NEW FRONTIERS
FORGING NEW FRONTIERS TOGETHER All of us at University of Utah Health Care are pleased to welcome five affiliate partners to our regional network. These hospitals and physician groups have partnered with us to offer their patients the highest standard of care, particularly those who require the expertise of world-class specialists. Affiliation offers substantial benefits. For example, we anticipate that soon we will be able to extend our Epic electronic medical records system to our affiliate partners, allowing those physicians to use Epic EMR for their own patients and have seamless access to the inpatient and outpatient records of care received at UUHC. In addition, our partners’ nurses can receive additional training at the university, TAD A. MORLEY, and affiliated physicians have the opportunity to become M.H.A., F.A.C.H.E. adjunct faculty and gain access to academic and research Executive director, Business and Network resources at the university. We look forward to strengthDevelopment, and ening these partnerships and forging new ones as our vice president, Outreach and Network outreach progresses. Development, Frontiers offers an exciting new way to connect with University of Utah Health Care our community of referring physicians and share the innovative practices of UUHC’s outstanding physicians and their care teams. In this issue, one of our top referring physicians describes our efforts to enhance the experience of physicians who refer patients to us. At the Huntsman Cancer Institute, dermatologists are using total body photography to spot malignant melanoma in its earliest stages. Our TeleStroke program, one of 15 telemedicine services offered by UUHC, brings our neurovascular specialists face-to-face virtually with patients in emergency rooms throughout the Intermountain West. Finally, a new clinic, established by a prominent neurologist who specializes in movement disorders and cognition, focuses on patients with dementia with Lewy bodies and Parkinson’s disease dementia. Please contact frontiers@hsc.utah.edu to learn more about our specialists and how we can collaborate with you to better serve your patients. Sincerely,
University of Utah Health Care was recognized by The University HealthSystem Consortium as a top 10 principal academic medical center in the U.S. and a recipient of the UHC Quality Leadership Award for the fourth year in a row.
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Editorial Director Dennis Scott Jolley, Senior Director of Clinical Marketing Managing Editor Edwin V. Lyons, Program Manager email: edwin.lyons@hsc.utah.edu Contributors Tad A. Morley, M.H.A., F.A.C.H.E.; Blake D. Hamilton, M.D.; Douglas Grossman, M.D., Ph.D.; Nate Gladwell, R.N., M.H.A.; Jill Austin, R.N., B.S.N.; Jennifer Majersik, M.D., M.S.; Rodolfo Savica, M.D. McMurry/TMG Senior Editor: Janice Sweeter Senior Art Director: Adele Mulford Art Director: Pamela Norman Writer: Janette Bowers
Frontiers is published quarterly by University of Utah Health Care for physicians and should be relied upon for medical education purposes only. This publication does not provide a complete overview of the topics covered and should not replace the independent judgment of a physician about the appropriateness or risks of a procedure for a given patient. © 2014 University of Utah Health Care. All rights reserved. Produced by McMurry/TMG. Contents of this publication may not be reproduced without the express written consent of University of Utah Health Care.
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Cover: Steve Gschmeissner / Science Source
Tad A. Morley
SPRING 2014 VOLUME 1, ISSUE 2
Frontiers in collaboration
Building Partnerships for Better Patient Care UUHC strives for broader access, better communication with referring physicians
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Chad Kirkland
Blake D. Hamilton, m.D. Associate professor, Surgery, University of Utah School of Medicine
systemwide effort to make it easier for physicians to refer their patients to specialists at UUHC is shortening wait times, says urologist Blake D. Hamilton, M.D., chairman of practice management for the 1,200-member University of Utah Medical Group. Getting their patients seen in a timely fashion has been a key concern expressed by referring physicians, Hamilton says. “We have very consciously made an institutional commitment to improving that, and we’re seeing those results. For example, we are improving the use of scheduling templates reserving time slots for new patients whose needs are urgent.” Once a patient has been evaluated and treated at UUHC, keeping the referring physician in the loop is essential to providing excellent care, both during and after the patient’s visit, Hamilton says. “Coordination of care is critical; the incomplete transfer of information can result in mistakes,” he points out. “The physicians who are seeing patients in their hometown need to know what’s happening at University Hospital.” A new portal to the UUHC electronic medical record system gives referring physicians access to information about their patients, and Hamilton says the university is also working on ways to push that information out to the physicians. Open communication is also key to building a partnership that can further benefit patient care, says Hamilton, adding that “I give all my referring doctors my cellphone number. Some will call and text me quite regularly. I’m also encouraging other UUHC physicians to make it easy for referring physicians to contact them.” For Patrick W. Kronmiller, M.D., a urologist in private practice in Payson, Utah, the ability to text Hamilton and his colleagues at any time, with questions or with a request to refer a patient, “has worked out great. Dr. Hamilton is exceptionally cordial, and the text messaging facilitates direct communication with ease and no interruption of busy schedules.” n FinD tHe rigHt specialist. To find the right specialist for your patient, call the UUHC physician referral center at 866-850-8863, or visit Physician Connection at physicians.utah.edu.
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Frontiers in EXPERTISE
Mapping a Route to Early Detection Total body photography helps nab early malignant melanomas
Melanin overproduction in a heavily pigmented human malignant melanoma that has metastasized to a lymph node. Melanin appears as the dense, dark patches in the image.
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New lesion noted
SPL/Science Source
utaneous melanoma claimed on the cheek of a nearly 9,500 lives in the 50-year-old man Baseline photo at a follow-up visit. U.S. last year, according to Biopsied and proved National Cancer Institute estito be an early-stage mates. Because early detection melanoma. is known to sharply increase the odds for survival, the Huntsman Cancer Institute (HCI), part of the University of Utah Health Care system, offers an innovative service tarPhoto on follow-up exam geting the emergence of malignant lesions in patients at high risk of developing melanoma. Results of the study indicated a lower biopsy Douglas Grossman, M.D., Ph.D., is a rate and a higher melanoma detection rate university dermatologist who has directed (the ratio of melanomas to nevi biopsied) for the Mole Mapping Program at HCI since patients monitored with total body photogra2004. He uses total body photography to crephy as compared with those whose suspiciousate a baseline set of high-resolution images looking nevi were individually monitored by showing the entire surface area of the skin. dermatoscopy alone.1 Another advantage of Patients are asked to perform monthly selfexaminations and to return in three months. total body photography over dermatoscopy During the first follow-up visit, a full skin (an approach used at HCI from 1999 to 2004), examination is performed, using the phoGrossman says, is that it tracks the developtographs to detect new moles (nevi) and ment of new lesions, and “about 80 percent of changes in existing nevi. Patients are mailed melanomas arise in normal skin rather than a CD of the photographs to refer to during from existing nevi.” their self-examinations at home and asked Although most patients come from the to return for follow-up exams every six to Salt Lake City area, “we see patients from 12 months, depending on their risk factors all the surrounding states, just as we do for and other circumstances. other types of cancers,” Grossman notes. “We’re the only center in the Primary care physicians and dermatologists Intermountain West to offer total body phoare encouraged to refer patients with one or tography, and we’re able to do it for the cost more of the major risk factors for melanoma. “We communicate with the referring physiof a regular dermatology visit, thanks to supcians, with the understanding that we will port from HCI,” Grossman says. For patients continue to see those patients for monitorat significantly increased risk for melanoma, ing. However, if they have other skin issues, “this is the best way to detect a new melalike acne or dermatitis, we noma.” Another key advantage always send them back to of monitoring patients through CONTACT the referring dermatologist total body photography is a Refer Your for treatment of those disorreduced number of unnecessary Patients ders,” Grossman says. “The biopsies, Grossman says. “In our To refer a patient for physicians who refer to us study, over a five-year period, we mole mapping, please recognize that the service we documented performing fewer call 801-581-2955 provide is unique, and it’s in than one biopsy per patient. (option 1). Email the patient’s best interest to Most patients with lots of moles questions to Douglas work with us.” n will have one or two removed DOUGLAS GROSSMAN, Grossman, M.D., Ph.D., M.D., PH.D. at doug.grossman@ 1 at every dermatologist appointGoodson AG, Florell SR, Hyde M, Bowen Associate professor, GM, Grossman D. Comparative analysis hci.utah.edu. For ment. It’s not uncommon for me departments of of total body and dermatoscopic a patient education Dermatology and to see patients who have had 30 photographic monitoring of nevi in video about total mole Oncological Sciences, similar patient populations at risk for to 50 moles removed; that’s a lot mapping, visit vimeo. Huntsman Cancer cutaneous melanoma. Dermatol Surg. Institute of scarring,” Grossman says. com/79165165, 2010;36(7): 1087-98. password: molemapping Spring 2014
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Frontiers in CONNECTIONS
Bridging the Distance
Jennifer Majersik, M.D., M.S., visits with a patient via the TeleStroke program.
Telemedicine program brings specialists’ expertise to communities
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ore patients and providers throughout the Intermountain West are gaining access to the expertise of specialists at University of Utah Health Care, thanks to UUHC’s commitment to expand and enhance its telemedicine services. “Our goal is to build connections to regions where specialist services are not available, extending the reach and influence of our world-class physicians,” says Nate Gladwell, R.N., M.H.A., director of telemedicine. “We partner with local communities to determine what services they need, then work with their physicians and hospitals to deliver those services.” Telemedicine services include video and telephone consultations, photo sharing between providers and patients, electronic medical record sharing, digital radiology services, and mobile apps. TELEMEDICINE At one time, telemedicine required PROGRAMS AT hospitals to install special, dedicated UUHC equipment. Now, “many of these ser∆ eConsults vices can be delivered on a laptop or ∆ Project ECHO tablet and a webcam,” Gladwell says. In ∆ TeleBurn addition, “there’s technology that allows ∆ TeleCardiology you to practice telemedicine safely and ∆ TeleDermatology securely right on your mobile phone.” ∆ TeleENT Fifteen UUHC telemedicine pro∆ TeleHealth grams connect physicians and patients and Wellness in the region with a broad range of ∆ TeleNeurology specialists. The TeleStroke program, ∆ TeleOncology now reaching 17 communities with oth∆ TeleOrthopaedics ers on the horizon, demonstrates the ∆ TelePlastics benefits of allowing those specialists ∆ TeleMental Health to visualize critical information and ∆ TeleRehabilitation communicate directly with patients. ∆ TeleSpeech “TeleStroke allows our neurovascu∆ TeleStroke lar specialists to examine the patient
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through video-conferencing equipment, personally review the radiology scans and consult directly with the emergency department physician,” says Jill Austin, R.N., B.S.N., nurse manager for the University of Utah Stroke Center. “When time is of the essence, stroke specialists virtually can be at the bedside of a stroke patient in an outside hospital and provide a diagnosis and treatment recommendations within minutes.” The majority of patients with acute stroke who require comprehensive stroke care are transferred to University Hospital, Austin says, while patients with mild stroke or nonstroke diagnoses may remain to receive care in their own communities, depending on the capabilities of the local facilities. The decision whether to transfer the patient is made in consultation between the ED physician and the neurovascular specialist. “Randomized studies and our personal experiences tell us that our diagnoses are more accurate using TeleStroke versus phone consultation because we can see, talk with and examine patients ourselves,” notes Jennifer Majersik, M.D., M.S., director of the Stroke Center and TeleStroke Services. “We are glad to have this technology to serve distant, acute stroke patients and we are excited to explore additional applications. Peter Hannon, M.D., one of our stroke fellows, is testing the feasibility of using the same technology to provide our outpatient stroke services to distant sites.” n
Frontiers in INNOVATION
Targeting Dementia with Lewy Bodies Clinic advances knowledge, treatment of common form of dementia
David Mack / Science Source
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new clinic at University of Utah Health Care is one of only a few in the United States to focus on patients with dementia with Lewy bodies (DLB), which is second only to Alzheimer’s disease as a cause of neurodegenerative dementia. This complex disorder, whose symptoms can overlap those of both Alzheimer’s and Parkinson’s diseases, can be exceptionally difficult to manage, says Rodolfo Savica, M.D., director of the clinic. “Our goal is to give patients with [DLB] the best possible care based on the most current understanding,” Savica says. “We have state-of-the-art diagnostic tools. We apply all available knowledge from the research and from the lab directly to the bedside, and we offer patients the opportunity to participate in studies that may lead to more effective treatment. They will be on the front line of current research.” DLB is not a single disorder, but “a spectrum of disorders involving disturbances of movement, cognition, behavior, sleep and autonomic function,” according to the Lewy Body Dementia Association. Although a Japanese physician first identified DLB in the 1980s, Savica says, “it has become clear in the last five to 10 years that these patients are somehow different from those with Parkinson’s disease, with different symptoms and different management needs.” Neurologically, Parkinson’s disease without dementia has been considered distinct from DLB; however, Parkinson’s disease with dementia is “more or less the same disorder [as DLB],” Savica says. All three disorders share the same protein, alpha-synuclein, that is deposited into the brain. “Unfortunately, it isn’t yet clear why some people develop some symptoms only and others develop dementia,” he notes, adding that the survival rate of patients with DLB also remains unknown. Patients with DLB are treated with some of the same drugs as those used to treat Parkinson’s and Alzheimer’s, but clinical care is challenging. For example, the Lewy Body Dementia Association points out that some medications for Parkinsonian symptoms may increase the “confusion, delusions and hallucinations” Computer artwork of human commonly experienced by patients with nerve cells (neurons, pictured in DLB. For this reason, patients with DLB green) affected by Lewy bodies (orange) in the brain of a person ideally should be managed by physicians with Parkinson’s disease. trained in both movement disorders and cognitive neurology, says Savica, who is trained in both and offers experience in these areas. “There is still much to learn about this disorder, and it is easily confused with other conditions,” he remarks. “We want physicians to know that if they have patients with Parkinsonism and dementia, we are more than happy to work with them to manage the care of these patients.” n
RODOLFO SAVICA, M.D. Director, Dementia with Lewy Bodies/ Parkinson Disease Dementia Clinic; assistant professor of Neurology, University of Utah School of Medicine
Spring 2014
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RECOGNITIONS
AMIT N. PATEL, M.D., M.S. Director, Clinical Regenerative Medicine and Tissue Engineering; associate professor, Division of Cardiothoracic Surgery, University of Utah School of Medicine
When cardiothoracic surgeon Amit N. Patel, M.D., M.S., successfully performed the world’s first retrograde gene therapy procedure on a 66-year-old patient with heart failure last November, it marked the culmination of eight years devoted to development of the retrograde technique. “This was the first time the FDA had approved of any type of retrograde delivery of anything,” Patel says, explaining that “retrograde means you go backward to the heart. We blocked the coronary sinus in order to deliver the gene therapy.” The minimally invasive outpatient procedure has since been performed on five additional patients, all of whom are doing well, Patel says. The patients are participants in a Phase I/II clinical trial testing the retrograde infusion of a nonviral, injectable form of stromal cell-derived factor-1 (SDF-1). The trial is recruiting; candidates must have ischemic cardiomyopathy and an ejection fraction less than 40 percent. Patel is training other physicians to perform the procedure,
“so there will be about 12 to 15 centers that will be able to perform it as part of this trial.” The SDF-1 trial is one of many studies Patel and his team are conducting to help patients with heart failure. The studies involve gene therapy or stem cells or “some combination thereof,” he notes. “Every Monday we conduct what we call the Optimist Clinic. We see any patient who has chest pain, shortness of breath and an ejection fraction less than 45,” he says. “We explore options and therapies, and for 99.9 percent of patients we find something that needs to be done. And then we work with their referring doctor to lay out the options we have and determine what is best for their patient.” To contact Patel, call 801-587-7946.
JEFFREY CAMPSEN, M.D., FACS Surgical director, Pancreas and Live Donor Kidney Transplant Program; assistant professor of Transplant Surgery, University of Utah School of Medicine, Huntsman Cancer Institute, Primary Children’s Medical Center
Jeffrey Campsen, M.D., FACS, a specialist in transplantation of the liver, kidney and pancreas, joined University of Utah Health Care in 2012. Campsen received his Bachelor of Arts from James Madison University and his Doctor of Medicine from Eastern Virginia Medical School. He completed his residency in general surgery and a fellowship in adult and pediatric multiorgan transplantation and hepatobiliary surgery at the University of Colorado. Campsen practices at University Hospital, Huntsman Cancer Institute and the Primary Children’s Hospital. To refer a patient, call 801-585-2708.