memphis medical news june 2014

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GTx Sees Better Times Ahead Biopharmaceutical fi rm hopes patience, perseverance will pay off

Financial losses, layoffs, administrative departures and underperforming clinical results would dampen the enthusiasm of most bio-pharmaceutical companies, but GTx, the only freestanding biopharmaceutical company in Memphis, said it expects to rise from the ashes created by the recent fi restorm of negative news ... 6

Telemedicine: An Idea Whose Time Has (Finally) Come?Technology can help underserved rural areas receive healthcare

Healthcare experts have suggested the time has come to electronically link the skills and knowledge of Memphis’ experienced medical specialists to underserved rural communities that are in desperate need of greater access to such care ... 10

FOCUS TOPICS RURAL HEALTH PRACTICE MANAGEMENT MEN’S HEALTH

By BOB PHILLIPS

Smack in the middle of one of the worst winters on record, a call came to Memphis-based Emergency Mobile Health Care LLC to pick up a seriously ill patient in East Tennessee and trans-port him to a Memphis hospital.

“It was January and we had ice and

snow on the ground,” recalled Michael W. Nolen Jr., vice president, chief ad-ministrative and compliance offi cer of EMHC, as the company is most widely known. “The weather was bad all the way. Fortunately, the patient made it, but the trip there and back – with the ice and snow – took 32 hours.”

(CONTINUED ON PAGE 8)

HealthcareLeader

Michael W. Nolen Jr. Emergency Mobile Health Care vice president and chief administrative offi cer

Robert W. Wake, MD

PAGE 3

PHYSICIAN SPOTLIGHT

The Car. The City. One of a kind.

Rural Hospitals Face Threat of ClosingWithout Medicaid expansion, more shutdowns likely

By EMILy KEPLINGER

Just six months ago, the Tennessee Hospital Association warned that rural hospi-tals would begin to close if Tennessee did not expand its Medicaid program. Now those prophetic words are ringing true as the hospital in Brownsville is scheduled to close this summer. Effective July 31, Community Health Systems is ending both inpatient and emergency services at Haywood Park Community Hospital because it cannot afford to keep operating them.

Craig Becker, president of the Tennessee Hospital Association, sees this closing of rural hospitals as an example of what is to follow.

“Closing a rural hospital is likely to trigger the departure of physicians, as well as pharmacists,” Becker said. “Patients will experience increased costs as they have to travel for their care. Acute care will likely necessitate the use of an ambulance. Even routine care will be impacted, especially if a patient needs to see a specialist.


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By RON COBB

While it’s unlikely that Rob-ert W. Wake, MD, wears orange scrubs in the OR, he’s pretty much orange to the core in most other respects.

The urologist grew up in Knoxville and attended the Uni-versity of Tennessee for both un-dergraduate and medical school. After receiving his degree in 1985, he did his residency at UT and then joined the faculty. He is now professor and chairman of the Department of Urology at the University of Tennessee Health Science Center.

We might also mention, to no one’s surprise, he is a big fan of Tennessee football.

“Even in the down times, like now, we remain loyal UT fans,” Wake said of himself and his wife of 29 years, Debbie.

Staying in the same state, much less within the same uni-versity system, is a bit uncommon for a doctor with his experience, but Wake’s loyalty to UT has rarely been shaken.

“A couple of times we have consid-ered opportunities, like everyone does, but I walk by faith, not by sight, and that has allowed me to remain in the place and ca-reer that I truly love,” he said.

Inspired by his parents and their sup-port, Wake went into healthcare for rea-sons he can’t specifically pinpoint.

“In high school,” he said, “I decided I wanted a career in medicine. It was just something I felt drawn to, despite having no true reason for my interest.”

Wake, now a member of UT Meth-odist Physicians, knew early on that he wanted to do surgery, but he also liked the variety that medicine offers.

“Urology was the best combination of a major surgical subspecialty that offered the opportunity to do major open surger-ies, endoscopic surgeries, and still have a great deal of medical care that could be offered to patients with a variety of uro-logical problems,” he said. “It also allowed me to care for male and female patients as well as adult and pediatric patients.

“I readily admit I’m biased, but if there’s a better surgical subspecialty in medicine, I haven’t found it.”

Throw in the opportunity to teach, and Wake has what he feels is the perfect situation. He calls his duties as program director of UTHSC’s urology residency program demanding, but also reward-ing. The responsibility of educating future urologists is what motivates him to keep his hand in academia.

“It challenges me on a daily basis, which I sincerely welcome,” he said. “Our

residents are like an extended family to me, and most become lifelong friends and peers.

“Many people misunderstand what is involved in an academic career. They often believe it means one doesn’t see their own private practice patients and that the residents do all the work while we sit in an office and monitor them from a distance. Nothing could be further from the truth.

“For example, I have an office in Germantown, where I see my private patients two full days and one half-day every week. There are no residents with me on these private office days. I have two and a half days for surgeries each week. One of those days, I spend operating with the residents at our Vet-erans Hospital, which is part of our training program.”

According to UTHSC’s website, Wake has an interest in kidney stone disease in addi-tion to treating and research-ing prostate cancer and its complications. He is described as one of the first to perform and report on a large series of second-generation targeted cryoablation of the prostate, and one of the first urologists to perform tubeless percutane-ous nephrostolithotomy.

Wake identifies two par-ticular areas in which ad-vancements have been made related to prostate cancer.

“Newer markers coming out to supplement, but not

necessarily replace PSA, for screening and to aid the urologists as to when a second biopsy may be indicated after a patient has had a previous negative biopsy,” he said.

“Other newer markers may help de-termine which patients may have an ag-gressive form of prostate cancer that needs treatment and those with less-aggressive types that may just be followed. So treat-

ment can be individualized for each pa-tient potentially based on these results.

“Also, the numerous drugs that have been developed and FDA-approved are currently being used in the treatment of patients with castration-resistant prostate cancer. In fact, new guidelines have been developed on the best way to implement the use of these new drugs in this group of patients.”

In terms of listing his rewards and challenges, Wake began with “taking care of my patients and doing my very best to resolve, or at least improve, their prob-lems. Realistic expectations for ourselves and our patients, as well as faith, are criti-cal to successful outcomes.

“The biggest frustration has to be the government intrusion into the patient-physician encounter. The use of Electronic Medical Records (EMR) despite potential benefits has certainly been a frustrating endeavor. I’m not against positive change to improve a situation and I embrace new technology, but with the Baptist, Method-ist and Regional Medical Center recently implementing three different EMR systems that do not currently communicate effec-tively and each requiring hours of class-room work to even attempt to learn how to use them, one can see how this may be a tad bit frustrating. But it is the world we live in, and all we can do is embrace the change and move forward.”

Five or 10 years from now, Wake says he still hopes to be chairman and program director at UTHSC and “still providing exemplary patient care. Maybe by then I will have mastered the EMR at all the hospitals as well, if they haven’t changed them again.”

Robert W. Wake, MDUrologist’s loyalty to UT is matched by his devotion to residents, patients

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Melanie Pafford remembers the exact day the Streetdog Foundation was created. It was August 7, 2009. She had been asked by a friend to help find a lost dog and ended up at Memphis Animal Services to look for Thurman, an Ameri-can Bulldog. Melanie was unable to lo-cate Thurman, but what she saw that day changed her and her husband’s lives for-ever.

Overall conditions at the shelter were not good, but even worse, there were about 70 dogs lined up on the “Green Mile” meaning that they had only a day or two to be claimed or they would be eu-thanized. The Paffords describe cage after cage of animals – some wounded, some “cowering in fear.”

“The dogs know,” claims Kent, Mel-

anie’s husband. “Nauseated with sorrow,” the Paffords vowed to make it their mis-sion to save as many of these “precious creatures of God’s creation” as they pos-sibly could.

Saving these “precious creatures” does not equate to finding homes for stereotypical miniature, fluffy, purebred types. Saving unwanted canines means finding homes for some of the most dif-ficult-to-place animals including pit bulls – the breed with the worst reputation and often the most abused. Streetdog Founda-tion specializes in helping the “misunder-stood” bully breeds.

Melanie will tell you that it hasn’t been easy. There have been many times that they’ve housed a dozen or so dogs in their home which obviously requires feed-ing, bathing and walking. The vet bills alone – to save, restore and rehab these animals – are enough to drive someone into bankruptcy. But she says they are on a spiritual mission and claims that every time she wonders how they’re going to continue, they get a “God Nod,” mean-ing something good will happen to enable them to move on. Since 2009, they have

successfully placed about 400 of these “temporarily unwanted” dogs in loving and forever homes.

Important AlliancesPart of the process of helping stray

dogs either find their way home or find a new home involves instructing those who find them what to do. Since the Streetdog Foundation is not a “shelter,” they first try to get the “finder” to keep the dog tem-porarily while trying to track down the owner. They recommend taking the ani-mal to their local vet to have it scanned for a microchip as one way to expedite that process. Posting fliers with photos is also recommended. Use social media resources such as the Facebook page called Lost and Found Pets of the Midsouth (www.face-book.com/lostandfoundmidsouth). This is where anyone can post a photo of an ani-mal that has either been lost or found and hopefully connect the owner and their pet.

The Streetdog Foundation is in the pet rehab business. Many of the dogs they rescue have been neglected, abused and in some cases tortured. Streetdog Founda-

tion makes sure that these animals get the medical care they need. They work with area veterinarians to mend the physical wounds, and then proceed to find a for-ever home so that the emotional wounds can heal as well.

How Big is the Problem?Melanie estimates that they get about

100 emails and calls every day regarding found street dogs. Based on what they have seen and experienced, she and her staff say that there are hundreds of strays wandering the greater Memphis area on any given day.

However, Memphis is also a city of dog lovers, and the Streetdog Founda-tion has 8,800 Facebook “Likes” and over 1,000 Instagram followers. Each week it estimated (by Facebook reports) that they reach more than 14,000 viewers through social media. This represents interest and hope for potential adoptions.

How Can You Help?Donate Streetdog Foundation is a 501(c )3 or-

ganization. Donations help purchase food, collars, leashes, toys, crates, bedding, and medical care for every rescue. Donations in any amount help the team of volunteers and veterinary professionals provide care. You can pay online using Paypal or send donations to:

Streetdog FoundationP O Box 485 Memphis TN 38101Or go to http://amzn.com/

w/3EGJ06GHRETE7 and check out Streetdog’s online wish list.

In addition, they will take new or used items such as:

• Crates (any size or type)• Dog beds/fleece pads• Dog Bowls• Dog food (canned and dry)

Streetdog Foundation: On a Spiritual Mission to get Temporarily Unwanted Dogs off the Street

MEMPHIS on the MEND

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By GINGER PORTER

Financial losses, layoffs, administra-tive departures and underperforming clin-ical results would dampen the enthusiasm of most biopharmaceutical companies, but GTx, the only freestanding biophar-maceutical company in Memphis, said it expects to rise from the ashes created by the recent fi restorm of negative news.

Marc Hanover, in-terim CEO and presi-dent and COO of GTx, based the optimism on a new dosage and applica-tion of one of the compa-ny’s drugs to be unveiled at the American Society of Clinical Oncology (ASOC) this month. Enobosarm (Ostarine®), previously tested in 3 mg doses for muscle wasting in non-small cell lung cancer patients, will have data presented for its ap-plication in a 9 mg dose for the treatment of androgen receptor and estrogen recep-tor positive metastatic breast cancer at the ASOC meeting.

Other anticipated news will come in the form of study results in fi rst quar-ter 2015 on GTx’s prostate cancer drug Capesaris®, a selective estrogen receptor (ER) alpha agonist for the treatment of men with advanced prostate cancer.

Enobosarm 3 mg did not meet expec-tations of a fast track development agree-ment between GTx and the U.S. Food and Drug Administration in August of last

year. “Obviously this was

a major letdown for the company,” Hanover said, “and we had to adjust our expenses to advance our late-stage programs. Discovery, benchwork and preclini-cal is not where value is created in biophar-maceuticals, and we couldn’t afford to keep paying that cost struc-ture.”

By October, com-pany administrators took pay cuts and laid off 60 percent of their 88-person work-force. All efforts were turned to studying potential for enobosarm in Europe.

“On the whole, the studies did not meet primary endpoints as required by study protocols and the FDA,” he said. “For European authorities, one of the studies potentially qualifi ed, so we are pursuing that with the European Medi-cines Agency (EMA) — the equivalent of our FDA in Europe. We feel we need ad-ditional studies to try to get approved in the U.S. at this time, and we can pursue that later.”

In April, Mitchell Steiner, MD, the co-founder of GTx, resigned as CEO. In a statement, he said, “After more than 15 years as CEO, it’s a good time for me to leave my position so that I can spend more time with my family and pursue different opportunities.”

Less than two weeks after the April 4 announcement about Dr. Steiner, James Dalton, PhD, the company’s vice president and chief scientifi c offi cer, an-nounced his resignation, effective the end of August. He is leaving to become dean of the University of Michigan College of Pharmacy.

“Dr. Dalton is primarily a preclinical PhD, and we are not doing much of the preclinical activities right now. That is the reason for his departure,” Hanover said.

He explained that GTx has a wealth

of clinical and regulatory expertise in their key offi cers and that they have enlisted the help of several clinical and industry-experienced MDs in the wake of Steiner’s resignation. Hanover described the past 10 months as “challenging” and extolled a “very patient and understanding share-holder base.”

The largest stockholder of GTx is J.R. “Pitt” Hyde, whose personal journey with cancer helped launch the fi rm in 1997. He is still an investor and chairman of the board, currently serving as a member of the compensation committee and the nominating and corporate governance committees. A bio on the company’s web-site describes him as “primary advisor to senior management on all matters of stra-tegic importance.”

“Dr. Steiner took care of Mr. Hyde during his prostate cancer treatment, as he was head of the University of Ten-nessee Urology Department back then,” Hanover said. “Some of the research Dr. Steiner was working on then was trans-ferred to GTx via a tech transfer from his lab to us, so we were basically partnering together. Mr. Hyde was our sole fi nancier shortly after the inception of the business.”

GTx was a privately held company and gradually attracted other healthcare funds and venture groups. It went public in February 2004.

Hanover spoke of the future of the biopharmaceutical industry and lauded American investors for being so devoted, as the research has come to a point where the long years of waiting are about to be rewarded.

“The U.S. is a wonderful place for biotech companies to get funded because there is dedicated capital to it. It is now paying off,” he said. “Cancer treatments and rare diseases have drugs coming to the end of their development. Applications are being submitted to the FDA, and it is obviously doing a good job of coordinat-ing with the biopharma space in order to get drugs approved.”

Locally, Steve Bares, PhD, MBA, executive director of Memphis Bioworks Foundation, believes there is a great deal of technology and research to support more biopharmaceutical efforts and companies. The foundation is a nonprofi t that assists in creating companies, jobs and investments in bioscience by investing in entrepre-neurs and building labs/facilities.

“There is the ecosystem to support it,” he said. “There is so much opportunity here. There is collaboration in research, with the government, across borders. I’m bullish on it.

“What happens if all the current drugs in research stages work and created thousands of jobs in Memphis?” he asked. “And at the endpoint, you are helping somebody.”

GTx Sees Better Times Ahead Biopharmaceutical fi rm hopes patience, perseverance will pay off

Mark Hanover

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Editor’s note: We originally produced the ar-ticle “Nurses, Doctors Agree on Rx for Improved Work Environment” with anonymous quotes to open a risk-free dialogue on the issues ad-dressed. In keeping with that parameter, we publish this anonymous letter to the editor.

In response to your May article, I would like to specifically address the com-ments related to surgeons and dis-ruptive behavior. Sadly, very little has changed since 2008, the year this entrenched prob-lem was addressed by the Joint Commis-sion.

According to Becker’s Hospital Re-view, the average operating margin of non-profi t hospitals now stands at 2.5 percent – probably less since the statistics were compiled. As a result of a rapid-changing healthcare system and the commercialization of healthcare, rules regarding disruptive behavior, horizon-tal violence and bullying (a documented recipe for medical error) are not enforced. This is especially true within the closed, non-transparent doors of the operat-ing room (OR), where losing a surgeon means losing money.

Although many healthcare organi-zations seem to have successfully created a culture of collegiality between hospital and medical staffs, the OR – a major source of income and revenue – seems to be the last holdout. It is also a place where errors made while distracted by aberrant behavior can mean the differ-ence between life and death (or errors leading to life-threatening complications) for an asleep and powerless patient – ut-terly dependent on the presence of a well-functioning team. Surgeons’ “run-amok” behavior and “captain of the ship” (rather than team) mentality remain the norm – so much so that most surgical team mem-bers fail to recognize it as a negative, potentially dangerous situation. This “abnormal normalcy,” best known as the “normalization of deviance,” – a term coined by NASA after the Challenger explosion – is alive and well in operating rooms across the country.

Quality and safety policies tout-ing zero-tolerance for disruptive

behavior, lateral violence, bullying and retaliation seem to be written for the sake of regulatory agencies and frequently unenforced by ineffective management teams. Management team members often fear for their own jobs when the mainstay of the OR – productivity – de-creases. Hospitals commonly mitigate risk through termination of nurses who inter-nally and/or externally report abusive physicians, rather than risk losing said revenue-producing surgeon. The decision to get rid of a nurse who dares to speak out is as simple as the decision between trying to contain costs and increase busi-ness – or the hospital shutting its doors.

When nurses (expense) are denied a voice and physicians (revenue) are al-lowed to exhibit abusive behavior, the result can be deleterious to patient safety and surgical outcomes. Patients are de-

nied the advocacy of the Registered Nurse, who knows he or she will most

likely be fi red after speaking up. Thus, the so-called “culture of silence” in

the healthcare industry translates to yet another risk for patients in the OR. It coincides with the

equally dangerous “culture of fear.” Nurses, when

faced with the poten-tial personal cost of reporting risks to patient safety, are

caught between the legal, ethical obligations

of every state Nurse Practice Act and the Nurses’ Code of Ethics, and the very real personal risk to career, reputation and fi -nancial stability.

There is more. According to OSHA, none of the 22 federal laws addressing re-taliation against whistleblowers mention the wrongful termination of healthcare workers who report threats to patient safety. Most federal whistleblower legis-lation concerns fraud, waste and abuse – protecting whistleblowers in the fi nancial industry or fi nancial realm of healthcare, but not healthcare workers who report patient safety issues, and certainly not pa-tients. Although several states have passed bills protecting healthcare whistleblowers, once a lawsuit is fi led, these statutes often lack the power wielded by hospital attor-neys and state judicial systems.

Once the nurse is wrongfully termi-

nated – potentially losing the ability to make a living in his or her chosen pro-fession – there are two choices available to fi ght the “system.” First, there is the Equal Employment Opportunity Com-mission (EEOC), the federal agency that addresses discrimination related to wrongful retaliatory termination. The other choice – IF one lives in a state with patient safety legislation – involves paying an attorney to fi ght the hospital system and its high-powered legal team. In doing so, the healthcare professional risks bank-rupting fi nancial resources, loss of repu-tation, ability to obtain employment and precious time fi ghting a legal battle that, statistically, will probably be lost. Thus, the “culture of silence” is reinforced by the legal system.

Sadly, nurses who have seen co-workers terminated for their courage to report a powerful physician are too afraid to speak up within this culture of silence and fear. This begs the question: Who is left to advocate for the patient during “free-for-all” aberrant behavior occur-ring daily behind the closed doors and windowless, non-transparent walls of the Operating Room?

— Memphis Operating Room Nurse

Letter to the Editor

Doctors and Nurses

Memphis Medical News welcomes letters, but they must be signed and include contact information. Please email your letters to [email protected]


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The event was the final piece of evi-dence the 17-year-old company needed to take a major step forward.

“We had been discussing adding an airplane for several months, and this con-vinced us to do it,” Nolen said.

So on March 10, less than two months after that treacherous January mission, EMHC became the first locally owned medical transport company in Memphis to offer airborne fixed-wing ambulance service.

“We have a plane, our own pilot and our own medical team,” Nolen said. “We can deliver bedside-to-bedside in four hours. We can be airborne 45 minutes after we get a phone call and go 800 miles non-stop. Typical time to complete a mis-sion is four hours.”

The two-member team, which con-sists of a registered nurse and a paramedic, specializes in critical care, burns and trauma. The staff is employed by EMHC. The plane is maintained by an aviation company that keeps everything current with FAA requirements.

The aircraft is equipped with a Zoll X Series Cardiac Monitor with trans-mission capabilities from the air, satellite telephone communications to the hospital and physician while in-flight. Its ventila-tor is approved for in-flight use and the medical team is able to monitor and infuse unlimited intravenous infusions with state-of-the-art infusion pumps. Also available is a video laryngoscope for intubation and electronic real-time medical records.

EMHC, which contracts with hos-pitals, nursing homes and other medical facilities, also has a fleet of 33 ambulances, some of which can hold additional pa-tients or team members. All the vehicles have EKG transmitting capabilities. The company also has 16 wheelchair transport vehicles, but no helicopters. (“There’s another firm in Memphis that does a wonderful job with medical helicopters,” Nolen said.)

Michael Arndt, who served two tours as a medic in Vietnam, and his wife, Bette, founded the company in 1997. Bette’s fa-ther was Bert Ferguson, founder of radio station WDIA, the nation’s first African-American station. The Arndts, proud that their company is the only locally owned ambulance service, have instilled a strong culture of community involve-ment. Nolen, who joined the company in 2002 as a driver, is a passionate disciple of the founders. He says EMHC has donated more than $1.5 million to local non-prof-its and another $5 million-plus in in-kind contributions.

The walls of Nolen’s large office are decorated with trinkets, banners, bobble heads, photos, official passes and flags from fund-raising events he and the com-pany have participated in. Nolen came to

appreciate the importance of giving about the same time he was learning about healthcare – when he was 5 years old.

In 1970 his mother was an operat-ing room nurse at St. Joseph Hospital, the 115-year-old downtown hospital that closed in 2000.

“That was before they had day care centers, so on weekends my mom took me to work with her,” said Nolen, now 38. “I loved going there. They gave me interest-ing things to do. I found healthcare fasci-nating.”

As he grew older, he would volunteer for work at the hospital on weekends and during the summer. By the time he was 13, he had worked in every department and even had spent time in the operat-ing room. One summer he worked in the emergency room.

“I’d see the ambulances come and go, delivering patients,” he said. “It made an impression on me. I liked the urgency and the people there. Some of the nurses I worked with then I still see at hospitals today.”

Not only did Nolen learn about healthcare, he also found a role model: Sister Annette Crone, who ran Saint Joseph.“She was a wonderful woman,” Nolen said. “She and the other sisters had a major positive impact on me.”

His dad, who worked at FedEx dur-ing the early years, stimulated his interest in planes and air travel.

After working for awhile in McDon-ald’s corporate training and then for Northwest Airlines, Nolen went to work at EMHC. Healthcare had always been beckoning.

“I didn’t know a thing about the am-bulance business,” he said. “In addition to being a driver, I worked in dispatch, in marketing, as a supervisor ... everything. In 2002 we had four ambulances and 40 staffers.”

As the company grew, so did No-len’s role. The Arndts filled his head with knowledge. He was sent to everything from EMT school to executive manage-ment classes. In 2006 the company had 75 employees and 13 units. And Nolen was a director. Two years later he was COO.

In 2011 the company moved to its current location at Appling Farms Park-way in Bartlett, less than a mile from I-40 and a quick jump to Memphis’ health-care facilities as well as the airport. EM-HC’s fleet now is composed of Mercedes “sprinter diesel ambulances,” which are expensive but fuel efficient and require less maintenance. The staff has grown to 220.

Nolen, too, has grown in stature. But his passion and caring have not dimin-ished. On a recent Monday his office was lined with 220 goody bags. “May is EMT Month,” he explained. “Last night I came in and put these together for our staff. There’s company coffee mugs and some other things.”

Those who work with Michael Nolen say that’s a perfect example: Sunday night the company’s vice president comes in by himself to stuff 220 goody bags for the em-ployees. Sister Crone would be proud.

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By JUDy OTTO

Healthcare experts have suggested the time has come to electronically link the skills and knowledge of Memphis’ experi-enced medical specialists to underserved rural communities that are in desperate need of greater access to such care.

The idea is actually not new. The first interactive telemedicine system was launched in 1989 over standard telephone lines. It was designed to remotely diagnose and treat cardiac patients at 12 hospitals in the United States. Since 1998, Memphis-based Interactive Solutions, Inc. (ISI), a leader in the field, has designed, installed and supported more than 1,500 telemedi-cine units across the country for a wide range of medical specialties and subspe-cialties, from neurology, emergency medi-cine and high-risk OB consults to stroke networks, surgery collaboration and more.

Brock Slabach, senior vice president of the National Rural Health Association (NRHA), says the need is definitely there and notes that 20 percent of Americans live in rural communities and only 9 percent of the nation’s doctors practice there.

The need is exceptionally keen in the Mid-South. Mississippi has the highest stroke prevalence rate in the nation, and Arkansas, Tennessee, Alabama and Loui-siana are among those sharing the top six highest rates; Mississippi likewise has the highest infant mortality rate, with Louisi-ana, Alabama, Tennessee and Arkansas

close behind.Telemedicine has proven it

can work – impressively and produc-tively: The University of Arkansas for Medical Sciences (UAMS) has spent $20 million to set up a model telemedicine pro-gram and, working in partnership with ISI since 2006, has deployed more than 500

remote/rural sites across the state. It con-tinues to grow and evolve, offering every flavor of telemedicine and subspecialty, and serving those who might otherwise go without healthcare service in any form.

The American Telemedicine As-sociation Conference’s credentials as the fastest-growing trade show in the U.S. also demonstrate the increasing fascination with the field. Yet, according to Jason Moore, ISI’s account manager, fewer than 10 per-cent of Memphis-area specialists are being utilized for telemedicine.

Slabach agrees that “although there are some specific niche programs that tele-medicine has been used for and continues to be very effective in terms of utilization, the spread of it has not gone as fast and as far as possibly we would have hoped.”

While the technology may be marvel-ous in its design and execution, the concept and operation are relatively simple. Jeremy Johnson, vice president of sales for ISI, described a hub-and-spoke structured net-work, with typically a convenient desktop terminal at the doctor’s end and a mobile cart that administrators or nurses at each

Telemedicine: An Idea Whose Time Has (Finally) Come?Technology can help underserved rural areas receive healthcare



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By CINDy SANDERS

At 11:59 p.m. on July 31, Haywood Park Community Hospital will cease inpa-tient admissions and emergency services. At the stroke of midnight, the Brownsville, Tenn. hospital will become an urgent care clinic, leaving the county’s rural residents to drive close to 30 minutes to hospitals in Covington, Ripley or Jackson.

According to a release from the hos-pital, operated by Community Health Sys-tems, inpatient admissions had dropped from 1,300 in 2009 to less than 250 in 2013. Additionally, the Emergency Room had also seen a sharp decline with 15 or fewer patients per day over the past sev-eral months. The release went on to cite changes in guidelines for inpatient ad-missions and federal reimbursement cuts under the Affordable Care Act that have not been offset by Medicaid expansion in Tennessee as contributing factors to the hospital’s demise. In light of the new re-ality, Haywood Park CEO Joel Southern said maintaining a full-service hospital was simply not sustainable.

Although the latest to make a news splash, Haywood Park isn’t the only hos-pital that has closed in Tennessee or been reassigned as an outpatient clinic in recent months. Craig Becker, president of the

Tennessee Hospital Association, noted Scott County in East Tennessee has only recently reopened (and without obstetric care) after being shuttered for several months and two others have closed in West Tennessee. Both Humboldt General Hos-pital and Gibson General Hospital both closed ear-lier this year, and yet another hospital in Upper East Tennessee is currently on life support.

A common theme among the recently departed inpatient facilities and the more than 50 others that have been deemed ‘in danger of closing’ is their rural location. “These rural areas are the most vulner-able,” Becker said, adding it was hard to envision how to adequately service these communities without hospitals.

Joellen Edwards, PhD, RN, FAAN, presi-dent of the Rural Health Association of Tennessee (RHAT), concurred, not-ing hospital closures have a ripple effect. “You lose your prenatal care. You lose your primary care because they just can’t

make it when the hospital closes.” Edwards, whose research focuses on

rural populations, is a professor and asso-ciate dean at East Tennessee State Uni-versity’s College of Nursing. Looking at a number of the threatened hospitals in the state, she said, “Some of these are criti-cal access hospitals, which means there is not another hospital for a minimum of 30 miles – or it could be even further away ... and probably is.”

She continued, “In East Tennessee, if you live in our mountains, 30 miles is not an easy drive. Not having a hospital avail-able in minutes … rather than an hour or more away … makes a difference literally to life and death.”

In addition to losing access to care, Becker said the economic impact of losing a hospital is a topic that has been glossed over. “These are often some of the best paying jobs in these communities,” he said.

Edwards pointed out hospitals are fre-quently the economic driver in rural towns and are sometimes one of the few jobs in the county that come with health benefits. Losing those jobs only exacerbates the problem of uninsured and under-insured rural populations.

“I can guarantee you Brownsville is hurting right now because of losing

those jobs,” Becker said. He added CHS couldn’t be blamed for their decision to cease emergency and inpatient services … it’s simply an economic reality. “It cer-tainly isn’t that the community doesn’t de-serve to have a hospital. The reality is now you can’t afford to have one.”

Even in communities that don’t close hospitals, Becker said he anticipated see-ing service lines that are not typically prof-itable … such as oncology and obstetrics … dropped. “Cutting services isn’t much of a strategy, but we’re going to see a lot of that,” he surmised.

He added lawmakers have, at times, accused the THA of ‘crying wolf’ as the association leaders have discussed the im-minent danger to numerous hospitals in the state. “This is the kind of thing we’ve been predicting,” Becker said of the re-cent closures, adding he wasn’t happy to be proven right.

The current closures, however, are feared to be the tip of the iceberg. Fuel-ing the concern is that the federal fund-ing cuts, such as DSH payments, are back loaded. Becker said Tennessee hospitals face $1 billion in cuts in the year 2019 alone. “Even with (Medicaid) expan-sion, it’s going to be difficult,” he said of the financial stressors hospitals face. “But

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“Underserved areas will increase, which is likely to be the beginning of the unraveling of an area’s social fabric. For example, businesses looking to locate to a particular area will consider available medical care, just as they consider school systems, in their decisions. Truly, it will have a wide-spread ripple effect.”

But these closings are not merely the result of what has happened in the last six months. For years, rural providers have been warning that failure to expand the public health program would put them in jeopardy.

Becker explained, “The choice was left to each state, and Tennessee is one of the states that is not participating in the Obamacare provision of Medicaid expan-sion. In fact, most of the states that are not participating are in the South, and have large segments of their population in rural areas.”

Many rural hospitals operate at a loss because they serve a high number of poor and uninsured patients who can’t always pay for their care. These hospitals, re-ferred to as Disproportionate Share Hos-pitals (DSH), received reimbursements from the federal government. Because the Affordable Care Act intended for every state to expand Medicaid, thereby reduc-ing the number of uninsured people who can’t pay their bills, the reimbursements for those DSH hospitals have been re-duced.

According to Kathleen Sebelius, former secretary of the Department of Health and Human Services, Tennessee began losing out on more than $6 million a day on January 1 when the federal gov-ernment began picking up all the cost for covering people who newly qualified for Medicaid under expanded guidelines -- an offer that goes away at the end of 2016. It then phases down the federal match to a permanent 90 percent in 2020.

W. Larry Cash, chief financial officer for the community health group that oper-ates the hospital in Brownsville, says Ten-

nessee’s refusal to expand Medicaid was a “contributing factor” in the move to close the hospital. The 62-bed facility will be-come an urgent care clinic, treating minor illnesses and non-life-threatening injuries.

A document prepared by the Rural Policy Research Institute Health Panel reports that states can opt to expand Medicaid at any time and receive the 100 percent federal match for newly eligible recipients. Arkansas is one of two states (the other is Iowa) that have been granted waivers from the Centers for Medicare and Medicaid Services (CMS) allowing Medicaid recipients with incomes between 100 percent and 138 percent of FPL to purchase health plans through the new marketplaces, using Medicaid payments to cover the costs of premiums.

Paul Cunningham, executive vice president of the Arkansas Hospital Associ-ation, said, “We have chosen to implement a state-tailored version of the expansion. We are losing financially on the Medicare side, but we hope to balance things out with our private option insurance option.

Yet, even in states that opted for Medicaid expansion, such as Arkansas, rural hospitals are still facing difficulties. Case in point, Crittenden Regional Hospi-tal in West Memphis. With or without its Medicaid expansion, the hospital serves a high number of people who cannot pay for their care. Crittenden Regional is trying to address its financial problems by asking local residents to vote for an increase in the local sales tax to help save the hospital. The vote is scheduled for June 24.

“Basically, what we’re seeing is just the beginning,” Becker said. “There will be more and more areas without acute care services. Similar situations have al-ready occurred elsewhere in Tennessee, in Jellico and in Scott County. In the latter case, the hospital reopened, but without OB services. The big question is, ‘How do we keep a medical presence in these com-munities?’ If not a hospital, then what?”

Rural Hospitals, continued from page 1

without expansion, we’ll lose even more hospitals and definitely see more services cut.”

He added, “One-third of the hospitals in the state are losing money. I see other hospitals on the border … on the brink.”

The Tennessee Plan proposed by Gov. Bill Haslam as an alternative to the Medicaid expansion program rolled out by the federal government, which has been accepted by 26 states plus the Dis-trict of Columbia so far, is still stalled … although not yet dead. During the 108th General Assembly, however, state law-makers added another hurdle to getting funding to Tennessee hospitals by passing a bill requiring Haslam to obtain legisla-tive approval before accepting any expan-sion dollars.

Becker, who called himself an eternal optimist, said he still believes the Tennes-

see Plan could pass. Unfortunately, he said it might take having more hospitals close to drive the message home. “Maybe there is going to be some pressure on some of these rural legislators when they realize they are losing part of the social fabric of their communities,” he said.

From RHAT’s standpoint, Edwards said, “We have a stance that uninsured people in Tennessee should have an opportunity to be covered just like in Maryland where they chose to expand Medicaid.”

Although she said the association doesn’t take a political stance as to which expansion plan is implemented, Edwards concluded, “We in the Rural Health Asso-ciation do want to see a reasonable expan-sion of services to people in this state … it’s what they deserve.”

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I enjoy looking at food magazines. One of the magazines I was reading recently was a summer edition that had some nice drink recipes, including Jimmy Buffett’s original Margarita. That interested me because I bartended all through college – and was a good one, if I do say so. I also noticed that almost every drink recipe included instructions to “pour over ice and shake well.”

At this point, you may be asking, what does a margarita recipe have to do with healthcare? Hopefully by the time you finish this article you may see some analogy, and possibly even have an “aha moment.”

I am blessed that my mom and dad, both in their early 80s, still live in the house they have lived in for years. From my house, I can be there between 15 to 30 minutes depending on traffic and how fast I drive. As their caregiver, it is important for me to be close.

Mom has been a patient of Frederick Pelz, MD, for a number of years. She looks forward to her appointment with Dr. Pelz and his nurse, Sandra. Dr. Pelz is board certified in Geriatrics and Internal Medicine and is a physician in Baptist Medical Group.

Mom was diagnosed with Alzheimer’s in May, 2013. Like most cases, Alzheimer’s usually comes on gradually and you start

noticing little things – not thinking too much of it at first. But then you start noticing more.

During one of the times I accompanied my mom to Dr. Pelz’s office, both he and his nurse Sandra, told mom and me about Baptist Onecare, MyChart. Of course, like many older Americans, my folks don’t have the internet (nor do they want it). However, this application enables my sister and me access to mom’s health records. Both of us downloaded MyChart to our iPhones, and we now have her information right at hand.

MyChart was easy for me to access. Its support line was very helpful when I called. They were able to tell me what I was doing wrong and help me fix it. (Of course, most technical issues like this can be traced to a problem being somewhere between the chair and the keyboard.)

There are a lot of things this system can do and I am discovering more useful things as I access it – labs, diagnostic results, consults etc. One thing that got my immediate attention was the segment regarding medications. My parents are just like anyone else’s – they have medicines in their medicine cabinet that have been there a long time. They never throw any of their pills away.

One area, safety concerns me the

most. I will periodically look at their medications; the dates, dosages etc. I am able to email Dr. Pelz and he returns my email by the next day. At the beginning of mom’s office exams, we reviewed her medications and were able to address any concerns. (I used the word “we” to include Dr. Pelz, his nurse, and me, son and caregiver.) It really doesn’t matter if you refer to it as Accountable Healthcare or Affordable Healthcare, it can’t be done without information, education and action.

As with all caregivers, you worry, you stress, and often you neglect your own health. But keeping up with my mom’s health has helped me be more informed about my own health issues as well.

In my opinion, the majority of patients are not purposely non-compliant. They just need the help of a competent bartender who can pour over ice and shake well. And, as I mentioned in the first part of this article, I’m a good bartender and mom enjoys a good margarita.

Bill Appling, FACMPE, ACHE, is founder and president of J William Appling, LLC. He is a national speaker, presenter and a published author. He serves as an adjunct professor at the University of Memphis and is on the boards of Hope House and Life Blood. For more information contact Bill at [email protected].

Pour Over Ice and Shake WellBY BILL APPLING

MedicalEconomics


Tim C. Nicholson is the President of Bigfish, LLC. His Memphis-based firm connects physicians, clinics and hospitals to patients and one another through healthcare social media solutions, branding initiatives and websites. His column, “Hey Doc”, appears here monthly. Find him on twitter @timbigfish or email [email protected]

By TIM NICHOLSON

Last month I sat with my son as he completed an online application for healthcare insurance via the Affordable Care Act Health Exchanges. I wasn’t there because he needed my help. He’s smart and web savvy like most of his gen-eration. I’m just into this subject to be helpful to you.

Anyway, he’s off mom and dad’s in-surance. He’s paying for his healthcare for the first time ever. He’s making his own decision about healthcare providers. He actually wants to get a physical and de-velop a relationship with a doctor. But surprise, he finds the whole thing exas-perating. It’s not for the reason you might think. No, it’s not the money. His frustra-tion stems from how counter intuitive the process is to the way his generation works.

His frustration is an opportunity for someone. It occurred to me that that someone might be you and that social media might be a way to bridge the com-munication gap, improve this generation’s perception of the healthcare community/process and drive patients to you.

Here’s how:

First, 90 percent of those 18 to 24 years of age said they would trust medical information shared by others on their social media net-works. A millennial’s network on social media is a group of people that is well trusted, which again, presents an oppor-tunity to connect with them as healthcare professional in a new and authentic way. Be transparent. Share information that’s helpful, and include how to pay for things. They just want to know.

Second, more than 80 percent of the millennial generation said that information found via social media affects the way they deal with everything – health, too. Healthcare professionals have an obligation to create educational content to be shared across social media that will help accurately in-form this generation about health related issues and squash misleading information. The opinions of others on social media are often trusted but aren’t always accurate, especially when it comes to a subject as sensitive as health. Be present. Listen as much as you “tweet”. Share what you’d want your child to know and dialogue with them if they reach out to you. Hey, their doctor’s voice will cut through the online clutter but they also expect to be heard.

Third, 75 percent of the 18 to 24 year olds said social media would affect their choice of a specific doc-tor or medical facility. This makes social media important as a tool to help accelerate positive and overcome negative word of mouth. It can attract new patients, minimize missed appointments, retain your patients, and win their referrals. Mil-lennials are using social media to discuss

everything in their lives including health and it is up to you to tune in.

Fourth, millennials are the most likely group of social media users to trust social media posts and ac-tivity by doctors. They see doctors as respected members of society (yeah, re-ally) who are also highly revered for their opinions when they are shared on social media, which is even more reason to help boost your reach as a healthcare provider and use social media to discuss health is-

sues, choosing healthcare plans, meeting providers, and getting well. This may re-quire that you explore some new channels. Think Instagram. This generation is defi-nitely a “show me don’t tell me” commu-nity of patients.

Hmmm. Now that I think about it, millennials are not the only ones who can relate to these ideas. The percentages may vary but the impact could be more im-mediate to your business if middle-aged people find you online. But if you’re think-

ing about tomorrow and the new patients coming into the healthcare stream, con-sider connecting with millennials via social media. Their moms and dads will thank you.

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Streetdog Foundation,Continued from page 4

Memphis Medical News

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By CINDy SANDERS

Value-based reimbursements, ICD-10 re-boot, meaningful use, clinical integration physi-cian alignment, transparency, PQRS, 5010 implementation, e-prescribing, staffi ng and train-ing, compliance, audits … oh yes … and caring for patients

There’s no question the American healthcare system is in the midst of a sea of change as foundational rules are rewritten and a new infrastructure for care deliv-ery is being put in place. While provid-ers, practice managers and administrators are supportive of many of the concepts, it doesn’t make the transition any easier.

With wave after wave of change washing over practices, it’s certainly ‘sink or swim’ time. For those trying to navi-gate the rough waters, the Medical Group Management Association’s extensive re-sources, advocacy and insights on critical issues help shore up practice managers as they fi ght to keep afl oat.

Laura Palmer, FACMPE, a senior industry analyst and subject matter expert for MGMA, said practices across the country are facing unprecedented change. While much of it is tied to the Afford-able Care Act, a move to restructure the deliv-ery and payment system was underway even before the landmark legislation was set in motion but has since been greatly accelerated. Today’s practice managers are being asked to alter ‘busi-ness as usual’ on most every front.

Benefi ts & EligibilityReferencing the ACA impact, Palmer

said it’s about much more than just ex-panding coverage. “It’s really a change in how insurance plans work,” she noted. Keeping up with who covers what, where, with whom and at what point has become increasingly complex as staff members drill down through eligibility require-ments and benefi ts to fi gure out the bot-tom line for patients.

While access might be expanding as more people join the insurance rolls, Palmer noted there has actually been a trend of narrowing networks. Not every physician or service provider is on every plan level under a payer. Adding to the confusion, not every family member is on the same plan.

“We’re starting to see more differenti-ation, and it’s more diffi cult for the patient and provider, who needs to know where to send someone for referrals,” she noted.

Whereas traditionally a lab company would have been on every plan under a payer, that’s not necessarily true today. A platinum plan might have more options than a gold or silver plan. “It’s a lot more complicated,” Palmer said. “You can’t depend on what you knew in the past to

be true.”Therefore, she continued, it’s critical

to regularly check coverage parameters and limits. Verifying benefi ts annually used to be pretty common. However, Palmer said that no longer works. “Best practices say we really need to check eli-gibility and benefi ts every single visit for every single patient,” she said.

Although patient benefi ts tied to large employers or government entities still aren’t likely to change more than once a year, the same isn’t necessarily true for smaller employers. And, Palmer pointed out, people change jobs much more fre-quently now so even if a company’s plan hasn’t changed, the patient’s job status might have.

Appropriate Staffi ngTrue access to care doesn’t mean sim-

ply having the coverage in place to allow a patient see a provider. The second part of the equation is having providers avail-able to meet appointment demands within a reasonable time frame.

“The days of a doctor’s offi ce being closed for two hours over lunch are long gone,” Palmer said. In fact, she noted, many practices are looking at evening and/or weekend hours, group care set-tings and adding non-physician extenders to meet demand.

From a reimbursement standpoint, practices must see enough patients to keep the doors open. From a quality standpoint, which now ties to reimburse-

ments, it’s critical to meet best prac-tice parameters. Palmer noted evidence-based s t a n d a r d s might call for a patient with a specific complaint to be seen within 48 hours. Prac-tices have to fi gure out how to do that or risk the consequences … both of missing quality benchmarks and of low-ered patient satisfaction scores, which also will soon tie into reim-bursement rates.

“You don’t want patients to go to the Emergency Room because they couldn’t get an appointment,” Palmer said. She added, “Practices need to make sure they have adequate staff coverage and a triag-ing system in place to ensure patients are getting the right care in the right environ-ment in the right time frame.”

Making New Friends“Practices that in the past might have

been competitors in a particular commu-nity are now having to play nice with each other,” Palmer pointed out of new cover-age rules and clinical integration models.

Tied to the narrowing network trend, providers are fi nding payers and plans in-

creasingly dictate referral pat-terns. Palmer said new pay-ment models, such as the formation of accountable care organi-

zations, also are forcing more

co l l abora t ions encouraged by both

the financial setup and patient need.

She added that while this kind of collaboration across

care settings is generally viewed as a good move for quality patient care, it is differ-ent than traditional practice silos and will take time for providers to adjust to creat-ing more community-based care than has been available in the past.

Adjusting to New Payment Models

Although the vast majority of reim-bursements remain in the fee-for-service world, the switch to a value-based sys-tem is already underway. “The practical aspect of how we deliver care is already changing,” Palmer said.

Practices have begun investing in changing technology and staffi ng models before reimbursements have caught up

Drowning in a Sea of ChangeMGMA Tackles Tough Issues to Help Practices Stay Afl oat

Laura Palmer


ments, it’s critical to meet best prac-tice parameters. Palmer noted evidence-based s t a n d a r d s might call for a patient with a specific complaint to be seen within 48 hours. Prac-tices have to fi gure out how to do that or risk the consequences … both of missing quality benchmarks and of low-

creasingly dictate referral pat-terns. Palmer said new pay-ment models, such as the formation of accountable care organi-

zations, also are forcing more

co l l abora t ions encouraged by both

the financial setup and patient need.

She added that while this kind of

Drowning in a Sea of ChangeMGMA Tackles Tough Issues to Help Practices Stay Afl oat


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to the new way of doing business. Case managers, nutritionists and non-physician providers are being added … even when those services aren’t clearly reimbursable across most payers … because of the value they add to patient care.

Currently, Palmer noted, only about 3-5 percent of a practice’s reimbursements are tied to quality metrics. While those numbers have remained pretty steady for the past few years as reported to MGMA, Palmer said she was eager to see if there is a change indicated in this year’s data. Anecdotally, she said MGMA staff mem-bers have heard from more practices that contracts are being negotiated with quality metrics in mind.

Despite payments lagging a bit be-hind, Palmer said practices have really embraced the concept of value-based care. “It’s the right thing to do,” she stated. “I think physicians and practices know to re-ally manage care, the best way is to look at total patient care.”

ICD-10Recognizing that not every provider

in every setting is on the same page about the latest ICD-10 delay (with a new im-plementation date of Oct. 1, 2015 as con-fi rmed by CMS in May), Palmer said it cropped up as the number one concern for 2014 in MGMA’s annual Medical Prac-tice Today survey.

Chief among worries are cash fl ow

concerns, vendor issues, testing, and ad-equate staff training. Palmer noted, “The delay in implementation is going to allow for more testing, and that’s got to be good for everyone.” She added, she thinks it will give vendors the needed extra time to re-solve software issues and practices time to get the technology and training in place.

However, Palmer acknowledged there would be some practices that once again put ICD-10 on the back burner only to panic again next year instead of using this time to really prepare.

Practice Setup“Integration and alignment issues are

still a big topic of conversation,” Palmer said.

What is the most effective practice model? Should practices merge? Sell to a hospital? Specialize or become multi-discipline? The ‘correct’ answer, she said, truly varies depending on circumstances and location.

“Healthcare is local,” Palmer pointed out. “What would work in Maine won’t necessarily work in Arizona.”

The MGMA LifelineMGMA’s resources can serve as a

lifeline to practice managers who are treading water as fast as they can. Palmer stressed the organization’s role is not to make decisions for practice managers but to put them in a position to proactively

make thoughtful choices based on their own unique set of circumstances.

The goal, she said, is to “bring people vetted information – good information from reliable sources – so practice man-agers can make informed decisions.” She continued, “There isn’t one right answer. The joke around here is if you’ve seen one practice … you’ve seen one practice.”

Although new delivery models are building local alliances, there is certainly still a competitive relationship among practices in a given geographic area. Palmer said a key benefi t of MGMA is that it provides a safe environment for

peer networking to allow the exchange of information across regions. Where a prac-tice manager might not ask the competing cardiology practice down the street how they are handling benchmarking or suc-cession planning, MGMA membership provides a forum where that manager could talk to cardiology practices outside the market catchment area to fi nd out how they are addressing those issues.

Finally, she noted, MGMA offers the tools to allow managers to excel in their careers. “We provide professional devel-opment so we grow the next generation of practice managers,” Palmer stated.

Drowning in a Sea of Change, continued from page 17

of the participating rural clinics or hospi-tals can move from room to room, utiliz-ing specialized technology that ranges from basic video conferencing to add-ons such as a digital stethoscope, an ultrasound ma-chine or an ear, nose and throat scope, for example.

“With some of the clinical assessment tools, we can integrate into these consults; it really is the closest thing to being there,” Johnson said.

Additionally, as new needs are discov-ered, e.g. for telestroke or telecardiology, the ISI technology can easily be expanded with additional scopes, pieces, even a computer — to make it as fl exible and cost-effective as possible. The video conferencing equipment is versatile enough to do double duty in also offering on-site access to CME credits for the physicians, Moore pointed out.

As in so many other contemporary healthcare frustrations, cost seems to be the culprit, Moore said. “A lot of the chal-lenges with telemedicine — and something that’s really starting to change — is the re-imbursement for it.”

An in-person consultation with a phy-sician is reimbursed at a different rate than a telemedicine visit — which reimburses at “much less,” Moore said. “That’s been the big hesitation, I think, for a lot of people: how can they make enough money doing this to sustain the program?” ISI helps to

identify available grant sources to fund the equipment and get the program going, but, Moore said, once the grant money is gone they haven’t been able to sustain, due to limited reimbursements.

Individual states are now starting to reimburse for many more procedures, he points out — Mississippi is leading the charge as one of 16 states that have open reimbursement for different levels of tele-medicine.

The House Energy and Commerce Subcommittee on Health is also seeking input on how 21st-century technology can improve healthcare and help patients — through government support of technol-ogy adoption and identifi cation of ways the government is currently inhibiting the use of such technologies — good news, indeed, for telemedicine’s future.

Slabach agrees that Medicare has already done some work on its telehealth reimbursement policy. “The real issue for Medicare is not that they don’t want to pay for it, necessarily, but that there’s a scarcity of data that shows the effectiveness of tele-health services,” he said. “A lot of research is being done now, however, so we should start seeing some peer-reviewed science coming out that could, with time, change Medicare’s mind on some of their payment policies.”

Prices of the technology itself also seem to be improving.

“The equipment and the software to run it have really become much more af-fordable,” Moore said. “A few years ago folks would spend typically $30,000 on a high-defi nition site; today, sub-$5,000.”

Costs will vary, depending on the dif-ferent subspecialties and the tools required, but outreach through telemedicine may be becoming a venture increasingly worth in-vestigating.

“People are looking at this as much more than just a technology decision,” Johnson said. “It’s now an access to care decision. We need to make sure that the hospital logistically is ready to serve poten-tial patients in the most effective way pos-sible.”

Telemedicine, continued from page 10

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L a s t J u n e , healthcare lead-ers from around the country – Stanford’s Lucile Packard Chil-dren’s Hospital, Oregon Health & Science Uni-versity, UCLA Health, the University of Michi-gan Health System, and Vancouver Coastal Health – converged on the campus of Nemours Children’s Hos-pital in Orlando to see lean healthcare transformation in action.

As usual, Joan Wellman, president of Seattle-based Joan Wellman & Associates (JWA Consulting), worked quietly and diligently behind the scenes, connecting hospital system admin-istrators with companies in a strategic way to build a more reliable healthcare system using lean manufacturing principles.

“A lean transformation is excruciat-ingly patient-focused,” said Wellman, who pioneered the application of Toyota principles in healthcare and helps com-plex systems facilitate large-scale lean healthcare transformations. “Every activ-ity in the organization is assessed, relative to whether it adds value for the patient. As waste is removed, more time and re-sources are paid to the patient. It’s a very smart move to use these principles in a highly competitive environment because if you can do more for your patients with the same resources, you obviously have competitive advantage.”

Wellman’s lean transformation jour-ney began in the early 1990s, when she was consulting with Boeing on its lean manufacturing effort.

“We were taking executive teams from Boeing to Japan,” explained Well-man. “In the course of two weeks, we took them by Toyota, Honda, Fuji, Xerox and other prize-winning companies to see how their manufacturing processes work. They saw the same principles in action at all these companies.”

In 1994, Wellman recalls a Boeing executive, who served on the board of directors of a Seattle hospital, pondering whether lean principles could apply to healthcare.

“At that time, none of us were health-care consultants, but we saw the appeal,”

she recalled. “We took a group of clinicians to Boe-ing’s fi nal assembly line in Everett, Washington, and trained them in lean principles alongside operators on the line. Then we went back to the hospital and scratched our heads, trying to fi gure out how to make it pal-atable to healthcare professionals so the same principles could be applied. We looked at the waste and prob-

lems in hospital processes as we would in a lean manufacturing line.”

Wellman spent a year at the hospital, better understanding the healthcare sector and the application of lean manufacturing principles to a healthcare setting. In 1996, Wellman became involved in delivering a series of lectures at Seattle Children’s Hospital about concurrently improving patient fl ow and quality while also reduc-ing costs.

In 1998, “it was time to put our big toe in the water,” said Wellman, who established JWA Consulting in 2000. A few years later, her book, Leading the Lean Healthcare Journey: Driving Cul-ture Change to Increase Value (CRC Press), was published with co-authors Pat Hagan and Howard Jeffries, MD. The book chronicles healthcare improvements at Seattle Children’s Hospital, Memorial Care, The Everett Clinic in Washington, and Children’s Hospitals and Clinics of Minnesota.

“I don’t see the lean principles move-ment slowing down at all because of the Affordable Care Act,” said Wellman, whose fi rm has grown to 22 associates. “I see an increased commitment and at-tention to building a more reliable sys-tem – with better quality, better safety, and better patient fl ow – at a lower cost. Applying the lean production system to healthcare is one of few models anywhere that simultaneously addresses all of those issues.”

A lack of time, attention, and leader-ship passion are the primary barriers to lean principle implementation in health-care systems, said Wellman.

“Mainly, it’s the lack of time,” she

Catching Fire: Lean Healthcare TransformationsJoan Wellman pioneered application of Toyota principles in healthcare; helps complex health systems facilitate large-scale change

Lucile Packard Chil-dren’s Hospital, Oregon Health & Science Uni-versity, UCLA Health, the University of Michi-gan Health System, and Vancouver Coastal Health – converged on the campus of Nemours Children’s Hos-pital in Orlando to see lean healthcare transformation in

As usual, Joan Wellman,

she recalled. “We took a group of clinicians to Boe-ing’s fi nal assembly line in Everett, Washington, and trained them in lean principles alongside operators on the line. Then we went back

lems in hospital processes as



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Creating High-Powered Healthcare Improvement Engines

Chapter 3 of Leading the Lean Healthcare Journey: Driving Culture Change to Increase Value (CRC Press, 2010), written by Joan Wellman with co-authors Pat Hagan and Howard Jeffries, MD, begs the question: What additional value do consumers in the United States receive for the extraordinary fi nancial commitment made to healthcare?

“A 2008 Commonwealth Fund Report ranked the United States last in quality of healthcare among 19 comparative, developed nations,” said Wellman, noting the United States spends twice as much per capita on healthcare than other developed nations. “Not a stellar track record for a society paying top dollar.”

The chapter, “Creating High-Powered Healthcare Improvement Engines,” provides a blueprint for change through:

• Brutally honest leadership• Moving from ‘episodic’ project based improvement to continuous

improvement;• Changing the mindset and the management system of the organization

vs. just applying lean methods;• Developing lean leaders; and• Developing a long term plan that ensures that this is a pervasive effort.“Although the quantitative evidence demonstrates undeniable success,

some of the emotional aspects of staff and clinicians engaging in improving the healthcare system are even more exciting,” said Wellman, after helping an organization through the early years of its lean transformation. “The sense of accomplishment – ‘we can do this!’ – is palpable. Even during the very early days of this organization’s lean transformation, improvement team members frequently expressed their enthusiasm for being engaged in the work. Other team members saw this as one of the most rewarding times of their careers. Still others keep asking, ‘When are we going to do this again?’ Such comments are the reward for the lean leader.”

said. “Money is not the issue because it’s rare for organizations to look back and say they aren’t getting fi nancial gains from doing this work.”

The application of lean principles is also aggressively being used in another segment of the healthcare industry: the design of healthcare facilities around the world, said Wellman, whose fi rm is be-coming well known for its work in what JWA Consulting refers to as Integrated Facility Design, applying lean principles

to the design and construction process. “We just fi nished up some work in the

Netherlands, and helped design a health-care facility in Saudi Arabia,” she said. “We’re also doing work in Canada and the U.S., whose clinical processes are fairly similar but social systems are quite differ-ent. All those factors have to be taken into account. One thing’s for sure: With the healthcare industry facing fi nancial chal-lenges and other market pressures, lean healthcare transformation is catching fi re.”

Catching Fire, continued from page 19

GrandRoundsUTHSC Graduates 672 Healthcare Professionals

Last month the University of Tennessee Health Science Center (UTHSC) graduated 672 healthcare professionals. UTHSC Chan-cellor Steve J. Schwab, MD, presided over the ceremony. UT System President Joe DiPietro conferred the degrees and gave the charge to the graduates.

The 672 graduates are from all six of the UT Health Science Center’s colleges.

• 185 from the College of Allied Health Sciences;

• 74 from the College of Dentistry;• 23 from the College of Graduate

Health Sciences;• 157 from the College of Medicine;• 107 from the College of Nursing;• 126 from the College of Pharmacy.

This year’s graduating class included 75 African-Americans, 12 Latino-Americans, and 147 graduates who came from out of

state to study at UTHSC. In addition, this graduating class was comprised of 411 women and 261 men. Sixteen of the out-of-state dentistry graduates were Arkansans who earned their doctoral degrees from the UT College of Dentistry. Arkansas students come to Tennessee to train as dentists be-cause their state has no dental college.

Saint Francis Hospital-Memphis Receives 5th Consecutive “A”

For the fi fth time, Saint Francis Hospi-tal-Memphis received the top grade from one of the nation’s leading patient safety ad-vocacy organizations. The hospital received an “A” in The Leapfrog Group’s Spring 2014 Hospital Safety Score The Leapfrog Hospi-tal Safety Score rating system is designed to give consumers information they can use to make the best healthcare decisions for themselves or a loved one.


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Health Choice Announces New Hires

Health Choice, LLC, has announced that Ellen Abisch, RN, has joined Health Choice in the newly created position of senior director of Popula-tion Health Services, and LaTasha Jones has been named director of Provider Engagement.

As director of Popula-tion Health, Abisch will be responsible for designing, implementing and manag-ing population health and wellness programs for the Health Choice network. Health Choice will use the overarching data from the network of providers and payors to identify and pri-oritize the healthcare needs of the popula-tion to work with patients and physicians to improve patients’ health and the quality of care, while also reducing costs.

Abisch brings more than 24 years of experience to Health Choice, having served most recently as manager of Benefits and Wellness for ServiceMaster. Prior to that, she was Global Health Promotion manager for General Electric in Schenectady, NY. She holds a Bachelor of Science degree in Nurs-ing from Russell Sage College in Troy, NY, and a Master of Science degree in Nursing

from Adelphi University in Garden City, NY.In her new role as director of Pro-

vider Engagement, Jones will direct the implementation of Health Choice’s Valence Healthcare Vision database for the inde-pendent MetroCare physician practices. Post-implementation, she will lead the train-ing efforts for physicians and practice staff on the database tools. She and her staff will train and coach the physician practice staff on improving the quality of the data and improving quality of care. She will also work closely with the MetroCare staff, leadership, and governance board on identifying and prioritizing opportunities in quality improve-ment.

Jones has more than 17 years of ex-perience in health information manage-ment and managed care. She has worked for Health Choice since 2012, serving most recently as the director of Operations. She has also served in a variety of managed care positions with companies including Ac-credo Health Group, Memphis Managed Care Corporation, and St. Jude Children’s Research Hospital. She holds a Bachelor of Science degree in Health Information Man-agement from the University of Tennessee, Memphis.

Methodist Le Bonheur Germantown Celebrates Newly Expanded, Renovated ER

Methodist Le Bonheur Germantown

Hospital celebrated the completion of the expansion and renovations of the hospital’s emergency room in May.

The entire space within the emergen-cy room has been redesigned to provide a more patient- and family-centered ap-proach to care. The waiting room allows for direct patient access, making emergency staff available to answer any questions. The nurses’ stations in the ER is also open and accessible for patients and family members to walk up to discuss any questions or con-cerns, or request general information.

Additionally, the new space creates a more efficient emergency room by chang-ing patient flow. Nurses and physicians now use direct bedding, which involves taking patients back to a treatment room soon af-ter they check in, so diagnosing and treating patients can begin sooner.

The hospital broke ground last April to add 5,050 square feet to the existing fa-cility and renovate the existing space. The new emergency room has an additional six new treatment rooms along with three tri-age rooms. A second floor above the emer-gency room will allow for future growth, as the hospital develops and advances the ser-vices it offers to meet the community needs.

Campbell Clinic Opens Surgery Center in Midtown

Campbell Clinic opened the doors to its midtown surgery center in April.

The center, previously known as Mid-town Surgery Center, was purchased by Campbell Clinic in October 2013. Located at 255 S. Pauline Street, this 18,000-square-foot, ambulatory surgery center allows Campbell Clinic, the largest provider of orthopaedic and sports medicine services in the region, to double the size of its out-patient orthopaedic surgery space, adding four new operating rooms under its man-agement and making surgical and block scheduling more convenient for its patients.

The clinic has owned and operated Campbell Surgery Center on its German-town campus since 2002. The Midtown facility operates as Campbell Clinic Surgery Center – Midtown, with the former becom-ing Campbell Clinic Surgery Center – Ger-mantown.

Campbell Clinic currently performs more than 7,400 surgical or block proce-dures on its Germantown campus annually, in addition to surgical capabilities the com-pany’s surgeons utilize at numerous other area hospitals and medical facilities.

The new outpatient surgery center will also further enhance the clinic’s training and research programs and complement other local partner facilities that include The Re-gional Medical Center at Memphis, Meth-odist Le Bonheur Hospital, and the Mem-phis VA Medical Center.

Ellen Abisch

LaTasha Jones


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GrandRounds

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

SVMIC Declares $7.5 M DividendState Volunteer Mutual Insurance

Company’s Board of Directors has declared a dividend of $7.5 million to be returned to all policyholders renewing in the twelve-month period following May 15, 2014.

This is the seventh consecutive year SVMIC has declared dividends for its physi-cian policyholders. Policyholders will receive the dividend in the form of a credit on the renewal premium. Additionally, rates will remain unchanged for 2014.

Since SVMIC’s inception, a total of $335.5 million has been returned to physi-cian policyholders.

Prime Urgent Medical Clinic Joins MedPost

Prime Urgent Medical Clinic, located in Cordova, now has a new name: MedPost Urgent Care. The center becomes part of a new and growing national network of urgent care centers launched by Tenet Healthcare, the parent company of Saint Francis Hospi-tal- Bartlett, to provide high-quality, efficient and convenient health services. The Med-Post network currently consists of 23 urgent care centers in eight states.

The walk-in centers are open seven days a week with extended hours to provide high quality care for residents in their com-munities.

MedPost Urgent Care centers also provide follow-up care and specialty refer-rals when needed. They are staffed with physician specialists in primary care, inter-nal medicine and emergency medicine, as well as nurse practitioners and other health professionals. The facilities are equipped with X-ray and laboratory capabilities and provide a comprehensive array of services ranging from flu shots and other immuniza-tions to treatment for such things as upper respiratory infections, sinus problems, aller-gic reactions, fever, ear aches and orthope-dic injuries.

UT Medical Group Welcomes Plastic and Reconstructive Surgeon

Dr. Uzoma Ben Gbulie has joined the department of plastic surgery at UT Medi-cal Group Inc. and been named assistant professor at the University of Tennes-see Health Science Center.

Gbulie earned his medical degree at the Uni-versity of Lagos in Nigeria and completed a residency in general surgery at Howard University Hospital in Washington, D.C. He furthered his training with a fellowship in plastic and reconstructive surgery at St. Louis University Hospital in St. Louis, Missouri, followed by a fellowship in craniofacial surgery at the UT Health Science Center and Hopital Necker-Enfants Malades in Paris, France. Gbulie is board certified by the American Board of Plastic Surgery and the American Board of

Surgery. He is also a fellow of the American College of Surgeons.

He cares for patients at 7945 Wolf River Boulevard in Germantown, where he spe-cializes in aesthetic and reconstructive sur-gery for the face and body, including facial rejuvenation, body contouring, breast sur-gery, complex flaps for traumatic wounds, and reconstruction for cancers of the skin, head and neck.

CBU Graduates First Class of Physician Assistants

Christian Brothers University (CBU) claimed the distinction of graduating the first class of physician assistants educated in the city of Memphis — 31 students who were admitted into the first cohort of the city’s first PA program.

Dr. John Mark Scott, director of Physi-cian Assistant Studies at CBU, says that the program is not only groundbreaking, but is also much needed in the city. The fact that this is the first program in Memphis is in-novative in itself, but the PA as well as the BSN programs made CBU competitive in the healthcare market he said. There was a known need for a program of this sort after a survey gauging the need for physician assis-tants went out to 100 Mid-South physicians. Eighty percent of the physicians responded positively to the survey and most expressed a desire to employ these students upon their graduation.

The CBU program, which currently numbers 106 students, is run and taught by Dr. Scott, along with six full-time and six adjunct faculty members. The cohort-based program consists of 110 credit hours offered over 27 months or seven continuous semes-ters.

West Cancer Center’s Daruka Mahadevan, MD, Presents Findings of Pre-Clinical Study

Dr. Daruka Mahadevan, Director of the New Therapeutics Program at the West Cancer Center, presented findings of a pre-clinical study at the recent Ameri-can Association for Cancer Research (AACR) meeting in San Diego, CA. The study looked at ways of improving response rates and duration of responses in patients with prostate cancer before or after they receive chemotherapy.

Patients with castrate-resistant prostate cancer (CRPC) or those who failed hormonal therapy have poor survival rates. Androgen receptor (AR) is a cancer causing protein that binds to the male sex hormone, testos-terone, and remains an important cause of CRPC progression. Despite recent phase III trials showing a survival advantage for AR inhibitors (e.g. abiraterone and enzalu-tamide), responses are often short lived, lasting generally less than one year.

It has been demonstrated that block-ing both the AR and a common cancer causing protein network (PI-3K/mTOR path-way in PTEN deficient prostate cancer) can prevent drug resistance. Greater than 50 percent prostate cancer patients have ac-

tivation of the PI-3K/ PTEN tumor suppres-sor pathway. We hypothesize that selecting patients based on genetic testing would identify those most likely to benefit and re-spond to this novel combination therapy. According to Dr. Mahadevan, significantly improving the response rates, duration of responses and overall survival in patients with CRPC with a good quality of life based on mechanistic biology is not incremental but is a big leap in the hope of curing this disease.

Dr. Mahadevan and his team in collab-oration with Dr. Bradley Somer conducted lab research on 5 different prostate cancer cell lines demonstrating increased anti-can-cer activity of Enzalutamide or Abiraterone when combined with a panel of pan PI-3K/mTor kinase inhibitors. Combination target-ing of PI3K/mTOR & AR pathway resulted in significant cell killing. Mouse model stud-ies are currently underway to evaluate the safety & activity of blocking the AR plus PI-3K pathways. This study represents a novel therapeutic strategy for patients with CRPC to be evaluated in clinical trials. It will be the first trial of its kind in the U.S. based on this pre-clinical work.

Regional One Health Foundation Launches ONEpulse Magazine

Regional One Health Foundation has launched a new semi-annual magazine for donors and friends of the Foundation called ONEpulse.

This launch of ONEpulse comes at an exciting time for Regional One Health Foundation. With the February 2014 intro-duction of the Regional One Health system of health services, (formerly Shelby County Health Care Corporation or The MED), there begins a new vision for an expanded future of healthcare and philanthropy in our region. This new publication will chronicle Regional One Health’s path to becom-ing a world-class academic medical center through the generosity of the Foundation’s dedicated supporters.

ONEpulse is available semi-annually to numerous donors and friends of Regional One Health Foundation.

OrthoOne Announces D1 Sports Training Facility Ground Breaking

OrthoOne Sports Medicine & Ortho-paedics and D1 Training and Therapy are pleased to announce the ground breaking of a 19,275 square foot D1 Sports Training Facility at 85 Market Center Drive in Collier-ville.

Similar to the 23 other training facilities, this one will be a membership based center that will offer scholastic, adult, family and elite benefits including D1-on-1, bootcamp, rookie (ages 7-11), developmental (ages 12-14), prep (ages 15-18), collegiate and pro training as well as physical therapy.

Professional athletes associated with the D1 facility will be announced closer to the grand opening. Building of the facil-ity has begun and completion is estimated for September. OrthoOne, currently a D1 Medical Partner, offers D1 therapy at both its Collierville and Olive Branch locations.

Dr. Uzoma Ben Gbulie

Dr. Daruka Mahadevan


Newlywed. Proud mother.Conquered breast cancer close to home.Just married, Grumeul and Johnny shared a dream of growing old together with her two children. But shortly after taking their vows, a diagnosis of breast cancer threatened their new life together. Grumeul and Johnny decided to � ght her disease together, choosing West Cancer Center as their partner. Pioneering leaders in cancer research, the doctors at West unite groundbreaking technology with years of expertise to treat cancer, of all types, at every stage. Perhaps best of all, their world-class resources are here in the Memphis area; this keeps Grumeul and Johnny closer during times of sickness, and through the journey to good health.

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memphis medical news june 2014

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