Beacon Health System Physician Quarterly - Fall 2015

BEACON WELCOMES

Shelly Harkins, M.D., Chief Medical OďŹƒcer

Fall 2015

PHYSICIAN Q UA R T E R LY

Hospital Provider Engagement

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COVER STORY: What Makes a Physician Leader?

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Welcome, New Docs

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Advances in Intracranial Stereotactic Radiosurgery

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TABLE OF CONTENTS E D I T ORI A L BOARD Ken Elek, M.D., Chief Medical Information Officer, Memorial Hospital Scott Eshowsky, M.D., Chief Medical Information Officer, Beacon Medical Group Shelly Harkins, M.D., Chief Medical Officer, Beacon Health System Vince Henderson, M.D., Chair, Physicians Governance Council, Beacon Medical Group Genevieve Lankowicz, M.D., Vice President, Medical Staff Affairs, Elkhart General Hospital D. Thomas Mellin, M.D., Chief Medical Information Officer, Elkhart General Hospital Dale Patterson, M.D., Director, Memorial Family Medicine Residency Program Cheryl Wibbens, M.D., Vice President, Medical Staff Affairs, Memorial Hospital

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Why Cost and Quality Matter in Health Care Hospital Provider Engagement What Makes A Physician Leader?

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Beacon Support Groups

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Beacon Bulletin

Welcome, New Docs Continuing Medical Education the Record: Protocols 10 For vs. Order Sets. Do You Know the Difference?

Physician Quarterly is published by Beacon Health System to connect and educate physicians and health care professionals in support of clinical integration, graceful patient transitions and improved quality and safety.

Contact Us

Do you have a story idea? Contact us at MScroope@BeaconHealthSystem.org or call 574.647.3234.

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A Physician’s Life: Diving Right In

One Year of 12 Celebrating Innovative Heart Procedure in Intracranial 13 Advances Stereotactic Radiosurgery Family Medicine 14 Memorial Residency Update Children’s Hospital 1 5 Memorial Symposium 2015 16 Get In the Game

Why Cost and Quality Matter in Health Care Most of us in the health care industry understand that we work in one of the most dynamic and fast-paced industries in our economy. This is especially true since the passage of the Affordable Care Act in 2010. Among other things, this legislation changed many long-held beliefs regarding reimbursement for care and created Accountable Care Organizations.

All Beacon Health System entities and The Medical Foundation are a part of the CHA ACO. As an Accountable Care Organization, data analytics and increased collaboration among providers are used to achieve these goals for our Medicare beneficiaries: • Improving the quality of care • Reducing the cost of providing care • Improving patient health and experience One of the most common questions that the CHA ACO staff receives from ACO participants and non-participants is: Why should providers worry about the cost and quality information that we provide?

The answer is precisely because of the accelerating change in the health care industry.

Even if ACOs are not the ultimate answer to how to change incentives and produce higherquality, lower-cost care, the move toward value-based reimbursement is quickly changing how providers need to think about health care.

Value-based reimbursement is not limited to ACOs. Almost every major insurance company has joined the Centers for Medicare and Medicaid Services (CMS) in establishing a goal of increasing the scope of their reimbursement that is tied to quality improvement and cost reduction.

Establishing a mindset that focuses on cost and quality will allow us to succeed in the future with whatever value-based reimbursement model our payors decide to implement.

The move to value-based reimbursement is happening. Currently, most of these programs are voluntary. However, the question is whether we will be ready for the time that a focus on quality and cost reduction becomes a requirement to compete in health care.

by Daniel T. Parker, ACO Manager CHA ACO, LLC Beacon Health System

Focus on Quality Eight of the 2015 ACO quality measures focus on preventive care. Two of these preventive measures are presented here: PREV-9 BMI Screening & Follow-Up For all patients older than 18, a BMI must be documented in the Medical Record.

CMS defines the normal BMI range to be: • (age 18-64) BMI = 18.5-25 • (age 65+) BMI = 23-30 If documented BMI is outside of the normal range, there must be documentation in the Encounter notes of a follow-up plan, such as nutritional/exercise counseling, referral to weight loss specialist, etc.

PREV-11 Blood Pressure Screening & Follow-Up For all patients older than 18, a blood pressure must be documented in the medical record.

CMS defines the normal BP range to be: <120 systolic AND <80 diastolic.

If documented BP is outside of the normal range, there must be documentation in the Encounter notes of a follow-up plan, such as nutritional/exercise counseling or follow-up screening.

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Hospital Provider Engagement

In March 2015, Beacon Health System conducted an online engagement survey among active medical staff (allied health professionals as well as physicians) at both Elkhart General Hospital and Memorial Hospital.

Invitations were emailed to 819 providers (269 to Elkhart General providers and 550 to Memorial providers). Of that number, 276 individuals responded, yielding a response rate of 34 percent (49 percent at Elkhart General and 26 percent at Memorial). Elkhart General conducted an initial survey during the spring of 2013 so the 2015 data is an update; this was the first year for the study at Memorial.

Beacon partnered with Press Ganey to conduct the survey. Press Ganeyâ&#x20AC;&#x2DC;s benchmark draws upon a database of over 1,300 health care facilities and 48,000 physicians.

OVERALL PROVIDER ENGAGEMENT SCORES*

5.0

2013

100

2015

5.0

90

90

80 4.5

79%

4.5

3.5

ELKHART GENERAL PROVIDERS

42% 40

4.07

4.0

30 3.5 20 10

3.0

0 NATIONAL AVERAGE (OUT OF 5)

3.0 PERCENTILE

* Special thanks to Ginny Kevorkian, MBA, PRC, Manager of Market Research and Planning at Beacon Health System, for her help in assembling this report.

Physician Quarterly | Fall 2015

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50 40 30 20 10 0

The engagement score for Elkhart General Hospital providers improved between 2013 and 2015.

Engagement for Memorial Hospital providers ranks close to the top 20 percent.

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54% MEMORIAL HOSPITAL PROVIDERS

50

ELKHART GENERAL PROVIDERS

4.06

80

60

4.11

NATIONAL AVERAGE

4.08

4.31 AVERAGE (OUT OF 5)

4.0

NATIONAL AVERAGE

AVERAGE (OUT OF 5)

70 60

100

TOP STRENGTHS AS IDENTIFIED BY PROVIDERS Areas in which Beacon is significantly above the national average

Elkhart General Hospital

Memorial Hospital

Resources

Resources

• Availability of beds (score 4.04, .55 above the national average)

• Availability of beds (score 4.2, .71 above the national average)

• Effective methods of communication with physicians (score 3.95, .35 above the national average)

• Ease of registration for patients (score 4.07, .57 above the national average)

Development

System Leadership

• Availability of education (CME) (score 4.17, .53 above the national average)

• Overall performance of Beacon Health System administration (score 3.92, .45 above the national average)

Hospital Leadership

Hospital Leadership

• Overall performance of hospital administration (score 3.82, .35 above the national average)

• Overall performance of hospital administration (score 3.92, .45 above the national average)

Teamwork

Operating Room

• Teamwork between physicians and nurses (score 4.44, .34 above the national average)

• Supplies and up-to-date equipment (score 4.19, .43 above the national average)

OPPORTUNITIES FOR IMPROVEMENT Elkhart General Hospital

Memorial Hospital

Resources

Resources

• Adequate IT support (score 3.22, .46 below the national average)

• Adequate IT support (score 3.33, .35 below the national average)

Laboratory Services

• Appearance and cleanliness of patient care areas (score 3.81, .04 below the national average)

• Timeliness of obtaining results (score 3.69, .35 below the national average) • Overall performance of laboratory services (score 3.78, .28 below the national average) • Accuracy of results (score 3.87, .27 below the national average) Operating room • Scheduling process for ORs (score 3.46, .20 below the national average, NOT significantly different from the national average)

• Efficiency of the EMR (score 2.99, .02 below the national average) Teamwork • Departments work well together (score 3.72, .07 below the national average) Quality • Effort to deliver safe, error-free care to patients (score 4.18, .03 below the national average)

NEXT STEPS Genevieve Lankowicz, M.D., CPE, Vice President of Medical Staff Affairs at Elkhart General, and Cheryl Wibbens, M.D., Vice President of Medical Staff Affairs at Memorial, are continuing to collect departmentlevel feedback. Action plans will be implemented to address concerns brought forward through the survey.

A huge “Thank You” to all providers who participated and offered feedback!

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What Makes a Physician Leader?

For Shelly Harkins, M.D., it includes a passion for science, good advice from Dad, and the magic behind a pair of horn-rimmed glasses.

Dr. Harkins began her new role as Chief Medical Officer of Beacon Health System in late August. Although the job title is new for Beacon, she recently served in the same capacity at St. Elizabeth’s Hospital in Belleville, Illinois.

Dr. Harkins will be meeting with many physicians on Beacon’s medical staff over the coming months. Physician Quarterly caught up with her just before her first day in the office.

[PQ]

What was your personal motivation or inspiration to become a physician?

[SH] I have heard so many eloquent stories from physicians over the years describing the defining moment they made the decision to become a doc. Most have at least an event of some sort that inspired them to begin their journey. I’m not able to name an event or tell a moving story. For me, I liked the sciences in high school, namely Biology, and so in college I chose a science major.

At NC State, life science students were lumped into two categories: plants (aka Botany) or animals (aka Zoology-Premed).

We had a world-class Veterinary school and it was assumed that if you came to NC State and liked animal science, you must want to be a vet. I chose State because of a cute guy. I never wanted to be a veterinarian — sick or injured animals break my heart in a way that makes me somewhat dysfunctional. But I liked the “pre-med” label. So as I approached my last year, there was only one thing to do to make that label meaningful but not go to Vet school, and that was to take the MCATS and try to get a seat in medical school. And here I am. I never looked back.

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Physician Quarterly | Fall 2015

[PQ] Do you have a personal credo or philosophy that guides you in your work?

[SH] There are three that come to mind

right away because I refer to them so often.

The first is, “Shoot for the moon, at least you will land among the stars…” I really love this and it applies to everything you do — your fitness goals, your parenting efforts, or hospital core measures.

The other two are from my dear father who has been the most important person in my life. He told me once that life is like a frequency line (I remember he drew a line with peaks and troughs across the page as he said it). He then drew a straight line right through the middle (the zero line, if you will) and said, “This is normal. It’s where you live most of your life — right here at just average emotions, average day, average happenings.”

“To be successful,” he explained, “you must never make important life decisions when you are here (he pointed to a peak) or here (he pointed to a trough). “For those important decisions,” he continued, “and you’ll know what those are, you must wait to decide when you are back here (he pointed to the zero line again).” The lesson has been strikingly relevant at every phase of my life and has saved me a few times.

Lastly, and also from my Dad, is the “squirrel in the road” analogy. He explained that when at a crossroad, a direction must be chosen and you have to go for it all out.

Never waffle back and forth trying to pick a side of the road for too long — you’ll just get run over. And those squirrels do that, don’t they? They dart back and forth as your car gets closer and closer. When I’ve seen a dead squirrel on the road, I’ve caught myself saying out loud, “You should have picked a direction and just gone, buddy.”

[PQ]

For Beacon, the role of Chief Medical Officer is new. How would you describe your position and what will be your top priorities as you begin?

[SH] I’m the physician perspective and

voice at the tables where decisions about how we will be successful in becoming the system delivering the highest value health care in the nation are made (that’s the shoot-for-themoon thing).

My top priority in the first weeks is to understand the health care market from every stakeholder’s perspective: the docs, the patients, the colleagues and the community.

Then, along with the whole Beacon team and what we’ve learned, develop a wellarticulated direction. We then clear the barriers and provide a smooth line of sight for our frontline leaders to see that vision become a reality.

[PQ] What do you find interesting

or challenging about being a Chief Medical Officer?

[SH] The changing landscape of health

care in America and the dynamics of the hundreds of moving parts gets my blood pumping. I could talk for hours about ideas and projections, the excitement of it all, the tragedy of it all, the possibilities — it’s a passion and I never tire of it. It is a God-given gift to love it all this much and it’s why I’m called to do this.

The most challenging part of being a physician leader is wanting to see that same excitement in our docs, but instead seeing frustration or a sense of loss. And more than just seeing it, I completely understand it.

Being a physician is a remarkably honorable career path and should be fulfilling and deeply meaningful, but for so many it’s just

not anymore. Finding a way, any way at all, to help a physician love his or her role and embrace it again with joy and pride is my most important job — and, without doubt, the most challenging.

[PQ] How will you know when you’re successful in the CMO role at Beacon?

[SH] Knowing myself, I doubt the day

will ever come when I sit back and consider myself successful in this role. There is always more to do, always something to improve, always someone more to inspire and help, and always failures and setbacks to learn from. Ultimately, success in health care leadership shows in the lives of those we serve.

[PQ]

In your bio information, it mentions that you served two medical missions while in the Air Force — would you care to share any details about those or how they may have influenced you?

[SH] I served two missions to the remote

mountain regions of Guatemala. We hiked over creeks and up cliffs with backpacks and loaded-up gurneys to carry supplies and equipment to villages in need — staging stations, we called them. They were typically in the center of a large region of villages for accessibility to as many as possible.

The people would begin to show up early each morning after walking or traveling all night on foot. They walked at night to avoid the heat and many carried their children.

They waited in lines of hundreds to see an American doctor. They wore their best clothes, which were usually still soiled and tattered. It certainly made me appreciate the little things we take for granted every day.

There was one little girl, maybe 7 or 8 years old. She couldn’t see well. We did our

rudimentary assessment of her visual acuity with an eye chart and fitted her with a pair of glasses. Unfortunately, the only pair we had in her prescription was a donated pair from our collection. They were those classic, 1950s horn-rimmed spectacles. I remember thinking she would hate them. But she was the most excited little girl on the planet. She could see the other side of the room now.

And her life was instantly higher quality.

She thought those glasses, which were way too big for her face and would look like a costume farce here in America, were the best thing that had ever happened to her. And her parents hugged us. That was humbling — both to see that the little joys escape us so often, but also to know that I brought with me the assumption that she would think those glasses were ugly and feel embarrassed. It makes me tearful to remember her face and that smile. I hope I never forget it.

[PQ] What helps you achieve work-life balance?

[SH] I have only one thing to say about

work-life balance and it was a hard reality to swallow. YOU cannot determine whether or not you have work-life balance. What YOU think does not matter. Only your family can determine if the balance is there. I always felt I had stellar work-life balance. I loved my work and felt I didn’t miss anything at home, either. In this age of iPhones and WiFi, it’s too easy to never turn off work. And though you may absolutely love your life and want nothing to change about it, if your spouse or your children don’t see the balance, you simply don’t have it — no matter how happy you think you are. And you can bet things will change — one way or the other. So go ask your family….and then make sure you do what you have to do.

Shelly Harkins, M.D. Chief Medical Officer Beacon Health System Dr. Harkins works with the executive leadership team and medical leaders at Elkhart General Hospital, Memorial Hospital, Memorial Children’s Hospital, Beacon Medical Group and Beacon Health Ventures, which includes Beacon Home Care.

Dr. Harkins was previously Chief Medical Officer at St. Elizabeth’s Hospital in Belleville, Illinois. She also served as Regional Medical Director of TIP Hospice, also in Belleville.

Prior to those roles, Dr. Harkins was as an Active Duty Faculty Attending Physician and Assistant Professor at Scott Air Force Base Family Medicine Residency Program. She served two medical missions and earned the United States Air Force Meritorious Service Medal and the Achievement Medal.

Dr. Harkins earned her medical degree from Brody School of Medicine, East Carolina University in Greenville, North Carolina; she received her master’s degree in Healthcare Administration from Saint Louis University in St. Louis, Missouri.

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Beacon Support Groups Memorial Weight Loss and Bariatric Surgery Center Surgical Support Group Pre- and post-op question and answer, education and support for bariatric patients.

6 p.m., third Tuesday of the month Bariatric clinic waiting room, 6913 N. Main St., Granger Contact: 574.647.6400

When: Where:

Elkhart General Bariatric and Metabolic Institute Post-Bariatric Surgery Support Group Open to anyone who has had bariatric surgery or considering bariatric surgery; speak with medical experts and share experiences.

When:

5 p.m., first Tuesday of the month (changes to first Monday starting January 2016)

Below is a sampling of support groups available to patients throughout the health system.

Prenatal Classroom in the West Wing Contact: 574.523.3264

Where:

Memorial Regional Cancer Center Patients (current and former) and caregivers are welcome to learn about different methods to help improve wellness.

5 to 6:30 p.m., second Monday of the month Where: Memorial Regional Cancer Center, Day Road, 301 E. Day Road, Mishawaka Contact: 574.647.1100

When:

Elkhart General Diabetes Support Group Participants discuss healthy habits and nutrition, establish long-term goals and make lifestyle changes to self-manage their disease.

6 to 7 p.m., first Thursday of the month (except July and August) Where: Elevator B, 2nd Floor, left turn out of the elevator, Room 2214, Diabetes Classroom Contact: 574.523.3297

When:

Healthy Diabetics/Diabéticos Saludables Through diabetes support and education, support with medication management, access to community resources and care providers and with social support, clients learn how to self-manage their diabetes.

10 a.m. and 5 p.m. alternating English/Spanish every Monday Where: Leighton Center, 534 N. Michigan St., South Bend Contact: 574.647.1359

When:

BEACON HEALTH SYSTEM Welcomes New Docs (April – June 2015) CARDIOLOGY Rishi Sukhija, M.D.

HEMATOLOGY/ONCOLOGY Rashid Khan, M.D.

PODIATRY/FOOT AND ANKLE SURGERY Corey Groh, DPM

DENTISTRY/PEDIATRIC Lauren Mummert, DDS

HOSPITAL MEDICINE Marlon Brathwaite, M.D. (Pediatrics)

PULMONOLOGY Diego Heredia, M.D.

DERMATOLOGIC SURGERY Luiz Pantalena, M.D., Ph.D. EMERGENCY MEDICINE Erin Clark, M.D. Kyle English, M.D.

RADIOLOGY/DIAGNOSTIC Nicholas Abel, M.D. Kyle Brock, M.D.

OPHTHALMOLOGY Drew Davis, M.D.

RADIOLOGY/TELERADIOLOGY Simon Abramson, M.D. Alexander Oshmyansky, M.D.

PATHOLOGY/ANATOMIC AND CLINICAL Shadia Alam, M.D. Erica Martin, M.D.

RADIOLOGY/VASCULAR & INTERVENTIONAL Kelly Mortell, M.D.

FELLOWS – BEACON MEDICAL GROUP E. BLAIR WARNER Michael Kozak, M.D. James Norman, M.D.

PEDIATRIC HEMATOLOGY-ONCOLOGY Michael Ferguson, M.D.

SURGERY/NEUROLOGICAL Neal Patel, M.D.

GENERAL SURGERY Ziad Fayad, M.D.

PHYSICAL MEDICINE AND REHABILITATION Amrita De Patel, M.D. Paul Smucker, M.D

FAMILY MEDICINE Robert Hays, M.D. Brian Huber, M.D. Thomas Larsen, M.D.

GYNECOLOGIC ONCOLOGY Nonyem Onujiogu, M.D.

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NEPHROLOGY Despina Hoffman, D.O. Christiane Mbianda, M.D.

Physician Quarterly | Fall 2015

PEDIATRICS Julie Mark, M.D.

For more information about the new physicians, check out either EGH.org or QualityOfLife.org.

Beacon Breaks Ground on New Fitness Center

Beacon Health System recently broke ground on a second location of the Memorial Health & Lifestyle Center.

Tentatively named Beacon Health & Fitness, the $15 million facility will be located in Mishawaka on the new Beacon Parkway off Capital Avenue and Exit 83 of the Indiana Toll Road.

The 74,000-square-foot fitness center will include a full-service fitness facility, sports medicine, physical therapy and a sports performance clinic. This facility is projected to open in summer of 2016.

BMG Portage Relocating

Construction crews broke ground on a new 20,469-square-foot medical facility on five acres of land on Cleveland Road in South Bend. Upon its completion, slated for August 1, 2016, the new facility will replace the current Beacon Medical Group Portage Road office.

The new facility will offer medical care to patients of all ages, including family medicine and podiatry services, and will be equipped with digital radiology services, EKG capabilities, and an onsite lab. It will also include a MedPoint Urgent Care clinic.

National Award Given for Collaboration Among Indiana CMEs

Thanks to the cooperative and innovative work of Continuing Medical Education providers from around Indiana, including at Elkhart General and Memorial Hospital, the Indiana State Medical Association (ISMA) was given the 2015 Rutledge W. Howard, M.D. Award for Outstanding Collaboration between Accreditors and Providers. The Accreditation Council for Continuing Medical Education recognized the ISMA for the work Continuing Medical Education providers in Indiana did to standardize forms and documents to ensure compliance among all providers.

“CME providers came together across the state to bring about continuity and ensure compliance. I was proud to be part of such a collaborative statewide effort,” says Ranae Obregon, CHCP, Manager, Elkhart General Medical Staff Services.

Vein Clinic Opening

Beacon Medical Group Vein Specialists will open at 233 Florence Avenue in Granger in October. The team provides total vein care for venous insufficiency/ varicose veins by using state-of-the-art

technologies and treatments including venous laser ablation, ultrasound guided sclerotherapy and surface vein sclerotherapy. The BMG Vein Specialists is led by Thomas Fischbach, M.D., and Kelly Mortell, M.D. To schedule a consultation, call 574.647.3990.

Elkhart General and Memorial Hospital Recognized

In U.S. News & World Report’s “Best Hospitals” rankings, Elkhart General Hospital (EGH) was recognized regionally as the #4 ranked hospital in Indiana.

Elkhart General was also rated “High Performing” in heart bypass surgery and knee replacement services. Both EGH and Memorial Hospital were also rated “High Performing” in heart failure services.

For the report, U.S. News analyzed more than 5,000 adult and pediatric hospitals to find the best in the nation based on critical criteria and patient outcomes.

The Medical Foundation Announces Leadership Changes

In June, The Medical Foundation board voted in Joyce Simpson, M.D., as President, replacing Robert Tomec, M.D., who retired after 35 years.

Dr. Simpson joined The Medical Foundation staff in 2007 and most recently served as Executive Vice President. She is a graduate of Indiana Un iversit y Scho ol of Med ici ne, completing her residency at Methodist Hospital of Indiana. She has a fellowship in surgical pathology and is certified in anatomic and clinical pathology and cytopathology.

Also, Amobi Ezenekwe, M.D., was named The Medical Foundation’s Executive Vice President, replacing Dr. Simpson. Dr. Ezenekwe, who joined the organization in 2005 as a staff pathologist, is a graduate of the University of Nigeria College of Medicine in Enugu-State, Nigeria. He completed his pathology residency and his fellowship in hematopathology at St. Louis University School of Medicine in Saint Louis, Missouri. He is certified in anatomic and clinical pathology by the American Board of Pathology.

CONTINUING

MEDICAL EDUCATION Memorial Hospital of South Bend Hospital Auditorium (unless otherwise noted)

12:10 to 1:10 p.m.

Lunch available at 11:30 a.m.

Registration is not required.

Call 574.647.7381 with questions.

October 14 Christine Carter, Ph.D. Mary Morris Leighton Lecture –

“Helping Others Find Their Sweet Spot”

A sociologist and happiness expert at UC Berkeley’s Greater Good Science Center, Dr. Carter is the author of The Sweet Spot: How to Find Your Groove at Home and Work.

October 28 Mark Toth, M.D. & Marjorie Daoud, M.D.

Is It Really a UTI? Does Every UTI Need Treatment?

November 6 Kirby R. Gross, COL, MC US Army M.D., FACS, Director, Joint Trauma System, U.S. Army Institute of Surgical Research, San Antonio, TX

Trauma Grand Rounds – The DoD Deployed Trauma Experience: A Learning System

November 11 Thomas Akre, D.O.

Innovations in Total Hip Replacement: Anterior Minimally Invasive Surgery

December 9 Luke White, D.O.

Patient-Directed Resuscitation: Beyond CPR and Epinephrine

December 17 Vicente Gonzaga, M.D.

Pediatric Ground Rounds: Adolescent Suicide and SelfHarming Behaviors 12:30 to 1:30 p.m.; lunch available at noon

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For the Record: Protocols vs.

Order Sets Do You Know the Difference?

Article submitted by: Kreg Gruber, Chief Operating Officer, Beacon Health System Michelle Howe, M.D. Beacon Medical Group Elkhart East

Let’s be honest — health care can be a confusing and complex profession. We don’t help ourselves when we apply three letters or more to describe almost every condition, situation or program: CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease) and ACO (Accountable Care Organization). And, when all else fails, we combine the letters with some numbers: ICD-10 (International Classification of Diseases, Revision 10).

Along the same lines, we like to adapt existing terms for new uses. Today, for example, the word “protocol” gets thrown around a lot when it comes to talking about what is the best or most effective care of the patient. A newer term — “order set” — also gets a lot of discussion these days as we figure out how to program what we want to have done into the computer, so when we push some buttons, the right thing happens for our patients. The

fewer buttons that get pushed, the better, thus “order sets.”

Now, these two terms — protocols and order sets — are often confused and interchanged inappropriately.

Let’s set the record straight and define the two and why they matter.

Protocols: Setting the Standard A protocol is more simply defined as local standardization of a conglomeration of guidelines that will structure care for a disease state. There are guidelines published by multiple societies covering different aspects of the same disease — take diabetes, for example. CMS has guidelines for postsurgical care inpatient (including glucose management); the American Diabetes Association has guidelines for diabetic care inpatient and outpatient; the American Academy of Clinical Endocrinologists has guidelines for diabetic care; and there

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are guidelines for seeking accreditations for centers of excellence, etc.

A protocol will take the parts of these guidelines that are applicable to local patients, providers and sites and place them into a concise document.

That document will contain algorithms, information that will structure clinical decision making, and tools to aid in operational processes. The protocol should be detailed enough to prevent any ambiguity on what would be considered best practice but still allow for providers to understand where a patient may have an exception to the protocol.

Order Sets: Best Practices for Treatment Within the protocol there are order sets. Order sets are a subset of the protocol. An order set should be simple and written so that the default setting for the order is what the protocol would want to have happen for

90 percent of the cases. There may be many order sets for one protocol to help with myriad exceptions that come with caring for a complex disease.

But once the main parameters are known — for example, diabetic, postsurgical, TPN vs. diabetic, ICU, NPO — the order set should be streamlined for all patients. Exceptions to the orders should be just that — exceptions — and not the rule.

Bonus Round: Policies Also, within the order set there may be reference to a “policy.”

Policies are a layer of standards with staff enforcement that requires staff/hospital committee voting to alter; they also have a longer review process. Protocols are usually easier to revise and fall under a steering committee that can meet when deemed necessary; they have a regular, scheduled review process to keep them updated.

A PHYSICIAN’S LIFE:

Diving Right In Physician from Beacon Medical Group LaPorte makes waves with his volunteer work.

Dr. Farrow empties the last of the restaurant-grade food for his finned charges just before getting photobombed by a hogfish.

Spending an afternoon gazing through the glass at hundreds of tropical fish in the Caribbean Reef exhibit at Chicago’s Shedd Aquarium is relaxing for most people. But family physician Freeman Farrow, M.D., J.D., FAAFP, knows firsthand that the view is a whole lot better from inside the exhibit.

As a volunteer diver at the Shedd, Dr. Farrow suits up one Sunday each month to help feed and clean up after the 500 or so animals found in the 90,000-gallon tank. Lured by the thrill of deep-sea diving when he was just 14, the Detroit native became hooked by the idea of volunteering at the aquarium in 2011 after a behind-the-scenes tour of the facility.

And while many landlubbers would fear getting nipped by a resident bonnethead shark or moray eel (equipped with not one, but two sets of toothy jaws), Dr. Farrow says divers use special

feeding techniques to condition certain animals to not associate one’s hands with food. Set feeding times and a long pole are the keys to successfully avoiding a mishap.

Certified at the rescue diver level and having logged more than 500 dives, Dr. Farrow admits that diving at the aquarium is a stress reliever — 20 minutes at a time doesn’t seem like long enough for him or his fellow divers: “Occasionally, we have to call each other out of the exhibit!”

And how does his volunteer work jibe with being a physician?

Swimmingly.

“Diving helps my outlook on the world — I feel I’m a caring person with my patients and that transfers into my caring for the animals and the ocean,” Dr. Farrow explains. Helping others develop compassion for wildlife is one of his personal missions.

“One of the things I try to do is to make sure I wave at all the little kids who are watching when I’m diving in the exhibit,” he says. “They may not remember me, but they may remember the experience, and it may help them become adults who learn to conserve and protect the environment. Then I’ve done my job.”

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CELEBRATING ONE YEAR OF INNOVATIVE HEART PROCED U R E

Elkhart General Hospital is nearing the one-year mark of the Transcatheter Aortic Valve Replacement (TAVR) program, a successful minimally invasive surgical approach that will grow in the years to come.

The TAVR procedure provides a valve replacement option to patients who are too high risk for traditional open aortic valve surgery. Patients with severe aortic stenosis receive a new valve using a less invasive approach. The approach varies with patient anatomy and includes transfemoral, transaortic and transapical. The TAVR team at Elkhart General is led by cardiologist Jagdeep Sabharwal, M.D., FACC, FSCAI and cardiothoracic surgeon Walter Halloran, M.D., FACS.

Elkhart General is the only hospital in the region performing TAVR Potential TAVR patients undergo extensive testing to determine their eligibility for this new procedure. All candidates must have a recent echocardiogram, heart catheterization, TEE, CTA of the abdomen and pelvis and gated CTA of the chest. Following this workup, patients see two cardiothoracic surgeons in consult to ensure that they are truly ineligible for standard valve surgery.

Elkhart General’s TAVR program adheres to CMS guidelines to determine that a patient is a candidate for this procedure. All patients must meet the following criteria: • Ejection fraction ≥20 percent • Aortic valve area <1 cm² squared or aortic valve index <0.6 cm² /m² • Mean aortic gradient >40 or peak jet velocity >4.0m/s • STS score > or equal to 8 percent • Frailty index of 2 or greater • Two cardiothoracic surgeons who deem the patient to be inoperable or high risk for standard open surgery

Patients Give High Marks Patients throughout northern Indiana, including Goshen, Mishawaka, South Bend, LaPorte, Bourbon, Plymouth and Michigan City, have come to Elkhart General for the TAVR procedure. The average patient age is about 85.

As part of screening, each patient is asked why he/she wants to have this surgery, and, without fail, each person cites something he/she wants to live for. A 92-year-old woman wanted to attend the weddings of several grandchildren across the country, which she has since done. In another case, a man with myelodysplastic anemia disorder wanted his valve fixed so he could “merely fight cancer.” Another woman responded, “I just want to go to the store to shop without getting so short of breath.”

The TAVR patients at Elkhart General have included a dialysis patient and a woman with severe COPD on home oxygen. The day after surgery, both of these very sick ladies reported, “I could tell last night in bed after surgery that I can breathe now.”

TAVR patients are followed by the TVT registry. Once patients leave the hospital, they are seen by the CTS and cardiology office at two weeks and one month respectively. At their one-month visit, patients complete blood work along with an echo and EKG. The same testing is repeated at a one-year follow-up per the CMS registry.

Questions about the TAVR procedure or patient referrals? Contact TAVR coordinator Mary Miller at 574.389.4889 or Memiller3@ BeaconHealthSystem.org.

Mary Miller, R.N., BSN TAVR Coordinator

TAVR Lunch and Learn Presented by Drs. Halloran and Sabharwal ALL STAFF ARE INVITED TO ATTEND

WEDNESDAY, OCTOBER 21 | NOON AUDITORIUM B – ELKHART GENERAL WEST WING Walter Halloran, M.D., FACS Cardiothoracic Surgery

Jagdeep Sabharwal, M.D., FACC, FSCAI Cardiovascular Medicine

12 PhysicianQuarterly Quarterly| |Vol. FallI,2015 12 Physician Issue I

For more information, contact: Mary Miller, R.N., BSN Elkhart General TAVR/CardioMEMS Coordinator 574.389.4889 or Memiller3@BeaconHealthSystem.org

Advances in Intracranial Stereotactic Radiosurgery

Physicist Daniel Archambeault and chief radiation therapist Jodi Dauby prepare a patient for stereotactic treatment using the AlignRT® SRS module.

Neurosurgeon Dr. Robert Yount (L) discusses a recent stereotactic plan with radiation oncologist Dr. Samuel McGrath (R).

Article submitted by: Samuel McGrath, M.D., Radiation Oncologist, and David Hornback, M.D., Radiation Oncologist, Memorial Regional Cancer Center

Memorial Offers Frameless SRS Option Stereotactic radiosurgery (SRS) is a radiation therapy delivery technique in which multiple beams converge onto a small intracranial target, depositing a high dose of localized radiation within a small volume. Radiation beams are delivered either via a Gamma Knife®, a dedicated radiosurgical unit using gamma radiation from multiple cobalt sources, or a conventional medical linear accelerator specially adapted with circular collimators of varying diameter as employed at the Memorial Regional Cancer Center (MRCC). Current applications include treatment of brain metastases, acoustic neuromas, arteriovenous malformations, pituitary adenomas and even recurrent gliomas.

Historically, a neurosurgeon affixed a stereotactic frame to the patient’s skull under local anesthesia until completion of the radiation treatment. Frame placement is critical in this process as it provides a relationship between the patient’s intracranial anatomy and the coordinate system employed for target localization.

Recently, MRCC transitioned to the AlignRT® SRS module. This frameless system utilizes optical surface tracking capabilities, allowing for the real-time assessment of facial movement during treatment with preset movement thresholds that trigger automatic beam interruption.

The open-faced, plastic mask used with this system is much more comfortable for the patient compared to a rigid frame

and facilitates facial recognition needed for target tracking.

Patients initially undergo a CT-based simulation with the mask in place.

These images are in turn fused with a thin-slice planning MRI. The radiation oncologist and neurosurgeon contour the target and normal surrounding critical tissue structures. The resulting treatment plan is subjected to exhaustive quality assurance prior to delivery. Treatment generally takes 30 minutes, after which time the patient is discharged home.

Eligibility for radiosurgical treatment is predicated upon the geometry of the target lesion. This treatment is best suited for spherical lesions under 4 cm in size. Selection of radiation dose is contingent upon the size of the lesion and biology of the tumor. Larger targets result in irradiation of more normal brain tissue, thus a lower dose is utilized.

Treatment can be administered as either initial therapy or as a salvage option in the setting of prior conventionally fractionated radiation treatment.

For those patients eligible for radiosurgical treatment, the advantages are numerous. Radiosurgery is extremely accurate, with dose being deposited with submillimeter precision. This optimally spares the normal surrounding neurologic tissue, resulting in less acute and chronic toxicity. This treatment approach circumvents the need for surgical removal of the lesion, offering up a much

Neurosurgeon Dr. Neal Patel (L) and radiation oncologist Dr. David Hornback (R) review Memorial’s new Vision RT guidance technology.

less invasive therapeutic alternative.

Radiosurgery is administered in a single fraction, replacing a standard three- to six-week treatment course, allowing patients the option to start additional treatment such as chemotherapy sooner.

Finally, the single large dose of radiation is advantageous radiobiologically, allowing less tumor cells to survive the initial radiation insult and in turn increasing the efficacy of treatment.

With over 100 cases treated to date, Memorial Regional Cancer Center is pleased to offer the region’s most robust, and only frameless, intracranial stereotactic radiosurgical program.

Working in close collaboration with the neurosurgeons from Beacon Medical Group North Central Neurosurgery South Bend, we are proud to offer this very precise and sophisticated treatment option to our community, delivering the highest quality of care close to home.

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Congratulations to Our 2015 Residency Graduates!

(L-R) Robert Westbrook, M.D.; Dane Schlinsky, M.D.; Jenna Ruple, M.D.; Ryan Ross, M.D.; James Norman, M.D.; Michael Kozak, M.D.; Julia Bisschops, M.D.; Stephen Harmon, M.D.; Thomas Larsen, M.D., Ph.D.; Matthew DuPre, M.D.

Residency Program Update Summer is an exciting time at the Memorial Family Medicine Residency Program â&#x20AC;&#x201C; graduating residents are moving on and the new class is just beginning. During the three-year program, residents provide excellent medical care to patients of all ages at the E. Blair Warner Family Medicine Center and at Memorial Hospital.

Family Medicine Residency Program Class of 2018 For more than 40 years, medical students from around the country have been coming to Memorial Hospital to be educated and trained in the specialty of family medicine. Interestingly, 40 percent of family medicine physicians at Memorial Hospital are graduates of the residency program as well as 47 percent of family medicine physicians at Beacon Medical Group. (See the class of 2018 residents pictured at right.)

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Susan Cheng, M.D. Medical school: Ben-Gurion University of the Negev Faculty of Health Sciences

Amanda Booth, M.D. Medical school: Southern Illinois University School of Medicine

Sergio SalĂŠs, M.D. Medical school: University of Illinois College of Medicine

Thomas Erickson, M.D. Medical school: University of North Dakota School of Medicine and Health Sciences

Angela Puthenveetil, M.D. Medical school: American University of Antigua College of Medicine

Rachel Schuster, D.O. Medical school: Chicago College of Osteopathic Medicine of Midwestern University

Paul W. Hannam, M.D. Medical school: Meharry Medical College

Senaka Ratnayake, M.D. Medical school: Indiana University School of Medicine

Jonathan Vida, M.D. Medical school: Michigan State University College of Human Medicine

Memorial Children’s Hospital Symposium

Friday, November 6 DoubleTree Hotel 123 N. St. Joseph Street South Bend, IN 46601

Registration: QualityOfLife.org Registration closes Friday, October 30.

7:30 to 8 a.m.

Schedule of Events

Registration and Breakfast

12:30 to 1 p.m. (Lunch) Clinical Case Presentation and Parent Perspective: Connor Shulke

Indiana Room

8 to 9 a.m.

Pediatric Immunizations: Pertussis, Measles and Flu – Oh My! – Lindsay Kramer, M.D.

Salon A/B

1 to 1:15 p.m.

Break; Exhibit Area Open 1:15 to 2:15 p.m. (BREAKOUT)

9:05 to 10:05 a.m.

Basics of Pediatric Radiology – Alexander Twadros, M.D.

Salon A/B

The Influences of Establishing Salon A/B a Palliative Care Protocol on Nurses’ Perceived Barriers to Palliative Care and Moral Distress – Christina Cavinder, R.N., DNP, CPNP-BC

Salon A/B

10:05 to 10:20 a.m.

Break; Exhibit Area Open

Autism – Seeing the World from Salon C a Different Angle – Andrea Karweck, Psy.D., HSPP

10:20 to 11:20 a.m. (BREAKOUT) Substance Abuse and Pregnancy: Caring for Mother and Baby – Erika Brandenstein, M.D., FACOG, Reid Hospital

Salon A/B

Overview of Neuro Trauma and Neuro Critical Care – Olajide Benson, M.D.

Salon C

2:20 to 3:20 p.m.

Respiratory Support of the Neonatal and Pediatric Patient – Melissa Bybee, RRT-NPS 3:25 to 4:25 p.m.

11:25 to 12:25 p.m. (BREAKOUT) NAS: One Hospital’s Journey – Lacrisha Whitley, R.N., Reid Hospital

Salon A/B

Preventing Youth Suicide: Risk Assessment, Formulation, and Care Management – Cheryl King, Ph.D., University of Michigan

Salon C

Salon A/B

Salon A/B

The Little Dudes You Can’t See – What You Need to Prepare – Kelly Jolliff, BA, CIC 4:30 to 4:45 p.m.

Evaluation

Memorial Hospital of South Bend (OH-425, 12/1/2015) is an approved provider of continuing nursing education by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

The members of the planning committee and presenters for this program have identified no conflicts of interest.

Criteria for successful completion includes attendance at 100% of the event and submission of a completed evaluation form. 7.0 contact hours will be awarded.

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615 N. Michigan Street South Bend, Indiana 46601

Get in the Game Physicians and staff from Memorial Regional Cancer Centerâ&#x20AC;&#x2122;s Medical Oncology and Radiation Oncology took to the field for the first annual Medical Oncology/Radiation Oncology softball game. After battling for six innings, Radiation Oncology held on to its lead and won the game 6-5. Congratulations to both teams!

Top photo: Thomas J. Reid III, M.D., Ph.D., FACP; David Hornback, M.D.; Sam McGrath, M.D.; Ivan Dario Bedoya-Apraez, M.D. Bottom photo: (Front row, L-R) Meredith Dupass, Shannon Nallenweg, Jodi Dauby, Cory Dolniak, Robyn Rogers, Caroline Nemeth (Back row, L-R) Amber Heckaman, Sam McGrath, M.D., Amy Tinlin, Dan Archambeault, John Dauby, Pamela Nacci, David Hornback, M.D., Katie Shively