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April 2016 | Volume 62, Number 4

Robert Guyette, MD, DMD From shooting hoops to medicine Page 23

Technology’s impact on medicine Page 6

Violating HIPAA in 140 characters or less Page 29



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February 2016 | Volume 63 Round-up (USPS 020-150) is published 12 times per year by the Maricopa County Medical Society, 326 E. Coronado, Phoenix, AZ 85004. Round-up is a publication of the Maricopa County Medical Society (MCMS). Submissions, including advertisements, are welcome for review and approval by our editorial staff at All solicited and unsolicited written materials and photos submitted to Round-up will be treated as unconditionally and irrevocably assigned to and the property of MCMS and may be used at MCMS’ sole discretion for publication and copyright purposes and use in any publication, website or brochure. MCMS accepts no responsibility for the loss of or damage to material submitted, including photographs or artwork. Submissions will not be returned. The opinions expressed in Round-up are those of the individual authors and not necessarily of MCMS. Round-up reserves the right to refuse certain submissions and advertising and is not liable for the authors’ or advertisers’ claims and/or errors. Round-up considers its sources reliable and verifies as much data as possible, but is not responsible for inaccuracies or content. Readers rely on this information at their own risk and are advised to seek independent legal, financial or other independent advice regarding the content of any submission. No part of this magazine may be reproduced or transmitted in any form or by any means without written permission by the publisher. All rights are reserved.



April 2016 | Volume 62, Number 4

5 6 8 10


Bridges to Recovery

Protect Your Most Important Asset …Yourself


Member Profile

Distraction and the Role of Mobile Device Technology in Healthcare


What’s Inside President’s Page Medical Technology

By Lisa M. Rudolph

by Karen Wright, RN, BSN, ARM, CPHRM

12 14

Maintaining the patient story

Innovative technologies that allow transcription to be used seamlessly with EMRs while still showing “meaningful use.” By Kamal Irani

The Employer-Led Health Care Revolution

By Patricia A. McDonald, Robert S. Mecklenburg, MD, and Lindsay A. Martin


Transforming Health Care Takes Continuity and Consistency

Understanding Unintentional Addiction to Prescription Medication Triggered by Chronic Pain in First Responders By Michel Sucher, M.D., FASAM, FACEP

Keeping ahead of medical technology: an interview with surgeon and inventor Robert Guyette, MD

Violating HIPAA In 140 Characters Or Less By Bryan Bailey, Esq.

32 39 41 43

Beers with Peers Mentoring Event Board Minutes In Memoriam Marketplace

By Mark Britnell


STAT Transcription Accurate, On-Time Reports









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What’s Inside April 2016


any have debated the role of technology in our society. Even those looking at how it impacts medicine have long wondered if it’s master or servant.

Most agree that technology has improved the accessibility of health information for so many, although many a physician will point to the trouble that arises when patients ‘self diagnose’ with resources such as WebMD. However, most would also agree that technology, though principally rooted in making our lives easier, has led to deteriorating health as we spend more and more time on a couch watching TV, in a chair on the computer, or oblivious to our surroundings as we look deeply into the soul of our smartphone. In the past three decades childhood obesity has exploded by more than 300%; it’s hard to argue technology isn’t the primary culprit. But technology isn’t all bad, especially in medicine. The boom of wearable devices has presented unique opportunities for physicians to peer in on the lives of patients. Take heart failure as an example. Researchers at the Scripps Institute are testing a number of wearables that will transmit data – in real-time – to care teams to let them know how a patient’s heart is functioning, and alert the patient to adjust routines, diet, and/or medications. A Silicon Valley start-up is developing a technology that sends ‘smart sensors’ into the digestive system, and transmits a signal to a skin patch, then to a smart phone to alert the patient’s physician what medication the patient is taking, at what dose, and when. Technology like this could go a long way addressing medical compliance concerns. Lastly, surgeons are now employing 3D printers to engineer exact replicas of surgical sites prior to operating to evaluate various procedure approaches to optimize outcomes. Wow. Technology is here to stay, especially in medicine. This bothers a number of phy-

sicians who long for the days of a stethoscope, an exam room, and plenty of time to examine their patient. I completely understand their concern. Many have called me upset by their own experiences as a patient, now that they’re on the other side of the (exam) table. I often hear stories of young docs entering the exam room, eyes focused on their iPhone. They gravitate straight to the computer, don’t make eye contact, and begin the Q&A with their back to the patient. Within five minutes, the exam is complete, and the doctor never put his or her hands on the patient. Has technology led medicine down this path?

Jay Conyers, PhD EXECUTIVE DIRECTOR 602.251.2361

This month in Round-up we profile a physician who truly embodies the spirit of technology in how he practices medicine: Robert Guyette, MD, DMD, who has been a Society member since 1989 and heads Guyette Facial & Oral Surgery Dental Implant Center. We also bring you an article from Bryan Bailey, healthcare attorney with Milligan Lawless, on the perils of texting patient information and some recommendations remaining HIPAA compliant. KPMG’s Mark Britnell offers a great narrative on how to successfully transform a health system and the keys to sustainability. We also have a great article by a team of experts who look at how employers such as Intel have changed the way employees access care, and the associated costs. Next month, we profile Sumer Daiza, MD, a born-and-raised Phoenician who heads a vibrant plastic surgery practice in Scottsdale. From day one, she’s been committed to ‘going it alone’ and hasn’t looked back. We have a great issue planned around Dr. Daiza’s profile and hope you enjoy reading it! Until then, we hope to see you at one of our events soon. Stay tuned for announcements in our e-newsletter, InforMED, and plan on joining us next time around.



President’s Page T

his month’s topic is medical technology. We are all familiar with the never-ending stream of advances in the biotech industry, encompassing everything from new medical implants (non-surgical heart valves, deep brain stimulators, MRI-safe pacemakers and defibrillators, dissolvable stents, joint implants, etc) to new tools allowing for minimally invasive surgeries (laparoscopic surgeries, robotic surgeries, ultrasound and CT guidance for biopsies and endovascular procedures, etc), to new or enhanced imaging modalities (PET scans, functional MRI, optical coherence tomography, portable 3D ultrasound, etc). However, I would like to highlight a few other areas in which technology has impacted the way we practice medicine. First of all, we should all understand that the explosion in the general use of social media has not left medicine untouched. There are numerous online platforms where patients can comment on and rate the physicians they use. When was the last time you stopped to check your online “reputation?” Does your practice have an active online presence? I make it a habit to ask my new patients how they discovered my practice, and I am often surprised that more and more patients have not simply been referred by their primary care physicians, but rather, have completed an exhaustive internet search and found my practice online by themselves. It is worth remembering that whether we choose to actively manage it or not, we all have an online presence. There are also social media outlets specific to physicians which allow only physicians to register, and offer a place for physicians to “virtually hang out” with other




physicians, to share stories (generalized and in a HIPAA-compliant fashion), commiserate about job satisfaction or lifestyle issues (in a legal, anti-trust-complaint fashion), etc. Most specialty societies now offer online educational opportunities, complete with case descriptions, graphics, and both audio and video files showing physical exam features and diagnostics, and many offer their own “chat-rooms” where physicians can offer comments about a specific case or other similar cases they have encountered in their own practice. This allows most physicians to obtain the majority of their required CME credits online without ever leaving their own office or living room. However, there are some pitfalls associated with the ease and expanded use of online access. How familiar are you with the legal rules regarding what you can and cannot post online about your practice? When was the last time you complained about a patient or nurse on a general social media outlet? I have personally witnessed several such instances. Is this legal? Perhaps. Is it appropriate? Perhaps not. Another example of medical technology helping both patients and physicians locally in Arizona and in Maricopa County is Arizona’s telemedicine parity law. This law, passed in 2013, provides telemedicine parity for certain

medical services in rural areas in Arizona. The law forces insurers to cover certain medical services to rural areas provided via telemedicine if those same services would be covered if rendered in a face to face physician encounter. Services covered include: trauma, burns, cardiology, infectious diseases, mental health disorders, neurological diseases including strokes, and dermatology. This is a clear and undeniable benefit to our state’s underserved areas. While currently limited, the future prospects for telemedicine are profound. The technology exists today to transmit not only voice and video, but also many diagnostic tools as well, such as ECGs, auscultory devices such as digital stethescopes, and even portable 3D ultrasounds. Finally, I would be remiss if I did not comment on the proverbial 400-pound elephant sitting in most of our exam rooms these days: the electronic medical record. Initially, the EMR was simply a way to replace paper, similar to the way in which I am typing this article on my computer rather than writing it out by hand or typing it on a typewriter. In this way, I can more easily edit my words, save them, make digital copies, and have remote access if I store the article online or in the cloud. When I practice at my outreach clinics, rather than carrying with me a load of paper charts for the day’s patients, I can simply log on remotely to our EMR and access my patients’ charts just as if I were in my main office. It has been a dream of many physicians, and patients as well, to have a nationally unified EMR so that one could have easy access to a patient’s past medical history wherever or whenever a patient presented for a health care issue. It was perhaps for this reason there was initially such a strong push nationally for doctors to switch from paper charts to EMRs. The federal government even gave physician prac-

tices monetary incentives to make the switch. Of course, in order to prevent doctors from gaming the system to gain the incentive dollars, physicians had to attest that they were actually using a “real” EMR. And we all know the fiasco that has ensued. Attesting to “meaningful use” of an EMR became so cumbersome as to be almost impossible, and the EMRs grew in complexity to meet the constantly morphing “meaningful use” standards. A typical office note nowadays has almost nothing to do with actual patient care. When I receive notes from primary care physicians, other specialty physicians, or even hospital notes, I engage in a game similar to the “Where’s Waldo” books my children used to read, where they would stare at a complicated picture of random items and try to pick out the tiny Waldo character from the rest of the background clutter. The EMRs we currently use, as well as every software upgrade we have purchased, are almost entirely designed to simply meet compliance rules for meaningful use attestation. Clearly, the EMR industry and its government regulators took a wrong turn somewhere. And clearly, only a strong and unified physician voice will allow us to get the EMR, which at its most basic level is a worthwhile endeavor, back on track to being meaningfully, medically useful.

Adam Brodsky, MD, MM

MCMS PRESIDENT 2016 602.307.0070

Dr. Brodsky specializes in Interventional Cardiology He joined MCMS in 2005. Contact Information: Heart & Vascular Center of Arizona 1331 N. 7th Street Suite 375 Phoenix, AZ 85006



Protect Your Most Important Asset…Yourself BY LISA M RUDOLPH


am a stage 4 terminal cancer survivor. I was diagnosed while pregnant with my daughter at the age of 29. I was diagnosed with mucoepidermoid carcinoma, a base of tongue tumor. After numerous surgeries, one being 14 ½ hours long, radiation treatments, physical therapy and a home care nurse, my last day of treatment was the night before Thanksgiving 1999, so I can now proudly say, I am cancer free! I am passionately aware of the financial devastation a Critical Illness can cause. I know how committed physicians are towards healing their patients and prolonging our lives. I have focused my career towards helping doctors protect themselves, their income, their family and their professional reputation. Today, patients are surviving Critical Illnesses; these patients would have been terminal just a few years ago. This is a direct result of what you do. Perhaps you have noticed that many of those who survive suffer from financial hardship. Lifestyles are adversely affected. So are the lives of their families during recovery. In 1983, Dr. Marius Barnard (of South Africa) envisioned




The sad truth is that the miracle of today’s medical procedures may save your life but create long-term financial challenges for you. a health insurance vehicle to help patients who are diagnosed with an illness. “It’s all about medical advances that have increased survival rates,” said Barnard, the father of Critical Illness Insurance, and cardiac surgeon who helped pioneer the first heart transplant. Dr. Barnard watched as new procedures saved the lives of countless patients who suffered critical illnesses,

but saw those same lives devastated by the financial impact. Many of these survivors are unable to return to their previous professions or incomes. Others are forced to return to work before they have had a chance to fully recover. The sad truth is that the miracle of today’s medical procedures may save your life but create long-term financial challenges for you. Barnard helped develop Critical Illness Insurance so that people can afford to survive and recover. He stated, “after all, that is the definition of insurance, to provide you money when you need it most.” Critical Illness Insurance differs from Disability Insurance because it provides a lump sum benefit up to $500,000. The policy benefit is paid upon the first confirmed diagnosis of any covered illness or medical procedure. The policy covers over 20 Critical Illnesses, some of which include: Heart Attack, Stroke, Cancer, Coronary Artery By-Pass, Severe Burns, Major Organ Transplant, Loss of Independent Living, Renal Failure, Paralysis, Blindness and Deafness, Coma, and in Situ Cancer. The cash benefit is paid directly to you and you can use the money any way you choose. In essence, it is “living insurance.” The tax-free lump sum benefit can be used to help maintain the financial independence and lifestyle of the insured. If you never use the policy and die of something other than one of the covered illnesses, 100% of the premiums you paid, minus any benefit pay-out, will be returned to your beneficiary. No receipts need to be presented. It’s a check made out

in a lump sum paid directly to you. Receiving the benefit does not change payments from any other insurance plan you may have–whether it’s health, disability income or worker’s compensation. The money is yours to ease the financial stress that a Critical Illness creates, and there are no restrictions in the use of these funds. Because of my personal experience in battling a critical illness, I thought you would like to be aware of this valuable coverage, and the benefits it could have not only for your patients, but for you as well. With the limitations that Physicians have with respect to Disability Insurance, you need to consider Critical Illness Insurance as a key part of your personal insurance protection.

LISA RUDOLPH Lisa Rudolph is the founder and CEO of Physician Insurance Specialists, a local Independent Insurance Brokerage firm that works exclusively with doctors and offers tailored products for your specific needs. Lisa has been in the insurance industry providing insurance protection to her clients since 1991. “I am very passionate about what I do, and I treat all my doctors like my family. As a stage 4 cancer survivor, I learned many years ago how important you are! I love what I do and take great pride knowing you and your family are protected in the best way possible.”

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Distraction and the Role of Mobile Device Technology in Healthcare BY KAREN WRIGHT, RN, BSN, ARM, CPHRM


ablets, smart phones, and other mobile device technology provide both opportunities and challenges in the healthcare setting. They can enhance communication, improve access to patient information, and reduce medical errors.1 However, this technology-rich environment may contribute to an unintended side effect, physicians and other healthcare practitioners can become focused on the device and not the patient. Mobile device technology can distract physicians and divert attention which is otherwise needed to safely complete a task. 2

Distractions can compromise cognitive processing of complex, constantly changing information, such as critical moments during patient care.3 A study explored the effects of distraction on arthroscopic knee simulator performance among residents at various levels of 10



experience. While residents were performing the procedure, two questions were asked at specified time intervals. The study found that the practice of residents at all levels of experience appeared to be negatively affected by distractions while performing the arthroscopic simulation.4 Human factors, including “distractions,� relate to the fallibility of human beings and are responsible for as many as 80% of healthcare errors.2 However, distractions from mobile device technology cannot be solely attributed to their use during direct patient care. The availability and ease of use of smart phones and other mobile devices provides the tempting opportunity to access entertainment, such as games and videos, and conduct personal communication and business almost anywhere with a touch of a finger.

The increasing popularity and dependence on mobile device technology is evident in almost every public setting and it would be naïve to think that this trend will fade. The technology allows users to remain constantly connected with work, friends and family. More research regarding the complexity of distracted practice is necessary and should account for the variables throughout the healthcare setting. Distracted driving is one activity that clearly presents a safety problem. There is ample evidence to support that distracted driving endangers drivers, passengers and bystanders. The official U.S. government website for distracted driving (distraction. gov) states, “Because text messaging requires visual, manual, and cognitive attention from the driver, it is by far the most alarming distraction.”5 Should the idea of distracted healthcare professionals be any less alarming? Awareness that distractions from smart phones and other mobile device technology can have negative implications for safe patient care is an important first step. Recognizing the dangers to patient safety posed by these distractions, specialty organizations, hospitals and outpatient facilities have begun recommending significant limits on the personal use of mobile devices in critical patient care settings, such as intensive care units and operating rooms. The personal use of smart phones and other mobile devices in the healthcare setting represents a significant source of distractions, here are some recommendations to help alleviate the negative effects of the technology. •

Educate clinicians about distraction and its potential detrimental effect on patient safety.

Develop policies and procedures regarding personal use of mobile devices for the office or organization. This could include the imperative that personal devices be stored out of reach while actively involved in patient care.

Avoid irrelevant communication or “small talk,” especially when performing tasks which require high cognitive processing.

Minimize interruptions during tasks that place high demands on working memory.

Establish specific hotspots where the use of personal mobile devices is permitted. These areas can be integrated with break rooms to discourage mobile device use while engaged in work-related activities.

Consider the use of organization-provided devices that contain preinstalled job-specific functions and apps.

Awareness that distractions from smart phones and other mobile device technology can have negative implications for safe patient care is an important first step.


1. The American Association of Nurse Anesthetists (AANA). Mobile information technology position statement. 2015 Available from: Mobile-Information-Technology.aspx 2. D’Esmond, L.K. Distracted practice: A concept analysis. Nurs Forum, 2015, 3. Feil, M. Distractions and their impact on patient safety. Pennsylvania Patient Safety Advisory, 2013.10(1),1-10. Available from: ADVISORIES/AdvisoryLibrary/2013/Mar;10(1)/Pages/01.aspx 4. Cowan JB, Seeley MA, Irwin TA, Caird MS. Computer-simulated arthroscopic knee surgery: effects of distraction on resident performance. Orthopedics. 2016 Jan 22:1-6. Available from doi: 10.3928/01477447-20160119-05. 5. U.S. Department of Transportation and National Highway Traffic Safety Administration Facts and statistics. (n.d.) Available from:

KAREN WRIGHT, RN, BSN, ARM, CPHRM Karen Wright RN, BSN, ARM, CPHRM, is a Senior Risk Management Consultant for the Mutual Insurance Company of Arizona (MICA). She has more than 20 years of risk management experience and provides a wide range of risk management education and consulting services to hospitals, out-patient facilities, clinics and medical offices.



Maintaining the patient story: Innovative technologies that allow transcription to be used seamlessly with EMRs while still showing “meaningful use.” BY KAMAL IRANI





ith the advent of EHRs, the Medical Transcription industry has adopted a lot of advanced technologies to integrate narrative dictations into EHRs while maintaining “meaningful use.” Because of the benefits of face to face interaction in delivering quality healthcare, many physicians still prefer to capture their patient encounter information via dictations. As well as providing speed and efficiency for the physician, dictation can also help maintain a more comprehensive patient ‘story.’ With dictation, physicians have the time and opportunity to fully record their impressions and notes, without taking the time away from the patient to type it out. New technologies for medical transcription have developed to more efficiently merge with the recording needs of today’s physicians. One example of advanced technologies currently available is Discrete Reportable Transcription (DRT). This is a technique where narrative dictations are first transcribed by the medical transcriptionist and then converted into discrete XML-embedded data elements which are subsequently auto-populated into appropriate placeholders inside an EMR. Sometimes these elements can also be reused by the EMR for subsequent visits of the same patient, thereby saving the amount of time physicians spend in dictating their patient encounters. The primary benefit of DRT is that structured data is fed into the EMR, so physicians can continue to use narrative dictation without the fear of not being able to show meaningful use. Another method is called Backend Speech Recognition (BESR), and it allows physicians to continue dictating as usual, and the audio file is then processed through the speech recognition engines in the background. The processed document created by back end speech recognition is then edited by the medical transcriptionist before it is sent back to the physician to review. Many backend speech recognition technologies support data structuring, but some gaps remain in getting applications written that seamlessly move the structured information into EHRs.

Finally, transcription services can also utilize Natural Language Processing (NLP). This technology extracts data from free text and in the clinical setting converts providers’ narratives into structured, standardized formats. NLP is not perfect and what is missing is the validation process necessary to ensure correctness of the results. Rather than requiring physicians to validate the results of NLP, skilled medical transcriptionists can verify that the NLP has correctly captured the discrete data documentation elements before attempting to upload to the EHR. By validating that the structure of the NLP created document

With dictation, physicians have the time and opportunity to fully record their impressions and notes, without taking the time away from the patient to type it out. New technologies for medical transcription have developed to more efficiently merge with the recording needs of today’s physicians. and all the fields such as medications and allergies are correctly encoded, the review of this documentation by medical transcriptionists can prevent errors in the EHR. With the use of the innovative technologies outlined above, it is possible to retain the narrative created by dictation and medical transcription while enjoying the benefits of electronically structured and encoded data. The knowledge and skill of medical transcriptionists can contribute significantly to physician satisfaction and documentation quality, while enabling providers to realize the maximum return on EHR investments and maintain “meaningful use”.

KAMAL IRANI Kamal Irani has owned and operated STAT Transcription since 2000. She is certified in Management of Clinic Information Technology, and previously had a 16-year career as a Software Engineer in the Medical Device industry. “My passion is forming a partnership with my clients and designing a personalized plan that fits the individual transcription needs of our diverse client base.”





n the years leading up to 2009, Intel tried a number of approaches to tame its soaring health care costs. To encourage employees and their families to be more involved in the purchase of their care and aware of its cost, the company implemented “consumerdriven health care” offerings such as higher-deductible plans with lower premiums. To save employees time and improve access, it opened primary care clinics at Intel work sites in Oregon, New Mexico and Arizona. While those programs generated improvements in employee engagement and accountability, it had become clear by 2009 that they alone would not enable Intel to solve the problem, because they didn’t affect the root cause: the steadily rising cost of the care that employees were receiving. Intel projected that expenditures for its 48,000 U.S. employees and their 80,000 dependents would hit $1 billion by 2012 - triple the amount it spent in 2004. Intel’s leaders wanted to protect the bottom line but were reluctant to shift more of the cost to employees. One of us (Patricia McDonald) suggested another option: Intel could use its purchasing power in markets where it had operations to influence health care players - care providers, insurers and other employers - to work together to redesign the local health care system. Specifically, the company would use its expertise in supply 14



chain management to reduce costs in local health care enterprises while putting the needs of their customers patients - at the center of everything they did. Intel would urge the health systems to standardize work by adopting best-practice clinical processes. In this case, the source would be Virginia Mason Medical Center, a health system based in Seattle. It was one of several providers in the United States that employed a version of the Toyota Production System to make its processes “lean” - in other words, strip them of activities that did not add value. Intel would pay for the clinical processes and Virginia Mason’s expertise in installing them and would train people at the local health systems to use Intel’s version of TPS to adapt them. Finally, Intel would enlist its health plan administrator, Cigna, to contribute the claims data required to track progress. Intel’s pilot Healthcare Marketplace Collaborative was launched in metropolitan Portland, Oregon. Over five years, it successfully implemented new clinical processes for treating six medical conditions and for screening patients for immunizations status. Although assessing the HMC’s full impact was not easy, the results that could be measured were significant: The HMC reduced the direct costs of treating three of the conditions by 24% to 49%. The HMC also emphasized evidence-based care

(clinical decision-making backed by validated research), eliminated unnecessary care and generated high levels of patient satisfaction. The need to accelerate the transformation of health care in the U.S. is urgent. We have seen some hopeful signs that the tide may be turning: Thanks to the Affordable Care Act, the proportion of adult Americans without health care coverage fell to 12.9% in 2014 from 18% in 2013. And the rate of increase in U.S. health care spending has recently slowed. Still, the crisis is far from over. We believe that other large employers should follow Intel’s example. As large purchasers of health services and experts in quality improvement, corporations are uniquely positioned to drive transformation of health care in the United States. Let’s take an in-depth look at the elements that were critical to the success of the Healthcare Marketplace Collaborative. 1. MAKE EXPLICIT WHAT EACH PLAYER IS BRINGING TO THE EFFORT Intel initially invited Cigna; Providence Health & Services, a multistate health care system; and Tuality Healthcare, a small local system with two community hospitals, to join the collaborative. On Providence’s recommendation, two state agencies, Oregon’s Public Employees’ Benefit Board and the Oregon Educators Benefit Board, were asked to participate in 2010. Each organization that joined the collaborative brought capabilities that the others lacked. It was important that each group’s unique value be recognized so that all team members would be motivated to fully engage. 2. ESTABLISH A SHARED AIM The purchase of health care services for employees is often a game in which each player - employer, payer or health care provider - tries to use its market power to secure the best deal for itself in annual negotiations. To break this dynamic, the HMC’s members agreed to focus on an aim that would be in the interests of all stakeholders: providing the right care in the right place at the right time and the right cost for Intel employees and families and all other Portland-area health care users. 3. DON’T REINVENT THE WHEEL Rather than develop new protocols from scratch, the HMC’s two health systems accepted Intel’s proposal to start out by acquiring proven clinical content and work processes - or, to use lean lingo, “value streams” - and quality metrics from Virginia Mason, whose lean clinical processes were evidence-based and focused on the patient. 4. MAKE IT FLEXIBLE No two health care providers are exactly the same in terms of size and structure. In some instances, a provider may already have an effective method of treating a targeted

condition. In others, internal or structural issues may make it difficult to install a clinical process without changes. Recognizing this, the collaborative agreed at the outset that Providence and Tuality would each decide whether or how to adopt each of the new clinical processes. 5. PRIORITIZE ON THE BASIS OF IMPACT AND DIFFICULTY Intel combed through Cigna’s claims data and chose which medical conditions to focus on initially - those whose improvement would most benefit its employees, their dependents and the company. About two years into the effort, the medical directors at Providence and Tuality selected additional conditions. The group used four criteria to establish priorities: • Expenditures and impact on patients. Intel focused on types of care on which it spent a lot of money and treated the most patients. • Level of complication and risk. Intel chose to start with less complicated and less risky conditions to make it easier for Providence and Tuality to put the new clinical processes in place. • Ease of standardization. Intel wanted processes that could be standardized easily across multiple care-delivery systems. So it initially chose value streams that Virginia Mason had already successfully implemented.

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We believe that other large employers should follow Intel’s example. As large purchasers of health services and experts in quality improvement, corporations are uniquely positioned to drive transformation of health care in the United States. •

Benefit to the health systems. Although Intel set the initial priorities, it recognized that all the stakeholders needed to benefit from implementation of the value stream. For example, certain “production” costs for the two health systems would be reduced by eliminating unnecessary procedures and optimizing staff.

6. CHOOSE SIMPLE METRICS AND GOALS The HMC chose simple metrics that addressed the aim of better, faster and more-affordable care. And it set audacious goals for each. •

Better care. The HMC used two metrics for this goal. One gauged medical quality: whether or not patients received evidence-based care. The other tracked patient satisfaction: the proportion of patients who responded “probably” or “definitely” to the survey question “Based on today’s visit, would you refer a friend to our medical clinic?” The goal for both measures was 100%.

Faster care. The HMC choose two metrics: sameday access to care and return to function (how many days before patients could resume their normal daily routines). The goal was that 85% of patients who called Monday through Friday could get an appointment with a provider within one business day of their call. For the return-to-function metric, the goal was for 90% of patients to meet or beat the target.

More-affordable care. The first metric for affordable care was the total cost to employer and patient of treating a condition - in other words, the fees paid to providers. The collaborative compared costs from when the need for care arose and when the problem was resolved using both the new approach and the one typically used in the health system. The goal was to reduce costs, not just slow the rate of increase.

The healthcare marketplace collaborative ended in June 2014. While results of the HMC experiment were hardly perfect, they proved that an employer can engage all the players in a market to accelerate health care reform. HMC’s focus on patient-centered care produced solid cost savings and behavioral changes grounded in evidence-based medicine and patient satisfaction.

In virtually all regions, at least some employers, providers and health plans will be able to transcend narrow self-interest and cooperate to develop new business models that result in the best health outcomes for individuals at lowest cost. We enthusiastically invite them to join us on the journey.

PATRICIA A. MCDONALD Patricia A. McDonald is Intel’s vice president of human resources and the director of the Intel Talent Organization.

ROBERT S. MECKLENBURG, MD Robert S. Mecklenburg is the medical director of the Center for Health Care Solutions at Virginia Mason Medical Center.

LINDSAY A. MARTIN Lindsay A. Martin is the executive director of innovation and an adviser at the Institute for Healthcare Improvement.

© 2015 The New York Times News Service From c.2015 Harvard Business School Publishing Corp. Distributed by The New York Times Syndicate HEALTH



Transforming Health Care Takes Continuity and Consistency BY MARK BRITNELL


n six years of working across 60 countries in search of the perfect health system, I’ve been fascinated by the fact that every country wants the same thing but no one has been able to deliver it: safe, consistently good, financially sustainable health care. At the heart of this problem is a paradox: Transformation in health care can only be achieved by continuity and consistency. Health systems the world over list a strikingly similar set of ambitions: moving to value-based care that improves outcomes, reduces costs and increases patients’ satisfaction; turning hospitals into health systems; focusing more on preventing ill health rather than treating it; implementing technology to make care more efficient; and empowering patients. But our systems reward leaders not for transforming health care but for making narrow improvements within it. I’ve seen examples of great health care all over the world, but too often the inspiring individuals delivering this care have been impeded, rather than helped, 18



by the system in which they work. Imagine the global potential if these local pockets of excellence could be harnessed for the benefit of whole populations. I’m one of the 15 health experts on the World Economic Forum’s Global Agenda Council on the Future of the Health Sector. We’ve been looking at why sustainable change in health care is slow, fragmented and difficult. It’s clear to us that different parts of the system — payers, providers, patients, professionals, policy makers, politicians, the public and the press — aren’t pulling in the same direction. That impedes innovation and progress. This failure to work together across a system vexes me. Organizations have a strong sense of their own value and a commitment to high quality care but little appreciation of others’ worth in their local, regional or national systems. I’ve been struck by the way that companies in industries as diverse as telecommunications and transport manage to collaborate in a competitive environment, yet health organizations find collaboration difficult even when they’re not competing.

The antidote to this fragmentation is integration, the most hotly discussed concept in health care today. What stops skilled, motivated people from making health care better, more integrated and ultimately more sustainable? The answer is the organizations in which they work and the pressures, incentives and regulations under which they operate. Three compounding problems inhibit large-scale, sustainable change. The first is organizational myopia. Organizations have a tendency to think that they’re basically good but that the health system in which they operate doesn’t support them properly. The second is the ability for transactional reform to trump transformation. I define transactional as “doing things better” and transformational as “doing better things.” Often it’s is easier and less threatening to make seemingly important but small changes than it is to hold individuals, organizations or systems to account for transformational change that will produce better care and value. The third is that large-scale change is as much an emotional issue as a technical one, which is rarely understood. A compelling vision of a better future needs to be communicated in a way that energizes and motivates. This means that staff members can relate to it, shape it and, crucially, feel empowered to challenge the status quo. In a recent survey of hundreds of health care leaders across the developed world, we found that while 73% of them thought their country’s health care system required “fundamental” change, only 35% felt change was needed in their own organization. Health care leaders often see the need for system-wide change before they see the need to transform their own organizations. They realize the scale of transformation required but believe that it’s somebody else’s problem. When this belief is coupled with a deeply transactional culture focused on incremental improvements, the status quo is unassailable. So what can we do? A recent report fromthe Institute of Medicine in America’s landmark report, identified four ingredients for a high-quality care system: having the right vision; designing clinical processes from the patient’s perspective; integrating organizations into systems; and successfully managing environmental factors such as regulations and financing. I’ve seen health systems in Japan, Singapore, Spain, New Zealand and the U.K. that show how population-scale health care with these ingredients can be achieved. But the best one I’ve worked with is the Geisinger Health System in Pennsylvania, which provides complete care for more than 2.6 million people. Its core way of working, ProvenCare, is built around population health and using data and clinical evidence to redesign care systems. Its structures and processes have been reengineered to maximize value. There is a

culture of safety and quality, and patients are involved in their own care. The payments system encourages the organization to get care right the first time, in the most appropriate setting. Geisinger had the audacity to try to change the way health care is provided and paid for in America, and it has succeeded in reducing mortality and costs while substantially improving quality. Its journey to become one of the world’s most innovative health systems has largely taken place during the 15-year tenure of Glenn Steele. When I spoke to Steele about what he learned as president and chief executive from 2000 to 2015, several things stood out. First is staying power. Steele was only the fifth leader that Geisinger had had since its establishment, in 1915, and his strategy remained consistent throughout his tenure at the top. The first clinical specialties started adopting ProvenCare in 2003, and the organization has been working through the rest for the past 12 years. This consistency, twinned with early successes, has made wider change possible. Steele freely admits that some of the founding principles of the transformations he drove were built more on beliefs than evidence. But once years of data had been amassed, bigger and bolder transformations could be achieved. Making these changes required skill, will and time underpinned by rigorous process. This is the paradox of change: It requires continuity and consistency. Health care leaders don’t spend enough time with other parts of the system, and they don’t place enough faith in their ability to develop and implement sustainable solutions to problems. So it’s easy to see why they spend their energy doing things better rather than doing better things. Nobody gets held to account for producing a more sustainable health system; they just get rewarded for surviving in the existing one. Health leaders need to recognize that they’re not alone in grappling with their health systems, and they shouldn’t be afraid of attempting to change them. They should remember, however, that transformation is impossible without continuity.

MARK BRITNELL Mark Britnell is the chairman of KPMG’s global health practice and the author of “In Search of the Perfect Health System.” © 2015 Harvard Business School Publishing Corp. Distributed by The New York Times Syndicate



Bridges to Recovery:

Understanding Unintentional Addiction to Prescription Medication Triggered by Chronic Pain in First Responders BY MICHEL SUCHER, MD, FASAM, FACEP


s the addiction to prescription pain medication becomes recognized as a national epidemic, more people are realizing that this disease is also impacting our First Responder community. As “Family Members,” we fiercely protect our communities of high-risk life savers (Police, Fire, Hospital ER’s, Ambulance, etc.) from hazards in the workplace. One of the most pernicious is the widespread availability of narcotics. Yet, pain medication use is on the rise everywhere. It’s not confined to the doctor/patient relationship; it cuts across all socio-economic levels and all walks of life. Medical practitioners and health workers have special risks because of a number of factors unique within our medical care community. As an emergency physician in Arizona for more than 20 years before specializing in the field of addiction medicine, I treated hundreds, if not thousands, of critical incidents arising from drug-related trauma, drug interactions and overdoses. I now lecture extensively to medical groups across the country on how dependence on pain medication has evolved and the successful integrated approaches to recovery. Opioid addiction is now an even larger problem than their 20



illegal cousins, methamphetamine and cocaine. Most physicians recognize that we have essentially become a society of painkillers-on-demand. One aspect that is particularly startling is the large and growing number of First Responder professionals who are susceptible to “unintentional” addiction. High-stress, physically demanding jobs are causing role-related injuries, often requiring these emergency response workers to rely on the steady use of painkillers just to function from day to day. According to a Newsweek June 18, 2015 investigative report by Kurt Eichenwald titled When Drug Addicts Work in Hospitals, No One Is Safe, “Federal researchers estimate that 100,000 health care workers in the United States are addicted, and their theft of narcotics from patients is believed to be widespread.” The article follows the story of one addicted health worker who moved through 18 different health systems in 6 states, so that he could continue his access to the powerful drugs, often landing a new job just as authorities had caught him raiding pharmaceutical supplies. By using syringes intended for patients, he inadvertently caught Hepatitis C and then spread the disease to at least 45 people among a potential 12,000 patients, and one of these infected pa-

tients has now died. He was eventually convicted and is serving 39 years without parole in a maximum security federal prison. Although this is an extreme example, it is part of what happens when our collective systemic denial causes us to fail to recognize and directly address these conditions as they impact our First Responder family. To stave off escalation, the Centers for Disease Control (CDC), recently “recommended” that doctors “avoid” over prescribing opiate painkillers. While the move was applauded by the American College of Emergency Physicians, personally, I don’t believe “recommending” decreased prescribing practices for opioids is strong enough to address the underlying problem. As the attending addiction medicine physician for all physicians identified as “impaired” by the State Medical Board in Arizona, I began to see this alarming pattern also emerge among ED and hospital physicians, nurses and related health workers. I am also the Chief Medical Officer of Community Bridges, Inc. (CBI) (see footnote). A number of years ago, we recognized a significant increase in heroin entries into our crisis and detox centers. Digging deeper, we tracked heroin use back to its origins in pain medication use and back to an injury or illness that caused chronic pain treatment with ever increasing amounts of opioids that triggered their “unintentional” addiction disorder, which ultimately morphed into heroin addiction. CBI then created an integrated model for treating opioid addictions which we called “Unscript” that focuses on “unintentional” opioid addiction as a result of chronic pain management with narcotics. From there, we created “Unscript First,” a treatment model specific to medical professionals and First Responders. Both Unscript and Unscript First treat “unintentional” addiction as the medical condition that it is and address all substances and behaviors associated with addiction in treatment. However, Unscript First was created with a focus on complete anonymity, so that health workers receive full treatment with the expectation of recovery, while they continue in their profession. We believe the results have been remarkable. Our special program for health care professionals begins with individual and family education (the physiology of addiction), supported by scientific principles and incorporating the most advanced medical protocols, including continued treatment of the underlying medical issue without the continued use of pain medications. As stated earlier, prescribing trends are driving the escalation of addiction rates. By way of perspective, 20 years ago, 60 mg. per day of Oxycodone was a high dose. Today we commonly see people who are taking 10 times the doses that we used to consider high. At today’s typically prescribed dosages, addiction in some individuals can occur in as little as 10 days, all while following label directions. The rise of painkiller addiction has been associated with the resurgence of street heroin. With skyrocketing street prices for prescription narcotics, heroin can be-

come a viable alternative. The surge in heroin addicts who started out on legitimate prescription pain medications is well documented by the CDC. At CBI, we explain in our Unscript education track, that addiction is almost impossible to understand without medical knowledge of its affect upon the nervous system and brain. It creates a “chemical lie” that becomes a driving force. I explain the syndrome this way: “We all have the biological drives to eat, sleep, drink liquids, but they are conscious drives experienced as hunger, fatigue or thirst. The most primitive drive you have is the drive to breathe. When addiction advances, the brain chemistry changes and meeting the needs of the addiction becomes as strong as the biological drive to breathe. Without integrated care, most addicts won’t quit using until they distance themselves from the drug for a sustained period of time (often jail or prison) and receive enough Bio-Psycho-Social-Spiritual treatment and education (often not in jail or prison) to master the tools that will help them stay strong in recovery.” Unscript First provides the highest levels of safety, security and confidentiality. There is no ‘blaming, shaming or guilting.” The unintentional addiction is treated as a “medical” problem with a medical origin. Health care workers and First Responders come to Unscript First in all stages of acceptance of their condition. The fear of being found out, or forced out of careers that “define” them (I am a Police Officer, I am a Fire Fighter), often keeps individuals from seeking treatment. Outpatient options for treatment work hand-in-hand with program anonymity that envelop and protect the doctor/patient relationship. At Unscript, recovery is not just possible, but expected. The key is early diagnosis and treatment in a safe, protected environment. The minute a man or woman puts on a First Responder uniform, they are putting their life on the line for us. Unscript First respects, honors, and preserves their heroic commitment. For additional information, refer to the following link:

MICHEL A. SUCHER, MD, FASAM, FACEP Michel A. Sucher, MD FASAM FACEP is Chief Medical Officer of Community Bridges, Inc., and also serves as the Medical Director of the Monitored Aftercare Programs for the Arizona Medical Board and the Arizona State Board of Dental Examiners. Dr. Sucher is a Fellow of the American College of Emergency Physicians and a Fellow of the American Society of Addiction Medicine (ASAM) and is a Past President of the Arizona Chapter of ASAM. He is a nationally known speaker on addiction medicine.



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Keeping pace with medical technology: an interview with surgeon and inventor

Robert Guyette, MD, DMD



n today’s gadget-driven world it’s no wonder that the sweeping tide of technology has also spilled over into medicine. Prior to the 1800s, the most advanced technology in a physician’s little black bag might have been a scapula. The 20th century, however, brought on a different approach to medical technology, and tools were invented to study, examine, and better understand medicine. Items as simple as reliable body temperature thermometers, microscopes, and stethoscopes opened a whole new world in comprehending and managing health and the human body. Obviously we’ve come a long way from thermometers. Today’s physicians and hospitals use a myriad of complex machinery to image, observe, diagnose, and treat their patients in new and innovative ways. With new products and techniques hitting the market — and the exam room —constantly, keeping up in a fast-paced, high-tech world can be a challenge. Not to mention the challenge in selecting products that



ally serve you and your practice, and putting them to work! Many have felt the discouragement of investing in something new only to have it sit in a corner or closet because it failed to do the one thing we ask of all new technology: make life easier.

sons out to visit the Woodens in California, and the two remained friends until Wooden’s passing in 2010. “Considered by many to be the best basketball coach in the history of the game, he was also a humble and gracious man and an inspiration to all who met him, regardless of their age or circumstance,” Guyette said.

We took the opportunity to sit down with Robert Guyette, MD and DMD, to discuss this constantly shifting landscape. Dr. Guyette is a board-certified facial and oral surgeon with a dynamic practice in Scottsdale, AZ, and is a fine example of keeping the upper hand in technology. He knows himself and his practice, and he knows where technology fits in. Not only does he use many innovative products in his practice and office, he also invented one himself! Now that’s making your tech work for you.

“I was drafted in the NBA and the old ABA but after careful consideration, decided to take an offer to play in Barcelona,” he said. He spent 5 years with the team, travelling and playing throughout Western Europe, the Middle East, and behind the Iron Curtain.

From shooting hoops to dental school

Guyette met his wife, Gina, while at the University of Kentucky. Two years into his career with Barcelona, they were married and she joined him in his travels.

Dr. Robert Guyette began life in a small Midwestern river town called Ottawa, Illinois, which he said, “was a fantastic place to start.” His father was an engineer, and played football for Notre Dame. It was he who originally encouraged Guyette to consider the medical or dental field. Guyette was not the only child to receive such encouragement; his older brother graduated in Biomedical engineering, and his sister is a dental hygienist and registered nurse. While he eventually followed the family in their medical pursuits, Guyette says his first passion was basketball. He received a scholarship to the University of Kentucky, where he was a pre-med major and played in the NCAA championship game in 1975 against UCLA. Guyette remembers that UCLA coach John Wooden announced his retirement the night before the final game. “We lost that game but I gained a mentor and role model in Coach Wooden,” he said. He and Coach Wooden stayed in touch throughout his time in both basketball in medicine. He even took his two oldest 24



After graduation, Guyette accepted an offer to play professional basketball for FC Barcelona in Barcelona, Spain.

“We enjoyed immensely the people, culture, food and lifestyle in Barcelona,” he said. Unfortunately, it couldn’t last. “A back injury during my last year forced us to consider our next move,” he said. Guyette returned to Kentucky, where he was accepted to the University of Kentucky College of Dentistry. During his third year he was introduced to Oral and Maxillofacial Surgery (OMFS). It was here he knew he had found his calling. “I was fascinated by the new surgical techniques that were being developed to treat patients with severe facial injuries and to correct facial skeletal deformities,” he said. “These were truly life-altering procedures.” Guyette decided he wanted to take his practice beyond the standard scope of oral surgery to further be a part of these life-altering services, so he applied to the four programs in the United States that offered a medical degree in combination with the OMFS residency training. “I was accepted at the University of Alabama so Gina

and I and our first two sons packed the U-Haul and moved to Birmingham,” he said.


While he was studying at UAB, Guyette performed his trauma rotation at Banner University Medical Center Phoenix (formerly Good Samaritan), where his brother-in-law, Dr. Tom Wachtel, was Chairman of the Department of Surgery, and Director of Trauma and the General Surgery residency program. “He was a great mentor and I had a fantastic experience. It was also November and the weather was beautiful,” Guyette said. “After looking at several other areas of the country, we decided to move the family to the Phoenix area and begin my practice in Facial and Oral surgery.”

Hanging a shingle

Guyette opened offices in both Scottsdale and West Valley in 1989. He also joined the staff of five hospitals in the Valley, and set to work building the practice. “As a sole practitioner and father of 3 boys, life was very busy,” he said. When he was asked to consider serving on the board of BOMEX in only his third year of practice, he was initially quite hesitant. However, he eventually agreed, and served a three-year term. “It was a tremendous learning experience involving a great deal of responsibility to both protect the public and be fair with our physicians,” Guyette said. In the early years of practice, Guyette performed his surgery cases in hospitals. However, as time went on, insurance companies covered fewer of these procedures and the cost of hospital-based surgery increased. Fortunately, many cases are now performed on an outpatient basis, or in an office surgical setting, thanks to new surgical techniques and improved anesthesia drugs and monitors. This also served to reduce patient costs significantly. “I designed and opened our current Scottsdale office and surgery center in 1998,” Guyette said. “It was designed specifically to provide facial and oral surgery procedures with either IV sedation or general anesthesia. A Board Certified Anesthesiologist administers general anesthesia. Now, 98% of the facial and oral surgery procedures that I perform are at our office based surgery centers.” “Although there is still insurance coverage for some of the procedures we provide, many are not covered at all. We are constantly looking for new ways to create value and provide superior service to our patients,” he said. Aside from his surgical practice, Guyette is also very active in other aspects of the business of

medicine. He joined the Maricopa County Medical Society in 1989. He is currently in his fourth year as a director of OMSNIC, a malpractice liability company that insures the majority of Oral & Maxillofacial Surgeons in the US. The goal of the company is to protect and enhance the practice of OMFS while improving patient safety through risk management education. “Much like my BOMEX experience, it is a lot of work but provides a tremendous learning experience,” he said.

“We are constantly looking for new ways to use technology to enhance our ability to provide our patients with the highest quality care available,” he said. Guyette also joined with several others to start a company called MediMin in 2006. After watching the trends in medical delivery, he saw a need and an opportunity to make service more accessible. The business model they created was to open small medical clinics staffed by Physician’s Assistants and Nurse Practitioners in the Basha’s grocery stores throughout Arizona that had pharmacies. “We grew to four locations throughout Phoenix before Basha’s ran into financial difficulties and we ran out of funding and ultimately closed the locations in 2009,” he said. “MediMin was one of the first companies in the US to offer this service. Both Walgreens and CVS purchased other smaller companies and expanded this model that is now present throughout the country.”

Making good use of current technologies

For someone continually looking to provide new and relevant value to both his practice and his patients, it comes as no surprise that Guyette has his eye on technology, and what it can do for him. “We are constantly looking for new ways to use technology to enhance our ability to provide our patients with the highest quality care available,” he said.



Considering the Affordable Care Act’s focus on quality improvement, we asked Guyette his opinion on the role technology would play. He agrees that forcing the adoption of EMRs has greatly increased the ability to collect medical data. “The thought is that with all this data, better treatment algorithms will develop and this will improve the quality of medical care,” he said. “Quality, however, has many facets and I don’t believe that it rests solely in technological advancement, data collection and standardization of care. The human component is being marginalized and that concerns me.”

“We are the people delivering the treatment and all of us come up with ideas, at once point or another...” With so many new devices hitting the market every day, the biggest challenge is not whether to adopt new technology, but which ones, and how to ensure it will fit in with your business. The last thing you want is to end up with the technological equivalent of a $100,1000 doorstop. Guyette says a new technology must pass at least one of four tests before they consider adopting it for his practice. The technology must either: 1) Enhance patient treatment results, 2) Improve doctor efficiency, 3) Improve assistant/staff efficiency, OR 4) Decrease the stress of practicing medicine (after training and implementation). “If the new technology fulfills at least one of these criteria AND if it pays for itself within 3 years, it is seriously considered for implementation,” he said. We asked Guyette to give us some examples of what he is currently using in his practice: EMR - adopted in 2008. Each back office assistant carries their own tablet PC that is used for utilizing the practice software, creating coding and billing statements, obtaining signatures for consent and other forms, showing informational videos, reviewing x-rays and transcribing clinical notes. Surgical planning imaging and software. In both of our offices, we have both two and three-dimensional imaging capabilities. Cone Beam CT (CBCT) scans focus 26



only on the facial region and are reconstructed within 60 seconds. With secondary software, the 3-D DICOM images are then manipulated and allow us to instantly plan surgical treatment of the facial skeleton and placement of dental implants. I frequently plan surgery with the patient present. This allows me to review the recommended treatment with them, including anatomical limitations and risks, utilizing the patient’s own images. Not only is this a very powerful education tool but it also makes the patient feel that they are a part of the decision making process. In addition, 3-D imaging and surgical planning can decrease patient risk and consistently improve surgical results. Video recording of surgical procedures. With the recent improvement in the image quality and decreased cost of small video cameras and the improvement of video editing software, we have decided to invest in both an OR light containing a video camera and cameras attached to our surgery headlights. We are initially creating staff training videos for our most commonly performed procedures. We believe that these videos will significantly decrease the time needed to train new surgical assistants. We envision many potential uses for these types of videos in the future. Nd:YAG lasers to treat vascular and pigmented lesions of the skin and for hair removal. Intense Pulsed Light (IPL) photorejuvenation to treat skin pigmentation, sun damage and superficial veins.

Leaving his mark

Guyette has long been fascinated with technological advances, in all areas of human endeavor, beginning with manned space flight when he was young. And he has been fortunate enough to take that love of ingenuity and make his own contributions to medical technology. While still in dental school he was first introduced to Nitrous Oxide (N2O), which is a gas frequently given to nervous patients to help them through dental procedures. “I was amazed by the analgesic and anxiolytic effects of this gas as well as its impeccable safety record,” he said. “But, it was no surprise to me that N2O was not used as frequently as it should because of the cumbersome delivery and scavenging devices that were on the market at that time.” At the time, the gas was delivered using a mask, which was uncomfortable for the patients, and inhibited the dentist’s ability to work in the mouth. The mask also allowed significant amounts of gas to escape around it, and while studies assured the safety of the gas for the patient’s use, prolonged exposure to the escaping gas could prove harmful to the dental personnel. “I remember as a student thinking that there had to be a better, safer way to deliver Nitrous oxide,” Guyette said. Eight years ago he decided to do something about it. Looking at the new devices on the market, and the in-

creased uses of N2O, Guyette launched a sixyear project to develop the Silhouette Nitrous Oxide delivery system, which boasts a significant increase in patient comfort, and doctor access.


The process was a long one, from ideas on paper to clinical utility. Guyette said he spent the first four years of his research working to develop a functional homemade prototype for demonstration. “This process involved taking moulages of (usually family) faces, and utilizing components from existing medical gas delivery systems mixed with parts from irrigation systems which I purchased at Home Depot and modifying dental modeling techniques,” he said. “Finally, we had a way to consistently make well-functioning masks that met all our design criteria.” With prototype in hand, he visited the Department of Biological and Health Systems Engineering at ASU, where he met with professors and hired graduate students to help with the patent search and project development.

Not all technological advancements are truly great. “I am reminded that we landed a man on the moon in 1969, but it wasn’t until 1987 that someone decided to put wheels on the bottom of a suitcase!”

“We scanned the prototype and used the 3D printers available at that time to create rigid printed models,” he said.

and all of us come up with ideas, at one point or another, and it would be good to know where to go to take the next step.”

He also entered into discussions with Porter Instruments Division – Parker Hannifin Corporation, who was one of the leading manufacturers of Nitrous Oxide delivery systems worldwide, which ultimately led to a licensing agreement.

And while the process may seem daunting, it may turn out to be well worth the journey. According to Guyette, furthering the truly great technological advances in medicine takes a willingness to push the envelope, to think differently, and to take risks.

“There were bi-monthly GoToMeeting teleconferences where design improvements were made utilizing CAD software with the input of engineers specializing in flow and materials and incorporating my clinical findings and recommendations,” Guyette said. “This was a fascinating process and was my first experience with CAD modeling and 3D printing. Silhouette has been well received in the marketplace and we believe has potential to make a significant difference wherever pain relief and reduction of anxiety is needed in the field of medicine,” he said. While not all doctors are as interested in developing new treatments or medical products as Guyette, many have had their own ideas for new products or system improvements, even if just in passing. Guyette said that he would have loved to have exposure to technology-centered subjects in medical school, such as patenting and testing processes and business development. “Perhaps these topics could be offered as an elective rotation during medical school,” he said. “We are the people delivering the treatment

“But not all technological advancements fall into that category,” he admits, speaking of the “truly great” ones. And sometimes the greatest advances are actually the simplest. “I am reminded that we landed a man on the moon in 1969 but it wasn’t until 1987 that someone decided to put wheels on the bottom of suitcases!”



Maricopa County Medical Society’s staff in 2014, and is currently serving as the Communications Coordinator. She has a bachelor’s degree in Communications and Journalism, and over 6 years’ experience as a writer, editor, and social media strategist. Dominique also enjoys helping with Society events, be sure to look for her the next time you attend! Dominique can be reached at




Dr. Robert Guyette | On the Personal Side Describe yourself in one word.

Curious (with Persistent a close second). I have many interests both within and outside of medicine. There is so much negativity in the world right now but with all the technologic advancements in every field, it is a great time to be alive and be a practicing physician.

What is your favorite food, and favorite restaurant in the Valley?

Spanish food, and Vincent’s on Camelback (haven’t found an authentic Spanish restaurant here yet).

What career would you be doing if you weren’t a physician? Architect/Builder

What’s a hidden talent that you have that most wouldn’t know about you (play the guitar, sing, etc.)?

I speak Spanish. (I’m usually the last one in the room who looks like they would speak Spanish.)

Favorite activity outside of medicine?

Visiting our children and grandchildren and figuring out ways to get everyone together. 28



Traveling, especially to Barcelona, Spain. Barcelona is like a second home to us. We have many friends and memories there.

Best movie you’ve seen in the last ten years?

“Bridge of Spies” I am an amateur history buff, especially the WWII era.

Favorite Arizona sports team (college or pro)? U of A basketball


I’ve been married to Gina, my life and business partner, for 39 years. We have three grown sons. Rob, who graduated in Aerospace Engineering from USNA. He flew the F/A-18 and F-35B and is currently a Marine test pilot stationed at Patuxent River, Maryland. Kevin, who works with Medtronic Spinal and Biologics Division at Barrows Neurological Institute, and Brian, who graduated in Systems Engineering from USAFA. He flies the B-1 bomber for the US Air Force and is stationed at Dyess AFB near Abilene, Texas. They are all married and we are blessed to have 4 fantastic grandchildren.

Violating HIPAA In 140 Characters Or Less BY BRYAN BAILEY, ESQ.


hysicians were one of the early adopters of text messaging for business purposes. For example, in 2011, the College of Healthcare Information Management Executives conducted a survey and found that 96.7% of their members allowed physicians to text orders to nurses and each other as part of their “bring your own device” policies.1 Text messaging can expedite physicians’ communications, possibly resulting in improved patient care. 98% of texts are opened within 15 minutes of receipt and the average person takes 90 seconds to respond to a text.2 Surgeons and other hospital-based physicians also can receive texts in places within a hospital where they can’t receive phone calls or emails.

However, have you ever wondered whether texting patient information complies with HIPAA? In 2013, the Department of Health and Human Services (DHHS) posted its answer to the following frequently asked question: “Can you use texting to communicate health information, even if it is to another provider or professional?”3 Like most things in healthcare, DHHS’s answer was: “It depends.” Sending a text message to the wrong number can be

embarrassing, but texting patient information to the wrong person can violate the Privacy Rule4 and require notification under the Breach Notification Rule.5 If the text wasn’t encrypted, it also would violate the Security Rule.6 With penalties of up to $50,000 per violation and the government continuously punishing healthcare providers for breaches involving mobile devices,7 physicians would be well advised to ensure their text messages comply with HIPAA. This article discusses the risks associated with texting patient information and identifies steps physicians can take to ensure compliance.

What’s Wrong with Texting Patient Information?

Of the 1.92 trillion text messages sent in the United States during 2014,8 most of them were via “short message service” or “SMS”. Text messages sent via your cellular carrier are SMS texts. SMS texts are inherently problematic under HIPAA because they aren’t encrypted; you can’t confirm whether the text was received by the intended recipient; and the texts remain on the cellular carrier’s server, perhaps indefinitely.



For example, if Dr. A uses his wireless plan to send a text message containing patient information to Dr. Z, and Dr. A is with Verizon© and Dr. Z is with T-Mobile©, at a minimum, the text will be on both doctors’ mobile phones, both wireless carriers’ servers, and it may have been routed over the internet. I’m not tech-savvy enough to know how to intercept (hack) a text message from any of these sources (but either doctor’s kids may read the text while “borrowing” the phone – which, incidentally, would violate both the Privacy and Security Rules), but apparently it isn’t difficult for certain individuals.9 Recognizing these problems, third-party developers have developed and implemented stand-alone secure (i.e., encrypted) texting applications. TigerText© is an example of a secure texting application. These applications can help physicians comply with HIPAA, but just because they say they are “HIPAA-compliant” doesn’t mean they are. No matter what anyone tells you, there is no such thing as a “HIPAA-compliant” application or device. The HIPAA Security Rule is technology neutral. Complying with it means you’ve implemented various physical, administrative and technical safeguards. In addition, a lot of these applications do not integrate with electronic medical records. Under Arizona law, a text message that relates “to a patient’s physical or mental health or condition” and that was sent or received “for purposes of patient diagnosis or treatment” constitutes a “medical record”.10 Medical records must be retained for at least six years from the last date of service.11 A physician who fails to maintain a medical record or the confidentiality of a medical record may be disciplined by his or her licensing board for “unprofessional conduct”.12 Moreover, the Privacy Rule provides individuals with the right to access and amend their information that is maintained in a “designated record set”.13 A “designated record set” includes patient information (i.e., “protected health information”) which is “used, in whole or in part, by or for a covered entity to make decisions about individuals.”14 Thus, a physician who fails to provide an individual with access to or the right to amend the individual’s information in the physician’s text message could violate the individual’s rights under the Privacy Rule.15 Lastly, not all of these secure text application developers will sign a Business Associate Agreement. A Business Associate Agreement is required with any vendor who will receive, maintain or transmit text messages containing patient information.16

How Can I Text Patient Information and Comply with HIPAA?

If you’ve already decided that it isn’t feasible to prohibit texting patient information, the first step in determining how you can text patient information is to perform a risk analysis. The Security Rule requires a risk analysis to determine potential threats to a covered entity’s electronic protected health information (ePHI). 30



Among other things, a risk analysis should identify potential threats to ePHI; analyze the sufficiency of current security measures; determine the likelihood and potential impact of a threat occurring; assign risk levels to the different threats; and identify and implement measures to address the threats. Failing to perform a risk analysis often is cited as a basis for HIPAA violations in settlement agreements with OCR. Some of the more common threats involved with texting patient information are the risk of loss, theft or improper disposal of a mobile device containing patient information; an unintended recipient gaining access to a text; and a third-party storing a text without a Business Associate Agreement. The next step is developing a risk management plan. In 2012, recognizing the threats posed by mobile devices, DHHS published online guidance regarding securing mobile devices.17 DHHS recommends the following steps to protect and secure patient information when using mobile devices: •

Install and enable encryption to protect health information stored or sent by mobile devices;18

Use a password or other user authentication;

Install and activate wiping and/or remote disabling to erase the data if the mobile device is lost or stolen;

Disable and do not install or use file-sharing applications;

Install and enable a firewall to block unauthorized access;19

Install and enable security software to protect against malicious applications, viruses, spyware and malware-based attacks;

Keep your security software up-to-date;

Research mobile applications before downloading;

Maintain physical control of your mobile device. Know where it is at all times to limit the risk of unauthorized use;

Use adequate security to send or receive patient information over public Wi-Fi networks; and

Delete all stored patient information on your mobile device before discarding it.20

I recommend utilizing a third-party application to send and receive encrypted texts. However, for the reasons previously stated, I would only use an application if I have a Business Associate Agreement with the application’s developer and only if the application integrates with my electronic health record. Lastly, no risk management plan can be effective unless it is reduced to writing and training is provided. Regular training is vital to minimizing the risk of a HIPAA violation and reportable breaches.


All forms of communication present some form of risk and text messaging is no different. Remember there is no “HIPAA compliant” device or application that will ensure your compliance with HIPAA. Compliance is a never-ending process, requiring ongoing analysis, planning, implementation, auditing and review. What works for one group may not work for another. If you or your group must text patient information, follow the steps outlined above to minimize your risk of noncompliance. Notes

1. Diagnotes. Behind the Product Design: Redesigning Secure Texting for Healthcare. Available at: Accessed March 23, 2016. 2. TextMarks. 6 Benefits of Text Messaging: Why Your Organization Should Use SMS. Available at: Accessed March 23, 2016. 3. Department of Health and Human Services. Office of the National Coordinator for Health Information Technology. Frequently Asked Questions. Available at: Accessed March 23, 2016. 4. The HIPAA Privacy Rule is at 45 C.F.R. Parts 160 and 164, Subparts A and E. 5. The Breach Notification Rule is at 45 C.F.R. Part 164, Subpart D. 6. The HIPAA Security Rule is at 45 C.F.R. Parts 160 and 164, Subparts A and C. 7. See March 17, 2016 Department of Health and Human Services Office for Civil Rights (OCR) press release regarding $3.9 million settlement of HIPAA violations arising from stolen laptop containing patient information. Available at: html#. See also September 2, 2015 OCR press release regarding $750,000 settlement of HIPAA violations with radiation oncology group arising from stolen laptop containing patient information. Available at: about/news/2015/09/02/750%2C000-dollar-hipaa-settlement-emphasizes-the-importance-of-risk-analysis-and-device-and-media-control-policies. html. Accessed March 23, 2016.

19. I don’t know if it is possible to install a firewall on your smart phone; check with your IT professional. 20. Department of Health and Human Services. Office of the National Coordinator for Health Information Technology. How Can You Protect and Secure Health Information When Using a Mobile Device? https://www. Accessed March 23, 2016.

BRYAN BAILEY, ESQ. Bryan has a broad-based practice in health care law and business transactions. He represents individuals and companies in the health care and life sciences industries regarding transactional, regulatory and operational issues. He has extensive experience helping clients structure, negotiate and implement effective and compliant relationships with their business partners, including hospital/physician joint ventures, management and administrative service arrangements, professional service agreements and other business relationships. He regularly advises clients regarding federal and state health care laws and regulations, including the AntiKickback laws, the Stark Law, HIPAA, Federal and State licensing and certification requirements and a myriad of other health care laws. Bryan is one of a handful of attorneys in Arizona with substantial experience advising health care providers regarding Medicare and Medicaid (AHCCCS) reimbursement laws, including representing providers involved in governmental and commercial payor audits, investigations and appeals. He also represents providers in government investigations and enforcement actions related to licensing and health care claims.

8. 2014 CTIA Annual Wireless Industry Survey. Available at: your-wireless-life/how-wireless-works/annual-wireless-industry-survey. Accessed March 23, 2016. 9. iSpyoo. How to Hack Text Messages on Mobile Phone? Available at -hack-tex t-messages- on-mobile -phone/. Accessed March 23, 2016. 10. A.R.S. § 12-2291(6). 11. A.R.S. § 12-2297(A). 12. See A.R.S. § 32-1401(27)(a) (“violating any federal or state laws, rules or regulations applicable to the practice of medicine”), (b) (“intentionally disclosing a professional secret or intentionally disclosing a privileged communication”), and (e) (“failing or refusing to maintain adequate records on a patient”); see also A.R.S. § 32-1854(1) (“knowingly betraying a professional secret or willfully violating a privileged communication”), (21) (“failing or refusing to establish and maintain adequate records on a patient”), and (35) (“violating a federal law, a state law or a rule applicable to the practice of medicine.”). 13. See 45 C.F.R. § § 164.524, 164.526. 14. 45 C.F.R. § 164.501. 15. Of course I am assuming the physician is a “covered entity” subject to the Privacy Rule. 16. See 45 C.F.R. § 160.103 and 45 C.F.R. § 164.504(e). 17. Department of Health and Human Services. Office of the National Coordinator for Health Information Technology. Guide to Privacy and Security of Health Information. Your Mobile Device and Health Information Privacy and Security. Available at: Accessed March 23, 2016. 18. Encrypted patient information likely does not constitute “unsecured protected health information”, when no notification is required under the Breach Notification Rule if the information is lost or compromised.

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Dr. John Middaugh, Dr. Diana Petitti


n February 4, 2016 Maricopa County Medical Society members gathered to share some of their wisdom with the up-and coming generation of medical students. Sponsored by MICA, the Beers w/Peers event was the first Society mentoring event of its kind, and we are pleased to say it was a great success! A variety of physicians showed up to answer questions posed by medical students from Midwestern University, A.T. Still University, Creighton School of Medicine, and the University of Arizona College of Medicine – Phoenix. Mentors and Students enjoyed craft beers and root beers as well as appetizers, and discussed the experiences and decisions involved in pursuing their medical careers. We are extremely grateful to all of our members who answered the call to help forward our future physicians, and to everyone who contributed their hard work and talents to make the evening so enjoyable. The event was photographed by Denny Collins, and you can view our entire photo album (and tag yourself & your friends!) on the Society Facebook page: medicalsociety.

One of our prize winners, Dr. Mark Kartub, and his wife Nancy.



A huge thank you to our Preferred Partner and Sponsor, MICA, for making this night possible!

Dr. James Carland and Nathan Goff




Everyone who filled their passports was entered into a drawing. The two winners received a new Fitbit.


Introducing the scholarship

MICA president & CEO Dr. James Carland introduced a new scholarship essay contest – co-founded by MICA Foundation and MCMS. Our first winning essay by Aishain Shi from University of Arizona College of Medicine – Phoenix, was featured in our March issue, page 20.

New party lights in the MCMS courtyard made the evening particularly festive.



Each group signed the passports of those they had the opportunity to speak with, hoping to fill the entire passport by the end of the evening. Here, Dr. Darren Wethers exchanges signatures with Ajali Taneja.

Jeneeca Bruce and Cailey Indech talking with Affiliated Dermatology providers Stephanie Blackburn, DO, and Michelle Goedken, DO.





Students and mentors each received Mentorship Passports for the mingling portion of the event. Jeneeca Bruce, Cailey Indech, and Dr. Sunil Jain.

Mentors answered questions about selecting their specialties, deciding how and where to begin their practice, and balancing their lives with work. Dr. James Carland, James Potter, Hilary Park, Fredi Doerstling.




Drs. Miriam Anand and Sunil Jain talking with Melvin Parasram & Ben Kenny.

Dr. Lee Ann Kelley and Cindy Chiu enjoying the evening.


Adam Brodsky, Ross Goldberg, May Mohty, John Couvaras, Jay Crutchfield, Shane Daley, Kelly Hsu, Lee Ann Kelley, Marc Lato, Richard Manch, John Middaugh, Tabitha Moe, Constantine Moschonas, Anita Murcko, Steve Perlmutter, Pamela McCloskey, and Kimberly Weidenbach were present.


Jay Conyers was present. Dr. Brodsky called the meeting to order at 6:04 pm.


Dr. Brodsky asked Jay to review the old business items on the agenda. Jay corrected the appointment of ArMA delegates as approved at the February 2016 meeting. Jay updated the board on the status of SB1473, concerning the nursing scope of practice expansion. Dr. Goldberg expanded on the discussion and provided an overview of recent stakeholder meetings, and the efforts made by ArMA’s lobbying team to reach a deal with the Nursing Association. Jay summarized the February 29th presentation made to the Alliance of Arizona Health Plans, for consolidation of medical records reviews. GACCP is a finalist for the contract and is waiting to receive notice from the Alliance. Jay updated the Board on the staffing changes with Round-up. Lastly, he presented a slide showing the financial performance of BME and GACCP through the month of February.


A motion was made to approve the consent agenda, comprising February Board minutes and the membership report. The motion carried.


Dr. McCloskey gave a presentation on committee

charges and summarized the committee’s recent meeting. She discussed the committee’s ideas to improve the Beers with Peers concept, and suggested that we host several events each year and move them throughout the valley. Dr. McCloskey summarized feedback she’s received from local students and residents. Residents would like the Society to offer a forum on contract review, with legal experts offering some pointers on what to consider when considering an employment contract. Residents also expressed interest in interacting with seasoned physicians to address solo practice versus partnership agreements versus employment. Students expressed a strong interest in the Society providing opportunities for them to speak directly with program directors to better understand what they’re looking for, what an ideal candidate looks like. Additionally, students would be receptive to opportunities to learn more about subspecialties and lifestyles associated with each, directly from physicians in a Q&A format. Dr. McCloskey summarized the committee’s recommendation that the Society better engage local residency programs. It was suggested that staff assemble a list of all programs in the valley and for each, know the primary points of contact and when orientation begins Dr. McCloskey also suggested approaching residents about MCMS membership in July since educating money is renewed during that month each year.


Dr. Middaugh gave a presentation on committee charges and summarized the committee’s recent meeting. He summarized a recent meeting he attended, held by The Arizona Partnership for Immunization (TAPI). The meeting was held to address an approach to curb the personal exemptions being exploited by many in the community. The Board also considered what percentage of our member physicians support personal exemptions, and considered a survey to better understand. Additionally, it was mentioned that may local charter schools may not support our efforts to assist with educating, since enrollment is tied to funding for them and they would potentially be opposed to initiatives that cut into their enrollment.






MCMS Board of Directors Meeting Minutes March 15, 2016 | 6 pm

Dr. Middaugh presented some data to the Board comparing Arizona’s ranking nationally for investment in public health. He pointed out that our state is 49th out of 51, with the median being roughly $33 per person and Arizona around $9 annually. He described the mechanism for distribution of CDC funding to states, pointing out that counties have to apply for funds directly through their own state health departments. Dr. Middaugh communicated to the Board that large census states can apply directly to the CDC for funding, and used San Antonio – a city of comparable size to Phoenix – as an example. He pointed out the fact that doing so requires a city health district, which we do not have here in Phoenix, but does exist in cities like San Antonio. Dr. Middaugh asked the Board to consider engaging the County Health Department in funding discussion, as well as policy topics such as e-cigarette regulation. Lastly, Dr. Middaugh updated the Board on SB1283 (pharmacy database mandate) and SB1445 (protection of personal beliefs against health board regulation), and concerns he and the Public Health committee have about each bill. Dr. Goldberg provided a brief update on the growing national movement towards stricter regulation of opioid prescribing, pointing out that there are presently 21 bills in the U.S. Senate and/or House of Representatives addressing the topic.


Dr. Lato gave a presentation on committee charges and summarized the committee’s recent meeting. He discussed the committee’s recommendation for the Society to not invest the time and money to go through the CME certification process. The committee did not feel the ends would justify the means, and instead suggested the Society consider partnering with other organizations that are certified to organize and offer CMEs. The committee saw value in the Society building a web resource on its website with links to various free online CMEs, local CMEs, and other ‘hot topic’ CMEs that physicians are currently interested in. Dr. Lato suggested that Society staff conduct a survey of its members to better understand what CMEs they are interested in, and include suggestions that include 40



topics such as Meaningful Use, MACRA, leadership, medical management, and medical administration. It was also suggested that the Society populate the online calendar with local CMEs being offered throughout the valley. Dr. Lato summarized the committee’s recommendation that the Society write about quality topics such as value-based purchasing, never events, and herd immunity, among others. Articles in Round-up could help to better educate our members about quality metrics. The committee also recommended that the staff reach out to local schools and hospitals to understand what CME resources they offer, and explore opportunities to partner with them.


Dr. Brodsky updated the Board on recent conversations held between the Society and ArMA concerning ways the two organizations can work together. The Board was concerned that we must fully understand the prior Supreme Court ruling against the Society and Arizona Foundation for Medical Care, dating back to the early 1980s, so as to avoid any legal issues arising from us working more closely with ArMA. The Board encouraged Dr. Brodksy and Jay to further discuss collaborative opportunities with ArMA, and agreed that a joint meeting of Boards would be beneficial in the near future.


Jay reminded the Board about the April 28th Medical Philanthropy event, and encouraged everyone to put the event on their calendar. Jay discussed with the Board a recent meeting he had with the Arizona Hospital & Healthcare Association (AZHHA). The Board agreed it made sense for Jay to explore collaborative opportunities with the organization. Dr. Manch offered to assist Jay with background and discussions with AZHHA. Jay also notified the Board of his decision to retain counsel to overhaul the Society’s policy manual.


The meeting was adjourned at 7:27 pm.

In Memoriam Patrick P. Moraca MD

Patrick P. Moraca MD passed away on January 21, 2016. He was born February 3, 1930 in Beaver Falls, Pennsylvania, 3 months after his mother arrived from Italy. Both parents Tredicino and Elisa Moraca preceded him in death, as well his sister Mary Jean Maresh. He graduated from Washington & Jefferson College with a BA degree and received his MD degree from Hahnemann Medical University in 1954. He had his anesthesiology training at Cleveland Clinic and served as assistant chief of anesthesiology at Brook Army Hospital in San Antonio, Texas for 2 years. He returned to staff at Cleveland clinic for 2 years before moving to private practice in anesthesiology in Phoenix in 1961. He joined the Maricopa County Medical Society in 1961, and served as president in 197. He was a founder and President of Maricopa Foundation for Medical Care. He was also a founder of Mutual Insurance Company of Arizona and board member for 12 years. He retired in 1998 and enjoyed playing golf with his friends of 50 plus years and RV-ing with many dear friends. He also enjoyed volunteering as a tax aide for AARP for 9 years. He is survived by the love of his life, best friend and wife, Tommie, bother John Moraca MD, sister Ann Aquino, and his five children, David (Maureen), Richard, Stephen (Carol), Michele (Shawn) and Patrick M. (Tracy). He will also be missed by his 9 grandchildren.

Meyer, Hermann Belton Perrin M.D. Ph.D., Knight of Malta

April 5, 1935-February 17, 2016. Our dear and most beloved father, husband, brother, mentor, teacher, healer and friend Belton passed away peacefully at home in the company of dear friends and his beloved wife following a brief but courageous battle with lung cancer. Belton was born

in Stockton, California, to Margaret Anna Kammerer and Hermann Perrin Meyer. Proud to call himself a fifth generation Californian, he was an avid student of family history and repository of family lore. His many reminiscences on growing up and on Sacramento and California history, were always fascinating. Belton earned an A.B. from UC Berkeley in 1957, his M.D. from UC San Francisco in 1960, then completed a rotating medical internship at Highland County Hospital in Oakland, where he met and courted the love of his life, Marion Annette Pinkerton of Alpena, Michigan. They were engaged on St. Patrick’s Day and married in Berkeley on July 2, 1961. He served two years’ active duty as a Lieutenant in the US Navy Medical Corps, then completed his pediatric residency at UC San Francisco and an NIH fellowship in newborn respiratory physiology at Stanford. In July of 1967 the family moved to Phoenix, where Belton directed the Arizona Premature Transport and Intensive Care Program. By most accounts he was the first physician in the new specialty. He helped to pioneer regionalization of care for mothers and infants, directing the establishment of two major maternal and nursery units in Phoenix. Thanks to his tireless work, by 1972 newborn mortality in Arizona had declined from 35th to 3rd nationally. Belton retired from medical practice in 1992 and served for 5 years as medical director of AHCCCS. He then returned to school and earned a Ph.D. in the ASU School of Justice Studies, focusing on the nature of the newborn. Belton was a devout Catholic, involved in numerous ministries. Particularly dear to him was his ongoing service since 1991 in the Order of Malta. He loved life--food, music, travel, and most of all time with Marion, children, grandchildren, and many friends. He was defined by an unshakable sense of values and spirituality, an almost child-like purity of love that touched all who knew him, and by his almost saint-like devotion to Marion who is suffering from advanced Alzheimer’s. Belton is survived by his wife Marion, sons Paul and Christopher, daughters-in-law Iris Colon and Charmaine Felix-Meyer, grandchildren Nicolas, Jack, Emma, Paul and Iris Meyer, niece Lisa Nelson and nephew Eric Meyer, cousins Robert, Jack and Carlton Meyer.



In Memoriam Stroth, Ronald Alan

Ronald Alan Stroth, MD, passed away on February 9, 2016 in Scottsdale, AZ. Born on March 31, 1936 to Mayor Samuel Atherstone Stroth and Florence A. Clint Stroth of Jamestown, New York, Ron was a standout athlete and Phi Beta Kappa scholar who attended Colgate University and then Cornell University for medical school. Ron served in the US Navy as a medical officer on the aircraft carrier USS Hornet. While docked in Long Beach, CA, Ron met his future wife, Myna Marie Meissner. After getting married in Tucson in 1968, Ron and Myna moved to Philadelphia, where Ron finished his anesthesia residency and Myna gave birth to their son, Bob. In 1970 the Stroths moved to Phoenix, where Stephanie was born the following year. For years, Ron practiced at the Scottsdale hospitals and Myna taught elementary school. Upon retirement, Ron and Myna bought their dream cabin in Munds Park and spent 15 idyllic summers with friends and neighbors. Their favorite pastime was traveling the world with close friends Stu and Anne Matheson and Chuck and Judy Johnson. After 46 years of loving marriage, Myna lost her struggle with ALS on May 15, 2015. Ron was known to all for his integrity, intelligence, and kind demeanor. Surviving Ron is his son, Robert Alan Stroth, M.D. (Amy) and grandson William; his daughter, Stephanie (Keith); his brother, Norman (Peggy); his sister-in-law, Lois Stroth; his brother-in-law, Tom Meissner (Carol); his nieces and nephews: Laurie Stroth Aloi (Bob), Leslie Stroth Wickham (Landon), Tim Stroth, Thomas Stroth (Theresa), David J. Stroth (Kate), Philip Stroth, Mary Stroth Hodge (Chris), Nancy Stroth (Mike Corner), David W. Stroth (Lisa), Andrew Stroth (Janel), Amanda Wray (Adam), Tom Meissner (Lynn), David Meissner, Susan Meissner (Ken), and his great nieces and nephews Peter, Betsy, Katie, Sam, T.J., Ella, Isabel, Connor, Heyward, Maggie, Taryn, Nick, Justin, Monroe, Jackson, Avery, Jason, Alexander, Julian, Will, Jack, and Emil. Ron was predeceased by his brother, John Wendell Stroth from Chicago (2014), as well as his father Samuel (1973) and his mother Florence 42



(2002), whom he moved to Phoenix and cared for until her death at 100 years old. Ron’s family would like to thank the Maravilla Scottsdale staff and caregivers for providing loving support for Ron and Myna throughout their end-of-life challenges.

Van Hoosear, Stewart

Dr. Stewart W. Van Hoosear, 71, passed away peacefully on February 11, 2016. Born June 7, 1944 in Oakland, California, Dr. Van Hoosear was preceded in death by his loving wife, Marlene Rose (Sloss) Van Hoosear. He is survived by his daughter Noel Cesena (Robert), grandchildren Tyler, Gabby and Hayden, as well as his brother Allen Van Hoosear. He was a long time resident of Mesa, AZ, and a practicing pediatrician in the community for 40 years.

Paul Philip Scheerer M.D.

Paul Philip Scheerer, M.D., 82, of Phoenix, died on Sunday, March 27, 2016 in the comfort of his home. He was born in Fairmont, West Virginia on August 8, 1933, son of the late Ruth and Paul Scheerer. He graduated from West Virginia University and Northwestern University Medical School. Dr. Scheerer practiced hematology in Phoenix for 36 years. He was a passionate physician who loved his work and made the world a better place. His family wants to thank him for always being there. “We love him and will never forget him.” He always enjoyed his time in the sun, whether it was working in the yard, out on the tennis court or talking to friends on the beach. He is survived by his wife of 56 years, Alice, and his children, Marie, Christine, Mark and John (Angela), five grandchildren, sisters Janice (Steve) and Judy (Len), and brother John.





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Since MICA’s Founding, Our Members have Received over $500 Million in Dividends.

As a mutual company, MICA distributes dividends to its members when financial conditions warrant. With the announcement of a $27 million dividend for the 2015 policy year, MICA’s total dividends distributed to members totals more than half a billion dollars.


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Round-upDividends declared for a policy year reflect the Company’s financial performance. Past performance does not guarantee future dividends.

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Round-up Magazine, April 2016