Austin Medical Times by Rick Delarosa

Recognizing National Breast Cancer Month

October Edition 2019

Inside This Issue

Detecting Breast Cancer – from Vigilance to Suspicion to Confirmation By Caroline Coombs-Skiles, M.D., FACS, Texas Breast Specialists–Austin Central

Exercise could slow withering effects of Alzheimer’s See pg. 10

INDEX Legal Matters....................... pg.3 Financial Forecast............. pg.4 Mental Health...................... pg.6

UT Health Austin Recognized for Using Integrated Technology to Benefit Patients See pg. 12

cornerstone of health consciousness for adult women includes being on the lookout for breast cancer. There’s plenty of evidence that this eternal vigilance is worth it. In fact, early stage breast cancer that hasn’t spread has a 99 percent five-year survival rate. The path from routine screening to suspected cancer to confirmed diagnosis usually is the shorter part of a longer cancer journey. But better understanding of these preliminary steps can help set you on the right course for a successful cancer fight. Over the past 30 years, research shows a steady decline in mortality rates due to a combination of early detection and improvements in treatment. Early detection is key because cancer in its early stages and localized to one location is the most treatable. Screening and testing methods and technologies continue to advance and include 3D mammograms which are currently available in some areas, and new blood tests that are in development. These innovations and

all screening options are intended to work in combination with this essential, albeit decidedly low-tech recommendation: Discuss with your

changes to a physician. Conducting regular self-exams is important in detection, but it has limitations in detecting early stage breast cancer, when symptoms do not always appear. That’s why physicians recommend additional screenings. Screenings Preventative, proactive screenings, such as mammograms, clinical breast exams, and MRI, are the most effective methods for early detection. Screenings can find cancer cells before symptoms are present. Mammograms, which use low-dose X-ray images to identify potentiallycancerous breast changes, are the most common screening. Mammograms identify any abnormal areas in the breast, such as calcifications (white spots) and masses (tumors) that can only be detected from screenings. According to the American Cancer Society, women who receive regular mammograms are more likely to detect

Over the past 30 years, research shows a steady decline in mortality rates due to a combination of early detection and improvements in treatment. Early detection is key because cancer in its early stages and localized to one location is the most treatable. doctor your individual risk factors, such as age, menopausal status, and family history. Self-Exams Starting in their 20s, women should check their breasts monthly for lumps or unusual changes in feeling, appearance, or discharge. Pay attention to how your breasts normally look and feel, and immediately report any

see Breast Cancer.. page 14

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Legal Matters Peer Review of Employed Physicians By John T. Synowicki, JD

s the health care industry sees increasing alignment among hospitals and other health care providers, a reoccurring issue is how to handle peer review for physicians who are engaged with the provider through credentialing, but also through an employment relationship. Inevitably, peer review concerns arise for some of those physicians, often resulting in separate employment and peer review evaluations of the physician. It is important for providers to look at these arrangements proactively, as the structure of the relationship can streamline how the hospital handles the underlying situation. This issue can arise where physicians are employed directly by the Hospital. Although this applies only on

a limited basis in Texas, some physicians enter into a physician employment agreement (PEA) with providers, in addition to receiving privileges with the provider. The PEA often contains a provision that the loss of employment by the physician will result in the automatic loss of membership and privileges at the hospital through immediate termination. Additionally – and more commonly in Texas – a situation can arise where the physician is employed by an affiliate of the Hospital, or with a group who is contracted as an exclusive provider. Under such circumstances, it is not uncommon for the affiliate to directly employ the physician, and for the PEA to contain a clause that the loss of employment by the physician requires the physician to immediately resign from any affiliated hospitals or other credentialing entities. This could trigger an automatic termination of privileges and membership, or require the physician to voluntarily resign his privileges and membership at affiliated entities.

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In April 2017, the National Practitioner Data Bank (NPDB) issued formal guidance on the issue of employed physicians to clarify issues surrounding loss of employment in relation to privileging issues. The NPDB clarified that where a physician was under peer review, but lost his privileges and membership due to an automatic action related to employment termination or resignation, the termination was not reportable to the NPDB. The NPDB stated the “termination was not a result of a professional review action and, therefore, was not reportable. It does not matter that the employment termination *** automatically resulted in the end of the practitioner’s clinical privileges.” National Practitioner Data Bank Insights Publication, April 2017. The NPDB publication provides several important takeaways. First, it confirmed that when the loss of privileges is automatic, it is considered an administrative action, and the loss of privileges is not reportable to the NPDB. Thus, even if there is a parallel

peer review investigation underway at the Hospital when the physician’s employment terminates, there is no reporting requirement related to the loss of privileges, provided that the loss of privileges was automatic. Second, the NPDB guidance focuses on the result that terminated the physician’s privileges, not whether the review began due to a peer review investigation or an employment concern. Thus, regardless of whether the underlying issue starts as an employment concern or a peer review concern, if the physician’s employment terminates, and there is a provision for an automatic termination of privileges and membership, it is not reportable to the NPDB. see Legal Matters...page 14

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Financial Forecast What Came First: The Happy Employee or The Happy Patient? By Reed Tinsley, CPA, CVA ,CFP, CHBC

t is no secret; a happy team leads to more satisfied customers and patients. Those that are engaged in their roles within the team and feel satisfied by the work they do, tend to give more on the job and care about the experiences their customers have. In fact, when it comes to larger cor porations, USA Today has found a correlation b e t w e e n e m p l o y e e engagement rates and stock prices. So, what makes this connection a reality? In most cases, rewarding employees can pay off in the long run. This works because: • Employees will take pride in their

work, and this is fueled by rewards and their feeling of importance. • You’ll see a far lower turnover rate, which means that your company will spend less time training new employees.

...be sure you are involved in engaging your employees. Be active in their work life through providing feedback and offering support. A team is only as great as the leader they look up to, so remember to give them the motivation they need! • You get what you pay for, especially when it comes to human resources. The more you invest in your

employees, the better your bottom line will turnout. The concept of rewarding employees doesn’t have to be extravagant and depend upon the leftover cash flow in the monthly company budget. Simple acts of recognition can go a long way when it comes to boosting self confidence and camaraderie in the office. Whether it be themed lunches (either bought by management or simply promoted in office), employee of the month recognition, or a friendly, “Great Job!” upon passing a team member with a recent triumph; taking the extra time to connect can create a stronger team and better overall customer service as an outcome.

What better way to become a team than to literally… become a team? A local practice in the Kansas City area recently decided to create an in-office kickball team and now meets weekly for a local parks and rec league in the area. Whether it be sports or hobbies, getting involved in new activities together can lead to a stronger team in the office! From a managerial standpoint, be sure you are involved in engaging your employees. Be active in their work life through providing feedback and offering support. A team is only as great as the leader they look up to, so remember to give them the motivation they need!

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October 2019

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Mental Health Addressing Texas’ Psychiatrist Shortage

lthough the entire nation is experiencing a shortage of mental health practitioners, Texas ranks far below the national average in terms of the number of mental health professionals per 100,000 residents. In fact, second to California, Texas has the largest number of Mental Health Care Professional Shortage Areas (HPSAs) in the United States. Furthermore, amplifying the difficulty of finding a solution to the mental health care provider shortage, the state faces a unique challenge as a large percentage of Texans live in a rural area. Thus, many Texans may need to travel large distances to get access to the few mental health care providers available. One way to address the lack of providers is—of course—to train additional psychiatrists. To that end, the Texas Higher Education Coordinating Board awarded a $250,000 planning grant to the Texas A&M College of Medicine. The grant prioritized primary care and psychiatry programs, especially in a rural setting. “With the help of the grant,

we hope to develop a Bryan-College Station-based psychiatry residency program,” said Andrew Harper, MD, child and adolescent psychiatrist with the Texas A&M Outpatient Psychiatry Clinic, associate department head for clinical care and clinical professor at the Texas A&M College of Medicine. “This grant will help us on several fronts as we plan and finance the project.” For example, the funds will help Harper and his team recruit top notch faculty, coordinate with community resources and potential partners and hire a consultant to make sure the Accreditation Council for Graduate Medical Education (ACGME) criteria are met. After completing medical school, a psychiatry resident undergoes a residency that lasts four years before they can become an independent practicing psychiatrist. “In our program, we hope to have three to four residents per year,” Harper said. “Our goal is to have the program running by summer 2020, so we have a lot to do between now and then.”

The grant is a part of the state’s effort to expand the graduate medical education programs in Texas. Within the last decade, the number of medical schools and spots within existing medical schools have expanded to attempt to solve Texas’ physician shortage. However, the available graduate medical education positions and residency program spots have not expanded at the same rate to match this growth. Statistically, matriculating medical residents are more likely to practice within 100 miles of their residency program. With the increase in medical school attendance, Texas has graduated more students from medical school than ever before, but those graduates are not finding a residency position in the state. As a result, many move out of state to complete their medical training and stay within 100 miles of that site to practice. Harper emphasized the importance of psychiatry residents getting an immersive training in primary care. “We know people with behavioral health problems often have shorter

lifespans,” he said. “Similarly, some medical problems can first present in changes to mental status. “Because there is a shortage of behavioral health providers of all types and due to the stigma of psychiatric illness, a huge number of patients show up in their primary care provider’s office asking for help,” Harper said. “It is important the family medicine residents know how to treat them.”

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Health Startups Have New Home for Growth, Opportunity at UT Austin Veteran Austin Entrepreneur Mellie Price Tapped to Lead New Business/ Medical Partnership

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ealth product innovators and entrepreneurs in the Texas capital are getting a leg up thanks to a new partnership at The University of Texas at Austin between the Jon Brumley Texas Venture Labs (JBTVL) at the McCombs School of Business and the Texas Health CoLab at Dell Medical School. The unique collaboration is intended to accelerate the pace of health product innovation in Austin. Health-focused entrepreneurs, inventors, clinicians and researchers are already working with the medical school’s hub for innovation, known as the Texas Health CoLab, to create products and services that improve patient health outcomes and lower the cost of health care. Their startups can now get an additional boost by also applying to be part of the business school’s JBTVL, an accelerator that matches early-stage startups with cross-functional student teams from across UT Austin graduate schools to help solve critical business problems. “Health care is perhaps the most pressing need for business transformation in our country,” said McCombs’ Dean Jay Hartzell. “Leveraging the joint power of the Health CoLab and JBTVL helps to support local startups and further advance Austin as a center for health care innovation.” Dell Med Dean Clay Johnston, M.D., agreed, saying, “This interdisciplinary effort combines innovation, collaboration and community benefit, and is absolutely aligned with Dell Med’s interest in making Austin a model healthy city.” Veteran Austin entrepreneur Mellie Price to lead partnership Leaders from both schools also announced that veteran local entrepreneur Mellie Price has been tapped to be the new executive director of the JBTVL, and to lead this unique cross-school partnership. Price will also continue her current work as executive director of commercialization and managing director of the Texas Health CoLab at Dell Med. John Sibley Butler, JBTVL’s past director, will now serve as its faculty director. Dell Med created the Texas Health CoLab to enable a robust health innovation ecosystem in

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Mellie Price

Central Texas, advance its mission to revolutionize how people get and stay healthy, and to support new business ventures focused on improving health. “This partnership reinforces the commitment of both schools to foster an environment supporting creative business solutions within the health care industry – something I have been passionate about throughout my career,” said Price, an experienced investor, technologist and co-founder of Austin’s startup ecosystems Capital Factory and SoftMatch. The JBTVL pairs graduate students with local startups from all industries, offering assistance in writing business plans, forecasting financials, performing competitive research, developing pricing and marketing strategies and more. Graduate students from the MBA, law, engineering, pharmacy and natural sciences programs participate in semester-long consulting projects and work alongside the company founders to earn academic credit in exchange for high-quality consulting work and real-world experience. “Under Mellie’s leadership, the JBTVL is taking business ventures to the next level, serving as a unique forum for investors to engage with researchers and startups from within the UT Austin community,” said Luis Martins, Ph.D., professor and chair in the Department of Management and director of the Herb Kelleher Center for Entrepreneurship at McCombs. At the end of each semester, the JBTVL hosts an expo to showcase its latest startup innovations. The next expo will take place on November 21, 2019. Apply for the 2020 Spring: https://www.mccombs.utexas. edu/Centers/Texas-Venture-Labs/ Startups

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Exercise Could Slow Withering Effects of Alzheimer’s Imaging Shows Less Brain Deterioration In Physically Active People At High Risk For Dementia

xercising several times a week may delay brain deterioration in people at high risk for Alzheimer’s disease, according to a study that scientists say merits further research to establish whether fitness can affect the progression of dementia. Research from UT Southwestern found that people who had accumulation of amyloid beta in the brain – a hallmark of Alzheimer’s disease – experienced slower degeneration in a region of the brain crucial for memory if they exercised regularly for one year. Although exercise did not prevent the eventual spread of toxic amyloid plaques blamed for killing neurons in the brains of dementia patients, the findings suggest an intriguing

possibility that aerobic workouts can at least slow down the effects of the disease if intervention occurs in the early stages. “What are you supposed to do if you have amyloid clumping together in the brain? Right now doctors can’t prescribe anything,” said Dr. Rong Zhang, who led the clinical trial that included 70 participants ages 55 and older. “If these findings can be replicated in a larger trial, then maybe one day doctors will be telling high-risk patients to start an exercise plan. In fact, there’s no harm in doing so now.” Reduced brain atrophy The study published in the Journal of Alzheimer’s Disease compared cognitive function and brain volume

Dr. Rong Zhang reviews data at the Institute for Exercise and Environmental Medicine (IEEM). A new study conducted at the IEEM shows regularly exercising may slow down brain deterioration in people at high risk for Alzheimer’s disease.

between two groups of sedentary older adults with memory issues: One group did aerobic exercise (at least a half-hour workout four to five times weekly), and another group did only flexibility training. Both groups maintained similar cognitive abilities during the trial in areas such as memory and problem solving. But brain imaging showed that people from the exercise group

who had amyloid buildup experienced slightly less volume reduction in their hippocampus – a memory-related brain region that progressively deteriorates as dementia takes hold. “It’s interesting that the brains of participants with amyloid responded more to the aerobic exercise than the others,” said Dr. Zhang, who see Alzheimer’s...page 14

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October 2019

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UT Health Austin Recognized for Using Integrated Technology to Benefit Patients, Improve Medical Practice T Health Austin, the clinical practice of Dell Medical School at The University of Texas at Austin, has been awarded HealthCare’s Most Wired Certified Level 9 Performance Excellence Award by the College of Health Information Management Executives (CHIME) for its exceptional use of information technology to improve health and care. UT Health Austin was only one of two ambulatory clinical systems in Texas to earn a Level 9 certification. More than 16,000 organizations were evaluated for their respective adoption, integration and impact

our patients as a complex individual with unique needs, beliefs and preferences,” he said. Integrated technologies are critical to building a more personalized system of care that allows for seamless connection of real-time data, analytics and functional capabilities. This integration makes it possible for clinicians to connect with patients in ways that positively impact each patient’s experience and health outcome. “What makes this recognition by CHIME particularly significant is that UT Health Austin is one of only two organizations in Texas to achieve

of technologies in their systems as part of the annual survey. All participants surveyed were assigned a benchmark rating on a scale of one to 10; organizations earning Levels 8-10 were honored with awards. “This award illustrates the transformative power that technology can play in a health system, and it is something we have built our practice around to provide the right care at the right place at the right time,” said Aaron Miri, CHCIO, Chief Information Officer of UT Health Austin and Dell Med. “Everyone at UT Health Austin is motivated to create a system of care that embraces each and every one of

this level of recognition, and our practice is relatively new,” said Amy Young, M.D., Chief Clinical Officer of UT Health Austin and Vice Dean of Professional Practice and Professor in the Department of Women’s Health at Dell Med. “We have assembled a unique group of providers that passionately believe in understanding outcomes that are important to patients and are harnessing the strengths of our technology team to enable the collection in a way that are clinically actionable,” she said. 

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St. David’s North Austin Medical Center Names New Chief Financial Officer

t. David’s North Austin Medical Center has selected Jill Leone as its new chief financial officer (CFO). Leone assumed her new role at St. David’s HealthCare this summer. “Jill has more than 20 years of experience managing finances in the healthcare industry and a deep understanding of hospital operations,” Tom Jackson, chief executive officer of St. David’s North Austin Medical Center, said. “She’s a certified public accountant with excellent leadership skills and a

welcome addition to our executive team.” Leone most recently served as the division controller at HCA Healthcare Capital Division, where she was responsible for the financial reporting of 18 hospitals across four states. Previously, she served as CFO at Capital Regional Medical Center, a 266-bed acute care hospital in Tallahassee. Prior to this, Leone served as interim CFO at Presbyterian/St. Luke’s Medical Center and Rocky Mountain

Hospital for Children in Denver, in addition to serving in various other roles, including physician practice management. Leone earned a bachelor’s degree in business from the University of Central Florida and an MBA from the Florida Institute of Technology. Jill Leone

Baylor Scott & White Health Opens Hospital in Buda, Expands Care Delivery in Hays County Largest Not-For-Profit Healthcare System in Texas Opens New Medical Center Campus To Serve One Of The Nation’s Fastest-Growing Communities

aylor Scott & White Health, the largest not-for-profit healthcare system in Texas, today opened its newest full-service hospital. Baylor Scott & White Medical Center – Buda, the System’s first medical center in Hays County, is located at 5330 Overpass Road and is open 24 hours a day, 7 days a week. The hospital joins primary care and specialty care clinics, which opened a month earlier on the medical center campus. This comprehensive model of co-locating the hospital and clinics on one campus means patients can receive greater care coordination, as hospital and clinic caregivers can work together seamlessly through a single electronic medical record to

prevent unnecessary medical tests, reduce wait times and improve the patient experience. “We are excited to open our first hospital in Hays County today, increasing the community’s access to our comprehensive model of quality care,” said Jay Fox, president, Baylor Scott & White Health – Austin/Round Rock Region. “Today’s opening is the culmination of years of collaborative work with the Buda community, and we believe our medical center reflects the community’s health needs while celebrating the history and culture of Hays County.” The full-service hospital provides 24/7 emergency care and comprehensive inpatient care, including diagnostic services,

intensive care, surgical services, and more. The clinics offer primary care and specialty care services such as pediatrics, cardiology, chiropractic care, endocrinology, gastroenterology, orthopedics, podiatry, general surgery, and pulmonology. With an ability to add future services, the hospital and the clinic can meet the needs of Buda as the area’s population grows. “Our focus is on keeping people healthy through wellness and preventative care,” said Robin Watson, MD, chief medical officer, Baylor Scott & White Health - Austin/Round Rock Region. “Bringing a multitude of services to

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Buda in one location gives patients more access to convenient and coordinated care.” Baylor Scott & White Medical Center – Buda joins the System’s Austin/Round Rock Region, which spans a five-county area and includes seven medical centers and more than 70 access points where patients can receive care from more than 420 providers in more than 70 medical specialties. A medical center in Austin is set to open in early 2020.

October 2019

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Austin Medical Times

Breast Cancer

Continued from page 1 cancer early, require less aggressive treatment, and have better outcomes. Women should have clinical breast exams at regular intervals depending on age. Physicians may recommend an MRI for some women. Confirmation and Identification If a suspicious area is found, additional tests can confirm if the area is benign or cancerous. Also, breast surgeons often perform procedures to collect tissue to determine if it is cancerous and identify the tumor characteristics.

Tests on tissues from the tumor help in determining staging and identifying tumor markers. Tumor markers provide valuable insights to a patient’s care team, such as how aggressive a cancer is, most appropriate treatments, and whether it is responding to treatment. If a tumor is cancerous, breast surgeons consult with patients and their care teams about the best course of treatment for the individual patient. More surgical options and techniques are now available to help patients make

a very personal decision that is right for them. Ultimately, patients are their bodies’ best advocates, and it is important for women to actively take control of their health with regular preventative checks for breast cancer. Early detection is important, but with the myriad of treatment options available and more promising treatments on the horizon, we offer women ever greater hope for successful outcomes.

it considered a separate resignation by the physician? • Does the automatic termination of privileges apply in all loss of employment situations, or only in for-cause terminations? The answer to each of these questions could have a decisive impact in how to handle the situation. While each situation is unique and requires a careful review of the relevant medical staff bylaws, PEA,

and facts involved in each matter, tying privileges to employment may provide an opportunity for hospitals to automatically terminate a physician’s privileges and membership without having to conduct a full-scale peer review investigation.

Web Development Lorenzo Morales

yielded no proven treatments that would make an early diagnosis actionable for patients. Fitness and brain health Dr. Zhang is among a group of scientists across the world trying to determine if exercise may be the first such therapy. His latest research builds upon numerous studies suggesting links between fitness and brain health. For example, a 2018 study showed that people with lower fitness levels experienced faster deterioration of vital nerve fibers in the brain called white matter. Research in mice has similarly shown exercise correlated with slower deterioration of the hippocampus – findings that prompted Dr. Zhang to investigate whether the same effects could be found in people. “I’m excited about the results, but only to a certain degree,” Dr. Zhang said. “This is a proof-of-concept study, and we can’t yet draw definitive conclusions.”

Expanded research Dr. Zhang is leading a five-year national clinical trial that aims to dig deeper into potential correlations between exercise and dementia. The trial, which includes six medical centers across the country, involves more than 600 older adults (ages 60-85) at high risk of developing Alzheimer’s disease. The study will measure whether aerobic exercise and taking specific medications to reduce high blood pressure and cholesterol can help preserve brain volume and cognitive abilities. “Understanding the molecular basis for Alzheimer’s disease is important,” Dr. Zhang said. “But the burning question in my field is, ‘Can we translate our growing knowledge of molecular biology into an effective treatment?’ We need to keep looking for answers.”

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Alzheimer’s

Continued from page 10

October 2019

Senior Designer Jamie Farquhar-Rizzo

Accounting Liz Thachar

Continued from page 3

conducted the trial at the Institute for Exercise and Environmental Medicine. “Although the interventions didn’t stop the hippocampus from getting smaller, even slowing down the rate of atrophy through exercise could be an exciting revelation.” However, Dr. Zhang notes that more research is needed to determine how or if the reduced atrophy rate benefits cognition. Elusive answers The search for dementia therapies is becoming increasingly pressing: More than 5 million Americans have Alzheimer’s disease, and the number is expected to triple by 2050. Recent research has helped scientists gain a greater understanding of the molecular genesis of the disease, including a UT Southwestern discovery published last year that is guiding efforts to detect the condition before symptoms arise. Yet the billions of dollars spent on trying to prevent or slow dementia have

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Legal Matters

Although the NPDB guidance provides important clarification for providers, it also leaves open several questions that have not been addressed by the NPDB and which require close factual scrutiny, including, but not limited to, the following: • Does the PEA allow the employer to notify the Hospital of the termination? • Is the termination of privileges under the bylaws automatic, or is

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