St Louis July 2013 by FW Publishing

PROUDLY SERVING THE GATEWAY CITY

July 2013 December 2009 >> $5

PHYSICIAN SPOTLIGHT PAGE 3

Navin Tekwani, MD ON ROUNDS Sports Medicine Community Weighs In Zurich 2012 Concussion Consensus Statement clarifies issues, muddles others, exemplifies mystery of TBI No RTP (return to play) on the same day, regardless of circumstances. An earlier return to light exercise, recommended. And the differential between pediatric and adult patients, clarified ... 4

The Move to DNP Nurses embrace advanced degree program to address the increasingly complex healthcare practice environment In October 2004, member schools of the American Association of Colleges of Nursing (AACN) voted to endorse the organization’s position statement calling for the transition of the level of preparation needed for advance practice nursing ... 13

ONLINE: STLOUIS MEDICAL NEWS.COM PRSRT STD U.S. POSTAGE PAID FRANKLIN, TN PERMIT NO.357

stlouismedicalnews

Tapping into Hospice and Palliative Medicine PCPs benefit from services of underutilized specialty By

LyNNE JETER

ST. LOUIS — Not long ago, hospice referrals for end-of-life care were typically made only a few weeks before the patient’s death. Now, good hospice referrals are made six months to a year in advance to allow time for patients and their families to transition to the final phase of life. Palliative care comes in sooner for patients suffering from serious illness, with specialists having the advantage of focusing on the patient, not the disease. Hospice is definitely underutilized in the United States, said Derrick O’Connell, RN, MBA, chief quality officer for Esse Health, a St. Louis-based practice group with nearly 100 physicians and specialists. “Just about any patient with a serious, life-limiting illness can benefit from palliative care,” said (CONTINUED ON PAGE 12)

The Business Side of Healthcare

Discover ﬁnancial solutions to post-health reform challenges at the inaugural St. Louis Physicians Business Conference By LyNNE JETER

This fall, St. Louis Medical News will present the first conference of its kind – the 2013 St. Louis Physicians Business Conference – devoted to the business side of medicine and providing financial solutions for healthcare professionals. The inaugural event will take place Saturday and Sunday, Oct. 26-27 at the Sheraton Westport Chalet Hotel in St. Louis, offering seminars from local and national experts on myriad issues facing healthcare professionals in post-health reform America. “The idea for the conference came from concerns I’ve heard re(CONTINUED ON PAGE 6)

Now Available!

Register FREE online at StLouisMedicalNews.com to receive your digital edition copy of Medical News optimized for your computer, tablet or smartphone!

PRINTED ON RECYCLED PAPER .com

JULY 2013

stlouismedicalnews

.com

PhysicianSpotlight

Navin Tekwani, MD By LUCY SCHULTZE

Growing up the son of a St. Louis ophthalmologist, Navin Tekwani, MD, spent time volunteering at a local hospital. But on the weekends and summers when he had a chance to visit his father’s office, he was able to gain a keen impression of the way his father enjoyed his work. “You could tell it was very satisfying,” Tekwani said. “Maybe that planted a little seed in the back of my head. “As I was looking for which area of medicine to go into, it seemed like correcting someone’s vision – even something as simple as fitting them with glasses – would change their world by allowing them to see. It had to be one of the most satisfying jobs.” That conviction coupled with the chance to work alongside his father led Tekwani to join his father’s practice in 2002. Today, Tekwani Vision Center spans three locations in a practice that includes both Tekwani and his father, H.T. Tekwani, MD, as well as optometrist Jessica Carson, OD. “It’s been really great working with my father, because he has a lot of experience he’s been able to impart on me,” the younger Tekwani said. “He’s been a great mentor to learn from.” The elder Tekwani has practiced ophthalmology in the St. Louis area for more than 40 years. He completed his training at the St. Louis City Hospital and Barnes Hospital. Both Tekwanis are certified by the American Board of Ophthalmology and have been honored among America’s Top Ophthalmologists for several years in a row. The younger Tekwani attended medical school at the University of Missouri-Kansas City, where he tried to keep an open mind about which specialty he would pursue. “I really liked seeing patients in the office, but I also liked doing surgery,” he said. “There are not a lot of fields where you’re able to combine both; it’s usually one or the other.” At the same time, Tekwani was attracted by opportunities to incorporate the latest technologies into his medical practice. As he researched his father’s field, it seemed to offer just the right blend for him as well. He completed an internship at the University of Chicago, followed by a residency in ophthalmology at the Eye Foundation of Kansas City. Tekwani went on to complete fellowship training in refractive eye surgery at the Cleveland Clinic Foundation. Training at a leading center gave Tekwani the chance to work with technologies that were not yet widely available outside of academic medicine. Those experiences allowed him to bring his own advantages to a partnership with his father. stlouismedicalnews

.com

“We were able to adopt those technologies into our practice as soon as they became available, and to incorporate them very quickly without a learning curve,” Tekwani said. One such advance was the wavefrontguided variation of the traditional Lasik procedure. The newer approach applies custom three-dimensional eye mapping to the laser-surgery technique. “That technology was not yet widely used during my fellowship,” Tekwani said. “Because I had trained on it, we were able to incorporate it as soon as it was available and translate it into optimal patient outcomes.”

From the day Tekwani joined his father in practice, a philosophy of mutual respect was critical in forging a new partnership in the office. “My dad was very good about the way he treated me when I came in,” Tekwani said. “He didn’t tell me, ‘This is what I expect you to do.’ He listened to me also, and we were able to meld that into a synergistic practice.” At the same time, his father’s longtime patients were able to overcome their hesitations about a new doctor joining the practice because of the familial similarities. “It wasn’t easy at first, because patients had been seeing my dad for many years and he was in practice by himself, so they were used to him seeing everyone,” Tekwani said. “Some of the patients were nervous about a new doctor being there. But as they got to know me, a comfort level developed. “I think adding a second doctor to a practice is always challenging, but when it’s a relative, it makes it easier for patients to adjust.” For the Tekwanis, achieving a peaceful and productive work environment with a family member began with practicing mutual respect. “I think the main thing is to put aside any ego that you may have, and just be respectful to each other,” the younger Tekwani said.

“It’s different being in the office than it is being at home. But I think the key is having mutual respect, and learning how to mesh different areas of expertise and different ideas – and translate all of that into what’s best for the patient.” The Tekwanis’ practice today includes everything from routine eye exams to a variety of laser surgeries and procedures for cataracts and glaucoma. Diabetic care is also part of the practice. Tekwani Vision Center is based at a main office just off I-270 in South County. The doctors also see patients at a second office in North Hampton and recently opened a third location in St. Peters. They perform surgery at the St. Louis Eye Surgery & Laser Center in Des Peres and at the St. Charles Surgery Center. In addition to dividing his time among those locations, Tekwani also serves as director of ophthalmology at St. Anthony’s Medical Center. The role includes overseeing ophthalmological care at the hospital as well as overseeing the emergency-room schedule, serving on surgical-department committees and ensuring credentialing is kept up-to-date for all ophthalmologists on staff. His off-hours are largely spent keeping up with his two daughters, whether playing with them or helping with homework. He and his wife, Monica, are the parents of Alina, 9, and Naya, 5.

YOU ARE SPECIAL. Your case is unique and you don’t want to be a number, you want to get the best treatment possible by people who will remember your name. You like things done a certain way, and for someone to understand what makes you special.

WE ARE SPECIALISTS. The people of Saint Louis University Hospital are specially trained to treat your unique case. We are caregivers at every level. We are exclusively SLUCare, the physicians of Saint Louis University, and we are steeped in the Jesuit tradition of teaching and research while continuing to be focused on the future with breakthrough services and technology.

Bruce Bacon, MD Professor of Gastroenterology and Hepatology

Gabriella Espinoza, MD Assistant Professor, Department of Ophthalmology Residency Program Director, Saint Louis University Eye Institute

Michael Lim, MD Associate Professor of Medicine Co-director, Center for Comprehensive Cardiovascular Care at Saint Louis University Hospital (C4)

sluspecialist.com 314-577-8000

JULY 2013

Sports Medicine Community Weighs In Zurich 2012 Concussion Consensus Statement clarifies issues, muddles others, exemplifies mystery of TBI By LYNNE JETER

No RTP (return to play) on the same day, regardless of circumstances. An earlier return to light exercise, recommended. And the differential between pediatric and adult patients, clarified. Those are among the highlights of the 2012 Concussion Consensus Statement derived from the 4th International Consensus Conference on Concussion in Sport, held last November in Zurich. Every four years, the International Ice Hockey Federation, International Olympic Committee, International Rugby Board, International Federation for Equestrian Sports, and FIFA (International Federation of Association Football) host the conference, which results in an updated concussion consensus statement. “The new statement shows that we basically still don’t understand concussions, and there are many opinions on how to diagnose and treat them,” said William Feldner, DO, a sports medicine specialist at South County Family & Sports Medicine and St. Anthony’s Medical Dr. William Feldner Center in St. Louis, Mo.,

and team physician for Lindenwood University and USA Volleyball. He’s also a board member of the Joint Commission for Sports Medicine and Science, an editorial board member of the Clinical Journal of Sports Medicine, and past president of the American Osteopathic Academy of Sports Medicine. “And, while it’s not in the (consensus) statement, there’s some interesting genetic research going on. We may eventually be able to predetermine if someone is more susceptible to concussion based on their genetic makeup.” Marc Hilgers, MD, PhD, director for sports medicine fellowship, sports medicine research, and a sports medicine physician at Level One Orthopedics with Orlando Health in Central FlorDr. Marc ida, said he didn’t expect Hilgers major changes in the 2012 consensus statement. “I’ve been keeping my finger on the pulse of knowledge and I knew what was coming down the pike,” said Hilgers, also the team physician for Orlando City Soccer and the Minor League Umpire Association, medical advisor for the Florida Orthopaedic Institute, and assistant profes-

“You have residency training… shouldn’t you expect the same from us?”

sor of family medicine at the University of South Florida. “That’s why I wasn’t surprised, especially with the broad spectrum of specialists from all over the world who met to write the updated statement, that it was kept general and not too progressive.” Bill Hefley, MD, an orthopedic surgeon and partner at OrthoSurgeons based in Little Rock, Ark., said the latest consensus statement showed “great development in the CRT (concussion recognition tool) for lay use.” The 2008 conference resulted in the development of the Sport Concussion Assessment Tool (SCAT2), a standardized method of eval- Dr. Bill Hefley uating athletes ages 10 years and older for concussions. “This tool takes out the ‘guesswork’ and interpretation for laymen,” said Hefley. “The SCAT3 has a background section, which is a great addition to the SCAT2. Also, the SCAT3 is much more streamlined with clinician instructions on its own page, rather than after each section. The ChildSCAT3 is a great new tool for younger athletes who may sustain concussions.” Todd Ross, MS, ATC, an athletic trainer for Pulaski Academy with OrthoSurgeons, highlighted the 2012 consensus statement’s importance “because it continues the worldwide awareness of concussions (and) shows the dedication the medical society has for learning more about concussions, how to recognize concussions, how to properly manage athletes with concussions, and how to properly and safely return an athlete to play after a concussion has subsided.” The only major blip noted repeatedly: the altered position on CTE (chronic traumatic encephalopathy). Hilgers called it

“an interesting update … on an issue that had ‘percolated up’ since 2008.” • The 2008 section on chronic traumatic brain injury (TBI) notes: “Epidemiological studies have suggested an association between repeated sports concussions during a career and late life cognitive impairment. Similarly, case reports have noted anecdotal cases where neuropathological evidence of CTE was observed in retired football players. Panel discussion was held, and no consensus was reached on the significance of such observations at this stage. Clinicians need to be mindful of the potential for long-term problems in the management of all athletes.” • The 2012 TBI section notes that “clinicians need to be mindful of the potential for long-term problems in the management of all athletes. However, it was agreed that CTE represents a distinct tauopathy with an unknown incidence in athletic populations. It was further agreed that a cause and effect relationship has not as yet been demonstrated between CTE and concussions or exposure to contact sports. At present, the interpretation of causation in the modern CTE case studies should proceed cautiously. It was also recognized that it’s important to address the fears of parents and athletes from media pressure related to the possibility of CTE.” “It seems unclear what their true position is between the two consensus statements and needs to be better explained,” said Ross, particularly given the unfortunate trend of former and current professional athletes taking their own lives for their families “to donate their brain … to prove CTE is in fact an issue.” Among high-profile, self-inflicted deaths in recent years are professional athletes Junior Seau, Derek Boogard, Dave (CONTINUED ON PAGE 13)

Notable Highlights

Your patients can choose from our 5 convenient locations in the St. Louis area. We have been providing expert orthopedic manual physical therapy care to your patients for over 10 years. Learn more about us and our services at: www.stlpt.com

To schedule an appointment, please call: Chesterfield 636-728-1777 | Des Peres 314-966-2273 Fenton 636-861-6969 | Hazelwood 314-395-9303 | Olivette 314-989-9500

JULY 2013

Todd Ross, MS, ATC, an athletic trainer for Pulaski Academy with OrthoSurgeons in Little Rock, Ark., emphasized other notable 2012 Concussion Consensus Statement highlights: • In the preamble, “ … therapists, certified athletic trainers … coaches and other people” were replaced with “primarily for use by physicians and healthcare professionals,” which better addresses who should be diagnosing concussions and handling RTP decisions concerning concussions. • “Brain injury” was added to the first sentence to read: “Concussion is a brain injury and is defined as a complex Todd Ross pathophysiological process affecting the brain induced by biomechanical forces.” “One could argue the point of, by definition, a concussion isn’t an injury but a process,” he said. “Adding the language of brain injury nullifies this objection.” • A timeline for concussion status was identified as “in some cases, symptoms and signs may evolve over a number of minutes to hours,” which could broaden the clinician’s interpretation of signs and symptoms. • The “Classification of Concussion” subtitle was changed to “Recovery of Concussion.” • In the neuropsychological assessment subtitle, the second and third paragraphs were rewritten and show less of an emphasis on the patient seeing a neuropsychologist. However, the emphasis changes to neuropsychological (NP) testing and a multidisciplinary approach to concussion management.

stlouismedicalnews

.com

MedicalEntrepreneurs

Selling for Success By MARTIN WILLOUGHBY Southwestern Advantage (formerly known as Southwestern Company) is a Nashville-based publishing company that recruits about 2,500 to 3,000 college students each summer to sell its educational products door-to-door using direct selling methods. Their summer associates fan out around the country and work long grueling hours making cold calls each day. A significant percentage of the summer associates quit within the first few weeks, but those who persevere have the opportunity to make a significant income and learn invaluable skills. For many people, just the thought of having to cold call can create a queasy feeling. Too often, the perception of “selling” is just this type of cold calling sales job. I also find there’s a misperception that selling requires a “good ole boy” back-slapping personality. However, in reality, almost all us of have some element of selling in our jobs regardless of our title, and it turns out the best sales people aren’t necessarily the over-the-top extraverts. I’ve never held a formal sales job; however, I’ve spent most of life in positions where I had to “sell” to make a living. As a college student, I taught tennis lessons, which led to my first career managing tennis complexes. I then went into the law and consulting business, where I had to grow my book of clients. In each facet of my career, I’ve needed to be able to use the skills of persuasion to move people to action. Best-selling author Dan Pink in his newest book, To Sell Is Human, makes his case that, “Whether its selling’s traditional form or its non-sales variation, we’re all in sales now.” He also shares that studies show the best sales people are actually “ambiverts” who have a mix of introvert and extravert characteristics. Even traditional professional careers have increased pressure to have practice development. I’ve found that many firms historically were able to stay busy simply because they had their doors open. However, today’s competition is fierce and global. Traditional professions in careers like medicine, law, accounting, and architecture have to hone their substantive professional skills and also their business development abilities. Regardless of your career path, undoubtedly, your job will include the need to move others to action, even if just a co-worker. Therefore, investing some and energy in learning how to motivate others to action is a worthwhile investment. I’ve summarized three key principles below that I teach in business development training for organizations. 1. Know yourself. It’s critical to have self-awareness when trying to stlouismedicalnews

.com

move others to action. I use the Birkman Method® assessment tool, but several other good tools exist to help you understand your own personality style. We tend to communicate in our own style instead of flexing to the style of the person needing motivation or direction. These tools allow us to become more in-tuned with our own style and more adept in speaking to people in their own “language.” As Pink found in his research, ambiverts have the greatest results in moving others to action because they can adapt to both introverts and extraverts. 2. Know what you do. This task may seem simple enough. However, I find that too often people struggle to articulate what they do in a clear and compelling manner. Too often, we just share our functional job title or profession. Consider sharing what you do for a living in a way that invites further conversation and questions. One of the best ways to do this is to describe what you do in a way that brings value to clients, customers, patients, et cetera. For example, you could say, “I help clients ______.” Being able to follow up that with a description of how you bring that value is also important. Bottom line: Make sure you have your “elevator speech” to share with people who are kind enough to ask about your occupation. 3. Know others. Dale Carnegie in his bestseller, How to Win Friends and Influence People, captured the key element to “selling,” which is to be genuinely and authentically interested in other people. The key is to ask great questions and listen to the response. Henry David Thoreau said, “The greatest compliment was paid to me today. Someone asked me what I thought and actually attended to my answer.” Thoreau spoke great truth with his comment. If you want to stand out from the crowd and really show people you care, ask them questions and be an attentive listener. When you start to learn more about others, you’ll be in a much better position to follow the Platinum Rule and “treat people as they deserve and want to be treated.” By knowing yourself, understanding how to communicate effectively about your role, and learning to be a great questionasker, you’re in a great position to succeed in sales even if you don’t sell for a living. For those who believe sales is a dirty word, I encourage you to rethink the importance of being able to influence and persuade people effectively. Your career might just depend on it! Martin Willoughby is a serial entrepreneur, author of the book Zoom Entrepreneur, and a business consultant. Direct questions to Martin at martin. willoughby@butlersnow.com

We Focus On Professional Liability Insurance SO YOU CAN FOCUS ON YOUR PATIENTS As a doctor, you have more important things to think about than professional liability insurance. At Galen Insurance Company, we provide the coverage you need to protect you and your practice, so you can keep your attention where it should be--on your patients.

Why You Should Choose Galen As a company founded by physicians, we understand how much you’ve put into your practice. Since our founding, in December 2005, we’ve been providing physicians and medical facilities in Missouri the protection and management strength that their investment of money, time, and reputation deserve. Since 2008, Illinois doctors have received the same protection.

We concentrate on what affects you most. Our sole focus is professional liability insurance, not non-medical risks like property damage or premises liability. Our number of policyholders has increased every year because we offer advantages that mean value, like a true consent to settle clause and policy limits that exclude claim expenses.

Our policyholders are also our owners. Galen started as a physician-owned company. From time-to-time we are able to offer our policyholders the opportunity to become owners, subject to the rules established by the securities laws. In this way, a large expense can become a long-term investment.

Call our Risk Management Hotline 314-721-2366 or Visit our web site at www.galeninsurance.com for more information

Insurance Company 7733 Forsyth, Suite 2000 | St. Louis, MO 63105 | 314-721-2366 | 314-721-2377 (Fax)

JULY 2013

The Business Side of Healthcare, continued from page 1 peatedly from physicians, C-suite executives, and practice managers. They’re all coping with the chaos of healthcare,” said Larry Henry, market publisher for St. Louis Medical News. “Physicians receive plenty of clinical education. What they need is current business education, because that’s where the pressure is.” Conference chairs, a group of 11 local healthcare leaders, are organizing approximately 25 seminars in the following categories: • Business technology for physicians • Change, regulation and transparency • Competition for patients • Financial management for physicians • Health delivery system models • Healthcare market trends • Income protection • Physicians as employers • Practice management • Professional real estate • Wealth management and retirement “The seminars are designed to give participants basic, elemental tools to maneuver the business side of their practice and how it relates to their personal finances,” said Henry, a veteran medical conference producer and publisher. “They’ll also shed light on how everything fits into different modes of practices that are emerging.” Because seminars will be presented on a category of business information instead of an individual company and its services, healthcare professionals will gain insightful knowledge about each subject

to then make informed choices about the company best-suited to provide services and solutions for them, said Henry. “This style of presentation will create a truly educational experience for each seminar,” he said. For example, Steve Laiderman, principal of The Laiderman Law Firm who pens The Estate Planner column for St. Louis Medical News, will discuss asset protection planning in an increasingly litigious society. “Many individuals are interested in methods available to avoid the loss of family wealth to creditors,” said Marshall Burstein of New York Life, chair of the wealth management and retirement planning committee for the conference. “There are several popular estate and gift tax planning tools for protecting your assets. This session provides attendees with an overview of some of the methods for protecting family wealth.” Also on the agenda: a seminar on the use of social media to enhance the patient experience and also to increase revenue. JoAnna Dettman and Kaysha Kalkofen, co-founders of the St. Louis-based digital marketing firm, tSunela, will be the presenters. “Attendees will leave this seminar understanding how a social media strategy can directly impact revenue, initiate community dialogue, provide important patient information, and result in revenueenhancing referrals,” said Eric Humes of Keystone-IT, chair of the business technology committee for the conference. “Attendees will get a better understanding about the future of social media in medi-

Mark your calendar for the last weekend in October to attend the 2013 St. Louis Physicians Business Conference. St. Louis Medical News is producing the Oct. 26-27 event at the Sheraton Westport Chalet Hotel in St. Louis, specifically designed to provide financial solutions for busy healthcare professionals.

cine, as well as the competitive power of social media to compete for patients. Discover best management practices for your social media involvement and how to reach your current and JoAnna Dettman prospective patient base effectively.” The conference, which begins at 8:30 a.m. and ends at 5 p.m. both days, is timely for physicians who have recently sold their practices to hospitals. Industry Kaysha trend reports show a reKalkofen cord number of practice acquisitions by hospitals this year. “We’ll also cover topics for physicians who have recently sold their practice and are transitioning from the role of employer to employee,” said Henry. “Most physicians who were in a private or group practice are very entrepreneurial. How do they maneuver in an environment that may stifle their entrepreneurial streak? Also, for physicians who haven’t yet sold their practice but are considering it, we’ll have a seminar that covers aspects of a sale.” Conference seminars will be presented in segments of an hour to oneand-a-half hours. Regardless of length, all seminars are priced the same. Lengthier seminars will typically headline multiple speakers. A brief question-and-answer period will end each session. Some seminars will run concurrently. “Each seminar is $25, with substantial discounts to those purchasing multiple seminars,” noted Henry. “The discounted seminar cost rewards participants for purchasing multiple seminars by giving them additional free seminars.” Because seating is limited, St. Louis Medical News is offering early registration for subscribers.

Is there a doctor in the house?

There can be with our exciting new home financing opportunity

Benefits worth examining • Consider a wider variety of homes - Loan amounts up to $850,000 • Pay lower up-front costs than traditional mortgages - Down payments less than 20% with no mortgage insurance required • Choose the product that fits your needs - Fixed-rate, and adjustable rate mortgages (ARMs) available

If you are a medical doctor and have completed your residency within the past 3 years, you may be eligible for a new opportunity to buy a home as you establish your practice. We understand what new doctors need Take advantage of higher loan amounts, a low down payment and flexible financing options. In order to be eligible for this program, you must agree to meet with one of our mortgage bankers, giving you the chance to work with an experienced professional.

Contact me today for more information. Michael Burge Sales Manager Wells Fargo Home Mortgage Office: 636.730.3332 Michael.d.burge@wellsfargo.com www.wfhm.com/michael-burge

Information is accurate as of date of printing and is subject to change without notice. Wells Fargo Home Mortgage is a division of Wells Fargo Bank, N.A©2011 Wells Fargo Bank, N.A. All rights reserved. NMLSR ID 399801

JULY 2013

To maintain the integrity of the conference, Henry has asked speakers to avoid “commercial” remarks in their seminar subject matter. “Products and services by a particular company will not be presented during the seminar,” he emphasized. “Physicians are attending these unique seminars to learn more about the category or seminar subject to expand their practice capabilities and revenue. No advertising about a product or service specific to a company should be given from the podium.” An exhibit hall at the 2013 St. Louis Physicians Business Conference will highlight companies and organizations that provide services and products to healthcare professionals, providing attendees the opportunity to gain additional detailed information focused on the business side of healthcare. All registrants will receive information and confirmation following their selection of seminars during the registration process. Participants will also receive a name badge allowing entry to the conference exhibit hall. Participants not attending seminars may also enter the exhibit hall with a free badge provided onsite at the conference registration booth. “Registrants may choose to receive their tickets and badges via email or U.S. mail if they register by Friday, Sept. 27,” said Henry. “Those registering after that date will need to pick up their registration information at the conference registration booth.” To confirm registration and seminar selection during conference registration, participants will be asked for personal information – name, address, phone number and email address. “St. Louis Medical News will hold this personal information in strict confidence,” Henry emphasized. “It will not be disclosed to any other organization.” The St. Louis conference is the first of its kind for Medical News, a division of the Brentwood, Tenn.-based publishing firm, SouthComm. “I haven’t found anything similar to this approach – the business side of medicine – except for a few offerings for professionals at universities such as Harvard or Berkeley,” said Henry. “We’ll have something for every doctor, regardless of age, in areas in which they can improve their professional and personal life. If you’re coming out of medical school, how do you start? If you’re selling your practice, what do you need to know? Our concept is to create this model and transplant the Physicians Business Conference as an annual event in our other markets.” Attendees may register online at www.saintlouismedicalnews. com or via phone at (615)844-9307.

REPRINTS: Want a reprint of a Medical News article to frame? A PDF to enhance your marketing materials? Email subscribe@medicalnewsinc.com for information.

stlouismedicalnews

.com

PHYSICIANS BUSINESS CONFERENCE TOOLS FOR SUCCESS

SEMINAR PROGRAM & REGISTRATION OCTOBER 26 & 27, 2013 | SHERATON WESTPORT LAKESIDE CHALET PRESENTED BY ST. LOUIS MEDICAL NEWS

BUILD YOUR OWN EDUCATIONAL EXPERIENCE Physicians and healthcare business managers may choose from a lineup of seminars detailed on the next page of this program to develop the tools they need to provide financial solutions to many post-health reform challenges. More than 20 seminars in 11 business categories will cover myriad subjects on the business side of healthcare. Local experts in each field will present the conference seminars specifically designed for St. Louis healthcare professionals.

REGISTRATION BEGINS NOW Because seating is limited for each seminar, we strongly encourage healthcare professionals to register early to ensure a seat in their choice of seminars. Complete registration information and seminar costs follow the list of individual seminars and their content, beginning on the next page. Seminars are listed chronologically by day. Select your seminars by number and follow the step by step registration procedure whether you are registering by phone or web site.

SEMINAR DETAILS INSIDE Seminar content details, along with bios of the individuals and organizations involved in the presentation, are listed on the adjacent page of this program guide. Because seminars will be presented on a category of business information instead of an individual company and its services, healthcare professionals will gain insightful knowledge about each subject to then make informed choices about the company best-suited to provide services and solutions for them. This style of presentation will create a truly educational experience for each seminar.

Attendees may register online at www.saintlouismedicalnews or via phone at 615-844-9307. stlouismedicalnews

.com

JULY 2013

PHYSICIANS BUSINESS CONFERENCE

SEMINAR CONTENT AND DETAIL Saturday

Panelists - Thomas H. Hale, MD, PhD Thomas Hale, MD, is executive medical director for Mercy’s Telehealth Services, a position he assumed in June 2009. Edwin Trevathan, MD, MPH Edwin Trevathan, MD, MPH is currently the Dean of the Saint Louis University College for Public Health and Social Justice, where he is also a Professor of Epidemiology, Pediatrics, and Neurology

SEMINAR 1

SATURDAY 8:30 A.M. – 10:00 A.M. 1.5 HOURS PERSONAL FINANCIAL MANAGEMENT FOR PHYSICIANS This workshop focuses on a physician’s personal finance practices. Topics of discussion include creating a retirement plan, choosing a financial planner, the personal benefits of medical real estate investments, managing debt, and the importance of disability income insurance. Speaker: Jeremiah Dellas, a wealth management advisor at Fifth Third Bank, responsible for the development and ongoing coordination of investment management, insurance planning, wealth planning, and private banking services for high net worth clients.

SEMINAR 9

SATURDAY 8:30 A.M. – 10:00 A.M 1.5 HOURS THEY DIDN’T MENTION THIS IN MEDICAL SCHOOL DEALING WITH LAWYERS AND LAWSUITS From records requests to lawsuits, dealing with lawyers and malpractice lawsuits can be an unavoidable part of the practice of medicine. This seminar will discuss potential issues when interacting with lawyers before a lawsuit is filed, as well as what to expect if you are sued or contacted by the Board of Registration for the Healing Arts. Topics include potential pitfalls when responding to records requests and subpoenas or providing opinions or depositions, what to expect if you are named in a lawsuit or contacted by the Board of Healing Arts, and an update on tort reform in Missouri. Speaker: Mark A. Gonnerman, Founding member of Gonnerman Reinert LLC Gonnerman Reinert LLC defends doctors and other healthcare providers from initial claims through trial. Gonnerman Reinert LLC serves as lead counsel for Missouri Phrofessionals Mutual.

SEMINAR 7

SATURDAY 10:00 A.M. – 11:00 A.M. 1 HOUR ASSET PROTECTION PLANNING The United States is an increasingly litigious society. Many individuals are interested in methods available to avoid the loss of family wealth to creditors, bankruptcy and divorce. There are several popular estate and gift tax planning tools for protecting your assets. This session provides attendees with an overview of some of the methods for protecting family wealth. Speaker: Steven M. Laiderman, Principal of The Laiderman Law Firm PC Laiderman Law Firm is an estate planning, probate and business law firm based in St. Louis. His business practice focus also extends to business tax planning, entity creation, succession planning, and the negotiation of business sales and acquisitions.

SEMINAR 10

John Ellena, MD Dr. Ellena is Medical Director, BJC Medical Group.

SEMINAR 17

SATURDAY 11:00 A.M. – NOON 1 HOUR SURVIVING THE CHAOS WHILE MAINTAINING YOUR INDEPENDENCE AND INCREASING YOUR INCOME This session will review major drivers of practice revenue, profitability and growth. We will review opportunities to maximize revenue and profitability on current operations and talk about exploring opportunities to expand business through new ancillary offerings and through leveraging existing resources (staff, equipment, and space). We will also review the changing Medicare and private insurance payment environment including those that tie payments to quality and cost effectiveness. We will explore how independent physicians can participate in Accountable Care Organizations (ACO) and the key elements for success. Speaker: Mike Linder, Owner and CEO/President of St. Louis based KSL Billing + Management KSL is a revenue cycle management company serving nearly 300 physicians across Missouri, Illinois, and Kansas.

SEMINAR 20

SATURDAY 11:00 A.M. – NOON 1 HOUR NAVIGATING YOUR REVENUE STREAM – BEST PRACTICES FOR MAXIMIZING CASH FLOW Effective revenue cycle management (RCM) will increase your net collections and assure prompt payments. Your revenue cycle is driven by medical procedure codes, detailed documentation, data capture, complex reimbursement guidelines and denial management…and your personal efforts can affect these outcomes. This fast-paced, practical workshop offers RCM strategies that physicians and managers can execute immediately to maximize reimbursements, sustain cash flow, improve liquidity and increase profitability. Learn proven methods for converting your medical procedures to cash. Speakers: Alan F. Dombrowski, vice-president of Hawthorn Physician Services Corporation, a nationally-recognized healthcare revenue cycle management company headquartered in St. Louis. Alan is a certified billing and management executive with more than 25 years in healthcare business management. Craig A. Williams is director of sales for Hawthorn. He began his 30-year healthcare career with Blue Cross and Blue Shield of Indiana where he served as manager of Medicare claims processing and as professional provider representative for the Medicaid program of Indiana. Stan Hosler joined Hawthorn in 2012 as a sales and marketing associate, responsible for new business development in the southeastern states. He has more than 15 years’ experience at Contel Corporation and Coca-Cola Company.

SATURDAY 10:00 A.M. – 11:30 A.M. 1.5 HOURS IMPLICATIONS OF POPULATION HEALTH MANAGEMENT FOR PHYSICIANS AND HOSPITALS In light of healthcare reform legislation, spiraling healthcare cost increases, and the looming retirement of the Baby Boomer generation, there is an increasing focus on managing population health. But what that means – and what it means for physicians and hospitals – is less clear. This session defines what is required to manage population health, the key milestones on the way there, and what doctors need to know. Speaker: Glenn Mitchell, MD, MPH Dr. Mitchell is a Senior Consultant at Numerof & Associates, Inc. He was formerly Chief Medical Officer at Mercy Health System. NAI is a strategic management consulting, bringing a unique cross-disciplinary approach to a broad range of engagements designed to sharpen strategic focus, increase revenues, reduce costs, and enhance customer value.

SEMINAR 4

SATURDAY 1:00 P.M. – 2:30 P.M. 1.5 HOURS OPERATIONAL AND LEGAL MATTERS REGARDING HIPAA COMPLIANCE This panel discussion will explore HIPAA compliance and cover data protection and transfer issues; business associates compliance determination; security breach and reporting; employee hiring, training and monitoring; employee handbook, policies and procedures; corrective action options for violations; and employee best practices. Moderator: Ron Present, Health Care Industry Group Leader, Brown Smith Wallace Panelists: Gerry Richardson, Partner, Evans and Dixon Tony Munns, Member, Brown Smith Wallace

SATURDAY SEMINAR GRID 8:00

8:30

9:00

9:30

10:00

10:30

11:00

11:30

SEMINAR 9

1:30

2:00

2:30

3:00

3:30

4:00

4:30

5:00

5:30

EXHIBIT HALL OPEN 4 HOURS SEMINAR 2

LUNCH SEMINAR 17

SEMINAR 10

1:00

SEMINAR 4

SEMINAR 7

JULY2013 2013 > JULY >

12:30

SEMINAR 20

SEMINAR 1

8 8

12:00

1 HOUR

SEMINAR 12

SEMINAR 6

SEMINAR 8 SEMINAR 14

s a i snttlloouui issm meeddi iccaallnneew wss..ccoom m

TOOLS FOR SUCCESS The 2013 St. Louis Physicians Business Conference seminars will be presented in segments of an hour to one-and-a-half hours. Regardless of length, all seminars are priced the same. Lengthier seminars will typically headline multiple speakers.

SEMINAR 12

SEMINAR 14

CONSUMER-DRIVEN HEALTHCARE – WHAT YOU NEED TO KNOW Trends point to an increasingly consumer-driven model for healthcare. As consumers bear more of the cost burden of their own healthcare, they will demand more information about cost, quality and outcomes than they have historically. This session will walk through what this shift will mean for providers and how they should prepare.

THE PHYSICIAN PRACTICE AS EMPLOYER Subjects that will be covered in the seminar will include interviewing techniques; recruitment agreements; non-competes; retention of employees and benefit packages; negotiations; and establishing compensation packages.

SATURDAY 1:00 P.M. – 2:00 P.M. 1 HOUR

SATURDAY 4:00 P.M. – 5:00 P.M. 1 HOUR

Speaker: Kim E. White, MBA Kim E. White is a Consultant at Numerof & Associates, Inc. NAI is a strategy consulting firm focused on organizations in dynamic, rapidly changing industries. Working globally across the healthcare industry, NAI brings a unique cross-disciplinary approach to a broad range of engagements designed to sharpen strategic focus, increase revenues, reduce costs and risk, and enhance customer value.

SEMINAR 2

SATURDAY 2:30 P.M. – 3:30 P.M. 1 HOUR BUSINESS FINANCIAL MANAGEMENT FOR PHYSICIANS This workshop focuses on the business financial aspect of managing a practice. Key topics include qualifying for a business loan, understanding the P&L, Revenue Cycle Management, Accounts Receivable and Reimbursement Concerns, and Managing Debt and Growth. Speaker: Mersed Halilovic Halilovic is a business banking officer at Fifth Third Bank, focusing on the healthcare industry. He provides customized solutions around credit and capital for small to medium size businesses.

SEMINAR 8

SATURDAY 2:30 P.M. – 4:00 P.M. 1.5 HOURS

Speakers: Elizabeth Ortmann Vincenzo, Esq., Senior Director of Compliance at Express Scripts Diane Robben, Esq., Partner, Sandberg, Phoenix & von Gontard, P.C. Jacque James, CEO, Asset Recovery Associates

Sunday SEMINAR 16

SUNDAY 10:00 A.M. – 11:00 A.M. 1 HOUR USING SOCIAL MEDIA TO ENHANCE PATIENT EXPERIENCE AND INCREASE REVENUE Attendees will leave this seminar understanding how a social media strategy can directly impact revenue, initiate community dialogue, provide important patient information, and result in revenue-enhancing referrals. Case studies will be presented to illustrate healthcare industry social media success and generate discussion. Attendees will get a better understanding about the future of social media in medicine as well as the competitive power of social media to compete for patients. Discover best management practices for your social media involvement and how to reach your current and prospective patient base effectively.

AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE – TIPS FOR MINIMIZING FOR MINIMIZING YOUR RISK OF A MALPRACTICE CLAIM Although some malpractice lawsuits are unavoidable, oftentimes small changes in your practice can prevent a patient from turning into a plaintiff. This seminar will discuss issues that commonly lead to medical malpractice lawsuits, and provide tips on how to minimize your risk. Topics include communicating with patients, charting and EMR issues, obtaining informed consent, and dealing with the disgruntled or non-compliant patient. Speaker: Mark A. Gonnerman, Founding member of Gonnerman Reinert LLC Gonnerman Reinert LLC defends doctors and other healthcare providers from initial claims through trial. Gonnerman Reinert LLC serves as lead counsel for Missouri Professionals Mutual.

SEMINAR 6

SATURDAY 4:00 P.M. – 5:00 P.M. 1 HOUR MARKETING A CLINICAL PRACTICE This seminar will cover strategies for the small to medium sized practice and include discussions on medical ethics, market research, patient outreach, professional networking and costeffective advertising. In addition to the primary speakers, representatives from an advertising agency and a market research company will join the discussion.

Speakers: JoAnna Dettmann and Kaysha Kalkofen Co-founders of St. Louis based digital marketing firm tSunela bring a great deal of internet marketing and social media experience to this discussion about why social media strategies must be a part of every healthcare provider’s marketing and communications plan. Dettmann and Kalkofen have many healthcare clients and speak nationally on social media subjects.

SEMINAR 19

SUNDAY, 10:00 A.M. – 11:00 A.M. 1 HOUR BUSINESS TECHNOLOGY FOR PHYSICIANS Have you begun using a computer to record patient information? Are you starting to see the benefits of this new medium? Are you aware of the risks? This seminar walks you through where we have been, where we are today and where technology is leading us in the future. This presentation will recap HITECH and the recent changes to the HIPAA laws and what this means for your practice’s technology architecture. We will also explore the future modalities of data collection, aggregation and analytics. Data and the ease of accessibility through mobile platforms are a driving force behind the success of tomorrow’s healthcare. Speaker: Eric W. Humes As CEO of Keystone IT, Eric Humes has established his company as a thought leader in healthcare IT. As a technology firm, Keystone focuses on the quality and efficiency of patient care as its number one priority. Keystone IT provides strategic consulting, support and cloud services to physician practices and hospital systems throughout the Midwest.

Speakers: Jacqueline Stack, PhD, Senior Director Marketing and Communication, Faculty Practice, Washington University Physicians Sarah Gladson, MBA, Director, Marketing and Communications, Faculty Practice, St Louis Medical School

SUNDAY SEMINAR GRID 8:00

8:30

9:00

9:30

10:00

10:30

11:00

11:30

12:00

12:30

LUNCH SEMINAR 11

SEMINAR 19

ss tali o i ceadli n se . cwos m nu t il somuei d sm ce aw ln .com

1:30

2:00

2:30

3:00

3:30

4:00

4:30

5:00

5:30

EXHIBIT HALL OPEN 3 HOURS

SEMINAR 13 SEMINAR 16

1:00

SEMINAR 15 SEMINAR 3

1 HOUR

SEMINAR 5

SEMINAR 18

JULY JULY 2013 2013

> >

PHYSICIANS BUSINESS CONFERENCE

SEMINAR CONTENT AND DETAIL SEMINAR 13

SUNDAY 10:30 A.M. – NOON 1.5 HOURS PRACTICAL ASPECTS OF THE LIFE CYCLE OF A MEDICAL PRACTICE A panel of physician practice advisors will comment on effectively managing a practice from start up to maintenance. This will include topics such as hiring the right experts, legal structure, taxes, credentialing, space and equipment, financing, hospital and other affiliations, billing/ coding, compliance, revenue cycle analysis, auditing to increase profits, malpractice insurance, and reimbursement. Speakers: Tony Soukenik, Partner, Sandberg, Phoenix & von Gontard, PC Bhavik Patel, Partner, Sandberg, Phoenix & von Gontard, PC Eric Humes, CEO, Omniscient HC and Keystone IT Chastity Werner, Health Care Consultant, Anders Michael Abrams, Managing Partner, Numerof & Associates

SEMINAR 11

SUNDAY 11:00 A.M. - NOON 1 HOUR REDUCING COSTS ACROSS SERVICE LINES Cost reduction is a perennial topic for healthcare providers. But the methods used historically have not typically focused on the leading factor in cost generation: clinical decision making. This session will walk through a systematic approach to reducing costs that addresses this sensitive area, the key considerations you’ll need to take into account, and steps you can take to build consensus within your practice or organization. Speaker: Jill E. Sackman, DVM, PhD, Senior Consultant at Numerof & Associates, Inc. NAI is a strategy consulting firm focused on organizations in dynamic, rapidly changing industries. Working globally across the healthcare industry, NAI brings a unique cross-disciplinary approach to a broad range of engagements designed to sharpen strategic focus, increase revenues, reduce costs and risk, and enhance customer value.

Donna Heinrich, VP, Wells Fargo Business Real Estate Finance Donna Heinrich has been in the banking industry for 30 years. Donna has been at Wells Fargo for 16 years with the last 7 years at Wells Fargo Business Real Estate Finance. Charles Grbcich, VP and Investment Officer, Wells Fargo Advisors Charles G. (Chuck) Grbcich is dedicated to providing exceptional service to his clients. Since entering the brokerage business, he has specialized with rollover retirees, mid-level corporate executives, and families committed to achieving their financial goals. Mr Grbcich also works with corporations assisting with their 401k plans, pensions, and other financial needs.

SEMINAR 5

SUNDAY 1:00 P.M. – 2:00 P.M. 1 HOUR MEDICAL MARKETING IN THE DIGITAL AGE This seminar will explore the development of websites and social media for the small to medium sized practice. Medical marketing experts will discuss developing a practice web site “somewhere between a brochure and the Library of Congress.” A social media discussion will discuss the pros and cons of getting out there and the perfect fit. Speaker: Jacqueline Stack, PhD, Senior Director of Marketing and Communication, Faculty Practice, Washington University Physicians

SEMINAR 3

SUNDAY 2:30 P.M. – 4:00 P.M. 1.5 HOURS CULTURAL AND LEGAL IMPACT ON PHYSICIAN CONSOLIDATION This topical panel discussion will discuss cultural changes of FFS to PFP; loss of independence; physician group conflict – new/tenured and primary/specialists; corporate environment changes; practice transitions legal issues; physician employee transitions; and benefit transitions. Moderator: Ron Steinkamp, Principal, Brown Smith Wallace Panelists: Brian Rogers, Partner, Evans and Dixon Ron Present, Health Care Industry Group Leader, Brown Smith Wallace

SEMINAR 15

SEMINAR 18

IS THERE A DOCTOR IN THE HOUSE? Exclusive home mortgage financing programs with low down payment options for Physicians will be featured. One of the area’s top realtor teams will discuss the dos and don’ts of buying and selling luxury homes. Also, representatives from Wells Fargo Advisors and Wells Fargo Business Real Estate will be on hand to discuss how to finance and protect your practice.

2013 HEALTHCARE REAL ESTATE STRATEGIES This informative seminar will investigate how real estate occupancy costs can be a source for improving your practice bottom line. Topics covered will include: The current medical office market conditions; The impact the market has on real estate occupancy costs; Various occupancy choices based on career stage and market conditions; The pros and cons of leasing vs. purchasing vs. development; and real estate exit strategies.

SUNDAY 1:00 P.M. – 2:30 P.M. 1.5 HOURS

Speakers: Michael Burge, Sales Manager, Wells Fargo Home Mortgage Michael Burge is a Professional Mortgage Banker with nearly 30 years of industry experience. He was the Founder and First President of the Missouri Association of Mortgage Professionals and was recruited by Wells Fargo specifically for his expertise in serving healthcare professionals. Kevin Kelley and Dana Snyder: Realtors with Coldwell Banker Gundaker Real Estate Kevin and Dana have been a top producing team at Coldwell Banker Gundaker Realtors for years.

SUNDAY 2:30 P.M. – 3:30 P.M. 1 HOUR

Speaker: Ann Dulle Ann Dulle is a senior associate and member of the National Healthcare Services Group of CBRE Inc., a Global Fortune 500, publicly traded company. Her architectural career, which included planning services for medical office practices, spanned 13 years, and then transitioned to commercial real estate property management in 2001 with Equity Office Properties and Duke Realty.

CONFERENCE COMMITTEE MEMBERS

St. Louis Medical News would like to thank the committee members below for their dedicated support constructing the conference seminars.

Dawn Van Houten, FIFTH THIRD BANK

Lauren Bowman, EVANS & DIXON

Ray Harter, MPM INSURANCE

Eric Humes, KEYSTONE IT CONSULTING

Jackie Stack, WASHINGTON UNIVERSITY IN ST. LOUIS

Sarah Gladson, ST. LOUIS UNIVERSITY

Marshall Burstein, NEW YORK LIFE

Larry Henry, ST. LOUIS MEDICAL NEWS

Michael Abrams, NUMEROF & ASSOCIATES

Jon Rehg, SANDBERG PHOENIX

Ron Present, BROWN SMITH WALLACE

Diane Robben, SANDBERG PHOENIX

Elizabeth Vincenzo, EXPRESS SCRIPTS

Michael Burge, WELLS FARGO HOME MORTGAGE

JULY 2013

s a i snttlloouui issmmeeddi iccaallnneew wss. .ccoomm

TOOLS FOR SUCCESS

REGISTRATION FOR CONFERENCE AND SEMINARS Follow the simple registration steps below to create your personal educational experience at Physicians Business Conference. Registration for seminars will automatically create a conference badge for you that will admit you to the PBC Exhibit Hall.

EXHIBIT HALL

HOW TO REGISTER 1

SELECT SEMINARS Review the seminar information, choose your seminars by day and

time and make note of each seminar number chosen. Because several seminars will be given concurrently, be careful not to pick seminars presented at the same time.

www.saintlouismedicalnews.com. Access the conference registration form where indicated on the site. Fill out the registration form completely, listing each seminar by number. We will use this information to confirm your registration by email. The complete conference program, seminar information and registration form is on the web site. You can pay for all seminars selected by credit card on this secure site.

REGISTER BY PHONE Call (615) 844-9307 to register by phone. An authorized Medical News representative will walk you through the registration process, review your seminar choices by seminar number, get your contact information and credit card information.

CONFIRMATION During the registration process, you will be asked several questions â&#x20AC;&#x201C; name, address, phone number and email address â&#x20AC;&#x201C; to confirm registration and seminar selection. You will receive confirmation of selected seminars and procedures for entrance to those seminars. St. Louis Medical News will hold this personal information in strict confidence. It will not be disclosed to any other organization.

An exhibit hall at the 2013 St. Louis Physicians Business Conference will highlight companies and organizations that provide services and products to healthcare professionals, providing attendees the opportunity to gain additional detailed information focused on the business side of healthcare. Entrance to the exhibit hall is free; attendees must have a badge to gain access. Badges are available at conference registration to qualified healthcare professionals. Seminar attendees automatically receive a conference badge.

SEMINAR PRICES Seminars begin at $25 each, with a price reduction based on volume of seminars. The discounted seminar cost rewards participants for purchasing multiple seminars by giving them additional FREE seminars. The following table demonstrates the seminar discount structure.

Seminars Purchased

Cost

Free Seminar(S)

Total # Seminar(S)

Cost Per Seminar(S)

$25

$50

$25

$72

1 FREE

$18

$96

2 FREE

$16

$112

3 FREE

$14

$120

4 FREE

$12

Each additional seminar purchased (more than 10) $8 EACH

ss tali o dm i ceadli n se . cwos m nu t il somu ei s ce aw ln .com

JULY JULY 2013 2013

> >

11 11

Tapping into Hospice and Palliative Medicine, continued from page 1 Robert Lehmberg, MD, FACS, assistant professor of hospice and palliative medicine at the University of Arkansas for Medical Sciences (UAMS). “It improves the patient’s quality – and sometimes length – of life.” Dr. Robert “There are barriLehmberg ers to hospice because of the inability to confront mortality as a psycho-social issue,” said O’Connell, “and barriers within the medical community to refer patients to hospice because phyDerrick sicians and their teams O’Connell may feel they’ve failed in the medical management of a patient.” Miguel A. Paniagua, MD, FACP, concurs. Because so many great technological advances in medicine have been Dr. Miguel A. made, he said a patient’s Paniagua treating physician may view their death as failure. O’Connell, a former hospice manager, said the emerging Patient Centered Medical Home (PCMH) model has a mechanism in place to assist primary care providers (PCPs) with the transition of patients to hospice and palliative care. “Primary care providers and their

JULY 2013

teams can facilitate the documentation of advanced directives for each patient,” he explained. “Each patient is counseled on choices in the event of a life-ending medical condition or event. It’s important when provider teams recognize that the patient is nearing the end of their life cycle and can begin the patient-centered collaboration for appropriate end-of-life care with a statement like: ‘there’s nothing more medicine can do for you. We’d like to refer you to hospice care because they’re experts at keeping you comfortable at end-of-life care and can enable you to die with dignity.’” Paniagua, associate professor and director of the Department of Internal Medicine Residency Program at Saint Louis University (SLU) School of Medicine in Missouri, said a smooth transition is easier when the primary care provider (PCP) team clearly communicates the endof-life plan with patients. “We similarly teach many high-tech and high-reimbursing procedures in medicine, but in my view, the most delicate and nuanced procedure we can teach and learn is the bedside conversation about goals of care and treatment planning,” he said. “Like any procedure in medicine, there are effective and ineffective ways of doing it. Unfortunately, not enough emphasis is placed on teaching and learning this procedure, which leads to much variability in the way it’s delivered, as well as providers’ discomfort and unease with doing it.”

Outside the Box When it was established 25 years ago, the American Academy of Hospice and Palliative Medicine (AAHPM) had 250 charter members. Now, the professional organization has 5,000 members. Yet even though four of five larger U.S. hospitals now have palliative care programs, and consultations for the specialty have spiked, new growth isn’t keeping pace with the coming demand. New hurdles hinder progress – a rapidly aging baby boomer generation coupled with the existing senior population, continued segmentation of care, and limited funding for specialty training programs. AAHPM leaders recently proposed a solution to the specialty shortage problem: Timothy E. Quill, MD, FACP, and Amy P. Abernethy, MD, FACP, president and president-elect of the AAHPM, respectively, suggested reserving palliative medicine physicians for more challenging cases, while also increasing the palliative skills of primary care providers (PCPs) and specialists who see patients daily. Using their model, PCPs would receive appropriate education to address management of pain and other symptoms and other basic palliative care needs. Palliative medicine physicians would be called in to manage difficult-to-treat pain, complicated depression, anxiety and grief and other more complex needs. SOURCE: AAHPM.

Paniagua also noted that mainstream media’s sensationalized coverage of euthanasia and physician-assisted suicide issues has hindered progress in the advancement of the specialty and public perception. “In reality, (euthanasia and physician-assisted suicide) is such a miniscule practice, and in only three states,” he emphasized. “But my view is that too often patients feel they have no other way out of their suffering. More often than not, we providers don’t do an adequate job providing palliative care to most of the suffering.” Lehmberg, who switched specialties to hospice and palliative medicine after a neck injury prevented him from continuing his nearly 30-year plastic surgery practice, said the most common misperceptions about the specialty are the differences between palliative care and hospice, and getting the team involved early enough to “truly assist the patients, their families and the treating physicians.” “Most people, physicians included, think of us only in terms of hospice and end of life,” said Lehmberg. “However, palliative care improves the quality of life of patients and their families with lifethreatening conditions through the prevention and relief of suffering, and also the treatment of pain and other problems – physical, psychosocial and spiritual.” Palliative care may be extremely helpful to physicians and patients in conjunction with therapeutic treatments, such as chemotherapy and radiation, said Lehmberg, noting that requests for hospice and palliative care consultations for the UAMS Department of Hematology and Oncology has increased significantly – from 400 in 2007 to more than 2,200 estimated this year. “As evidenced by our program growth, an awareness of the role of palliative care is increasing,” he said. “Still, I’d like to continue to contribute to a better understanding of our subspecialty and how we can help. Once a patient has been diagnosed with a life-threatening ill-

ness, it’s really never too early to involve a multi-disciplinary palliative care team.” Palliative care transitions to hospice care when the illness progresses to the point that therapeutic treatments are no longer applicable, explained Lehmberg. “In palliative care, an experienced team is best at fitting in with the primary medical approach, not rivaling it,” said Lehmberg. “As consultants, the palliative care team … complements the treatment and care provided by the primary physicians.”

Palliative v. Hospice Care Palliative care: • provides comfort and relief from pain and other distressing symptoms; • is meant to neither hasten nor postpone death; •integrates the psychological and spiritual aspects of patient care; • affirms life while regarding dying as a normal process; • assists patients in living as actively as possible until death; • helps the family cope during the patient’s illness; • uses a specialized team approach including physician, nursing, chaplaincy and social work; and • is provided in conjunction with therapeutic treatments such as chemotherapy and radiation. Hospice: • focuses on caring, comfort and dignity at end of life; • provides relief from pain and other distressing symptoms; • is meant to neither hasten nor postpone death; • integrates the psychological and spiritual aspects of patient care; • helps the family cope with the patient’s end of life and their own bereavement • uses a specialized team approach including physician, nursing, chaplaincy and social work. stlouismedicalnews

.com

The Move to DNP

Nurses embrace advanced degree program to address the increasingly complex healthcare practice environment By CINDY SANDERS

In October 2004, member schools of the American Association of Colleges of Nursing (AACN) voted to endorse the organization’s position statement calling for the transition of the level of preparation needed for advance practice nursing from the master’s degree to the doctorate level by 2015 through the addiDr. Jane tion of the DNP — DocKirschling tor of Nursing Practice. “Will we have all of our APRN pro-

PhD vs. DNP Jane Kirschling, PhD, RN, FAAN, president of the American Association of Colleges of Nursing, said the addition of the Doctor of Nursing Practice (DNP) degree was the clinical complement to the long-standing Doctor of Philosophy (PhD) or Doctor of Nursing Science (DNSc) degrees, which prepare students for scientific research. The PhD, she noted, “is really intended to prepare the next generation of scientists for new discovery so they are generating new knowledge for the discipline.” In addition to an interest in a nursing faculty career with a research component, Kirschling said it was fairly common for nurse executives to obtain a PhD as they sought to increase leadership roles. With the addition of the DNP, nurses now have two terminal degree tracks from which to choose — research and practice. The newer DNP quickly overtook PhD and DNSc programs in terms of the number being offered across the country. Currently, there are 131 research-focused programs in the U.S. The number of research doctoral programs grew from 103 to 131 between 2006 and 2012. During that same time period, DNP programs grew from 20 to 217. As the field looks to increase the number of doctoral-prepared nurses, the good news is enrollment is up in both research-based and practice-based doctorate programs, although the newer DNP degree has seen much more rapid growth as more academic institutions have begun offering the option. Between 2004 and 2012, the number of students enrolled in DNP programs increased from 170 to 11,575. The number of students seeking a PhD in nursing grew from 3,439 to 5,110 during the same timeframe.

stlouismedicalnews

grams transition to DNP by the 2015 deadline? Probably not … but we will have a critical mass that are,” said Jane Kirschling, PhD, RN, FAAN, dean of the School of Nursing for the University of Maryland who serves as 2012-2014 board president for AACN. “I feel like we’ve reached the tipping point,” she added. Indeed, the growth of DNP programs nationwide has been remarkable. By spring 2013, programs existed in 40 states and the District of Columbia. “We are extremely pleased that we currently have 217 Doctor of Nursing Practice programs up and running in the United States. If you go back to 2004, we only had seven programs,” Kirschling noted. “In addition, we have 97 new programs under development.” She added enrollment has jumped from 170 DNP students in 2004 to 11,575 last year. Rooted in the desire to deliver the highest quality of care in the practice setting, Kirschling said the addition of the DNP was consistent with what is happening in other healthcare disciplines includ-

ing pharmacy, audiology and physical therapy. Grounded in evidence-based practice, she said the hope is that these doctoral-prepared nurses will take existing discoveries and more rapidly drive that knowledge to the bedside. Additionally, she said the degree is anticipated to prepare these nurses to provide leadership in an increasingly multifaceted healthcare environment. “What I project we’ll see with time as we graduate more from the DNP program is they will actually partner with PhD nurses to create some really interesting synergy to solve really difficult clinical issues and to solve them in a quicker timeline that directly impacts patient care,” stated Kirschling. The reason for the DNP movement is multifactorial. In addition to aligning with other health profession disciplines that offer a clinical doctorate, Kirschling said the degree also recognizes the complexity of the nation’s evolving healthcare delivery system.

The number of hours and amount of academic work required to become an advanced practice registered nurse provided another impetus behind the DNP movement, Kirschling noted. Nursing had already moved to increase and expand practical knowledge in APRN master’s programming. Where many master’s degrees in other fields require 30-36 credit hours, the four recognized APRN master’s programs — Nurse Practitioner, Clinical Nurse Specialist, Nurse Anesthetist, and Nurse Midwife — already required a minimum of 40-55 credit hours. With the newer doctoral degree, students need, on average, 80 credit hours in the baccalaureate to DNP program and an additional 39 credits in the master’s to DNP path. “Healthcare in the county has changed dramatically,” Kirschling concluded. “The depths of knowledge and the skill set any provider needs have just increased over time. We, as a discipline, felt it was critical that our graduates be prepared to meet the demands of the future.”

Sports Medicine Community, continued from page 4 Duerson, who may have been the only one to commit suicide and leave instructions donating his brain for the study of CTE. Former NFL Chicago Bears quarterback Jim McMahon has agreed to donate his brain to science after his death. Another point of controversy: concussion determination. A neuropsychologist in the field of treating concussions pointed out the 2004 consensus statement was driven largely on a grading scale (1-3) for concussion with loss of consciousness serving as a means of grading the severity of concussion, from which the 2008 consensus statement began to deviate.

MedEvolve RCM n

Turnkey Billing and Collections

Reduce Management Headaches

Improved Bottom Line

Peace of Mind

97% 27% 38%

Clean Claims Rate Average Increase in Revenue Average Reduction in AR days

“My take is that a concussion is more black and white,” he said. “Either you have a concussion or you don’t. When you get into grading scales and severity ratings, you oftentimes relay misinformation to patients and the other providers involved in the case. Calling it a yes-or-no decision takes that away. Oftentimes, athletes get caught up in whether their concussion was mild or severe, which leads to poorly-based expectations about recovery. A concussion is a concussion and everybody recovers differently.” In the clinical treatment and management of concussion, the clinician is the key, said the neuropsychologist.

“The consensus statements, the most recent one included, spend a lot of effort discussing sideline assessment tools, baseline testing, cognitive assessment tests, balance testing, RTP decisions, and preferred means of assessment or treatment,” he said. “All these components are tools that, when used correctly by a well-trained clinician, can be extremely valuable. But the clinician remains the most important piece in terms of concussion treatment and management. The consensus statements do very little in terms of providing practical guidelines for the clinical care of concussion with respect to the individual clinician.”

“The very positive experience with the MedEvolve PM software prompted our decision to expand their services to include Revenue Cycle Management, which has absolutely improved our billing services. Overall a very positive experience, with a few key contacts in the company that are always available and promptly responsive and accountable to our practice. MedEvolve really does stand out not only in software performance, but particularly in customer service.” Barry Seibel, M.D., Los Angeles, CA, is a worldrenowned ophthalmic surgeon, author, inventor and frequent consultant to the ophthalmology industry. MedEvolve customer since 2008.

Call to speak to an RCM specialist today!

1-800-964-5129 medevolve.com

.com

JULY 2013

Learn More

theEstatePlanner BY STEVEN M. LAIDERMAN

Will or Trust? Dispelling the myth: ‘I don’t have enough assets for a trust ...’ One of the most common comments I hear is “I don’t think I have enough assets for a trust.” Let me introduce you to Karen. We met to discuss planning options for her elderly father, who was in failing health. He owned a $60,000 home and a $30,000 bank account. Planning doesn’t get much simpler. Or does it? We discussed his options; they chose the less expensive route. Concerning his bank account, Karen’s name was added, and we prepared a beneficiary deed that would transfer ownership of his home to her and her sister upon his death. His intent was for Karen, as the surviving owner of the bank account, to share the money with her sister. With a beneficiary deed, the title to the home would pass to Karen and her sister without probate upon her father’s death. After he died, Karen called me. The bank wouldn’t allow her access to his account. She discovered that even though her name was added to the bank statement, it hadn’t been added to the signature card. So we had to probate the bank account. Concerning her dad’s home, it passed to Karen and her sister pursuant to the beneficiary deed. However, in Missouri and other states, spouses have marital rights. Even though the title to the home passed to Karen and her sister automatically upon her father’s death, they could not transfer title of the home when they sold it without the signature of their spouses. Karen’s spouse is a real estate broker. He knew that a few bucks would be needed to market the home. Her sister’s

LUNG CANCER IS THE DEADLIEST CANCER IN THE WORLD. WE CAN CHANGE THAT. The American Lung Association is leading the fight against the deadliest cancer there is—lung cancer. Join the fight by giving a gift to the American Lung Association today.

spouse didn’t want to spend any money on it. In effect, we were in a stalemate among owners. Only after Karen met with a litigation attorney, who threatened her sister and spouse with litigation to force a sale of the property, did her sister’s spouse agree to cooperate. How could this scenario have been avoided? If Karen’s father had elected to establish a trust, the bank account would’ve been retitled in the trust. As soon as Karen presented the bank with a death certificate, she would’ve had access to the account as trustee. With a trust, we would’ve filed a deed to transfer the home to the trust rather than use a beneficiary deed. Karen, as trustee, could have cleaned up the home, put it on the market and sold it, without the need for consent from the spouses or her sister. Needless to say, the probate and litigation attorney costs were significant. In addition, if Karen’s father had been disabled prior to dying, then as successor trustee, she would’ve been able to manage his bank account, pay his bills, and sell the home if needed. A power of attorney may also help during times of disability. Powers of attorney are typically used for managing financial assets and making medical decisions. Unfortunately, they’re unreliable because they’re only good among the living. Powers of attorney must be specific. General instructions aren’t effective. Worse yet, not all financial institutions accept powers of attorney. Some institutions will only accept their own form. This is rarely a problem with a trust. Not every client has these issues. However, most clients have more to plan for, and that means more opportunity for conflict and probate. Karen’s situation also ignores the positive aspects of trust planning, such as planning for disability, protecting inheritance from division due to a divorce or lawsuits, and professional asset management when necessary. There’s virtually no cost to administer the trust while you’re alive. However, like any plan, it’s important to keep it up to date with changes in tax and non-tax laws. After death, an estate plan has some cost. A plan as simple as the one described above could be administered after death at minimal cost. Steven M. Laiderman, principal of The Laiderman Law Firm PC, an estate planning, probate, and business law firm based in St. Louis, has extensive experience in estate planning. His business practice focus extends to business tax planning, entity creation, succession planning, and the negotiation of business sales and acquisitions. He also represents clients in the negotiation of real estate leases, sales and acquisitions. A frequent speaker, he serves as adjunct professor at the Washington University School of Law, teaching estate planning and family wealth management classes. He may be reached at Steve@ LaidermanLaw.com.

GrandRounds Deadly infections cut in sickest hospital patients A major study in hospital intensive care units shows that bathing patients daily with an antimicrobial soap and applying antibiotic ointment in the nose reduced by 44 percent the bloodstream infections caused by dangerous pathogens, including the drug-resistant bacteria MRSA. The effort to remove potentially harmful bacteria from ICUs also lowered by 37 percent the number of patients who harbored MRSA (methicillin-resistant Staphylococcus aureus) on their bodies. These patients were not sick from the bacteria but were at risk for MRSA infections and spreading the germ to other patients. The study’s findings are published online May 29 in The New England Journal of Medicine. Researchers at Washington University School of Medicine in St. Louis, the University of California at Irvine, Harvard Pilgrim Health, Hospital Corporation of America and the U.S. Centers for Disease Control and Prevention (CDC) were involved in the study. The research involved nearly 75,000 patients who were treated at 43 hospitals, all owned by the Hospital Corporation of America. Infectious diseases physician Victoria Fraser, MD, head of Washington University’s Department of Medicine, helped design and oversee the study. Of the strategies tested for reducing MRSA infections, the one that proved most effective was arguably the simplest and most straightforward. Rather than screening patients in intensive care units for MRSA and isolating or treating only the carriers, all ICU patients were bathed daily using a soap treated with an antiseptic (chlorhexidine), and all received an antibiotic ointment (mupirocin) applied in the nose for five days. At Barnes-Jewish Hospital, which was not part of the study, all ICU patients already are bathed daily with the chlorhexidine soap. That routine practice was implemented in 2009 after a study by Fraser and her colleagues showed that the antiseptic soap reduced hospital-associated infections by 25 percent among patients in the medical and surgical ICUs at BarnesJewish. Mupirocin ointment is not used routinely in Barnes-Jewish ICUs or in most other hospital ICUs. There are a small number of bacteria that are already resistant to the antibiotic in the ointment and some concerns about whether broad use of mupirocin in ICUs could speed antibiotic resistance. Based on the new data, David Warren, MD, medical director for infection prevention at Barnes-Jewish Hospital and Washington University School of Medicine said they’ll evaluate whether to incorporate mupirocin into routine use in their ICUs.

PUBLISHED BY: SouthComm, Inc. CHIEF EXECUTIVE OFFICER Chris Ferrell PUBLISHER Jackson Vahaly jvahaly@southcomm.com ASSOCIATE PUBLISHER Larry Henry lhenry@medicalnewsinc.com Ad Sales: 314.917.6107 NATIONAL EDITOR Pepper Jeter editor@medicalnewsinc.com LOCAL EDITOR Lynne Jeter lynne@medicalnewsinc.com CREATIVE DIRECTOR Susan Graham susan@medicalnewsinc.com 931.438.8771 GRAPHIC DESIGNERS Katy Barrett-Alley Amy Gomoljak Christie Passarello CONTRIBUTING WRITERS Lynne Jeter, Cindy Sanders, Lucy Schultze ACCOUNTANT Kim Stangenberg kstangenberg@southcomm.com CIRCULATION subscriptions@southcomm.com —— All editorial submissions and press releases should be emailed to: editor@medicalnewsinc.com —— Subscription requests or address changes should be mailed to: Medical News, Inc. 210 12th Ave S. • Suite 100 Nashville, TN 37203 615.244.7989 • (FAX) 615.244.8578 or e-mailed to: subscriptions@southcomm.com Subscriptions: One year $48 • Two years $78 SOUTHCOMM Chief Executive Officer Chris Ferrell Chief Financial Officer Patrick Min Chief Marketing Officer Susan Torregrossa Chief Technology Officer Matt Locke Business Manager Eric Norwood Director of Digital Sales & Marketing David Walker Controller Todd Patton Creative Director Heather Pierce Director of Content / Online Development Patrick Rains St. Louis Medical News is published monthly by Medical News, Inc., a wholly-owned subsidiary of SouthComm, Inc. ©2013 Medical News Communications.All rights reserved. Reproduction in whole or in part without written permission is prohibited. Medical News will assume no responsibilities for unsolicited materials.        All letters sent to Medical News will be considered Medical News property and therefore unconditionally assigned to Medical News for publication and copyright purposes.

stlouismedicalnews.com 14

314-645-5505 x1009 | 1-800-LUNG-USA www.breathehealthy.org JULY 2013 1118 Hampton Ave., St. Louis, MO 63139

stlouismedicalnews

.com

GrandRounds Fun Guide for Children about Sun Safety Amalyn Martin, founder of Miles Against Melanoma, an annual race that raises money for research and patients with the deadliest form of skin cancer, recently published Max & Mila at the Beach, a fun guide for children about skin cancer, melanoma, and sun safety. Martin collaborated with Jennifer Anne Danker on the content and illustrations. “This book was written to facilitate conversation between parents and children on how to stay sun safe,” said Martin. “It’s (about) two children on the beach who talk to their friend Colin the crab, notice his sunburn, and teach him how to avoid sunburn in the first place. It gets kids thinking about wearing sunscreen, hats, glasses and sun shirts and allows them to know what moles are and how to tell someone if they change. It’s geared towards preschoolers or kindergartners, but there’s also a note to guardians in it telling them the dangers of the sun and about melanoma.” Proceeds of Martin’s book go to Miles Against Melanoma. For information, visit http://www. amazon.com/Max-Mila-Beach-SafetyGuide/dp/0615790186.

Missouri Professionals Mutual Launches Disability Insurance Program For Physicians Missouri Professionals Mutual (MPM), provider of medical professional liability insurance in Missouri and Kansas, is making available to physicians in both states as much as $1.5 million in disability insurance for injuries and illnesses that interrupt or end their ability to practice medicine, it was announced today. The new policy will enable Missouri and Kansas doctors to buy $500,000, $1 million or $1.5 million in lump sum disability insurance coverage, if they become disabled and can no longer perform their regular specialty and sub-specialty practice, said Timothy H. Trout, founder and managing director of MPM and president of MPM subsidiary, MPM Insurance Company of Kansas. The benefit is a guarantee issue, meaning no medical exams will be required. (The highest level of coverage among competitors reportedly is $1 million.) The new disability coverage – which is being offered by Lloyd’s of London -provides the highest guaranteed benMedical 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. stlouismedicalnews

.com

efit for doctors in Missouri and Kansas without a medical examination, Trout said. He added that MPM was able to secure better terms and higher half-amillion dollar limits than previously offered in Missouri and Kansas. Interested physicians can visit www. hanleighenrollment.com/mpm to view rates and a brief video overview. The website also offers a detailed Q&A, and an easy on-line enrollment that can be completed in as little as five minutes.

Discovery Helps Show How Breast Cancer Spreads Collagen fiber alignment at the tumor boundary (dashed lines) is predictive of prognosis. Fibers that tend to be perpendicular to the tumor surface (top right, for example) encourage metastasis and indicate a poor prognosis. Fibers that run parallel to the tumor surface (bottom right) protect against cancer spreading. Tumors without DDR2 or SNAIL1 tend to show the protective parallel fiber alignment. Image courtesy of Nature Cell Biology Researchers at Washington University School of Medicine and the Siteman Cancer Center have discovered why breast cancer patients with dense breasts are more likely than others to develop aggressive tumors that spread. The finding opens the door to drug treatments that prevent metastasis. It has long been known that women with denser breasts are at higher risk for breast cancer. This greater density is caused by an excess of the structural

protein collagen. They’ve shown how increased collagen in the breasts could increase the chances of breast tumors spreading and becoming more invasive, according to Gregory Longmore, MD, professor of medicine and co-director of the Section of Molecular Oncology. It doesn’t explain why women with dense breasts get cancer in the first place. But once they do, the pathway they describe is relevant in causing their cancers to be more aggressive and more likely to spread. The results appear online May 5 in Nature Cell Biology.

SLU Chair of Dermatology to Hold National Leadership Position Scott W. Fosko, M.D., chairman of dermatology at Saint Louis University has been elected president of the American College of Mohs Surgery for 20132014, after serving in other leadership roles for the organization since 2011. Mohs surgery is the Dr. Scott W. Fosko preferred treatment for many skin cancers on the face and in other sensitive areas. It is a state-ofthe-art treatment for skin cancer that involves removing an entire cancerous tumor, layer by layer, while preserving the surrounding healthy tissue. Because Mohs surgery precisely targets the skin cancer, tumors are less likely to regrow and scarring is minimized.

College members who perform the procedure are sub-specialty trained physicians and have completed a threeyear dermatology residency and at least one additional year of fellowship training under the supervision and guidance of a Mohs College physician.

Neurologist joins SSM Neurosciences Institute at St. Clare Health Center Neurologist Aloka Amarakone, MD, has joined SSM Neurosciences Institute at St. Clare Health Center in Fenton, Mo. Dr. Amarakone is board certified in neurology and psychiatry. He has practiced in Missouri since 2011, most recently in Jefferson City. He earned his medical degree from Ross University School of Medicine in Dominica, and completed his internship, residency and neurology fellowship at the University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School. Dr. Amarakone joins fellow neurologist Laurence Kinsella, MD, in practice at St. Clare Health Center. Both physicians provide a full range of diagnostic and treatment services to address diseases that affect the brain and nervous system, including stroke, aneurysms, multiple sclerosis, peripheral nerve disorders, movement disorders, dementia, epilepsy and seizure disorders, autonomic function disorders and headaches.

Washington University

Pituitary Center

Comprehensive, multidisciplinary evaluation and treatment of pituitary disorders: • • • • • • • •

non-functioning pituitary tumors acromegaly Cushing’s disease hyperprolactinemia prolactinomas TSH-secreting pituitary tumors craniopharyngiomas diabetes insipidus

• • • • •

pituitary cysts recurrent pituitary tumors parasellar meningiomas hypopituitarism other hypothalamic tumors

(314) 362-3577

Center for AdvAnCed MediCine 4921 Parkview Pl., Suite 6C, St. Louis, MO 63110 Endocrinologist: Julie Silverstein, MD Neurosurgeons: Michael Chicoine, MD; Ralph Dacey, Jr., MD; Albert H. Kim, MD, PhD; Keith Rich, MD; Gregory Zipfel, MD

JULY 2013