West TN Medical News January 2016

FOCUS TOPICS OBESITY/DIABETES HEALTHCARE LEGISLATION OPHTHALMOLOGY

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PHYSICIAN SPOTLIGHT PAGE 3

Brad Priester, MD ON ROUNDS Tennessee Improves, but Still Near the Bottom, in Annual Health Rankings United Health Foundation Releases 26th Annual Report on Health in America Last month, United Health Foundation released the 26th annual report on the state of health in the nation.

Hawaii received top honors in “America’s Health Rankings®,” while Louisiana came in dead last. Although Tennessee moved up two spots from last year, the state still finished near the bottom at 43rd in the country ... 4

8 Steps to Improve Revenue Cycle Efficiency Even though patient care is top priority for doctors, administrative drills remain a nagging worry.

To take the pressure off the financial side of a medical practice, the American Medical Association (AMA) recently launched a module on revenue cycle efficiency in the AMA STEP Forward series, aimed at making life easier for physicians nationwide ... 5

ONLINE: WESTTN MEDICAL NEWS.COM

TMA Kicks Off the New Year with Targeted Initiatives

TMA Pushing Healthcare Improvement, Healthcare Provider Stability and a Constitutional Amendment

By SUZANNE BOyD

Even before the start of the second year of the 109th Tennessee General Assembly, the Tennessee Medical Association has several key legislative priorities it will be working on. The ultimate goal of the organization’s 2016 Legislative priorities is to help create a better, safer healthcare environment for Tennessee doctors and patients. Three of the five main initiatives the TMA has on its agenda are bills already in the pipeline that should pave the way for a healthcare future that is patient-centered and physicianled, holds insurance companies more accountable when changing fee schedules and payment policies as well as preserves Tennessee’s

favorable medical malpractice climate.

The Tennessee Healthcare Improvement Act (SB00521/ HB0861) calls for physician-led coordination and collaboration.

The bill creates a blueprint for the future delivery of healthcare by implementing a team-based care model with doctors as the team leaders in patient care coordination. The legislation calls for collaboration between physicians and advanced practice nurses to ensure patients receive care from the appropriate providers. Under present law, an advanced practice nurse is a registered nurse with a master’s degree or higher in a nursing specialty and national spe(CONTINUED ON PAGE 6)

Proton Beam Therapy Pioneer Improves Survival Rates for Children with Cancer

Thomas Merchant Marvels at What St. Jude’s Amazing New Tool Can Do

By JUDy OTTO

Last month, a few weeks before Christmas, St. Jude Children’s Research Hospital presented us with another world-class “first” – the St. Jude Red Frog Events Proton Therapy Center – the first center of its kind dedicated exclusively to pediatric cancer treatment.

But for Thomas Merchant, DO, PhD, and Chair of Radiation Oncology at St. Jude, it was a personal milestone, as well. Even before choosing a career in medicine, as a senior studying nuclear engineering at the University of Michigan, Merchant wrote a paper on particle therapy research being done at the Swiss Institute for Nuclear Research in Villigen, Switzerland (now known as the Paul Scherrer Institute). Twenty-five years later, as a St. Jude researcher, (CONTINUED ON PAGE 9)

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PhysicianSpotlight

West Tennessee Retinal Surgeon on a Mission to Change Unhealthy Habits Eyes Often an Early Indicator of Disease

Dr. Brad Priester shares his love of Rhodes College with his daughter, Halle, and wife, Joanna. They are all graduates of the liberal arts college

By SUZANNE BOYD

When he went into practice as a retinal surgeon nearly 19 years ago, Brad Priester, MD, had no idea it would turn into a crusade to change the way people eat. Seeing first-hand the effects preventable conditions such as diabetes and obesity have on the eye, Priester made it a mission to educate people on healthy eating. From encouraging his staff and his patients to adopt healthy eating habits to his website, mouthplague.com, Priester wants to help decrease the incidence of diseases that can be prevented or reduced through dietary changes and a healthier lifestyle.

A native of Memphis, Priester knew early on he would be a doctor. “My grandfather was a general surgeon, my uncle an internist, and my dad is a dentist,” he said. “They were three great role models taking great care of people and watching them is what shaped me.”

While at Rhodes College working on a degree in biochemistry, Priester served as the student coordinator for the Kinney Community Service Program where he arranged volunteer activities with different organizations in Memphis such as United Cerebral Palsy. “I also worked in the ER at St. Joseph’s and was a patient transporter at St. Francis,” said Priester.

“But, I cannot imagine having an education that would prepare you any better to be a doctor than Rhodes. In addition to a phenomenal and rigorous science curriculum, I loved every moment of “Man,” a two year course surveying history and religion, as well as all of my other nonscience courses. It was transformational for someone who had not really applied himself in high school.”

Priester was accepted to several medical schools but chose to defer his admission for a year to be a ski bum in Aspen.

“While in Colorado, my parents cut me off financially, even my health insurance.

Their idea was to make sure I didn’t waver from my original plan,” he said. “It was a great life lesson. I shattered my collarbone on the first day of ski season and had $2000 in medical bills. Everything I saved during the summer season went right out the window to cover those bills.”

His love for the mountains was still strong, so rather than starting at Emory School of Medicine, he remained in Colorado and started medical school at the University of Colorado in 1987. He transferred to the University of Tennessee College of Medicine after his first year. “I started dating Joanna, who eventually became my wife.” he said. “She was in her senior year at Rhodes and did not want to be a mountain girl.” westtnmedicalnews

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In his fourth year of medical school, Priester decided it was time to not only get married but to also decide what he wanted to do. While he initially considered neurosurgery, it was his grandfather and father who encouraged him to look at ophthalmology. “My grandfather had an amazing experience with his cataract surgery and told me to give it a try. My dad was taking care of several ophthalmologists and was preaching the same sermon. I chose to do ophthalmology first followed by neurosurgery, but never made it to neurosurgery. I saw my first retinal surgery and had an epiphany. The moment the surgeon freed a piece of scar tissue from a retinal blood vessel, I was hooked. I substituted another month of ophthalmology for neurosurgery. Retinal surgery is like being on a research submarine. You work on the ‘seabed’ or retina by extending your instruments through the ‘sub portals’ or scleral incisions. It is just the coolest aquatic environment.”

After completing his transitional internship year at Baptist Memorial Hospital in Memphis, Priester completed his general ophthalmology residency through UT Health Science Center. During his second year, he and Joanna welcomed a daughter, Halle, to the family. He completed a two-year retinal surgery fellowship at the University of Alabama at Birmingham.

Priester began his professional career as a retinal surgeon in Jackson in 1997 and a year later he joined Mid-South Retina Associates and welcomed Sunny Khamapirad, MD, to the Jackson practice in 2003.

Priester and Khamapirad are the only two retinal surgeons residing between Memphis and Nashville. Two additional surgeons are needed to handle the workload, but young surgeons prefer the big cities with less call and more entertainment options.

Over his 18 years in practice, Priester

found himself in the middle of a horrible epidemic. “It is as though we are engulfed in a huge tsunami of disease. It is devastating because the eye is so sensitive to dietary and environmental toxins,” he said.

“Our patient referral area ranks number

one in the United States in diabetes and every day we treat preventable retinal disease, such as diabetic retinopathy and retinal vein occlusions.”

This tsunami of disease so profoundly affected Priester that he started a website, mouthplague.com, to address what he feels is the leading cause of the problem – heavy consumption of fast food and processed food. “Since the advent of farming and mass-produced chemicals, the consumption of unhealthy foods has become an integral part of our culture. It is not a complicated equation. The more fast food and processed food a person eats, the earlier they will encounter disease in their life. We see the evidence daily. The worst disease in the epidemic is diabetes. Uncontrolled diabetes damages retinal blood vessels and once the vessels are damaged, there is no way to repair them. We spend (CONTINUED ON PAGE 8)

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Tennessee Improves, but Still Near the Bottom, in Annual Health Rankings United Health Foundation Releases 26th Annual Report on Health in America

By CINDY SANDERS

Last month, United Health Foundation released the 26th annual report on the state of health in the nation.

Hawaii received top honors in “America’s Health Rankings®,” while Louisiana came in dead last. Although Tennessee moved up two spots from last year, the state still finished near the bottom at 43rd in the country.

With a starting position of 42nd in 1990, Tennessee hasn’t managed to gain much traction over the last 26 years despite increased attention and efforts to positively impact the determinants of health.

The state’s worst showing came in 2005 with a rank of 49th, and the best was in 2011 at 41st.

Rankings were determined by weighting more than 60 core measures and supplemental measures across the broad topics

of physical and behavioral health, access to care, clinical quality targets, environment, policy and other societal factors including education and poverty levels. Among core measures, Tennessee makes a good showing in several categories, including having a

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high rate of high school graduates and low prevalence of excessive drinking. However, we rank in the bottom third for obesity and physical inactivity and at or near the very bottom for diabetes (48), poor mental health days (50), smoking (47), and violent crime (47).

In the supplemental measures, the state ranks among the best for issues related to binge and chronic drinking and having cholesterol checked. Unfortunately, knowing those lipid numbers haven’t done much to impact the rate of high cholesterol (30), or to slow down heart attacks (46) and heart disease (45). Tennesseans seemingly are among the worst for eating fruits (49) and administering the HPV immunization for females (50).

Unfortunately, Tennessee saw a 20 percent increase in poor mental health days over the last two years and an 11 percent increase in violent crime since the rankings were launched in 1990. With 591 violent offenses per 100,000 population, Tennessee fares far worse than the top state of Vermont with only 121.1 such offenses per 100,000. Tennessee also compares unfavorably with much larger states often portrayed as having big city dangers, including New York (393.7) and California (402.1). Only Nevada (603), New Mexico (613), and Alaska (640.4), have a bigger issue with violent crime than Tennessee.

On the plus side, cardiovascular deaths are down 22 percent over the past decade from 382.3 to 299 per 100,000 population. That’s still a far cry from the best state, Minnesota, which has a rate of 186.5 deaths per 100,000. Other positives include a 26 percent decrease in preventable hospitalizations over the past five years from 87.7 to 64.8 per 1,000 Medicare beneficiaries, and a significant decrease of 28 percent over the last year in physical inactivity, which is down from 37.2 percent to 26.8 percent of adults selfreporting as inactive.

The State Weighs In In light of the recent metrics, a spokesperson with the Tennessee Department of Health offered the following commentary on the pluses and minuses of the state’s recent ranking with specific attention to the change in physical activity.

“While the Tennessee Department of Health is pleased to see data indicating an improvement in the number of residents who are self-reporting being more physically active, we must all understand annual fluctuations in calculations and periodic shifting of survey methodology

are factors that must be considered when reviewing new numbers. The effort to improve physical activity across Tennessee is an important component of the Big Three Plus One initiative to improve health for all residents. The components include: 1). Reducing excessive caloric intake to reduce overweight/obesity; 2). Improving physical activity among all residents; and 3). Reducing the number of Tennesseans who use tobacco products; plus reducing misuse/abuse of both prescribed and illicit drugs.”

Department of Health officials went on to point out that in addition to statistical changes that might have been impacted by the way the question was phrased, they believe improvement is also attributable to the contributions of several new programs across the state aimed at enhancing fitness, including: • Engaging in a partnership with Tennessee Department of Environment and Conservation to convene school running clubs across the state, providing non-competitive physical activity in an after-school setting to interested students.

• Funding for walking tracks at multiple schools across the state.

• Encouragement and support for Go Noodle, which provides fun, physical activities in classroom settings in over 1,000 Tennessee schools.

• Construction on walking trails and greenways across the state.

• Implementing a program to provide free access to recreation centers, as well as an exercise coach for citizens wanting to reduce weight and improve health.

• Encouraging increased physical activity through a series of healthy actions and challenges as part of the Small Starts tools developed and offered by the Governor’s Foundation for Health and Wellness to engage Tennesseans at home, in the workplace and at worship.

• Statewide implementation of the Healthier Tennessee Communities initiative to motivate community-level ownership of population health and to support positive changes among fellow residents.

“These and other efforts focus on the importance of helping all individuals understand the importance of physical activity and encouraging them to take action to become more physically active in meaningful ways,” concluded the TDH official.

The Big Picture The interactive report, which also includes data specific to seniors, allows comparison of Tennessee to other states and national averages for the broad range of measurable metrics. Custom reports, state infographic and summary, and ‘take action’ resources to improve rankings are all available at AmericasHealthRankings.org. westtnmedicalnews

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WHO’S TENDING OUR DOCTORS?

8 Steps to Improve Revenue Cycle Efficiency

By LYNNE JETER

Editor’s Note: This article is part of a Medical News exclusive series, “Who’s Tending Our Doctors?” to focus on ways the industry can help alleviate physician stress and allow physicians to return to the joy of practicing medicine.

Even though patient care is top priority for doctors, administrative drills remain a nagging worry. To take the pressure off the financial side of a medical practice, the American Medical Association (AMA) recently launched a module on revenue cycle efficiency in the AMA STEP Forward series, aimed at making life easier for physicians nationwide.

“An efficient revenue management system is critical for your practice’s financial health and sustainability,” said Christine A. Sinsky, MD, FACP, an internist with Medical Associates Clinic, a multispecialty group practice with sites in Iowa, Wisconsin and Illinois, and the AMA point person Dr. Christine A. Sinsky for STEPS Forward.

“Electronic methods can streamline revenue-related processes, such as eligibility checks, claims submissions and payments,

all allowing your practice to maximize the amount of time available for patient care.”

To improve revenue cycle efficiency, doctors may follow eight steps: 1. Select a practice management system (PMS) that fits your needs.

2. Verify insurance eligibility electronically before every patient appointment.

3. Reduce prior authorization burdens through electronic transactions.

4. Submit claims electronically to save time and money.

5. Determine the status of submitted claims.

6. Leverage electronic remittance advice (ERA) to simplify processing of payment information.

7. Review electronic payment options and make an informed choice for the practice.

8. Maximize collection of patient payments.

“As with any technology selection, the ‘right’ PMS for your practice is the one that will best meet the needs of you and your staff,” said Sinsky. “Whether purchasing your first PMS or changing to a different product, first turn your attention inward to your practice. Soliciting input from all staff who use and interface with a PMS and including them in the selection

process will ensure that you pick a vendor and product that matches your practice’s priorities and needs. A thorough analysis of your practice’s revenue cycle process and workflow will provide valuable insight into your system’s requirements. Additionally, this type of analysis will help to identify opportunities for automation through the PMS that will improve the efficiency of your practice.”

Verifying insurance eligibility electronically before every patient appointment is greatly underrated.

“Ideally, this eligibility check should be performed electronically,” said Sinsky.

“Although most health plans allow patient eligibility to be verified over the phone or via a health plan web portal, these methods are often inefficient and may not provide you with all the necessary information.”

Because reducing prior authorization burdens via electronic transactions dovetails nicely with the AMA’s belief that prior authorization is overused, the AMA urges health plans to limit the use of these programs to true utilization outliers, instead of broadly applying coverage restrictions to all practices. To reduce the physician’s time spent on prior authorizations, the AMA recommends incorporating a team-based model into the practice

routine. (Medical News will cover the teambased model in 2016.)

“Ideally, a physician will be aware of drugs’ prior authorization requirements before sending a prescription to the pharmacy, which minimizes the chances of patient medication nonadherence,” said Sinsky, pointing out that electronic prescribing system vendors are in various stages of implementing electronic prior authorization technology.

To save time and money, submit claims electronically.

“Healthcare claim submission used to require a cumbersome, manual process of completing a paper form, mailing it to a health plan, and waiting – sometimes weeks! – for a response,” said Sinsky. In addition to time and cost savings, “electronic claims submission often speeds heath plan adjudication and payment.”

Determine the status of a submitted claim via the electronic claim status inquiry to confirm receipt of submitted claims, and to garner claim status.

“Health plans are required to support real-time claim status processing,” said Sinsky. “To electronic eligibility inquiries, practices can also send ‘batch’ transmissions to health plans to check the status of multiple claims at the same time. By (CONTINUED ON PAGE 6)

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TMA Kicks Off the New Year with Targeted Initiatives, continued from page 1 cialty certification as a nurse practitioner, nurse anesthetist, nurse midwife or clinical nurse specialist. Under this bill, an advanced practice nurse will instead be certified as an advance practice registered nurse (APRN).

“Having the proper collaboration from a physician in diagnosing and Dr. John Hale treating a patient ensures the highest quality of care and patient safety,” said John Hale, MD, TMA president. “We want to knock down silos among providers, increase care collaboration and create a model that supports the best possible outcomes for patients. The Healthcare Improvement Act will allow advanced practice nurses to use the full extent of their training, but makes sure that a physician is involved in the care of every patient. It is in the best interest of all Tennesseans.”

This bill requires every APRN to practice as part of a patient care team. Each member of the patient care team provides healthcare services within the scope of that team member’s practice area.

The bill would change the relationship between physicians and advanced practice nurses from one of supervision to one of collaboration. The goal is to ensure patients receive care from appropriate providers with proper oversight. This is a very different approach to the Nurse Inde-

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pendent Practice/Full Practice Authority Bill, which is designed to give nurses the ability to diagnose and treat patients and prescribe drugs without a physician supervisor to review charts or provide consultation. The bill was taken off notice in order for involved parties to discuss compromises during the summer.

Representative Steve McDaniel (RParkers Crossroads) says he wants to see each side get together to make things work and hopes he can further that process. “I think that a collaborative effort between Advanced Practice Registered Nurses and Primary Care Physicians is something that needs to be looked at. I am not Rep. Steve sure how well the curMcDaniel rent system is working so I am interested in seeing it work better,” he said. “I represent four rural counties where healthcare is not as available as in urban and suburban areas and where it is harder to attract physicians. So we need to find a way to utilize nurse practitioners to best serve the underserved.”

Reimbursements

The Healthcare Provider Stability Act (SB0937/HB0963), if passed, would make Tennessee the first state in the country to limit how often payment policies can be changed. The bill changes the way the insurance companies negotiate contracts with doctors and hospitals. The central issue is that physicians rely on insurance companies to refer patients through provider networks. Under the current guidelines, insurers can change the terms of agreements with providers in the middle of multiyear contracts. If a physician does not agree to the change, health plans will drop them from the network forcing patients to find a new provider or pay higher “out-of-network” fees.

“It’s impossible for a physician to make sure the business side of a practice runs smoothly when health plans can cut reimbursement mid-contract with no recourse for the physician,” said Hale.

The goal of the bill is to achieve much needed predictability in reimbursement for healthcare providers by limiting arbitrary reimbursement changes in the middle of a contract period. By requiring notice of changes to fee schedules and payment policies, the bill would make it easier for providers to see, understand and deal with contract changes as they are made.

As amended, this bill establishes limits on a payer’s ability to make changes to a fee schedule to 1 time in a 12-month period. It limits changes to payment policies and other administrative changes to only 2 times per year by a third-party payer.

It also provides for transparency of all payment policies and methodologies on a payer’s website.

“I think that insurance companies should not be allowed to unilaterally change the terms of their contracts midstream,” said Tennessee State Senator Brian Kelsey (R-Germantown). “Doctors

should have confidence in the fairness of their negotiations with insurance companies.”

Insurance companies oppose the bill claiming it will affect patient care and could increase the cost for plan members, since renegotiating contracts annually Sen. Brian would be costly. The bill Kelsey is currently in the Senate Finance Committee and the House Finance Subcommittee. The administration added a $5 million fiscal note to the bill at the end of the previous session.

Democracy.

The joint resolution is expected to be introduced in the 2016 session. The proposed amendment would be required to pass two separate General Assemblies before it would be placed on the ballot for a vote in 2018. “The General Assembly needs to act now to prevent us from going backwards on the issue of a noneconomic damages cap,” said Hale. “The cap fosters growth in Tennessee’s healthcare industry by cutting back on frivolous lawsuits and the costs that come with them. I’m confident Tennessee voters will support it if given the chance to have their voices heard.”

Damage Caps

Another issue on TMA’s agenda is proposed legislation that would set parameters for in-office dispensing of medications in order to ensure that unscrupulous doctors are not able to abuse this ability.

The other top issue is a bill to establish penalties when insurance companies don’t comply with regulations already in place for workers’ compensation silent PPOs. “TMA’s legislative priorities are about making improvements for Tennessee physicians and the patients they serve,” said Hale. “We are looking out for the future of Tennessee healthcare, working to make sure it evolves in ways that allow doctors to provide the best care possible to their patients. The issues on our 2016 agenda reflect our mission as an organization.”

An amendment to the Tennessee constitution clarifying that the General Assembly can cap noneconomic damages in cases including medical liability is the third major initiative for TMA. The Tennessee Civil Justice Act of 2011 places a cap of $750,000 on non-economic damages such as pain and emotional suffering and a $500,000 cap on punitive damages in medical malpractice and personal injury cases. The cap on noneconomic damages is currently being threatened by lawsuits, including one in Chattanooga in which the judge ruled the cap unconstitutional. Groups with opposing views to the cap include trial lawyers through the Tennessee Association for Justice and the New York-based Center for Justice and

Other Issues

8 Steps to Improve, continued from page 5 law, the practice must receive a response by the next business morning, although some practices report receiving these responses much sooner. Rather than waiting two or more weeks before taking action on a submitted but unadjudicated claim, using the electronic claim status request provides the practice with an immediate status report on the claim. The practice can then fix a problem, resubmit the claim and lower the days in accounts.”

Leverage the ERA, an electronic version of a paper explanation of benefits (EOB), to simplify processing payment information.

“Manual reconciliation processes and sifting through stacks of paper EOBs can be sizable administrative hassles,” said Sinsky. “The standardized ERA offers a way for practices to reduce these burdens, more quickly identify those claims that require reworking, and generally have staff spend more time on higher-value activities.”

When determining electronic payment options, consider the hassle attached to paper checks, a time-consuming activity that’s ripe for fraud.

“Using electronic payment can simplify your practice’s revenue cycle and lead to faster payment from health plans,” said Sinsky, pointing to the industry standard Automated Clearing House electronic funds transfer (ACH EFT). “However, be aware of the benefits and risks of various electronic payment options to make the best choice for your practice.”

For example, even though health plans and their vendors may offer supplemental “value-added” services for an additional, percentage-based fee, all health plans are required to offer basic ACH EFT upon physician request and at no additional cost beyond a nominal, per-transaction banking fee of approximately 34 cents.

“In addition to ACH-EFT payments, health plans frequently use virtual credit cards (VCCs) for physician claims payments,” said Sinsky. “Practices are charged interchange fees of up to 5 percent of their total payment to receive these VCC payments. In some cases, health plans are receiving cash-back incentives of up to 1.75 percent from the credit card merchants for using this payment method.”

Collecting payments at the time of service is the vital first step in any effective patient collections strategy.

“Especially because of the growing prevalence of high-deductible health plans leaving many patients to bear additional financial responsibility for their treatment, doing so will increase your practice’s cash flow, decrease accounts receivable, and reduce billing and back-end collection costs,” said Sinsky.

In summary, “Every workflow that a practice converts from manual to electronic process will save valuable time and resources while also reducing the overall administrative burdens of practicing medicine,” said Sinsky. westtnmedicalnews

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Evidence-based Design: Marrying Form & Function on the Front Line

By CINDY SANDERS

When is a painting much more than just a pretty picture?

When it promotes health and healing.

Designers and healthcare industry leaders from around the nation recently gathered in Washington, D.C. for the annual Healthcare Design Conference. Convened by The Center for Health Design (CHD) and Healthcare Design Magazine, the four-day meeting and exposition unveiled the latest in evidence-based strategies and products.

Rosalyn Cama, president and CEO of Connecticut-based health design firm CAMA, Inc. and the immediate past chair of CHD summed up the conference experience as ‘awesome.’

“It’s rich in attendance with folks who are well-versed in the business of healthcare … not only how you design it, Rosalyn but how to build it and Cama then manage it and sustain it over time,” Cama said of the multidisciplinary professionals in attendance.

No doubt the event also held special significance to Cama this year as she was presented with the Russ Coile Lifetime Achievement Award. Cama, who has served as CHD board chair for 14 years, was also named chair emeritus of the organization, which is dedicated to bringing together a community of designers, architects, executives, manufacturers and students to improve quality of care and outcomes through evidence-based design principles.

With dozens of educational tracks, facility tours, and keynote presentations, Cama said the conference covered a broad spectrum of topics and provided insights for veteran designers, as well as those newer to the field. “Because this is a research conference, they are revealing new data,” she noted. “You can’t think that what you heard five years ago is how you are going to operate. Demographics change, culture changes, operational models change. You have to stay current.”

One major change, she continued, is how technology is integrated into care and the built environment. “Technology is forcing us to change dramatically.

It affects how care is delivered and how patients move through space and the system.”

While technology dominated many conversations on the acute side of the equation, Cama said, “On the ambulatory side, we heard a lot about patient experience – how to know your customers, deliver a more meaningful experience, and then measure it.” Additionally, she noted there were an increasing number of conversations centered on health and wellness and moving care from the hospital into westtnmedicalnews

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the community.

Nature equals Nurture Roger Ulrich, PhD, is often credited as the pioneering researcher whose work transformed how nature is viewed within the healthcare setting. Cama noted a landmark study Ulrich performed more than two decades ago underscored the difference in outcomes between patients whose rooms had a view of a brick wall compared to those who saw a stand of trees.

In the study, patients recovering from abdominal surgery with a view of nature required less pain medication, had fewer complications, and were discharged from the hospital earlier than their counterparts viewing the brick wall.

The study, Cama continued, caused healthcare designers to really consider how to create environments that speak to the human condition … particularly when that condition is in a fragile and vulnerable state. “Looking at a wall of technical outlets is not a calming view,” she pointed out.

However, Cama was quick to add that same clinical equipment is critical to quality care. Therefore, the task of the designer is to place technology in a way that is easily accessible to clinicians while preventing it from being the focal point for patients and families so as to lower their stress levels.

She said there are a number of ways to bring nature indoors – from rooftop gardens and water features to rooms with a view and artificial illumination that simulates natural lighting. Cama also pointed out these features aren’t just for the benefit of patients but also speak to the needs of families and healthcare staff.

number of care settings, Cama said the idea really emerged out of conversations and requests from worried parents.

Her firm does a lot of design for pediatric hospitals. For nearly 20 years, she has heard parents say they wished they could just crawl in the hospital bed with their children to comfort them at night.

Since that option is neither safe nor feasible with children who might be hooked up to monitors, Cama came up with a stylish alternative – a chair that rises and reclines.

At night, a parent can stretch out at equal height to the hospital bed and easily touch and comfort their child without disturbing critical equipment.

“The research around the power of touch, is compelling” Cama added, pointing to the work of Tiffany Field, PhD, director of the Touch Research Institute at the University of Miami. Since the design conference, the Cama Bed Chair won the BOY (Best of Year) award in the Healthcare Furniture Category.

bits of time where you’re waiting. Where do we allow people to relax and be nourished?” she questioned.

Whether it’s by creating a chair, designing a curated program, incorporating a healing garden or botanical walk, or employing the power of local art to trigger pleasant memories, designers around the country are focused on enhancing outcomes by improving the outlook, even for a little while.

Cama concluded, “If you can get a family member or patient to pause and just forget for one second, then that’s pretty awesome … and you can do that through design. At Cama, we strive to design a better life indoors where you can thrive and flourish. We are seeking to design interiors that improve our health and wellbeing while supporting our constantly evolving lives.”

The Time Between In the inpatient setting, Cama noted that increasing attention is being focused on the ‘time between’ seeing clinicians, going for tests, or waiting for a loved one to come out of surgery. “There are long

The next Healthcare Design Conference is scheduled for Nov. 12-15, 2016 in Houston, Texas. For more information, go online to healthdesign.org.

Mark Your Calendar

A Hint of Hospitality While much has been made of the hospitality industry’s influence on healthcare, Cama cautioned that it should only go so far. “It can look inviting and beautiful if that’s how one interprets ‘hospitality.’ But it can’t be fussy, and it has to be clean,” she stressed of healthcare design.

Cama added products have evolved over time to give healthcare designers many beautiful options that marry the twin needs of form and function. “The manufacturing industry has grown up with us. Now there are so many more choices that have been engineered for this setting. Our kit of parts is much broader,” she said.

Cama noted one of the highlights of the conference is that it introduces attendees to new and improved products each year. Cama said there is now a luxury flooring product that truly has the look of hardwood. “I’ll look at real wood now and say, ‘Is that vinyl?’” she laughed.

This year, the designer was actually one of the exhibitors, as well. The IOA Cama Bed Chair debuted at the 2015 meeting. Although designed for use in any JANUARY 2016

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Obesity Worsens Lung Function in Young Adults with Asthma Washington University Study Chronicled Asthmatic Patients from Elementary Age to Post College have more difficulty controlling their symptoms and as ST. LOUIS, MO. – A a result, need more medicanew study following nearly tions.

800 asthmatic patients over “Our study suggests that 15 years shows the progression younger obese patients can toward worse lung function in expect worsening lung functhose who become obese as tion as they age,” said Strunk. they age.

“We want to emphasize that None of the participants doctors and patients need to of the Washington University pay attention to weight.”

School of Medicine study were Strunk noted it’s encourobese at the beginning of the aging that obese young adults research project (ages 5-12), in the study don’t report worse yet 25 percent were obese asthma symptoms. by the end of the study (early “But it’s worrisome that twenties). their lung function has clearly Researchers reported that gotten worse,” he quickly pediatric asthma patients who added. had become obese by their The CAMP (Childhood early twenties had measurably Asthma Management Proworse lung function than those gram) research group has Dr. Robert C. Strunk treats patients at St. Louis Children’s Hospital in St. Louis, Mo. with asthma who didn’t bepublished more than 150 arcome obese by the end of the ticles on the study results, with study. many publications focusing on the genettion due to the airways being more narrow Surprisingly, both groups showed no ics of asthma and/or clinical outcomes. and nothing to do with the chest wall. difference in the severity of their asthma “We’re now working on determinOthers have shown in adults with asthma symptoms. ing characteristics of the children when and obesity (and the same obstruction we “In extreme situations in adults (morthey were school age that were associated found) that there’s likely to be some conbid obesity), the chest wall is so thick that with the onset of smoking cigarettes,” he nection between the airways being narrow it interferes with movement and there are said. “In spite of our best efforts and their and molecules that come from fat tissue decreases in lung function on that basis,” asthma, yes, some 20 to 25 percent were and cause inflammation. We didn’t colexplained Robert C. Strunk, MD, a pedismokers.” lect data to examine this possibility in our atrics professor at Washington University, Strunk noticed no difference in study population, but the obstruction in who treats patients at St. Louis Children’s outcomes by gender. “Young men and those who became obese is likely to be reHospital in St. Louis, Mo. “This is a difwomen gained weight and had decreased lated to some type of increased inflammaferent kind of abnormality (a restriction lung function,” he said. tion related to the fat tissue.” because of the interference with moveWhen asked about indications Study findings differ from research ment) than we found, which was obstrucwhether asthma symptoms had any efin older obese patients with asthma, who

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fect on gaining weight, Strunk said many thought participants with more asthma symptoms might exercise less and therefore gain more weight. “Or that those who gained weight were the sickest and took more steroid medication,” he said. “Neither symptoms nor steroids were related to the changes in lung function … and thus on gaining weight.”

Trial patients were enrolled in CAMP, a nationwide study originally designed to determine best practices in treating asthmatic pediatric patients. In 2000, the study produced a landmark paper in The New England Journal of Medicine that altered the standard of care for children with asthma when it demonstrated that a regular medication routine was superior to as-needed asthma treatments.

“That paper launched a whole new approach to childhood asthma management, changing the guidelines for physicians treating those patients,” Strunk pointed out. “We were fortunate to be able to continue following this group of children all the way to their mid-twenties. Nobody had been able to do that before. We could answer a lot of questions with data gathered over such a long period of time.”

Because CAMP study patients were only their twenties, they weren’t old enough to have developed COPD. “Good studies show that childhood asthma is a clear risk factor the development of COPD,” he said.

Research from the Washington University study was published in a 2015 edition of The Journal of Allergy and Clinical Immunology.

West Tennessee Retinal Surgeon, continued from page 3

a great deal of time every day injecting medications into the eye just to try to slow down the progression of a preventable disease.”

Priester is a huge proponent of eating healthy. “I am an avid supporter of local organic farmers,” he said. “If you don’t think you can afford to eat organically, then just eliminate white foods from your diet such as flour, rice, potatoes and sugar.

That will knock out about 99 percent of processed and fast foods.”

Besides his passion for educating people on the benefits of healthy eating, Priester is an “after hours” inventor. He holds two patents in ophthalmology and nine in the robotics field of altered task dynamics with one patent pending and more in the works. Google “Whirley by Brad Priester” to see an animation of Priester’s robotics journey.

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Findings on Fat Cell Metabolism

New Insights Could Lead to Novel Approaches to Treating Obesity, Diabetes A recent study out of the University of California, San Diego uncovered new insights into what nutrients fat cells metabolize in order to make fatty acids.

Christian Metallo, PhD – an assistant professor of bioengineering in the Jacobs School of Engineering at UCSD and senior author of the study that was published online in the Nov. 16, 2015 issue of Nature Chemical Biology – said a better understanding of how fat cells develop, change, consume and metabolize their surrounding nutrients could help researchChristian ers find new approaches Dr.Metallo to treating a number of diseases.

“This study highlights how specific tissues in our bodies use particular nutrients,” he explained. “By understanding fat cell metabolism at the molecular level, we are laying the groundwork for further research to identify better drug targets for treating diabetes and obesity.”

The research team discovered that as fat cells develop, they change the types of nutrients they metabolize to produce fat and energy. In the pre-adipocyte state,

which is the precursor to fat cells, mally functioning adipocytes.” glucose is the meal of preference A working hypothesis, then, to grow and make energy. Howis that higher accumulation of ever, as the cells mature into branched-chain amino acids ocactual fat cells, the team found curs when there are irregularithey not only metabolize simple ties in fat cell metabolism. sugars but also the more complex While this first step toward branched-chain amino acids, a understanding how amino acids small set of the essential amino are accumulating in the blood acids for humans. of those with obesity and diabeThe team induced pre-adtes is important, the next step is ipocytes to differentiate into fat to figure out how and why the cells and cultured the cells in a metabolic pathways become media containing nutrients enimpaired. “This gives us a pathriched with carbon-13 isoptopes, way to understand and look at which are a form of carbon atoms its function … or dysfunction used as metabolic tracers in cells, Microscopy image depicting fat cells (or adipocytes) after differentiation. The cells … in detail,” Metallo said. He animals and people. By doing are stained with Oil Red O, which highlights lipid or fat droplets that accumulate added, “We have a couple of this, the research team could see with the fat cells. The metabolic study indicated that fat cells produce these fatty different lines of investigation what carbon-based nutrients the acids, in part, from essential amino acids rather than sugar only. to determine what might cause cells metabolized and what they dysfunction of this pathway in produced at different stages of the cell difadipose tissue in diabetics.”

Metallo said. “We used metabolic tracers ferentiation process.

Metallo also noted that studies such as and mass spectrometry-based metaboloTheir findings are important in showthis one are significant because they have mics to track or trace the carbon in differing fat cells play a role in regulating the the power to change the questions being ent nutrients to quantitatively determine body’s levels of branched-chain amino asked.

Is someone obese or diabetic bewhere it went in the adipocytes. By visualizacids, which typically are elevated in indicause they eat too much and move too liting the biochemistry in that way, we could viduals who are obese or diabetic. tle, because they are not burning correctly quantify how amino acids, or proteins, con“We quantitatively showed that this at the cellular level, or some combination of tribute to fat production.” branch-chain amino acid pathway was factors?

“Knowing that answer can change He added, “The importance of this almost equivalent to the contribution of treatment approaches,” he pointed out. study is that it shows branched-chain sugar or carbohydrate to fat production,” amino acids are highly metabolized by norPHOTO CREDIT: METABOLIC SYSTEMS BIOLOGY LAB AT UC SAN DIEGO.

By CINDY SANDERS

Proton Beam Therapy Pioneer Improves Survival Rates, continued from page 1 he visited the institute and studied firsthand its program in proton spot scanning.

There, in perhaps the premier facility in the world where proton spot scanning, aka pencil-beam scanning, was developed, he experienced what many inventors, scientists, and researchers identify as an “Aha!” moment.

“We have GOT to have this!” Merchant realized.

“St. Jude had proton therapy on its radar and followed it very carefully,” he explained. “But the technology available Dr. Thomas Merchant then (in 2008) wasn’t this leading edge technology. When it became available, that’s when we made the decision to develop our own treatment center.”

Now that St Jude has treated its first few patients, carefully selected, in meticulously controlled clinical trials, he marvels at the ‘unbelievable’ focus and accuracy in delivering a radiation dose precisely shaped to match its target.

Previously available pencil-beam systems were limited by their comparatively large beams. “Our beam size is the smallest clinical beam in the United States today,” he believes.

Being one of the first systems to employ exclusively pencil-beam technology is not without risks. Whether to include, in part, older “passive scattering” technology with the new was a big decision, said Merchant. “Since we had waited for this new westtnmedicalnews

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technology to implement proton therapy however, we chose to make the entire facility pencil-beam. Obviously that was a good decision.”

Medical technology is perpetually threatened by obsolescence, so one of Merchant’s concerns was how long the new technology would retain its cutting edge.

“This is one of the biggest challenges that the administration put before me in 2011,” he recalls. “They said, ‘You need to open a proton therapy center in the next five years, and it absolutely has to be cutting edge.’

But how do you predict the future?”

Hitachi Ltd.’s ability to make improvements during system development—even up to the last minute—made them an attractive proton therapy vendor partner, said Merchant. “The Center was designed so that we can make modifications over time that will also keep it cutting edge for a long time. What we have today is just the beginning; a year or two from now, it will have more functionality –and allow us to do more and more.”

In the future, will all children be treated with proton therapy?

“I think it’s moving in that direction.

The number of children each year in the United States who need radiation therapy as part of their front-line management is difficult to estimate, but may be from 3,000 to 5,000. If I had my way, we would treat every child with cancer here –but that’s not practical. So St. Jude helps others by performing trials that are designed to treat a specific number of patients, and we share

those results with other institutions in the U.S. and around the world.”

Merchant is not a stranger to successful research results that have far-reaching benefits. His proudest achievement, in fact, is a change in U.S. and international philosophy regarding the use of radiation therapy on brain tumors in young children under the age of three—which has saved countless lives.

“When I came to St. Jude (from Memorial Sloan-Kettering Cancer Center, New York) in 1996, it was to implement conformal radiation therapy using Xrays. At that time, children under the age of three with brain tumors did not receive radiation therapy as a part of their initial treatment because everyone was concerned about the side effects of radiation.”

Then, for example, children with a tumor known as ependymoma would have surgery and chemotherapy, receiving radiation therapy (potentially) only when the tumor grew back. Merchant characterizes those results as “miserable”, with five-year overall survivals in the 40% range. His efforts galvanized St. Jude’s teams to offer these children radiation immediately after surgery. Five-year overall survival rates have since jumped to 85%.

Merchant then led a five-year national trial (2003-2007) that duplicated St. Jude’s results. “Just by bringing radiation therapy in immediately after surgery for those very young children, we doubled their survival.

I’m proud that we pioneered the use of radiation therapy in children under the age of

three years with brain tumors.”

He points to St. Jude’s track record of doing pilot studies that lead to national and international studies that bring about change. “We’re going to do the same with proton therapy,” he predicts.

Seeing children in follow up for tumor surveillance once treatment is completed is the most challenging part of his work, he notes. “We’re concerned about each and every patient. We want clean scans, good exams, and we worry a lot about that.”

Does working with children make the job emotionally more difficult?

“Heartbreaking things happen here all the time; but by and large it’s a joyous place to work. Our results are good, and that keeps us going.

Post-college, Merchant worked for the French Atomic Energy Commission (CEA), evaluating radiation protection and safety and partnering with investigators at the famed Curie Institute. After medical school (Chicago College of Osteopathic Medicine), he was a Fulbright Scholar to the Netherlands at the University of Utrecht, where he received his PhD, cum laude, in experimental pathology.

“The great thing about the field of pediatric oncology and radiation oncology,” he notes, “is the small community. We know each other; we really enjoy helping others – both nationally and internationally.”

For Merchant, this particularly includes one person: his wife, Dr. Jenny Tibbs, who also practices radiation oncology in Memphis.

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A Clearer Picture: Imaging Rhodopsin Could Shed Light on Retinal Disorders

By CINDy SANDERS

A collaborative effort between Bascom Palmer Eye Institute and Florida International University (FIU) has resulted in what the team of biomedical engineers and physician-scientists believe to be a true breakthrough in retinal imaging.

Building on the foundation of traditional optical coherence tomography (OCT), the group created technology to image the light-sensitive receptor protein rhodopsin. Three years of hard work recently culminated in the successful test of the first technology based on visible-light optical coherence tomography (VISOCT).

Shuliang Jiao, PhD, an associate professor of biomedical engineering at FIU who led the project, said OCT is an established imaging technique that has been used extensively in clinical settings and allows ophthalmologists to map and measure layers of the retina.

Yet, OCT on its Dr. Shuliang Jiao own has limits to the information it can yield.

Byron Lam, MD, and Rong Wen, MD, PhD, both professors of ophthalmology at Bascom Palmer and key members of the research team, said OCT is very good at Dr. Byron Lam uncovering the anatomy of the retina but cannot tell whether a cell is functional or not.

Assessing Functionality Wen explained the photoreceptors in the Dr. Rong Wen retina that convert light signals to the neuronal signals degenerate

at rates that vary by patient and condition. Currently one of the most common ways to assess the extent of vision loss is to simply ask a patient ‘what’ and ‘how well’ they see. As Wen pointed out, it’s a reasonable test but also a subjective one.

“We wanted to come up with an objective way to tell if the photoreceptors are functional,” he said.

To assess functionality, the research team focused on rhodopsin, also known as visual purple, which converts light into electrical signals and is exclusively found in the photoreceptors of the retina. Wen explained rhodopsin has two states – dark adapted and light adapted.

“Rhodopsin will flip a switch after it absorbs a photon, and that flip of the switch starts a process called phototransduction that will send out a signal to the brain. In that flip of the switch,” he continued, “rhodopsin’s optical absorption spectrum changes.”

Lam added, “It’s really the first step of how we see. It’s the cornerstone of the visual process.”

It’s also measurable. Lam explained that by quantifying the efficiency of photon absorption, it should be feasible to assess the functionality of rod photoreceptors in the retina. By calculating the difference between the two states of rhodopsin – light adapted and dark adapted – the theory was that the research team should be able to accurately determine the amount of rhodopsin in the retina … thus providing an objective answer to the question of visual acuity.

“When you want to detect rhodopsin, you want to use the wavelengths at the peak of the absorption spectrum,” Wen continued. “That particular wavelength for rhodopsin is around 500 nanometers.

We actually used 520 nm.”

Noting that visible light isn’t easy to handle, Wen explained conventional OCT uses the much longer wavelength near-infrared light, whereas VIS-OCT

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employs green light.

Jiao added that in order to see the difference in dark-adapted absorption and light-adapted absorption, it was imperative to have both resolution and contrast, which necessitates the use of shorter wavelengths in the visible spectrum. “The intensity of the reflection from photoreceptors is affected by the bleaching state of rhodopsin,” he noted.

Crunching the Numbers Obtaining an objective measure of rhodopsin is the first step in being able to improve diagnostics and treatment of retinal disease, Lam said. “The important clinical implication is that it can give you a gauge of how the photoreceptors are functioning,” he noted.

That, in turn, could give ophthalmologists a new diagnostic tool and a baseline number to assess how disease is progressing and to evaluate therapeutic effectiveness. “It also gives you a topographical map so you also know the specific areas where rhodopsin is functioning … or not,” Lam added.

Wen, a photoreceptor cell biologist, also believes VIS-OCT could be useful to study future photoreceptor regeneration, including transplant stem cell-derived photoreceptors, gene therapies and neuroprotection therapies.

“The rapid development in regenerative medicine to restore vision has raised a hope that regeneration of photoreceptors and restoration of photoreceptor function will become reality in the near future,” Wen said. “When that time comes, this technology will be used to see whether the new photoreceptors are functional.”

Moving from Bench to Bedside While this first successful test was conducted in vivo on rats, Lam said it should be relatively easy to transition the imaging technique to humans. Wen stressed VISOCT is “absolutely non-invasive” and that the ultimate goal is to make the test office-based and widely accessible.

To conduct the study, the research team designed and built a 3D retinal densitometry system. Jiao said he is currently modifying the design a bit to improve the prototype and make the system easier to use in a clinical setting.

While there is still a long way to go … and no one could commit to an exact timeframe … Wen said it was feasible this technology could be available within the next five years.

For those tasked with diagnosing and treating a range of conditions from retinitis pigmentosa to age-related macular degeneration, any new technology that could more accurately assess a patient’s condition should be a welcome addition to the toolkit.

PUBLISHED BY: SouthComm Business Media, Inc. MARKET PUBLISHER Pamela Harris pamela@memphismedicalnews.com Ad Sales: 501.247.9189 LOCAL EDITOR Pamela Harris pharris@medicalnewsinc.com CREATIVE DIRECTOR Susan Graham susan@medicalnewsinc.com 931.438.8771 GRAPHIC DESIGNERS Katy Barrett-Alley Amy Gomoljak Liz Loewenstein CONTRIBUTING WRITERS Suzanne Boyd Lynne Jeter Judy Otto Cindy Sanders CIRCULATION subscriptions@southcomm.com —— All editorial submissions and press releases should be emailed to: westtneditor@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

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GrandRounds The Jackson Clinic Announces Addition of Convenient Care Physician JACKSON - The Jackson Clinic recently added Dr. John Guidi to their Convenient Care Department. Dr. Guidi joins Dr. Sharon D. Hopkins, Dr. Benny C. Houston, Dr. Chris L. Lewis, Dr. Dr. John Guidi Jim McCauley, Dr. Luis Pagoago, Dr. Joseph L. Ragon, Dr. Amanda M. Reiter, Dr. Maryanne T. Rodriguez and Dr. Rosilin K. Wright. Convenient Care is located on the Highway 45 Bypass.

Dr. Guidi received a Bachelor’s Degree from Rhodes College in Memphis, Tenn. He received his Doctor of Medicine from the University of Tennessee College of Medicine. Dr. Guidi completed his Residency at the University of Tennessee Family Practice Program, JMCGH in Jackson. Dr. Guidi is Board Certified, American Board of Family Practice.

West Tennessee Healthcare Welcomes New Vice President JACKSON – West Tennessee Healthcare is excited to announce the addition of Darrell King as its new Vice President.

Darrell King began his new role as Vice President, West Tennessee Medical Group, with the organization in December.

Darrell King A native of Jackson, Tennessee, King has 25 years of experience managing large multispecialty practices. He most recently served as Chief Executive Officer for NEA Baptist Clinic in Jonesboro, Arkansas and Executive Director for the Arkansas division of Baptist Medical Group in Memphis, Tennessee.

Throughout his career, King has been active in leadership and community organizations across Arkansas and Tennessee. He is a 1991 graduate of Leadership Jackson. He has served on the Board of Directors for the Jonesboro Chamber of Commerce, the Chancellor’s Cabinet at Arkansas State University and the Physician and Hospital Advisory Council for U.S. Representative for Arkansas Rick Crawford.

As Vice President, West Tennessee Medical Group, King will provide administrative oversight of the West Tennessee Medical Group consisting of approximately 80 providers providing services in 15 outpatient clinics, 6 inpatient/surgical service lines, and 4 hospitalist practices.

King has a Bachelor of Business Administration in Finance from the University of Tennessee-Knoxville and a Master of Business Administration from Union University. westtnmedicalnews

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Tennova Healthcare-Regional Jackson Supports Local Charities JACKSON – Tennova Healthcare-Regional Jackson celebrated the holiday season with the 2015 Parade of Trees. Local healthcare clinics, physicians, and wives donated their time and attention to make the holiday season brighter for the Jackson community.

There were 9 beautifully decorated Christmas trees spread across the city. The trees were decorated by members of Tennova-Regional Jacksons medical community and were auctioned to raise money for local non-profit organizations according to Catherine Miller, chair of the event and wife of Tennova-Regional Jackson CEO Charles Miller.

The total raised from the silent auction of the trees was $6,725 said Ms. Miller.

The decorated and auctioned trees benefitted these local charities: Ballet Arts of Jackson, Mainely Dogs, Youth Town-Eden Center, the Dream Center, RIFA, Carl Perkins Center for the Prevention of Child Abuse, Boys & Girls Club, Veterans Home, and the Jackson Police Department’s K-9 Unit.

Dr. and Mrs. Bourji present a donation to Sheriff John Mehr for the Jackson Police Department’s K-9 Unit. Sheriff Mehr accepted on behalf of Jackson Police Chief Wiser.

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