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FOCUS TOPICS WOMEN’S HEALTH HIT

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PHYSICIAN SPOTLIGHT PAGE 3

Peter Earl, MD ON ROUNDS HEALTHCARE LEADER: Dr. Steve Adkins While many clinicians struggled to meet deadlines for setting up electronic medical records systems within their practices, most feel that the time and effort have been worth it. ... 4

LEGAL MATTERS: Profit And Loss: The Top Ten Things Providers Need To Know ... 6 Special Advertising Insights ... 2 Quillen Heart Talk ... 9 Partnering with Compounding Pharmacists ... 13

ONLINE: EASTTN MEDICAL NEWS.COM

Identity as a Risk Factor Heart disease and the feminine mystique By CINDy SANDERS

Despite the fact that heart disease is the number one killer of women in America and stroke the leading cause of disability, women often don’t identify with the very real dangers the disease holds for their gender, according to Robert Wood Johnson Foundation Clinical Scholar Lisa Rosenbaum, MD. “We all know men drop dead of heart attacks … we don’t think of women dropping dead of a heart attack,” the University of Pennsylvania cardiologist noted of the masculine attributes often attached to heart disease. Furthermore, women tend to fear

other diseases, notably breast cancer, more than heart disease. The HealthyWomen 2010 survey, in partnership with the National Stroke Association and the American College of Emergency Physicians, found that women believe breast cancer is five times more prevalent than stroke, and 40 percent of those surveyed were ‘only somewhat’ or ‘not at all’ concerned about experiencing a stroke. Yet, stroke is significantly more prevalent in women than in men, and stroke kills twice as many women as breast cancer each year. “There’s a certain sort of female solidarity around breast cancer,” Rosenbaum stated. In a perspective piece published earlier this year in the New England Journal of Medicine, Rosenbaum wrote about an encounter with a middleage woman with high blood pressure and hyperlipidemia. When Rosenbaum asked the new patient what was the number one killer for women, (CONTINUED ON PAGE 10)

SANS Cyberthreat White Paper Shows Dark Clouds on HIT Horizon Widespread security issues put systems, patients at risk By CINDy SANDERS

Consider yourself warned. A white paper released earlier this year by SANS, a global leader in cybersecurity research, training and certification, painted a bleak picture of where those in the healthcare industry currently stand in terms of keeping protected information safe and secure. The report was created using healthcarespecific data provided by Norse, a live threat intelligence and security solutions firm, from September 2012-October 2013. The eye-opening results underscored the vulnerability of providers, payers, business associates and patients. Authored by Barbara Filkins, a senior SANS analyst and healthcare specialist, (CONTINUED ON PAGE 10)

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InSights Age-related Macular Degeneration and the Prevention of Vision Loss Age-related macular degeneration (AMD) is a complex, multifactorial disease with progressive degeneration of the retinal pigment epithelium and photoreceptors. This degenerative process can lead to symptoms that vary from no visual loss at all to profound visual loss. Early symptoms of low vision from AMD may include shadowy areas in the central visual field or unusually blurry vision. In developed countries such as the U.S., AMD is the leading cause of irreversible blindness. Risk factors include age, smoking and genetic predisposition. To a lesser extent, hypertension and hyperlipidemia (high cholesterol and/or triglycerides) may also play a role in the disease. There are also ethnic differences with AMD, which is more prevalent in Caucasians than in black and Hispanic populations. The genetics of AMD is under intense scrutiny, with several genes implicated in many cases of AMD, especially in severe AMD. At this time, there is no treatment for any genetic abnormality found in patients with AMD. “AMD is the number one cause of vision loss in senior citizens,” said John Johnson, MD, a physician with Johnson City Eye Clinic and Surgery Center. “Age-related macular degeneration often results in ‘low vision’ or significant vision loss, which cannot be helped by normal correction, such as eyeglasses or contacts lens.” AMD begins with changes in and under the retinal pigment epithelium (“dry AMD”) and can progress to new vessel formation under and in the retina itself (“wet AMD”), leading to loss of all central vision. The symptoms of AMD depends on the stage; in early dry AMD, there are no symptoms at all. As the disease progresses, there may be gradual blurring of central vision, and if wet AMD develops, there may be sudden marked loss of central vision. The treatment for AMD depends on the stage. In moderate to severe dry AMD, antioxidant vitamins plus zinc have been shown to reduce the

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progression of the disease to wet AMD. For wet AMD, there are three medications available that can be injected into the eye to slow down the progression of the disease. At the present time, there is no cure for AMD. The top five risk factors for AMD include being over the age of 60, having a family history of AMD, smoking, obesity, and hypertension. Patients with just two of these risk factors should see their eye care provider to determine preventive measures, thereby reducing the risk of vision loss from AMD. Earlier diagnosis gives a much better chance of successful treatment. “With or without a family history of AMD, patients should be referred for regular eye exams to include a dilated exam of the retina to rule out AMD,” said Johnson. “If AMD is diagnosed, we can recommended therapy, if indicated. “At the Johnson City Eye Clinic, we have extensive experience with both wet and dry AMD and have the necessary diagnostic tools to diagnose, treat, and follow the disease,” Johnson added. “All of our physicians are prepared to discuss this disease with the patient and his or her family.”

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PhysicianSpotlight

Peter Earl, MD By BRIDGET GARLAND

Although Colorado was home for Peter Earl, MD, for the first half of his professional career, Earl, who practices general obstetrics and gynecology with Wellmont Medical Associates, has made a place for himself here in the Tri-Cities, providing superior care for the women of the region. Earl received his undergraduate degrees at Hobart College in Geneva, N.Y., and the University of Colorado in Boulder. He went on to receive his medical degree at the University of Colorado Health Sciences Center in Denver. He completed his residency in obstetrics and gynecology from Good Samaritan Regional Medical Center in Phoenix, Ariz., before going into private practice in Colorado. Even as a young child, Earl said he knew that he wanted to be a doctor, perhaps because of all the time he spent in the ER as a patient. He said he was fascinated by the field and never swayed off his career path until later in medical school. “I started to get really nervous because I hadn’t found a specialty that I really liked. I even considered doing something else,” he confessed. “But after talking with my dad, he convinced me to stay until I was finished. Fortunately I listened to him.” As soon as he started his OB/GYN rotation in medical school, Earl was asked by his attending physician to help deliver a baby, and a second, and a third—remarkable moments that helped focus his direction. Even though Earl has since spent

over two decades practicing as a general OB/GYN, he hasn’t lost his enthusiasm about the services he provides and passes along his knowledge and experience as a preceptor for the Department of Family Medicine at the Quillen College of Medicine. While Earl offers a full gamat of OB/ GYN services to patients both in Johnson City and Kingsport, he has a few areas of particular interest, including menopausal medicine and incontinence. Although he is skilled in using the da Vinci Robotic Surgical System, Earl says he prefers to offer his patients non-surgical options whenever possible. “Sometimes surgery is not always the best option,” explained Earl. “For instance, we offer bladder training for some types of incontinence. It’s a simple office program, and is pretty effective, with 80% of patients seeing improvement.”

Although he has been offering the therapy to patients in other areas of the region, Earl will be provding the therapy to patients in Johnson City, as part of Wellmont Medical Associates expansion of services throughout the Tri-Cities. “Pelvic floor therapy is a great way to go when treating both stress incontinence and urge incontinence,” Earl said. “It doesn’t cure everybody, but it does have high outcomes, and patients don’t have to worry about complications associated with surgery.” Earl also has a special interest in endometriosis, and when surgery is indicated for a patient, is highly skilled in using the da Vinci Surgical System, an alternative to more invasive surgical procedures. “I love what I do,” said Earl. “And it just gets better every year.” Earl and his wife Linda, originally from Roanoke, Va., moved to the area

so that their daughter Madeline could be close to family. Madeline, now 18, was homeschooled through 8th grade by a mother with a wide variety of skill sets, including spinning, weaving, and knitting; goat farming; and growing orchids. Earl lends a hand when needed and admits that he’s became pretty good a spinning and weaving, but teased that he isn’t allowed to touch the orchids. He also helps out with the animals, including the new chicks just hatched. Earl’s biggest interest outside of medicine, however, is ice hockey; perhaps an unusual sport for this area of the country, but as an avid hockey player and fan, he joined an adult league in Knoxville and plays a couple of days a week. “I’ve been playing since I could walk,” he enthused. “It’s a lot of fun, and a big stress relief. I can take out all my frustration on the ice.”

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HealthcareLeader

See-Through Efficiency Making HIT Work In the Era of Meaningful Use By JOE MORRIS

While many clinicians struggled to meet deadlines for setting up electronic medical records systems within their practices, most feel that the time and effort have been worth it. That’s especially true as Meaningful Use’s second phase rolls out in tandem with additional recordkeeping requirements under the Affordable Care Act. Now the trick is to not only keep EMR systems working well for the office, but also ready to interface with other providers, hospitals, government agencies, insurance companies, and even patients via publicfacing online portals. It’s a tall order, but one that Dr. Steve Adkins believes can be managed with the right amount of knowhow and forward thinking. As Chief Medical Information Officer for Holston Medical Group and its Healthcare Information Technology (HIT) sister company OnePartner, Adkins has worked on the EMR committee and has overseen the implementation of the Allscripts TouchWorks Electronic Health Record at HMG’s Kingsport office. He also serves on the board of directors for the Highlands IPA in Kingsport, and the Qualuable Medical Professionals ACO. His practice is based at HMG Primary Care in Weber City. “Our electronic health records product goes back to the mid-1990s, and I began using EMR to see my patients in my clinical practice back in 1997,” Adkins said. “I’ve always been interested in technology, and gradually over time due to that interest and maybe some aptitude just began to participate with it more and more.”

After working as a clinical lead on upgrades and changes, Adkins, who holds a Bachelor’s of Science from the College of William and Mary and received his medical degree from the Medical College of Virginia (now Virginia Commonwealth University), found himself moving more and more into the HIT world. “Around 2000, I became involved with some clinical advisory groups, as well as physician advisory boards, and continued to work heavily as a developer partner with Allscripts,” he said. “Over time, I found I was devoting more time to administrative duties, and five years ago realized I needed to spend more time on our HIT issues. I’m now working with HMG on our HIT needs, but really emphasizing the work of our sister HIT company to develop health information exchanges and that kind of thing.”

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Describing that ongoing work as “extraordinary,” Adkins says that it’s important for any medical group to have strong physician buy-in to its EMR and other HIT systems, but having a physician leading that development is even better. “It really helps in terms of staff engagement,” he explained. “ I’ve said for years that the initial focus of any technologyadoption process is getting the clinicians and staffers to use the product. Dealing with data entry and all the pain of a new setup is important, and you have to get everyone to recognize the value of the huge amount of clinical information you’re building a system on top of. For years, we’ve been using analytics packages to pull data from our EMR for our own purposes, and giving that data back to the physician. Now, with a regulatory environment that includes Meaningful Use, the Recovery Act, and more, we are now looking at how we can step up our commitment to the technology.” That can mean upgrades or implementation, he says, noting that the onslaught of deadlines for Meaningful Use and other programs has meant that many vendors’ bandwidth is completely consumed by just meeting those commitments. “That has kept a lot of innovation from coming online, but I think that we at Holston now are in a position where we can not only meet the requirements that are out there, but also move into the next phase of development, which will be true population management.” To that end, HMG’s Health Information Exchange is up and running through OnePartner, and data is coming in from groups all across the area.

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“All of this is driven by everyone who is participating in our Accountable Care Organization, those member groups,” Adkins said. “Everyone is feeding into the HIE, and now we are working on our next phase, which will be to put an analytics engine on top of that so that we can record and share a lot of different types of results with the entire community.” The move, both from the federal viewpoint as well as at the local level, continues to be toward data accessibility across a wide range of platforms, as well as the creation of transparent data portals for patients. Adkins said that the move is in line with the overall shift in how healthcare costs are billed, and paid for, now. “We are in a big transition from a feefor-service model to what some are calling a fee-for-value payment model,” he explained. “That’s going to be more and more data driven, and so we’re going to have to have the tools in our electronic health record systems to provide better clinical decision support at the point of care, but also management options for patients. They see that as value — not just their doctor giving them clinical data, or cost data, but them being able to look at it themselves.” He points to the attention generated by the Centers for Medicare & Medicaid Services recent unveiling of payment data for the 2012 payment year. “Anybody with an Internet connection can go online and get a breakdown of what their provider was paid for various categories,” Adkins said. “That kind of transparency is good, and we are making sure that when our patients log in, they are able to see all their information from any provider they have who is participating in our exchange. That gives patients more control over their health data, and we think that’s really valuable.”

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Clinical Evaluation and Documentation Key to ensuring patients with diabetes-related complications receive prosthetic, orthotic and pedorthic devices By Chad McCracken, MS, CPO

Brief History of Audits and Changes in Documentation

In 2011, Medicare sent a “Dear Physician” letter to all participating physicians instructing physicians that physician clinical records are the only records relevant in determining the medical necessity of prosthetic care, and the prosthetist’s records must corroborate the physician medical records. In effect, it is the treating physician records that justify payment for specific devices. This sounds great for the overall patient management, but it presents one major problem: most physicians don’t understand differences in prosthetic designs related to suspension, component selection, and evaluating functional level (K-level) as defined by Medicare. In common practice, the physician relies on the prosthetist as the allied health professional trained to understand and provide these

types of devices and services. Technically, these “changes” were not really changes, but more of a clarification of their “original intentions.” Soon after the new standards of documentation went into effect, Medicare began enforcing their intentions in the form of aggressive RAC audits. The results of these new documentation standards has been delays in patient prosthetic care, additional physician visits specifically to meet insurance requirements for documentation, and additional evaluations related to recommending devices and evaluating their outcomes. Without sufficient physician documentation, prosthetic providers are hesitant to recommend and provide devices and technologies.

Prescribing Devices for Patients with Diabetes and Related Complications

Two of the most commonly prescribed types of orthotic and prosthetic devices are basic diabetic shoes with inserts and below knee prosthesis. In providing orthotic and prosthetic devices for complications related to diabetes, we O&P providers typically provide both ends of the spectrum from the most basic devices like diabetic shoes, inserts, and shoe modifica-

tions to some of the most advanced prosthetic designs. Goals for these devices are also as varied from unloading diabetic ulcers, accommodating foot deformities, increasing stability from gait deviations, to prosthetic devices that aim to return people to active independence. Unfortunately, the Medicare-driven requirements for documentation, specifically physician clinical notes are as stringent for both the high end prosthetic devices as they are for the most basic diabetic shoes and inserts. Being aware of the documentation requirements and meeting these requirements at the time of evaluation will save you time, will avoid irritating requests for “additional documentation or justification,” and will help your patient receive their device in a more timely manner.

Qualifying Criteria for Diabetic Shoes/Inserts

Medicare has made it very clear that a diagnosis of diabetes alone does not justify dispensing diabetic shoes. Patients must have diabetes, be treated under a comprehensive plan of care related to diabetes and have a specified condition justifying the need for diabetic shoes. These qualifying conditions are as follows: (CONTINUED ON PAGE 12)

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You may have noticed an increase in requests for clinical documentation and justification for prescribed prosthetic, orthotic, and pedorthic devices. This is due, in part, to clarification by CMS concerning who is able to recommend and justify the medical necessity of these devices and enforcement of this policy in the form of RAC (Recovery Auditor Contractors). Basically, CMS expects physician documentation to justify the need and expectations for the prescribed devices. As cited from their 2011 “Dear Physician” letter, “It is the treating physician records, not the prosthetist’s, which are to be used to justify payment.” Auditors can deem an “overpayment” or “improper payment” in any case where the physician’s notes do not independently corroborate the prosthetist’s clinical file, even when prosthetist’s notes document the medical justification for prescribed devices. Reimbursement recoupment of expensive devices already delivered up to three years prior has put prosthetic providers on the defensive to make sure that we have on-file all necessary documentation prior to delivery of devices and services. Therefore, physician documentation is the key to ensure patients receive appro-

priate orthotic and prosthetic devices in a timely manner. Failure to adequately document the need and functional goals of any prescribed prosthesis or orthosis can place providers at risk of recoupment of these services for up to three years after delivery. These nationwide recoupment efforts have caused may O&P providers to close their doors, limiting patient access to qualified practitioners.

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LegalMatters BY ERIN B. WILLIAMS AND DIANA L. GUSTIN, LONDON & AMBURN, P.C.

Profit and Loss: The Top Ten Things Providers Need to Know Part I: The 2014 OIG Work Plan This article is the first installment in a series which explores the top ten health law issues and their potential financial consequences on a provider’s practice. The U.S. Department of Health and Human Services (“HHS”) Office of Inspector General (“OIG”) was created to detect and prevent fraud, waste, and abuse within the federal programs provided by HHS. The OIG’s central activities include audits, evaluations, investigations, enforcement, and compliance related to federal healthcare programs. For the fiscal year 2013, the OIG reports “expected” recoveries to be over $5.8 billion, including nearly $850 million in audit receivables. Being the subject of an OIG audit or investigation can create economic hardship for any healthcare entity, but the smaller physician practices may be the most at risk for a devastating financial impact.

Earlier this year, the OIG released its 2014 Work Plan (1), which helps providers identify the issues the federal government will review during the 2014 fiscal year. The 2014 Work Plan is quite lengthy, but it is well worth the read if it alerts your practice to potential problems and prevents an overpayment that may otherwise be assessed. Below are just a few of the important highlights in the 2014 Work Plan, which should now be at the top of every physician’s compliance plan. Evaluation and Management Services – Inappropriate Payments Since the widespread adoption of electronic health records (“EHR”), in large part due to the federal government’s implementation of the incentives for adoption of EHR systems, Medicare reimbursement for E&M services has surged. Specifically, the OIG has suggested that two EHR documentation

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practices – copy/pasting and overdocumentation – have enabled providers to commit fraud. In fact, 2014 makes the third consecutive year that the OIG has included this topic in its Work Plan. The 2014 Work Plan indicates that Medicare contractors have noted an increase in frequency of medical records with identical documentation across services. Known as “cloning,” the OIG has strongly criticized the use of the copy/paste function in EHR, which often significantly decreases the time a physician spends creating a record. At the same time, the use of copy/paste creates a longer record indicating a more extensive patient evaluation or treatment than what actually occurred and, thus, a higher billing rate. However, if left unedited, it may also create false or inaccurate information for the patient visit. The OIG has suggested that providers put in place specific policies and procedures related to the use of copy/paste in patient records (1). Overdocumentation occurs when the patient’s record includes irrelevant or inaccurate information to create a longer record supporting a higher level of service than what was actually performed. Overdocumentation can unintentionally occur when EHR systems use auto-populated templates or fields and providers fail to edit the record to remove the inaccurate information. In addition to the Work Plan, the OIG has recently submitted two reports specifically addressing issues related to potential fraud and abuse associated with EHR (2). Providers can be assured that reimbursement for higher level E&M services will be closely scrutinized, with the auditors specifically looking for potential cloning and overdocumentation issues. Sleep Disorder Clinics – High Utilization of Sleep Testing Procedures The OIG conducted an analysis of 2010 Medicare payments for CPT codes 95810 and 95811, which totaled $415 million in

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reimbursement. The OIG concluded that there was a high utilization of the sleep testing procedures. Specifically, sleep testing procedures were being performed on patients for whom the procedure was not necessary or were being performed too often on those for whom it was necessary. Medicare does not consider duplicative testing reimbursable because it is not “reasonable and necessary.” Physicians – Place-of-Service Coding Errors Medicare reimburses at a higher rate when the service is performed in a non-facility setting (such as a physician’s office) than it does in a facility setting (such as an ambulatory surgery center or hospital outpatient department). In prior reviews, the OIG determined that Medicare Part B claims are not always properly coded for the place where the service occurred. Physicians’ coding for services performed in ambulatory surgical centers and hospital outpatient departments will be reviewed to ensure they were reimbursed at the proper rate. Providers should be aware that coding errors (such as place-of-service) are ripe for review in Recovery Audit Contractor (RAC) audits because this issue can often be reviewed through data analysis of billing records. While this article summarizes only a few of the many items highlighted in the 2014 OIG Work Plan, the OIG’s areas of interest in audits, investigation, enforcement, and compliance are also related to preserving the Medicare Trust Fund. Providers need to protect their own financial interests by keeping abreast of the OIG’s game plane for audit, enforcement, and compliance. A review of the 2014 OIG Work Plan is certainly a good place to start. Notes

1.The 2014 OIG Work Plan may be found online at http://www.oig.hhs.gov 2. See “CMS and its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs,” Department of Health and Human Services, Office of Inspector General Report (January 2014). Attorneys Erin B. Williams and Diana L. Gustin focus their practice on healthcare compliance and regulatory matters. For more information on any health law or compliance matters, you may contact Ms. Williams or Ms. Gustin at (865) 637-0203 or visit www.londonamburn.com. Disclaimer: The information contained herein is strictly informational; it is not to be construed as legal advice.

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TMS Therapy Offers Treatment Option to Patients Diagnosed with Depression By BRIDGET GARLAND

Individuals who have been diagnosed with depression suffer tremendously from the symptoms associated with the disorder. Feelings of guilt, the inability to experience pleasure, and a preoccupation with death or suicide are primary symptoms and can be accompanied by irregular sleep habits, change in appetite, fatigue, lack of interest in physical activity, and impaired concentration. Treatment for depression usually includes a medication regime, but for some patients, medication does not work. Fortunately, other options are available, including a therapy just recently offered to patients living in and near Johnson City. Transcranial Magnetic Stimulation (TMS) is a procedure in which the brain is stimulated through the scalp and skull using a strong magnet rather than an electrical current. Each time the magnet switches on and off, it creates an electrical field, allowing the brain to be stimulated by electricity, but not directly. “We have discovered that we can

treat many things with TMS,” said Norman Moore, MD, a psychiatrist who practices with Quillen ETSU Physicians, “but the one that has been approved by the FDA is the treatment of depression. “Patients who are eligible for the treatment must have failed several adequate courses of antidepressant medication, Dr. Norman Moore in other words, a sufficient dose for a sufficient time to give it a chance to work. If we can show that they have had two or three courses of antidepressant medication and they have not improved, then they are eligible for TMS.” Individuals who cannot take medications because of side effects are also eligible. TMS therapy requires approximately 30 treatments, and patients must receive the treatments five days a week for the duration of the therapy. While the length of therapy may seem extensive, the outcomes are potentially life changing for

patients debilitated from depression. One third of patients will see a measurable improvement, and another third of patients experience a form of remission. Maintenance treatments are required, but some patients are so improved from the therapy that they are willing to pay out of pocket for treatments not covered by insurance. Medicare covers TMS treatment, and other insurances will pay for TMS, but they typically require a prior authorization. Even so, Moore says he has had good success with the prior authorization process. Some insurance companies also require that the patient have a trial of electroconvulsive therapy (ECT). ECT uses a direct electrical current to stimulate the same area of the brain

(the frontal lobe) as TMS; ECT, however, usually requires about ten treatments, and each requires general anesthesia. When patients wake up, they aren’t capable of driving, and memory loss is common. TMS therapy, conversely, does not cause memory loss, and the patient is not put to sleep. He or she can drive home immediately following the treatment. TMS also has very few side effects, the most common being a mild headache centered at the location of the magnet. Although TMS requires more treat(CONTINUED ON PAGE 14)

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Enjoying East Tennessee International Biscuit Festival - Knoxville By LEIGh ANNE W. hOOVER

Southern women sure are known for their homemade biscuits! My husband’s late grandmother, Grace Ragsdale, or “Mamaw,” made some of the very best. Brad’s mother, Charlotte, also makes delicious biscuits, and his Aunt Patty has a wonderful recipe for her infamous, melt in your mouth, homemade rolls. Personally, I make banana-nut bread, but I buy “Sister Schubert” homemade frozen rolls for our table. In fact, in 2011, I met Patricia “Sister Schubert” Barnes when she was in the Tri-Cities for a special segment of Liz Bushong’s “Serve it Up Sassy” on Daytime Tri-Cities. She was delightful and just as pretty as her picture on the package. “Sister” signed her gorgeous “Cast Your Bread Upon the Waters” cookbook, which benefits orphans and the hungry in our country and the Ukraine through the Barnes Family Foundation. The beautiful book is filled with wonderful recipes and, of course, all types of breads. It’s also

brimming with personal antidotes of family and faith. Bread unites us, and Knoxville, Tennessee, has capitalized on this shared custom by celebrating the biscuit. Described as “a celebration of that most perfect of foods, “the biscuit,” the International Biscuit Festival, May 15th -18th, brings everything biscuit related to the region. Interestingly, Knoxville is the perfect

home for just such a festival. “This idea has been talked about in Knoxville for awhile,” said International Biscuit Boss John Craig. “Knoxville is the original home of White Lily flour, and White Lily makes the best biscuits!” As the idea germinated and interest was expressed, festival organizers decided the “biscuit” fit the niche and would be celebrated annually each spring. May 2014 marks the fifth year of the festival, and what was originally imagined as a smaller festival for friends and family has grown exponentially to attract visitors from everywhere. According to festival organizers, it’s also a “tasty opportunity” to showcase downtown Knoxville. “We have branched out, and there are so many aspects to it that we wanted to make sure that we had something for everybody,” said Craig. “It’s grown from a half-day event the first year to four days of activities.” Everything from biscuit-themed art and music to a Southern Food Writers Conference, which attracts the best in “food” writing from across the country, encompass the festival. “Everybody loves a biscuit,” explained Craig. “It’s a fun, unique and delicious event…that attracts just about

everyone who has Southern blood in them.” A Biscuit Bash with noted food authors, book signings, music and food samplings is scheduled for Friday night. On Saturday, “Biscuit Boulevard,” which is located downtown on Market Street in the heart of the festival, will feature over 20 restaurants preparing specialty biscuits for sampling. Tickets allow visitors to choose and taste signature recipes. “Some of the most popular ones go through two or three thousand biscuits on a Saturday,” added Craig. Cross streets will feature vendors, a live bakeoff, and musicians. Among the festival sponsors, notables, such as Blackberry Farm and Southern Living Magazine, are included. “Southern Living Magazine will be building a special front porch set, which will expand their presence even further,” said Craig. “They will bring their test kitchen team and be part of our Biscuit Boulevard tasting area with a signature biscuit.” Scipps Network, which is based in Knoxville, is also participating in the International Biscuit Festival through the Food Network by presenting “An Evening with Tyler Florence.” On Sunday, May 18th, this ticketed event at the Tennessee Theatre will be a concluding highlight of the festival. “He [Tyler Florence] is the host of their highest rated show, ‘The Great Food Truck Race,’” explained Craig. “Before the show, we will be having a Food Truck Extravaganza outside of the Tennessee Theatre that’s open to the public.” The International Biscuit Festival truly appeals to all senses. “Come down with your stomach as empty as you can get it,” said Craig. “We’ll fill it up with good biscuits!” For additional information on the International Biscuit Festival, visit www. biscuitfest.com Leigh Anne W. Hoover is a native of South Carolina and a graduate of Clemson University. She has worked for over 25 years in the media with published articles encompassing personality and home profiles, arts and entertainment reviews, medical topics, and weekend escape pieces. Hoover currently serves as immediate president of the Literacy Council of Kingsport. Contact her at hoover@chartertn.net.

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Quillen Heart Talk A New Frontier: Cardiac Catheterization and Coronary Angiography via Radial Approach By Kais Al Balbissi, MD, FACC, FSCAI

Coronary artery disease (CAD) is responsible for significant morbidity and mortality worldwide. One of the crucial ways to evaluate and treat CAD is through cardiac catheterization, coronary angiography, and angioplasty. The more common, older approach for this procedure is femoral artery access. Unfortunately, the femoral arterial access approach carries a higher risk for complications, mainly associated with access site complication and bleeding. This is of utmost significance given that bleeding is a major predictor of higher mortality and morbidity, regardless of patient baseline risk status. A relatively novel approach for performing these procedures is via the radial approach, which has a considerably lower complication rate and consequently better patient outcomes. The technique simply involves testing the hand arterial circulation with an Allen’s test to confirm the patency of the ulnar artery. Given the fact that hand arterial supply will be dependent on the ulnar artery once the radial artery is cannulated, given the small caliber of the vessel. Then, the radial artery is accessed via a small needle which is exchanged over a wire to a small, thin (5-6F) sheath. Through this sheath, the remainder of the procedure is carried out in the usual fashion. At the end of the procedure, this sheath is removed and a special wrist band is applied to the access site to achieve hemostasis. This provides comfort and early ambulation with minimal site complications to the patient. Naturally, there are no procedures without limitations. For the radial approach, these limitations include some technical issues such as radial spasms and vascular tortuosity. However, these road blocks could be easily overcome with simple measures and proper technique. In the worst case scenario, cross over from the radial approach to a femoral approach could always be done. There are some reservations in regards to the radial approach, which usually stem from misconceptions and myths. One such misconception is that the radial approach has a higher complication rate. The radial approach does not have a higher complication rate, but rather different types of complications, including radial artery spasms and the inability to cross due to tortuosity. In actuality, the radial approach has a lower complication rate. Other concerns include questionable higher stroke rate. In the recent SCIPION trial, however, data revealed no difference in both approaches. As for the concerns for radial artery occlusion and patency post procedure, this issue only involves 3-5% of the cases, and in 50%, the artery will re-canalize in the future. This limitation is also considerably reduced via appropriate application of the hemostasis device, avoiding prolonged periods of occlusive hemostasis. The radial approach provides very important advantages in contrast to the femoral approach. One of the most important advantages is the considerable lower access site complications with lower risk of bleeding complications. This was clearly demonstrated in the RIVAL Trial. Moreover, the radial approach provides much faster ambulation, which leads to better patient comfort and better quality of life. These advantages are of critical importance in patients who are overweight, have peripheral vascular disease, bleeding tendencies, or have orthopedic disease that prevent them from lying down for prolonged periods of time. In addition, the lower complication rate and early ambulation translate to lower economical costs and medical expenses, which is becoming a significant burden on our economy. Ultimately, there is no one procedure that fits all patients, and patient care individualization is of utmost importance. Nevertheless, the radial approach does provide a considerable benefit over the femoral approach from a patient’s safety and comfort standpoint. It does have limitations, which are easily avoided with proper patient selection. Dr. Kais Al Balbissi, Director of Interventional Cardiology for Quillen ETSU Physicians, was fellowship trained as an interventional cardiologist at the Mayo Clinic in Rochester, Minn., Dr. Al Balbissi performs a wide range of interventional cardiac procedures, including complex cases such as high-risk percutaneous coronary interventions (PCI) and chronic total occlusion interventions. Dr. Al Balbissi also has a special interest in and recent training in structural valve disease, patent foramen ovale closure, atrial septal defect (ASD), balloon valuloplasty, and transcatheter aortic-valve implantation (TAVI). Dedicated to both his patients and profession, Dr. Al Balbissi has championed the radial approach to cardiac catheterization at Johnson City Medical Center and was awarded membership in the Gold Humanism Honor Society in honor of his excellence in practice and his commitment to serving patients with compassion. In addition to his board certification in cardiovascular medicine and interventional cardiology, he is board certified in echocardiography and nuclear cardiology. He is also Level II certified in cardiac and coronary ct angiography.

329 North State of Franklin Road Johnson City, TN 37604 Call 423.979.4100 • Fax 423.979.4134

Dr. Al Balbissi completed his residency in internal medicine and fellowship in cardiology at East Tennessee State University’s Quillen College of Medicine. He currently serves as vice chair of cardiology at Johnson City Medical Center.

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SANS Cyberthreat White Paper Shows Dark Clouds, continued from page 1 the report detailed the widespread problem. In analyzing the Norse data collected during the 13-month sample, the intelligence found: • 49,917 unique malicious events, • 723 unique malicious source IP addresses, and • 375 US-based healthcare-related organizations compromised … averaging about one a day. Filkins wrote, “The data analyzed was alarming. It not only confirmed how vulnerable the industry had become, it also revealed how far behind industry-related cybersecurity strategies and controls have fallen.” Furthermore, the analysis made it clear that the threats aren’t unique to any one type of healthcare company, but providers are seemingly the most vulnerable. In looking at the sectors compromised by malicious traffic, healthcare providers led the way with 72 percent. Business associates accounted for 9.9 percent of the malicious traffic, health plans 6.1 percent, healthcare clearinghouses 0.5 percent, pharmaceuticals 2.9 percent, and other related entities 8.5 percent. Most alarming, noted Filkins, was the level of activity found in what was just a sample set. Speaking to Medical News from her California office, Filkins said ‘malicious events’ are defined as an outside threat or event that might have penetrated the system and could range from hijacking contacts to pushing sensitive information outward. She noted that many companies, practices and facilities have policies in place warning employees not to click on an unknown email or link. (And who hasn’t received a suspicious link under the guise of coming from a friend or colleague?) Yet, she said, “People need to be looking at not only what comes into their network, but what goes out of their network.” To find and address malware typically requires a HIT professional. “A lot of times an attacker will use a very common protocol so it might look like someone is

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browsing the web, but you might have to dig a little deeper under the covers,” she noted of finding and locating problems. “A lot of these events continued not just for days … but for months,” she added.

Locking the Front Door, Leaving the Back Wide Open

Oftentimes the point of entry for attackers was not the main information system. Instead, those with malicious intent entered through peripheral surfaces like network printers, call contact software, routers, medical devices, and … ironically … security cameras. While the main system was securely locked and password protected, many times, Filkins said, the default password remains on these addon surfaces. Finding the admin password, she continued, is as easy as doing a quick Internet search for the device in question. “There are some very basic things that can be done to get started with protection,” Filkins noted. The most obvious … but clearly overlooked … is to change those default passwords. However, she continued, changing to an easily deciphered password isn’t much help. Avoid using your children’s names, street address, pet names, combined physician names, name of the practice, or other easily discernable choices. The best passwords, Filkins said, include numbers and

unique characters. Mobile devices can also cause headaches … in part because of unrealistic expectations and policies. “Everyone uses mobile devices,” Filkins stated. “Rather than trying to bury that and say, ‘oh, we never use mobile devices,’ maybe relax the punitive policies and instead say, ‘let’s get honest and figure out how to make them more secure.’”

Measures to Improve Security

“Know what’s on your network,” Filkins said. “Make sure your network is configured properly and devices are configured properly.” She added it’s important to know who is using what and how it’s being used. Having a strong password policy is critical to proper configuration. “Think like an attacker,” she continued. “And if you can’t do it, get someone who can.” There are numerous resources and companies that can help with this task. It boils down to being aware, Filkins noted. “It’s basic awareness but in a digital world.” She continued, “Know what your network pathways are for your organization.” Filkins said that often there’s an emphasis on protection for “bad things coming in” … but if something does penetrate the system, there isn’t much moni-

toring of outbound traffic. Egress filtering is as important as ingress protection.

The Cost of Failure

The healthcare industry is particularly attractive to cyber attackers because of the type of information housed on servers. With medical identity theft, the victim is responsible for costs related to a compromised medical insurance record. A survey by the Ponemon Institute last year estimated that cost to be $12 billion in 2013. Security breaches also represent major costs to the compromised entity. Steep fines, incidence handling, victim notification, credit monitoring for victims, and potential legal action represent direct out-of-pocket expenditures. In addition, a data breach could also significantly harm reputation and future business opportunities. The greatest cost, however, is to a patient who winds up with inaccuracies in his medical record that could result in a misdiagnosis or wrongly prescribed medication.

The Takeaway

“Today compliance does not equal security,” Filkins wrote. “Organizations may think they’re compliant, but this data shows that they are not secure.”

Identity as a Risk Factor, continued from page 1 she noted the patient “answered in a way that sticks with me: ‘I know the right answer is heart disease,’ she said, eyeing me as if facing an irresistible temptation, ‘but I’m still going to say breast cancer.’” Rosenbaum is quick to say breast cancer is a valid concern, but the emotions linked to the disease go beyond just the facts. She pointed to the controversy surrounding mammography as a clash between data and identity at the social level. Despite a recDr. Lisa ommendation from the Rosenbaum U.S. Preventive Services Task Force to decrease mammography frequency for most women under age 50 based on decades of data, Rosenbaum wrote, “So intense was the outrage over these evidence-based recommendations that a provision was added to the Affordable Care Act specifying that insurers were to base coverage decisions on the previous screening guidelines.” No matter where you stand on mammography, most healthcare professionals are united in agreeing lifestyle modifications and appropriate use of medications have been proven to prevent heart disease and save lives. However, Rosenbaum contends that facts alone aren’t enough. Instead, she said the healthcare community needs to find a way to tap into the emotional aspects of heart disease as successfully as has been done with breast cancer. In the her perspective piece, Rosenbaum wrote that although the first decade

of educational campaigns such as Go Red for Women “led to a near doubling of women’s knowledge about heart disease, in the past few years, such efforts have failed to reap further gains.” She told Medical News, “Our default in medicine is to give people facts, and then we don’t know what to do when we hit the wall. We know how to disseminate facts … we don’t know how to change feelings.” Complicating the issue with heart disease is that in so many cases it is preventable, and therefore comes with builtin guilt. Risk factors, which have been well publicized, include smoking, obesity, high blood pressure, high cholesterol, and sedentary lifestyle. “All of these are embedded with a sense of not taking care of yourself,” Rosenbaum said. “You should have done something differently.” Conversely, breast cancer is imbued with a sense of having a terrible disease visited upon a victim, which is true. Also, because breast cancer kills more women at a younger age than heart disease, there are multiple media images of beautiful, strong heroines fighting and surviving … or succumbing … to a disease that attacks a body part that is so uniquely feminine. Rosenbaum pointed out Angelina Jolie’s message about breast cancer resonated with women across the nation who saw the actress as a lovely, brave, fierce role model. Again, she stated, it isn’t ‘bad’ that breast cancer has pushed its way to the front of female consciousness. It’s smart … and perhaps it’s the type of message the field of cardiology should consider to reach more women.

However, Rosenbaum said it isn’t fair to ask healthcare providers to try to change identity beliefs in a brief office visit. Instead, she said the subject requires research regarding social values and group identity. Ultimately, Rosenbaum added, cultural messaging will likely come from a variety of sources including media outlets. Today, she said, “Our biggest challenge is translating what we know into better health of our population. The next phase of evidence based-medicine should be as much about figuring out how to communicate that evidence to our patients … to do that we have much to learn from the methodological approaches of the social sciences.” Rosenbaum added the starting point to address women’s perceptions of heart disease should be to conduct focus groups to evaluate where emotional beliefs currently stand and assess the impact of framing messaging in different ways. “This is decades worth of work,” she stressed, “to ultimately understand not just how they feel and where those feelings come from, but to evaluate whether there are appropriate interventions that help women adopt more heart-healthy behaviors.” While heart disease might have a decidedly masculine feel, there’s no reason why research can’t point to ways to soften the message and appeal on an emotional level to women, as well. After all, women are often identified with their capacity to love … the trick will be finding the right words to help a woman celebrate her big heart while being cognizant of the dangers that come with having an enlarged one. EASTTNMEDICALNEWS

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RXforReform BY ALEXANDER T. RENFRO, JD, LLM

Preparing for PPACA The Patient Protection and Affordable Care Act, or PPACA, presents a number of challenges to employers. Chief among these challenges are the employer mandates, excise penalties for failure to offer health coverage at a certain level of benefit and below a certain cost to plan participants. As the employer mandates go into effect beginning this coming January, planning is required to ensure that excise taxes are avoided, efficiency in plan design is preserved, and employees are provided a tangible benefit. A positive method which can assist in meeting these goals exists. This method, known as the 8 Step Prep, separates the major tasks required of ideal PPACA preparation into eight manageable tasks. By completing each task, an employer creates a roadmap from planning to plan selection to execution in a timely manner, preserving the goals of compliance, efficiency, and benefitting plan participants. Step 1: Education. With respect to PPACA, the more one knows, the more money one will save. PPACA contains a number of statutes and regulations which challenge employers, but a variety of exceptions, alternatives, and options are provided as well. Knowledge of these opportunities within the law will create savings and create an awareness of viable solutions for employers. Step 2: Employer Classification. Building off of education, precise knowledge of how PPACA affects one’s own business is critical to determining a number of design and structural options with respect to a benefits plan. Many employers are not subject to the employer mandates, or are permitted to delay the effective date of the employer mandates until potentially December 2016. Three general classifications are of most importance to employers. First, is the employer small or an applicable large employer with 50 or more full time employee equivalents? Applicable large employers are subject to the employer mandates. Second, on what market does the employer purchase insurance: the small group market (100 employees or less), the large group market (more than 100 employees), or the self-insured market? Finally, does the business qualify for transitional relief under the latest employer mandate regulations? (1) Step 3: Employee Classification. Only certain employees need be provided coverage, namely full time employees. Identifying which employees must meet this easttnmedicalnews

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classification, which employees may meet this classification, and which employees do not meet this classification will ensure an efficient, compliant benefits offering. Furthermore, by understanding what PPACA considers a full-time employee through a look-back stability period, employers can effectively manage certain employees and maintain control of eligibility. Step 4: Avoiding Discrimination. PPACA contains at least three forms of health discrimination rules. These rules vary based on how the employer insures the plan: through a commercial insurance company or on a selfinsured basis. Currently, commercially insured plans have greater freedom with respect to discriminatory plans but less flexibility in plan design. Furthermore, a third type of health discrimination exists based on the cost of plan premiums for participants who are “similarly situated.” Though less known, this form of discrimination penalizes employers at $100/effected employee/day in excise taxes and should be carefully observed. Step 5: Plan Design. Plan design, as noted above, is more flexible among self-insured plans. Irrespective of how a plan is designed, however, numerous factors must be considered to identify the most efficient, compliant plan which provides an appropriate level of benefits to participants. In some cases, this may mean higher deductibles, out of pocket expenses, and less benefits. In other cases, the employer may favor a more affordable plan for participants with a comprehensive benefits offering, blending medical benefits

subject to PPACA and excepted benefits which (when structured properly) avoid subjugation to PPACA. Step 6: Participant Considerations. Once a plan design has been selected, the employer must properly communicate the terms of this plan well in advance of open enrollment for exchange plans, which will begin in October. These communications must advertise the benefit of the plan to employees, the compliance of the plan with PPACA requirements, which also entail a lack of subsidies for eligible participants, and offer guidance to those with questions. Note that employers must deny subsidy access to employees to avoid excise penalties under the employer mandates. However, without properly communicating this fact, employers could still find themselves appealing pre-qualifications for subsidies or even paying excise penalties without adequately preparing employees. Step 7: Plan Selection. Simultaneous with Step 6, employers must identify the correct product which meets the plan design considerations determined in Step 5. Adjustments to the plan design may be required, as employers are ultimately limited in plan design to products offered on the commercially insured and self-insured markets. Fortunately, a great variety of products exists on these markets. Thus, attention should be focused on identifying the appropriate plan for the employer and securing that plan for a start date which coincides with the effective date of the mandates for the employer.

Step 8: Managing Open Enrollment. Employers must be concerned with two open enrollment periods: the employer’s open enrollment and the exchanges’ open enrollment. As noted above, even employers with compliant plans can be penalized or subject to appeals of subsidy pre-qualification during open enrollment. Employers are encouraged to have documents evidencing compliance (such as the Plan Document) at hand, ready to meet the demands of regulatory agencies on short notice. Finally, as employees ask questions, the employer must be ready with the answers. Controlling the education and enrollment activity of employees will ultimately build trust and permit the employer to effectively manage entrance into the employer plan. Through this method, employers can create a compliant, efficient, and beneficial plan. As needed, employers are encouraged to seek advice from advisors knowledgeable and capable in assisting with PPACA preparations. Though PPACA is a challenging law, proactive involvement can lead to a positive response for employers. The 8 Step Prep is a means of achieving such a response. Alexander T. Renfro, JD, LLM, Ratliff Law Firm, collaborates with Lattimore Black Morgan & Cain, PC (LBMC), and the LBMC Family of companies, to bring you the latest healthcare reform information on a new Tennessee Healthcare Reform website, www. TNHealthcareReform.com. After graduating from the University of Notre Dame, Renfro went on to earn his JD from Southern Methodist University’s Dedman School of Law, and then to the Georgetown University Law Center, completing a Taxation LLM as well as a Certificate in Employee Benefits. He specializes in tax law, estate planning, and employee benefits. He is licensed to practice law in both Tennessee and Texas. He can be contacted at arenfro@ratlifflawfirm.com

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ClinicallySpeaking BY C. STONE MITCHELL, MD, FACS

Leave Pain Behind: Treatment Options for Pregnancy Hemorrhoids

As a surgeon who specializes in hemorrhoid treatment, I see many women who suffer from pregnancyrelated hemorrhoids. Hemorrhoids are blood vessels in the rectal area that have become swollen. They may be inside or outside the anus and range from the size from a pea to the size of a cluster of grapes. Hemorrhoids can be simply itchy and mildly uncomfortable, or quite painful. An estimated 20 to 50 percent of pregnant women experience hemorrhoids. The pressure of an enlarged uterus and increased blood flow to the pelvic area, plus constipation, may cause the condition during gestation, especially during the third trimester. Straining and pressure during labor can also aggravate existing hemorrhoids, causing extra discomfort and pain for new mothers. Unfortunately, because of embarrassment or a belief that

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hemorrhoids are just an unpleasant byproduct of pregnancy, many women may be hesitant to discuss the condition with their physician during or after pregnancy. Some women, concerned about a possible painful surgery and long recovery period never seek treatment. I have encountered numerous female patients who have been living with painful pregnancy hemorrhoids for years and years, unaware that gentle relief and treatment are readily available. Physicians should discuss the occurrence of hemorrhoids with female patients and encourage them to seek treatment, if needed. During pregnancy, general hemorrhoid therapy includes soaking in warm (not hot) water several times a day, and propping up the legs as much as

possible. If a hemorrhoid has become painfully thrombosed, with the blood pooling and clotting, it can be gently drained. The patient will feel immediate pain relief. For the comfort of the patient, the expertise of an experienced hemorrhoid specialist is invaluable in identifying and treating a thrombosed hemorrhoid. During pregnancy, an evaluation with a hemorrhoid specialist can provide immediate relief or a plan of treatment after delivery can be discussed, when their venous pressure has returned to a normal state. In most people, 95% of hemorrhoids do not require surgery. Infrared coagulation is a painless, non-surgical treatment for hemorrhoids. It involves using a small

probe that exposes the vein above the hemorrhoid to short bursts of warm light, causing the hemorrhoid to shrink and recede. This treatment can be performed quickly, with no anesthesia, incisions, or stitches. Women should understand that they do not have to live with the pain of pregnancy hemorrhoids. Gentle treatment can provide welcome, lasting relief to this common condition. C. Stone Mitchell, MD, FACS, is a physician with the Premier Hemorrhoid Treatment Center in Knoxville, a division of Premier Surgical Associates. Dr. Mitchell is board certified in general surgery by the American Board of Surgery and is a fellow of the American College of Surgeons. Premier Surgical Associates is the Knoxville area’s largest surgical group, performing general, vascular, bariatric, breast, and laparoscopic procedures. Premier has offices in Knoxville, Dandridge, Maryville, Lenoir City, Sevierville, and Seymour.

Clinical Evaluation and Documentation, continued from page 5 • History of partial or complete amputation of the foot • History of previous foot ulceration • History of pre-ulcerative callus formation • Peripheral neuropathy with evidence of callus formation • Poor circulation • Foot deformity The specifics of any of these inclusion criteria must be not only listed on the Physician Certifying Statement, but must also be specifically corroborated in the physician encounter notes. Make sure your patient encounter notes document that a foot evaluation was performed, and specifically document any of the justifying criteria

Prosthetic Environment, Daily Activities, and Functional Potential

When your patient receives the most appropriate device for them, they are more likely to be active, stabile, and perform activities of daily living at their fullest potential. Physicians must evaluate and document both medical necessity and

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functional capabilities. Medicare has established five categories of “functional potential.” These are referred to as “K-levels” and range from K0 (prosthesis would not enhance quality of life or mobility) to K4 (ability or potential for prosthetic ambulation that exceeds basic ambulation skills). Always document patient’s pre-prosthetic activities and your expectation that they can return to that level of activity.

Requirements for Prescribing Prosthetic Devices

This part is not nearly as overwhelming as it sounds. It just takes discussion with your patient, and you need to include the following: • Basic patient information, history, and need for use of a prosthesis • History of amputation including therapeutic intentions, date, and side of amputation • Description of functional limitations in a typical day • Description of activities of daily living • Other relevant diagnoses and comorbidities that would impact a patient’s ability to use a prosthesis • Ambulatory assistive devices used or expected to use • Functional capabilities prior to amputation and expected potential Any problems amputees are having with their prosthesis and a plan to address these problems. Don’t just list the problems, but also report how patients use their prosthesis to perform their daily activities. This documents a history of use to justify contin-

ued repairs and replacements as necessary.

Recommendations

Communicate effectively with your O&P providers. Work with your prosthetist to evaluate, justify, and document a patient’s needs. We want to make the process from evaluation to delivery and follow up as smooth and efficient as possible. Ensure that your notes cover the criteria from the very initial consultation by communicating with your patients early on in the process. Separate right and left devices as needed. Ask prosthetic patients about their activities, environments, and daily use of their prosthetic devices and document them. When prescribing diabetic shoes/ insert, make sure that patients meet the qualifying criteria. Rely on the expertise of your prosthetist and physical therapist. Our recommendations revolve around our understanding of a patient’s functional needs, functional potential, and appropriate prosthetic design to achieve this potential. Take advantage of this expertise; however, the final approval comes from the physician and physician documentation. Chad McCracken, MS, CPO, is a Certified Orthotist/Prosthetist, Clinical Manager, and Residency Directory with Victory Orthotics & Prosthetics in Bristol, Tennessee. He is certified by the American Board of Certification in Orthotics, Prosthetics & Pedorthics, and a member of The American Academy of Orthotists & Prosthetists and The Association of Children’s ProstheticOrthotic Clinics.

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Compounding Pharmacists Provide Customized Solutions for Women’s Health Needs By Cleve Anderson, RPh

W

omen have unique health needs, which change as they enter different stages of life and assume new roles. Hormone replacement therapy and pain management are two common health concerns for women of all ages. Unfortunately, not all therapies are effective for or well tolerated by all women seeking prescription relief for their health needs. Custom compounding can help bridge the gap between the limited choices in commercially available prescription medications and a patient’s specific needs. Compounding professionals can prepare: • Unique dosage forms containing the best dose of medication for each individual; • Medications in dosage forms that are not commercially available, such as transdermal gels, troches, “chewies” and lollipops; • Medications free of problem-causing excipients, such as dyes, sugar, lactose or alcohol; • Combinations of various compatible medications into a single dosage form for easier administration and improved compliance; • Medications that are not commercially available. Hormone Replacement Therapy In hormone replacement therapy, structural differences exist between human, synthetic and animal hormones. In order for a replacement hormone to fully replicate the function of hormones, which were originally naturally produced and present in the human body, the chemical structure must exactly match the original. There are significant differences between hormones that are natural to humans and synthetic or horse preparations. Side chains can be added to a naturally occurring hormone to create a synthetic drug that can be patented by a manufacturer. A patented drug can be profitable to mass produce, and therefore a drug company can afford to fund research as to the medication’s use and effectiveness. However, naturally occurring substances cannot be patented, so scientific studies are less numerous on natural hormones because medical research is usually funded by drug companies.

Studies suggest that there are no great restrictions on the type of drug that can be incorporated into a properly compounded transdermal gel. When medications are administered transdermally, they are not absorbed through the gastrointestinal system and do not undergo first-pass hepatic metabolism.

Natural hormones include estrone (E1), estradiol (E2), progesterone, testosterone, dehydroepiandrosterone (DHEA) and pregnenolone. Compounding pharmacists work with patients and practitioners to provide customized hormone therapy in the most appropriate strength and dosage form to meet each woman’s specific needs. Hormone therapy should be initiated carefully after a woman’s medical and family history has been reviewed. Every woman is unique and will respond to therapy in her own way. Close monitoring and adjustments are essential.

Partnering with Compounding Pharmacists for Successful Therapies Compounding pharmacists work together with patient and practitioner to solve problems by customizing medications that meet the specific needs of each individual. Compounding offers each patient a wider array of delivery systems from which to choose. When combined with individualized counseling from the compounding pharmacist in conjunction with the prescribing physician, these increased options result in therapies that are more likely to produce successful results for the patient.

Pain Management Pain management is essential because even when the underlying disease process is stable, uncontrolled pain prevents patients from working productively, enjoying recreation or taking pleasure in their usual roles in the family and society. Chronic pain may have a myriad of causes and perpetuating factors, and therefore can be much more difficult to manage than acute pain, requiring a multidisciplinary approach and customized treatment protocols to meet the specific needs of each patient. Optimal treatment may involve the use of medications that possess pain-relieving properties, including some antidepressants, anticonvulsants, antiarrhythmics, anesthetics, antiviral agents and NMDA (N-methyl-D-aspartate) antagonists. NMDAreceptor antagonists, such as dextromethorphan and ketamine, can block pain transmission in dorsal horn spinal neurons, reduce nociception, and decrease tolerance to and the need for opioid analgesics. By combining various agents that utilize different mechanisms to alter the sensation of pain, physicians have found that smaller concentrations of each medication can be used. Topical and transdermal creams and gels can be formulated to provide high local concentrations at the site of application (e.g., NSAIDs for joint pain), for trigger point application (e.g., combinations of medications for neuropathic pain), or in a base that will allow systemic absorption. Side effects associated with oral administration can often be avoided when medications are used topically.

The efficacy of any formulation is directly related to its preparation, which is why the selection of a compounding pharmacy is critical. Ongoing training for compounding pharmacists and technicians, state-of-the-art equipment and highquality chemicals are essential. Experience and ingenuity are important factors as well. When tweaking a formula or developing a unique preparation, the compounding pharmacist must consider physical and chemical properties of both the active ingredient and excipients, solubility, tonicity, viscosity, and the most appropriate dosage form or device for administering the needed medication. Standard Operating Procedures should be in place, stability studies should be considered when compounding, and appropriate potency and sterility testing should be performed. Cleve Anderson, chief pharmacist and owner of Bristol, Tenn.-based Anderson Compounding Pharmacy, received his Doctor of Pharmacy degree from Mercer University. He is a member of the American Chemical Society and the Rho Chi Society, an academic honor society for the pharmaceutical industry.

The professionals at Anderson Compounding Pharmacy have received advanced training and use specialized equipment, FDA-certified chemicals and cosmetically appealing bases to customize medications that address the individual needs of each patient. We work together with physicians and other healthcare practitioners to solve medication problems. Anderson Compounding Pharmacy is a member of Professional Compounding Centers of America, Inc., and is the only compounding pharmacy in Tennessee to earn both the Pharmacy Compounding Accreditation Board’s (PCAB®) Seal of Accreditation as well as the Healthcare Quality Association on Accreditation’s (HQAA) Seal of Accreditation.

www.andersoncompounding.com andersonpharmacy@andersoncompoundingpharmacy.com

800-263-8890

PAID ADVERTORIAL

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Healthcare Apps Are All the Rage, But Do You Need One? By HEATHER RIPLEY

There are recent reports claiming that more than 100,000 health-related apps are available for use on smartphones, tablets and other smart devices today. It’s incredible, when just 17 months ago it was reported that there were only an estimated 40,000 health-related apps. And, if you Google the term “healthcare apps,” you’ll get approximately 380 million results in less than half a second. To say the health-related app business is booming is almost an understatement. With that said, it’s worth mentioning to both consumers and businesses looking for ready-to-use apps or help creating new custom apps: choose wisely. From a consumer point of view, some health-related apps are extremely helpful. Top rated apps include BMI Calculator, Fitness Buddy, Nike+ Running, GoodFoodNearYou, LiveScape and CalorieTracker. These apps help people track calories, miles walked, speed, intensity, body mass, food calories, nutritional content of food and calories burned. Many offer tips on staying healthy, making good food choices and even provide exercise routines with photos showing the right way to perform each exercise. These apps can’t really hurt you, and may offer people reminders or information they can use throughout the day. However, there are also apps available that claim to detect skin cancer or diagnose patients with a variety of conditions. Doctors warn people with health concerns to consult a doctor, not an app - and that is good advice. The best approach is to see

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a doctor first, and ask him/her if a medical app can help and which one is the best one, then use it according to the doctor’s recommendations. In the business-to-business (B2B) arena, health and medical apps are becoming more and more useful to healthcare practitioners, doctors, nurses and even emergency medical technicians and paramedics. From simple apps that reduce the amount of time needed to research a condition to medical apps with the latest clinical information, online access to medical journals and updated textbooks on prescription drugs with photos and possible interactions and side effects, medical apps are becoming more sophisticated. Apps already available allow doctors to access electronic medical records

(EMR), share X-rays and EKGs with other doctors, review clinical photos of a variety of conditions, see images of organs from medical journals and case studies, view 3D layer images of muscles and anatomy and much more. The most exciting news in mobile medical healthcare involves apps that can be used by doctors and other healthcare professionals via Google Glass, a wearable microcomputer. Ripley PR, with extensive experience in healthcare IT, is currently developing Google Glass apps for a variety of uses. This will be a huge business in the future as more developers find innovative ways to utilize the capabilities and potential capabilities of wearable computers in healthcare situations. There is another type of healthcare business app I haven’t touched on that I think will revolutionize the way healthcare is performed on-site and clinically. We’re in development with several apps that will streamline the way healthcare businesses provide in-home healthcare. Used in conjunction with smartphones and tablets, these apps can manage complex dispatch and shift systems for home health providers with a simple dashboard that automates much of the work formerly done by office staff, dispatch staff and health workers. This frees up staff to deal with the other important tasks they perform, rather than spending hours scheduling and rescheduling and tracking where workers are and how long they were at a home or care facility. Apps even provide automation of visit purpose, client status, hours and billing in addition to reducing or even eliminating paper forms.

It is a brave new world in business app development, but as always the onus is on the buyer. Make sure you work with a developer who has a track record in your field and check out their other apps. The right business apps can save you a lot of money, but be sure to do your due diligence up front before you sign on the dotted line. Heather Ripley is the founder and CEO of Ripley PR, a business-to-business (B2B) public relations agency specializing in Healthcare IT. For more information, visit www.ripleypr.com or email hripley@ ripleypr.com.

TMS Therapy Offers Treatment Option, continued from page7 ments than ECT, the cost is normally less than ECT when factoring in facility charges and the cost from general anesthesia. For patients located near Johnson City, TMS is also much more convenient, located in the ETSU Innovation Lab at 2109 West Market Street, Suite 122. The closest facility for ECT is located in Lebanon, Va. As Moore pointed out, “TMS is convenient for both the patient and treating physician.” Patients may be a little apprehensive about the therapy, but most patients who truly need the therapy want to try it, and their willingness helps to confirm the diagnosis. As Moore explained, education about the therapy also sets their mind at ease. During the initial visit, we locate the target point for stimulation of the frontal cortex by taking measurements and adjusting the chair accordingly. We also measure the motor threshold, which varies in each patient. Although the first visit takes a little longer, most treatments take about 45 minutes to an hour.” Moore, along with three other physicians who practice in the Department of Psychiatry with Quillen ETSU Physicians, are trained to oversee the therapy, including Faith Aimua, MD, Joel P. Chisholm, MD, and Rushiraj C. Laiwala, MD. Excited about the opportunities TMS provides for both patients and ETSU, Moore, who is the chief editor of the peer-reviewed journal ‘Clinical EEG & Neuroscience,’ said that he and his colleagues will be traveling to the Journal’s International Annual Meeting, in September, to present a half-day workshop on TMS therapy. The department is currently accepting new patient referrals.

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GrandRounds

theLiteraryExaminer BY TERRI SCHLICHENMEYER

Heimlich’s Maneuvers

make me notice. I think that if you ignore the commercials, you’ll like what you ultimately find here. If it’s a good memoir you want, Heimlich’s Maneuvers has that down pat.

by Henry J. Heimlich, MD; c.2014, Prometheus Books; $19.95 / $21.00 Canada, 253 pages In the new book Heimlich’s Maneuvers by Henry J. Heimlich, MD, you’ll find out why you deserve a pat on the back – except if you’re choking – from the man who invented the lifesaving measure. From the time he was a small boy growing up in New York, Henry Heimlich wanted to be a doctor. His parents were role models: he watched them help others, and he noticed that they never turned anyone away. He wanted to be like them – and he started down that path at age 21, when he assisted the victim of a train wreck until rescuers arrived. That was the first of “hundreds of thousands” of lives Heimlich would save. While in college, Heimlich led the ROTC band, then, as required, enlisted in the military. After graduation, he was called for duty and served in the Navy on a special mission to China during World War II. There, he taught Chinese soldiers firstaid basics and, because anti-Semitism was rampant in America, he taught fellow soldiers that the myths they believed about Jews were largely wrong. That bias against Jews almost cost the doctor his career: Heimlich had a hard time finding a residency position after the war ended, but he knew he was in a good spot when he landed at Bellevue in New York. He had his sights set on becoming a thoracic surgeon specializing in the esophagus and, ever the tinkerer, Heimlich began looking for ways to improve old methods of treatment. Back in China, he’d developed an easier way to treat trachoma and save the eyesight of sufferers. In the 1950s, he developed the reversed gastric tube operation (though he later learned that he wasn’t the first to use it). During the Vietnam War, he developed a way to drain post-surgery chest wounds. And in 1972, he gave the world a life-saving hug… There’s so much delight in Heimlich’s Maneuvers and so many surprises to uncover while reading this book. Too bad there’s one big thumbs-down. First, I was overwhelmingly charmed by author Henry J. Heimlich’s story, and by the jaunty way he tells his tales. Heimlich writes with an obvious sparkle in his eye, and it’s a worthwhile trip we take with him, back to his childhood, his young marriage, his early career, his keen eye for invention, and his battle with the Red Cross. Even his World War II tales held excitement. Unfortunately, it seemed to me that this book sometimes descends into infomercial territory, in which Heimlich uses his memoir to promote his inventions. I thought that marred the feel of this book–not enough to make me want to quit reading, but enough to easttnmedicalnews

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The Mayo Clinic Guide to StressFree Living by Amit Sood, MD, Msc; c.2014, DaCapo Lifelong Books; $19.99 / $23.00 Canada, 320 pages You’re over just about everything: overworked, overloaded, and overwhelmed. But when you read The Mayo Clinic Guide to Stress-Free Living by Amit Sood, MD, M.Sc, you might start to feel overall better. In today’s world, it’s nearly impossible not to feel strain. At least that’s how it seems, and it only gets worse as we “get hijacked by impulses, infatuation, and fear,” the brain wants to “escape the present moment,” and the mind thinks everything’s a danger. Says Sood, we “struggle with what is,” which is the very definition of stress. Part of the reason for the struggle is that, when you’re awake, your brain operates in one of two ways: default or focused. You’ve undoubtedly experienced both. In focused mode, you’re so immersed in the task at hand that you forget about almost everything surrounding you. In default mode, your brain wanders like an idle shopper, moseying from problem to worry to idea, spinning and projecting future scenarios. The key is to teach yourself to stay on “focused” mode and out of the “black hole” of meandering default. Part of that can be done with “at-

tention training,” which has many facets and which “speaks to the child” in you; and by “refining interpretations,” which appeals to the adult within. Learn to pay “joyful attention,” which helps with calming and keeps your mind occupied so it doesn’t wander. Learn CRAVE, patience, and CALF when relating to others. Free your prejudices in order to “open to the world.” Accept that nothing is perfect and that there are times when forgiveness isn’t required. Begin each day with thankfulness. Learn pride in work. And remember that compassion for others should extend to compassion for yourself. When an institution like the Mayo Clinic attaches its name to a book, you kind of expect it’d be totally serious stuff, right? Nope. Author Amit Sood has quite a bit of fun in this book, which certainly supports its title and its joyful cover. But first, The Mayo Clinic Guide to Stress-Free Living opens in a classroom, then turns to the science of the brain, which serves as a nice reminder, but – since bookstore shelves are packed with brain books – might be unnecessary for some readers. That’s okay, though, because what comes next is worth it: Sood teaches us to “train” our minds to stress when appropriate, live with acceptance, and appreciate others. This, too, might be repetitious for readers who’ve filled up on motivational-type books like this one, though I took great delight in this particular handling of the subject. I also liked that Sood didn’t pretend this is easy, but reducing stress and lessening worry sure sounds appealing and that’s enough for me. Terri Schlichenmeyer has been reading since she was 3 years old, and she never goes anywhere without a book.  She lives on a hill in Wisconsin with two dogs and 11,000 books.

Graduating ETSU medical students open envelopes on Match Day JOHNSON CITY – The Class of 2014 at East Tennessee State University’s James H. Quillen College of Medicine opened their envelopes today during the annual Match Day celebration to learn where they will go for residency training beginning July 1. The National Resident Matching Program pairs graduating medical students with residency programs throughout the country. Sixty-four members of the Quillen Class of 2014 celebrated a successful match in 13 different specialty or sub-specialty fields at 38 residency sites throughout the United States. Fifty-five percent of the Class of 2014 will enter the primary care fields of family medicine, pediatrics, internal medicine, and obstetrics and gynecology, and 77 percent of Quillen students will train at institutions in the South. Eight graduates will continue their training in the medical residency programs at Quillen, and 18 additional graduating students matched with other programs in Tennessee. Quillen students also matched to highly competitive specialty programs that include anesthesiology, dermatology, otolaryngology, orthopedic surgery, and radiology. Three students will complete their residency training through military service. Members of the Class of 2014 will attend residency programs at institutions that include the University of Tennessee, Medical University of South Carolina, Wake Forest University, University of Virginia, University of Kentucky, Vanderbilt University, Emory University, Yale University, and Mayo School of Medicine. The Quillen College of Medicine residency programs also had a highly successful match. Local Match Day festivities were hosted by the ETSU Alumni Association and the Quillen College of Medicine Alumni Society.

Mark Your Calendar

Your local Medical Group Managers Association is Connecting Members and Building Partnerships. All area Healthcare Managers are invited to attend.

3RD THURSDAY Knoxville MGMA Monthly Meeting Date: 3rd Thursday of each month Time: 11:30 AM until 1:00 PM Location: Bearden Banquet Hall, 5806 Kingston Pike, Knoxville, TN 37919 Lunch is $10 for regular members. Come learn and network with peers at our monthly meetings. Topics are available on the website. Registration is required. Visit www.kamgma.com.

2ND WEDNESDAY Chattanooga MGMA Monthly Meeting Date: 2nd Wednesday of each month Time: 11:30 AM Location: The monthly meetings are held in Meeting Room A of the Diagnostic Center building, Parkridge Medical Center, 2205 McCallie Avenue, Chattanooga, TN 37404 Lunch is provided at no cost for members, and there is currently no cost to a visitor who is the guest of a current member. Each member is limited to one unpaid guest per meeting, additional guests will be $20 per guest. All guests must be confirmed on the Friday prior to the meeting. RSVP to Irene Gruter, e-mail: irene@chattmedsoc.org or call 622.2872. For more information, visit www.cmgma.net.

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GrandRounds Frontier Health Presents Five Core Skills of Mindfulness

JOHNSON CITY – Frontier Health is offering an APA training, “Five Core Skills of Mindfulness: Practices that Change the Brain and Improve Client Outcomes,” with Terry Fralich, LPC, on Thursday, May 21, 2013, at 8:30 a.m. to 4:30 p.m. at the Millennium Centre Ballroom in Johnson City. Mindfulness is now pervasive in the mental health profession. It is a major component of DBT, ACT, MBSR, MindfulnessBased Cognitive Therapy for Depression and many other modalities. The challenge is to find practical, accessible approaches to nurturing mindfulness in clients so that it is an active force of change. The Five Core Skills are unique in the field of mindfulness. In this seminar, you will develop a clear understanding of fundamental mindfulness skills that will strengthen your own mindfulness and enhance your effectiveness with clients. This workshop is designed to help attendees learn the five core skills of mindfulness; teach clients the five core skills as an integrated mindfulness practice; understand the brain’s survival and warning systems; explain how mindfulness practice is self-directed neuroplasticity; evaluate your own level of mindfulness; improve the stability of therapeutic presence through practice of the five core skills; lead clients through mindfulness exercises that nurture change; apply specific mindfulness practices in both your personal and professional lives. The program is for psychologists, psychiatrist, psychotherapists, educators, social workers, pastoral counselors, crisis intervention counselors, guidance counselors, alcoholism and drug abuse counselors, marriage and family therapists, other healthcare professionals, and community members. Terry Fralich is a Licensed Clinical Professional Counselor with a private practice in Southern Maine and a former Adjunct Faculty Member of the University of Southern Maine Graduate School. He also is an attorney who practiced Terry Fralich law in New York City, Los Angeles, and Portland prior to

becoming a counselor. He is a co-founder of the Mindfulness Retreat Center of Maine. He has led more than 300 seminars and retreats at the Center, Omega Institute, Kripalu Center for Yoga and Health, nationwide and in Australia in mindfulness, meditation, emotional intelligence, stress reduction, and the latest developments in neuroscience. In addition, he taught mindfulness, meditation and behavioral change for six years at Maine Medical Center’s cardiac rehabilitation program and the Cancer Community Center in Southern Maine. Frontier Health is approved by the American Psychological Association to sponsor continuing education for psychologists. Frontier Health maintains responsibility for this program and its content. Six hours of credit is available. Full attendance is required to receive credit; variable credit for partial attendance may not be awarded based on the APA guidelines. Cost is $135. There will be an hour and a half for lunch on your own from noon to 1:30. Six hours credit. Make checks payable to Frontier Health. To register: Diane Whitehead, Ph.D., Frontier Health, P.O. Box 9054 Johnson City, TN 37615 or fax, (423) 2241023 or email: rstewart@frontierhealth.org.

Wellmont, Eastman, Food City Encourage People, Business to Participate in Healthier Tennessee

KINGSPORT – Three of the region’s most prominent and respected organizations, which have worked extensively to improve people’s health, are encouraging individuals and businesses to support a statewide initiative that promotes wellness. Wellmont Health System, Eastman Chemical Company, and Food City leaders say Healthier Tennessee and its Small Starts tools are transforming lives and improving the state’s well-being. Executives for these companies encourage other businesses, as well as individuals, to use these resources. They became more convinced of the program’s impact after listening to a recent talk at the Kingsport Chamber of Commerce by Rick Johnson, CEO of the Gover-

nor’s Foundation for Health and Wellness, the organization that leads the Healthier Tennessee initiative. Announced in August and launched in October, Healthier Tennessee inspires people to adopt beneficial lifestyle patterns, such as becoming more physically active and eating nutritious foods in the right portions. The program is designed to reverse Tennessee’s standing as one of the least healthy states in the nation. The Small Starts tools, which are available at www.healthierTN.com, offer individuals and businesses strategies and ideas for becoming healthier. Small Starts @ Home provides more than 60 personal health challenges that encourage physical activity and healthy eating. These can lead people to even more ambitious goals that will put people on a path to better health. Small Starts @ Work offers more than 30 actions to help employees get healthier together. Many changes people can implement are relatively simple, such as eating balanced meals, keeping healthy snacks nearby, parking farther away from a person’s destination, using steps instead of the elevator, and stretching. Other ways people can make a positive difference in their lives are setting and keeping dates to quit smoking and obtaining at least seven hours of sleep a night. In kicking off Healthier Tennessee, Gov. Bill Haslam highlighted the Volunteer State’s high rates of hypertension, stroke, Type II diabetes, heart disease and several forms of cancer. People can reduce their risk of developing many of these conditions and diseases through behavior modification. Denny DeNarvaez, Wellmont’s president and CEO, said the regional health system sees firsthand the prevalence of preventable illnesses. That led to the creation in July of Wellmont LiveWell , an online initiative to improve the region’s health status through healthy lifestyle choices. Eastman and Food City are among the multiple regional businesses to partner with Wellmont on LiveWell. All three organizations are also involved in community efforts such as Healthy Kingsport and others that focus efforts on a local level.

Mark Your Calendar

Your local Medical Group Managers Association is Connecting Members and Building Partnerships. All area Healthcare Managers (including non-members) are invited to attend.

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3RD THURSDAY

JOHNSON CITY MGMA MONTHLY MEETING

KINGSPORT MGMA MONTHLY MEETING

Date: The 2nd Thursday of Each Month Time: 11:30 AM – 1:00 PM

Date: The 3rd Thursday of Each Month Time: 11:30 AM – 1:00 PM

Location: Quillen ETSU Physicians Clinical Education Building, 325 N. State of Franklin Rd., Johnson City

Location: Indian Path Medical Center Conference Room, Building 2002, Second Floor, Kingsport

MAY 2014

Wellmont’s Wise Guardianship of Finances Results in Affirmation of BBB+ Rating From Fitch

KINGSPORT – Wellmont Health System’s prudent stewardship of its finances during an unprecedented era in healthcare has earned the respect of a national rating agency. Fitch Ratings recently affirmed Wellmont’s BBB+ bond rating and classified its financial outlook as stable. The national firm, which thoroughly reviewed Wellmont’s finances, concluded the health system is in solid shape, including having a strong balance sheet. Fitch said Wellmont’s liquidity continues to be strong, with unrestricted cash growing 6 percent in the first six months of the 2014 fiscal year compared to the year before. This figure has grown 49 percent from the end of the 2010 fiscal year. Another impressive element of Wellmont’s finances is its revenue minus expenses, excluding tax, interest, depreciation and amortization. Fitch said Wellmont’s has averaged 11.5 percent for the past four audited years and was 9.9 percent for the first six months of this fiscal year. Wellmont has 213 days cash on hand compared to the median of 145 days for others with a BBB rating. The firm complimented Wellmont for its implementation of the electronic health record through the Epic platform. This $100 million project enabled Wellmont to develop an innovative system that places all details of a patient’s care at its facilities in one record. Caregivers can securely access this information at any Wellmont location, empowering them to fully understand a patient’s medical history and eliminate potential duplication of tests and services. In its review, Fitch discussed Wellmont’s ongoing evaluation of its strategic options for the future. Wellmont’s board of directors and leadership team are working with Kaufman Hall & Associates Inc., which provides a full range of strategic and financial consulting services for healthcare, to determine the best direction for the not-for-profit organization. As Wellmont participates in this process, it continues to lead the region with high-quality care and key initiatives, particularly in the diagnosis and treatment of cancer. These include the installation of Trilogy at Holston Valley Medical Center and the planned acquisition of TrueBeam at Bristol Regional Medical Center. These types of technology further advance the Wellmont Cancer Institute’s ability to treat some of the most complex cancers in areas such as the head, neck, lung, prostate, liver and breast. The cancer institute has also elevated its delivery of compassionate oncology care with the relocation of its facility in Johnson City and the opening of the Leonard Family Comprehensive Breast Center at Bristol Regional. Many of these developments have occurred through partnerships with forwardthinking philanthropists in the community who have helped the cancer institute bring strength for today and hope for tomorrow to cancer patients. In addition to cancer, Wellmont remains the standard bearer for cardiovascular care in the region with national and state recognition.

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GrandRounds Marsh Regional Honors 47 Blood Drive Sponsors That Helped Meet Area’s Need in 20013

KINGSPORT – Organizations large and small have saved lives in Northeast Tennessee and Southwest Virginia with their commitment to ensure Marsh Regional Blood Center has a sufficient blood supply to meet the area’s needs. Marsh Regional recently held its seventh annual awards luncheon at Bristol Motor Speedway to honor the top 47 blood drive sponsors for 2013. Schools, hospitals, businesses, and churches were among the groups recognized for their contributions to patient health. Together, the support from these organizations was vital to Marsh Regional’s collection of more than 26,000 units to meet the region’s needs. Recognized at the event were: • Medical centers – Holston Valley Medical Center, Bristol Regional Medical • Center and Indian Path Medical Center • Colleges and universities – University of Virginia-Wise, East Tennessee State University and Milligan College • Community colleges – Northeast State Community College, Mountain Empire Community College, Southwest Virginia Community College and Tennessee College of Applied Technology • Tennessee large high schools – Dobyns-Bennett High School, Volunteer High School and Daniel Boone High School • Tennessee medium high schools – Sullivan South High School, Sullivan North High School and Sullivan East High School • Virginia medium high schools – Gate City High School, Union High School and Richlands High School • Tennessee small high schools – Cloudland High School and Hampton High School • Virginia small high schools – Thomas Walker High School, Lebanon High School and Haysi High School • Business and industries – Nuclear Fuel Services, Domtar and Bristol Virginia Utilities • Civic groups and clubs – Richlands Masonic Lodge, Black Wolf HarleyDavidson and South Holston Ruritan Club • Churches – St. Dominic’s Catholic Church, First Broad Street United Methodist Church, St. Anne’s Catholic Church and Valley View Freewill Baptist Church • Community hospitals – Sycamore Shoals Hospital, Clinch Valley Medical Center and Norton Community Hospital • Job corps – Jacobs Creek Job Corps and Flatwoods Job Corps • Small businesses – ACT, CGI and BAE Systems • Correctional facilities – Red Onion State Prison, Wallens Ridge State Prison and Keen Mountain Correctional Center • Career centers – Scott County Career and Technical Center and Wise County Career-Technical Center More information is available at www. marshblood.com.

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Ken Buchanan Named Wellmont’s Executive Director of Internal Audit

KINGSPORT – Ken Buchanan, a leader with broad experience in financial matters, has been named executive director of internal audit for Wellmont Health System This division audits financial data, information technology, compliance, performance and procedures. It also provides Ken Buchanan Wellmont’s management and board of directors with independent and objective assurance and consulting services so the organization’s operations can improve. Prior to joining Wellmont, Buchanan served as vice president for business and financial affairs at Lees-McRae College in Banner Elk, N.C. He also served as an internal auditor at Appalachian State University in Boone, N.C.; chief executive officer of Financial Partners Credit Union in Morganton, N.C.; and controller of The McDowell Hospital in Marion, N.C. Buchanan has a Bachelor’s degree in accounting from Gardner-Webb University in Boiling Springs, N.C., and is a certified public accountant. He is a member of the American Institute of Certified Public Accountants.

Benton to serve as interim CEO of Washington County hospitals for Mountain States Health Alliance

JOHNSON CITY – Tony Benton has been selected to serve as interim CEO of Mountain States Health Alliance’s Washington County facilities, Mountain States officials announced recently. Benton will fill the role while a search team identifies a permanent candidate to replace David Nicely, who Tony Benton announced in March that he would pursue a new professional opportunity near Nashville. Benton’s role as interim CEO of Washington County facilities will include the CEO role at Johnson City Medical Center (JCMC), along with oversight for the operations of Franklin Woods Community Hospital and Woodridge Hospital. When a permanent candidate is selected, Benton will become the Chief Operations Officer for Washington County facilities. Benton most recently served as CEO of Franklin Woods Community Hospital, a role he assumed in February 2012. Under Benton’s leadership, Franklin Woods has maintained patient satisfaction scores that rank among the top 10 percent of all hospitals nationwide. The hospital was recently listed by Becker’s Hospital Review as having the 22nd highest patient satisfaction score in the country. In 2013, Franklin Woods became one of four hospitals in the nation to be honored by the American Hospital Association for leadership and innovation in quality improvement and patient safety. Benton joined Mountain States in 2002 as vice president of strategic planning. In that role, he oversaw a number of capital improvement and growth projects as Mountain States brought five new hospitals into the system and helped to develop Johnson City’s Med Tech Corridor with the construc-

tion of Franklin Woods Community Hospital. As head of strategic planning, Benton also oversaw the facility and construction activities during the construction of Niswonger Children’s Hospital, Johnston Memorial Hospital, and Smyth County Community Hospital. He has also held leadership and administrative oversight roles for Mountain States’ Marketing and Communications Department and the Wellness Center. Prior to joining Mountain States, Benton served as finance manager and decision support analyst for Central Baptist Hospital in Lexington, Ky. Benton received a Master’s degree in business administration from the University of Kentucky, Lexington. He serves as an adjunct faculty member at East Tennessee State University and has served as a senior examiner on the Malcolm Baldrige National Board of Examiners. He also serves on the boards of directors for the United Way of Washington County, Tenn.; Appalachian Mountain Project Access; the Hands On! Regional Museum; and the Tennessee Center for Performance Excellence.

Niswonger Children’s Hospital, East Tennessee Brain and Spine Center bring pediatric neurosurgery services to TriCities

JOHNSON CITY – Officials from Niswonger Children’s Hospital and Mountain States Health Alliance announced recently a major development in the expansion of high quality specialized services for children. In partnership with East Tennessee Brain and Spine Center, the hospital is launching a pediatric neurosciences program with the introduction of Dr. Valentine T. Nduku, who comes to the area from Cincinnati Chil- Dr. Valentine T. Nduku dren’s Hospital. Nduku will join East Tennessee Brain and Spine Center to provide advanced neurosurgical services at Niswonger Children’s Hospital as the region’s first pediatric neurosurgeon. In partnership with Niswonger Children’s Hospital, Nduku will help lead efforts to establish and build the region’s first pediatric neurosciences program. Nduku’s practice will treat the full spectrum of pediatric neurosurgery needs, including epilepsy and seizure disorders, congenital neurological diseases, and pediatric head trauma. He is currently covering trauma call one weekend per month at Johnson City Medical Center and will officially join East Tennessee Brain and Spine Center full time October 1. Nduku is currently completing his specialized fellowship training at Cincinnati Children’s Hospital, which is affiliated with Niswonger Children’s Hospital. The most recent rankings from US News and World Report place Cincinnati Children’s Hospital’s Pediatric Neurosurgery and Neurology program as the 4th best in the nation among all children’s hospitals, and overall rank ten of the specialties at Cincinnati Children’s as among the best in the nation. In addition to its affiliation with Cincinnati Children’s Hospital, Niswonger Children’s Hospital is also one of only six children’s hospitals in the nation to be affiliated with St. Jude Children’s Research Hospital. “We are very excited to add pediatric neurosurgery to our practice and to the community,” said Dr. David Wiles, president

of East Tennessee Brain and Spine Center. “Our goal as a practice has always been to provide a comprehensive service. By partnering with Mountain States Health Alliance to recruit Nduku, we will be much closer to that goal. The people of this region will benefit greatly by being able to get the care they need closer to home.” Nduku’s recruitment represents an example of the focus Mountain States Health Alliance is placing on expansion of pediatric specialties at Niswonger Children’s Hospital. Nduku’s other areas of interest include brain diseases and spinal disorders, including hydrocephalus, complex and simple craniostenosis, brain and spinal tumors, spina bifida and congenital malformations, Chiari malformations and syringomielia, vascular malformations, and trauma. Nduku graduated from Georgia State University with a Bachelor of Science degree in biology and chemistry, and completed his Doctor of Osteopathic Medicine training at the Virginia College of Osteopathic Medicine. He completed his internship at Michigan State University and his residency in osteopathic medicine at the Philadelphia College of Osteopathic Medicine. Nduku is a member of the American Medical Association and the American College of Osteopathic Surgeons – Neurosurgery.

Wellmont Introduces New Electronic Health Record, Portal for Patients to Access Own Medical Information

KINGSPORT – A patient who has regularly received care at one of Wellmont Medical Associates’ primary care practices suddenly experiences great discomfort and heads to the emergency department at a Wellmont Health System hospital. Meanwhile, a Wellmont CVA Heart Institute patient has gone to a Wellmont Urgent Care facility with an illness that might require medication. As physicians treat each patient, they can deliver even better care because of Wellmont’s innovative and robust electronic health record. It enables them to supplement what they learn during the physical examination with a comprehensive, yet quick, review of the patient’s history of care at Wellmont facilities. This became possible through Wellmont’s adoption of the nationally respected Epic platform. It was an 18-month project to replace multiple medical record and financial systems that were not fully integrated or able to communicate with each other easily. The use of Epic is Wellmont’s latest advancement in the use of electronic medical records. The health system was a leader in implementing computerized provider order entry and has met all federal standards for meaningful use of certified electronic medical records. The Epic system went live Dec. 9 at Wellmont Medical Associates offices and is set to launch March 29 everywhere else at Wellmont. To celebrate this achievement, Wellmont executives held a news conference on Thursday, March 20, to detail the scale of this project and congratulate the nearly 200 co-workers and physician leaders who guided this successful transition. During this event, Wellmont also highlighted MyWellmont, a secure new portal for patients to review a significant portion (continued on page 18)

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GrandRounds of their electronic medical record. This webbased program provides multiple ways for patients to participate in greater depth with their healthcare and was created as part of the Epic conversion. Wellmont physicians and other medical personnel in the health system’s hospitals and other facilities have received extensive training to use the new Epic system. Cory Siffring, a medical doctor who serves as a general surgeon at Holston Valley Medical Center, said the change to Epic is worthwhile because it enhances patient safety and offers a broader picture of a patient’s medical condition – all in one place. “Physicians provide the best care when they have the most accurate and complete information,” Siffring said. “When we review a patient’s record, we might discover something important that will help us better understand that person’s condition and treat it most effectively.” In addition to offering secure access, MyWellmont takes further protective measures. For example, people cannot submit requests for refills of narcotic medications, and some particularly sensitive test results, such as for HIV, are not available. To sign up for MyWellmont, patients are given an activation code after receiving care at a Wellmont facility or by requesting one through the website. Once they have the code, they log on to the website and se-

lect a username and password and answer a few other simple questions. Then they can use the site. Wellmont patients can access this program through their computer or use official mobile apps for smart phones and tablets available through the Apple store or Google Play. One of the many ways the Epic conversion and MyWellmont work in harmony is providing assistance for people who travel. Information stored in MyWellmont can be placed on a jump drive and taken with patients in case they need medical attention during their trip. Likewise, if Wellmont patients are out of town and need services of a hospital or other healthcare provider that uses the Epic system, those caregivers can be authorized to access the patient’s Epic profile. The same applies to someone visiting the region who needs care from Wellmont.

The Dude abides: Testicular cancer survivor now helps raise awareness

ABINGDON, Va. – John Taylor is a regular blogger and a talented writer, and he writes from personal experience. It used to be primarily about parenting, which he did as a stay-at-home dad, but then he was confronted with something else that grabbed his attention – testicular cancer.

Holston Valley Enhances Patient Comfort With New Gastroenterology/Bronchoscopy Unit

KINGSPORT – Patients undergoing many common procedures at Holston Valley Medical Center will experience additional comfort in an updated and more accessible unit. The hospital recently unveiled and began using its relocated gastroenterology and bronchoscopy unit. Hospital leaders, as well as physicians who practice in the unit, held a ribbon-cutting ceremony and open house. Previously, patients received these treatments on the hospital’s second floor, near the pediatric and neonatal intensive care units. Now conveniently located on the first floor, the gastroenterology/bronchoscopy unit is easier for patients and visitors to reach and has doubled in size. It features an expanded waiting area, improved patient privacy measures, and additional procedure rooms and restrooms. Procedures performed in the unit include bronchial thermoplasty, colonoscopies, endoscopies, and endoscopic ultrasounds. Services in the new unit are performed by physicians with Wellmont Medical Associates, as well as more than a dozen other members of Holston Valley’s medical staff, including physicians with Gastroenterology Associates. More information about the unit’s services is available by calling 423-224-5197.

Participating in the ribbon-cutting ceremony are, left to right, Joan McVey, Dr. Douglas Springer, John Chiles, Tim Attebery, Dr. Rathi Narayan, Dr. Robert Strickland, Dr. Jerry London and Karen Cain

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At age 29, he was diagnosed with Stage 3 testicular cancer, which had spread to his lymph nodes, abdomen, and lungs. Taylor fought through that ordeal from September 2012 John Taylor to February 2013, giving regular accounts of the experience in his blog, and now that he’s finished treatment at Johnston Memorial Hospital (JMH) and been declared cancer-free, he’s become a strong advocate for testicular cancer awareness. Taylor helps the Testicular Cancer Awareness Foundation with their online presence, serves as a peer-to-peer mentor for people with testicular cancer, and continues to write blog articles about parenting and about dealing with cancer at his site TheDaddyYoDude.com. April was National Testicular Cancer Awareness Month, so the month was busy for Taylor. He’s appeared on TV, in a JMH calendar and on a billboard, talking about his ordeal and saying “thank you” to his caregivers. (He’s featured as “Mr. April” in the calendar.) One of his last blog pieces was “An Open Thank You Note to Those Who Saved My Life,” in which he praised the staff at Johnston Memorial Hospital for their care. He wrote: “It requires dedicating so much of your day to patients who are fighting for their lives, knowing that some may not see the end of the long journey. It takes a strong heart, a caring soul, and a will beyond all to do what you do. … So today, I thank you because YOU are the ones that saved my life.” Taylor’s blog is called “The DaddyYo Dude: Slowly Losing it Since 2007.” His discourses about surviving cancer are honest and edgy, and they contain the kind of perspective and information you won’t find in many other places. They can also be humorous. His titles include “6 Things They Don’t Tell You about Surviving Cancer,” “The Tough Testicles Talk,” “Then There was One: My Testicular Cancer Story,” and “I Beat Cancer and All I Got was this Billboard.” Taylor said he’s doing well now, with some lingering side effects from his treatment. He credits a strong online support system for helping him and that’s how he tries to give back. He helps the TC Awareness Foundation with their Facebook, Twitter, and Tumblr accounts and through that kind of work has found himself answering questions or chatting online with testicular cancer patients, giving them the kind of support that can only come from someone who’s been through it himself. Visit TheDaddyYoDude.com to read the full story about his ordeal with cancer, how Johnston Memorial Hospital’s cancer care helped save him, and how men can be on the lookout for testicular cancer. You can also view his 30-second video.

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5 reasons to get the Niswonger Children’s Hospital mobile app: 1. It’s FREE and interactive for both adults and kids! 2. Learn about our physicians and services. 3. Get up-to-date information and health tips for kids, teens, and parents. 4. Enjoy daily devotionals and a photo gallery. 5. Receive exclusive mobile alerts specific to children’s health care.

The Niswonger Children’s Hospital app is available at Google Play Store or the iPhone App Store. Get yours today!

www.msha.com/children Home of the St. Jude Tri-Cities Affiliate Clinic • Affiliated with Cincinnati Children’s Hospital Medical Center Located in Johnson City, Tennessee • Serving children and families of Southern Appalachia


Tri Cities Medical News May 2014  

Tri Cities Medical News May 2014

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