Nashville Medical News August 2013

By CINDy SANDERS

Back pain plagues millions of Americans annu-ally and is the leading cause of disability world-wide according to the Institute for Health Metrics and Evaluation’s Global Burden of Disease 2010. The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) reports that as many as 80 percent of Americans will experience back pain in their life-time and nearly a quarter of the adult population reports one or more days of back pain in any given three-month period.

To address one of the nation’s most prevalent health complaints, researchers look to new techniques, treatments and technologies to provide relief. Much of what has been de-buted over the last few years has simply augmented the existing knowledge base. “The changes now seem to be more incremental than revolutionary,” noted L. Brett Babat, MD, a board-certifi ed orthopaedic surgeon with Premier Orthopaedics. He added the tweaks are geared to make procedures or equipment easier, safer, faster and more powerful.

Babat is part of that movement. He recently sold a patent for a new iliac fi xation device to Spine 360 to improve upon the large pedicle screws typically used. “When you do spine sur-

By BILL HEFLEy, MD

With the rapidly approaching ICD-10 ‘go live’ date of Oct. 1, 2014, medical practices should be well on their way in preparing for the transition. With implementation of ICD-10, physician offi ces accustomed to the 13,000 ICD-9 codes must be prepared to transition seam-lessly to a new set of 68,000 codes. More specifi cally, a physician or billing cle rk currently using ICD-9 to properly code the diagnosis of ‘patella fracture’ must choose between two possible codes … when utilizing ICD-10 that number explodes to 480 codes. Yes. Get ready.

In 1992 the World Health Organization (WHO) published the International Classifi cation of Diseases, Tenth Revision. The U.S. made modifi cations to the WHO ICD-10 creating the ICD-10-CM (Clinical Modifi cation) which is the diagnosis code set that will replace ICD-9-CM Volumes 1 and 2. The Department of Health and Human Services (HHS) published a regula-tion requiring the replacement of ICD-9 with ICD-10 and later pushed back the compliance date one year to Oct. 1, 2014. Farzad Mostashari, MD, the national coordinator for Healthcare Information Technology, asserted last month that there would be no extension of the deadline.

While many physicians see the transition to ICD-10 as an unnecessary burden, other

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New Techniques, Treatments for Lower Back Pain

FOCUS TOPICS ORTHOPAEDICS/SPORTS MEDICINE PHYSICIAN/HOSPITAL ALIGNMENT

Matthew Rose, MD

PAGE 3

PHYSICIAN SPOTLIGHT

(CONTINUED ON PAGE 6)

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By CINDy SANDERS

Matthew Rose, MD, a board certified general orthopaedic surgeon with Tennes-see Orthopaedic Alli-ance (TOA), describes himself as a ‘seasonal athlete.’ What that re-ally means is he loves to stay active all year long.

An avid wake-boarder and wakesurfer when the sun shines, he also loves bow hunting in the colder months. Unfortunately, he noted, “I have torn both my ACLs in the last eight years wake-boarding.”

Making the best of a bad situation, Rose said being a patient actually enhanced his practice by giving him a new perspective. “I understand the disap-pointment of not being able to do your activity,” he said. Rose hopes his personal experience makes him more relatable to his patients as someone who has truly walked in their shoes. “It makes the doctor very understanding of pain and the difficulties of recovery,” he said.

His love of all things outdoors goes back to a childhood spent on a farm and in a boat. “I grew up in Somerset, Ky., which is a small town on Lake Cumber-land,” Rose said. “We took advantage of everything a small town had to offer,” he added of his close-knit family.

His upbringing also shaped his view of practicing medicine. Rose saw the plea-sure his father, an ophthalmologist, took in caring for patients of all ages. Rose liked the easy familiarity that comes with treat-ing patients over the course of time and sees everyone from newborns to seniors in his practice at TOA’s Gallatin and Hen-dersonville locations. “I treat people like I’ve known you for years … I’m a country guy,” he explained.

That small town touch is accom-panied by training at major academic medical centers. Rose received his under-graduate degree in biomedical engineer-ing from Vanderbilt University followed by medical school and residency at the University of Louisville School of Medi-cine. He was introduced to his specialty while still at Vanderbilt.

“I didn’t know about orthopaedics when I started school, but I could run an MTS machine in the lab,” he said, noting that a material testing system is used for the biomechanical testing of tissues, joint systems, large bones, and implants. “I did my senior design project with Kurt Spin-dler, who is an orthopaedic physician at Vanderbilt,” Rose continued. “I was very lucky to have someone young and enthu-siastic who was willing to involve me,” he added.

At Louisville, he found that he loved surgery but didn’t want to limit his prac-tice to one area. “I liked seeing everything … I liked the diversity. I’m kind of a gen-eralist specialist,” Rose said with a laugh. “I can get most everything done … but if I can’t, I know some great doctors who can.”

After medical school, Rose estab-lished a successful practice in Glasgow, Ky., where he took on leadership positions at T.J. Samson Community Hospital in-cluding stints as chief of staff and chief of surgery. Additionally, Rose established a dedicated program focused on progressive care management for joint replacement patients.

Through his connections with the University of Louisville, Rose has also been tapped to deliver a number of lec-tures abroad. He has discussed commu-nity orthopaedic trauma care and rural

case management with physicians in Bei-jing and lectured on fracture care in Mon-tevideo, Uruguay.

During his time in Glasgow, Rose served as football physician for area schools and was instrumental in develop-ing the sports medicine program for the city and county school systems. “I really like taking care of athletes — especially the high school athlete,” he said. “I love their enthusiasm.”

In fact, it was his own love of athlet-ics that eventually brought Rose and his family to Middle Tennessee. He and wife Aileen, who met at Vanderbilt where they were both cheerleaders for the Commo-dores, are avid football and basketball fans. Over the years, the Vandy season ticket holders became friends with local urologist Bob Sewell, MD, and former Tennessee Tourism Commissioner John Wade, who sat behind them at games. “They were always so nice, and they al-ways said, ‘You should come to Nash-ville,’” Rose recalled.

Although the couple loved Glasgow, they also liked the idea of giving their children the opportunities afforded by a larger city. Eventually their Commodores connection prevailed, and Sewell helped the orthopaedist pass along his resume

to TOA. “Those two guys are why I got my foot in the door,” Rose said with evident gratitude.

The position with TOA has provided the Rose family the best of both worlds. “The stars aligned, and we really got lucky with Tennessee Or-thopaedic Alliance,” he said of moving to Hendersonville. “We have all the amenities of what Nashville has to offer a few minutes down the road, but Hendersonville and Gall-atin are still their own small communities.”

Rose was also attracted to living on the lake as he did growing up. “I hop in the boat after work with my wife and kids. I think it’s a great family activity,” he said.

The family relocated to Middle Tennessee last sum-mer, and Rose started his practice in the fall. “We’ve got a 13-year-old daughter named Olivia … a nine-year-old daughter named Julia … and … a seven-week-old daughter named Audrey. We had been told we could not have any

more children … surprise,” Rose laughed. Happily, the growing family has quickly adapted to their new hometown, and the older girls are flourishing in their schools. “They’ve made it so easy. I can just focus on work,” Rose said of the transition.

“Not to sound cheesy,” he contin-ued, “but I love what I do. I feel very lucky and blessed for all the opportuni-ties I’ve had.”

As his practice with TOA continues to grow, Rose said he would like to ex-pand the sports medicine side to help care for area athletes alongside his partners Rob Dyer, MD, and Brian Koch, MD. He also hopes to teach again in the Nash-ville area. In Kentucky, he served as gra-tis faculty at the University of Louisville Department of Orthopaedic Surgery and worked with the Family Practice residency program, as well.

“I love to teach. It keeps you focused, keeps you current, and it’s a way to give back. I was very fortunate to have men-tors and teachers who took an interest in me,” he said of paying it forward. “If you teach 10 people and you can touch even one person and show them how much you love what you do, maybe they can find that passion and joy.”

Orthopaedic Surgeon Matthew Rose Really Relates to Those Who Want to Get Back in the Game

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By CINDy SANDERS

When Kristin Archer, PhD, DPT, tells patients she has been where they are, she is speaking literally.

An avid runner and athlete, she was sidelined by an injury several years ago. “I had back surgery in 2002, and I just expe-rienced a lot of pain after surgery … and I had a lot of trouble getting back to activity because I was always worried about hurting myself,” Ar-cher recalled.

That personal experience has helped inform her professional research. Archer, an assistant professor in the Department of Orthopaedic Surgery and Rehabilitation at Vanderbilt, serves as the department’s director of orthopaedic research. With a background in health policy and public health alongside her physical therapy train-ing, Archer’s interests lie in moving effec-tive interventions from the research stage to the bedside. “Research, itself, needs to become embedded in health policy to help change clinical care,” she stated.

As for her recovery, Archer noted, “I really had to build my confidence back up myself. I think I was able to pull myself up out of this because of my physical therapy background, but a lot of people don’t have that.”

In fact, for many the post-surgical therapy instructions almost feel counterin-tuitive. Archer pointed out patients don’t

want to have more pain or rein-jure what they’ve just had surgery to fix. “You have that worry and fear that is holding you back,” she noted.

This summer, Archer and colleagues published a case study in Physical Therapy, looking at the results of a cognitive behavioral-based physical therapy (CBPT) intervention in patients with high fear of movement following lum-bar spine surgery. “The interven-tion came from what they told us they needed after surgery. It’s very patient-centered,” Archer said.

She stressed the six-session intervention, which employs evidence-based cognitive behavioral tech-niques, isn’t meant to replace physical ther-apists or clinical psychologists, but instead is another tool in the toolbox for clinicians and patients to improve outcomes. Archer added it’s a matter of finding a way to meet the needs of the patient and tailoring the approach to the individual.

The first session, she explained, is focused on patient education with an ex-planation of the mind/body connection, creation of a graded activity plan and weekly goals. Patients are also taught deep breathing techniques to help with pain. “Each session we weave in a cognitive or behavioral technique and set the next ac-tivity and walking goal … they are always progressing,” she noted.

The intervention typically begins around week six post-surgery, following

clearance by the surgeon. Archer said the shared goal setting is really at the heart of the intervention. “This is all about having them tell us where they want to get to … what is important to them,” she said. Ar-cher explained the physical therapist uses a graded activity hierarchy (0-100 scale) with the goal activity being assigned a number. Each week, the patient moves up the scale in terms of accomplishing more complex physical challenges.

Archer said doing laundry or unload-ing a dishwasher, both of which require bending and stooping, might be among early goals with gardening and mowing the lawn coming a little later. She noted it is important for the goals to be realistic and manageable. “The key is they have to have success,” she said of patients.

Archer continued, “The issue is before

surgery they stopped doing things because they were in so much pain. Afterwards, they should be able to do these things. They do have pain because they have had surgery so there is some acute surgical pain, but they don’t separate it from the pain they had before. When you have had chronic pain, there is a lot of fear for a long time. That doesn’t just go away because you had surgery.” Unfortunately, she added, if patients don’t get back to activity once cleared by their surgeons, they often never

achieve the desired … and possible … out-come of surgery.

During the course of the intervention, patients are given a number of cognitive behavioral tools including behavioral self-management strategies, problem-solving techniques and cognitive restructuring and relaxation strategies. Therapists work with patients on identifying and replacing nega-tive thoughts about pain and physical activ-ity with a positive substitute. In fact, Archer said, the concept of ‘positivity’ is becoming much more ingrained in clinical literature.

The original case series study included 20 patients in the intervention, all of whom saw clinically significant changes on clinical measures. The published study centered on eight patients from the group with physi-cal performance data. Of that subsection, seven of the eight demonstrated a clinically significant reduction in pain and all eight had a clinically significant reduction in dis-ability at six-month follow-up compared to baseline measures at six weeks post-surgery.

Currently, Archer and her team are in the midst of an NIH-funded trial with 80 patients. Half were randomized to the CBPT intervention and half to speaking with a physical therapist about traditional therapy activities without the cognitive behavioral support. Archer said the team is now in the follow-up portion of the trial and hopes to have results published fairly early in 2014.

She noted that in the NIH-funded trial, all 80 participants received a physician’s referral to physical therapy. However, she added, not all of the patients completed the therapy. “What we’re finding is less people are going to therapy for different reasons,” she said, noting those reasons range from access issues to higher out-of-pocket costs as individuals take on more financial responsi-bility with insurance plans.

While the current intervention in-cludes one in-person meeting followed by five sessions on the phone, Archer would like to look at options to conduct all six ses-sions remotely to meet the needs of patients in rural areas where access to a physical therapist is limited. She noted the Vander-bilt team is establishing an advisory board of patients and clinicians to discuss ways to disseminate the intervention more broadly.

The Mind/Body ConnectionCognitive Behavioral-Based Therapy to Improve Surgical Spine Outcomes

Dr. Kristin Archer


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By CINDy SANDERS

Should patients steer clear of steroid injections in light of the recent events that have made headlines in Middle Tennessee and around the nation?

Although an understandable concern for patients, the reality is those events have potentially made such injections safer. If there is any positive outcome to the tragic meningitis outbreak following in-jections of contaminated preservative-free meth-ylprednisolone acetate (MPA) from the New England Compound-ing Center … and more recently reports of less severe adverse events from MPA manufactured and distributed by Tennes-see-based Main Street Family Pharmacy … perhaps it is a heightened awareness regarding safety and suppliers.

In the wake of these events, the Ten-nessee Board of Pharmacy has announced new measures and regulations to improve the safety and oversight of state-licensed sterile compounding pharmacies (Nashville Medical News, July 2013) and has promised more action is on the way.

“Frankly, I would think it must be one of the safest procedures in the country now,” William Schaffner, MD, professor and chair of Vanderbilt’s Department of Preventive Medicine, said of the injec-

tions. Schaffner, who is a frequent na-tional spokesperson on prevention and safety issues, said it would be surprising if physicians had not reviewed their policies and procedures regarding the use of MPA and reviewed the sources of their medica-tion.

“I always tell patients they should feel empowered to inquire of their physicians, ‘Where do you get your medication? Are you getting it from a compounding phar-macy or from a major pharmaceutical manufacturing company?’ If the physician is unsure about the source of the medi-cation, given recent events, that should frankly be a yellow caution flag for the patient,” Schaffner said.

Brett Babat, MD, a board certified orthopaedic surgeon with Premier Or-thopaedics, concurred, saying the general feeling is that physicians and practices are doing more research and homework on their suppliers to ensure safety.

As for the value of such injections, Babat said in the proper patient popula-tion they play an important role. “An epidural can make the pain negligible while the body does some healing,” he ex-plained. “A well done epidural injection probably has less risk than a well done sur-gery … but,” he stressed, “it also may have less efficacy in a good number of patients.”

Since the point of the injection is to decrease inflammation, Babat said deter-mining the underlying cause of the inflam-mation is crucial to achieving sustained

improvement. “If the source of the inflam-mation is not an ongoing insult, then they (injections) can have a long term effect. However, if there is a structural problem in the spine causing this inflammation, the patient is likely to have a return to symp-toms as the steroid wears off.”

Ultimately, discussions about safety and efficacy should not be limited to MPA injections but should extend to all treat-ment options as patients and physicians work together to find the most suitable options for each individual.

Latest Medicare Kyphoplasty Overbilling Settlement

Last month, the U.S. Department of Justice (DOJ) announced 55 hospitals throughout 21 states, including Tennessee, have agreed to pay the United States more than $34 million to settle allegations of false claims being submitted to Medicare for kyphoplasty.

The minimally invasive procedure used to treat vertebral compression fractures, such as those due to osteoporosis, often can be performed on an outpatient basis. The July settlement resolves allegations that the hospital facilities included in the agreement billed for kyphoplasty on the more costly inpatient basis for the purposes of increasing Medicare reimbursements.

“Hospitals that participate in the Medicare program must bill for their services accurately and honestly,” said DOJ Acting Assistant Attorney General Stuart Delery. “The Department of Justice is committed to ensuring that Medicare funds are expended appropriately, based on the medical needs of patients rather than the desire of medical providers to maximize profits.”

HCA has agreed to pay more than $7.145 million for 23 affiliated hospitals, and LifePoint has agreed to a settlement of more than $2.522 million for six of its affiliated hospitals. Also in Tennessee, three hospitals affiliated with Baptist Memorial Health Care Corporation in Memphis will pay $691,168, and two hospitals affiliated with Covenant Health in Knoxville will pay just over $1.845 million as part of the settlement.

This latest round of settlements brings the number of hospitals paying to resolve allegations to more than 100 with a combined payment of nearly $75 million. Additionally, Kyphon, which makes the equipment, has also paid $75 million to resolve allegations by two former employees who claim the company encouraged hospitals to file inpatient claims rather than bill on the outpatient basis. Neither Kyphon, now owned by Medtronic Spine, nor the hospitals have admitted to any wrongdoing.

Safety and Efficacy of Spinal Steroid Injections

Dr. William Schaffner TriStar Summit to

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gery down to the pelvis, we need to protect that stopping point with additional points of fixation,” he explained. With his new de-vice, Babat noted, “It’s still screw fixation, but it’s lower profile to allow you to get one or two screws into the pelvis on each side, where typically we could only get one, for better fixation, and (it) allows us to attach the rods more easily, faster and more rigidly.”

Babat said he also worked with the company on a new version of their pedicle screw program “combining multiple key features from dif-ferent techniques into one system.” This newest option is rolling out now.

The surgeon, who has held multiple leadership positions at Skyline Medical Center including terms as chief of staff and chief of the Division of Orthopaedics & Neurosurgery, finds the move toward mini-mally invasive surgery effective for a num-ber of procedures including dealing with a ruptured disc or arthritic compression. Yet, Babat said not every procedure lends itself to that direction.

“There’s been a big move toward min-imally invasive surgery. However, it turns out it may not be as useful in the spine as in some other surgeries,” he said. “It has not seemed to have the benefit everyone hoped it would have.” He added this is particularly true when dealing with major spinal deformities or working on multiple

vertebral levels. “There are people who will do better with minimally invasive op-erations, but trying to fit everyone into a minimally invasive operation is not the way to go,” Babat stated, adding that preopera-tive screening is extremely important when deciding which patients are the best candi-dates for minimally invasive or traditional open surgeries.

An area where Babat thinks his field has made great strides is in honing in on the importance of the spine’s alignment curva-ture and how that ultimately impacts a pa-tient’s quality of life. “It’s not enough to get two bones to fuse together,” he said. “Over the past five to 10 years, we’ve really begun to understand the overall importance of the alignment of the spine as it relates to the pelvis and overall balance.” When the patient’s alignment is more natural, he con-tinued, “You make such a dramatic change in their lives.”

At Tennessee Orthopaedic Alliance, spine surgeon Gray Stahlman, MD, has seen some of those dramatic results in pa-tients with unresolved low back symptoms re-lated to the sacroiliac (SI) joint. Among the first surgeons in Middle Ten-nessee to perform sacro-iliac joint fusion using the minimally invasive iFuse Implant System, Stahl-man, who sees patients at TOA’s Saint Thomas Midtown and Wil-liamson Medical Center locations, said his

patients have reported 75-98 percent relief of preoperative pain since he first began performing the procedure in January 2012.

“The sacroiliac joint is kind of a mis-understood joint,” Stahlman noted. In the early 1900s, physicians recognized the joint as a cause of low back pain. But, he contin-ued, because there was no surgery or real treatment for it, “People concentrated on other parts of the spine, such as discs.”

More recent studies looking at possible sources of back pain, he continued, suggest up to 25 percent of cases might be associ-ated with the SI joint. Connecting the sa-crum, the triangular bone at the bottom of the spine, with the pelvis iliac crest, the SI joint can become damaged due to injury, arthritis, normal wear and tear, or it might degenerate over time following a previous fusion surgery. Stahlman noted, “Forty to 50 percent of people who have had a spinal fusion have radiographic evidence of adja-cent segment deterioration.”

Although the traditional open surgery, which has been available for decades, has undergone various tweaks, Stahlman said all the approaches have entailed large in-cisions, significant blood loss and a slow recovery process ranging from weeks to months of recuperation. Not surprisingly, the option hasn’t been very popular with patients or physicians.

If Stahlman suspects the SI joint could be at the root of a patient’s lower back/upper leg pain, the first step is to try the patient on non-steroidal anti-inflam-matory medication and physical therapy. If that fails, an MRI is ordered to make sure there isn’t another structural issue. “Then I’ll try the SI steroid injection,” he continued. If the patient still doesn’t find relief from these more conservative op-tions, only then will he begin considering a surgical option.

Stahlman said appropriate screening is critical to selecting candidates who might benefit from iFuse. “The gold standard test to determine if the sacroiliac joint is indicated is a diagnostic fluoroscopically-guided SI joint injection,” Stahlman ex-plained. He noted patients are given a pre- and post-procedure examination. “If the patient demonstrates 75 percent or greater relief of their pre-procedure pain, that suggests the sacroiliac is a major con-tributor to their pain problem,” he contin-ued, noting these patients are often good candidates for iFuse.

“The premise behind SI surgery is to restrict or stop movement of the joint … that’s what causes pain,” Stahlman said. The iFuse procedure, developed by SI-BONE, Inc., involves small titanium implants inserted across the SI joint. The implants are coated with a porous plasma spray, which acts as an interference surface fit to help decrease implant motion and provide immediate post-op fixation.

Typically performed on an outpatient basis in about an hour, the entire process is done through a small incision with no soft tissue stripping and minimal tendon irrita-tion. Patients, who are on crutches for a couple of weeks to minimize weight-bear-ing on the operative side, generally resume normal daily living activities within six

weeks, pending physician approval. “Most people notice substantial improvement in their preoperative pain within two to three weeks,” said Stahlman. “It generally takes three to six months for the implants to be-come osseointegrated,” he continued.

Minimally invasive Transforaminal Lumbar Interbody Fusion (MIS TLIF) is another relatively new technique being used in Middle Tennessee to treat patients with lower back and leg pain that have failed more conservative treatment mea-sures.

“We are now able to perform a tradi-tional fusion through incisions that are as small as 5 cm,” said TOA surgeon Juris Shibayama, MD. “I utilize a retractor … a tube … only 22 mm in diameter to perform the entire surgery through.” He added a highly specialized microscope al-lows surgeons to visualize the surrounding structures to minimize the amount of col-lateral damage. “We have seen amazing results using this technique, providing our patients with dramatic pain relief with less recovery time,” Shibayama continued.

Patients with a single-level fusion have generally achieved the best clinical results. In some cases, fusion at two levels might be performed on carefully selected and screened candidates. Last fall, Matthew McGirt, MD, with the Vanderbilt Spine Center in the Department of Neurosurgery at Vanderbilt University Medical Center, presented his team’s findings on the cost of TLIF and found it to be cost effective when compared with comprehensive medical management for lumbar spondylolisthesis.

Additionally, in January of this year in World Neurosrugery, a group of Vander-bilt researchers published results of a study looking at the comparative effectiveness and costs of MIS vs. open TLIF. The team found the surgical morbidity, hospital read-mission rate and short- and long-term clini-cal effectiveness to be similar between the two options. However, with the minimally invasive surgery, patients had a shortened hospital stay, decreased operative blood loss, lower costs at two years, and a more rapid return to work, which had cost-saving and quality-of-life benefits.

Despite advances in operative care, Babat said most people with back pain don’t need to see a spine surgeon. Among the group of patients who are referred to a specialist, the majority still won’t need sur-gery. “Probably we should only be operat-ing on 3 to 5 percent of people who come through our offices, and I think that holds true for what most surgeons are doing,” he said.

However, he stressed, that doesn’t mean these patients must live in pain. To-day’s orthopaedists have many treatment options to address back pain — from a host of conservative measures all the way up to evolving surgical procedures. At hospitals and practices across the metro area, Babat said Nashville’s position as a major medi-cal hub has attracted orthopaedic surgeons with a broad range of specialty interests to address even the most difficult and complex cases.

“I would encourage people not to give up hope,” Babat concluded.

New Techniques, Treatments for Lower Back Pain, continued from page 1

Dr. Brett Babat

Dr. Gray Stahlman


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By CINDy SANDERS

The American Academy of Orthopae-dic Surgeons (AAOS) recently released a revised clinical practice guideline for treat-ment of osteoarthritis of the knee with key changes to recommendations regarding the dosage of acetaminophen and use of intra-articular hyaluronic acid (HA).

David S. Jevsevar, MD, MBA, chair of the AAOS Evidence Based Quality & Value Committee and chair of the work-group for OA of the knee, said the 2013 edition of the clinical practice guideline (CPG) contains 15 recommendations and replaces the first edition of the CPG, which had elicited some concern over the meth-odology employed in garnering some of the evidence … specifically that attached to the use of HA.

Jevsevar, a board-certified orthopedic surgeon at Intermountain Zion Ortho-pedics & Sports Medicine in St. George, Utah, said it is the policy of the AAOS to do all CPG data analysis in-house. How-ever, the earlier guideline utilized synthe-sized data from three outside sources — the Agency for Healthcare Research and Quality, Osteoarthritis Research Society, and Cochrane Database of Systematic Reviews.

Both those who sell and manufacture HA, as well as a number of AAOS members, were specifically concerned about the issue of visco-supplementation, which garnered an ‘inconclu-sive’ recommendation in the first issue. Jev-sevar said the committee was clear that a more vigorous internal review of the use of intra-articular hyaluronic acid could result in the same outcome, a stronger recom-mendation backing the use of HA … or a reversal recommending physicians not use the treatment option. “When we actually did the analysis, that’s what happened,” he said of the reversal, which resulted in a ‘cannot recommend’ designation for the use of HA for patients with symptomatic OA of the knee.

“When you use clinical significance as your bar for recommendation — and we took the 14 best studies out there — it re-ally doesn’t support the use of viscosupple-mentation, or HA,” he said. “Although a few individual studies found statistically sig-nificant treatment effects, when combined together in a meta-analysis, the evidence did not meet the minimum clinically im-portant improvement thresholds.”

Jevsevar went on to explain there is a difference in statistical significance and clinical significance. He noted that on the clinical pain analysis where 0 is no pain and 10 is the worst pain, having patients move from a 9 to an 8.8 after treatment could be considered statistically significant but wouldn’t feel much different to the person with OA. “We use the higher bar of clinical

significance,” he continued. ”We feel that’s the one most important to patients.”

Perhaps not surprisingly, the strong recommendation against the use of HA has created some pushback from physicians. “They feel like we have very few treat-ments for osteoarthritis that work so they are always concerned when we take one away,” he said. However, Jevsevar contin-ued, “Doing something that is expensive and hasn’t been proven isn’t the right thing either.”

He said it’s hard to gauge the true effectiveness of various treatments in the clinical setting for a couple of reasons. “Arthritis research is hard because osteo-arthritis patients don’t have the same level of pain everyday,” he explained. “Many of those patients want to do anything but surgery, which is understandable,” Jevse-var continued. “They want the treatment to work, but that creates a placebo effect or bias for whatever is being used.” More research, he added, is certainly needed.

One concern for physicians using HA is that insurance companies will quit reim-bursing for the treatment. “We synthesize the evidence, but we don’t make recom-mendations for insurance,” Jevsevar said.

However, he admitted insurance compa-nies could misapply the guidelines for finan-cial purposes. Still, he noted, discontinuing reimbursement for viscosupplementation might not be to a payer’s benefit since it could drive more OA patients to opt for the much more expensive knee implant.

Furthermore, Jevsevar said treatment decisions should replicate the foundation of a three-legged stool — 1) the evidence, 2) physician expertise and experience, and 3) patient preferences and values. “You have to take all three into account when treating a patient. One doesn’t trump the other,” he said.

In addition to the controversial HA ‘no’ recommendation, the work group also reduced the recommended dosage of acet-aminophen from 4,000 mg to 3,000 mg a day, which mirrors an overall change made by the Food and Drug Administration for individuals using acetaminophen for any purpose. In patients with symptomatic OA of the knee, Jevsevar said, “Actually, there’s not a lot of evidence to support the use of acetaminophen.”

Other important recommendations that remained the same in the revised guidelines included:

• Patients who only display symptoms of OA and no other problems, such as loose bodies or meniscus tears, should not be treated with arthroscopic lavage.

• Patients with a body mass index (BMI) greater than 25 should lose a mini-mum of five percent of their body weight.

Jevsevar noted telling patients to lose weight and get active are “tough discus-sions” to have but important ones. Low im-pact exercises including swimming, walking and using an elliptical machine have been proven effective to slow the progression of OA of the knee.

The work group strongly recom-

mended against the use of glucosamine and/or chondroitin sulfate or hydrochlo-ride and against the use of acupuncture. A “strong” strength of recommendation means the quality of the supporting evi-dence was high with an implication that practitioners should follow strong recom-mendations unless a clear and compelling rationale for an alternative approach exists. Jevsevar added the ‘no’ recommendations were based on a lack of efficacy rather than a potential for harm. The group also had a moderate recommendation against custom lateral wedge insoles. A moderate recom-mendation also is compelling, but the qual-ity or applicability of the existing evidence is not as strong.

Due to a lack of research, the CPG was unable to recommend for or against the use of physical agents including elec-trotherapeutic modalities, manual therapy, bracing, growth factor injections and/or platelet rich plasma.

In the second edition, all included stud-ies had to have a sample size of at least 30 participants and a follow-up period of at least four weeks. More than 10,000 separate pieces of literature were reviewed during the evidence analysis phase. When com-pleted, Jevsevar said the updated OA knee CPG was subjected to the most extensive peer review to date for any AAOS CPG. Ultimately, 16 peer reviewers representing multiple specialty societies submitted for-mal reviews. “Each meticulously dissected the final recommendations of the document and, based on their well-informed and in-sightful comments, important changes were made to the final document,” Jevsevar said in an AAOS editorial.

For more information on the second edition OA knee CPG, go online to: www.aaos.org/research/guidelines/Guideli-neOAKnee.asp

AAOS Updates Clinical Practice Guidelines for Osteoarthritis of the Knee

Dr. David S. Jevsevar


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By KELLy PRICE

“Nashville is a hub of healthcare tal-ent, and I’m glad to discuss pioneering changes that can be made to positively shape the future of care with leaders in this city,” Bruce Hamory, MD, said in opening his remarks to the audience at the Nashville Health Care Council luncheon on June 28.

Hamory is executive vice president and managing partner of Geisinger Con-sulting Services, part of the Geisinger Health System, which is widely recognized as a national role model for health reform and for offering high quality care at costs well below average. Technology plays a large role in Geisinger’s success story … and technology was used to remotely bring Hamory to Nashville as he addressed the crowd gathered at the Renaissance Hotel.

Geisinger, an integrated health ser-vices organization, has been lauded for its innovative use of the electronic health re-cord and the development and implemen-tation of inventive care models including ProvenHealth Navigator, an advanced medical home model, and ProvenCare program. The system serves more than 2.6

million residents throughout 44 counties in central and northeastern Pennsylvania.

Wayne Riley, MD, former president and CEO of Meharry Medical College and Council board member served as moderator for the program. “Like the Geisinger community, Nashville is a col-laborative and progressive healthcare cen-ter with a strong desire to fi nd solutions to improve patient care throughout the country,” Riley said in his program intro-duction.

Hamory spoke to the Nashville group about the Geisinger model and its repu-tation for innovation in quality and value through integration, collaboration and investment in patient-focused health in-formation technology at costs well below average.

Geisinger operates both the payment and provider entities within its system and has made signifi cant progress in achiev-ing value-based care through cutting edge practices. Up to 20 percent of physician pay at Geisinger is based on favorable outcomes and the use of advanced tech-nology, a fundamental difference from the fee-for-service payment system most hos-pitals currently use.

Hamory cited the active use of elec-tronic medical records data to create standards of care as an important step in Geisinger’s ability to increase quality and reduce costs. “Truly integrated healthcare organizations provide the right care at the right time in the right place, which is what we strive to do at Geisinger.”

He also pointed out as much as 50 percent of care dispensed in this country yields no benefi ts. It is important to elimi-nate inappropriate use of care, he said, and instead to dedicate those resources to increasing quality. Through the use of technology, Geisinger has developed sev-eral platforms for measuring and deter-mining best practices, which have shown to decrease cost and attain better patient results.

Caroline Young, president of the Nash-ville Health Care Council, said “Home to a dynamic community of more than 250 health care companies, Nashville has a sig-nifi cant infl uence on the provision of care across the country. We are pleased to host Dr. Hamory for a dialogue on the opportu-nities and challenges ahead in ensuring coor-dinated care and better patient outcomes.”

Hamory Addresses Nashville Health Care Council Members Innovative Geisinger Health System Leader Shares Insights


Dr. Wayne Riley, moderator of the recent Nashville Health Care Council event, leads an interactive discussion with Dr. Bruce Hamory of the Geisinger Health System on innovations in care.

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By CINDy SANDERS

… And they all lived happily ever after.

In fairytales, the two protagonists manage to overcome many barriers to ul-timately ride off into the sunset … presum-ably for a lifetime filled with sunshine and roses. In the real world, we only have to look to divorce statistics to know that ‘wed-ded bliss’ frequently dissolves into angry recriminations, mistrust and broken vows.

As it turns out, marriage makes for an interesting analogy to the wave of physi-cians, practices and hospitals rushing to the altar under the new world order of healthcare reform. Thanks to economic strain, the market has seen quite a few shotgun weddings lately. In other cases, such as some ACO affiliate agreements, the parties have opted to cohabitate rather than legally wed. And in some instances, the belief is that the union completes and complements each party to the ultimate benefit of both.

No matter how the parties entered the relationship, once the honeymoon phase wears off, both are left to figure out how to navigate this new partnership and work as a team. Of course if that was easy, there wouldn’t be such a high divorce rate. You only have to look back to the rash of merg-ers and buyouts in the ‘90s to know that many of these marriages between practices and hospitals don’t end harmoniously.

So what can you do to beat the odds? Medical News had the opportunity to chat with Ken Hertz, FAC-MPE, principal with MGMA Health Care Consulting Group, about the keys to creating a last-ing union. Hertz, who has nearly 40 years of man-agement experience, has held leadership positions with primary care and multispecialty care organizations, as well as large integrated systems. He works with practices and hos-pitals on strategic planning, integration, operational improvements, compensation, conflict resolution and governance issues.

Marry in Haste, Repent at Leisure

In the current transformational land-scape, Hertz has seen a lot of hasty mergers and alignment contracts executed without taking the time for proper due diligence … the ‘chicken little’ syndrome. “I tell people I’m not necessarily sure the sky is falling or that the world is ending. What we’re deal-ing with is this funny word called ‘change,’ and some of us can barely say it without stroking out,” he noted.

Hertz was quick to add that change is scary, but that’s all the more reason to take time to prepare properly on the front end to ensure each partner stays commit-ted when the relationship hits an inevitable rough patch down the road. He noted the rush to ‘do something’ happens on both

sides with physicians worried about the changing regulatory and reimbursement landscape and hospitals snapping up prac-tices before a competitor has the opportu-nity to grab them.

It’s probably wise to note, however, that few couples married at a Las Vegas drive-thru chapel at 3 a.m. make it to their golden anniversary celebration. Instead, many of them wake up the next day with the question of ‘Now what?’ hanging heav-ily in the air.

Premarital Counseling“It’s like the Yogi Berra line, ‘If you

don’t know where you’re going, there’s a good chance you won’t get there,’” Hertz said. “When we work with physician prac-tices and they say, ‘We need to get aligned with the hospital or need to merge with another practice,’ the first thing we ask is why?”

It’s important, he said, to really ex-plore what each partner hopes to accom-plish through the alignment or merger. How does each of you define success?

Once the ‘why’ has been sufficiently vetted, the attention shifts to the ‘who.’ Hertz said it is essential to honestly evalu-ate your core values and deal-breakers and then see how those align with your poten-tial partner.

“The key to any relationship is you’ve got to understand what makes you tick and what’s important to you … and … you’ve got to understand what makes your part-ner tick and what’s important to them,” Hertz said.

Ultimately, Hertz noted, each party is aligning themselves to a vision. “It’s really critical, I think, that there be a shared vi-sion … and the shared vision can’t be just about money.”

PrenupChances are not everyone is going to

get everything they want in any relation-ship, but both parties should address the ‘must haves’ and ‘won’t dos’ and write those into the contract. The reimburse-ment plan, governance structure, conflict resolution protocol, and practice pattern expectations should all be thoroughly dis-cussed on the front end and clearly out-lined in the final agreement. Equally, the repercussions for both parties of not living up to the agreement should be spelled out.

Making the Marriage LastAlthough it might seem like the heavy

lifting happens in the planning stage, any-one who has been married long knows that once the honeymoon is over, the real work begins. “Each party has to put in a hun-dred percent. It is the only way this works,” Hertz said.

For physicians used to making snap decisions and having their orders carried out, following the maze of corporate pro-tocols that are inherent in most health sys-tems and large practices can be frustrating. For hospitals shifting from a volume-based

to an outcomes-based reimbursement model, it can be equally difficult to under-stand how less truly can mean more.

The best antidote for frustrations that build up and fester over time is open com-munication. Hertz pointed out, “Com-munication is broadcasting, but it’s also receiving. The notion of two-way commu-nication is critical.”

Not only does there have to be com-munication, but it must also be meaning-ful. “Most of the physicians I know were absent the day they taught mind-reading in their training programs,” he said. It does no one any good to have an administrator walk into a physician’s office at the end of the month, tersely tell the doctor the num-bers aren’t where they ought to be, and walk out … which Hertz has witnessed. Instead, he said, the two need to work to-gether to figure out where the problem lies and what steps could be taken to fix it.

Being open to different viewpoints al-lows both physicians and administrators to see care delivery issues in a new light. It’s one reason why physician governance is critical to the health of the overall or-ganization. Having physicians involved in planning for the future keeps them en-gaged in the mission and shared vision.

Having a voice, however, doesn’t al-ways mean one party gets their way. Hertz

noted, it’s better to hear an honest ‘no’ than a sugar-coated answer that is mean-ingless. Trust and transparency, he said, are the cornerstones of any good relation-ship.

“Do what you say you’re going to do when you say you are going to do it,” he stated, noting the axiom is equally true for physicians as it is for administrators.

Hertz continued, “If I’m a system, and I’m going to pay you based on work RVUs or based on charges or visits or collections or whatever, I need to make sure I can do a really good job of collecting that infor-mation; that it is accurate; that it’s timely; and that you trust it. If we don’t trust each other, it doesn’t work so well.”

Ultimately, those who have realistic expectations and are willing to put in the work to achieve the shared vision enjoy the strongest partnerships. “You’ve got to know what is going on in the world around you … so you’ve got to be informed. You must do your due diligence. You must know yourself, and you’ve got to do this with your eyes open — wide open — and never assume. Those are the top five things,” Hertz said.

“The bottom line is none of this is brain surgery, but there is no silver bullet, no magical answer. It’s darn hard work,” he concluded.

Making the Marriage WorkAlignment & Integration Strategies to Strengthen Physician, Hospital Unions

Ken Hertz


Read Nashville Medical News Online:

NASHVILLEMEDICALNEWS.COM

Editor’s Note: After this interview was com-pleted but before we went to press, Scott Raynes, CEO of NorthCrest Medical Center, announced his resignation from the Springfi eld hospital as he has accepted an executive position with Baptist Health Care in Pensacola, Fla.

By CINDy SANDERS

“Being professionally managed while being clinically driven is a partnership,” stated Scott Raynes, president and CEO of NorthCrest Medical Center in Springfi eld.

Historically, he added, payers, physi-cians and hospitals often had fractured relation-ships with different in-terests and end games. Today, the three must align to survive.

“We’ve got to be effi cient and lean in our mindset. The problem is that philoso-phy fundamentally has not been present in the healthcare industry before,” noted Raynes, the immediate past chair of the Tennessee Hospital Association Board of Directors. “We have to make ourselves do it every day … and every day is hard.”

“In the past, what was good for the hospi-tal might not necessarily be good for the physician and vice versa,” noted Alan Watson, CEO of Maury Regional Medi-cal Center. “Now, we’re seeing more and more where our goals are aligned. I think some of it is because of reform … some of it is the change in qual-ity reporting.”

Either way, the outcome is that hospi-tals and physicians must be closely aligned to achieve common goals and survive eco-nomically. “I think the mistake hospitals made in the past is we’ve bought up prac-tices, but we have not involved the physi-cians in management of the practices … in strategic discussions. You’ve got to get them involved in the decision-making pro-cess; otherwise, you aren’t going to suc-ceed,” Watson continued. He added that in today’s landscape, there are a number of ways to accomplish a physician-led, professionally managed operation aside from direct employment.

In addition to the traditional medical staff structure at Maury Regional, Watson noted, there is a strategic physician advi-sory group that crosses specialties and a similar service line advisory council to pro-vide insight and help with planning and decision-making. But, he cautioned, hav-ing these types of groups in ‘name only’ is detrimental to the organization. “The worst thing you can do is call physicians to-gether and then not act on what comes out of those meetings,” he pointed out.

Where historically physicians have been the driver on the clinical side and the

administrator the dollar cruncher, Raynes said neither could afford to be a ‘one-headed monster’ going forward. “You have to be very, very well versed at both.”

The most successful unions between physicians and hospitals have great com-munication, philosophical alignment and transparency at the foundation. The ‘se-cret,’ Raynes said, is “keeping the patient at the center of everything we do. It sounds a bit cliché-ish, but it always re-centers the conversation.”

Watson added, “If we’re moving toward a system of care where we’re re-sponsible for the patient from the doctor’s visit through rehabilitation, it’s got to be a collaboration. That means we all have to have partners … to help each other.”

He continued, “I think we’re talking more. We’re working together to the ben-efi t of the patient. There are a lot of things I don’t like about the Affordable Care Act, but collaboration is always a good thing.”

Raynes noted the next few years would undoubtedly be a diffi cult transi-tion as healthcare reimbursement catches up to new delivery models. “As the dollars become tighter, we’ll all fi gure out how to operate effi ciently within that space. Those who don’t fi gure it out will cease to exist. It’s a heck of a wake-up call,” he said.

He continued, “Today we’re still paid, as hospitals and as physicians, over-whelmingly on a fee-for-service basis … it’s just less fee than it was before.” Philo-sophically, however, providers across the continuum of care are beginning to shift their mindsets to population-based health and preventive medicine. “We have one foot on the dock (fee-for-service) and the other on the boat (outcomes-based), but the payer world has not shifted to the boat, yet,” Raynes said.

While there is some chaos and un-certainty right now, the direction hos-pitals, physicians, community providers and payers must go is clear, he continued. “We’re being pushed to get there. We’re not being asked to get there at our own pace … we’re being driven there. All of a sudden we have to look at who we’re in the game with and fi gure out how to play better ball.”

And that, Raynes said, comes back full circle to aligning around the best, most effective and most effi cient ways to serve patients. “As frightening as it is on the one hand, it is as exciting on the other. It’s helping us become what we wanted to be all along.”

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By CINDy SANDERS

“We’re seeing an explosion in two dominant models of physician alignment,” said hospital/physician relationship ex-pert John Deane, CEO of Southwind, a division of The Advisory Board Com-pany. “The first is physician employment … direct employment. The second is the clinical integration enterprise.”

While everyone understands the basics of the direct employment model, exactly what is a ‘clinical integration’ enterprise? Deane likened it to a ‘next generation’ physician hospital organiza-tion (PHO) but with key differences and enhancements.

At its root, clinical integration (CI) re-fers to a specific type of legal arrangement allowing hospitals and physicians to col-laborate in order to improve quality and efficiency while remaining independent entities. The physicians invest in perfor-mance improvement and in turn are al-lowed to negotiate collectively for better rates and bonuses from payers if they meet specified benchmarks.

“A popular model we’ve set up in over 50 markets is to measure and moni-tor adherence to best practice clinical guide-lines and cost effective-ness … or measuring quality … and then to tie financial incentives through the payer con-tract to those quality measures,” Deane explained, adding it is a contractual relationship with incentives.

But wait ... isn’t collusion among in-dependent physicians to set rates against the rules? Yes, but capitation and CI are the exceptions to that rule. The govern-ment has decided that in the case of CI, the broader healthcare quality benefits outweigh the risk of higher costs … and, like capitation, the physicians do have some skin in the game.

“The Federal Trade Commission says in order for this to be legal, there do need to be consequences for physicians

who are out of compliance,” Deane noted. “There’s a transfer of information that didn’t used to be there from the practice to the clinical integration organization,” he continued, explaining how the organi-zation determines adherence to best prac-tices. “If you’re an outlier, you are going to be spoken to about your performance. If you don’t remediate, you are kicked out of the organization.”

When Deane and his colleagues dis-cussed this type of alignment strategy with hospital CEOs almost four years ago, most of the administrators had a bit of the ‘deer in the headlines’ look about them. At that time, there were only about a half dozen examples around the country. Now, however, the concepts of shared savings, outcomes bonuses, accountable care orga-nizations and bundled payments have be-come part of the everyday vernacular, and Deane noted Southwind has presented this type of program in a little more than 75 markets and is actively involved in CI enterprises in 50 markets.

“You have the foundational elements for the accountable care organization in the clinically integrated enterprise,” Deane pointed out. In fact, he noted, the evolution has been that doctors who were

already in CI enterprises are now making an easier transition to ACOs because it is a much smaller leap than starting from ground zero.

“I think it’s catching fire,” Deane continued of the concept. “The physi-cians like it because it is a vehicle for them to align with the hospital and each other without having to give up their indepen-

dent, private practice. The hospitals like it because it binds the physicians to the institution and creates a platform to move toward healthcare reform.”

Deane added, CI allows hospitals to move the needle on quality performance and get the integration they want without having to go out and buy a lot of practices. He also noted payers like the CI model be-cause it brings physicians into a network and actively engages them with a tangible benefit for improving quality while lower-ing cost.

“Doctors like this program because it is about doing the right thing for the pa-tient,” Deane continued. “Physicians … especially private practice physicians … value their independence, and if they can sustain the economic viability and quality of their practices, that’s very satisfying to them.”

In the long run, Deane said the con-cept of health reform is changing the game and shifting the physician’s role from mak-ing solo decisions and care calls to becom-ing the leader of a team of care providers. “It’s going from playing an individual sport to playing a team sport,” he noted. “Those who are team players are going to prosper. Those who aren’t will struggle.”

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Last month, Brentwood-based Life-Point Hospitals hosted the inaugural meet-ing of the company’s newly formed National Physician Advisory Board in Durham, N.C. Rusty Holman, MD, MHM, chief medical officer for LifePoint, said the group was created to provide strategic guidance to the company to enhance clinical quality, physician engagement, and innovations in care delivery.

A key focus of the board will be to provide on-going leadership to support LifePoint’s efforts to develop integrated healthcare delivery systems within the com-munities served by its hospitals. The group will also share its collective expertise on is-sues ranging from IT solutions and health informatics to patient safety to provider re-cruitment, retention and satisfaction.

Holman noted some of the earliest topics being addressed are quality initia-tives, disease and population manage-ment models, technology and information management, and the development and advancement of talent within the organiza-tion. “We serve non-urban communities, and it’s so important to us to invest in and develop our people within these communi-ties,” Holman said.

The board, which currently includes nine physicians representing a cross-section of employed and independent physicians from across the country, has been in the works for several months. Part of that time, Holman explained, was spent looking for

physicians with diverse experience, exper-tise and backgrounds to ensure a variety of viewpoints and perspectives are represented around the table to meet the unprecedented challenges facing the healthcare industry.

“There was no time like the present to convene a group of physician thought lead-ers across our organization to advise and guide strategic decision-making as it relates to supporting LifePoint’s mission of making communities healthier,” Holman stated.

He noted, “So much of healthcare happens outside the hospital, and it is es-sential that we engage the physicians in our communities in order to provide a strong continuum of care for our patients.”

The July 9-10 meeting was the first time the board met in person to begin look-ing at the issues facing physicians, hospitals, practices, patients and communities. While the group’s mission statement was still in draft form at press time, Holman said the physicians around the table … both those

employed by LifePoint hospitals and those who have no formal ties to the hospital com-pany other than having privileges at one or more facilities … immediately gravitated to the corporate mission and vision. “With a shared sense of purpose and a shared vi-sion, then all future discussions can emanate from that common ground,” Holman said.

“The mission we discussed is to have a patient-centered and physician-led partner-ship to guide LifePoint’s mission of making communities healthier,” he continued. Hol-man noted that having a single physician on a corporate board was certainly one a way to meet that objective, but forming the Na-tional Physician Advisory Board provides the benefit of garnering the collective view-point … or not.

“There is value in both agreement and disagreement,” Holman stressed. “Differ-ing viewpoints will heighten a board’s or executive panel’s sensitivity to those issues. It really does enhance an informed point of

view.” While the panel’s job is to guide Life-

Point’s strategic mission from the depths of their own expertise, Holman said the mem-bers are also conduits to seeking input from other providers and relaying corporate in-formation and decisions back to community stakeholders. “I see the nine physicians in this group as being a vehicle for two-way communication with physicians in their communities and surrounding communi-ties,” he said.

Another point of consensus coming out of the inaugural meeting was the need to expand the group slightly to further drive diversity. While the first meeting was held on the Duke University campus, underscor-ing LifePoint’s unique partnership with the academic medical center, the next meet-ing is scheduled in Nashville in September. Holman said the intention is to convene quarterly with a lot of dialogue and confer-ence calls in between.

LifePoint Launches National Physician Advisory Board

The Inaugural Board Members

Sid King, MD, of Sumner Medi-cal Group in Gallatin is one of the nine inaugural members of LifePoint’s National Physician Advisory Board. The local physician is joined by:

• John Andazola, MD, FAAFP (Las Cruces, N.M.), Southern New Mexico Family Medicine Residency Program

• Michael Alan Caplan, MD (Danville, Va.), Piedmont Internal Medicine

• Jonathan Barry Dixon, MD (Somerset, Ky.), Lake Cumberland Regional Hospital

• William Hunter Housman, MD (Lexington, Ky.), MESA Medical Group

• William J. Jean, MD (Mar-quette, Mich.), Upper Michigan Car-diovascular Associates, PC

• Michael A. Kelly MD, FACEP (Daniels, W.Va.), TeamHealth Atlantic

• Jacques Yves LeBlanc, MD (Fort Morgan, Colo.), Salud Family Health Center

• Karen Murray Radley, MD (Price, Utah), The Family Clinic

physicians and industry stakeholders believe the ICD-9 code sets are obsolete and inad-equate. ICD-10 codes have more characters and a greater number of alpha characters creating space for new codes and flexibility for future medical advances.

ICD-10 has increased specificity that will improve the ability to identify diagnosis trends, public health needs, epidemic out-breaks, and bioterrorism events. In addition, ICD-10 will improve claims processing, quality management and benchmarking data.

A successful ICD-10 transition requires exhaustive preparation by medical practices. Yet recent research by the Medical Group Management Association indicates only 4.7 percent of practices reported that they have “made significant progress” when rat-ing their “overall readiness level for ICD-10 implementation.” The research was derived from respondents in 1,200 medical practices in which more than 55,000 physicians prac-tice.

Preparing to practice medicine in the world of ICD-10 is no small undertaking. It will require time and money. Having an experienced billing clerk “coder” in the practice will no longer be sufficient to gen-erate accurate codes. Simply converting the practice’s ICD-9 superbill to ICD-10 is problematic. Many industry experts don’t see the superbill being preserved at all. The American Academy of Professional Coders (AAPC) recently issued a two page ICD-9 superbill, which when cross-walked to ICD-10, became nine pages long. Another indus-try consultant sites an example of a two page ICD-9 superbill translating into a 48-page ICD-10 superbill.

Preparation for the medical practice begins with internal training and testing of all parties involved in producing proper cod-ing. Administrators must establish a training

and implementation schedule; set dead-lines; create a project team; identify train-ing resources; perform documentation gap analysis; evaluate and modify the practice’s forms; budget for transition expenses; com-municate with practice management (PM) software and EHR vendors; assess hardware and software update requirements; and ar-range testing with clinical and billing staff, PM and EHR vendors, clearinghouses and major health plans.

Providers must be trained on the changes in clinical concepts and the level of detail in ICD-10 so that their documenta-tion supports the ability to code to the high-est level of detail. For many specialties, it is highly recommended that physicians take anatomy and physiology refresher courses. Billing staff must increase their knowledge of anatomy and physiology, learn and adopt a completely different coding system and be able to code to the greatest level of detail. Training options include sending staff for offsite training, hiring an outside trainer to come to the practice, online training, webinar training and book-based training. Frequent testing and trial coding for all staff is also highly recommended in the months leading up to the ICD-10 ‘go live’ date.

In addition to internal preparation, medical practices must also arrange testing with their PM vendor, EHR vendor, clear-inghouse and major health plans. Many PM vendors and EHR vendors will not be ready to meet the ICD-10 compliance date. Prac-tices must communicate with their vendors months in advance to schedule software up-grades and testing to assure readiness. If the practice’s PM or EHR vendor is not going to be prepared for the ICD-10 launch, the practice will need to make plans to switch in time for the transition date. Many practices with in-house billing departments will weigh

the benefits of outsourcing the practice’s rev-enue cycle management.

Costs associated with the preparation for the ICD-10 transition are not insignifi-cant. Industry experts suggest budgeting $200,000 to $280,000 for an eight-physician practice. Expenses include training, testing, hardware upgrades and PM/EMR software upgrades. In addition to the one-time costs associated with implementation, many prac-tices will experience ongoing, recurring costs related to the need for increased coding staff, consulting services, subscriptions to print and software-based coding aids and reduced productivity as a result of increase need for documentation and coding complexity.

The ICD-10 transition will undoubt-edly eclipse Y2K and the HIPAA 4010 to 5010 transition in terms of the impact on the healthcare industry. Unprepared prac-tices will face painful disruptions in cash flow and a chaotic scramble to regain practice productivity. Even well prepared practices that execute ICD-10 implementation flaw-lessly will likely experience some disrup-tion in cash flow. Remember, a successful revenue cycle requires every entity in the claims processing chain be fully prepared for ICD-10. The PM system, EMR system, clearinghouse and payer must all communi-cate properly electronically and adjudicate ICD-10 claims correctly. Some bugs are inevitable. Practices should have in place a line of credit sufficient to cover three months operating expenses prior to ‘go live.’ Prepa-ration will take considerable planning, time and money and should begin immediately. Oct. 1, 2014 is just around the corner.

Bill Hefley, MD, is president and CEO of MedEvolve, offering a full range of highly evolved application software, interoperability interfaces, and revenue management services focused on practice profitability and efficiency. Visit the website at www.medevolve.com

ICD-10: Are You Ready? continued from page 1

Dr. Rusty Holman


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Through special funding, tnREC is Through special funding, tnREC is offering free or low-cost health information technology services if an EP meets the Medicaid patient volume thresholds.

We help healthcare providers take We help healthcare providers take the right steps to implement new technologies that enhance and improve the quality of care available.

Apply onlinewww.tnrec.org

This presentation and related material was prepared by tnREC, the HIT Regional Extension Center for Tennessee, under a contract with the Office of the National Coordinator for Health Information Technology (ONC), a federal agency of The Department of Health and Human Services (HHS). Contents do not necessarily reflect ONC policy. 90RC0026/01 13.TREC.04.049

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By CINDy SANDERS

As the nation’s health-care delivery system moves toward integrated care models where teams of providers work in concert to keep patients well or restore them to health, having the abil-ity to securely share information across care settings is vital.

Achieving this goal is one step closer in Tennes-see as the Health eShare Direct Project moves from the pilot stage to a broad-based program open to all pro-viders. Working in partnership, the Of-fi ce of eHealth Initiatives and Qsource, a Tennessee-based nonprofi t healthcare quality improvement and information technology company, are encouraging the adoption of health information exchange (HIE) utilizing Direct technology. Direct is a secured messaging system that allows healthcare providers, facilities, clinical labs, patients and public health offi cials to send and receive encrypted electronic health information.

George Beckett, HIT coordinator for the Offi ce of eHealth Initiatives, said Direct, which is available nation-ally, is meant to be one of the universal information exchange methods for healthcare providers. “It really is ‘medical mail’ for everyone,” he explained.

Beckett continued, “It was always a HIPAA violation to send patient information through email before Direct. Now, providers do have permis-sion to use this secured messaging sys-tem.” Beckett added the technology is also available for patient use.

By January 2014, all certifi ed elec-tronic health records will be required to have Direct built into their system. How-ever, even facilities or providers without an EHR can access the technology as a stand-alone component. “In fact, many of the providers we worked with in the pilot did not have an EHR, and it still worked,” Dawn FitzGer-ald, CEO of Qsource, said of information shar-ing.

For those taking advantage of HITECH incentives, she added, the ability to securely share patient data is a key component of meeting Stage 2 meaningful use requirements. In fact, FitzGerald continued, “There are several elements of meaningful use that can be met through Direct.”

Five healthcare organizations in Chattanooga and Memphis participated

in the pilot phase of the Health eShare Direct Project. The

four Chattanooga or-ganizations were HealthSouth Chat-tanooga Reha-bilitation Hospital, Erlanger Health System, Southeast Tennessee Area Agency on Aging and Disability and Home Health Care of East Ten-nessee, Inc. and Hospice. In Mem-

phis, Health Choice LLC, a joint venture between MetroCare Physicians and Meth-odist LeBonheur Healthcare, also par-ticipated. Health Choice has developed a patient-centered medical home model for their region called Memphis Accountable Care Home (MACH1).

FitzGerald said working with the Of-fi ce of eHealth Initiatives to roll out the Direct technology was a natural extension of the relationship that already existed between the state and Qsource, the au-thorized Tennessee’s Regional Extension Center (tnREC) charged with helping providers statewide integrate HIT and adopt EHRs. “It was the perfect marriage to create the technical last mile for mean-ingful use to get EHRs to talk to each other rather than live in a physician offi ce silo,” she said.

FitzGerald added the pilot program provided a number of lessons regarding implementation and usage. Once par-ticipants got used to relying on the tech-nology, they found a lot of effi ciencies in replacing the fax machine with Direct transmission. “The healthcare industry demands greater effi ciency and cost re-duction, and sharing health information is needed to operate in this new environ-ment,” said FtizGerald.

Beckett said the expectation is that Direct will catch on for the same reasons email has become so popular. Unlike the fax machine where an employee must print out information, leave his worksta-tion, key in a phone number, feed the documents and then call to verify the in-formation was received and delivered to the appropriate person, Direct messaging allows that same information to be trans-mitted securely to the intended recipient without the sender ever having to leave his keyboard.

“Transmitting health information electronically can reduce clerical errors and provide a full picture of a patient’s status for all involved in the continuum of care,” said FitzGerald. She added the ease of sharing information could also eliminate duplicate testing and procedures to reduce overall costs. Other benefi ts of Direct include the ability to quickly and reliably send orders to labs and receive re-sults, streamline offi ce workfl ow and sim-

plify reporting to payers.During the pilot program, Qsource

worked with a couple of leading tech-nology companies and helped individual providers register, authenticate and verify their Direct address. However, FitzGer-ald said more certifi ed vendors are being added to the website and noted Qsource is ‘vendor agnostic.’

Although there is no charge for the sup-port services provided by Qsource, the Di-rect license typically costs between $10-$15 a month. However, Beckett said the program is offering a one-time incentive per partici-pant per account for those signing up and demonstrating use of their Direct address. “Providers will actually get a check for $500,

which will pay for two to three years of their Direct license,” Beckett noted.

In order to tap into the maximum effi ciency of interoperability and secure messaging, both Beckett and FitzGer-ald stressed the need for broad adoption across the continuum of care. The pro-gram, therefore, is open to a range of indi-viduals and facilities delivering healthcare including mid-level providers, long term care facilities, hospice providers, rehabili-tation facilities, eye doctors and dentists. “We are looking for about 4,000 providers to come forward between now and next January,” said Beckett. Added FitzGerald, “Our goal is by September of this year that everyone will have heard of Direct.”

You’ve Got (Secure) MailState Expands Health eShare Direct Project after Successful Pilot

Interested in Direct?Go online to www.HealtheShareTN.com.

In addition to the online information, there are a number of up-coming educational conferences across the state for those who want to learn more about the technology. The Health eShare Direct Project will also have a presence at several association meetings including the TMGMA Legislative/Payer Conference in Memphis in late August, the TN HIMSS Summit of the Southeast in Nashville in September, and the THA meeting in Nashville in late October. For a full list of conferences and dates click on the “Events” tab of the website.

George Beckett

Dawn FitzGerald

By CINDy SANDERS

As the nation’s health-care delivery system moves toward integrated care models where teams of providers work in concert to keep patients well or restore them to health, having the abil-ity to securely share information across care

Achieving this goal is one step closer in Tennes-see as the Health eShare Direct Project moves from the pilot stage to a

in the pilot phase of the Health eShare Direct Project. The

four Chattanooga or-ganizations were HealthSouth Chat-tanooga Reha-bilitation Hospital, Erlanger Health System, Southeast Tennessee Area Agency on Aging and Disability and Home Health Care of East Ten-nessee, Inc. and Hospice. In Mem-

phis, Health Choice LLC, a joint venture

State Expands Health eShare Direct Project after Successful Pilot


HealthcareEnterprise

Relatient The Patient Relationship & Engagement Engine That Can

By KELLy PRICE

As lives get busier and calendars be-come more crowded with appointments, engagements, responsibilities, and unend-ing to-do lists, “reminding” is becoming a big business. This is especially true in the changing world of healthcare.

As reimbursement models continue to shift toward accountable care and outcomes-based medicine, there will be a growing need … and bigger role … for im-proved patient compliance.

Enter Relatient — the only com-plete, web-based patient relationship and engagement engine of its kind. Borrowing from the classic children’s story, this is a little engine that “can.” Relatient can as-sist healthcare organizations with patient outreach by automating the communica-tion necessary to create a more compliant, and ultimately healthier, patient popula-tion. Relatient’s customers include pro-vider groups, hospitals, ACOs, PCMHs and employers.

Sam Johnson, co-founder of Relatient, LLC, and an EHR veteran, saw a growing market need for a competitive, con-sumer-driven movement in healthcare. He also recognized that “the data collected in EHR systems was not being used for anything. It was just lying dor-mant inside today’s digital chart rooms.” He began to think of ways this data could be useful to providers and patients.

Johnson asked, “Is the data being col-lected in a systematic and disciplined man-ner in order to make ‘meaningful use’ of that data?” He continued, “We believe that ‘meaningful use’ supersedes how a prac-tice records their data. It should be used to benefit lives … and consequently enhance practice revenues. The question is ‘how will your organization manage all of those de-tails in an affordable way?’

The Relatient technology offers the an-swer,” he answered.

“This is not new,” Johnson continued, “but it is most certainly gaining momentum now, and we’ve made it affordable for every practice.”

Working with expert IT program-mer Kevin Montgomery of Cookeville and his Solutions ITC company, Relatient emerged in 2012 as a cloud-based patient engagement technology that can be applied to all categories of patient communication. Whether the message is related to health maintenance, appointments or collections, Johnson noted, “Relatient allows the indi-vidual care provider to decide how, when, and at what interval, those health reminders are delivered.”

Noting patients can be divided into three groups — The Compliant, The Dis-tracted, and The Careless — the Relatient

team focuses on finding ways to move more patients into the compliant category to ben-efit their lives, while simultaneously making the provider more successful and efficient.

RelatientEHR™ (electronic health reminder) is made up of custom, provider-specific criteria sets, which are stored in the Relatient cloud, to create a policy of auto-matic health reminder triggers that contact patients at designated intervals. This auto-mated outreach results in a communication that is personalized, consistent, and effort-less after the initial setup.

Other message applications range from appointment reminders to dissemi-nating preventive care information to col-lection reminders to patient satisfaction surveys. RelatientODM™ (on demand messaging) can even send instant notifica-tions to patients listed on the day’s schedule to alert them of staff delays, office closures, or other unplanned events.

Johnson pointed out that the chang-ing mindset of today’s patient demands a changing strategy from providers. “Yes-terday’s passive marketing approach won’t work in today’s social marketing world,” he said. “Today’s consumers (of anything) are being taught to listen to their mobile device and respond to automated reminders. Get within 100 yards of a Starbucks with your smartphone today, and you’ll be reminded of your need to buy coffee.”

Johnson said Relatient’s technological advantage takes care of the “massive” gaps in care that are identifiable with today’s electronic health records. “Practices that are weak in ability to mine data and are not able to convert those results into actionable outreach strategies won’t be able to close those gaps in care,” he said.

He continued, “Patients need to be reminded of everything, including things as simple as today’s appointment and as com-

plex as what screening procedure they are overdue for this year based on their family medical history or genetic makeup.”

Johnson noted, “It boils down to ac-tive communication. When was the last time you didn’t hear from your hotel chain or airline choice just prior to your leisure trip? Healthcare is more complex than a quick trip to Disney, and more consumers utilize healthcare than any number of tour-ist destinations combined. Setting up con-tact policies for disease states, risk groups, or health maintenance reasons is not only smart … but proves a thought leadership which will stand out in the next decade or so of healthcare.”

Ultimately, he said, the take-away message for providers is that they can be a leader in patient engagement by utiliz-ing the technological tools available today. “That’s where Relatient comes into the pic-ture,” Johnson concluded.

Hamory is a nationally known speaker on designing care for value and improved quality. As Geisinger’s System chief medi-cal officer from 1997 to 2008, he led the growth of a 535-physician multi specialty group practice to 750 physicians in 40 lo-cations serving 41 counties and the three Geisinger hospitals. He also oversaw the installation of an advanced EHR, led the development of a physician compensation model incorporating pay for performance, and a reorganization from discipline-based

departments to a service line operating structure.

Hamory’s other responsibilities included compensation, quality and performance im-provement, credentialing, clinical operations, and capital planning, as well as education and research for the health system.

Before joining Geisinger, he was a pro-fessor of Medicine and associate dean for Clinical Affairs at Penn State University. Hamory also served as executive director of Penn State’s University Hospitals and

chief operating officer for Penn States Mil-ton S. Hershey Medical Center. In addition to serving on several boards, Hamory also serves on a number of national committees and panels concerned with improving the quality of medical care and use of informa-tion technology in healthcare.

Blue Cross Blue Shield Tennessee Health Institute was presenting sponsor of the Nashville Health Care Council event. Bass, Berry & Sims and Intel were support-ing sponsors.

Hamory Addresses, continued from page 8

Former Geisinger Exec Joins JarrardNashville-based healthcare communications firm Jarrard Phillips Cate & Hancock has recruited Susan Alcorn, former chief com-

municaitons officer for Geisinger Health System, as senior vice president. At Geisinger, Alcorn led a team responsible for all public relations, marketing communications, media rela-

tions, employee communications and issues and crisis management across the $4-billion integrated health services organization. She is also the former president of and a past member of the board of directors for the American Hospital Association’s Society for Healthcare Strategy and Market Development, the professional association for hospital communications, marketing and planning professionals.

“Susan brings our clients her rich perspective from leading communications and positioning at one of the country’s most innovative and highly regarded healthcare systems,” said David Jarrard, president and CEO of Jar-rard Inc. “In her 15 years of leadership at Geisinger, Susan tackled many of the communications challenges facing hospitals and health systems across the country: mergers and acquisitions; healthcare reform; re-engineering; and physician and employee relations. Our clients will be well served by Susan’s experience.”

Prior to Geisinger, Alcorn served in executive public relations positions for several hospitals and health systems in New Jersey. Recently, Alcorn and Jarrard co-authored Healthcare Mergers, Acquisitions, and Partnerships: An Insider’s Guide to Communica-tion, which was published through HealthLeaders Media.

Susan Alcorn

At the end of July, the American Hos-pital Association Board of Trustees announced the election of Jonathan B. Perlin, MD, president of clinical and physician services and chief medical officer of HCA, as its chair-elect designate. Perlin will assume the chairmanship in 2015, becoming the

top elected official of the national organiza-tion that represents America’s hospitals and health systems.

Since 2006, Perlin has provided lead-ership for clinical services and performance improvement at HCA’s 161 hospitals, 114 ambulatory surgery centers and approxi-mately 650 physician practices. Under his direction, HCA has been a leader in a num-ber of areas, particularly perinatal safety and infection prevention.

Perlin currently serves on the board of trustees for the AHA, National Patient Safety Foundation and Meharry Medical College. He also has served on the boards of the Na-tional Quality Forum and The Joint Com-mission. He chairs the Department of Health and Human Services Health IT Standards Committee. Broadly published on health care quality and transformation, he is a fellow of the American College of Physicians and the American College of Medical Informatics.

Dr. Jonathan B. Perlin

Perlin to Chair AHA Board in 2015

Sam Johnson


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By LyNNE JETER

Just before Thomas Pre-witt, MD, relocated to the University of Mississippi Medi-cal Center (UMMC) as asso-ciate professor of surgery and director of health policy, a breast surgical oncologist, an educator, and a health policy advisor to the vice chancellor, he detoured to Salt Lake City, Utah, to complete Intermoun-tain Healthcare (IHC)’s Insti-tute for Health Care Research and Advanced Training Pro-gram (ATP), the international standard bearer for healthcare delivery improvement training programs.

“I was so very inspired by my time spent in that program, and I wanted to do that sort of work,” said Prewitt, who joined HORNE on Jan. 2, 2012, to launch the Health-care Delivery Institute (HDI). HORNE is among the nation’s top 100 accounting and business advisory firms, and repre-sents one of the southeast region’s top 10.

Patterned after IHC, the HDI has two components: the ATP focusing on healthcare delivery improvement training, and clinical improvement services with HORNE partner, Health Catalyst. “I’m still practicing medicine,” explained Pre-witt, “but more from a macro than micro level. It’s very rewarding.”

For the ATP, participants meet two-and-a-half-days a month for four months to complete the training program, of

which a total of 80 CME hours are avail-able.

“This is for people who are going to be true leaders in healthcare, and that was certainly the case for the people I trained with at Intermountain,” said Prewitt, noting that all learning takes place in a classroom, not online. “Face-to-face re-lationship building of participants is very important. So much of learning occurs at the participant level, with the cross-talk about experiences taking up a large part of training.” Cost of the ATP is $5,000, with incremental discounts for multiple participants from the same institution. It’s a bargain compared to $10,500 for a 20-day executive session at IHC, and a simi-

lar program at the Institute for Health-care Improvement in Cambridge, Mass.

Graduates of the inaugural ATP include health-care leaders and physicians from Mississippi and Tennessee.

“It’s encourag-ing to meet a group of medical leaders who see the innova-tion challenge as an opportunity rather than an unwanted burden,” said HDI instructor Andre Delbecq, DBA, the J. Thomas and

Kathleen A. McCarthy University Profes-sor at Santa Clara University.

HDI instructor Niall Brennan, direc-tor of the Office of Information Products and Data Analytics, Office of Enterprise Management for the Centers for Medi-care and Medicaid Services (CMS), was inspired “seeing the energy in the room of frontline care providers as they realized

the potential of data to improve care.”HDI instructor Larry Grandia, a

Health Catalyst board member, said tech-niques taught in the ATP have eliminated “spotty” results of applying classic perfor-mance improvement techniques to clini-cal care processes by offering a solution to data access and also focusing on quality.

“Clinicians welcome performance improvement when high quality is the de-sired outcome,” he said. “Experience … has proven that consistent higher quality actually reduces cost, not the reverse.” (See sidebar for more detail.)

HDI is gearing up for the fall and winter sessions, which can accommodate up to 30 participants per term. The geo-graphic reach for the next classes will in-clude Medical News’ 14 markets.

“No pre-requisites needed,” ex-plained Prewitt. “Participants are those likely to be leading improvement teams while also reducing costs. They’re two sides of the same coin; it reduces variation at the level of the clinical enterprise. I just returned from a health data conference, and it’s amazing how some major players still don’t understand some of that messag-ing. It’s the overarching goal we’re striving to communicate.”

For more information, visit www.horne-llp.com.

Healthcare Delivery InstituteTennessee, Mississippi graduates of HORNE’s charter ATP class better prepared for post-reform era

True NorthWhen Healthcare Delivery Institute (HDI) instructor Larry Grandia served

as Intermountain Healthcare’s director of information systems, he was intimately involved in ways to increase quality and reduce cost by collecting and analyzing operational data in search of ways to eliminate unnecessary or inefficient processes.

“The results were consistently astonishing,” he said. “Higher quality, lower cost, and more consistent and predictable care were always the outcome. It’s hard work, but with the right data, right tools and right people involved, improvement is assured.”

The good news: operational data in healthcare is abundant. The bad news: typically data are isolated within discrete, operational

systems.“Extracting and linking these data to each other in a nimble enterprise

data warehouse exposes the collective data to analytic tools like Key Performance Analysis, resulting in real insight into performance improvement opportunities,” he said.

The only question about inevitable industry change involves how much will come from externally-imposed change, compared to internally-driven performance improvement through systematic elimination of waste, Grandia said.

“Interestingly, the more internally-driven change that occurs, the less externally-driven change is required,” he said. “Further, whichever healthcare provider seriously initiates the data-driven improvement journey, the better that organization will be prepared for future success, regardless of the transformation approach ultimately selected. The ATP approach will never lose its value with the passage of time. Data-driven continuous process improvement will be a – if not the – sustainable winning strategy for all future healthcare organizations.”

Presenter Thomas D. Burton, senior vice president and co-founder of Health Catalyst. Well known as a clinical quality improvement guru, he was a member of the team that led Intermountain Healthcare Institute’s nationally recognized improvements in quality of care delivery and reductions in cost.


GrandRounds

Save the DateAug. 15-16 • Tennessee Breast

Cancer Coalition’s 17th Annual Celebration of Life Golf Classic & Auction PAR-tee • Hermitage Golf Course

More than 275 auction items avail-able Thursday evening followed by the tournament on Friday with two shotgun starts at 7:30 am and 1:30 pm. For infor-mation, go to: www.tbcc.org/golf.htm.

Aug. 22-23 • 2013 TMGMA Legislative/Payer Conference • Downtown Marriott • Memphis

Reform, reimbursement and regu-lation are recurring themes for the 2013 event. With the changing healthcare landscape, TMGMA notes 2014 will be a pivotal year in healthcare management. Sessions include critical information on payer contracting, ICD-10, new regula-tory compliance issues, eHealth Direct and more. To register, go online to www.tmgma.com.

Aug. 22-24 • Women Survivors Alliance (WSA) Inaugural Event • Gaylord Opryland Resort & Convention Center • Nashville

Nashville will play host to more than 2,000 survivors, caregivers, family members and healthcare professionals at the National Women’s Survivors Con-vention. Guest speakers for the inaugu-ral event include cancer survivors and Olympic Gold Medalists Shannon Miller (gymnastics) and Scott Hamilton (figure skating) plus many others. The three-day experience for women survivors of all types of cancers offers a program of interactive workshops, keynotes, net-working with other survivors, a special track for younger survivors (ages 18-35), an expo, makeovers, spa experiences, a 5K, individual breakout sessions and a celebrity concert finale. To register for the conference or more information, visit www.survivorsconvention.com.

Aug. 28 • The TAMHO Symposium • Hotel Preston • Nashville

The event by the Tennessee Asso-ciation of Mental Health Organizations focuses on security, privacy and contin-gency plans for behavioral health pro-viders. Sessions include information on the HIPAA Omnibus Final Rule, security concerns in the IT environment, key ele-ments of a contingency plan, and more. The daylong event begins at 9 a.m. For more information or to register, go to www.tamho.org.

Sept. 5-6 & 12-13 • Registration Deadline Aug. 27 • Saint Thomas Health Faith Community Nursing Classes • Saint Thomas West Hospital

Saint Thomas Health is hosting a Faith Community Nursing (FCN) Pro-gram to help grow and support faith community or “parish” nursing, a spe-cialized area of nursing where registered

nurses help care for the congregation of a church and promote overall wellness in the community. The 32-hour course is open to registered nurses throughout Tennessee, Kentucky and Alabama and will be held from 7 am-5 pm with free breakfast and lunch included.

Class fee is $350 and includes all educational materials and meals. Spon-sorship from nurses’ local church lead-ership is encouraged. Financial schol-arships are available. To register, visit www.sths.com and click on “Classes and Events.” Select Sept. 5 and click the course name.

Sept. 24-26 • Early Bird Registration Deadline Aug. 23 • Infocast’s Healthcare Deal Making Summit 2013 • Nashville Music City Center

Healthcare executives come to-gether with leading investors and fi-nancial service providers to explore business strategies, models and invest-ments in a post-ACA world. For more information, go to www.information-forecastnet.com/events/healthcare13.

Saint Thomas Health Renames Member Hospitals, Makes Executive Leadership Changes

Last month, Saint Thomas Health announced the renaming of its family of five hospitals in Middle Tennessee to better reflect the organization’s com-mon mission.

“Renaming our hospitals unites us in our mission and publicly reflects the size and scope of our health system, as well as the collaboration that has ex-isted among the hospitals for the past 10 years,” said Michael Schatzlein, MD, president and CEO of Saint Thomas Health.

The hospitals will now be known as:Saint Thomas West Hospital (for-

merly Saint Thomas Hospital)Saint Thomas Midtown Hospital

(formerly Baptist Hospital)Saint Thomas Rutherford Hospi-

tal (formerly Middle Tennessee Medical Center)

Saint Thomas Hickman Hospital (formerly Hickman Community Hospital)

Saint Thomas Hospital for Spinal Surgery (formerly The Hospital for Spi-nal Surgery)

The organization has also restruc-tured its leadership. Dawn Rudolph, currently president and CEO of Saint Thomas West Hos-pital, will become chief experience officer for Saint Thomas Health. In her new role, Rudolph’s focus will be operationalizing patient, physician and family experience strate-gies across all facilities. This will include monitoring patient satisfaction scores, providing tools to address improve-ment opportunities and creating poli-cies and procedures to insure a consis-

tent, yet distinctive, experience for all Saint Thomas Health facilities. “With the rise of accountable care organiza-tions, patient loyalty can mean the dif-ference between success and failure, making satisfaction an organizational imperative,” Schatzlein said. “Most important, delivering a positive experi-ence is essential to the core mission of the Saint Thomas Health ministry. It’s the right thing to do.”

Bernie Sherry, currently president and CEO of Saint Thomas Midtown Hospital will be-come president and CEO of Nashville Inpatient Op-erations for Saint Thomas Health. In this role, Sherry will oversee operations at both Saint Thomas Mid-town Hospital and Saint Thomas West Hospital. He will help to accelerate syn-ergy between the two Nashville facili-ties including rationalization of service lines and capital allocation.

Training Program Meets ‘Critical Need’ for Earlier Autism Identification

Last month, Vanderbilt University Medical Center researchers released the results of a three-year study that evaluated the effectiveness of a training program designed to enhance autism spectrum disorder (ASD) identification and assessment within community pe-diatric settings across Tennessee in the journal Autism. The hope is to more rapidly diagnose the disorder that now affects an estimated 1:88 children. Early intervention has been documented to be critical to outcomes.

After participating in training to learn strategies for conducting rapid di-agnostic assessments following positive ASD screenings, pediatricians reported significant changes in their screening and consultation practices, with 85 per-cent reporting an increase in numbers of children with autism evaluated within their practice. The study also found that pediatric providers were nearly as ac-curate as specialists in their diagnoses, with agreement seen in more than 90 percent of all cases.

“Ideally, definitive early diagnosis of ASD would be rapidly accomplished by a team of developmental special-ists, and children at risk for diagnosis would obtain services immediately after screening positive. The reality is that such diagnostic teams, or even indi-vidual professionals, are not available in most locations,” said corresponding author Zachary Warren, PhD, associ-ate professor of Pediatrics, Psychiatry and Special Education and director of the Vanderbilt Kennedy Center’s Treat-ment and Research Institute for Autism Spectrum Disorders (TRIAD) at Vander-bilt. “Even when available, the waitlists for diagnostic services are so long that children referred for evaluation wait

extended periods of time for diagno-sis. As a parent, I cannot fathom how stressful it would be to be told that your child may have autism, and we’ll let you know the answer to that question in six to 12 months.”

Although advances have been made in early screening, the most re-cent CDC data suggests the diagnosis is still not made until 4-5 years of age. “Essentially, more children are being referred for a very limited number of ex-pert diagnostic assessment resources. Because of this, wide-scale screening for ASD at young ages may in fact in-crease wait times for diagnostic assess-ment,” said Warren. “Given this con-text, it is critical to develop enhanced ASD-specific diagnostic training pro-grams if we hope to shift the age of di-agnosis and promote earlier access to early intervention.”

The training was designed to teach enhanced diagnostic consultation and interactive screening procedures to community pediatricians so that they could offer families the opportunity to be rapidly evaluated within practice rather than being referred to a specialty clinic, where they would likely have to wait many months before being seen.

Well-Being a Predictor for Identifying Those at High Risk for Hospital and Emergency Room Admissions

In a first-of-its-kind study looking at 8,800 employees at a Fortune 100 com-pany, Healthways researchers found the level of overall well-being to be the most predictive variable for hospitaliza-tion events, even controlling for factors known to increase risk.

In the study, middle-aged Ameri-cans with high well-being were less likely to be admitted to the hospital than younger Americans with medium to low well-being. Those people in each age group with the highest well-being had significantly lower risk of a hospi-tal event. The study was published in the peer-reviewed journal Population Health Management.

“The study breaks with the notion that age alone is the primary determi-nant of poor health,” said Elizabeth Rula, PhD, co-author of the study and principle investigator of Healthways Center for Health Research. “In fact, 26-year-olds with low well-being had a higher risk for a hospital event com-pared to 60-year-olds with high well-being.”

She continued, “Well-being is a powerful predictive factor, regardless of age. Research shows improving well-being can keep people out of the hos-pital, which has a dramatic impact on cost and productivity for employers.”

Dawn Rudolph

Bernie Sherry

More Grand Rounds Online nashvillemedicalnews.com


Tennessee Early Elective Deliveries Down 75 Percent in Seven Months

At the end of May 2012, prevent-able early deliveries at 37 Tennessee hospitals that provide labor and deliv-ery services accounted for 14.1 percent of all deliveries. By the end of last year, that number had dropped to just 3.5 percent of all births, according to data released this summer by the Tennessee Hospital Association (THA).

The drop is no coincidence. Healthy Tennessee Babies are Worth the Wait, a partnership launched last year by the Tennessee Center for Patient Safety (TCPS), Tennessee Initiative for Peri-natal Quality Care (TIPQC), Tennessee Department of Health (TDH), March of Dimes (MOD) and the Tennessee Hospital Association (THA), set out to improve awareness about the benefits of full-term delivery among expecting parents, their families, health providers and organizations that serve pregnant women.

TMA, INSBANK Partner to Create Physician Banking Division

Last month, the Tennessee Medical Association and INSBANK announced a multi-year agreement to establish TMA Medical Banking, which will pri-marily provide Tennessee’s physicians customized financing solutions for working capital, medical equipment and facilities, and practice acquisitions. Members will also have access to cus-tomary banking products and services. Finworth Mortgage, LLC, a subsidiary of INSBANK, will offer mortgage solutions for TMA members and employees.

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

Kelly Carden, MD, a sleep medi-cine expert with Sleep Medicine of Middle Tennessee, an affiliate of Saint Thomas Physician Services, has been elected to serve on the Board of Directors of the American Academy of Sleep Medicine (AASM). Carden previously served as chairman of the AASM’s Committee on Coding and Compliance, vice chairman of the Health Care Policy Committee and was named a fellow of the AASM in 2005 for her accomplishments in the field of sleep medicine.

Gregory R. Weaver, MD, a partner with Radi-ology Alliance, PC, was recently inducted as a fel-low in the American Col-lege of Radiology (ACR). The induction took place at a formal convocation ceremony during the ACR Annual Meet-ing and Chapter Leadership conference in Washington, D.C.

LBMC Technologies has been se-

lected as a member of the Bob Scott’s Top 100 VARs for 2013, a group of 100 organizations honored for their accom-plishments in the field of midmarket fi-nancial software. Members of the Top 100 mid-market resellers were selected based solely on annual revenue.

Tim Jones, MD, state epidemiolo-gist and director of the Tennessee Department of Health Communicable and Environmental Dis-eases and Emergency Preparedness division, has assumed the presi-dency of the Council of State and Territorial Epidemiologists for 2013-2104. Jones has been with TDH since July 1999.

The American Gastroenterological Association (AGA) has honored Pelayo Correa, MD, with its Distinguished Achievement Award, which recognizes an individual for contributions to research that have advanced the science and prac-tice of gastroenterology. He is interna-tionally recognized for his work in the pa-thology and epidemiology of GI cancers and has been instrumental in identifying the multistage mechanisms involved in gastric carcinogenesis. Correa is Anne Potter Wilson Professor of Medicine in the Division of Gastroenterology, Hepa-tology and Nutrition and professor of Pa-thology, Microbiology and Immunology at Vanderbilt University Medical Center.

Vanderbilt University Medical Center has once again been recog-nized by U.S. News and World Report’s recently released “America’s Best Hos-pitals” guide. In the 2013-14 edition, VUMC placed among the best in the na-tion with four specialties ranked among the top 10 nationally. The academic medical center equaled an all-time best with 11 out of a possible 16 specialty programs being ranked among the top 50 in their respective fields. VUMC was also again lauded as both the No. 1 hospital in Tennessee and No. 1 in the Metro Nashville area in the magazine’s “Regional Recognitions” segment of its annual ranking.

Nashville law firm Waller was re-cently recognized by the American Health Lawyers Association (AHLA). The June 2013 issue of AHLA Connec-tions magazine highlighted Waller as the nation’s third largest healthcare law firm based on AHLA membership — up from number four in 2012. This is the firm’s seventh consecutive year on the industry-esteemed “Top Ten” list. The company was also recognized for Most Members in Tennessee and #1 in South-east Region, among other participation honors. Also honored in the “Top Ten in 2013” was Baker Donel-son in the tenth slot.

John Chauvin, MD, internist at TriStar Summit Medical Center, has been inducted as a Fellow of the American College of Physicians (ACP), the na-

tional organization of internists. He was inducted during the annual meeting in San Francisco.

The National March of Dimes re-cently honored four exceptional nurses and awarded each a scholarship for graduate and doctoral studies in the field of maternal-child nursing. Among the national award-winners was Kath-leen Danhausen, SNM, MPH, of Nash-ville, who is seeking a master’s degree with a specialization in nurse midwifery and family health at Vanderbilt Univer-sity School of Nursing. Her goal is to ad-dress the roles social and environmen-tal factors such as stress, poverty, and housing, play in pregnancy and parental care. Danhausen has volunteered ex-tensively to provide low-income women with medical and prenatal care.

The Buffkin Group has been ranked by Modern Healthcare as the top healthcare search firm in Nashville in the recent national rankings of the industry’s top executive recruiting firms.

NAMI, the nation’s largest grass-roots mental health organization, re-cently honored local psychiatrist David Street, MD, among 20 professionals nationwide given Exemplary Psychia-trists Awards for going above and beyond. Street was honored at the Amer-ican Psychiatric Associa-tion’s annual conference in San Francisco and at NAMI’s annual meeting in San Antonio.

Recent Certifications, Accreditations & Commendations

BlueCross BlueShield of Tennes-see has named TriStar Skyline Medi-cal Center a Blue Distinction Center in Spine Surgery. The Blue Distinction Centers for Specialty Care® program is a national designation awarded by BCBS companies.

The Vanderbilt Stroke and Cere-brovascular Service has received ad-vanced certification as a Comprehen-sive Stroke Center by The Joint Com-mission and the American Heart Asso-ciation/American Stroke Association, one of only four in Tennessee.

TriStar StoneCrest Medical Cen-ter in Smyrna been awarded a three-year term of accreditation in magnetic resonance imaging (MRI) as the result of a recent review by the American Col-lege of Radiology (ACR).

Behavioral health not-for-profit Centerstone Research Institute (CRI) received exemplary commendation from the Commission on Accreditation of Rehabilitation Facilities (CARF) In-ternational because of its utilization of Enlighten AnalyticsTM, a business intel-ligence tool. Created by CRI, Enlighten AnalyticsTM is an interactive healthcare analytics platform that captures rev-enue, cost, productivity and quality outcomes data collected by healthcare providers and reports it in simple-to-

interpret charts and graphs.Sumner Regional Medical Center

recently announced Leila August, MD, medical director of HighPoint Hospice, has achieved a certificate from the Amer-ican Board of Family Medicine, and is now also board certified in hospice and palliative medicine. She was already a board-certified family practice physician on staff at the Gallatin hospital.

Saint Thomas Midtown Hospital has received full chest pain accredita-tion with percutaneous coronary inter-vention (PCI) from the Society of Car-diovascular Patient Care (SCPC), for-merly the Society of Chest Pain Centers, an international organization dedicated to eliminating heart disease as the num-ber on cause of death worldwide.

Cogent Names Weiland President, CEOCompany Also Rebrands to Former Name

It has been a couple of busy years filled with change at Cogent Healthcare … Cogent HMG … make that Cogent Healthcare (again). The company an-nounced late last month that industry veteran Dean Weiland has been hired as president and CEO. The move, which comes amid a number of changes among top executives, was unveiled along with the announcement that the hospitalist staffing company would revert to its old name of Cogent Healthcare Inc.

Weiland assumes the CEO role from executive chairman Randy Thur-man (whose position was formerly held by Gene Fleming), who recently took the place of John Donahue (who took the place of HMG founder Stephen Houff) when Donahue stepped down as CEO after 18 months on the job. Thurman is an operating executive with AEA Inves-tors, LP, Cogent’s majority owner.

Prior to Cogent, Weiland was a founder and COO of Renal Advantage, spearheading the merger of the compa-ny with Liberty Dialysis. He then led the merger of Renal Advantage with Frese-nius Medical Care. Prior to that, Weiland was CEO of The Work Institute, COO of CLEARTRACK Information Network and executive vice president at MedStat Inc.

Avenue Launches Medical/Professional Private Client Group

In late July, Avenue Bank an-nounced the addition of three expe-rienced bankers to expand its private client team and focus on the medical industry, physician practices and profes-sional services firms.

The trio, all formerly with SunTrust, is led by Steve Jaynes, senior vice presi-dent and director of the new medical and professional services unit within private client banking. Bob Lawhon and Mike Blanchard are joining Jaynes as senior vice presidents. The team will be based initially at the bank’s corporate office in the historic Baggage Building at Union Station.

GrandRounds

Dr. Kelly Carden

Dr. Tim Jones

Dr. John Chauvin

Dr. Gregory Weaver

Dr. David Street


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GrandRoundsPediatric Radiologist Pierre Joins Radiology Alliance

Ketsia B. Pierre, MD, has joined Ra-diology Alliance, PC, one of the largest private practices of ra-diologists in the state of Tennessee.

Previously she com-pleted a fellowship in pediatric radiology at Boston Children’s Hospi-tal. Board certified by the American Board of Radiology, Pierre specializes in pediatric and diagnostic radiology. She received her medical de-gree from the University of South Flori-da College of Medicine in Tampa and a

Master’s of Science and Clinical Investi-gation at Vanderbilt University Medical Center. After completing three clinical years of a general surgery residency at VUMC, she completed two years of surgical research, while earning her master’s degree, followed by a general radiology residency, also at Vanderbilt.

Hickson Promoted to New Senior VP Role at Vanderbilt

Gerald Hickson, MD, Vanderbilt University assistant vice chancellor for Health Affairs, associate dean for Fac-ulty Affairs and the Joseph C. Ross Pro-fessor of Medical Education and Ad-ministration, has been promoted to the

newly created position of senior vice president for Quality, Patient Safety and Risk Prevention.

Hickson, a pediatri-cian by training, will serve as the chief quality, pa-tient safety and risk pre-vention officer for Vanderbilt University Medical Center and all VU-related en-tities. He reports directly to C. Wright Pinson, MD, deputy vice chancellor for Health Affairs, senior associate dean for Clinical Affairs and CEO of the Vander-bilt Health System.

“This new position effectively con-solidates oversight responsibilities from across the clinical enterprise within the areas of quality improvement, patient safety and risk prevention to bring greater strategic alignment to these intrinsically related missions. Dr. Hick-son is uniquely qualified to serve in this role,” Pinson said.

Mazzo Appointed COO for River Park Hospital

Joseph Mazzo, RN, BSN, MA, CEN, has been named chief operating officer for River Park Hospital (RPH). A new position for the Mc-Minnvile hospital, RPH is a part of the joint venture Capella-Saint Thomas sys-tem of hospitals.

Mazzo comes to RPH from Centennial Medical Center where he has been vice president of Clinical Operations and administrative director of Critical Care Services since 2009. He has worked in clinical roles for the past 14 years, in-cluding leadership positions for the past eight. Prior to moving to Nashville, he was director of Emergency Services at North Short Forest Hills Hospital in New York. He also has experience working in the Emergency Departments of UCLA Medical Center and Cedar Sinai Medical Center in California. The Certified Emer-gency Nurse received his undergraduate nursing degree from Queens College in Charlotte, N.C. and his masters in nurs-ing in the Nurse Executive Program from Columbia University, Teachers College in New York City.

NextGxDx Names Noel CFOIn late July, NextGxDx Inc., which

provides an online genetic testing mar-ketplace for healthcare professionals and hospitals, announced veteran healthcare ex-ecutive Trey Noel III has joined its leadership team as chief financial officer.

Noel’s background includes multiple man-agement roles at McKes-son over the past nine years, most recently serving as vice pres-ident and general manager of McKesson Specialty Care Solutions. He received his undergraduate degree in Economics and MBA in finance and corporate strat-egy from Southern Methodist University.

TriStar Skyline Announces Plans for Level II Trauma Center, Opens Sleep Center

Last month, TriStar Skyline Medical Center announced plans to open a Level II Trauma Center, making it the second hospital in Middle Tennessee and Southern Kentucky to have special resources dedicated to treat complex and life-threatening injuries.

Following preliminary approval from the State of Tennessee Department of Health, TriStar Skyline plans to begin offering trauma services starting in September. This is the first step in the hospital seeking formal designation as a Level II Trauma Center. A one-year provisional period is required prior to a formal designation. Dur-ing that year, TriStar Skyline will undergo a review by the state on all aspects of the program including patient treatment and outcomes, quality improvement process-es, and evidence based care.

Roger Nagy, MD, was recently appointed as medical director for Trauma at Tri-Star Skyline. The hospital cited American College of Surgeons recommendation of having one to two high-level trauma centers per 1 million population. The Nashville MSA is anticipated to have a population of 1.6 million by 2016.

On Aug. 1, TriStar Skyline opened the new Sleep Disorders Center, located at 3443 Dickerson Pike in the Medi-cal Office Plaza. The center will diagnose and treat patients suf-fering from sleep apnea, nar-colepsy, restless leg syndrome, insomnia and other sleep disor-ders. The new center features a four-bed sleep laboratory and operates under the medical directorship of Murray Arons, MD. Patients receive care from licensed sleep technologists and a team of physicians who are board certified in pul-monology and sleep medicine. The center is accredited by the American Academy of Sleep Medicine.

AmSurg Breaks Ground on New Corporate HeadquartersThis summer, Nashville-based AmSurg Corp. broke ground on the company’s

new 110,000 square foot headquarters. Community and government officials were in attendance for the of-ficial ceremony, along with more than 300 local employees. Key-note speeches were provided by Mayor Karl Dean, AmSurg CEO Chris Holden, John Eakin of Eakin Partners and Ralph Schulz, president of the Nashville Area Chamber of Commerce.

AmSurg’s Nashville headquarters is currently split between two buildings in the Burton Hills office park located in Green Hills. In seeking to consolidate its headquar-ters and provide room for growth, the company opted to remain in Nashville.

“Nashville is where healthcare works. This new headquarters solidifies our com-mitment to being surrounded by the best healthcare companies and employee tal-ent in the country,” said Holden.

The new headquarters, designed by Hastings Architecture Associates, will house the company’s 350 Nashville employees on three floors and will sit on over two acres in the last remaining parcel of the Burton Hills office park. AmSurg expects to move into its new headquarters in early 2015.

Dr. Ketsia B. Pierre

Dr. Gerald Hickson

Joseph Mazzo

Trey Noel III


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