East Tn Medical News May 2014

Amy R. Rosine, MD

PAGE 3

PHYSICIAN SPOTLIGHT

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HEALTHCARE LEADER: Joseph Ortiz, MSCE, MBAOne of the trickier aspects of health information technology in today’s climate is not just keeping up with what’s new, but fi guring out how to do that across multiple platforms ... 4

LEGAL MATTERS: Profi t And Loss: The Top Ten Things Providers Need To KnowThis article is the fi rst installment in a series which explores the top ten health law issues and their potential fi nancial consequences on a provider’s practice ... 6

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By CINdy SANdERS

Consider yourself warned.A white paper released earlier this year by SANS, a global leader in

cybersecurity research, training and certifi cation, painted a bleak picture of where those in the healthcare industry currently stand in terms of keeping pro-tected information safe and secure. The report was created using healthcare-specifi c data provided by Norse, a live threat intelligence and security solutions fi rm, from September 2012-October 2013. The eye-opening results underscored the vulnerability of providers, payers, business associates and patients.

SANS Cyberthreat White Paper Shows Dark Clouds on HIT HorizonWidespread security issues put systems, patients at risk

(CONTINUED ON PAGE 10)

FOCUS TOPICS WOMEN’S HEALTH HIT

Identity as a Risk FactorHeart disease and the feminine mystique

By CINdy SANdERS

Despite the fact that heart disease is the number one killer of women in America and stroke the leading cause of disability, women often don’t identify with the very real dangers the disease holds for their gen-der, according to Robert Wood Johnson Foundation Clinical Scholar Lisa Rosenbaum, MD.

“We all know men drop dead of heart attacks … we don’t think of women drop-ping dead of a heart attack,” the University of Pennsylvania car-diologist noted of the masculine attributes often attached to heart disease.

Furthermore, women tend to fear

other diseases, notably breast cancer, more than heart disease. The HealthyWomen 2010 survey, in partnership with the National Stroke Association and the American College of Emergency Physi-

cians, found that women believe breast cancer is fi ve times more prevalent than stroke, and 40 percent of those surveyed were

‘only somewhat’ or ‘not at all’ concerned about experiencing a stroke. Yet, stroke is signifi cantly more prevalent in women than in men, and stroke kills twice as many women as breast cancer each year.

“There’s a certain sort of female solidarity around breast cancer,” Rosenbaum stated. In a perspective piece

published earlier this year in the New England Journal of Medicine, Rosenbaum wrote

about an encounter with a middle-age woman with high blood

pressure and hyperlip-idemia. When Rosen-baum asked the new

patient what was the number one killer for women,


2 > MAY 2014 e a s t t n m e d i c a l n e w s . c o m

Age-related macular

degeneration (AMD) is

a complex, multifacto-

rial disease with progres-

sive degeneration of the

retinal pigment epithelium

and photoreceptors. This

degenerative process can

lead to symptoms that vary

from no visual loss at all to

profound visual loss. Early

symptoms of low vision

from AMD may include

shadowy areas in the cen-

tral visual fi eld or unusually

blurry vision. In developed

countries such as the U.S.,

AMD is the leading cause of

irreversible blindness.

Risk factors include

age, smoking and genetic

predisposition. To a lesser

extent, hypertension and

hyperlipidemia (high cho-

lesterol and/or triglycerides)

may also play a role in the disease. There are also ethnic diff erences with

AMD, which is more prevalent in Caucasians than in black and Hispanic

populations. The genetics of AMD is under intense scrutiny, with several

genes implicated in many cases of AMD, especially in severe AMD. At this

time, there is no treatment for any genetic abnormality found in patients

with AMD.

“A MD is the number one cause of vision loss in senior citizens,” said

John Johnson, MD, a physician with Johnson City Eye Clinic and Surgery

Center. “Age-related macular degeneration often results in ‘low vision’ or

signifi cant vision loss, which cannot be helped by normal correction, such

as eyeglasses or contacts lens.”

AMD begins with changes in and under the retinal pigment epithe-

lium (“dry AMD”) and can progress to new vessel formation under and in

the retina itself (“wet AMD”), leading to loss of all central vision.

The symptoms of AMD depends on the stage; in early dry AMD, there

are no symptoms at all. As the disease progresses, there may be gradual

blurring of central vision, and if wet AMD develops, there may be sudden

marked loss of central vision.

The treatment for AMD depends on the stage. In moderate to severe

dry AMD, antioxidant vitamins plus zinc have been shown to reduce the

progression of the disease

to wet AMD. For wet AMD,

there are three medica-

tions available that can be

injected into the eye to

slow down the progression

of the disease.

At the present time,

there is no cure for AMD.

The top fi ve risk factors

for AMD include being

over the age of 60, having

a family history of AMD,

smoking, obesity, and

hypertension. Patients

with just two of these risk

factors should see their eye

care provider to determine

preventive measures,

thereby reducing the risk

of vision loss from AMD.

Earlier diagnosis gives a

much better chance of

successful treatment.

“With or without a

family history of AMD, patients should be referred for regular eye exams

to include a dilated exam of the retina to rule out AMD,” said Johnson. “If

AMD is diagnosed, we can recommended therapy, if indicated.

“At the Johnson City Eye Clinic, we have extensive experience with

both wet and dry AMD and have the necessary diagnostic tools to diag-

nose, treat, and follow the disease,” Johnson added. “All of our physicians

are prepared to discuss this disease with the patient and his or her family.”

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PhysicianSpotlight

By JENNIFER LAWSON

Amy R. Rosine, MD, was born in Chattanooga and grew up in rural Mc-Donald, Tennessee. She graduated from Bradley Central High School and received a BS in Biological Sciences with a minor in History from East Tennessee State Univer-sity. She earned an MD from The Univer-sity of Tennessee, Memphis Health Science Center in 1998. Rosine completed her res-idency in Family Practice in 2001 and a fel-lowship in Obstetrics in 2002. She started full time in private practice with Fountain City Family Physicians, a division of Sum-mit Medical Group, in 2002. Rosine sits on the board of directors for Summit Health Solutions. She is the proud wife of Doug Rosine and mother of three daughters, ages 12, 9, and 3. She enjoys being the team doctor for the middle school soccer team at Berean Christian School, volunteering with Summit Medical Group at Interfaith Health Clinic, and serving on the medical board at the Hope Resource Center. In recent years, Rosine has become very pas-sionate about medical missions in Guate-mala and is looking forward to going back with a group from her church this year.

As a family practice physician, Ros-ine provides overall healthcare services for men and women of all ages. Over the past few years, Rosine has noticed a trend in women’s care – the tendency to sometimes overlook healthcare threats in women that are common among both men and women.

“As a physician, it is important to keep in perspective that heart disease and stroke are the first and third causes of death in women and are frequently preceded by years of high blood pressure, cholesterol, smoking, and sedentary lifestyle,” Rosine said. “With appropriate medical interven-tion, we can prevent untimely death or dis-ability.”

With limited time in the examination room, physicians often focus on preven-tive and problem care appointments. For women especially, areas of focus tend to be on breast health and menstrual/sexual/menopausal health.

“Breast and reproductive health are important, but we have to be careful not to let them overshadow everything else that is perhaps collectively more impor-tant,” Rosine said. “Among the top ten causes of death in women are cancer (all types), chronic lower respiratory diseases, Alzheimer’s disease, unintentional injuries, diabetes, influenza and pneumonia, kid-ney disease, and septicemia. Awareness of these conditions allows both the physician and the patient to address personal and family history risk factors specific to each individual with targeted interventions that

are more likely to be beneficial.”When thinking about cancer in

women, it is again surprising that while breast cancer remains the most common type of cancer to occur in women, lung cancer is the leading cause of cancer death in women. Although smoking trends have changed in the last 20 years, Rosine ac-knowledged that it is still very challenging to motivate women who smoke to quit because their reasons for smoking and/or barriers to quitting are often different.

“Breast cancer is, of course, a very prevalent disease that we help women fight daily and having had a family member die of metastatic breast cancer in the last ten years, it is a very personal topic for me,” Rosine said. “It is encouraging to have so

much awareness in the community and patient-directed screening.”

Recent research on the human papil-loma virus (HPV) has introduced changes in guidelines and recommendations about cervical cancer screening and Rosine stresses that it is important for patients to discuss screening guidelines with their phy-sician.

“As a physician who provides care for women, I am constantly reminded that they look to me to help them live well,” Rosine said. “Patients want more than just the prevention and treatment of the most common serious diseases and death.”

She added that women often face dif-ferent stressors that impact their daily qual-ity of life. It is vitally important to be able to recognize which patient is stressed and which patient is depressed and to treat ap-propriately.

“In today’s society, many women are secondary, or even primary, bread-win-ners as well as still being primarily respon-sible for the executive functions of running

households and managing childcare ar-rangements,” Rosine said.

With the aging of the population and cultural changes, women are often multi-generational caretakers and find themselves providing care without adequate support.

“Finding resources to help patients in all the domains in which they operate is often the most important prescription I can write,” she said. “As a physician, it is encouraging to see women and men em-bracing technology that often lessens this burden.”

Technology ranges from cool, low-cost, electronic medication-dispensing tools for elders that can be filled in advance and controlled remotely to patient portals that allow patients to communicate with provid-ers without having to miss work to attend appointments.

“There are so many tools available now that can make responsibilities as the family medical navigator a little more man-ageable,” Rosine said.

Perhaps the most rewarding aspect of the physician’s job is being a good listener, understanding what the patient is commu-nicating, and developing a good rapport.

“In general, I find it very rewarding to provide care to both men and women who have so many similar problems tem-pered by differences unique to each gen-der,” she said. “I consider myself fortunate to practice in a medical community that is dedicated to the care of each patient as an individual, and I am excited about medi-cal advances in the care of women in the future.”

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HealthcareLeader

MultitaskingMaking HIT Work for Practices, ACOs in New Era of Accountability

By JOE MORRIS

One of the trickier aspects of health information technology in today’s climate is not just keeping up with what’s new, but figuring out how to do that across multiple platforms.

For back-office operations, electronic medical records continue to present chal-lenges for implementation and adaptation. New tablet and phone apps allow physi-cians to diagnose literally on the fly in some cases, but those systems have to inte-grate to mainframe operations. Meaning-ful Use continues to demand that systems all tie together, and the growing popular-ity of patient portals does the same.

Still, it’s an environment that’s as in-vigorating as it is challenging for many in the field, including Joseph Ortiz, MSCE, MBA, who recently stepped into the Chief Information Officer position at Summit Medical Group. As the founder and presi-dent of 4D Imaging Systems, a healthcare imaging system provider, Ortiz knows the ins and outs of healthcare IT and data needs. He’ll need that savvy, as informa-tion technology is moving faster now than ever before.

“The CIO role, not just in healthcare but in general, has undergone a structural change and is in the midst of changing from something more operationally fo-cused to a more strategic position,” said Ortiz, who holds an MBA from Arizona State University, a Master’s degree in computer engineering from the Univer-sity of South Carolina, and a Bachelor’s degree in computer science from Georgia Tech. “That is an elevation in many as-pects. At Summit Medical Group, it’s im-

portant for our CEO and our board that we move away from dealing with informa-tion technology as an expense, and deal with it by having an individual responsible for making decisions about HIT from a strategic viewpoint with regard to how we operate in the marketplace.”

A key point to remember now is that information technology, as it relates to healthcare, is now being used to deliver specific information to individuals, be they physicians, clinicians, or patients versus just as storage for records and other data. Consumers, by way of patient portals, increasingly want to access their records so they can work alone or with their care team on wellness efforts. Physician groups, hospitals, and accountable care organiza-tions want that data as well so they can put together patient populations and offer treatments and services accordingly.

“Knowing that is of strategic impor-tance to our business,” Ortiz said. “Be-cause the people here had vision, much of Summit’s culture had changed before

I came on board. I sent my first three months assessing the state of our HIT, and now we are working on continuing to shift away from thinking of HIT on a project basis, and instead having more of a product focus.”

That means, Ortiz explained, having a “one and done” approach to HIT, such as framing out a project for a patient por-tal, building it, and then moving on. He and his team will focus on that same task, but ensuring that it’s a product of value to the business and to its patients. The por-tal should live and breathe well beyond its launch date.

“We have to think of how we are using what we have, and how our cus-tomers, who are the patients we provide healthcare services to, are using it,” he said. “This shift is going to allow us to deliver better products and technology to those who are using it, versus just another thing we have to deal with that delivers information.”

Summit is fully automated in terms of electronic medical records, and part-ners with its vendors to remain complaint with regard to Meaningful Use and other mandates from the U.S. Dept. of Health and Human Services with regard to the Affordable Care Act and other governing legislation. The challenge, Ortiz said, is making sure that compliance also works its way back into office operations as well.

“We want to make sure that our staff, from physicians and office managers to the back-office personnel, are collecting data in such a way that we successfully map Meaningful Use and other informa-tion technology into our workflow,” he said. “We have to make sure our provider

are capturing their notes, for example, in a way that can be attested to the Meaningful Use criteria we are being required to re-port on. And we also have to look at how we do that while reducing wait times and making sure our patients get through our system as efficiently as possible.”

These days, Ortiz and his team are in the throes of the Meaningful Use’s second phase, which is the first step of standard-izing the collection and reporting of data on a per-patient basis, he said.

“The next big wave is dealing with population health management, and deal-ing with care coordination across a range of different care providers through our accountable care organization,” he said. “We’re going to be working with the har-monization of data and workflow across a diverse group of providers, to make sure that the information flows as seamlessly as possible between primary care physicians, specialty providers, acute care hospitals, and care providers.”

To that end, Summit is working with the East Tennessee Health Information Network as a mechanism for getting data interoperability into place, with the end goal being faster and more efficient com-munication for multiple processes.

It’s a big job, but Ortiz said he enjoys making all the puzzle pieces fit.

“My experience has been primarily across a number of tech-provider firms, creating products and services to medical providers,” he said. “I haven’t been in a situation where I was actual delivering IT solutions to the end customer. It’s been a great thing to focus all my energies and le-verage what I’ve learned, but also working on products that support a more strategic view of IT. I’m using the full depth and breadth of my experience here, and I’m loving it.”

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Best Practices and Principles for Utilizing Physician Assistants within Healthcare Facilities

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You may have noticed an increase in requests for clinical documentation and justification for prescribed prosthetic, or-thotic, and pedorthic devices. This is due, in part, to clarification by CMS concern-ing who is able to recommend and justify the medical necessity of these devices and enforcement of this policy in the form of RAC (Recovery Auditor Contractors). Ba-sically, CMS expects physician documen-tation to justify the need and expectations for the prescribed devices. As cited from their 2011 “Dear Physician” letter, “It is the treating physician records, not the prosthetist’s, which are to be used to justify payment.” Auditors can deem an “over-payment” or “improper payment” in any case where the physician’s notes do not independently corroborate the prosthe-tist’s clinical file, even when prosthetist’s notes document the medical justification for prescribed devices.

Reimbursement recoupment of ex-pensive devices already delivered up to three years prior has put prosthetic provid-ers on the defensive to make sure that we have on-file all necessary documentation prior to delivery of devices and services. Therefore, physician documentation is the key to ensure patients receive appro-

priate orthotic and prosthetic devices in a timely manner. Failure to adequately document the need and functional goals of any prescribed prosthesis or orthosis can place providers at risk of recoupment of these services for up to three years after delivery. These nationwide recoupment efforts have caused may O&P providers to close their doors, limiting patient access to qualified practitioners.

Brief History of Audits and Changes in Documentation

In 2011, Medicare sent a “Dear Phy-sician” letter to all participating physicians instructing physicians that physician clini-cal records are the only records relevant in determining the medical necessity of prosthetic care, and the prosthetist’s re-cords must corroborate the physician medical records. In effect, it is the treating physician records that justify payment for specific devices. This sounds great for the overall patient management, but it pres-ents one major problem: most physicians don’t understand differences in prosthetic designs related to suspension, component selection, and evaluating functional level (K-level) as defined by Medicare. In com-mon practice, the physician relies on the prosthetist as the allied health professional trained to understand and provide these

types of devices and services. Technically, these “changes” were

not really changes, but more of a clarifi-cation of their “original intentions.” Soon after the new standards of documentation went into effect, Medicare began enforc-ing their intentions in the form of aggres-sive RAC audits. The results of these new documentation standards has been delays in patient prosthetic care, additional phy-sician visits specifically to meet insurance requirements for documentation, and additional evaluations related to recom-mending devices and evaluating their out-comes.

Without sufficient physician docu-mentation, prosthetic providers are hesi-tant to recommend and provide devices and technologies.

Prescribing Devices for Patients with Diabetes and Related Complications

Two of the most commonly pre-scribed types of orthotic and prosthetic de-vices are basic diabetic shoes with inserts and below knee prosthesis. In providing orthotic and prosthetic devices for compli-cations related to diabetes, we O&P pro-viders typically provide both ends of the spectrum from the most basic devices like diabetic shoes, inserts, and shoe modifica-

tions to some of the most advanced pros-thetic designs. Goals for these devices are also as varied from unloading diabetic ulcers, accommodating foot deformities, increasing stability from gait deviations, to prosthetic devices that aim to return people to active independence.

Unfortunately, the Medicare-driven requirements for documentation, spe-cifically physician clinical notes are as stringent for both the high end prosthetic devices as they are for the most basic dia-betic shoes and inserts.

Being aware of the documentation requirements and meeting these require-ments at the time of evaluation will save you time, will avoid irritating requests for “additional documentation or justifica-tion,” and will help your patient receive their device in a more timely manner.

Qualifying Criteria for Diabetic Shoes/Inserts

Medicare has made it very clear that a diagnosis of diabetes alone does not justify dispensing diabetic shoes. Patients must have diabetes, be treated under a comprehensive plan of care related to dia-betes and have a specified condition justi-fying the need for diabetic shoes. These qualifying conditions are as follows:

Clinical Evaluation and DocumentationKey to ensuring patients with diabetes-related complications receive prosthetic, orthotic and pedorthic devices



REPRINTS: Want a reprint of a Medical News article to frame? A PDF to enhance your marketing materials? Email [email protected] for information.

LegalMatters

Profit and Loss: The Top Ten Things Providers Need to KnowPart I: The 2014 OIG Work Plan

BY ERIN B. WILLIAMS AND DIANA L. GUSTIN, LONDON & AMBURN, P.C.

This article is the first installment in a series which explores the top ten health law issues and their potential financial consequences on a provider’s practice.

The U.S. Department of Health and Human Services (“HHS”) Office of Inspector General (“OIG”) was created to detect and prevent fraud, waste, and abuse within the federal programs provided by HHS. The OIG’s central activities include audits, evaluations, investigations, enforcement, and compliance related to federal healthcare programs. For the fiscal year 2013, the OIG reports “expected” recoveries to be over $5.8 billion, including nearly $850 million in audit receivables. Being the subject of an OIG audit or investigation can create economic hardship for any healthcare entity, but the smaller physician practices may be the most at risk for a devastating financial impact.

Earlier this year, the OIG released its 2014 Work Plan (1), which helps providers identify the issues the federal government will review during the 2014 fiscal year. The 2014 Work Plan is quite lengthy, but it is well worth the read if it alerts your practice to potential problems and prevents an overpayment that may otherwise be assessed. Below are just a few of the important highlights in the 2014 Work Plan, which should now be at the top of every physician’s compliance plan.

Evaluation and Management Services – Inappropriate Payments

Since the widespread adoption of electronic health records (“EHR”), in large part due to the federal government’s implementation of the incentives for adoption of EHR systems, Medicare reimbursement for E&M services has surged. Specifically, the OIG has suggested that two EHR documentation

practices – copy/pasting and overdocumentation – have enabled providers to commit fraud. In fact, 2014 makes the third consecutive year that the OIG has included this topic in its Work Plan.

The 2014 Work Plan indicates that Medicare contractors have noted an increase in frequency of medical records with identical documentation across services. Known as “cloning,” the OIG has strongly criticized the use of the copy/paste function in EHR, which often significantly decreases the time a physician spends creating a record. At the same time, the use of copy/paste creates a longer record indicating a more extensive patient evaluation or treatment than what actually occurred and, thus, a higher billing rate. However, if left unedited, it may also create false or inaccurate information for the patient visit. The OIG has suggested that providers put in place specific policies and procedures related to the use of copy/paste in patient records (1).

Overdocumentation occurs when the patient’s record includes irrelevant or inaccurate information to create a longer record supporting a higher level of service than what was actually performed. Overdocumentation can unintentionally occur when EHR systems use auto-populated templates or fields and providers fail to edit the record to remove the inaccurate information.

In addition to the Work Plan, the OIG has recently submitted two reports specifically addressing issues related to potential fraud and abuse associated with EHR (2). Providers can be assured that reimbursement for higher level E&M services will be closely scrutinized, with the auditors specifically looking for potential cloning and overdocumentation issues.

Sleep Disorder Clinics – High Utilization of Sleep Testing Procedures

The OIG conducted an analysis of 2010 Medicare payments for CPT codes 95810 and 95811, which totaled $415 million in

reimbursement. The OIG concluded that there was a high utilization of the sleep testing procedures. Specifically, sleep testing procedures were being performed on patients for whom the procedure was not necessary or were being performed too often on those for whom it was necessary. Medicare does not consider duplicative testing reimbursable because it is not “reasonable and necessary.”

Physicians – Place-of-Service Coding Errors

Medicare reimburses at a higher rate when the service is performed in a non-facility setting (such as a physician’s office) than it does in a facility setting (such as an ambulatory surgery center or hospital outpatient department). In prior reviews, the OIG determined that Medicare Part B claims are not always properly coded for the place where the service occurred. Physicians’ coding for services performed in ambulatory surgical centers and hospital outpatient departments will be reviewed to ensure they were reimbursed at the proper rate. Providers should be aware that coding errors (such as place-of-service) are ripe for review in Recovery Audit Contractor (RAC) audits because this issue can often be reviewed through data analysis of billing records.

While this article summarizes only a few of the many items highlighted in the 2014 OIG Work Plan, the OIG’s areas of interest in audits, investigation, enforcement, and compliance are also related to preserving the Medicare Trust Fund. Providers need to protect their own financial interests by keeping abreast of the OIG’s game plane for audit, enforcement, and compliance. A review of the 2014 OIG Work Plan is certainly a good place to start.

Notes1.The 2014 OIG Work Plan may be found

online at http://www.oig.hhs.gov2. See “CMS and its Contractors Have

Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs,” Department of Health and Human Services, Office of Inspector General Report (January 2014).

Attorneys Erin B. Williams and Diana L. Gustin focus their practice on healthcare compliance and regulatory matters. For more information on any health law or compliance matters, you may contact Ms. Williams or Ms. Gustin at (865) 637-0203 or visit www.londonamburn.com. Disclaimer: The information contained herein is strictly informational; it is not to be construed as legal advice.

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Individuals who have been diagnosed with depression suffer tremendously from the symptoms associated with the dis-order. Feelings of guilt, the inability to experience pleasure, and a preoccupa-tion with death or suicide are primary symptoms and can be accompanied by irregular sleep habits, change in appetite, fatigue, lack of interest in physical activ-ity, and impaired concentration. Treat-ment for depression usually includes a medication regime, but for some patients, medication does not work.

Fortunately, other options are avail-able, including a therapy just recently offered to patients living in and near John-son City. Transcranial Magnetic Stimula-tion (TMS) is a procedure in which the brain is stimulated through the scalp and skull using a strong magnet rather than an electrical current. Each time the magnet switches on and off, it creates an electrical field, allowing the brain to be stimulated by electricity, but not directly.

“We have discovered that we can

treat many things with TMS,” said Nor-man Moore, MD, a psychiatrist who practices with Quillen ETSU Physi-cians, “but the one that has been approved by the FDA is the treatment of depression.

“Patients who are eligible for the treatment must have failed several adequate courses of an-tidepressant medication, in other words, a suffi-cient dose for a sufficient time to give it a chance to work. If we can show that they have had two or three courses of antidepressant medication and they have not improved, then they are eli-gible for TMS.”

Individuals who cannot take medi-cations because of side effects are also eligible. TMS therapy requires approxi-mately 30 treatments, and patients must receive the treatments five days a week for the duration of the therapy. While the length of therapy may seem extensive, the outcomes are potentially life changing for

patients debilitated from depression. One third of patients will see a measur-able improve-ment, and another third of patients ex-perience a form of remission. Maintenance treat-ments are required, but some patients are so improved from the therapy that they are willing to pay out of pocket for treatments not covered by in-surance.

Medicare covers TMS treatment, and other insurances will pay for TMS, but they typically require a prior autho-rization. Even so, Moore says he has had good success with the prior authorization process. Some insurance companies also require that the patient have a trial of electroconvulsive therapy (ECT).

ECT uses a direct electrical current to stimulate the same area of the brain

(the frontal lobe) as TMS;

ECT, however, usually requires about ten treat-

ments, and each requires general anesthesia. When patients wake

up, they aren’t capable of driving, and memory loss is common. TMS ther-apy, conversely, does not cause memory loss, and the patient is not put to sleep. He or she can drive home immediately fol-lowing the treatment. TMS also has very few side effects, the most common being a mild headache centered at the location of the magnet.

Although TMS requires more treat-

TMS Therapy Offers Treatment Option to Patients Diagnosed with Depression

Dr. Norman Moore



easttnmedicalnews.com

Enjoying East TennesseeInternational Biscuit Festival - Knoxville

Leigh Anne W. Hoover is a native of South Carolina and a graduate of Clemson University. She has worked for over 25 years in the media with published articles encompassing personality and home profi les, arts and entertainment reviews, medical topics, and weekend escape pieces. Hoover currently serves as immediate president of the Literacy Council of Kingsport. Contact her at [email protected].

By LEIGh ANNE W. hOOVER

Southern women sure are known for their homemade biscuits! My husband’s late grand-mother, Grace Ragsdale, or “Mamaw,” made some of the very best. Brad’s mother, Charlotte, also makes delicious biscuits, and his Aunt Patty has a wonderful recipe for her infamous, melt in your mouth, homemade rolls.

Personally, I make ba-nana-nut bread, but I buy “Sister Schubert” home-made frozen rolls for our table. In fact, in 2011, I met Patricia “Sister Schubert” Barnes when she was in the Tri-Cities for a special segment of Liz Bushong’s “Serve it Up Sassy” on Daytime Tri-Cit-ies. She was delightful and just as pretty as her picture on the package.

“Sister” signed her gorgeous “Cast Your Bread Upon the Waters” cookbook, which benefi ts orphans and the hungry in our country and the Ukraine through the Barnes Family Foundation. The beauti-ful book is fi lled with wonderful recipes and, of course, all types of breads. It’s also

brimming with personal antidotes of fam-ily and faith.

Bread unites us, and Knoxville, Ten-nessee, has capitalized on this shared cus-tom by celebrating the biscuit. Described as “a celebration of that most perfect of foods, “the biscuit,” the International Biscuit Festival, May 15th -18th, brings everything biscuit related to the region. Interestingly, Knoxville is the perfect

home for just such a festival.“This idea has been talked

about in Knoxville for awhile,” said International Biscuit Boss John Craig. “Knoxville is the original home of White Lily fl our, and White Lily makes the best biscuits!”

As the idea germinated and interest was expressed, festival or-ganizers decided the “biscuit” fi t the niche and would be celebrated annually each spring. May 2014 marks the fi fth year of the festival, and what was originally imagined as a smaller festival for friends and family has grown exponentially to

attract visitors from everywhere. According to festival organizers, it’s also a “tasty opportunity” to showcase downtown Knoxville.

“We have branched out, and there are so many aspects to it that we wanted to make sure that we had something for everybody,” said

Craig. “It’s grown from a half-day event the fi rst year to four days of activities.”

Everything from biscuit-themed art and music to a Southern Food Writers Conference, which attracts the best in “food” writing from across the country, encompass the festival.

“Everybody loves a biscuit,” ex-plained Craig. “It’s a fun, unique and delicious event…that attracts just about

everyone who has Southern blood in them.”

A Biscuit Bash with noted food au-thors, book signings, music and food sam-plings is scheduled for Friday night.

On Saturday, “Biscuit Boulevard,” which is located downtown on Market Street in the heart of the festival, will fea-ture over 20 restaurants preparing specialty biscuits for sampling. Tickets allow visitors to choose and taste signature recipes.

“Some of the most popular ones go through two or three thousand biscuits on a Saturday,” added Craig.

Cross streets will feature vendors, a live bakeoff, and musicians. Among the festival sponsors, notables, such as Black-berry Farm and Southern Living Maga-zine, are included.

“Southern Living Magazine will be building a special front porch set, which will expand their presence even further,” said Craig. “They will bring their test kitchen team and be part of our Biscuit Boulevard tasting area with a signature biscuit.”

Scipps Network, which is based in Knoxville, is also participating in the Inter-national Biscuit Festival through the Food Network by presenting “An Evening with Tyler Florence.” On Sunday, May 18th, this ticketed event at the Tennessee The-atre will be a concluding highlight of the festival.

“He [Tyler Florence] is the host of their highest rated show, ‘The Great Food Truck Race,’” explained Craig. “Before the show, we will be having a Food Truck Extravaganza outside of the Tennessee Theatre that’s open to the public.”

The International Biscuit Festival truly appeals to all senses.

“Come down with your stomach as empty as you can get it,” said Craig. “We’ll fi ll it up with good biscuits!”

For additional information on the International Biscuit Festival, visit www.biscuitfest.com

Photo: Amy Baldwin, Mike Ostroski, Gwen Edwards, Rick McVey from The Wizard of Oz (2009)

276.628.3991 • bartertheatre.com • Abingdon, VA

EAST TN MEDICAL NEWS

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e a s t t n m e d i c a l n e w s . c o m MAY 2014 > 9 e a s t t n m e d i c a l n e w s . c o m

Coronary artery disease (CAD) is responsible for significant morbidity and mortality worldwide. One of the crucial ways to evaluate and treat CAD is through cardiac catheterization, coronary angiography, and angioplasty. The more common, older approach for this procedure is femoral artery access. Unfortunately, the femoral arterial access approach carries a higher risk for complications, mainly associated with access site complication and bleeding. This is of utmost significance given that bleeding is a major predictor of higher mortality and morbidity, regardless of patient baseline risk status. A relatively novel approach for performing these procedures is via the radial approach, which has a considerably lower complication rate and consequently better patient outcomes.

The technique simply involves testing the hand arterial circulation with an Allen’s test to confirm the patency of the ulnar artery. Given the fact that hand arterial supply will be dependent on the ulnar artery once the radial artery is cannulated, given the small caliber of the vessel. Then, the radial artery is accessed via a small needle which is exchanged over a wire to a small, thin (5-6F) sheath. Through this sheath, the remainder of the procedure is carried out in the usual fashion. At the end of the procedure, this sheath is removed and a special wrist band is applied to the access site to achieve hemostasis. This provides comfort and early ambulation with minimal site complications to the patient.

Naturally, there are no procedures without limitations. For the radial approach, these limitations include some technical issues such as radial spasms and vascular tortuosity. However, these road blocks could be easily overcome with simple measures and proper technique. In the worst case scenario, cross over from the radial approach to a femoral approach could always be done.

There are some reservations in regards to the radial approach, which usually stem from misconceptions and myths. One such misconception is that the radial approach has a higher complication rate. The radial approach does not have a higher complication rate, but rather different types of complications, including radial artery spasms and the inability to cross due to tortuosity. In actuality, the radial approach has a lower complication rate.

Other concerns include questionable higher stroke rate. In the recent SCIPION trial, however, data revealed no difference in both approaches. As for the concerns for radial artery occlusion and patency post procedure, this issue only involves 3-5% of the cases, and in 50%, the artery will re-canalize in the future. This limitation is also considerably reduced via appropriate application of the hemostasis device, avoiding prolonged periods of occlusive hemostasis.

The radial approach provides very important advantages in contrast to the femoral approach. One of the most important advantages is the considerable lower access site complications with lower risk of bleeding complications. This was clearly demonstrated in the RIVAL Trial. Moreover, the radial approach provides much faster ambulation, which leads to better patient comfort and better quality of life. These advantages are of critical importance in patients who are overweight, have peripheral vascular disease, bleeding tendencies, or have orthopedic disease that prevent them from lying down for prolonged periods of time. In addition, the lower complication rate and early ambulation translate to lower economical costs and medical expenses, which is becoming a significant burden on our economy.

Ultimately, there is no one procedure that fits all patients, and patient care individualization is of utmost importance. Nevertheless, the radial approach does provide a considerable benefit over the femoral approach from a patient’s safety and comfort standpoint. It does have limitations, which are easily avoided with proper patient selection.

Dr. Kais Al Balbissi, Director of Interventional Cardiology for Quillen ETSU Physicians, was fellowship trained as an interventional cardiologist at the Mayo Clinic in Rochester, Minn., Dr. Al Balbissi performs a wide range of interventional cardiac procedures, including complex cases such as high-risk percutaneous coronary interventions (PCI) and chronic total occlusion interventions.

Dr. Al Balbissi also has a special interest in and recent training in structural valve disease, patent foramen ovale closure, atrial septal defect (ASD), balloon valuloplasty, and transcatheter aortic-valve implantation (TAVI). Dedicated to both his patients and profession, Dr. Al Balbissi has championed the radial approach to cardiac catheterization at Johnson City Medical Center and was awarded membership in the Gold Humanism Honor Society in honor of his excellence in practice and his commitment to serving patients with compassion.

In addition to his board certification in cardiovascular medicine and interventional cardiology, he is board certified in echocardiography and nuclear cardiology. He is also Level II certified in cardiac and coronary ct angiography.

Dr. Al Balbissi completed his residency in internal medicine and fellowship in cardiology at East Tennessee State University’s Quillen College of Medicine. He currently serves as vice chair of cardiology at Johnson City Medical Center.

Quillen Heart

Talk A New Frontier:

Cardiac Catheterization

and Coronary Angiography via Radial Approach

By Kais Al Balbissi, MD, FACC, FSCAI

329 North State of Franklin RoadJohnson City, TN 37604

Call 423.979.4100 • Fax 423.979.4134

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10 > MAY 2014 E A S T T N M E D I C A L N E W S . C O M

SANS Cyberthreat White Paper Shows Dark Clouds, continued from page 1

Identity as a Risk Factor, continued from page 1

Dr. Lisa Rosenbaum

Online Event CalendarTo submit or view

local events visit the East TN Medical News

website and click on the calendar icon on the right hand sidebar.


Authored by Barbara Filkins, a senior SANS analyst and healthcare specialist, the report detailed the widespread prob-lem. In analyzing the Norse data collected during the 13-month sample, the intelli-gence found:

• 49,917 unique malicious events,• 723 unique malicious source IP ad-

dresses, and• 375 US-based healthcare-related

organizations compromised … averaging about one a day.

Filkins wrote, “The data analyzed was alarming. It not only confi rmed how vul-nerable the industry had become, it also revealed how far behind industry-related cybersecurity strategies and controls have fallen.”

Furthermore, the analysis made it clear that the threats aren’t unique to any one type of healthcare company, but pro-viders are seemingly the most vulnerable. In looking at the sectors compromised by malicious traffi c, healthcare providers led the way with 72 percent. Business as-sociates accounted for 9.9 percent of the malicious traffi c, health plans 6.1 percent, healthcare clearinghouses 0.5 percent, pharmaceuticals 2.9 percent, and other related entities 8.5 percent. Most alarm-ing, noted Filkins, was the level of activity found in what was just a sample set.

Speaking to Medical News from her Cal-ifornia offi ce, Filkins said ‘malicious events’ are defi ned as an outside threat or event that might have penetrated the system and could range from hijacking contacts to pushing sensitive information outward. She noted that many companies, practices and facilities have policies in place warn-ing employees not to click on an unknown email or link. (And who hasn’t received a suspicious link under the guise of coming from a friend or colleague?) Yet, she said, “People need to be looking at not only what comes into their network, but what goes out of their network.”

To fi nd and address malware typi-cally requires a HIT professional. “A lot of times an attacker will use a very common

protocol so it might look like someone is browsing the web, but you might have to dig a little deeper under the covers,” she noted of fi nding and locating problems. “A lot of these events continued not just for days … but for months,” she added.

Locking the Front Door, Leaving the Back Wide Open

Oftentimes the point of entry for at-tackers was not the main information sys-tem. Instead, those with malicious intent entered through peripheral surfaces like network printers, call contact software, routers, medical devices, and … ironi-cally … security cameras. While the main system was securely locked and password protected, many times, Filkins said, the default password remains on these add-on surfaces. Finding the admin password, she continued, is as easy as doing a quick Internet search for the device in question.

“There are some very basic things that can be done to get started with pro-tection,” Filkins noted. The most obvious … but clearly overlooked … is to change those default passwords. However, she continued, changing to an easily deci-phered password isn’t much help. Avoid using your children’s names, street ad-dress, pet names, combined physician names, name of the practice, or other easily discernable choices. The best pass-

words, Filkins said, include numbers and unique characters.

Mobile devices can also cause head-aches … in part because of unrealistic expectations and policies. “Everyone uses mobile devices,” Filkins stated. “Rather than trying to bury that and say, ‘oh, we never use mobile devices,’ maybe relax the punitive policies and instead say, ‘let’s get honest and fi gure out how to make them more secure.’”

Measures to Improve Security

“Know what’s on your network,” Filkins said. “Make sure your network is confi gured properly and devices are con-fi gured properly.” She added it’s impor-tant to know who is using what and how it’s being used. Having a strong password policy is critical to proper confi guration.

“Think like an attacker,” she contin-ued. “And if you can’t do it, get someone who can.” There are numerous resources and companies that can help with this task. It boils down to being aware, Filkins noted. “It’s basic awareness but in a digital world.”

She continued, “Know what your network pathways are for your organi-zation.” Filkins said that often there’s an emphasis on protection for “bad things coming in” … but if something does pen-etrate the system, there isn’t much moni-

toring of outbound traffi c. Egress fi ltering is as important as ingress protection.

The Cost of FailureThe healthcare industry is particu-

larly attractive to cyber attackers because of the type of information housed on serv-ers. With medical identity theft, the vic-tim is responsible for costs related to a compromised medical insurance record. A survey by the Ponemon Institute last year estimated that cost to be $12 billion in 2013.

Security breaches also represent major costs to the compromised entity. Steep fi nes, incidence handling, victim notifi cation, credit monitoring for victims, and potential legal action represent direct out-of-pocket expenditures. In addition, a data breach could also signifi cantly harm reputation and future business opportuni-ties.

The greatest cost, however, is to a pa-tient who winds up with inaccuracies in his medical record that could result in a misdiagnosis or wrongly prescribed medi-cation.

The Takeaway“Today compliance does not equal

security,” Filkins wrote. “Organizations may think they’re compliant, but this data shows that they are not secure.”

she noted the patient “answered in a way that sticks with me: ‘I know the right an-swer is heart disease,’ she said, eyeing me as if facing an irresistible temptation, ‘but I’m still going to say breast cancer.’”

Rosenbaum is quick to say breast cancer is a valid concern, but the emo-tions linked to the dis-ease go beyond just the facts. She pointed to the controversy surround-ing mammography as a clash between data and identity at the social level. Despite a recom-mendation from the U.S. Preventive Services Task Force to decrease mam-mography frequency for most women under age 50 based on decades of data, Rosenbaum wrote, “So intense was the outrage over these evidence-based recom-mendations that a provision was added to the Affordable Care Act specifying that in-surers were to base coverage decisions on the previous screening guidelines.”

No matter where you stand on mam-mography, most healthcare professionals are united in agreeing lifestyle modifi ca-tions and appropriate use of medications have been proven to prevent heart disease and save lives. However, Rosenbaum con-tends that facts alone aren’t enough. In-stead, she said the healthcare community needs to fi nd a way to tap into the emo-tional aspects of heart disease as success-fully as has been done with breast cancer.

In the her perspective piece, Rosen-baum wrote that although the fi rst decade

of educational campaigns such as Go Red for Women “led to a near doubling of women’s knowledge about heart disease, in the past few years, such efforts have failed to reap further gains.”

She told Medical News, “Our default in medicine is to give people facts, and then we don’t know what to do when we hit the wall. We know how to disseminate facts … we don’t know how to change feelings.”

Complicating the issue with heart disease is that in so many cases it is pre-ventable, and therefore comes with built-in guilt. Risk factors, which have been well publicized, include smoking, obesity, high blood pressure, high cholesterol, and sedentary lifestyle. “All of these are em-bedded with a sense of not taking care of yourself,” Rosenbaum said. “You should have done something differently.”

Conversely, breast cancer is imbued with a sense of having a terrible disease visited upon a victim, which is true. Also, because breast cancer kills more women at a younger age than heart disease, there are multiple media images of beautiful, strong heroines fi ghting and surviving … or suc-cumbing … to a disease that attacks a body part that is so uniquely feminine. Rosen-baum pointed out Angelina Jolie’s message about breast cancer resonated with women across the nation who saw the actress as a lovely, brave, fi erce role model.

Again, she stated, it isn’t ‘bad’ that breast cancer has pushed its way to the front of female consciousness. It’s smart … and perhaps it’s the type of message the fi eld of cardiology should consider to reach more women.

However, Rosenbaum said it isn’t fair to ask healthcare providers to try to change identity beliefs in a brief offi ce visit. Instead, she said the subject requires research regarding social values and group identity. Ultimately, Rosenbaum added, cultural messaging will likely come from a variety of sources including media outlets.

Today, she said, “Our biggest chal-lenge is translating what we know into better health of our population. The next phase of evidence based-medicine should be as much about fi guring out how to communicate that evidence to our pa-tients … to do that we have much to learn from the methodological approaches of the social sciences.”

Rosenbaum added the starting point to address women’s perceptions of heart disease should be to conduct focus groups to evaluate where emotional beliefs cur-rently stand and assess the impact of fram-ing messaging in different ways. “This is decades worth of work,” she stressed, “to ultimately understand not just how they feel and where those feelings come from, but to evaluate whether there are ap-propriate interventions that help women adopt more heart-healthy behaviors.”

While heart disease might have a de-cidedly masculine feel, there’s no reason why research can’t point to ways to soften the message and appeal on an emotional level to women, as well. After all, women are often identifi ed with their capacity to love … the trick will be fi nding the right words to help a woman celebrate her big heart while being cognizant of the dangers that come with having an enlarged one.


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SPRING ALLERGIES?

Preparing for PPACABY ALEXANDER T. RENFRO, JD, LLM

The Patient Protection and Affordable Care Act, or PPACA, presents a number of challenges to employers. Chief among these challenges are the employer mandates, excise penalties for failure to offer health coverage at a certain level of benefit and below a certain cost to plan participants. As the employer mandates go into effect beginning this coming January, planning is required to ensure that excise taxes are avoided, efficiency in plan design is preserved, and employees are provided a tangible benefit.

A positive method which can assist in meeting these goals exists. This method, known as the 8 Step Prep, separates the major tasks required of ideal PPACA preparation into eight manageable tasks. By completing each task, an employer creates a roadmap from planning to plan selection to execution in a timely manner, preserving the goals of compliance, efficiency, and benefitting plan participants.

Step 1: Education. With respect to PPACA, the more one knows, the more money one will save. PPACA contains a number of statutes and regulations which challenge employers, but a variety of exceptions, alternatives, and options are provided as well. Knowledge of these opportunities within the law will create savings and create an awareness of viable solutions for employers.

Step 2: Employer Classification. Building off of education, precise knowledge of how PPACA affects one’s own business is critical to determining a number of design and structural options with respect to a benefits plan. Many employers are not subject to the employer mandates, or are permitted to delay the effective date of the employer mandates until potentially December 2016.

Three general classifications are of most importance to employers. First, is the employer small or an applicable large employer with 50 or more full time employee equivalents? Applicable large employers are subject to the employer mandates. Second, on what market does the employer purchase insurance: the small group market (100 employees or less), the large group market (more than 100 employees), or the self-insured market? Finally, does the business qualify for transitional relief under the latest employer mandate regulations? (1)

Step 3: Employee Classification. Only certain employees need be provided coverage, namely full time employees. Identifying which employees must meet this

classification, which employees may meet this classification, and which employees do not meet this classification will ensure an efficient, compliant benefits offering. Furthermore, by understanding what PPACA considers a full-time employee through a look-back stability period, employers can effectively manage certain employees and maintain control of eligibility.

Step 4: Avoiding Discrimination. PPACA contains at least three forms of health discrimination rules. These rules vary based on how the employer insures the plan: through a commercial insurance company or on a self-insured basis. Currently, commercially insured plans have greater freedom with respect to discriminatory plans but less flexibility in plan design. Furthermore, a third type of health discrimination exists based on the cost of plan premiums for participants who are “similarly situated.” Though less known, this form of discrimination penalizes employers at $100/effected employee/day in excise taxes and should be carefully observed.

Step 5: Plan Design. Plan design, as noted above, is more flexible among self-insured plans. Irrespective of how a plan is designed, however, numerous factors must be considered to identify the most efficient, compliant plan which provides an appropriate level of benefits to participants. In some cases, this may mean higher deductibles, out of pocket expenses, and less benefits. In other cases, the employer may favor a more affordable plan for participants with a comprehensive benefits offering, blending medical benefits

subject to PPACA and excepted benefits which (when structured properly) avoid subjugation to PPACA.

Step 6: Participant Considerations. Once a plan design has been selected, the employer must properly communicate the terms of this plan well in advance of open enrollment for exchange plans, which will begin in October. These communications must advertise the benefit of the plan to employees, the compliance of the plan with PPACA requirements, which also entail a lack of subsidies for eligible participants, and offer guidance to those with questions.

Note that employers must deny subsidy access to employees to avoid excise penalties under the employer mandates. However, without properly communicating this fact, employers could still find themselves appealing pre-qualifications for subsidies or even paying excise penalties without adequately preparing employees.

Step 7: Plan Selection. Simultaneous with Step 6, employers must identify the correct product which meets the plan design considerations determined in Step 5. Adjustments to the plan design may be required, as employers are ultimately limited in plan design to products offered on the commercially insured and self-insured markets. Fortunately, a great variety of products exists on these markets. Thus, attention should be focused on identifying the appropriate plan for the employer and securing that plan for a start date which coincides with the effective date of the mandates for the employer.

Step 8: Managing Open Enrollment. Employers must be concerned with two open enrollment periods: the employer’s open enrollment and the exchanges’ open enrollment. As noted above, even employers with compliant plans can be penalized or subject to appeals of subsidy pre-qualification during open enrollment. Employers are encouraged to have documents evidencing compliance (such as the Plan Document) at hand, ready to meet the demands of regulatory agencies on short notice.

Finally, as employees ask questions, the employer must be ready with the answers. Controlling the education and enrollment activity of employees will ultimately build trust and permit the employer to effectively manage entrance into the employer plan.

Through this method, employers can create a compliant, efficient, and beneficial plan. As needed, employers are encouraged to seek advice from advisors knowledgeable and capable in assisting with PPACA preparations.

Though PPACA is a challenging law, proactive involvement can lead to a positive response for employers. The 8 Step Prep is a means of achieving such a response.

Alexander T. Renfro, JD, LLM, Ratliff Law Firm, collaborates with Lattimore Black Morgan & Cain, PC (LBMC), and the LBMC Family of companies, to bring you the latest healthcare reform information on a new Tennessee Healthcare Reform website, www.TNHealthcareReform.com.After graduating from the University of Notre Dame, Renfro went on to earn his JD from Southern Methodist University’s Dedman School of Law, and then to the Georgetown University Law Center, completing a Taxation LLM as well as a Certificate in Employee Benefits. He specializes in tax law, estate planning, and employee benefits. He is licensed to practice law in both Tennessee and Texas. He can be contacted at [email protected]

RXforReform


• History of partial or complete amputation of the foot

• History of previous foot ulceration• History of pre-ulcerative callus

formation• Peripheral neuropathy with

evidence of callus formation• Poor circulation• Foot deformityThe specifi cs of any of these inclusion

criteria must be not only listed on the Phy-sician Certifying Statement, but must also be specifi cally corroborated in the physi-cian encounter notes. Make sure your pa-tient encounter notes document that a foot evaluation was performed, and specifi cally document any of the justifying criteria

Prosthetic Environment, Daily Activities, and Functional Potential

When your patient receives the most appropriate device for them, they are more likely to be active, stabile, and per-form activities of daily living at their full-est potential. Physicians must evaluate and document both medical necessity and

functional capabilities.Medicare has established fi ve catego-

ries of “functional potential.” These are referred to as “K-levels” and range from K0 (prosthesis would not enhance quality of life or mobility) to K4 (ability or poten-tial for prosthetic ambulation that exceeds basic ambulation skills). Always document patient’s pre-prosthetic activities and your expectation that they can return to that level of activity.

Requirements for Prescribing Prosthetic Devices

This part is not nearly as overwhelm-ing as it sounds. It just takes discussion with your patient, and you need to include the following:

• Basic patient information, history, and need for use of a prosthesis

• History of amputation including therapeutic intentions, date, and side of amputation

• Description of functional limitations in a typical day

• Description of activities of daily living

• Other relevant diagnoses and comorbidities that would impact a patient’s ability to use a prosthesis

• Ambulatory assistive devices used or expected to use

• Functional capabilities prior to amputation and expected potential

Any problems amputees are having with their prosthesis and a plan to address these problems. Don’t just list the problems, but also report how patients use their pros-thesis to perform their daily activities. This documents a history of use to justify contin-

ued repairs and replacements as necessary. RecommendationsCommunicate effectively with your

O&P providers. Work with your prosthe-tist to evaluate, justify, and document a patient’s needs. We want to make the pro-cess from evaluation to delivery and follow up as smooth and effi cient as possible.

Ensure that your notes cover the cri-teria from the very initial consultation by communicating with your patients early on in the process.

Separate right and left devices as needed.

Ask prosthetic patients about their activities, environments, and daily use of their prosthetic devices and document them.

When prescribing diabetic shoes/insert, make sure that patients meet the qualifying criteria.

Rely on the expertise of your prosthe-tist and physical therapist. Our recommen-dations revolve around our understanding of a patient’s functional needs, functional potential, and appropriate prosthetic de-sign to achieve this potential. Take advan-tage of this expertise; however, the fi nal approval comes from the physician and physician documentation.

Chad McCracken, MS, CPO, is a Certifi ed Orthotist/Prosthetist, Clinical Manager, and Residency Directory with Victory Orthotics & Prosthetics in Bristol, Tennessee. He is certifi ed by the American Board of Certifi cation in Orthotics, Prosthetics & Pedorthics, and a member of The American Academy of Orthotists & Prosthetists and The Association of Children’s Prosthetic-Orthotic Clinics.

ClinicallySpeakingBY C. STONE MITCHELL, MD, FACS

Leave Pain Behind: Treatment Options for Pregnancy Hemorrhoids

As a surgeon who specializes in hemorrhoid treatment, I see many women who suffer from pregnancy-related hemorrhoids. Hemorrhoids are blood vessels in the rectal area that have become swollen. They may be inside or outside the anus and range from the size from a pea to the size of a cluster of grapes. Hemorrhoids can be simply itchy and mildly uncomfortable, or quite painful.

An estimated 20 to 50 percent of pregnant women experience hemorrhoids. The pressure of an enlarged uterus and increased blood fl ow to the pelvic area, plus constipation, may cause the condition during gestation, especially during the third trimester. Straining and pressure during labor can also aggravate existing hemorrhoids, causing extra discomfort and pain for new mothers.

Unfortunately, because of embarrassment or a belief that

hemorrhoids are just an unpleasant byproduct of pregnancy, many women may be hesitant to discuss the condition with their physician during or after pregnancy. Some women, concerned about a possible painful surgery and long recovery period never seek treatment. I have encountered numerous female patients who have been living with painful pregnancy hemorrhoids for years and years, unaware that gentle relief and treatment are readily available.

Physicians should discuss the occurrence of hemorrhoids with female patients and encourage them to seek treatment, if needed. During pregnancy, general hemorrhoid therapy includes soaking in warm (not hot) water several times a day, and propping up the legs as much as

possible. If a hemorrhoid has become

painfully thrombosed, with the blood pooling and clotting, it can be gently drained. The patient will feel immediate pain relief. For the comfort of the patient, the expertise of an experienced hemorrhoid specialist is invaluable in identifying and treating a thrombosed hemorrhoid. During pregnancy, an evaluation with a hemorrhoid specialist can provide immediate relief or a plan of treatment after delivery can be discussed, when their venous pressure has returned to a normal state.

In most people, 95% of hemorrhoids do not require surgery. Infrared coagulation is a painless, non-surgical treatment for hemorrhoids. It involves using a small

probe that exposes the vein above the hemorrhoid to short bursts of warm light, causing the hemorrhoid to shrink and recede. This treatment can be performed quickly, with no anesthesia, incisions, or stitches.

Women should understand that they do not have to live with the pain of pregnancy hemorrhoids. Gentle treatment can provide welcome, lasting relief to this common condition.

C. Stone Mitchell, MD, FACS, is a physician with the Premier Hemorrhoid Treatment Center in Knoxville, a division of Premier Surgical Associates. Dr. Mitchell is board certifi ed in general surgery by the American Board of Surgery and is a fellow of the American College of Surgeons.

Premier Surgical Associates is the Knoxville area’s largest surgical group, performing general, vascular, bariatric, breast, and laparoscopic procedures. Pre mier has offi ces in Knoxville, Dandridge, Maryville, Lenoir City, Sevierville, and Seymour.

Clinical Evaluation and Documentation, continued from page 5

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Women have unique health needs, which change as they enter different stages of life and assume new roles. Hormone

replacement therapy and pain management are two common health concerns for women of all ages. Unfortunately, not all therapies are effective for or well tolerated by all women seeking prescription relief for their health needs. Custom compounding can help bridge the gap between the limited choices in commercially available prescription medications and a patient’s specifi c needs.

Compounding professionals can prepare:

• Unique dosage forms containing the best dose of medication for each individual;• Medications in dosage forms that are not commercially available, such as transdermal gels, troches, “chewies” and lollipops;• Medications free of problem-causing excipients, such as dyes, sugar, lactose or alcohol;• Combinations of various compatible medications into a single dosage form for easier administration and improved compliance;• Medications that are not commercially available.

Hormone Replacement TherapyIn hormone replacement therapy, structural differences exist between human, synthetic and animal hormones. In order for a replacement hormone to fully replicate the function of hormones, which were originally naturally produced and present in the human body, the chemical structure must exactly match the original. There are signifi cant differences between hormones that are natural to humans and synthetic or horse preparations. Side chains can be added to a naturally occurring hormone to create a synthetic drug that can be patented by a manufacturer. A patented drug can be profi table to mass produce, and therefore a drug company can afford to fund research as to the medication’s use and effectiveness. However, naturally occurring substances cannot be patented, so scientifi c studies are less numerous on natural hormones because medical research is usually funded by drug companies.

Natural hormones include estrone (E1), estradiol (E2), progesterone, testosterone, dehydroepiandrosterone (DHEA) and pregnenolone. Compounding pharmacists work with patients and practitioners to provide customized hormone therapy in the most appropriate strength and dosage form to meet each woman’s specifi c needs. Hormone therapy should be initiated carefully after a woman’s medical and family history has been reviewed. Every woman is unique and will respond to therapy in her own way. Close monitoring and adjustments are essential.

Pain ManagementPain management is essential because even when the underlying disease process is stable, uncontrolled pain prevents patients from working productively, enjoying recreation or taking pleasure in their usual roles in the family and society. Chronic pain may have a myriad of causes and perpetuating factors, and therefore can be much more diffi cult to manage than acute pain, requiring a multidisciplinary approach and customized treatment protocols to meet the specifi c needs of each patient.

Optimal treatment may involve the use of medications that possess pain-relieving properties, including some antidepressants, anticonvulsants, antiarrhythmics, anesthetics, antiviral agents and NMDA (N-methyl-D-aspartate) antagonists. NMDA-receptor antagonists, such as dextromethorphan and ketamine, can block pain transmission in dorsal horn spinal neurons, reduce nociception, and decrease tolerance to and the need for opioid analgesics. By combining various agents that utilize different mechanisms to alter the sensation of pain, physicians have found that smaller concentrations of each medication can be used.

Topical and transdermal creams and gels can be formulated to provide high local concentrations at the site of application (e.g., NSAIDs for joint pain), for trigger point application (e.g., combinations of medications for neuropathic pain), or in a base that will allow systemic absorption. Side effects associated with oral administration can often be avoided when medications are used topically.

Studies suggest that there are no great restrictions on the type of drug that can be incorporated into a properly compounded transdermal gel. When medications are administered transdermally, they are not absorbed through the gastrointestinal system and do not undergo fi rst-pass hepatic metabolism.

Partnering with Compounding Pharmacists for Successful TherapiesCompounding pharmacists work together with patient and practitioner to solve problems by customizing medications that meet the specifi c needs of each individual. Compounding offers each patient a wider array of delivery systems from which to choose. When combined with individualized counseling from the compounding pharmacist in conjunction with the prescribing physician, these increased options result in therapies that are more likely to produce successful results for the patient.

The effi cacy of any formulation is directly related to its preparation, which is why the selection of a compounding pharmacy is critical. Ongoing training for compounding pharmacists and technicians, state-of-the-art equipment and high-quality chemicals are essential. Experience and ingenuity are important factors as well. When tweaking a formula or developing a unique preparation, the compounding pharmacist must consider physical and chemical properties of both the active ingredient and excipients, solubility, tonicity, viscosity, and the most appropriate dosage form or device for administering the needed medication. Standard Operating Procedures should be in place, stability studies should be considered when compounding, and appropriate potency and sterility testing should be performed.

Compounding Pharmacists Provide Customized Solutions for Women’s Health Needs

Cleve Anderson, chief pharmacist and owner of Bristol, Tenn.-based Anderson Compounding Pharmacy, received his Doctor of Pharmacy degree from Mercer University. He is a member of the American Chemical Society and the Rho Chi Society, an academic honor society for the pharmaceutical industry.

The professionals at Anderson Compounding Pharmacy have received advanced training and use specialized equipment, FDA-certifi ed chemicals and cosmetically appealing bases to customize medications that address the individual needs of each patient. We work together with physicians and other healthcare practitioners to solve medication problems.

Anderson Compounding Pharmacy is a member of Professional Compounding Centers of America, Inc., and is the only compounding pharmacy in Tennessee to earn both the Pharmacy Compounding Accreditation Board’s (PCAB®) Seal of Accreditation as well as the Healthcare Quality Association on Accreditation’s (HQAA) Seal of Accreditation.

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By hEAThER RIPLEy

There are recent reports claiming that more than 100,000 health-related apps are available for use on smartphones, tablets and other smart devices today. It’s incredible, when just 17 months ago it was reported that there were only an estimated 40,000 health-related apps.

And, if you Google the term “health-care apps,” you’ll get approximately 380 million results in less than half a second. To say the health-related app business is booming is almost an understatement. With that said, it’s worth mentioning to both consumers and businesses looking for ready-to-use apps or help creating new custom apps: choose wisely.

From a consumer point of view, some health-related apps are extremely helpful. Top rated apps include BMI Calculator, Fitness Buddy, Nike+ Running, Good-FoodNearYou, LiveScape and Calori-eTracker. These apps help people track calories, miles walked, speed, intensity, body mass, food calories, nutritional con-tent of food and calories burned. Many offer tips on staying healthy, making good food choices and even provide exercise routines with photos showing the right way to perform each exercise.

These apps can’t really hurt you, and may offer people reminders or informa-tion they can use throughout the day. However, there are also apps available that claim to detect skin cancer or diag-nose patients with a variety of conditions. Doctors warn people with health concerns to consult a doctor, not an app - and that is good advice. The best approach is to see

a doctor first, and ask him/her if a medi-cal app can help and which one is the best one, then use it according to the doctor’s recommendations.

In the business-to-business (B2B) arena, health and medical apps are be-coming more and more useful to health-care practitioners, doctors, nurses and even emergency medical technicians and paramedics. From simple apps that reduce the amount of time needed to research a condition to medical apps with the latest clinical information, online access to med-ical journals and updated textbooks on prescription drugs with photos and pos-sible interactions and side effects, medical apps are becoming more sophisticated.

Apps already available allow doc-tors to access electronic medical records

(EMR), share X-rays and EKGs with other doctors, review clinical photos of a variety of conditions, see images of or-gans from medical journals and case stud-ies, view 3D layer images of muscles and anatomy and much more.

The most exciting news in mobile medical healthcare involves apps that can be used by doctors and other healthcare professionals via Google Glass, a wear-able microcomputer. Ripley PR, with extensive experience in healthcare IT, is currently developing Google Glass apps for a variety of uses. This will be a huge business in the future as more developers find innovative ways to utilize the capabili-ties and potential capabilities of wearable computers in healthcare situations.

There is another type of healthcare business app I haven’t touched on that I think will revolutionize the way health-care is performed on-site and clinically. We’re in development with several apps that will streamline the way healthcare businesses provide in-home healthcare. Used in conjunction with smartphones and tablets, these apps can manage com-plex dispatch and shift systems for home health providers with a simple dashboard that automates much of the work formerly done by office staff, dispatch staff and health workers. This frees up staff to deal with the other important tasks they per-form, rather than spending hours schedul-ing and rescheduling and tracking where workers are and how long they were at a home or care facility. Apps even provide automation of visit purpose, client status, hours and billing in addition to reducing or even eliminating paper forms.

It is a brave new world in business app development, but as always the onus is on the buyer. Make sure you work with a developer who has a track record in your field and check out their other apps. The right business apps can save you a lot of money, but be sure to do your due dili-gence up front before you sign on the dot-ted line.

Healthcare Apps Are All the Rage, But Do You Need One?

ments than ECT, the cost is normally less than ECT when factoring in facility charges and the cost from general anes-thesia. For patients located near Johnson City, TMS is also much more convenient, located in the ETSU Innovation Lab at 2109 West Market Street, Suite 122. The closest facility for ECT is located in Leba-non, Va. As Moore pointed out, “TMS is convenient for both the patient and treat-ing physician.”

Patients may be a little apprehensive about the therapy, but most patients who truly need the therapy want to try it, and their willingness helps to confirm the di-agnosis. As Moore explained, education about the therapy also sets their mind at ease.

During the initial visit, we locate the target point for stimulation of the fron-tal cortex by taking measurements and adjusting the chair accordingly. We also measure the motor threshold, which var-ies in each patient. Although the first visit takes a little longer, most treatments take about 45 minutes to an hour.”

Moore, along with three other phy-sicians who practice in the Department of Psychiatry with Quillen ETSU Physi-cians, are trained to oversee the therapy, including Faith Aimua, MD, Joel P. Ch-isholm, MD, and Rushiraj C. Laiwala, MD. Excited about the opportunities TMS provides for both patients and ETSU, Moore, who is the chief editor of the peer-reviewed journal ‘Clinical EEG & Neuroscience,’ said that he and his col-leagues will be traveling to the Journal’s International Annual Meeting, in Sep-tember, to present a half-day workshop on TMS therapy.

The department is currently accept-ing new patient referrals.

TMS Therapy Offers Treatment Option, continued from page7

Heather Ripley is the founder and CEO of Ripley PR, a business-to-business (B2B) public relations agency specializing in Healthcare IT. For more information, visit www.ripleypr.com or email [email protected].


Knoxville MGMA Monthly MeetingDate: 3rd Thursday of each month

Time: 11:30 AM until 1:00 PMLocation: Bearden Banquet Hall, 5806 Kingston Pike,

Knoxville, TN 37919Lunch is $10 for regular members.

Come learn and network with peers at our monthly meetings. Topics are available on the website.

Registration is required. Visit www.kamgma.com.

Chattanooga MGMA Monthly MeetingDate: 2nd Wednesday of each month

Time: 11:30 AMLocation: The monthly meetings are held in Meeting Room A of the Diagnostic Center building, Parkridge Medical Center, 2205

McCallie Avenue, Chattanooga, TN 37404 Lunch is provided at no cost for members, and there is currently no cost to a visitor who is the guest of a current member. Each member is limited to one unpaid guest per meeting, additional guests will be $20 per guest. All guests must be confi rmed on

the Friday prior to the meeting.RSVP to Irene Gruter, e-mail: [email protected] or call

622.2872. For more information, visit www.cmgma.net.

3RD THURSDAY 2ND WEDNESDAY

Mark Your CalendarYour local Medical Group Managers Association is Connecting Members and

Building Partnerships. All area Healthcare Managers are invited to attend.

Heimlich’s Maneuvers

by Henry J. Heimlich, MD; c.2014, Prometheus Books; $19.95 / $21.00 Canada, 253 pages

In the new book Heimlich’s Maneuvers by Henry J. Heimlich, MD, you’ll find out why you deserve a pat on the back – ex-cept if you’re choking – from the man who invented the lifesaving measure.

From the time he was a small boy growing up in New York, Henry Heim-lich wanted to be a doctor. His parents were role models: he watched them help others, and he noticed that they never turned anyone away. He wanted to be like them – and he started down that path at age 21, when he assisted the victim of a train wreck until rescuers ar-rived. That was the first of “hundreds of thousands” of lives Heimlich would save.

While in college, Heimlich led the ROTC band, then, as required, enlisted in the military.

After graduation, he was called for duty and served in the Navy on a special mission to China during World War II. There, he taught Chinese soldiers first-aid basics and, because anti-Semitism was rampant in America, he taught fel-low soldiers that the myths they believed about Jews were largely wrong.

That bias against Jews almost cost the doctor his career: Heimlich had a hard time finding a residency position after the war ended, but he knew he was in a good spot when he landed at Bel-levue in New York. He had his sights set on becoming a thoracic surgeon special-izing in the esophagus and, ever the tin-kerer, Heimlich began looking for ways to improve old methods of treatment.

Back in China, he’d developed an easier way to treat trachoma and save the eyesight of sufferers. In the 1950s, he developed the reversed gastric tube operation (though he later learned that he wasn’t the first to use it). During the Vietnam War, he developed a way to drain post-surgery chest wounds.

And in 1972, he gave the world a life-saving hug…

There’s so much delight in Heim-lich’s Maneuvers and so many surprises to uncover while reading this book. Too bad there’s one big thumbs-down.

First, I was overwhelmingly charmed by author Henry J. Heimlich’s story, and by the jaunty way he tells his tales. Heimlich writes with an obvious sparkle in his eye, and it’s a worthwhile trip we take with him, back to his childhood, his young marriage, his early career, his keen eye for invention, and his battle with the Red Cross. Even his World War II tales held excitement.

Unfortunately, it seemed to me that this book sometimes descends into infomercial territory, in which Heimlich uses his memoir to promote his inven-tions. I thought that marred the feel of this book–not enough to make me want to quit reading, but enough to

make me notice.I think that if you ignore the com-

mercials, you’ll like what you ultimately find here. If it’s a good memoir you want, Heimlich’s Maneuvers has that down pat.

The Mayo Clinic Guide to Stress-Free Living

by Amit Sood, MD, Msc; c.2014, DaCapo Lifelong Books; $19.99 / $23.00 Canada, 320 pages

You’re over just about everything: overworked, overloaded, and overwhelmed. But when you read The Mayo Clinic Guide to Stress-Free Living by Amit Sood, MD, M.Sc, you might start to feel overall better.

In today’s world, it’s nearly impossi-ble not to feel strain. At least that’s how it seems, and it only gets worse as we “get hijacked by impulses, infatuation, and fear,” the brain wants to “escape the present moment,” and the mind thinks everything’s a danger. Says Sood, we “struggle with what is,” which is the very definition of stress.

Part of the reason for the struggle is that, when you’re awake, your brain op-erates in one of two ways: default or fo-cused. You’ve undoubtedly experienced both.

In focused mode, you’re so im-mersed in the task at hand that you for-get about almost everything surround-ing you. In default mode, your brain wanders like an idle shopper, moseying from problem to worry to idea, spinning and projecting future scenarios. The key is to teach yourself to stay on “focused” mode and out of the “black hole” of me-andering default.

Part of that can be done with “at-

tention training,” which has many facets and which “speaks to the child” in you; and by “refining interpretations,” which appeals to the adult within.

Learn to pay “joyful attention,” which helps with calming and keeps your mind occupied so it doesn’t wander. Learn CRAVE, patience, and CALF when relating to others. Free your prejudices in order to “open to the world.” Accept that nothing is perfect and that there are times when forgiveness isn’t required. Begin each day with thankfulness. Learn pride in work. And remember that com-passion for others should extend to com-passion for yourself.

When an institution like the Mayo Clinic attaches its name to a book, you kind of expect it’d be totally serious stuff, right?

Nope. Author Amit Sood has quite a bit of fun in this book, which certainly supports its title and its joyful cover.

But first, The Mayo Clinic Guide to Stress-Free Living opens in a classroom, then turns to the science of the brain, which serves as a nice reminder, but – since bookstore shelves are packed with brain books – might be unnecessary for some readers.

That’s okay, though, because what comes next is worth it: Sood teaches us to “train” our minds to stress when appropriate, live with acceptance, and appreciate others. This, too, might be repetitious for readers who’ve filled up on motivational-type books like this one, though I took great delight in this par-ticular handling of the subject.

I also liked that Sood didn’t pretend this is easy, but reducing stress and less-ening worry sure sounds appealing and that’s enough for me.

theLiteraryExaminerBY TERRI SCHLICHENMEYER

Terri Schlichenmeyer has been reading since she was 3 years old, and she never goes anywhere without a book. She lives on a hill in Wisconsin with two dogs and 11,000 books.

The University of Tennessee Medical Center Cole Neuroscience Center Recognized as a Center for Comprehensive MS Care

KNOXVILLE – The Cole Neurosci-ence Center at The University of Tennessee Medical Center is now officially recognized as a Center for Comprehensive MS Care through the National MS Society’s Partners in MS Care program. This formal recogni-tion honors Cole Neuroscience’s commit-ment to providing exceptional coordinated, comprehensive MS care; and a continuing partnership with the Society to address the challenges of people affected by MS. The center is a leading provider of care for peo-ple living with MS in the region.

A Center for Comprehensive MS Care recognizes the critical need for access to a full array of medical, psycho-social and re-habilitation services to address the varied and often complex issues related to living with MS, an unpredictable, often disabling disease of the central nervous system. The Partners in MS Care program acknowledges and encourages total care of people living with MS. The central focus is on the ability of patients to access the needed services, which may be offered on-site or through re-ferral, while upholding excellence in coordi-nated and comprehensive MS care.

“We are so proud to partner with the Cole Neuroscience Center to enhance co-ordinated, comprehensive care for the more than 1,600 people who live with MS in East Tennessee,” said Stacy Mulder, president of the Society’s Mid-South Chapter. “In earn-ing this recognition, Cole Neuroscience has demonstrated extraordinary leadership in MS care, making a tremendous impact on people affected by MS in our community.”

For information about this program, please visit http://www..org/Treating-MS/Comprehensive-Care/Find-an-MS-Care-Provider/Partners-in-nationalmssocietyMS-Care. For information about the National MS Society, visit www.nationalMSsociety.org

GrandRounds


Mark Your CalendarYour local Medical Group Managers Association is Connecting Members and Building

Partnerships. All area Healthcare Managers (including non-members) are invited to attend.

JOHNSON CITY MGMA MONTHLY MEETING

Date: The 2nd Thursday of Each MonthTime: 11:30 AM – 1:00 PM

Location: Quillen ETSU Physicians Clinical Education Building, 325 N. State of Franklin Rd.,

Johnson City

KINGSPORT MGMA MONTHLY MEETING

Date: The 3rd Thursday of Each Month Time: 11:30 AM – 1:00 PM

Location: Indian Path Medical Center Conference Room, Building 2002,

Second Floor, Kingsport

2ND THURSDAY 3RD THURSDAY

First Emergency Medicine Fellowship in Tennessee Begins at Erlanger and UT College of Medicine Chattanooga

CHATTANOOGA – The Accreditation Council for Graduate Medical Education re-cently approved the first Emergency Medi-cine Fellowship in the state of Tennessee for the UT College of Medicine Chattanooga (UTCOMC), based at Erlanger. The program will begin operations on July 1, 2014, for the upcoming academic year.

Erlanger and UTCOMC is also the home base for the first Emergency Medi-cine residency program within the UT sys-tem, serving as a model for emergency medicine education programs throughout the state and region. “The addition of the state’s first Emergency Medicine Fellowship at Erlanger showcases our commitment to

the pre-hospital environment and trauma care,” said Kevin M. Spiegel, FACHE, Er-langer President and CEO.

Knoxville’s Leigh Sterling Elected to Healtheway, Inc. Board of Directors etHIN Director to Help Guide Ongoing Development of National Health Information Network

KNOXVILLE – The East Tennessee Health Information Network (etHIN) an-nounced that Executive Director Leigh Sterling has been elected to serve on the Board of Healthe-way, Inc., the organization charged with operational support of the nationwide eHealth Exchange. Sterling

joins healthcare leaders from across the United States in the endeavor to empower modern healthcare through secure, nation-wide, electronic information exchange.

The eHealth Exchange, formerly known as the Nationwide Health Information Net-work Exchange, is a group of organizations operating together to improve patient care, streamline disability benefit claims, and im-prove population health.

The Exchange solves many of the chal-lenges health organizations face in setting up secure, online data exchange with other groups. Among other benefits, the eHealth Exchange provides a standardized and cost-effective way to securely share clinical infor-mation, complements state and regional health information organization efforts to connect their communities, and expedites processing of disability claims and payment of benefits to the disabled.

For more information about etHIN, contact [email protected]

Provectus Biopharmaceuticals’ PV-10 Data to Feature in Poster Presentation at the American Society of Clinical Oncology (ASCO) Annual Meeting

KNOXVILLE – Provectus Biopharma-ceuticals, Inc. (OTCQB:PVCT) (http://www.pvct.com), a development-stage oncology and dermatology biopharmaceutical com-pany, announced that data on its investi-gational drug PV-10 will be featured in a presentation by investigators from Moffitt Cancer Center in a Poster Highlights Ses-sion of the American Society of Clinical Oncology (ASCO) Annual Meeting at Mc-Cormick Place, Chicago, IL, May 30-June 3, 2014. The time and date of the presentation are expected to become available on the ASCO website, http://am.asco.org, on April 21, 2014.

The poster, based upon abstract #9028, is entitled “Assessment of immune and clinical efficacy after intralesional PV-10 in in-jected and uninjected metastatic melanoma lesions,” and is authored by Amod Sarnaik, MD, and colleagues of Moffitt.

Craig Dees, PhD, CEO of Provectus said, “We value our relationship with Moffitt

greatly, and we are excited by the assess-ment Dr. Sarnaik has made on clinical and immunologic activity of intralesional PV-10.”

Provectus has recently submitted an application to the FDA for breakthrough therapy designation for PV-10 based on the results from its Phase 2 clinical study of melanoma and is researching its efficacy for other indications.

Phillip Fulmer Recruited for New Effort with Red Cross Former Coach to Advocate for Community Preparedness

KNOXVILLE — Phillip Fulmer has been named Community Resiliency Spokesper-son for the East Tennessee Region of the American Red Cross.

In his new role, Fulmer will advocate for emergency planning, disaster response, and training for life saving skills.

Fulmer recently learned of the impor-tance of first aid training after realizing he didn’t have the necessary skills to help a friend who began choking.

“Phillip Fulmer has a long history of success,” said East Tennessee Regional CEO Michelle Hankes. “He knows how to build a winning team and we’re confident his leadership will help save lives”.

As temperatures begin to warm up across East Tennessee, more people will be out and about potentially increasing the chances you’ll encounter someone suffering an emergency.

Fulmer steps into his new role immedi-ately. He will be the Keynote Speaker at the 7th Annual Hometown Heroes Luncheon in Chattanooga on May 14th. Tickets are avail-able at redcross.org/setn

The East Tennessee Region of the American Red Cross encompasses 36 coun-ties and includes Knoxville, Chattanooga, Kingsport, Johnson City, and Crossville.

Turkey Creek Medical Center Achieves New Status of Accredited Chest Pain Center

KNOXVILLE – Tennova Healthcare is pleased to announce that the Chest Pain Center at Turkey Creek Medical Center has received full accreditation from the Soci-ety of Cardiovascular Patient Care (SCPC), an international organization dedicated to eliminating heart disease as the number one cause of death worldwide.

“Our goal when we started the rigor-ous process of becoming accredited was to be a leader in the region in the care of patients with chest pain,” said Ravi Mehta, MD, FACC, a board-certified cardiologist with East Tennessee Health Consultants at Turkey Creek Medical Center.

The Accredited Chest Pain Center at Turkey Creek has demonstrated its exper-tise and commitment to quality patient care by meeting or exceeding stringent criteria and undergoing an onsite review by a team of SCPC’s accreditation review specialists.

“I am proud of our entire cardiac and emergency medicine team,” said Lance Jones, CEO of Turkey Creek Medical Cen-ter. “This accreditation is a testament to the hard work and dedication of our medi-cal staff, registered nurses, EMS, and other clinicians to provide the highest quality, evidence-based care. Turkey Creek Medical Center remains a leader in establishing the highest level of care for our patients as rep-resented by this achievement.”

Turkey Creek Medical Center is among

GrandRounds

Surgeon and Facility are Designated National Observation Sites for Prostatectomy Procedure

KNOXVILLE – On April 4, Christopher Ramsey, MD, urologist with Physicians Regional Medical Center (PRMC), performed his one-thousandth robotic-assisted prostate surgery with the facility’s surgical team.

Established in 2006, the robotic-assisted surgical team at PRMC per-forms the most prostatectomy pro-cedures in the metro region. “The team is the key to an excellent and efficient program,” said Ramsey. “Ef-ficiency means that patients are in the operating room and under an-esthesia for less time and can begin their recovery more quickly.”

Ramsey and Physicians Region-al Medical Center are designated National Observation Sites for robot-ic-assisted prostate surgery. National Observation Site designation rec-ognizes a surgeon who consistently demonstrates exceptional outcomes with high numbers of patients. Physi-cians who are interested in learning more about robotic-assisted surgery can arrange to visit National Observation Sites to observe successful programs first-hand.

“Physicians Regional congratulates Dr. Ramsey on this milestone achievement. We are pleased to be able to provide the technology for robotic-assisted surgery and a skilled and dedicated surgical team to our patients,” said Karen Metz, CEO of Physicians Regional Medi-cal Center. “We are committed to making investments that improve patient safety, quality and outcomes.”

Urologist Christopher Ramsey, M.D., performed his 1,000th robotic-assisted prostate surgery with the Robotics Team at Physicians Regional in early April.

Leigh Sterling


GrandRoundsthe first hospitals in the region to receive this prestigious recognition. The Chest Pain Center at Tennova Healthcare’s Physicians Regional Medical Center was accredited in 2012.

Community Health Council Announces New Members

KNOXVILE – The Community Health Council has elected eight new members and appointed a new chair-elect. New members began service in April 2014.

The Community Health Council evolved from the Together! Healthy Knox Leadership Team, which was convened in 2010 by the Knox County Health Depart-ment with the mission: a community ap-proach to better health. Since its inception, the partnership has assessed health and perceptions of health in Knox County and used the data to identify overarching stra-tegic issues for health improvement. The initiative has also recruited representatives from more than 50 community organizations and agencies to develop and implement ac-tion plans to improve public health.

Elected in March, the new Community Health Council members are: Kindall Aaron, coordinator of the Knoxville Area Coalition on Childhood Obesity; Gaye Fortner, presi-dent and CEO of Healthcare 21 Business Coalition; Ben Harrington, executive direc-tor of the Mental Health Association of East Tennessee; Melissa Knight, executive direc-tor of Interfaith Health Clinic; Laurie Me-schke, associate professor of public health at the University of Tennessee; Eve Thomas, captain with the Knoxville Police Depart-ment; Lisa Wagoner, supervisor of Health Services and Coordinated School Health for Knox County Schools; and Carlos Yunsan, associate with Baker Donelson, Bearman, Caldwell and Berkowitz, PC.

The council also appointed Kristy Alt-man, director for client service for Mary Beth West Communications, LLC, as the chair-elect. Altman is the Knox County Mayor’s appointee and is currently serving a three-year term. She will serve alongside Karen Pershing, chair of the council and executive director of the Metropolitan Drug Commis-sion.

Erlanger awarded highest recognition for complex stroke care

CHATTANOOGA – Erlanger’s South-east Regional Stroke Center has been awarded the Comprehensive Stroke Center Certification by The Joint Commission and the American Heart Association/American Stroke Association. This certification rec-ognizes hospitals offering the highest level of care for those with the most severe and challenging types of strokes and cerebro-vascular disease.

Health care systems awarded the Com-prehensive Stroke Center Certification are recognized for having state-of-the-art infra-structure, staff, and training to receive and treat patients with acute to the most com-plex stroke cases.

To achieve this certification, Erlanger’s stroke center team underwent a rigorous onsite review. The Joint Commission survey-ors reviewed Erlanger’s compliance with the Comprehensive Stroke Center standards and requirements, including advanced im-aging capabilities, 24/7 availability of spe-cialized treatments and staff with the unique education and competencies to care for

complex stroke patients.“By achieving this advanced certifica-

tion, Erlanger has thoroughly demonstrated the greatest level of commitment to the care of its patients with a complex stroke condition,” said Mark R. Chassin, MD, FACP, MPP, MPH, President of The Joint Commis-sion. “Certification is a voluntary process, and The Joint Commission commends Er-langer for successfully undertaking this chal-lenge to elevate the standard of its care for the community it serves.”

For more information on The Joint Commission and American Heart Associa-tion’s Advance Certification for Comprehen-sive Stroke Center visit www.jointcommis-sion.org/ or www.heart.org/myhospital.

Helen Ross McNabb Center CEO Andy Black announces retirement and welcomes Jerry Vagnier as successor

KNOXVILLE –Helen Ross McNabb Center’s CEO, Andy Black, announced his plans to retire, effective June 30, this week.

In turn, the Center’s Board of Directors voted to name Jerry Vagnier as the Center’s new CEO. Jerry has been serving as President since 2013 and will now as-sume the additional respon-sibilities of CEO, effective July 1, 2014. Black will re-main close to the organiza-tion in an advisory role.

Black has served as CEO since 2003 and began his career at the Helen Ross McNabb Center in 1986 as the Director of Develop-ment. In 2003 when Black was named CEO, the Center served approximately 7,000 children and adults. Last year, the Center served approximately 20,000 individuals in 21 East Tennessee counties.

During his tenure with the Helen Ross McNabb Center, Andy Black has increased access to affordable, quality health care for thousands of East Tennesseans facing men-tal health, addiction and social challenges. He has led the charge to expand access to care in rural communities and has built out continuums of service that help those in our communities with the greatest needs and the least resources. Most recently, Black oversaw mergers with organizations like Child & Family Tennessee, Fortwood Center of Chattanooga, Youth Emergency Shelter of Morristown and the Sexual Assault Cen-ter of East Tennessee.

Black has raised more than $20 million on behalf of the Helen Ross McNabb Foun-dation, establishing a legacy, which will en-sure the sustainability of services long into the future. Black’s fiscal conservative lead-ership has allowed the Center to direct its resources towards providing quality services to individuals in East Tennessee.

Jerry Vagnier has been with the Helen Ross McNabb Center for 26 years, starting as a social worker, providing direct care to children and adolescents. He has since held a number of clinical management positions before moving into administrative roles.

Patricia Neal Rehabilitation Center Receives Accreditations

KNOXVILLE – The Commission on Accreditation of Rehabilitation Facilities (CARF) has awarded the Patricia Neal Reha-bilitation Center a three-year accreditation for the following programs.

•Brain Injury Inpatient Rehabilitation (Adults, Children, and Adolescents)

•Brain Injury Outpatient Rehabilitation (Adults, Children, and Adolescents)

•Inpatient Medical Rehabilitation (Adults, Children, and Adolescents)

•Outpatient Medical Rehabilitation (Adults, Children, and Adolescents)

•Stroke Inpatient Rehabilitation•Stroke Outpatient RehabilitationThis represents the highest level of ac-

creditation that can be awarded to an orga-nization and shows Patricia Neal Rehabilita-tion’s substantial efforts to meet the CARF standards. With Patricia Neal Rehabilitation receiving a three-year accreditation, it has put itself through a rigorous peer review process. It demonstrated to a team of sur-veyors during an on-site visit its commit-ment to offering programs and services that are measurable, accountable and of the highest quality.

CARF is an independent, nonprofit ac-crediting body whose mission is to promote the quality, value and optimal outcomes of services through a consultative accredita-tion process and continuous improvement services that center on enhancing the lives of the persons served.

Lattimore Black Morgan & Cain, PC Among Accounting Today’s Top 50 Firms

NASHVILLE – Lattimore Black Morgan & Cain, PC (LBMC), Tennessee’s largest re-gional accounting and business consulting firm, has ranked 44th among the top 100 accounting, tax and consulting firms in the United States by Accounting Today.

LBMC made the TOP 50 in the account-ing industry trade publication’s 2014 Top 100 firms, moving up three slots in the rankings. The rankings for the publication’s report were based on the annual revenue size with an average overall revenue growth for the Top 100 firms of eight percent among the industry leading firms. LBMC saw a strong net revenue growth and organic growth well above the national average and was named an Accounting Today Best Firms to Work for in 2013.

Study of New Treatment During UT LIFESTAR Flights May Reduce Trauma Deaths

KNOXVILLE –The University of Tennessee Medical Center is participating in a clinical trial aimed at saving the lives of trauma patients who have uncontrolled bleeding. The treat-ment involves admin-istering plasma, which has clotting capabilities, to patients while they are aboard UT LIFE-STAR helicopters. This is a standard process of care, but it typically occurs several minutes later, once the patient arrives at the trauma center.

Giving plasma to patients quicker has resulted in improved survival rates in previous trials of injured soldiers in combat zones, such as Afghanistan. This study will bring the battle-field tested process to the East Tennessee community.

“We utilize UT LIFESTAR as an integral extension of the Trauma Center at The University of Tennessee Medical Center,” said Dr. Brian J. Daley, principal investigator of the study and Trauma Medical Director at UT Medical Center. “On the helicopters we carry lifesaving re-suscitation techniques proven on the battlefield and in our domestic Trauma Centers to the patient rather than simply having the aircraft serve as a transport mechanism for our patients. This study enables us to see if the known benefits of plasma treatment, normally delivered in the Emergency Department, are improved by delivering it at the earliest possible moment by our flight nurses and paramedics.”

Significant blood loss can lead to multiple organ failure and is a leading cause of death among trauma patients. The study, known as the Pre-hospital Air Medical Plasma Trial (PAM-Per), will be conducted at six trauma centers throughout the nation. It is sponsored by the U.S. Department of Defense, the University of Pittsburgh and the University of Pittsburgh Medical Center.

UT LIFESTAR medical helicopters are already stocked with red blood cells for in-flight transfusion, but plasma has not been available on the aircraft previously.

Severe trauma patients are generally unable to give consent to participate in a study of this nature. According to Daley, this is believed to be the first community consent study conducted in the Knoxville region, meaning the plasma can be administered for lifesaving purposes without specific consent from trauma patients. Any member of the community not wanting to receive plasma or take part in the study can opt out of inclusion.

For more information or to opt out, visit http://pamperstudy.com or contact Meghan Buck at (855) 730-8140 or by email at [email protected].

Andy Black

Jerry Vagnier


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Summit Opens Statcare Pulmonary Consultants Location in West Knoxville

KNOXVILLE – Statcare Pulmonary Consultants, a division of Summit Medical Group, has expanded to better serve the healthcare needs of the West Knoxville area. The practice is now seeing patients within

Farragut Summit Express Clinic’s new loca-tion in Century Plaza, 10820 Kingston Pike, Suite 11, Knoxville.

Hours are Monday-Friday, 7:30 – 11:30 am. Physicians accepting patients at the lo-cation: Dr. Scott Luchsinger, Dr. John Prince and Dr. Matthew Reichert.

New patients are accepted as well

as existing patients of Statcare Pulmonary Consultants, Sutherland Avenue location.

Concord Medical Center Opens New Location in Lenoir City

KNOXVILLE – Loudon County resi-dents now have a new Summit Medical Group location to visit for primary health-care needs. Concord Medical Center, Lenoir City, opened at 721 Highway 321 North, Suite C. Office hours are Monday – Friday, 8 am to 5 pm.

Antoin Mardini, MD, will provide office hours Tuesday and Wednesday afternoons; Walker Nowell, MD, Thursday and Friday afternoons. Nurse Practitioner Richard Fee will provide office hours Monday-Friday from 8 am to 5 pm.

Concord Medical Center is one of Sum-mit’s Medical Group’s largest family practice locations, serving the Farragut community at 10215 Kingston Pike.

Summit Express Clinic Farragut Opens in New Location10820 Kingston Pike, Century Plaza

KNOXVILLE – A new location for ur-gent care needs in Farragut/West Knoxville opened recently in Century Plaza, across from Costco. Summit Express Clinic, Farra-gut, moves from the Grigsby Chapel loca-tion to 10820 Kingston Pike, Suite 11. The address is new, but hours and phone num-ber remain the same.

The move will provide greater acces-sibility and convenience. Summit Express Clinic, Farragut, is one of three urgent care centers. Other locations include Fountain City and Deane Hill.

Hours: Monday–Friday: Noon (12 p.m.)–8 p.m. Saturday: 9 a.m.–5 p.m. Sun-day: Noon (12 p.m.)–8 p.m. Walk-ins are wel-come. Appointments are encouraged

RaceWay Fuel Centers & Red Cross Present “Fill Up & Fuel Disaster Relief”

KNOXVILLE – The American Red Cross of Southeast Tennessee is proud to partner with RaceWay Petroleum Company to launch a new joint fundraising initiative, “Fill Up & Fuel Disaster Relief” – an initiative engaging drivers to fuel up at participating RaceWay locations, then gallon for gallon, RaceWay will make a donation each month to support American Red Cross Disaster Relief.

“One cent of every gallon pumped off the Red Cross logoed pumps at any of these loca-tions will be donated to the American Red Cross for the remainder of 2014,” said Greg Waite, CEO, American Red Cross of Southeast Tennessee. “We are fortunate to have great supporters in our community like RaceWay Fuel Centers that are willing to help us raise critical funds to support our mission in the community,” Waite added. Drivers are encouraged to find a RaceWay loca-tion nearest to them and help the Red Cross help others one gallon at a time.

•Cleveland: 1565 25th Street NW, Cleveland

•Rossville Blvd: 2720 Rossville Blvd. Chattanooga

•Kimball: 141 Main Street, Kimball•Manchester: 2277 Hillsboro Blvd,

Manchester•Dayton Pike: 7019 Hwy 153, Hixson•Ooltewah: 9208 Lee Highway, Ooltewah•Signal Mtn: 405 Signal Mtn Rd.,

Chattanooga•Hixson: 5455 Hixson Pike, ChattanoogaIn addition, all area RaceWay Fuel Centers

will participate in a Customer Donation program encouraging the public to make donations to support the American Red Cross at any of their fuel centers.

“Every donation – big and small will help people right here in our community impacted by disaster.” Waite said. “In the month of March alone, Red Cross volunteers have assisted over 150 people post-disaster including the most recent Jaycee Towers evacuation and shel-ter. This is in addition to supporting national and larger scale disasters like the ongoing effort in Oso, Washington after the landslide.”

Learn more about the partnership or how to find a RaceWay Fuel Center near you by visiting: www.redcross.org/SETN or www.racewaypetroleum.com.

The Fill Up and Fuel Disaster Relief Fundraising program will run through December 31, 2014.

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