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Peer Review Law ChangesArkansas joins other states narrowing healthcare peer review privileges for the Patient Safety and Quality Improvement Act of 2005

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Diabetic Wound Care Saves Lives, Limbs and Money for the Healthcare System

One of the most common mistakes primary care providers make with diabetic patients with a foot wound is to clean the ulcer, remove all the infected tissue, bandage it and then send the patient out of the offi ce on foot ... 4

Preparing for ICD-10 Conversion Part 2Practice management consultant shares the ‘4 Ts’ for physicians to consider

Even though ICD-10 conversion has been anticipated for many years industry-wide, most physician practices haven’t had the resources or the inclination to start preparing before now ... 5

By LYNNE JETER

Two new peer review laws in Arkansas should make it easier for doctors to focus on the practice of medicine instead of peer review concerns.

“Peer review is such an impor-tant part of medicine … the more steps taken to make it objective for the provider who’s on the line, the better the decisions will be made,” said Janet Pulliam, a healthcare attorney with Watts, Donovan & Tilley PA in Little Rock, who frequently represents providers. “It’s important for people on peer review committees to know that Arkansas has public policy that supports this kind of objectivity.”

Sponsored by Sen. Cecile Bledsoe (R-Rogers), Senate Bill (SB) 790 improves the quality of healthcare and ensures that peer review committees for medical professional associations are afforded confi dentiality, while SB 887 establishes

the Arkansas Peer Review Objectiveness Act. Both bills were approved during the 2013

legislative session.In SB 887, Bledsoe noted the

General Assembly found the peer re-view process “well established as the most important and effective means of monitoring quality and improv-ing care within an institution,” and

that “peer review is essential to pre-serving the highest standards of medical

practice.” “However, peer review that’s not

conducted fairly results in harm to both patients and physicians by limiting access to care and patient

choice, and it’s necessary to balance carefully the rights of patients who benefi t by peer review with

the rights of those who may be harmed by improper peer review,” she said.

Comparing the bills, Pulliam noted that SB 790 doesn’t require clinic practices

BY BECKY GILLETTE

The concept of individual genetic testing to tailor the best type of medicine and treatment for pa-tients is no longer just theoretical. Precision or personalized medicine using genetic testing for diagnosis and treatment of patients is now available and being used often in Arkansas.

“The take home message is that the time is now,” said Bradley Schaefer, MD, division chief of the University of Arkansas for Medical Sciences (UAMS) Medical Genetics Division, who also practices at the Arkansas Children’s Hospital. “It is amazing what can be done. This technology has moved out of the re-search lab and can be applied in clinics to help people. It is unbelievable what it does for children we see who in


Genomically Directed Medicine Using Genetic Profi le to Tailor Better Drug Treatment

Elylem Ocal, MD

PAGE 3

PHYSICIAN SPOTLIGHT

2 > MARCH/APRIL 2014 m e d i c a l n e w s o f a r k a n s a s . c o m

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BY LYNNE JETER

It doesn’t take long for Elylem Ocal’s personality to sparkle. The self-deprecat-ingly funny pediatric neurosurgeon from Istanbul admittedly has “a mix of Cana-dian–Arkansan English, with a Turkish accent.”

“This’ll never go away,” she joked. “I make funny mistakes still, and my staff in the office teaches me one new word or phrase every week,” said Ocal, who also speaks Spanish.

She’s quick to admit she likes her first name – Elylem, means action of deed, usually in reference to a rebellious figure.

“I’m an action figure,” she joked, ad-mitting that as the older of two daughters born to Tahsin, a government employee, and Adalet, a sales manager, she was very adventurous. “I liked to make experi-ments, which usually ended in accidents. I call it ‘scientific curiosity,’ which helped me a lot in my career.”

Ocal’s youngest aunt, Sehnaz, cared for her while her parents worked. “She’s like a sister,” she said, recalling that Sehnaz “taught me my first English words.”

An elementary schoolteacher, Mrs. Cakir, also influenced Ocal.

“She gave me a strong foundation and … always pushed me to my limits, sometimes too much,” said Ocal. “She always wanted to see me as doctor in a white coat. She was there for my gradua-tion from medical school! It was a dream fulfilled to see her there, looking at me proudly.”

However, before medical school, Ocal considered other interests.

“As a teenager, I wanted to go in poli-

tics, study international relations, or be a businesswoman,” she said. “My dream was to become the first female prime min-ister of Turkey.”

Ocal graduated at the top of her class at the Marmara University School of Medicine in 1999. As the first physician in the family, her relatives urged her to consider specializing in family or internal medicine.

“Everyone was so excited to have a doctor in the family,” she said. “They weren’t happy with my choice of neu-rosurgery! I love children and thought about becoming a pediatrician for a while, but the brain and entire nervous system was exciting to explore, challeng-ing to understand. It was a puzzle waiting to be solved. Even with the invention of new technologies and better understand-ing of its function and structure, the brain and entire nervous system is still a mys-tery. It amazes me every day. That’s why I chose neurosurgery. Combined with

my love for children and passion for their wellbeing, I decided to do pediatric neu-rosurgery. I find it very fulfilling when a child smiles back at you after undergoing surgery.”

Ocal completed her internship and residency requirements at the Cerrahpasa School of Medicine at Istanbul University in 2004, followed by specialized training at Yale University School of Medicine, and a clinical fellowship in pediatric neu-rosurgery from British Columbia Chil-dren’s Hospital in Vancouver, Canada, that ended in 2011. “This is one of the well-respected places to train for pediatric neurosurgery,” said Ocal. “My mentors – Drs. Steinbok, Cochrane and Singhal – helped me define my path as a pediatric neurosurgeon.”

Ocal has a special interest in spina bi-fida and brain tumors, rare conditions that are challenging to treat.

“We still have a limited understand-ing of their genetic basis, etiology and pa-thologies,” she said. “These patients may need a lot of care, multiple treatments and/or surgeries. It takes a team to deal with these conditions, including the pa-tient, parents, multiple medical disciplines and professionals. You have to push the limits most of the time and I like to do that!”

Ocal’s decision to relocate to Arkan-sas required little consideration.

“As one of the best children’s hos-pitals in the nation, Arkansas Children’s Hospital seemed a place that would pro-vide me with opportunities as a new at-tending taking her first job,” she said. “It has more than enough amenities to serve a large population of patients with diverse clinical conditions to treat, research to do,

well-known mentors and experienced col-leagues from every discipline. Most im-portantly, the passionate staff gives hope, care and love. Although Little Rock is the littlest place I’ve ever lived in, I found ev-erything that I was looking for, including very good, welcoming people.”

Ocal, a Turkish folk dancer who’s done the international dance festival cir-cuit and is now learning salsa dancing, re-cently discovered fishing and horse riding as new outdoor hobbies.

“Recently I did ice fishing and dog sledding, which was cold but fun,” said Ocal, who swims regularly, practices yoga, and is a certified Level 3 wine expert. “My next big thing will be duck hunting … and, of course, Razorback games!”

Of her “bucket list” items, Ocal wants to teach pediatric neurosurgery in devel-oping and underdeveloped countries (“I always wanted to join Doctors Without Borders, but they don’t want neurosur-geons,” she noted), take a trip to the North Pole, watch aurora borealis with a hot cup of tea in hand, and skydive, “if I can find enough courage,” she said.

“It was difficult to be away from home, family and friends in Turkey,” said Ocal, whose mother lives with her six months every year. They often visit Evrim, a political analyst in Washington DC, and her family, including Mavi and Liam. “However, I like to explore new things, new cultures and new places. I’m also very adaptable. Every place I’ve lived was a new adventure. I met valuable peo-ple, friends, and colleagues from different backgrounds, cultures, religions, and lan-guages. This gave me a better understand-ing and wider perspective of our world. I am truly blessed.”

Elylem Ocal, MDAssistant Professor of Neurosurgery, UAMS/Arkansas Children’s Hospital

PhysicianSpotlight


BY BECKY GILLETTE

One of the most common mistakes primary care providers make with diabetic patients with a foot wound is to clean the ulcer, remove all the infected tissue, ban-dage it and then send the patient out of the office on foot.

If it is a weight-bearing wound, it will not heal unless it is treated with a special cast or brace to allow weight bearing, said Ruth Thomas, MD, an orthopedic surgeon who is director of the University of Arkansas for Medical Sciences (UAMS) Center for Foot and Ankle Surgery.

“For weight bear-ing ulcers, you must to find a way to get the pa-tient’s weight off the foot whether it is by using a cast or brace, or a wheelchair to get all of the weight off the foot,” Thomas said. “The standards have been around for years that after you clean the wound and remove the dead tissue, the ulcer on the foot can’t bear weight. Even though it is a standard of care, a lot of our general practitioners don’t realize it. They

will do the wound care and turn around and let the patient walk out of the office in a shoe. When that happens, whatever they have done is essentially neutralized.”

Thomas said there is nothing extraor-dinarily new on the horizon for wound care. There is no drug out there to cure all wounds.

“We use a lot of topical agents to try to encourage a clean environment in the wound, but none of them have been shown to be miracle drugs,” she said. “They can assist, but they are not a sure cure.

“VAC therapy or negative pressure wound therapy can be very effective in healing wounds. It is certainly a therapy that has been shown to improve or speed up wound healing. It is basically a sponge that is applied to the wound, and then a little slit or hole is put in the covering of the sponge before applying a dressing that is not permeable. Then you cut a hole in it and attach suctions. The suction will pull all of the fluid out of the wound. It stimulates healing while drawing away unhealthy things like bacteria. So it can be effective even in wounds that are in-fected.”

Biological skin equivalents are skin replacements made out of viable cells

taken from different sources such as pigs or humans. Biological skin substitutes can be put over clean wounds and the wound will epithelialize.

“The wound has to be healthy and the patient in good health or skin replace-ment therapies will not work,” Thomas said.

Researchers are finding simple soap products can cleanse wounds as well as more expensive products sold by commer-cial companies that have silver or other added special agents.

“No one has shown any of those are better than standard debridement and routine wound care,” Thomas said.

Thomas recommends healthcare pro-viders take time to talk to diabetic patients about basic rules such as not walking bare-foot, wearing closed shoes instead of open toe sandals, and not cutting their own toe-nails. See a physician at the first sign of any trouble with your feet.

“Management needs to be started quickly,” Thomas said. “You get in trou-ble with diabetics where there are little cuts in the skin, bacteria enters, the foot becomes infected, and can quickly dete-riorate.”

Angela Driskill, MD, a wound care specialist at Baptist Health Medical Cen-ter-North Little Rock, agrees about the impor-tance for diabetics to be instructed on foot care. As the occurrence of all diabetic associated co-morbidities rise in each individual patient, the importance of nightly self-foot examination rises.

“The patient who has retinopathy and neuropathy will have more difficulty performing a nightly foot exam, and yet the importance of the nightly exam in-creases exponentially as the co-morbid-ities take their toll,” she said. “Teaching patients to examine their feet is almost as important as teaching them to check their blood sugar.”

As diabetes soars to epidemic pro-portions in the U.S., diabetic foot ulcers (DFU) have increasingly become a costly problem. In 2013 the Diabetes Associa-tion reported that 25.8 million Americans have diabetes, representing nearly ten per-cent of the population and 25 percent of seniors.

“Patients with diabetes have a 25 percent risk of developing a DFU in their lifetime,” Driskell said. “Of those who present with a DFU, 50 percent will be infected. Of the infected ulcers, 65 per-cent will have underlying osteomyelitis. It is well documented that osteomyelitis car-ries with it a high risk for lower extrem-ity amputation. Once the lower extremity is amputated, that patient has a five-year mortality risk of 50 percent. Those statis-tics show the significant economic, physi-

cal and emotional impact to patients from a single diabetic foot ulcer.”

Driskell recommends the monofila-ment exam for pedal neuropathy be per-formed.

“Your monofilament exam may save your patient’s life,” she said. “As a quick reminder, the monofilament exam is done with a 10 g filament. The great toe, and then the first, third and fifth metatarsals are tested. Enough pressure is applied to slightly bend the filament and this pressure is held for two-three seconds. The test is positive if the patient fails to detect pres-sure at any single point.

“Once it is established that the pa-tient’s foot is insensate at any of these points, custom fit insoles and diabetic shoes are indicated to prevent ulceration. A diabetic shoe should be properly fit and if there is any structural abnormality a cus-tom orthotic or insole needs to be made.”

Driskell said it is unfortunate that often patients order shoes online or pur-chase shoes from a retailer who does not have anyone trained in pedorthics. Typi-cally the diabetic patient will need to have a larger toe box and adequate room for the toes, which often are deformed.

“If there is any mechanical abnor-mality, the insole will need to custom fit to offload this abnormality,” she said. “Someone who specializes in pedorthics should assist your patient in obtaining the appropriate shoe.

“Even with good care of their feet, more than five percent of diabetics will develop an ulcer each year. When this happens, the basics of ulcer care should be started. This entails five basic steps:

1. Removing the offending callous and any dead tissue.

2. Clean the area and get a culture. 3. Treat infection: topically if local-

ized, systemically if there is cellulitis.4. Offload the ulcer. 5. Maintain a clean moist wound en-

vironment to promote healing.”If the wound has not healed by 50

percent of the surface area in four weeks, the patient may need more advanced wound care.

Healing the patient’s wound is es-sential to the patient’s quality of life, and greatly lessens the financial burden on the healthcare system. The average cost of healing a DFU has been estimated at $26,000 with the cost of care of a diabetic who underwent amputation was estimated to be greater than $200,000.

Driskell said another important point is that healing a DFU often means the pa-tient can stay in his or her own home and remain independent, whereas an amputa-tion often leads to placement in a skilled nursing facility or extensive home care.

“Financially, it is much better for the healthcare system and for the health of the individual to have advanced wound care to accomplish healing of the wound,” Driskell said.

Diabetic Wound Care Saves Lives, Limbs and Money for the Healthcare System

Refer your patients to the American Lung Association for

smoking cessation options.

HELP PATIENTS QUIT.

For questions or more information, contact Laura Frick at 314.645.5505 x1014 or [email protected].

Dr. Ruth Thomas

Dr. Angela Driskill


BY LYNNE JETER

Editor’s note: The Medi-cal News series, “Preparing for ICD-10 Conversion,” began last month with “8 Steps” for physicians to take now. This month, implementing the “4 Ts” is the focus recommendation to facilitate a smooth transition.

Even though ICD-10 conversion has been anticipated for many years industry-wide, most physician practices haven’t had the resources or the inclination to start preparing before now.

It’s not too late to bring those prac-tices up to speed, said Jennifer O’Brien, MSOD, a practice management consul-tant with KarenZupko & Associates Inc.

“Time is of the essence, however,” she said. “Physician practices need to under-stand the enormity of this mandated tran-sition that will affect their bottom line.”

O’Brien recommends applying the “4 Ts.”

Team: Establish a work group for ICD-10 conversion.

“The group should be a cross sec-tion of the practice, including at least one

physician, biller, and clinical assistant, and representatives from other functions in the practice that have diagnosis coding as part of their work, such as a surgery scheduler or ancillary service provider,” said O’Brien. “The practice manager or administrator, someone who has an un-derstanding of the whole practice, should also be included. This will require true teamwork. No one person should be shoul-dering the bulk of the conversion for two reasons: it’s too much and it’s too risky. If one person is doing almost everything and wins the lottery in July, the conversion will fall apart.”

Place a year-at-a-glance calendar in a common staff area so all employees may see the deadlines and target dates, sug-gested O’Brien.

“The group will need to meet regularly,” she said. “Someone

should create and be the keeper of a work plan

that lists tasks, dates and who’s responsible. We recommend keep-ing a single work plan

so that everyone can see the progress, looming

dates, and the specifi cs of the shared responsibility.”

Testing: Communicate with your EMR, Practice Management Software (PMS) vendor, clearinghouse and biggest payors concerning if, when and how testing of claims with ICD-10 will be done.

“Medicare has announced that test-ing will occur the week of March 3-7. A couple of fi scal intermediaries are requir-ing providers to register to participate in the testing. At this point, there’s no indica-tion of another testing period, so if prac-tices or clearinghouses miss that testing, there may not be another opportunity before October 1. That’s just Medicare; communicate with other big payors to fi nd out about their testing. ”

Training: Make time for training sessions, both self- and instructor-led.

Self-training exercises are available to all physicians, such as running a report of the 25 to 75 most frequently used ICD-9 codes and then crosswalking those to ICD-10.

“I have a client who’s pregnant with her fi rst, and due in April,” said O’Brien. “She’s already started on this process to teach herself how she’ll need to code and document differently and is planning on implementing necessary changes before she goes on maternity leave, so that when she returns in the summer, she’s not hav-ing to learn and prepare for ICD-10, in addition to adjusting to her new work-life balance.”

Specialty societies, state medical soci-eties, hospitals, software vendors and con-sulting fi rms also provide ICD-10 training sessions for physicians and staff.

“Sign up for those sessions, go to them, listen and learn,” he said. “For most physicians, the dread associated with at-tending coding training is akin to that of having a root canal. It’s not going to be fun; it may be barely tolerable. Thing is, it’s not optional. In the past, when phy-sicians considered coding training, it’s

Preparing for ICD-10 Conversion Part 2Practice management consultant shares the ‘4 Ts’ for physicians to consider

BY LYNNE JETER

Medi- series, “Preparing

implementing the “4 Ts” is the focus recommendation to facilitate a smooth transition.

Even though ICD-10 conversion has

“The group will need to meet regularly,” she said. “Someone

should create and be the keeper of a work plan

that lists tasks, dates

ing a single work plan so that everyone can

see the progress, looming dates, and the specifi cs of the

shared responsibility.”

“Medicare has announced that testing will occur the week of

March 3-7. A couple of fi scal intermediaries are requiring providers to register to participate in the testing. At this

point, there’s no indication of another testing period, so if practices or clearinghouses miss that testing, there may not

be another opportunity before October 1.”– Jennifer O’Brien, MSOD, Practice Management

Consultant, KarenZupko & Associates Inc.



Specialties RecognizedCancer

Cardiology & Heart SurgeryGastroenterology & GI Surgery

GeriatricsNephrology

Neurology & NeurosurgeryOrthopaedics

Urology

See the complete rankings for yourself at

health.usnews.com/best-hospitals

When the experts at U.S. News & World Report reviewed all 108 hospitals World Report reviewed all 108 hospitals World Reportin Arkansas, including 22 in central Arkansas, they ranked St. Vincent as the No. 1 hospital in the state and listed us as “high-performing” in eight clinical specialties – more than twice as many as any other Arkansas hospital.

For 125 years, the Sisters of Charity of Nazareth have taught us that the patient comes first. We made the Sisters proud with the state’s only Magnet® recognition for nursing excellence and this high ranking from U.S. News & World Report.

A major thank-you to all our associates for their unwavering commitment to our healing ministry. We are also blessed to work every day with truly world-class physicians. Our associates and physicians make us No. 1.

St. Vincent is Arkansas’ beSt

hospital

StVincentHealth.com

Magnet® names and logos are registered trademarks of the American Nurses Credentialing Center. All rights reserved.

BY LYNNE JETER

Controversy has swirled about a re-cent New York Times article stating that “some healthcare executives say predic-tions of a fi asco next Oct. 1 will prove as erroneous as those that said civilization would collapse on Jan. 1, 2000 ... the so-called Y2K issue.”

“It’s not going to be a shock to the industry to confront this,” Christopher G. Chute, professor of biomedical infor-matics at the Mayo Clinic, told the NYT. “We’ve literally had seven or eight years to anticipate it.”

Underestimating the conversion to ICD-10 is dangerous, say practice man-agement experts.

“When you’re in a roomful of pay-ors hearing them talk about how they’re worried, it scares me,” said Shelly Bangert, di-rector of revenue cycle management for Haw-thorn Physician Ser-vices Corporation, one of the nation’s leading healthcare revenue cycle management compa-nies. “Bigger payers are still expecting hiccups, and they’ve been working on this conversion for several years. We want to make sure practices are prepared.”

The cost of preparing the new system by the original implementation date of Oct. 1, 2013, has already been fi nancially draining for some providers, who had sunk hundreds of thousands of dollars into meeting that deadline.

“Some hospitals had teams ready to go, consultants in place,” said Bangert. “Then when the start date was postponed a year, everything was put on hold and money was lost. The payors were saying

the same thing, but they were losing mil-lions trying to convert dozens of systems – antiquated, those inherited from buyouts, and new and upcoming systems – into one that would work with ICD-10 codes.”

Practice management consultants also expressed concern about the Ameri-can Medical Association’s recent ICD-10 readiness survey that ended Jan. 31, say-ing it’s irresponsible of the national group to take such a step nine months out, and will only put physicians in a greater state of denial and therefore less prepared for the new conversion date.

“Some will run smoothly,” said Bangert. “Others will be total catastro-phes. When you have a payor who’s just as worried about underpaying as overpay-ing, and reconciling and going through millions of provider contracts manually to make sure they’re all updated is over-whelming. That worries me. It won’t be a piece of cake. Some practices may go out of business as a result.”

Risk Assessment Hospital informatics folks and ad-

ministrators may have done a thorough job of preparing on behalf of the hospital but the situation physician practices face is different, said Jennifer O’Brien, MSOD, a consultant with KarenZupko & Associates Inc., a Chicago-based fi rm that has been specializing in physician practice manage-ment for 29 years.

“If everything isn’t perfectly in place for the conversion to ICD-10, it’s not re-duced reimbursement rates (that) practices are facing; it’s zero reimbursement,” said O’Brien. “Reimbursement rates for phy-sician services aren’t directly attached to diagnosis codes, but rather to CPT codes. Diagnosis codes provide the justifi cation for those CPT codes. It’s an all-or-noth-ing thing. We’re not talking about a risk

of reduced reimbursement on a claim-by-claim basis; the risk is zero reimbursement because the ICD-10 code isn’t accurate and specifi c to justify the CPT code.”

Decidedly, overall reimbursement fl ow will be slower, said O’Brien.

“Hospitals and larger healthcare or-ganizations have larger IT and adminis-trative support structures, profi t margins, cash fl ow, established credit lines and lon-ger revenue cycles than physician prac-tices,” she said. “If a physician practice averages 45 days (from the date of service) in accounts receivable (before payment) and a hospital averages 105, the practice is going to feel it in the reimbursement by November 15, 2014, whereas the hospital payment cycle doesn’t have it receiving payments for early October services until later.”

Unfortunately, most practices haven’t been preparing well enough for the con-version date.

“One large, Midwestern specialty

practice client of ours has been prepar-ing for the transition since 2011,” said O’Brien. “They’ve been doing bilingual coding (both ICD-9 and ICD-10 for some time) and still, they’ve bolstered their line of credit to cover six months of operating expenses and minimal physician salaries in anticipation of October 1, 2014.”

Regardless of physicians’ prepara-tion for ICD-10 conversion, or lack of, the looming Oct. 1 coding change date will signal one of the most signifi cant chal-lenges the medical industry has faced, said Bangert.

“Likening it to Y2K is a risky over simplifi cation” said O’Brien. “Y2K ap-plied to two digits in the year fi elds of four digits, and while it had global implications in every industry and system, it was that contained. In other words, there was some analysis, hypothesis and possibly software changes to prepare, but that along with crossed fi ngers could be, and in fact was, enough. Not the case with ICD-10.”

Predicting the ICD-10 Conversion OutcomeSome pundits liken it to Y2K issue; others call underestimating change ‘dangerous’

Shelly Bangert

The following list may facilitate tool identifi cation:

Billing system

Charge tickets

Claims/clearinghouse

Clinical trials/studies

Eligibility

EMR discreet data templates ASC

Encounter forms

Orders (imaging, lab, therapy)

Payment posting

Patient information/history

Prior authorization

Referrals (incoming, outgoing)

Registration

Scheduling

Subcontracted services

Surgery scheduling

Tumor/disease registry

Voice recognition templates

Preparing for ICD-10, continued from page 5

been for the opportunity to improve their existing CPT and ICD-9 coding, which they’ve been doing for decades. They al-ready have a base fund of knowledge and experience with those two coding systems. This is completely new to everyone. Basic training on how to use the system – look up, differentiate, assign and document codes – is essential for every physician. Everyone is starting at a base of zero.”

Tools: Identify all practice tools, processes and systems that use diagnosis codes.

“They’ll all need to be converted to ICD-10, and folks will need to be intro-duced to and trained in their use,” said

O’Brien. “At one of the early meetings, have your work team brainstorm to cre-ate a list of all affected tools, processes and systems. For example, if the practice contracts with an outside lab, which in-cludes diagnosis codes in its orders form, the lab will likely issue a new form. Creat-ing the list is just to understand the scope and delegate specifi c assignments so that everything can get done by October 1.”


I n 2010, Carroll Martindale should have been waiting for a tee time at his favorite golf course. Instead, he was waiting for I time at his favorite golf course. Instead, he was waiting for I something entirely more important: a new liver.

After being diagnosed with liver cancer, Carroll was told he was a candidate for a transplant. While waiting for a donor, he underwent life-prolonging chemotherapy and radiation treatment at the UAMS Winthrop P. Rockefeller Cancer Institute, Arkansas’ official cancer research and treatment facility.

Three years later, the call came and Carroll returned to UAMS for a successful liver transplant.

Today, he is healthy, back on the course and thankful that the best things in life are worth waiting for.

Success.

Visit cancer.uams.eduor call: 501-526-2272

After beating liver cancer, UAMS has Carroll Martindale back in the swing of things.


For advertising opportunities, please contact Rebekah Hardin501.580.8903 • [email protected]

STRAIGHT TO THE SOURCE

BY BECKY GILLETTE

Misuse of prescription drugs is second only to marijuana as the nation’s top illicit drug problem, and in some previous studies Arkansas ranked first in the nation in the percentage of youths aged 12 to 17 abus-ing prescription pain relievers, according to the National Survey on Drug Use and Health. In 2008, Arkansas ranked the sec-ond highest nationally in overall drug over-dose deaths with 5.1 per 100,000 deaths resulting from nonmedical use of opioid pain relievers.

The state’s new Arkansas Prescription Monitoring Program (PMP) instituted in March 2013 is already making a big differ-ence addressing that public health problem by reducing doctor shopping and pharmacy shopping, going from one doctor or phar-macy to another to get prescriptions filled for the same type of medication.

The number of flagrant doctor shop-pers in the state had decreased 60 percent from the beginning of March 2013 through the end of the year.

“That is absolutely fantastic,” said De-nise Robertson, PD, administrator of the Arkansas PMP. “The system is running well and our users are pulling information and communicating it to each other. PMP data is unique and provides an important tool for identifying questionable activity

with respect to prescription drugs, such as doctor and pharmacy shopping, prescrip-tion fraud, and problematic prescribing. The incorporation of information from the Arkansas PMP into current healthcare practice can be instrumental in reducing the devastating effects of prescription drug abuse in Arkansas.”

At nearly a year into the program, there were 9.6 million prescription records in the database. Controlled substance pre-scription data is collected from both in-state pharmacies and from out-of-state pharma-cies that are licensed to deliver prescriptions to Arkansas residents. Pharmacies uploaded six months of back data before March 1, so there are now about a year and a half of records.

By January there had been about 400,000 reports requested by pharmacists and prescribers.

“That is a lot,” Robertson said. “They are using it. In addition to preventing peo-ple from getting multiple prescriptions that are not justified, the good thing about the program is that users can see other practi-tioners involved, and can get them involved in patient care and referral to treatment, if needed. The feedback we are getting is that people find the automated system easy to use and very helpful. Physicians are using it in their drug treatment programs, and they love it. They can see the patterns of usage in their patient, seeing how consistent they are in refilling prescriptions.”

Feedback from users is that the system is very easy to use. Software used by phar-macies can automatically upload the infor-mation into the database so no extra, time consuming steps are needed to comply. A report is created weekly.

In addition to reducing problematic use, the PMP can also verify legitimate use. Robertson said it takes suspicion away from a person who really needs the medication so they don’t have to be worried about getting their pain meds. And physicians can feel as-sured they are writing a prescription for a

legitimate purpose.Arkansas chose a software company

that already operated PMPs in 22 other states.

“They are very knowledgeable in doing PMPs already,” Robertson said. “The pro-gram combines information from differ-ent pharmacies and pulls people together by names, alias, birthdates and addresses. When a prescription comes in, a pharma-cist looks into the system and sees prior fill-ings and prescriptions for that person so the pharmacist can make an informed decision if it is the proper time to fill the prescription, if there are duplications, and if there are po-tential drug interactions. The pharmacist brings up the information before filling the prescription.”

The program can reveal people who are consistently running out of pills early, and asking for a refill before it is time. It also shows if the patient has visited another practitioner for the same type of medica-tion.

The program also provides recom-mendations for physicians on dealing with patients who may be abusing prescription drugs through resources links such as www.samshsa.gov. Also, the website www.arkan-saspmp.com has signage pharmacies and clinics can put up at their intake and out-take windows stating, “We participate in the prescription monitoring program.”

The PMP is also an effective tool for emergency room physicians designed to reduce prescription drug abuse. These physicians frequently see patients about whom they have little previous information. Jim Myatt, PD, branch chief, Pharmacy Services, Arkansas Department of Health, said a number of groups in the state came together to get the PMP legislation passed in 2011. “I have to give credit to State Drug Director Fran Flener, who convened a group that came together in 2010 to try to address the prescription drug abuse prob-lem,” Myatt said. “The legislation had been tried previously a couple of times without success. She brought together a big group of interested parties, got consensus and the legislation passed due to her efforts.”

Flener said while the program is user friendly, during the 2015 legislative session there will be efforts to improve the legisla-tion. Any dispensers or prescribers with complaints or suggestions for improvement should contact the PMP advisory commit-tee.

While participation in the program is mandatory in some states, it is voluntary in Arkansas. Flener is hoping that a lot more subscribers and prescribers will sign up to increase the reach and effectiveness of the program.

“We’re trying to get more people aware that the program is there and to use it,” she said.

Prescription Monitoring Program Making Major Progress Combating Illicit Drug Use

Dr. Denise Robertson


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BY BECKY GILLETTE

Primary care providers (PCPs) should never underestimate the amount of influ-ence they can have in encouraging pa-tients to take steps to reduce their stroke risk. For the best results, in addition to talking to patients about lifestyle changes to decrease their stroke risk, it is important to refer patients to resources that can help them lose weight, quit smoking and exer-cise, said Margaret Tremwel, MD, a neu-rologist with the Sparks Regional Medical Center Vascular Neurology and Memory Disorders Clinic in Fort Smith.

“Absolutely healthcare providers can get through to patients,” Tremwel said. “As part of routine office visits, we cer-tainly need to help patients look at ways to address their barriers about diet and exercise.”

One example of a barrier for stopping smoking might be other members of their household who smoke. In cases like that, Tremwel advises the patient that it can’t be just one person who quits; it needs to be the entire family that quits.

Tremwel also often tries to get through to patients by telling them that they should know a stroke doesn’t usu-ally kill them, but leaves them in a nurs-ing home unable to do basic functions like going to the bathroom alone.

“That is why you do what you can to reduce stroke risk,” she said. “Regarding diet, instead of telling people to adhere to a particular diet, I tell them to look at their demons. Don’t try to do everything at once. If you have several bad things you are eating, first cut out the donuts, and then the fried foods. Then, the first thing you know, you are eating a healthy diet.”

She also advises people that making lifestyle improvements like exercise can be easier with a group. Refer patients to local fitness programs at a YMCA or gym.

Tremwel highly recommends a new program in Fort Smith called the Healthy Congregation Ministry. This program provides nurses in many different de-nominations with educational materials, a blood pressure cuff and glucose monitor-ing sticks. The program also includes fun group exercise programs and classes on topics like heart healthy cooking.

The program has been modeled after similar faith-based health promotion pro-grams in Memphis, Tenn., and in Missis-sippi.

“Some people respond more to a faith-based approach,” she said. “These wellness programs can be included as part of Bible studies, retreats and educational events.”

Tremwel said it is also important to get across the message to patients that the incidence of stroke is increasing in the U.S. and Arkansas in people under 65.

The Arkansas Department of Health (ADH) is also a good resource for patient tools to prevent heart attack and strokes.

Appathurai Balamurugan, MD, MPH, medical director, ADH Chronic Dis-

ease Prevention and Control Branch, said that PCPs need to be aware that Arkan-sas consistently ranks first or second in the country in stroke deaths, with stroke being the fourth leading cause of death in Arkansas.

“Every year about 1,800 people die due to stroke in Arkansas,” Balamurugan

said. “The number one risk factor is hy-pertension. It is one of the biggest chal-lenges for the state both from a medical perspective and a public health perspec-tive. About 35 percent of Arkansans have been diagnosed with hypertension, and a significant portion of adults who have it have not been diagnosed. Even of those di-agnosed, only 50 percent have their blood pressure under

control. So this is a big problem for Ar-kansas. If we want to really bring down stroke deaths in Arkansas, prevention with blood pressure control is critical.”

There are some excellent and inex-pensive medications for hypertension con-trol including $4 generics. Balamurugan, a family physician who also works at the UAMS Family Medical Center one day

Help Patients Reduce Stroke Risk: Find Their Barriers to Better Health



a week, said clinicians need to make sure they work with patients ensuring that they take the medication, and that they have a prescription for a 60- to 90-day supply so the medication doesn’t run out. One of the common reasons for non-compliance is patients running out of medications and not being able to get through to the physi-cian’s offi ce for a refi ll or not making an effort to get prescriptions refi lled.

Medication reminders like pill dis-pensers have been shown to increase medication compliance. And these days when most people have a cell phone, pa-tients might consider a smart phone app medication reminder.

Balamurugan recommends that PCPs advise their patients to purchase a blood pressure monitor and monitor their blood pressure at least once per day. Studies have shown that checking blood pressure regularly increases medication compli-ance.

Patients often think they need to make big lifestyle changes to achieve a signifi cant decrease in blood pressure. But even as little as a fi ve millimeter decrease in blood pressure reduces stroke deaths 10

to 15 percent. Losing weight and increas-ing physical activity, cumulatively, can result in a fi ve to ten point drop in blood pressure.

“Empower them with that,” Balam-urugan said. “Also, I tell my patients to avoid canned foods, which are loaded with salt, and use frozen foods instead. Avoid salty foods like chips and sodas. Patients are surprised to learn sodas have salt in them, but indeed they do. Reducing salt intake can decrease blood pressure fi ve to ten millimeters. The average American consumes 3.5 grams of salt per day, which is nearly double the recommended two grams per day. There are numerous stud-ies showing reducing salt intake reduces blood pressure and reduces stroke deaths.”

Another major risk factor is smoking. It is hard to bring the blood pressure of smokers into a normal range. Smokers can be referred to the Arkansas Tobacco Quitline at 1-800-QUIT-NOW (1-800-784-8669) for free counseling and smoking cessation aids.

The American Heart Association and American Academy of Family Physicians have good patient educational materials

available that Balamurugan recommends.“Additionally, many of the clinics

have now started providing high-risk case management for individuals who are non compliant and don’t show up for regular offi ce visits,” he said. “Clinics usually use a case manager or nurse call to make sure they keep appointments, and are keeping up with taking medications. With the emer-gence of patient centered medical homes, many are using the case management model for hypertension control, as well.”

Balamurugan also recommends the Million Heart Initiative, promoting the ABCS program (aspirin therapy, blood pressure control, cholesterol management and smoking cessation).

“Defi nitely aspirin plays a big role in stroke prevention,” he said.

Another way the ADH is involved is through the Arkansas Stroke Registry which is housed at ADH, and working with hospitals in improving care and en-suring that quality care is provided to pa-tients from the time they enter the hospital to discharge and is based on the standards of care.

to have peer review committees. “But for those who choose to do so, it protects the proceedings and communications as privi-leged without having to involve an attor-ney in every detail of the proceedings,” she explained.

SB 887 “is especially important now that more clinics are owned by hospitals,” said Pulliam.

For myriad public policy reasons, physicians would rather be monitored by their peers, said Pulliam.

“Yet at the same time, there’s some kind of hesitancy among physicians to re-port one another,” she said, noting that 1986 federal legislation established a na-tional reporting databank which, after going through the peer review process that provides due process to a physician, is publicly accessible. It also encouraged re-alistic and thorough peer reviews by creat-ing immunity for peer review participants.

Since then, various trends have af-fected the peer review process. Hospitals

have had two major rushes on physician practices acquisitions – in the 1990s and now. (Hospital-owned clinics are subject to Joint Commission review, not the employ-ment of physicians.) Also, until recently, the attorney who repre-sented the hospital typi-cally represented the peer review committee.

“Now we’re start-ing to see that some-times those interests are competing or different,” said Pulliam.

For the most part, physicians haven’t kept pace with peer review pro-cess changes primarily because they spend an extraordinary amount of time keeping up with their profession, espe-cially specialists and subspecialists. As a result, physicians often delegate public policy issues to others, said Pulliam.

“There’s a general awareness among providers and healthcare attor-neys of the need for adequate protection in peer review meetings,” she said. “Tra-ditionally, in Arkansas at least, the hear-ing offi cers have often been attorneys or physicians with close ties to hospital ad-ministration. In and of itself, that’s not a bad thing. But there’s certainly the appearance on the part of the provider in a peer review hearing that the hear-ing offi cer, if representing the hospital, might not be objective.”

Pulliam said she’s often hired after providers have completed one or two steps of the peer review process before the fi nal hearing, She’s now being retained much earlier in the process.

“There seems to be more awareness on the part of the provider of a potential problem,” she said.

The American Bar Association Health Law Section has actively sup-ported public policies to make peer review hearings equally objective to the hospital and to the provider.

“That’s a delicate, important bal-ance,” said Pulliam. “It’s going to become even more so as more physicians become

employed by hospitals.”

Peer Review Law Changes, continued from page 1The Catalyst

The federal Patient Safety and Quality Improvement Act of 2005 (PSQIA) was the impetus for the bill introductions at the state level. Passage of the PSQIA was geared toward decreasing the occurrence of medical error and improving the quality of healthcare via voluntary reporting by clinicians and healthcare practitioners of patient safety and quality information – without fear of the potential legal ramifi cations of disclosure.

Because of its state law counterparts, practitioners were unlikely to take advantage of the new federal law and voluntarily report patient safety and quality information. States were given the responsibility to consider how interpretations of peer review privilege laws would interact with the creation of a voluntary reporting system designed specifi cally to address patient safety issues, while also creating a stronger incentive for practitioners to report their patient safety data in accordance with the PSQIA.

In December 2009, Eric Scott Bell, a healthcare attorney at Rose Law Firm in Little Rock, wrote in Arkansas Law Review’s “Make Way: Why Arkansas and the States Should Narrow Health Care Peer Review Privileges for the Patient Safety and Quality Improvement Act of 2005,” that Arkansas “should reduce its state statutory healthcare quality assurance and privilege to the furthest extent necessary to instigate reporting by healthcare practitioners.”

“The (PSQIA) provides a self-interest incentive for practitioners to report patient safety data to PSOs, envisioning a data system that could instigate much-needed change in the U.S. healthcare system,” he wrote, noting that medical errors represent the eighth-leading cause of death in the United States. “But Arkansas’s peer review privilege undermines the effectiveness of this incentive because it provides the same amount of legal protection as the PSQIA without imposing or implementing the PSQIA reporting requirements. Without incentive, the businesses that provide healthcare will not report patient safety and quality information. The pervasiveness of medical error in the U.S. compelled Congress to act by passing the PSQIA, and now Arkansas must act by narrowing its peer review privilege and removing the only signifi cant obstacle to the PSQIA’s vision of signifi cantly improving the U.S. healthcare system.”

Help Patients Reduce Stroke Risk, continued from page 9

The American Health Lawyers Association (AHLA) recently published the second edition of the Peer Review Hearing Guidebook to address medical staff peer review and credentialing issues, including medical staff hearings. The guidebook provides alternative approaches to various issues; its authors present “best practices” that reconcile the various points of view that may be found in healthcare law.

The AHLA will host a two-part program May 1-2, “Health Care Arbitration and Peer Review Hearings” at the Tremont Chicago Hotel in Chicago to qualify participants to serve as both an arbitrator and a hearing offi cer for the AHLA Dispute Resolution Service. Participants will receive a complimentary copy of the guidebook, edited by Allan Adelman and Ann O’Connell.

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The recession took a heavy toll on healthcare construction projects across the nation. However, as the economy has begun to improve, projects are beginning to move forward again.

Experts in healthcare real estate devel-opment and evidence-based design recently shared their insights with Medical News re-garding the current state of healthcare con-struction projects in the ambulatory setting.

Real Estate DevelopmentAfter seeing a number of plans put on

hold over the last few years, Bond Oman, chief executive officer of OGA, a national full-service real estate development and project management firm based in Nash-ville, said there has been an increase in activity lately. While dialysis projects have remained fairly steady throughout, he said, the improved financial environment has resulted in an uptick in ambulatory sur-gery centers, urgent care centers and behavioral health facilities, among other sectors.

Oman said OGA presently has 21 projects in various stages of pro-duction. That is about a 30 percent increase over what the company was doing during the recession and quickly approaching pre-recession numbers, ac-cording to Oman. The company’s current portfolio includes work crossing the United States from California to Texas, Ohio to Florida.

One trend Oman said he is seeing nationwide is an emphasis on building smarter. He noted clients are trying to be more efficient by using basic green design to lower ongoing costs and keeping the building footprint as tight as possible.

“With the health systems we are work-ing with, we haven’t done a total gold or silver building,” he said, referring to Leadership in Energy and Environmental Design (LEED) status. However, Oman added, many employ green design when it comes to choosing lighting, insulation, windows, paint, and other elements that increase energy efficiency. In most cases, developers are still trying to strike a balance between the cost of adding green elements and the payoff in reduced monthly costs.

As a whole, Oman said he thinks fa-cilities are being built a little smaller on the front end but with room for growth. “We are designing a large number of our build-ings for expansion,” he noted. Rather than creating facilities with shell space to be fin-ished off later, Oman said he is really see-

ing more facilities completely finished but designed from the outset with the ability to blow out a wall for future outward expan-sion.

What might be surprising to some is how quickly pricing has rebounded. Oman noted those considering developing health-care properties aren’t going to find any real deals. “The cost of doing business is get-ting back to where it was pre-recession,” he noted. “I’d say we’re definitely going to see an increase in cost because the economy is doing better … not doing great but defi-nitely doing a little better each year.”

Oman noted landowners who survived the recession are holding firm on real es-tate prices. Many municipalities that dialed back or waived impact fees to try to entice developers a few years ago have reinstated, and in many cases increased, those fees. He said prices are also inching up for mechani-cal, electrical and plumbing.

In general, Oman said healthcare de-velopment doesn’t tend to be speculative in nature. “It’s a different animal than a lot of the other real estate sectors,” he said, not-ing a demonstrated patient base and service need must be present before most in the medical industry will consider building. He added that while some markets — includ-ing Dallas, Denver, Houston and Nashville — are “on fire” right now, there is still a feeling of cautiousness across most of the nation. Still, projects that were halted a few years ago are beginning to get the green light again.

An Evidence-Based Design Aesthetic

Where facilities are sprouting up, more and more of them are relying on research to inform design decisions.

Ellen Taylor, AIA, MBA, EDAC, an architect for more than 25 years, began vol-unteering with the Center for Health De-sign (CHD) before she began working with the organization in 2008. As director of research, the New York-based Taylor helps spread the word about the best available information and latest credible research to help those creating healing spaces.

“The Center for Health Design is a non-profit based in California that looks at how the built environment can affect health outcomes … whether for the patient or staff,” she noted, adding CHD accomplishes this goal through research, education and advocacy.

While elements of evidence-based design (EBD) have intuitively been incor-

Developing & Designing Effective Ambulatory Facilities

Bond Oman

Ellen Taylor



the past we would never have known what was going on. It happens almost every day in my clinics now.”

Although commonly referred to as genetic or precision medicine, Schaefer prefers the term “genomically directed medicine” better because it is more specific about using genetic information to direct treatment.

The concept is what has been known intuitively for a long time: people are dif-ferent. Some people are more sensitive to certain medications, and other are less sensitive. Some patients won’t be helped by a medicine that is a lifeline to others.

Arkansas has more people working in the area of precision medi-cine than most states with eight or nine researchers including clinical geneti-cists and molecular geneticists working at UAMS.

“We are moving out ahead,” Schaefer said. “We are being pretty proactive on this and setting up these really novel programs.”

Progress in the field has meant today’s genetic testing is far less expensive than in the past. The federally funded human ge-nome product that sequenced the whole ge-netic code completed in 2001 took 13 years and cost $13 billion.

“Now we can do the same thing for $15,000 to $20,000 and get it done in about six months,” Schaefer said. “The positive side is that it is absolutely fascinating, the whole idea of knowing what is going on with genetic material and using it to im-prove treatments and health. The other side of the coin is that the information could be pretty darn scary. What if I find I have colon cancer risk? Could this information be used against me by insurers and employ-ers? We don’t jump into tests without cover-ing all the aspects of it with a patient.”

Genetic tests are not always covered by insurance.

“The tests are relatively expensive,” Schaefer said. “We have to work with each patient to learn if it is going to be covered and if not, do they still want it. Third party payers are just starting to learn about it. It is like other technologies like laptop comput-ers. Prices will continue to get less expen-sive.”

Often people have a specific medical question in mind when undergoing genetic testing, and then there are those who are medically curious. One practical applica-tion is finding out how your specific gene type reacts to medications. The FDA cur-rently has 155 medications that have been studied for how genetics will influence the drug.

The applications are of particular interest in psychiatry. A precision psychiatry program being established at the UAMS Psychiatric Research In-stitute (PRI) involves a multi-disciplinary team that includes Schaefer, Jef-frey Clothier, MD, medi-

cal director, UAMS Psychiatric Research Institute, Jennifer Hunt, MD, chair of the UAMS Department of Pathology, William Bellamy, MD, and Charles Sailey, MD, of the laboratory medicine molecular pathol-ogy group, and Elvin Price, MD, UAMS Pharmacy School.

“The central dilemma of psychiatry is selecting a treatment for the individual patient,” Clothier said. “The diagnostic schemes of DSM IV and now DSM 5 are silent about causation of these syndromes. The assumption that all patients with a particular DSM diagnosis have the same pathophysiology is certainly no more cor-rect than the premise that all patients with a cough have the same pathophysiology.”

It is readily apparent that there are sev-eral contributors to depressive illness. This may explain why so many patients fail to respond to the initial treatment provided.

“At the current time, the majority of treatments for depressive illness are bio-logical in nature,” Clothier said. “In gen-eral, one third of patients respond to the initial medication trial, another one third respond partially, and a full one third have little to no response. Said another way, two thirds of patients with significant depres-sive syndromes fail to respond completely to the initial medication. Many patients will fail multiple trials of medications.” Precision psychiatry attempts to identify fac-tors that may predict treatment response, clinical course, and side effects of treatment.

Previous attempts to do so were primarily based on clinical\behavioral subtypes of depression, melancholic depression vs. re-active depression for instance.

“This was somewhat useful, but still created a situation where a patient may not have received a full response to the treat-ment,” Clothier said. “Even before the complete human genome was sequenced, researchers found markers that related to treatment response. Some markers are re-lated to the stress response such as the dexa-methasone suppression test. Others have studied functional imaging to identify pre-dictors of treatment response.”

There are dozens of studies that have identified candidate genes for predict-ing treatment response. At PRI they have begun to harvest some of this research.

“Over the past two to three years, we have used a commercially available genotyping service that looks at 11 gene markers and found that it was helpful in explaining a number of patients’ failure to respond and selecting specific changes in their regimen,” Clothier said. “How-ever, the genes selected are a minority of the genes that have been identified in replicated studies. For this reason, we have selected a group of 40 genes from the lit-erature that we believe are actionable. In other words, we believe knowledge of the individual’s genotype on these genes will inform and influence the treatment of the patient. The gene array is being built

and tested and until it is ready for clinical use, we will rely on the limited commer-cially available products when necessary.” Clothier said the information provided by the individual’s genotype is not diagnostic or deterministic of outcome. It provides part of the biologic context of the patient’s suffering. Psychotherapy such as cognitive and behavioral therapy is still important.

“Other markers such as markers of the immune system and fMRI will likely be the next step in precision psychiatry as we move forward to extend biomarker evaluation to other conditions,” Clothier said. “I would expect that we will likely be able to find genotypes related to severe side effects for specific medications that will avoid the trial and error approach.”

There are only a couple of commer-cially available genetic testing products. The PRI uses one that costs about $700. Some insurance companies have paid for it while others decline payment as ‘experimental.’

“Another product has a different set of genes and prices at $3,800,” Clothier said. “I have not been convinced that this is a price point where I can say it is cost effec-tive. Both services provide a genotyping of the principle enzymes related to medication metabolism. This can be useful information for a variety of non-psychiatric conditions. Our current plan is to provide a separate genotyping for more of the genes related to drug absorption, distribution, metabolism and elimination.”

Genomically Directed Medicine Using Genetic Profile, continued from page 1

Dr. Bradley Schaefer

Dr. Jeffrey Clothier

porated in healing spaces for centuries, the formalized concept is relatively new. Taylor said a landmark 1984 study by Roger Ul-rich, PhD — which found surgical patients with a view of nature had a reduced length of stay, required reduced levels of narcotics and had fewer complications — really cap-tured people’s attention and launched the EBD movement. Since 2009, CHD has of-fered the Evidence-Based Design Accredita-tion (EDAC) to those who have proven their expertise in the field.

Although launched in the acute setting, Taylor said an increased awareness of how design impacts outcomes and a focus in the Affordable Care Act on engaging patients and keeping them out of the hospital have combined to create a recognition that EDB has an important role in outpatient settings, as well.

Another major trend for ambulatory spaces, she said, is the notion of flexibility and adaptability. It isn’t uncommon for one specialty to utilize a space two days a week with another specialty using it the rest of the time. “There’s this real need to be nimble,” Taylor said. “You can’t have a room that’s just designed for one purpose.”

Taylor added the concept of the pa-tient-centered medical home has really had an impact on facility design, as well. It is in-creasingly common to see outpatient clinics and facilities, particularly community health centers, include larger multipurpose rooms that could be used for a support group, to teach a health class or to hold neighborhood meetings.

When working on safety net facility design in California, Taylor noted a center added a walking trail behind the facility so that a physician could prescribe ‘four loops’ to a patient in need of physical activity. To make it truly useful, a playground was in-stalled in the center of the trail so parents could easily keep an eye on children, who coincidentally were also engaging in fun, physical activity playing outside. Similarly, some facilities have begun hosting a farm-er’s market or have created a community garden and offer cooking classes to demon-strate the benefits of making simple, nutri-tious meals.

Along the same vein, Taylor said it is becoming increasingly common for out-patient settings to be embedded in retail locations. Vanderbilt One Hundred Oaks in Nashville is an example of having mixed health and retail venues under one roof. Storefronts featuring supplies a patient needs to support a prescribed treatment sit next to national retailers featuring clothing or home goods. “It’s that concept of the one-stop-shop … if you can make it easier, you’ll have better compliance,” Taylor said.

The Mayo Clinic, she continued, offers another example of innovative, flexible de-sign. “They started realizing not everyone needed to disrobe for every appointment with physicians,” Taylor said. To address this, ‘Jack and Jill’ rooms were created — two offices with an exam room in between them. One patient could meet with his phy-sician in the office, while another patient was using the exam room … or a patient

might begin in the physician’s office and then move to the exam room to complete the appointment. “You have a more effi-cient flow,” Taylor pointed out. “You are freeing up that valuable exam space.”

In addition to efficiency, however, Ad-elante Healthcare in Arizona is also study-ing whether or not the setup might also reduce stress levels and lead to increased patient satisfaction. Is it easier to pay atten-tion and be more engaged in a conversation with a physician when fully clothed in an office compared to sitting on an exam table in a cold room while wearing a thin gown? Does the setting change patient behavior? Does the setup change outcomes? Finding quantifiable answers to those types of ques-tions is key to EBD.

Adelante is also studying other de-sign tweaks that might shift the traditional power concept between physician and pa-tient. Something as simple as having pa-tients and physicians sit side-by-side and share a computer screen while discussing treatment options or giving a patient the ability to choose what they wish to view on a video monitor while waiting to see a provider can shift the perception of power. “That’s creating much more equality in care,” Taylor said. “There is a cultural awareness that needs to happen from a physician side, but then the design needs to accommodate that, as well.”

Taylor concluded, “Ultimately what we hope is that the design of the built envi-ronment is one tool in the toolkit to improve outcomes and improve health overall.”

Developing & Designing, continued from page 11


UAMS Programs Receive More Than $450,000 in Grants

The University of Arkansas for Med-ical Sciences’ (UAMS) Center for Dental Education, the planned internal medi-cine residency program in northwest Arkansas and the physician assistant program were among UAMS programs that received grants totaling more than $450,000 from the Blue & You Founda-tion and its parent company, Arkansas Blue Cross and Blue Shield.

The Blue & You Foundation award-ed more than $350,000 in grants to UAMS programs including $150,000 to the Center for Dental Education and $95,000 to the physician assistant pro-gram, both in the UAMS College of Health Professions. A $77,500 grant was presented to the UAMS Northwest re-gional campus and area hospitals creat-ing an internal medicine residency pro-gram to expand the number of resident physicians being trained in that part of the state. A $29,722 grant was awarded to the Safety Baby Showers program at UAMS South in Magnolia that has pro-vided infant safety training and safety equipment to new or expectant parents in south Arkansas.

The Center for Dental Education also received $100,000 in support from Arkansas Blue Cross and Blue Shield. Together the $450,000 in grants and support from the two organizations will allow for continued development or ex-pansion of education, patient care and outreach programs at UAMS.

The $95,000 grant to the physician assistant program will continue devel-opment for the program established in 2011, including raising awareness of the physician assistant profession among Arkansas physicians and preparing them to host students while they gain further clinical experience.

The first class of 26 physician as-sistant students started the 28-month master’s degree program in 2013. Phy-sician Assistants are licensed medical providers who work with the supervision of a physician. They take patient medi-cal histories, conduct physical exams, order diagnostic tests, diagnose medi-cal conditions, write prescriptions and manage acute illness and chronic dis-ease with the supervision of a physician.

The internal medicine residency program in northwest Arkansas, which hopes to admit its first group of eight physicians in July 2015, is continuing to move through the accreditation pro-cess. The three-year program will have a total of 24 residents, admitting eight each year, who will see patients at five hospital systems in the region — Mercy Rogers, Mercy Fort Smith, the Spring-dale-based Northwest Health System, the Sparks Health System in Fort Smith and the Veterans Health Care System of the Ozarks — as the physicians serve a

post-medical school residency.Funding to the residency program

is for equipment and resources to coor-dinate the conferences and continuing education fees associated with provid-ing CME credit to physicians who will be preceptors supervising the resident physicians at the hospitals.

The grant to the three-year-old Safety Baby Showers program, based at UAMS South in Magnolia, will cover program costs for a year of safety class-es that have reached about 200 new or expectant parents a year in Ouachita and Columbia counties. Participants learn about motor vehicle injury pre-vention, safe sleep practices for infants, infant CPR and choke-safety, and home safety.

Healthcare Industry Solutions Developer SOAPware to Hold 2014 User Meeting in Orlando

SOAPware, Inc. is pleased to an-nounce the SOAPware User Meeting, in Orlando, Florida. The meeting will be held at the beautiful Rosen Plaza Hotel the evening of June 19th through June 21st, 2014. Attendees will receive un-precedented access to the SOAPware staff, partners, and 3rd party integrators through presentations and breakout sessions covering topics such as ICD-10, Meaningful Use, and much more! This venue is a perfect opportunity to immerse yourself in the SOAPware ex-perience, meet and collaborate with other users, and get one-on-one time with many of the SOAPware staff.

Training Workshop: Due to the overwhelming demand for training during the SUM in 2012, a special pre-conference training workshop has been designed for Thursday, June 19th, prior to the SUM event kickoff later that eve-ning. There is a separate charge for this Training Workshop, and seating is lim-ited, so sign up today.

Personal Training Sessions: Ad-ditionally, many of our users asked for personalized, One-on-One Training Sessions tailored to address their spe-cific clinic workflows One-on-One Train-ing Sessions will be offered on Friday and Saturday of the this year’s SUM! Classroom training sessions are sold in one-hour increments and reservations are required. Seating is limited, so sign up early to guarantee getting the most out of your SUM 2014 experience.

For more information, or to regis-ter for the event, visit: http://usergroup.soapware.com/

Baptist Health First to Partner With DOD to Provide Life-Saving eICU® Care Services to Fort Leonard Wood Hospital

Baptist Health is the first civilian healthcare provider to partner with the Depart-ment of Defense to provide remote high tech intensive care coverage for General Leonard Wood Army Community Hospital in Fort Leonard Wood, Mo.

Through this first ever civilian-military eICU pilot program, the Army hospital will provide its patients with an additional team of critical care specialists who will watch over their active duty military, family members and retiree patients 24/7. Baptist Health was awarded the five-year eICU care contract in August 2013 and services began at the 65 inpatient bed Mis-souri hospital in early January.

Each critical-care room with eICU technology is equipped with a camera, microphone, and speaker that enable staff in the control center to communicate with caregivers and the patient in real time. The two-way video and “cockpit-like sensors” of this advanced telemedicine technol-ogy enables the eICU care staff to detect even the slightest change in the patient’s condition and commu-nicate more effectively with the bed-side team. This model reduces the time between problem identification and enhances the quality of direct care intervention.

The hardware at General Leon-ard Wood Army Community Hospi-tal includes four mounted cameras in their intensive care unit rooms and two additional mobile carts for use in the emergency room and inpatient medical sur-gical ward. The system is projected to save the Army hospital $1.7 million the first year, plus an additional $2 million each following year, according to Wiley.

By simply pressing a button the physicians, nurses or support staff at General Leonard Wood Army Community Hospital will be instantly joined by Baptist Health’s experienced critical care team to collaborate and treat their patients. The eICU care team includes certified physician intensivists and nurses who specialize in critical care and are highly trained to execute predefined plans; monitor lab, heart, blood pressure and oxygen saturations; or intervene in emergencies when a patient’s attending physi-cian cannot be immediately present.

Staffed round-the-clock, every day of the year, the Baptist Health eICU care com-mand center and its staff help hospitals like General Leonard Wood Army Community Hospital provide state-of-the-art intensive care to its sickest patients. The addition of eICU care will allow the hospital to keep sicker patients who must previously had to be transferred for various intensive care, said Wiley.

Nationwide, hospitals using eICU technology with critical care specialists have seen reductions in complications, reductions in mortality, and better outcomes for patients.

With the addition of eICU care at General Leonard Wood Army Community Hos-pital, Baptist Health now supports seven of its own hospitals, 10 community hospitals throughout Arkansas, and the first ever military base Army hospital located across our state borders.

GrandRounds

Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.


Northwest Medical Center-Springdale Joins UAMS-Led Program to Provide Emergency Stroke Care

Northwest Medical Center-Spring-dale has partnered with the University of Arkansas for Medical Sciences (UAMS) to provide life-saving emergency care for stroke patients in the region.

Called AR SAVES (Arkansas Stroke Assistance through Virtual Emergency Support), the program uses a high-speed video communications system to help provide immediate, life-saving treatments to stroke patients 24 hours a day. The real-time video communication enables a stroke neurologist to evalu-ate whether emergency room physicians should use a powerful blood thinner within the critical 4.5-hour period follow-ing the first signs of stroke.

The AR SAVES program is a partner-ship between the UAMS Center for Dis-tance Health, the state Department of Human Services, Sparks Regional Health System in Fort Smith, Northwest Medi-cal Center-Springdale and 40 other Ar-kansas hospitals.

Arkansas, which ranks first in the nation in stroke death rates, had 1,560 stroke-related deaths in 2011, according to the national Centers for Disease Con-trol and Prevention. The nationwide di-rect and indirect cost of medical and in-stitutional care of permanently disabled stroke victims was $73.7 billion in 2010, according to the American Heart Asso-ciation’s 2012 Heart Disease and Stroke Statistics.

Stroke patients are at high risk of death or permanent disability, but cer-tain patients can be helped with the blood-clot dissolving agent tissue plas-minogen activator (t-PA) if given within 4.5 hours of the stroke.

Since the program began Nov. 1, 2008, more than 2,038 patients have re-

ceived stroke consults through AR SAVES and 518 patients have received t-PA.

Forty other Arkansas hospitals are participating in the AR SAVES program.

UAMS College of Pharmacy Dean Named President of National Council

UAMS College of Pharmacy Dean Stephanie Gardner, Pharm. D., Ed. D., has been elected to serve as president of the Accreditation Coun-cil for Pharmacy Education (ACPE) for the 2014-2015 term.

Elections took place in February during the ACPE Board of Directors meeting in San Antonio, Texas.

Gardner became dean of the col-lege in May 2003 and before her ap-pointment as dean, she served for 13 years as a member of the college’s fac-ulty. She recently served as a Fellow of the American Council on Education. The American Association of Colleges of Pharmacy appointed her to the ACPE Board of Directors.

In 1989, Gardner earned her doc-torate in pharmacy from the University of North Carolina. She held a research fellowship in cardiovascular pharmacol-ogy at Case Western Reserve University in Cleveland from 1989-1991. In 2001, Gardner earned a doctorate in educa-tion from the University of Arkansas at Little Rock.

The ACPE is an independent, na-tional agency for the accreditation of professional degree programs in phar-macy and providers of continuing phar-macy education. The council also offers evaluation and certification of profes-sional degree programs internationally.

Dr. Anthony Lamkin Joins St. Bernards Wound Care Center

Dr. Anthony Lamkin has joined the medical staff at St. Bernards Wound Healing Center on a full-time basis as medical di-rector.

Originally from Jones-boro, he is a member of the American Academy of Family Physicians and is certified as a wound care specialist by the American Academy of Wound Management. Lamkin is one of 11 physicians in Arkansas who hold cer-tification as wound care specialists. He is also board certified in Undersea and Hyperbaric Medicine through the Ameri-can Board of Preventive Medicine.

Lamkin earned his medical degree from the University of Arkansas for Medi-cal Sciences and completed a residency in family practice at the Area Health Education Center Northwest, where he served as chief resident.

He formerly worked in emergency medicine and wound care in Batesville and worked part-time at St. Bernards Wound Healing Center for the last two years.

St. Bernards Wound Healing Cen-ter takes a multidisciplinary approach to healing complex wounds. Individualized treatment programs are developed us-ing wound care pathways proven suc-cessful at centers nationwide.

Arkansas Urology Announces Acquisition of Epoch Health Brand

Arkansas Urology, the state’s lead-ing urology clinic, has acquired the Ep-och Health brand, which created and launched the state’s first physician-run testosterone therapy clinic.

The Epoch Health brand pioneered the concept of a physician-run testoster-one therapy clinic.

Arkansas Urology has also opened its first Epoch Health clinic. The clinic, lo-cated on E. McCain Blvd. in North Little Rock, provides comprehensive men’s healthcare. The site was formerly an En-core Health clinic.

Epoch Health created a physician-run clinic model designed to help men as young as 29 enjoy an enhanced qual-ity of life through proper health screen-ings, treatments and lifestyle modifica-tions, specifically focusing on symptoms of low testosterone.

The medical term for low testoster-one, or “Low T,” is hypogonadism, a dis-ease in which the body is unable to pro-duce normal amounts of testosterone. Only within the past several years has the medical community acknowledged the prevalence and negative impact of Low T in men. Epoch Health focuses on each patient’s specific healthcare needs by conducting a thorough evaluation that precisely tests testosterone levels and a host of other potential symptom-causing conditions during initial and ongoing vis-its.

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GrandRounds

Dr. Stephanie Gardner

WRMC Medical Complex Satellite ER Construction to Begin

M&A Jones Construction sub-mitted the successful bid for conver-sion of the WRMC Medical Complex Urgent Care Clinic into a Satellite Emergency Room. Work on the project has begun and is expected to be completed this spring. As re-ported earlier, the building was con-structed to comply with healthcare code and only minor modifications are needed to prepare for installa-tion of cardiac monitoring equip-ment and relocation of the CT scan-ner. The satellite emergency room will be licensed by the Arkansas Department of Health and provide 24/7 access to physician led medi-cal care. Officials at the Arkansas Department of Health granted the verbal approval necessary for reno-vations to begin. Upon clarification of procedural questions final written approval will be granted.

Terry Watson, Cromwell Architects Engineers; Gary Paxson, WRHS Chief Information Officer; and Robert Bateman, Cromwell Architects Engineers, review final plans for the WRMC Medical Complex Satellite Emergency Room.

Dr. Anthony Lamkin


Mutual Interests. Mutually Insured.

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ARKANSAS MUTUAL

Industry Experience 37 years 5 years

Arkansas Experience 24 years 5 years

A.M. Best Rating A (Excellent) Not rated

A.M. Best Rating History A (Excellent) or better for 30 consecutive years

None

Operations Managed 100% in-house with some of the lowest expenses in the country

Managed pursuant to a contractual agreement with an affiliated entity that is partially owned by management of Arkansas Mutual and outside investors

Percentage of premium spent on operating expenses

14% 54%

Surplus as regards policyholders

$464.0M $2.5M

Total dividends returned to Arkansas physicians

$12.6M $0

Dividends returned to Arkansas physicians in the last three years (2010, 2011, 2012)

$6.6M $0

Overall percentage of premiums returned to policyholders in the form of dividends in the last three years

9% 0%

This chart contains information extracted from the December 31, 2012 Statutory Annual Statements of each company and from other publicly available sources.

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Documents

Medical News of Arkansas April 2014