief and assessment It contains advanced Vanderbilt University sessions. Students being recorded during equipment and 13 patient School of Nursing one their simulation experience then watch care bays with highof the most innovative their experiences post-simulation. fidelity mannequins that and high-tech nursing Promoting Wellness can be used for training programs in the U.S. As part of the School of Nursing’s focus for emergency, obstetrics, The 18-month on well-being, the building incorporates pediatric, bedside, expansion project, which natural lighting, improved air quality, a practitioner office or broke ground in June rooftop green space and open staircases neonatal nursery settings. 2017, includes a statewith wide landings. It was constructed to The space looks like any of-the-art simulation lab, meet LEED Gold certification and rigorous hospital floor, complete technologically advanced WELL Building Standard requirements with headwalls, hospital classrooms and student Women’s Health Academic Director Ginny Moore provides feedback to a student after a simulation that consider a structure’s impact on beds, simulated gasses services offices. The high- with an actor portraying a patient. its occupants in the areas of air, water, and computer monitors. tech building also features nourishment, light, fitness, comfort and Additional equipment can be rolled in from wellness components designed to support classroom is equipped with green, black and mind. The university will apply for WELL the storage room as required by the specific well-being in health and comfort for the white screens, as well as sound abatement Silver certification and anticipates that it simulation. program’s 852 graduate nursing students. and professional lighting, that can be will be Nashville’s first building designed The lab also utilizes a product from configured to meet most production needs, from the ground-up to be WELL-certified. Fulfilling a Vision B-Line Medical®, called SimCapture, whether for a panel presentation or to help So what’s next for “This has been a part of our vision students defend dissertations the high-tech program? for a number of years now,” said VUSN’s and doctoral projects in Weiner said leaders Senior Associate Dean for Informatics Betsy a live environment from are now focusing on Weiner, PhD, RN-BC. “We’ve always been anywhere in the world. faculty development and such a strong distance learning program “What makes training to maximize but needed better multimedia production Vanderbilt different from VUSN’s world-class facilities and better ways to integrate any other nursing program is capabilities. Students will interactive technology that allows students our comprehensive support be able to participate more to work together or apart.” team, from academic interactively and will be The Wachtmeister Interactive instructional designers asked to provide feedback Classroom is equipped with five, highto graphic designers and on the use of technology. definition, interactive displays that allow programmers,” Weiner said. “Our philosophy is that students to huddle for collaborative work, “Schools don’t generally these students are our show content to small groups on individual have that, but we knew that clients, and if they don’t displays from their own laptops or smart if we were going to offer feel comfortable with devices, and to share the results of their distance learning we needed technology, they won’t be work on multiple displays with the entire to do it right.” The Wachtmeister Interactive Classroom features five interactive displays that can be used good distance learners,” classroom. Meanwhile, VUSN’s new virtual Formerly housed in a individually or for the entire class. 10

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Health Care Council Hosts Eyles, Kahn for Policy Discussion At the end of February, the Nashville Health Care Council hosted a lively discussion on healthcare policy with the leaders of two of the most influential industry advocacy groups in Washington, D.C. Matt Eyles, president and CEO of America’s Health Insurance Plans, and Chip Kahn, president and CEO of the Federation of American Hospitals, covered a wide range of topics with panel moderator Melinda Buntin, professor and Mike Curb Chair of the Department of Health Policy for Vanderbilt University Medical Center. Buntin led off the discussion by asking about the Medicare-for-All movement and recent legislation by House Democrats to cover all Americans through the federal healthcare program. Both Eyles and Kahn said the bill is mostly symbolic with little chance of passing in the near term, but both also agreed the proposal should be taken seriously. “It could fundamentally change the economic landscape of this city and many other parts of the country,” said Eyles. While there has been some backing off of the idea of getting rid of all insurance, Eyles said it’s important to take the frustrations seriously and come up with a better way forward to improve access to care. “People want to fix what’s broken. They don’t want to start all over,” he said. “That bill being introduced is a tremendous disappointment to me,” said Kahn, noting the Affordable Care Act could have provided coverage for all. In 2018, Kahn formed the Partnership for America’s Health Care Future, of which AHIP is a participant, in hopes of bringing the industry together under a unified voice in opposition for Medicare for All. “Once President Trump was elected and Bernie Sanders continued to tout Medicare for All, I thought that we in the industry really needed to take the momentum for it seriously,” said Kahn. “We are for having everyone covered,” he continued, but added the industry needed to have cohesive counter-messaging around why Medicare for All isn’t the solution. “I think at the end of the day, if the industry is united, it will make a difference in whether the legislation goes forward.” Buntin also asked about the recent Congressional hearing where seven pharmaceutical executives were called to D.C. to discuss drug pricing and affordability. Eyles, who used to work in the pharmaceutical industry, pointed out the CEOs who testified “said nothing about how they’re going to lower prices.” He continued, “Manufacturers completely control the list price of drugs. They decide if they want to go higher than what’s on the market, or if they want nashvillemedicalnews

.com

© 2019, DONN JONES

By CINDY SANDERS

(L-R) Health Care Council President Hayley Hovious with panelists Matt Eyles, Melinda Buntin and Chip Kahn.

to go lower. Blaming PBMs for rebates is really a deflection.” In addition to addressing the “gaming of pharma prices,” Eyles said he would also like to see increased transparency about how pricing is set. When there are multiple drugs for a disease or condition, Eyles said the marketplace does work. “The problem is when there is no competition, no other option,” he continued, adding there is a need for more biosimilars. The panelists agreed the move toward value-based care will continue, consideration of social determinants of health will take on increasing importance, industry workforce issues need to be addressed, and the hot topic of “surprise bills,” which is a bipartisan concern, will garner increased attention. However, one major area of disagreement came when the discussion shifted towards consolidation within the industry, particularly hospital consolidation. “The consolidation on the insurance side is integration happening along the entire continuum of care, or vertical integration,” said Eyles. “This will lead to better outcomes at a lower cost. However, with straight up horizontal consolidation, like what you see on the provider side, it’s more about market power.” Kahn countered that the consolidation happening on the provider side, particularly with hospitals, is an inevitability of the changing healthcare landscape. “I think all the noted economists, insurance CEOs and policymakers who complain about hospital consolidation live in a total fantasy world,” said Kahn. “The traditional hospital model is fundamentally changing. Inpatient revenue is no longer able to support many hospital systems because so much care is no longer being provided

on an inpatient basis.” He added, “It’s unrealistic to think we’re going to have free-standing hospitals competing with each other. The institution is unsustainable.”

Back in agreement mode, both panelists expressed concern over access to care in rural communities. Kahn said he worried about whether or not healthcare would continue to be there for rural communities in the way they expect. Eyles noted a few short-term options are in play to help alleviate some immediate issues but added long-term solutions are needed to address the problems, such as provider shortages and the changing delivery model, that disproportionately impact rural healthcare. “Rural hospitals have high populations of Medicare and Medicaid patients,” noted Kahn. “They just can’t make it only on the federal mix,” he said of reimbursement woes. Kahn opined proponents of Medicare for All should look at rural hospitals as a leading indicator of why a single payer model isn’t viable. As the discussion drew to a close, Buntin asked the panelists if Nashville has a role to play when it comes to impacting policy on the federal level. “Nashville is absolutely a hub of disruption, innovation and change we want to see within the healthcare system,” said Eyles. “As an industry, Nashville’s healthcare leaders need to engage with

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Addressing the GAPs in Alzheimer’s Trials, Treatment Recent Meeting Brought Clinical Trials Professionals to Nashville By CINDY SANDERS

The Global Alzheimer’s Platform (GAP) Foundation, an organization dedicated to improving Alzheimer’s clinical trials in the quest of a cure, has just wrapped the GAP-NET Site Optimization Conference in Nashville. The Feb. 27-March 1 meeting brought together approximately 150 representatives from its network of Alzheimer’s clinical research sites. The third annual GAP-NET conference attracted the range of professionals required to successfully plan and launch Alzheimer’s clinical trials including major researchers, pharmaceutical executives, trial site managers, principal investigators, and representatives of clinical research organizations and institutional review boards. The 2019 event came at a time when a number of once-promising molecules targeting amyloid plaque have fallen short in clinical trials.

Filling a Gap

John Dwyer, president and founding board member of the Global Alzheimer’s Platform Foundation, said the organization came about as an effort to make the trials process more efficient in order to speed treatment options to John Dwyer patients. Currently, more than 120,000 Tennesseans and 5.5 million Americans over the age of 65 have

Alzheimer’s. Those figures are anticipated to rise by 17 percent by 2025. “In light of how difficult clinical trial successes are with Alzheimer-targeted molecules, a group of philanthropic organizations and larger pharmaceutical companies came together to look to lower the cost, shorten the duration, and improve the overall effectiveness of trials,” he explained of the foundation’s work, which officially launched operations in January 2016. “Our first step was to identify the things that are preventing Alzheimer trials from being operationally effective,” Dwyer continued. “A lot of clinical trials fail … it’s typical … but in Alzheimer’s trials, it’s 10-20 times worse. Every study that gets done gets us closer to a cure or shuts the door on an avenue of inquiry that wasn’t fruitful.”

Aiming for Efficiency

Alzheimer’s trials face multiple hurdles impacting efficiency and effectiveness. According to GAP, nearly 90 percent of Alzheimer’s clinical trials are delayed because there aren’t enough volunteers. Dwyer also said there has been too much variance in how trials are conducted and too many administrative delays in the startup. GAP’s goal was to disrupt the traditional launch process by addressing operational efficiencies with a variety of tools, including utilizing a common IRB for all GAP-NET trial sites involved in a specific trial rather than have individual IRBs review and sign off. Dwyer likened it to the Common App, which allows students to apply to multiple colleges through a

Blog Log The Nashville Medical News Blog features additional insights and information from a cross-section of industry leaders. The blog can be accessed directly through NashvilleMedicalNews.Blog or from the homepage of the main website.

NEW IN MARCH Don Baham, CISSP, CISA, MCSE, president of Kraft Technology Group, discusses four trends in blockchain to watch this year as the healthcare industry looks to leverage the technology to improve communication across the continuum, reduce administrative costs and enhance quality of care. Philip Betbeze, senior advisor with Lovell Communications, shares strategic insights into the lessons learned from the first two months of “price transparency” following new requirements that hospital post chargemaster prices online. Dennise Brogdon shares the history and legacy of The Hughston Clinic, which is celebrating 70 years of service in 2019. Founded by renowned Georgia physician Jack Hughston, today the practice has grown to include clinics in six states, specialized trauma services in major hospitals and more than 50 board-certified, specialty-trained physicians, including the specialists of Hughston Clinic Orthopaedics Tennessee. George Buck, president emeritus, and Judd Peak, chief compliance officer and general counsel, with Frost-Arnett Company, take a vendor’s perspective to drill down on “Laws and Regulations Continue to Affect Patient Pay.” Postponed from last month in order to include the latest information out of D.C., part five of this six-part series looks at the Bureau of Consumer Financial Protection.

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streamlined process. “We now have 72 clinical trial sites in North America – Canada and the United States – that have agreed to work with us on this new, disruptive way to design and launch trials,” Dwyer said. He noted among the participants are Vanderbilt University Medical Center and Clinical Research Associates (CRA) in Nashville. “Vanderbilt and CRA have been foundational to assisting us in implementing trials more efficiently and collaborating on better trial design,” he added. The proof of concept began last January when the first trial utilizing GAP operational efficiencies launched. By June, the trial was underway. “Our first study was up and running in six months,” said Dwyer. “The comparable average is 18 months.” Dwyer said GAP is agnostic when it comes to the science behind the trials. Instead, the focus is on “recognizing the greater good requires standardization.” Dwyer added, “That means we might get a cure in the hands more quickly, and we reduce the amount of time a trial participant spends in the study.” CRA President and CEO Linda Moore Schipani, RN, MSN, said Alzheimer’s studies tend to be very complex, so standardization of best practices is welcomed. Schipani, who helped found the Nashville-based clinical trials company in 1990, said sharing information with other partner sites helps everyone improve approaches to Alzheimer trial administration, training and recruitment.

If at First You Don’t Succeed

Referencing a recent Fortune magazine Article (“Alzheimer’s: A Trail of Disappointment for Big Pharma,” Jan. 2019), Schipani said in the last year alone, half a dozen potential Alzheimer’s drugs have failed, at a cost of billions of dollars. “We find we’ve all been racing down the wrong path,” she said. Schipani added the frustration is magnified by the tremendous need for new treatment options. “The last drug that was approved by the FDA was in 2003.” Noting all scientific endeavors start with a hypothesis, CRA Medical Director Stephen C. Sharp, MD, said Alzheimer’s research has heavily focused on amyloid lumps, which differentiate the disease from other forms of dementia. “We’ve had a little bit of ‘everyone putting their eggs in one basket’ approach,” he said. “I think the evidence clearly suggests there has been a lot of negative results when you target beta amyloid in its single strand form,” agreed Dwyer, who added there are still a couple of studies focused on beta amyloid oligomers that could hold promise. While the results have been disappointing, both Sharp and Dwyer pointed out negative results also move the

body of knowledge forward. “Making lemonade out of lemons, this opens the door to funding for some of the other approaches,” said Sharp. “There’s nobody with Alzheimer’s who doesn’t have a buildup of beta amyloid and tau,” Dwyer said. He added more attention might now focus on the tau part of the equation or follow inflammation studies that offer another interesting angle. Echoing those sentiments, Schipani said she is grateful to have helped bring some drugs to market and equally grateful that trials have kept other drugs off the market when they offer false hope or prove harmful. “It’s really hard to be safe and effective,” she pointed out.

Searching for New Solutions

As with any clinical trial, it takes patients willing to give of their time to make a breakthrough. Sharp said clinicians desperately need new options. “We have a toolbox that’s almost empty right now, and we need more tools. We have to develop those drugs, and that’s never going to happen if we don’t get more people into trials.” Schipani pointed out working with a clinical trial site offers extra support for patients, families and providers. “We can do many more tests than is going to be available in a standard practice,” she noted, adding CRA is happy to share lab work and testing results that don’t impinge on proprietary information. Working in partnership with primary care providers, researchers also would love to get more patients into Alzheimer’s trials earlier in the disease process. “There are some pretty standard tools for cognitive function, and I think that should be part of an annual physical,” Schipani said. “Generally, people are having some issues five years before they mention it to their provider.”

Front Row View in Nashville

GAP-NET in Nashville included discussions on successful recruiting strategies and regulatory changes in Medicare Advantage that could help identify patients with dementia – with and without complications – at an early stage. Dwyer said the success of the GAPNET Site Conference has been bringing together all the folks on the front lines who are doing the heavy lifting to gain their insights on trial designs, implementation protocols, what works, and what doesn’t. He added everyone “leaves their ego at the door” to allow for open discussions. “It’s a wonderful exchange between people doing the work and people dreaming up the work,” Dwyer said. “It’s a collective activity where the whole ecosystem comes together to collaborate and ensure best practices to make clinical trials better.” nashvillemedicalnews

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GRAND ROUNDS Mark Your Calendars Friends & Fashion • April 1 Music City Center

Save the date for the annual silent auction, runway show, shopping and luncheon event benefiting the Monroe Carell Jr. Children’s Hospital at Vanderbilt. For more information or to purchase tickets, go online to ChildrensHospitalVanderbilt.org/friendsandfashion.

Dr. Matthew Walker, Sr. Legacy Breakfast • April 4 Cal Turner Family Center at Meharry

these women who died while pregnant or within a year of their pregnancies,” said TDH Commissioner Lisa Piercey, MD, MBA, FAAP. “We are grateful to the committee members who contributed to this report by reviewing information about these deaths and developing recommendations that can save lives.” The full report is available online at NashvilleMedicalNews.com.

Researchers Push Forward Frontiers of Vaccine Science

Using sophisticated gene sequencing and computing techniques, researchers at Vanderbilt University Medical Center (VUMC) and the San The second annual breakfast event Diego Supercomputer Center have benefitting the Matthew Walker Comachieved a first-of-its-kind glimpse into prehensive Health Center and honorhow the body’s immune system gears ing the clinic’s founder is set for 7:30up to fight off infection. 9 am on April 4. Dr. Stephanie Bailey, Their findings, published last senior associate dean of Public Health month in the journal Nature, could Practice at Meharry and lifelong comaid development of “rational vaccine munity health champion who previously design,” as well as improve detection, led efforts for the Metro Department of treatment and prevention of autoimHealth and CDC’s Public Health Pracmune diseases, infectious diseases, tice is the 2019 keynote speaker. Admisand cancer. sion is free (donations appreciated) but The study focused on antibodyreservations are required. Go online to producing white blood cells called B bit.ly/legacybreakfast to register. cells. These cells bear Y-shaped receptors that, like microscopic antenna, can ACRP 2019 • April 12-15 detect an enormous range of germs Omni Hotel Nashville and other foreign invaders. They do The Association of Clinical this by randomly selecting and joining Research Professionals is holding their together unique sequences of nucleoannual meeting in Nashville. Don’t tides known as receptor “clonotypes.” miss out on this premier education and In this way a small number of genes can networking event for clinical research lead to an incredible diversity of recepprofessionals featuring six educational tors, allowing the immune system to tracks plus the Signature Series. Regisrecognize almost any new pathogen. tration is available online through the Understanding exactly how this NashvilleMedicalNews.com website or process works has been daunting. “Priat 2019.acrpnet.org. or to the current era, people assumed it would be impossible to do such a Tennessee Issues Maternal project because the immune system is Mortality Report theoretically so large,” Last month, the Tennessee Departsaid  James Crowe Jr., ment of Health issued the first materMD, director of the nal mortality review report, TennesVanderbilt Vaccine see Maternal Mortality Review of 2017 Center  and the paper’s Maternal Deaths. The report describes senior author. “This new the state of maternal mortality in Tenpaper shows it is posnessee based on a comprehensive sible to define a large review of deaths of women who died Dr. James portion,” Crowe said, Crowe Jr. while pregnant or within one year of “because the size of pregnancy. State officials said the goal each person’s B cell receptor repertoire of the effort is to identify opportunities is unexpectedly small.” for preventing maternal deaths and The researchers isolated white promoting women’s health. blood cells from three adults, and then The MMR committee determined 85 cloned and sequenced up to 40 billion percent of all maternal deaths reviewed B cells to determine their clonotypes. to be preventable.  In 2017, 78 women in They also sequenced the B-cell recepTennessee died while pregnant or withtors from umbilical cord blood from in one year of pregnancy. Substance use three infants. This depth of sequenccontributed to 33 percent of all preging had never been achieved before. nancy-associated deaths in 2017 and What they found was a surprisingly mental health conditions contributed to high frequency of shared clonotypes. 18 percent of these deaths. The MMR “The overlap in antibody sequences in Committee recommended increasing between individuals was unexpectedly access to mental health and substance high,” Crowe explained, “even showabuse treatment both during and for ing some identical antibody sequences the year following pregnancy.  Viobetween adults and babies at the time lence was also noted as a significant of birth.” contributing factor to maternal deaths Understanding this commonality is with 14 percent of the maternal deaths key to identifying antibodies that can in 2017 being the result of homicide.     be targets for vaccines and treatments “We dedicate this report with deepest that work more universally across popusympathy and respect to the memory of lations.  nashvillemedicalnews

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Centerstone’s Research Institute Announces Promotions

Community-based behavioral health provider Centerstone recently announced two executive promotions for its Research Institute. Ashley Newton, MPS, PMP, has been named chief operating officer for Centerstone’s Research Institute and vice president of Center for Clinical Excellence. Newton previously served as vice president of Center for Clinical Excellence for Centerstone’s Research Ashley Newton Institute. Newton joined Centerstone in 2006 and has previously held both clinical and leadership roles. She earned both her undergraduate and master’s degrees from Middle Tennessee State University. She is a certified by Massachusetts Institute of Technology in Design Thinking, Lean Six Sigma methodologies, is an ACRA-ACC clinical supervisor and a Project Management Professional (PMP). Jennifer Lockman, PhD, has been named vice president of Clinical & Transitional Research. She previously served as the director of the research area. She joined Centerstone in 2007 and Dr. Jennifer earned her doctorate Lockman

in counseling psychology from Purdue University, West Lafayette, Ind. and her master’s in professional counseling from Lipscomb University.

Business Briefs

Nashville-based Cumberland Emerging Technologies (CET) – a joint initiative between Cumberland Pharmaceuticals, Vanderbilt University, LaunchTN, and China’s Gloria Pharmaceuticals – recently announced a collaborative agreement with the technology transfer organization for the Medical University of South Carolina (MUSC) Foundation for Research Development to develop new biomedical products. Under the agreement, CET will evaluate MUSC discoveries, license intellectual property rights to promising technologies, and partner with MUSC research scientists to advance product development toward commercialization. EvidenceCare, a Nashville-based innovator in clinical decision support technology, recently announced its partnership with MCG Health, part of the Hearst Health network, to embed MCG’s industry-leading admission indications into the EvidenceCare clinical decision support tool. With the new partnership arrangement, admission indications from the MCG care guidelines will be integrated with EvidenceCare’s point-of-care protocols to support clinicians and their hospitals with improving the quality of patient care.

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GRAND ROUNDS BlueCare Tennessee Selects Dungan as CFO

BlueCare TennesseeSM, the Medicaid subsidiary of BlueCross BlueShield of Tennessee, recently named Casey Dungan, MPA, vice president and chief financial officer. In this role, he will supervise the organization’s financial planning and administration of Med- Casey Dungan icaid contracts with the Bureau of TennCare. Dungan’s career in healthcare finance has included extensive experience with industry advocacy and government programs. He comes to BlueCare from the Tennessee Hospital

Association (THA), where he served as senior vice president of finance. Prior to that, he served for nearly 10 years in TennCare’s financial division, including as CFO from 2011-2016. He earned his undergraduate degree from Duke University and a Master of Public Administration from the University of Georgia.

Blakely Joins Bradley as Healthcare Associate

In late February, Bradley Arant Boult Cummings LLP announced Derick Blakely has joined the firm’s Nashville office as an associate in the Healthcare Practice Group. Blakely provides healthcare regulatory counsel related to compliance, operational and transactional matters. He works with a vari-

State Considers Raising Age to Purchase Tobacco, Vaping Products

In late February, Tennessee Sen. Shane Reeves (R-Murfreesboro) and Rep. Bob Ramsey (R-Maryville) held a press conference in conjunction with NashvilleHealth to announce sponsorship of legislation to raise the minimum age to purchase tobacco and vaping products to 21 from the current age of 18. The proposed legislation comes at a time when the health risks associated with vaping are becoming clearer. Last year, the U.S. Surgeon General released an advisory on e-cigarettes (L-R): Sens. Richard Briggs, Joey Hensley, Shane Reeves, Rosalind Kurita and use by teens. and Rep. Bob Ramsey. An earlier Surgeon General’s report on tobacco use noted nine out of 10 smokers began when they were teens. In addition to raising the minimum age for purchase, SB 1200/HB 1454 would remove penalties for purchase from the purchaser, strengthen penalties for those selling to minors, redefine “electronic smoking device,” and redefine “tobacco product.” At the press conference, attendees noted Tennessee’s smoking rate of 22 percent is among the worst in the nation. In Tennessee, 20.3 percent of high school students reported smoking cigarettes or cigars or using smokeless tobacco or electronic vapor products at least one day during the last 30 days. Currently, seven states and more than 400 municipalities have raised the tobacco and/or vape age minimum to 21 with several others considering similar measures.

Ascension Saint Thomas Health Announces New Neurosciences Intensive Care Unit

ety of healthcare clients, including hospitals, ambulatory surgery centers and other providers. Prior to joining Bradley, he was an associate with Bass, Berry & Sims PLC. Blakely earned his Derrick Blakely undergraduate degree from the University of Virginia and his law degree from American University Washington College of Law. During law school, he worked at the U.S. Department of Health and Human Services Office of Inspector General and the D.C. Office of Inspector General, where he investigated and analyzed healthcare fraud and abuse issues. Prior to law school, he worked in the government services and consulting industry.

Gresham Smith Expands Healthcare Practice, Welcomes Langlois

Nashville-based Gresham Smith has added to the company’s healthcare expertise with the addition of Jim Langlois, AIA, LEED AP, as executive vice president for the firm’s Healthcare market and Lesa Lorusso as healthcare directorof research and Jim Langlois innovation. Additionally, the firm has added an office presence in Chicago to enhance healthcare market growth strategy. Langlois brings more than 30 years of diverse experience to his new role. Most recently, he served as Healthcare Principal and Studio Director for a Carolina-based design firm. Prior to that, he had a 13-year career with HDR Architecture serving as Managing Principal and National Healthcare Principal for the firm’s Federal Program. Langlois has worked with an array of clients from academic medical centers to large healthcare systems to the Veterans Affairs. He earned a Bachelor of Architecture from Boston Architectural College and also holds a Master of Science in Executive Coaching from Queens University of Charlotte, McColl School of Business.

In late February, Ascension Saint Thomas Health announced the opening of their new multidisciplinary Neurosciences Intensive Care Unit located at Saint Thomas West Hospital. According to health system officials, the Neuro Intensive Care Unit is focused on advanced, multidiscipline, patient-centered treatment of some of the most perilous neurological conditions patients can face. Saint Thomas West will expand from 86 ICU beds to 100 ICU beds because of this change, including 14 dedicated Neuro ICU beds. A Comprehensive Stroke Center, the unit includes the latest advanced imaging capabilities available around the clock to help patients with complex stroke cases, as well as specialized cerebrovascular neurosurgeons and participation in stroke research. In addition, the hospital is recognized for its expertise in treating brain tumors and other brain disorder through an innovative, individualized approach. The UNITY System is a fully integrated neurosurgical center that brings together a team of brain specialists for every patient. It is one of only a few such centers in the United States.

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Y O U R M I D D L E T N S O U R C E F O R P R O F E S S I O N A L H E A LT H C A R E N E W S

PUBLISHED BY: Graham | Sanders Publishing, LLC PUBLISHERS Susan Graham & Cindy Sanders SALES 615.397.2836 Cindy Sanders Maggie Bond Pamela Z. Haskins Jennifer Trsinar MANAGING EDITOR Cindy Sanders csanders@nashvillemedicalnews.com CREATIVE DIRECTOR Susan Graham sgraham@nashvillemedicalnews.com CONTRIBUTING WRITERS Melanie Kilgore-Hill Cindy Sanders CIRCULATION subscribe@nashvillemedicalnews.com —— All editorial submissions and press releases should be emailed to: editor@nashvillemedicalnews.com —— Subscription requests or address changes should be mailed to: Nashville Medical News 105 Spring Ridge Lane Nashville, TN 37221 615.646.3916 • (FAX) 615.673.8819 or e-mailed to: subscribe@nashvillemedicalnews.com

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GRAND ROUNDS Price Joins TriStar Women’s & Children’s as COO

TriStar Centennial Medical Center recently welcomed Amber Price, DNP, CNM as chief operating officer for TriStar Centennial Women’s Hospital and The Children’s Hospital at TriStar Centennial. Most recently, she served as associate administrator and vice Amber Price president of Women and Children at The Women’s Hospital at Henrico Doctors’ Hospital in Richmond, Va. Price earned her undergraduate degree in nursing from Old Dominion University, her master’s in the field from the University of Cincinnati, and her Doctor of Executive Nursing Practice degree from Johns Hopkins University in 2016. She also earned a post-master’s certificate in Global Women’s Health from the University of Cincinnati in 2010.

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

HCA Healthcare, with 185 hospitals and approximately 1,800 sites of care in 21 states and the United Kingdom, has been recognized for a 10th consecutive year as one of Ethisphere Institute’s World’s Most Ethical Companies. BlueCross BlueShield of Tennessee has recognized TriStar Centennial Medical Center with a Blue Distinction Centers for Cardiac Care designation, as part of the Blue Distinction Specialty Care program. Blue Distinction Centers are nationally designated providers that show expertise in delivering improved patient safety and better health outcomes, based on objective measures. Additionally, TriStar Centennial Heart and Vascular Center has earned The Joint Commission’s Gold Seal of Approval™ for its ventricular assist device destination therapy program. Nashville-based HealthTrust Workforce Solutions has been recognized with a Best of Staffing® Client Award by ClearlyRated for endorsements received from its client organizations. South College has announced the launch of two new programs in dental assisting and hygiene at its Nashville Campus with the first classes scheduled to start in April. Both programs blend theoretical, laboratory, and clinical instruction to prepare graduates to become licensed dental practitioners. In other news, South College has once again has earned the Military Friendly® School designation for 2019-2020 and is among the Top 10 in the country. The list is created each year based on research using public data sources for more than 8,800 schools nationwide, input from student veterans, and responses to a proprietary survey. South College is one of 770 schools across the country that earned the designation. Sharon Reynolds, president and CEO of Nashville-based DevMar Products LLC, is the newest at-large member of the Women Presidents’ Organization (WPO, a prestigious peer advisory group for million dollar plus women-led companies. nashvillemedicalnews

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Local Orthopaedic Specialists Carry out Hughston Legacy Malcom E. Baxter, MD Hip Arthroscopy, Shoulder & Knee Surgery, Sports Related Injuries & Joint Replacement

Jonathan P. Cornelius, MD Orthopaedic Trauma, Joint Replacement, MAKOplasty Robotic Joint Replacement & Sports Medicine

Robert P. Fogolin, MD General Orthopaedics, Arthroscopy, Joint & Partial Knee Replacement, Regenerative Medicine & Orthopaedic Trauma

Christopher M. Jones, MD Shoulder, Elbow, Hip, Knee & Sports Medicine

Christopher P. Kauffman, MD Orthopaedic Spine Specialist, Orthopaedic Trauma & Fracture Care

William C. Mayfield III, MD Arthroscopy, Knee & Shoulder Reconstruction & Sports Medicine

Tiffany Feltman Meals, DO Total Joint Replacement & General Orthopaedics Arthroscopy, Shoulder, Knee, Regenerative Medicine, General Orthopaedics & Sports Medicine

Shawn P. Mountain, DO General Orthopaedics & Sports Medicine

James Renfro, Jr., MD Joint Replacement, Arthroscopic Surgery, Knee and Shoulder Injuries & Sports Medicine

Lucas B. Richie, MD General Orthopaedics, Sports Medicine & Regenerative Medicine

Todd A. Rubin, MD Hand & Upper Extremity Surgery, Elbow & Wrist Arthroscopy, Upper Extremity Joint Replacement, Sports & Work Injuries, Arthritis & Carpal Tunnel Release

Matthew Sarb, DO, MPH Joint Replacement, Anterior Hip Replacement, Orthopaedic Trauma, General Orthopaedics & Sports Medicine

Marc A. Tressler, DO Orthopaedic Reconstruction, Orthopaedic Trauma, Foot & Ankle & Regenerative Medicine

Joseph A. Wieck, MD Arthroscopy, Orthopaedic Trauma, Joint Replacement, General Orthopaedics & Sports Medicine

‘‘

As a practice, we have an orthopaedic-specialized team of healthcare professionals and some of the best … and most well known … board-certified, fellowship-trained surgeons in the country. For years, many in Middle Tennessee knew us as Premier Orthopaedics & Sports Medicine. In the fall of 2016, we affiliated with the renowned Hughston Clinic, which is celebrating its 70th anniversary this year. Internationally recognized for research excellence and the highest standard of patient outcomes, the alignment with Hughston Clinic matched our own culture of care that our patients and referring physicians have long relied upon, and the partnership has enhanced our work by giving us increased access to education and training on the cutting-edge techniques that come with being part of a larger organization. We bring the combined experiences of our local team and colleagues across the Southeast home to Middle Tennessee to provide innovative surgical and nonsurgical treatments of musculoskeletal disorders and injuries. From the rapidly growing areas of regenerative medicine — including stem cell therapies and platelet rich plasma treatments — to being on the forefront of robotic joint replacement, we are constantly striving to provide the best-possible options for our patients. We have specialists in hand, elbow, shoulder, spine, orthopaedic trauma, hip, knee, foot and ankle, joint replacement, and sports medicine, who provide the most up-to-date treatments used today. Our goal is to provide the quickest return to sport and to life that our patients want. We partner daily with our patients to work toward their goals and the best possible outcomes for the life they want to live.

‘‘

Gregg A. Motz, MD

Jon Cornelius, MD President, Hughston Clinic Orthopaedics

LOCATIONS Nashville Hughston Clinic Orthopaedics at TriStar Centennial 2400 Patterson Street, Suite 300 Hughston Clinic Orthopaedics at TriStar Harding Place 394 Harding Place, Suite 200 Hughston Clinic Orthopaedics at TriStar Skyline 3443 Dickerson Pike, Suite 190 Hughston at TriStar Summit 5655 Frist Blvd. Surgeries Only

Dickson Hughston Clinic Orthopaedics at TriStar Horizon 111 Highway 70 East, Suite 103

Hendersonville Hughston Clinic Orthopaedics at TriStar Hendersonville 353 New Shackle Island Road, Ste 141C

Lebanon 100 Physicians Way, Suite 110 Lebanon, TN 37090

Smyrna Hughston Clinic Orthopaedics at TriStar Stonecrest 300 StoneCrest Boulevard, Suite 200

www.hughston.com/tn

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