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Stroke Risks in WomenNew guidelines address risk factors unique to women ... 5

A New View on Stroke ResearchEveryone wants to build a better mousetrap … but building it over and over again isn’t very effi cient. Finding a way to keep the ‘mousetrap’ infrastructure in place while adding new features based on a collective body of knowledge is fundamentally the basis of the new National Institutes of Health Stroke Trials Network ... 6

A Look at the State’s CON ProgramLast year, members of the 108th Regular Session of the Tennessee Legislature voted unanimously to extend the life of the Health Services and Development Agency through June 30, 2017. This action ensured the state’s certifi cate of need (CON) program would continue, uninterrupted, into its 44th year ... 8

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FOCUS TOPICS STROKE HEALTHCARE DESIGN & CONSTRUCTION

Robert A. Mericle, MD

PAGE 3

PHYSICIAN SPOTLIGHT

ONLINE:NASHVILLEMEDICALNEWS.COMNEWS.COM

A Master PlanHealthcare’s Evolving Delivery Needs Change the Design Process

Beating the Odds: Medical Breakthroughs Decrease Stroke Risk for AFib Patients

By MELANIE KILGORE-HILL

Stroke is the fourth leading cause of death in the United States and the leading cause of disability. Fortunately, innovations in technol-ogy and medicine are making prevention more attainable than ever before in high-risk patient groups.

AFib & Stroke RiskChristopher Ellis, MD, cardiac electrophysiologist at Vanderbilt

Heart and Vascular Institute, said atrial fi brillation makes patients fi ve times more likely to have a stroke. In AFib, which affects an esti-mated 3 million Americans, the irregular heartbeat makes it harder for the upper and lower chambers to work together, leading to an increased likelihood that blood will pool and clots form.

“When it comes to AFib management, the most important thing in my mind is how I can prevent stroke,” said Ellis, who specializes in invasive atrial fi brillation therapies. “A lot of people think if you have a history of AFib but aren’t currently in AFib, you don’t need treat-ment, but it doesn’t take long for it to fl ip in and throw a clot. The risk of stroke is the same for patients with intermittent or chronic AFib.”

(CONTINUED ON PAGE 4)

By CINDy SANDERS

Long before the ribbon is cut … before the very fi rst rendering is unveiled … the real work of today’s healthcare design typically begins in a boardroom with a list of thought-provoking questions and a notepad.

While ‘form follows function’ has been a design staple for many years, the architec-tural commandment has traditionally focused on crafting the optimal space within a single facility to meet a client’s needs. Yet, the changing healthcare delivery landscape means architects now must consider not only what happens inside the four walls of a healthcare structure but also how that facility must interact and function within the larger community.


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begins with the identification of visible landmarks on brain imaging. Next, the target of choice is located by measuring known distances relative to those landmarks. Unfortunately, this indirect method does not account for individual anatomic variability. Improved technology in magnetic resonance imaging (MRI) allows direct visualization of deep brain regions, which can help account for some individual variation. After selecting the target point, an entry point is selected such that the trajectory avoids vessels, which reduces the incidence of bleeding complications. The translation of the target coordinates from the image space to the patient’s physical space is traditionally performed using a rigid frame that locks the patient’s skull to the operating table. More recently, frameless systems have been developed with equivalent accuracy and improved patient comfort. Physiologic target confirmation is performed in the operating room with the patient awake. Intraoperative physiologic mapping consists of MERs, test stimulations, or both. MER can discern different brain areas based on characteristic neuronal electrical firing patterns. Identification of areas where neuronal

signals correlate to movements in specific areas of the body can help refine the stimulation target even further. Test stimulation provides the final confirmation of the optimal target location. Clinical efficacy, side effects, and therapeutic window are noted for each test stimulation area. After the desired physiologic target has been determined, the actual DBS electrode is inserted into that final target. The electrode is then connected to an extension wire, which is tunneled under the skin and connected to the IPG, which is generally implanted over the chest wall. General complications of DBS surgery include intracranial hemorrhage, lead migration, skin erosion, and infection. The risk of intracranial hemorrhage is <3%, causing permanent deficits in <1% of cases. Infection occurs in <10% of cases, which usually requires hardware removal as well as antibiotic therapy. Stimulation-induced adverse effects can be reduced by changing stimulation parameters or turning the DBS off. While DBS is not a cure for Parkinson’s disease, it has become an important part of our armamentarium. The goal of DBS is to control the motor symptoms of Parkinson’s disease and improve patients’ quality of life. Prospective randomized controlled trials demonstrate that DBS is the standard of care for appropriately selected patients with Parkinson’s disease. R E F E R E N C E S :1. Lang AE. When and how should treatment be started in Parkinson disease? Neurology. 2009;72(7

Suppl):S39‐43.2. Weaver FM, et al. Bilateral Deep brain stimulation vs best medical therapy for patients with

advanced Parkinson disease: a randomized controlled trial. JAMA. 2009;301(1):63‐73.3. Yu H, Neimat JS. The Treatment of Movement Disorders by Deep Brain Stimulation.

Neurotherapeutics 2008;5(1): 26-36.

Parkinson’s disease is the second most common neurodegenerative disease, affecting approximately 4 million people worldwide. The motor symptoms of Parkinson’s disease, including tremor, rigidity, and bradykinesia, can make simple tasks impossible to perform. Parkinson’s disease is caused by the progressive loss of dopamine producing neurons in the substantia nigra, which disrupts the normal balance of circuits that are necessary for the production of movement. Dopamine replacement is the main medical therapy for Parkinson’s disease. Unfortunately, as the disease progresses, the effectiveness of medications often declines and side effects become more disruptive. It is estimated that 28% of Parkinson’s patients suffer from debilitating motor symptoms despite optimal medical therapy. Deep brain stimulation (DBS) is a surgical therapy where electrical current is applied to targeted locations in the brain through implanted electrodes. These electrodes are connected to a programmable internal pulse generator (IPG) buried under the skin. High frequency electrical stimulation at precise locations in the brain is thought to restore the balance of the circuits that are disrupted in Parkinson’s disease. DBS is reversible and adjustable, thus providing a safe and adaptable treatment method for a progressive disease. Preoperative medication responsiveness is the best predictor of DBS efficacy. In general, the motor symptoms that improve with dopamine replacement therapy will be alleviated by DBS. The ideal DBS candidate is disabled from Parkinson’s without medications but can function independently with medications. DBS can extend the period of time that the patient is on medications and reduce unpredictable off-medication periods. Contraindications to DBS include dementia, inadequately treated psychiatric illness, extensive brain atrophy, and concurrent medical conditions that preclude safe surgery. Patients should not undergo DBS implantation if they anticipate needing future MRI scans of the body. The specific symptoms treated by DBS depend on the location of the implant, which is carefully selected for each patient by a neurologist and neurosurgeon. Cognitive and psychiatric factors are also considered as different target locations can have varying impact. Therefore a team approach to DBS therapy is critical to achieving a successful outcome. The surgical procedure for the implantation of the DBS unit involves the following basic steps: 1) image-guided target localization, 2) physiologic target confirmation using microelectrode recordings (MERs) and test stimulations, and 3) implantation of final DBS lead and connection to the IPG. Traditionally, image-guided target localization

Deep Brain Stimulation for Parkinson’s DiseaseBy Hong Yu, M.D., Assistant Professor of Neurological Surgery

All source data for this article has been provided by

Evidence-Based Standards of Care

B E S T P R A C T I C E S

n a s h v i l l e m e d i c a l n e w s . c o m MARCH 2014 > 3

By KELLy PRICE

Robert A. Mericle, MD, likes to get into a patient’s head and fi x things.

The neurosurgeon specializes in treating brain aneurysms, brain and spi-nal arteriovenous malformation (AVMs), brain tumors, trigeminal neuralgia, Moyamoya disease, carotid stenosis, and stroke, among other neurological issues. Although Mericle is internationally recog-nized as a leader in performing minimally invasive treatments of brain aneurysms and AVM through needle stick using liq-uid embolic agents, to his patients, he is simply known as “Dr. Miracle.”

His two favorite procedures, he said, involve eliminating the severe pain of tri-geminal neuralgia, which has been likened to being hit in the head with a cattle prod, and performing brain bypasses to prevent strokes for sufferers of Moyamoya disease. Moyamoya disease is a rare and progres-sive cerebrovascular disorder caused by blocked arteries at the base of the brain in the area of the basal ganglia. It is char-acterized by a narrowing of the internal carotid artery, middle cerebral artery, and anterior cerebral artery, leading to irre-versible blockage of the main blood vessels to the brain as they enter into the skull.

Moyamoya disease was fi rst described in Japan in the 1960s. Since then, cases have been reported in individuals in the United States, Europe, Australia, and Af-rica. The singsong name, which means “puff of smoke” in Japanese, is used to describe the way the tangle of tiny ves-sels that are formed to compensate for the blockage look when imaging the brain.

The disease primarily affects children, but it can also occur in adults, often strik-ing in the third to fourth decades of life. Children with Moyamoya present with symptoms of stroke, such as weakness of an arm or leg, or seizures. Adults tend to present with ischemic or hemorrhagic stroke. Mericle explained treatment starts with blood thinning therapy, usually aspi-rin, to help the blood travel through the narrowed intracranial vessels. Surgery is indicated if there are worsening symp-toms. An extracranial to intracranial (EC-IC) bypass that provides a direct and immediate supply of fresh blood to the

affected area is the preferred treatment whenever possible.

An expert in the procedure, Mericle is president of Nashville Neurosurgery Group PLC, located at Medical Plaza One on the campus of Saint Thomas Mid-town Hospital. Prior to going into private practice, he performed the majority of EC-IC bypass operations done at Vander-bilt University Medical Center and Mon-roe Carell Jr. Children’s Hospital over the past decade.

Mericle and partner Arthur Ulm, MD, who are both nationally recognized leaders in the treatment of trigeminal neuralgia and have extensive experience performing surgery for hemifacial spasm, were principals with HW Neurological Institute, which merged with Tennes-see Brain and Spine last year to form the Nashville Neurosurgery Group. A past

president of the Tennessee Neurosurgical Society, Mericle is a Fellow of the Ameri-can Association of Neurological Surgeons.

Growing up in a tiny town outside Barlettsville, Okla., where not one of the 3,000 residents had gone to college, it’s doubtful Mericle could have foreseen the path his career would take. However, he recalled, “I knew I wanted a progressive career, like the eye doctor I went to in Barlettsville, and that college was neces-sary for that.”

He enrolled at the University of Okla-homa, graduating in the top 3 percent of a class of 25,000 students, and was named to Phi Beta Kappa … just one of many accolades he has received throughout his education and the course of his practice.

In high school science classes, Mericle was always fascinated by the way the brain interprets information from sound and light waves and decided he wanted to pur-sue that line of investigation. After gradu-ating from Oklahoma summa cum laude with a BA in psychology and BS in zoology, Mericle applied to medical school.

He was accepted to Vanderbilt Uni-versity School of Medicine and awarded the prestigious Canby Robinson Scholar-ship – a four-year, full-tuition merit schol-arship. After graduation from Vanderbilt, Mericle continued with a general surgery internship and neurosurgery residency at the University of Florida with a two-year neuroendovascular fellowship at the State University of New York in Buffalo. Upon completing his residency at Florida, he served as chief of Endovascular Neurosur-gery Service and program director for the university’s fellowship program in his spe-cialty.

In 2004, Mericle received a call from George Allen, MD, who was chair of Neurosurgery at Vanderbilt at that time. Allen, who remembered Mericle from his student days in medical school, offered him an opportunity to return to Nashville to help build the academic medical cen-ter’s cerebrovascular and endovascular neurosurgery program.

“I was glad to return to Vanderbilt,” Mericle said. “My wife and I love Nash-ville.”

Since his return 10 years ago, Mericle has treated thousands of neurosurgery pa-tients and has taught dozens of physicians from around the country. Widely pub-lished, he has contributed to more than 100 books and medical journals on neu-rology topics.

When Mericle ponders the changes that have occurred in neurosurgery since he started his training, he is most aware of the rapid growth of the use of technology.

“We used to have to get to the brain by going though the cranium and opening up the skull. Now we have fi ve or six ways to treat an aneurysm that are so much less invasive and less diffi cult for the patient,” he observed.

“I can use 600 milligram thread to bypass a blockage and sew the two sec-tions together to an artery in the scalp,” he continued of advances in the fi eld, add-ing this provides an increased blood fl ow expansion allowing the vessel to actually grow and get stronger.

When he isn’t busy repairing brains, he loves spending time with his family. Mericle’s wife is in her last year of train-ing as a medical pharmacist, and the cou-ple has three children, ages 19, 17 and 11.

Robert A. Mericle, MD — Brain RepairUsing New Solutions to Tackle Complex Neuro Issues

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According to national research, AFib is responsible for approximately 25 per-cent of all ischemic strokes, and AFib resulting in cardioembolic stroke is associ-ated with a mortality rate of 30 percent at one year.

Stroke Risk Factors Ellis said the most current risk pre-

dictor for stroke is the CHA2DS2-VASc score. A modification to the earlier CHADS2 score, the newer iteration adds three additional risk factors. Patients are as-signed points for each risk factor, with a maxi-mum score of 9. Factor-ing into the equation are Congestive heart failure, Hypertension (consis-tently above 140/90 mmHG), Age (≥ 75), Diabetes and prior Stroke (or TIA or thromboembolism) plus Vascular disease, Age (65-74) and Sex (gender).

The score is calculated by allotting one point to each item except stroke and age. Prior stroke, TIA or thromboembo-lism is weighted at two points, and age is either scored at one point from 65-74 or two points at age 75 and above.

Medication & Stroke Prevention

While a score of zero indicates low risk for patients, scoring a single point moves a person into the moderate risk category. For these patients, physicians often prescribe a daily aspirin regi-men. A score of two to three could be a medical therapy ring toss, Ellis said, with some physicians opting for aspirin and others a prescription blood thinner. “Blood thinners like warfarin are proven more effective head-to-head against aspi-rin but require blood tests and dietary re-strictions,” Ellis noted. While warfarin is among the most widely prescribed drugs in the U.S., the anticoagulant also puts patients at increased risk of internal bleed-ing, mandating frequent monitoring. However, a new class of blood thinners – novel oral anticoagulants (NOACs) – are promising better results with less complications. The U.S. Food and Drug Administration recently approved three new oral anticoagulants – dabigatran, rivaroxaban and apixaban – for stroke prevention in patients with atrial fibril-lation. These new anticoagulants do not require strict and frequent lab monitor-ing, or dietary restrictions, and incur fewer drug interactions than warfarin. Dosing may be adjusted based on kidney function. Still, lack of a specific reversal agent and clinical data regard-ing their long-term safety could keep warfarin in the game for years to come. “There are two ways to get off blood thinners,” Ellis continued. “Your risk for stroke changes, or something bad hap-pens while on blood thinners.”

Surgical Treatment Bleeding, bone breaks or stroke

make some warfarin patients ideal can-

didates for procedural treatment to lower stroke risk. Two novel proce-dures, now available at Vanderbilt, focus on closing the left atrial appendage (LAA), to eliminate the risk of bleeding. “When we find a clot in patients who’ve had a stroke and AFib, it’s almost always in the left atrial appendage,” Ellis explained. “If we can shut the appendage off, we can typically prevent stroke without the bleed-ing risks associated with blood thinners.” Anatomy of the LAA holds clues, as well. Cardiologists have identified four consis-tent shapes of left atrial appendages, and Ellis said identifying structural consisten-cies in stroke patients could help predict the best candidates for procedural treatment.

LARIAT™ Suture Delivery Device

Ellis was the first … and currently only … cardiologist to use the LARIAT™ Suture Delivery Device at Vanderbilt Heart, and he has seen positive results since debuting the procedure in July. Performed under general anesthesia, the LARIAT procedure places one catheter under the patient’s rib cage with another guiding it into place. The catheter is sent to the heart’s LAA and places and tightens a loop stitch around the base of the append-age, sealing it off from the rest of the heart

and blocking clots from traveling to the brain. LARIAT patients typically spend two days in the hospital for follow-up.

AtriCure® AtriClip PROA second option available to pa-

tients is the AtriCure® AtriClip PRO, offered at Vanderbilt as part of a six-site clinical trial. Working through a small incision, surgeons use a bar-rette-like device to clamp off the LAA. “First we look at the size and shape of an appendage, and if it’s too big or pointing the wrong way for the LAR-IAT, we use the AtriClip,” Ellis said. The procedure is more invasive than the LARIAT and typically requires three to four days of hospitalization.

Watchman™ LAA Closure Device

A third option cardiologists hope to see widely available soon is the Watch-man™ Left Atrial Appendage Closure Device, now in its final stage of FDA ap-proval. In 2011, Saint Thomas Heart at Baptist Hospital (now Saint Thomas Mid-town) became the first hospital in Tennes-see to implant the Watchman as part of a clinical trial. The device is introduced into the heart via a catheter through a vein in the upper leg or groin and captures clots

that might form in that area of the heart. “The concept of closing the appendage has been around for many years but was only done during major heart surgery,” Ellis said. “Now it’s a stand-alone procedure with minimally invasive complications.”

Reveal® Insertable Cardiac Monitor

According to Christopher Conley, MD, cardiologist with Centennial Heart at Skyline, the cause for stroke goes un-identified in 30 percent of patients. He and other cardiologists nationwide are using the Reveal Insert-able Cardiac Monitor by Medtronic as part of a stroke workup to help detect irregular heart rhythm. Smaller than a pack of gum, the monitor is inserted just beneath the skin in the upper chest area. “When someone is hos-pitalized and no source is found, neu-rologists are asking for long-term heart rhythm monitoring to try to find unde-tectable AFib,” Conley explained. “It’s the same technology we’ve used for years to look for other conditions like unexplained fainting but going in a new direction.”

Beating the Odds: Medical Breakthroughs Decrease Risks, continued from page 1

Dr. Christopher Ellis

Dr. Christopher Conley


In 2013, TriStar Skyline Medical Center became the first hospital in Tennessee to receive Advanced Certification for Com-prehensive Stroke Centers from the Joint Commission and The American Heart Association/American Stroke Association. They are now one of 59 hospitals nationwide to receive the certifi-cation including Vanderbilt Uni-versity Hospital and Knoxville’s Fort Sanders Regional Medical Center and UT Medical Center. Complex Stroke Centers are rec-ognized as industry leaders and are responsible for setting the na-tional agenda in highly specialized stroke care.

“Stroke is the leading cause of disability, and Skyline really wanted to push forward with decreasing that,” said Michelle Bertotti, RN, unit director for Neuroscience and Neurointensive Care at TriStar Skyline Medical Center. “Im-

mediate intervention is essential because time loss is brain loss.” The hospital provides 24/7 comprehensive stroke care including neurology, neurosur-gery and radiology so patients receive the same specialized care

day or night. That distinction means TriS-tar Skyline’s interventional radiologists are able to administer IV tPA, the enzyme that dissolves blood clots, four to eight hours following stroke rather than the standard three-hour window available at most hos-pitals.

“What we look at is a very detailed stroke scale that includes when symptoms started,” Bertotti explained. “We have op-portunities for patients who may not be a match at other hospitals … and being able

to treat them up to eight hours is a huge lifesaving opportunity.” Specialized services also include a 12-bed Neuro ICU, a dedicated stroke unit and a 41-bed inpatient rehab center. The Rehab Center at TriStar Skyline, which is accred-ited by the Commission on Accred-itation of Rehabilitation Facilities, starts working with patients from day one. Their average length of stay for stroke patients from admis-sion through rehab is 17.7 days.

The hospital also provides ad-vanced continuing education for ICU, neurology and emergency staff, and holds multi-disciplinary neurovascular conferences to re-view complex cases. Working closely with patients and their families to offer stroke and brain aneurysm support groups and to promote stroke awareness within the community is another priority.

“From the community stand-point, education is key,” Bertotti

said. “We want people to know warning signs of stroke, the importance of calling 911, and not ignoring symptoms.”

Bertotti noted TriStar Skyline also is pursuing Level 2 trauma status, which she expects to significantly increase the number of patients admitted with brain injury.

“As we plan to grow our neuroscience program overall, trauma will definitely be a piece of that that and our technology and equipment will grow as we begin taking in a higher volume of patients,” Bertotti said.

Steve Johnson, 54, recovers at TriStar Skyline after experiencing a stroke. Johnson is exercising on a new piece of equipment used for stroke rehabilitation called ICare. The support at the top helps lift the patient to exercise on an elliptical-type machine.

When Seconds Count

Michelle Bertotti



Stroke Care: Most Have Access, Few Get Recommended Treatment

Four out of fi ve people in the United States live within an hour’s drive of a hos-pital equipped to treat acute stroke — yet very few get recommended treatment, ac-cording to research presented at the Ameri-can Stroke Association’s International Stroke Conference 2014.

Of the more than 370,000 Medicare stroke claims for 2011 that researchers ex-amined:

• Only 4 percent received tPA, a drug that can reduce disability if given intrave-nously within three to four hours after the fi rst stroke symptoms.

• Only 0.5 percent had endovascular therapy to reopen clogged arteries.

The study found that within an hour’s driving time:

• 81% had access to a hospital capable of administering tPA.

• 66% had access to a primary stroke center.

• 56% had access to a hospital capable of performing endovascular therapy.

Within an hour by air:

• 97% percent could reach a tPA-ca-pable hospital.

• 91% could reach a stroke center.

• 85% could reach a hospital capable of performing endovas-cular therapy.

In 2011, 60 percent of U.S. hospitals didn’t administer tPA. These hospitals dis-charged about 1 in 5 of all stroke patients.

Stroke Campaign Focuses on the Need for Speed

When someone is having a stroke, they need help FAST. The American Stroke As-sociation hopes its new campaign will help people remember the signs of stroke and act quickly. Experts also encourage individuals to note the time symptoms fi rst appear so that tPA, if appropriate, could be admin-istered.

Face: Ask the person to smile. Does one side of their face droop?Arms: Ask the person to raise both arms. Does one arm drift downward?

Speech: Ask the person to repeat a simple phrase. Is their speech slurred or strange?Time: If you observe any of these signs, call 9-1-1 immediately.

Video Game Teaches Kids Stroke Symptoms

Children improved their understand-ing of stroke symptoms and what to do if they witness a stroke after playing a 15-min-ute stroke education video game, according to new research reported in the American Heart Association journal Stroke.

“We need to educate the public, includ-ing children, about stroke, because often it’s the witness that makes that 9-1-1 call … not the stroke victim. Some-times, these witnesses are young children,” said Ol-ajide Williams, MD, MS, lead author and associate professor of neurology at Columbia University in New York City.

Williams and a team of researchers tested 210

children (9- and 10-year-olds) from low-income homes in the Bronx, New York to measure whether or not they could identify stroke and knew to call

9-1-1 if they witnessed a stroke. The same children were tested again after playing an educational video game, Stroke Hero. Fi-nally, the group was given remote access to the video game and encouraged to play at home. Re-testing of 198 of the children happened seven weeks later.

Researchers found:• Children were 33 percent more likely

to recognize stroke from a hypothetical sce-nario and call 9-1-1 after they played the video game. They retained the knowledge when they were re-tested seven weeks later.

• Children who continued to play the game remotely were 18 percent more likely to recognize the stroke symptom of sud-den imbalance than were the children who played the video game only once.

• 90 percent of the children studied re-ported they liked playing Stroke Hero.

The video game involves navigating a clot-busting spaceship within an artery, and shooting down blood clots with a clot-busting drug.

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Stroke Notes

Dr. Olajide Williams

AHA Addresses Stroke Risks in Women, Presents New Guidelines

BY MELANIE KILGORE-HILL

The American Stroke Association estimates 425,000 women suffer a stroke each year … 55,000 more than men. Although stroke has fallen to the fourth lead-ing cause of death overall, it remains the third leading cause of death in women.

“If you are a woman, you share many of the same risk factors for stroke with men, but your risk is also infl uenced by hormones, reproductive health, pregnancy, childbirth and other sex-related factors,” said Cheryl Bushnell, MD, MHS, author of the new scientifi c statement published in the American Heart Association jour-nal Stroke. In fact, she added, preeclampsia doubles the risk for stroke and qua-druples the risk for high blood pressure later in life.

For the fi rst time ever, the American Heart Association has set guidelines geared to primary care providers, including OBGYNs, for preventing stroke in women. The recommendations take into account risk factors unique to women, and the AHA has crafted evidence-based actions to address to address them, including:

• Women with a history of high blood pressure before pregnancy should be considered for low-dose aspirin and/or calcium supplement therapy to lower preeclampsia risks.

• All women with a history of preeclampsia should be regularly evaluated and treated for cardiovascular risk factors such as high blood pressure, obesity, smoking and high cholesterol. Screening for risk factors should start within one year after delivery.

• Pregnant women with moderately high blood pressure (150-159 mmHg/100-109 mmHg) may be considered for blood pressure medication, whereas expectant mothers with severe high blood pressure (160/110 mmHg or above) should be treated.

• Women should be screened for high blood pressure before taking birth control pills because the combination raises stroke risks.

• Women who have migraine headaches with aura should stop smoking to avoid higher stroke risks.

• Women past age 75 should be screened for atrial fi brillation risks due to its link to higher stroke risk.

Preeclampsia and eclampsia during pregnancy increase the risk for stroke long after child-bearing years. Additionally, high blood pressure, migraine with aura, AFib, diabetes, depression and emotional stress are stroke risk factors that tend to be stronger or more common in women than in men.

Bushnell, an associate professor of Neurology and director of the Stroke Cen-ter at Wake Forest Baptist Medical Center, said additional studies are needed to create a female-specifi c score to identify and stratify stroke risk in women.


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By CINDY SANDERS

Everyone wants to build a better mousetrap … but building it over and over again isn’t very efficient. Finding a way to keep the ‘mousetrap’ infrastructure in place while adding new features based on a col-lective body of knowledge is fundamentally the basis of the new National Institutes of Health Stroke Trials Network.

Funded and managed by the National Institute of Neurological Disorders and Stroke (NINDS), NIH StrokeNet is focused on the three prongs of stroke research — prevention, treatment and recovery. The new structure utilizes a network of aca-demic medical centers across the country working with nearby satellite facilities to co-ordinate and streamline stroke research by centralizing approval and review, while cre-ating a comprehensive data-sharing system. The network also is expected to lessen the time required to set up clinical trials since the infrastructure will already be in place, thereby making research more efficient and less costly.

Scott Janis, PhD, program director in the Office of Clinical Research at NINDS and the scientific direc-tor for NIH StrokeNet, explained, “We identified 25 geographically dis-tributed regional centers and identified over 200 hospitals that will be part of the network. Many are primary stroke centers, but many are community hospitals aligned with the regional stroke participant.”

The 25 lead sites were chosen based on a demonstration of past experience in stroke research and recruitment, includ-ing the ability to enroll underrepresented populations. Each center has been granted five-year funding with $200,000 in research costs and $50,000 for training stroke clini-cal researchers per year over the first three years. The completion of milestones will drive additional funding. The University of Cincinnati has been named the national clinical coordinating center.

With the new structure in place, Janis said it should be possible to more rapidly add studies to the pipeline. NIH StrokeNet also creates a central institutional review board and has a built-in master trial agree-ment to further expedite launching new trials.

Janis also noted the network calls on a truly intraprofessional team of provid-ers and researchers — from first respond-ers and emergency room physicians to the specialists caring for patients acutely all the way through to ambulatory rehabilitative therapists. By having a coordinated team across the continuum of care, including pediatric specialists in the 25 regional cen-ters, the hope is that stroke patients will be rapidly identified and more easily followed throughout their journey.

“This network fosters communication in a collaborative way,” he said. “We can’t control when someone has a stroke, but we

can control our ability to identify them for a potential study.”

Previously, the model for stroke clini-cal trials happened in a stand-alone man-ner. A large team, often over multiple centers across the country, had to be as-sembled, and the infrastructure set up for each trial. Then, once completed, the en-tire team had to be disassembled only to start the process all over again for the next study. The cumbersome method led to de-lays in patient recruitment and repeated costs to initialize new projects. Sometimes those delays caused a stroke trial to go much longer than initially anticipated, costing millions of dollars more than the original estimate.

“That effort in building and tearing down, building and tearing down, doesn’t efficiently allow us to ask the questions to move the science forward,” Janis said. Drug research to control stroke risk factors has improved to the point that Janis said sometimes the medicine had moved on by the time a stroke trial that had undergone delays managed to wind down. “You really want to get to answers more rapidly,” he noted.

Janis said the tipping point to change the way stroke research occurred across the country came about in a couple of dif-ferent ways. First, stroke experts identified key research priorities during a NINDS strategic planning meeting two years ago and stressed the need for an orchestrated effort. Second, Janis said NINDS already had honed their ability to manage a coordi-nated effort through SPOTRIAS (Special-ized Programs of Translational Research in Acute Stroke).

“The idea behind the network is to take what we already know how to do and do it in a more efficient way,” Janis said.

NINDS has a long history of overseeing successful stroke clinical trials, including the first treatment for acute stroke, announced in 1995. Although sometimes slow, research translated from bench to bedside still has been so successful that mortality rates from stroke have declined significantly over the past decade. While still a leading cause of disability, stroke recently moved from the third leading cause of death in the United States to the fourth.

Janis noted funding still would be avail-able to researchers outside the network when appropriate. However, he added, the goal would be to collaborate with the net-work and to coordinate trials through the new mechanisms now in place.

“We want to be able to use this infra-structure we’re investing in to be our front-line sites for stroke trials,” he stated.

In the Southeast, lead research sites in-clude Emory University School of Medicine in Atlanta, Medical University of South Carolina in Charleston, Miller School of Medicine at the University of Miami, and Vanderbilt University Medical Center in Nashville. Providers and researchers can learn more about the network and clinical trials through the new website at nihstro-kenet.org.

A New View on Stroke Research

Dr. Scott Janis


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By CINDy SANDERS

A number of new fa-cilities have debuted in the first quarter of 2014 with more on the way. Below is a snapshot of just a few of the construction projects around Middle Tennessee that recently have been completed.

CenterstoneBehavioral health

not-for-profit Centerstone recently opened the doors on their latest project. The new $6 million outpatient facility on the grounds of the Dede Wallace Campus on White Avenue was designed to provide the full continuum of services for all ages. In ad-dition to behavioral health services, the new facility includes primary care through United Medical Clinic as part of Center-stone’s partnership with Unity to help care for medically underserved patients through integrated care clinics.

Designed by InForm Smallwood +

Nickle, LLC of Nashville and built by Orion Building Corporation, the 18,000 square-foot facility includes 37 clinician offices for counselors, psychiatrists and nurses plus space for specialty programs, group therapy and play therapy areas. Large windows and bright interiors help integrate nature and sunlight into the fa-cility.

The new construction stands on a site

filled with healthcare his-tory. The White Avenue property began serving children with polio and mental illness in 1930 after the Nashville Junior League quickly outgrew their original nine-bed Home for Crippled Children at Ninth and Monroe, which had opened seven years ear-lier in 1923. The campus again expanded in 1956 with the opening of the Mental Health Guid-ance Center, which was renamed the Dede Wal-lace Center in 1970 to

honor Junior League volunteer and men-tal health advocate Louise “Dede” Bullard Wallace.

With a nod to its storied past, bricks from the original building serve as pavers to create garden areas and outline the old facility’s footprint. However, the facility utilizes thoroughly modern design theo-ries including removing large desks be-tween providers and patients to create an

environment conducive to more natural conversation.

“We are very excited to open this innovative new healthcare facility and explore a clinical model that connects pri-mary care and behavioral health providers under one roof,” Centerstone CEO Bob Vero, PhD, said last month at the facility’s grand opening. “Being able to continue our legacy on this important property that is deeply rooted in Nashville’s history is incredibly inspiring. We look forward to advancing the treatment and prevention of mental illness and addiction from this new location, and working to ensure the health and wellbeing of our clients’ minds and bodies.”

Vanderbilt Heart & Vascular Institute

Just in time for ‘Heart Month,’ Vanderbilt Heart and Vascular Institute moved all of its key procedure areas to its new home on the fifth floor of the Critical Care tower, which connects to Vanderbilt University Hospital.

Designed by Nashville architectural firm Earl Swensson Associates (ESa), the

Recent DebutsCutting the Ribbon on Some of Middle Tennessee’s Newest Healthcare Construction Projects

Designers of Centerstone’s new outpatient facility removed large provider desks that might inhibit patient engagement and created more natural conversational areas.



By CINDy SANDERS

Last year, members of the 108th Regu-lar Session of the Tennessee Legislature voted unanimously to extend the life of the Health Services and Development Agency through June 30, 2017. This action ensured the state’s certifi cate of need (CON) pro-gram would continue, uninterrupted, into its 44th year.

History of Tennessee’s Program

Melanie M. Hill, executive director for the Tennessee HSDA, noted the state has relied on a CON program to drive the or-derly creation and expan-sion of health facilities and services since 1973, a year prior to a federal man-date for such programs. In Tennessee, the Health Facilities Commission ad-ministered the CON pro-gram until 2002 and was the predecessor to the current agency. Hill joined the Health Facilities Commission in 1998 and was named to the director’s post

in 2001. The following year, the Tennes-see Legislature passed the Health Services and Planning Act of 2002, which created HSDA.

“Our sole responsibility is the certifi cate of need program and related activities,” Hill said, adding that includes providing techni-cal assistance and collecting data on certain medical equipment including MRIs, PET scanners, CT scanners and linear accelera-tors, among others. “There is a requirement in the statute that the equipment be regis-tered with the agency and that owners re-port usage data annually.”

After establishing CON programs na-tionwide through the 1974 National Health Planning and Resources Development Act, the law was repealed in 1987, eliminating federal funding assistance for state planning offi ces. However, CON programs remain in place across much of the country. “There are 36 states plus the District of Columbia that have certifi cate of need programs,” Hill stated. She added each state is different with some having more stringent requirements than others.

According to the American Health Planning Association’s website, there are

30 coverage areas for which state programs might choose to require a CON. On one end of the spectrum, Vermont requires an application be made for all 30 of those op-tions from acute hospital beds and air am-bulances to medical offi ce buildings and ultrasound. On the opposite end of the spectrum, Ohio requires an approved CON only when adding skilled nursing/long-term care beds for projects exceeding $2 million in cost. With 20 service and equipment areas covered by CON regulations, Ten-nessee falls a little right of the middle.

Application TrendsThe economy and uncertainty over

the Affordable Care Act have impacted the number of CON applications being fi led in the state. Hill said, “We used to aver-age 100-120 applications annually.” Now, she continued, “We’re probably looking more in the range of fi ve full applications a month.”

She added, “In 2008, we dropped from 121 applications to 56 in 2009.”

After rebounding slightly to 62 CON applications in 2012, the number dipped down to 51 last year.

Gaining Approval for a CONAt the heart of the approval process is

the need to meet three criteria:• Answering a healthcare need,• Proving a plan is economically fea-

sible, and• Showing how the plan contributes to

the orderly development of adequate and effective healthcare facilities and services.

Actually, Hill noted, “Most applica-tions are approved. It’s a fairly strenuous process so you really have to have your in-formation together by the time you fi le.”

Prior to fi ling an application, Hill said her agency could provide technical assis-tance to help navigate the process, impor-tant background information regarding utilization for those considering adding equipment or services, and insight into needs outlined in the state health plan.

Although applications are assessed against the state health plan, which outlines the numbers that would indicate a commu-nity might need to add a facility or service line, Hill was quick to add there are valid reasons to override those numbers … or lack thereof. “That’s why it is guidance and not set in stone,” she said of the health plan. Hill added, “I hope we’re never strictly ‘just numbers.’ There are certainly circum-stances in each community that are unique to that community.”

For example, she said population fi g-ures alone might not warrant the addition of a second MRI in a community. However, she continued, if the owner of the current MRI doesn’t accept many insurance plans, or doesn’t participate in TennCare, or has excessive wait times for appointments, then circumstances could demonstrate a need for a second MRI operator in that area.

Hill added the monthly CON meet-ings are open and transparent … and highly participatory. She said those for and against an application are welcome to come to the meeting and are given an opportunity to speak. She added that when an appli-cation is controversial, her team has even held town hall meetings to allow residents to voice concerns. She noted this extra step isn’t requested very often, though.

Ultimately, an 11-member board de-cides the fate of a CON application. There are three consumer appointees – one each from the speaker of the house, governor and lieutenant governor. Three more board members are state offi cials with the comp-troller, commissioner for Commerce and In-surance and the director of TennCare each designating an appointee. The remaining fi ve board members are chosen by the gov-ernor with one each being selected to repre-sent home health, surgery centers, nursing homes, hospitals and physicians. While the related associations often provide a list of possible appointees, the selection is at the governor’s discretion.

Building or Expanding Health Facilities in Tennessee? There’s an ‘App’ for ThatA Look at the State’s CON Program

FacilitiesThreshold: A modifi cation, expansion or renovation in excess of $5 million for a hospital or $2 million for other healthcare facilities.

• Hospital

• Nursing Home

• Recuperation Center

• Ambulatory Surgery Center

• Mental Health Hospital

• Intellectual Disability Institutional Habilitation Facility

• Home Care Organization (Home Health & Hospice)

• Outpatient Diagnostic Center

• Rehabilitation Facility

• Residential Hospice

• Nonresidential Substitution-based Treatment Center for Opiate Addiction

• Birthing Center

Addition of Services• Burn Unit

• NICU

• Open Heart Surgery

• Positron Emission Tomography

• Swing Beds

• Home Health

• Psychiatric (Inpatient)

• Rehabilitation (Inpatient)

• Hospital-based Alcohol & Drug Treatment (for adolescents under a program of care exceeding 28 days)

• Extracorporeal Lithotripsy

• MRI

• Cardiac Catheterization

• Linear Accelerator

• Hospice

• Opiate Addiction Treatment (provided through a facility licensed as a nonresidential substitution-based treatment center)

ActionsIn addition to the cost triggers listed under facilities, the following actions also require CON approval. Go online for details.

• Change to the bed makeup of a healthcare institution.

• Change in location or replacement of existing or certifi ed facilities providing healthcare services, major medical equipment, or healthcare institutions.

• Change of parent offi ce of a home health or hospice agency from one county to another county.

• Acquisition of major medical equipment with a cost in excess of $2 million.

• Discontinuation of obstetrics.

• Closure of any hospital that has been designated a critical access hospital or the elimination of any services for which a certifi cate of need is required in those hospitals.

What Requires a CON?As outlined by Tennessee code, certain facilities, services and actions trigger the need for an approved certifi cate of need before proceeding. Visit Tennessee.gov/hsda for more information.

Prior Approval or Notifi cation

Additionally, there are some actions that require individuals to notify or seek prior approval from the Tennessee HSDA even though a formal CON is not required. Details are available on the HSDA website.

Melanie M. Hill



By SAM SARBACKER The national media has declared

Nashville the new “It” city, crediting the area’s unparalleled music scene, rising culinary environment, and compelling Southern culture as primary factors for the region’s growth. Evidence of the city’s prosperity can be seen in local headlines, which constantly feature stories about this new development or that multistory build-ing groundbreaking.

Nashville’s skyline is evolving as the real estate industry works to meet the de-mand for an influx of new businesses and residents. According to the Nashville Area Metropolitan Planning Organization, the greater Nashville region is poised to grow to over 2.6 million people over the next 25 years. As the country’s economy con-tinues to flounder, Nashville is fortunate to be picking up steam locally.

One of the main aspects contribut-ing to the city’s booming economy is the

healthcare industry. The Nashville Health Care Council recently conducted an eco-nomic impact study which reveals that $30 billion flows into Nashville’s economy from the healthcare sector alone. A focal point of growth within the healthcare in-dustry is the substantial rise in outpatient care facility development.

It is estimated that by 2019, the amount of outpatient care in America will see an increase of 22 percent. The rising demand for outpatient facilities will put pressure on healthcare providers to move quickly to secure property in order to meet their growth needs. Critical to the success of delivering these projects will be health-care providers engaging development ex-perts to assist them in meeting their goals.

No one is more aware of the real es-tate frenzy than those who are currently listing properties for sale. In the current market, sellers naturally feel more em-boldened to seek prices that are higher than market value, and can be more hard-

fisted on key purchase agreement terms. Being approached by a physician in lieu of a developer can give the seller an opportu-nity to push the limits further than if they were dealing with someone who works in the industry – an advantage that can cost a physician thousands of dollars and leave them with a subpar property.

Additionally, physicians might be drawn to a specific property because it appears on the surface to be a great deal. There is a litany of reasons that could lead to a listing being significantly below mar-ket value, and the old saying — “if sounds too good to be true, then it probably is” — certainly applies to real estate.

Flood plains, wetlands, inadequate zoning, onerous easements, use restric-tions, endangered species, underground fuel storage tanks, and … believe or not even live bombs on the property due to prior use as a WWII training area … can all be factors behind that “great deal” that can dupe an unsuspecting buyer. Physi-

cians could enter into a literal minefield of issues if purchasing a property without performing the proper due diligence. A thorough vetting by experienced profes-sionals could ensure you don’t get stuck with a property that is unsuitable for your needs.

You should be excited about the real estate windfall and subsequent economic boom that is taking place in Nashville. If you are considering an investment in a healthcare property, however, be sure to seek proper assistance in order to get the best available real estate to suit your growth needs.

Sam Sarbacker is a LEEP AP, EDAC-certified project manager for OGA, a Nashville-based real estate services and development company specializing in outpatient healthcare facilities. The company’s projects span the country and include cancer centers, medical office buildings, urgent care facilities, orthopaedic offices, behavioral health facilities and others. www.oman-gibson.com.

Healthcare Helps Fuel Nashville’s Booming Real Estate Market … But Buyers Need Guidance

Jim Easter, MArch, FAAMA, se-nior vice president and director of plan-ning for Hart Freeland Roberts (HFR) De-sign, said his firm has invested in the belief that the design process is changing and evolv-ing. Recently, Brandon Harvey, MArch, CDT, joined HFR as an intern architect/planner to focus on the connections between health facilities and the broader com-munity. Harvey holds both a bachelor’s de-gree in urban planning and a master’s degree in architecture from the University of Tennessee – Knoxville.

“Brandon has joined us to help de-fine, with our architects and our firm, how healthcare facilities will be developed as part of the urban fabric of a community … not just as stand-alone facilities,” Eas-ter explained.

With an emphasis on preventive care and population health, new reimburse-ment models that pull together providers across the continuum, a focus on patient engagement, enhanced technology needs, increased connectivity and changing demo-graphics, Easter said the expectation is that clinics, medical office buildings, outpatient facilities and acute care hospitals will in-creasingly need to partner with each other and plug into the communities they serve.

As a result of health reform, Easter said there is an increased need to deliver spaces very tailored to the specific clinical services provided and supportive of the push to streamline processes and increase efficiency.

One example has been HFR’s work over the past year in analyzing the effect of the Affordable Care Act on emergency services. Working with Todd Warden, MD, the founder and president of Emer-genuity, the design team has used perfor-mance metrics to create the physical plant to support streamlined clinical pathways. As Easter explained, the idea is to ‘batch’ consumers into appropriate areas of care so that a senior presenting with stroke symptoms, a parent with a sick child, and an adult with substance abuse issues ac-cess the ED in different ways. “We make sure people are in the right pathway for the right reasons. What this system is de-signed to do is to allow care to be delivered quickly, efficiently and in the most appro-priate manner,” he said.

So how does that knowledge fit in the larger context of community? Harvey noted, “We’ve defined a lot of urban dy-namics. One of those urban dynamics is public policy and how that affects plan-ning and design. The Affordable Care Act is a forcible vehicle for pushing the health-care industry in the direction of patient-centered care rather than merely patient volumes-for-profit.”

That, he continued, changes how you envision accessing care and design-ing and locating spaces to fill needs within a community. A project in Carthage, Ill. underscored the need to think about de-livering services differently. Harvey noted it became clear some services needed to be decentralized to better serve patients. Breaking memory care out of the critical access hospital allowed the design team to deinstitutionalize the feel of the new facili-ties to care for early Alzheimer’s and other dementia patients. The result is 10-bed residential cottages that feel and function much more like a home than a hospital

with places for walking, reading, exercis-ing and visiting with family.

“The healthcare industry needs to fol-low urban trends,” Harvey said. “Now we live in a microwave society where every-thing is about convenience. It’s changing the dynamics of the way healthcare can and should be delivered in the future.”

Harvey added more suburbanites are beginning to move back into urban areas, leading to the creation of a lot of mixed used developments. Perhaps that means accessing healthcare in the same place con-sumers access retail outlets and dining ven-ues. Perhaps, as in Dallas, it means creating a major light rail transportation connection point actually on the hospital property.

Designing for a ‘big picture’ world has forced the creative process to shift and expand. “In the old days, you’d sit down and design an office building or sit down and design a hospital,” Easter said. “Now, it’s not that simple. We’re doing a full analysis.”

When working with a hospital cam-pus or health system, Easter noted the first step in the process is to assemble a group of professionals including those with ex-

pertise in strategic alignment, architec-ture, engineering, finance, urban planning and market analysis to assess how the cur-rent alignment does or does not meet the needs of the community. Steps include:

• Assessing the current situation.• Determining a strategic direction

based on market need and workload re-quirements.

• Assessing current facility conditions and future facility needs. “Most of our hospitals are way too big in spaces that are not well defined,” Easter noted.

• Creating a composite redevelop-ment of an area-wide plan, which Easter said is taking what you know and redis-tributing it to meet population needs.

• Scheduling and pricing that redis-tribution.

• Building consensus with stakehold-ers and seeking specific design input. However, Easter and Harvey said this is actually a recurrent step integrated from start to finish.

• Developing a phased implementa-tion plan.

• Measuring the overall economic de-velopment impact factors and considering regional implications.

• Considering the full continuum of care including patient transitions from in-patient to step-down or home-based care and how technology impacts those moves.

As for when the design process be-gins, Easter said time constraints demand incremental decisions be made along the way with heavy design lifting occurring about halfway through the steps.

“We still believe form follows func-tion, and you can’t begin to design a build-ing until you first know what the function is going to be and how process improve-ments enhance the design,” Easter con-cluded.

A Master Plan, continued from page 1

Jim Easter

Brandon Harvey

Brains before bricks ... designing modern health facilities requires a great deal of due diligence before the first architectural drawings are even conceived.


new space incorporates the latest evidence-based trends to meet the needs of providers, patients, staff and families. David C. Miller, AIA, EDAC, principal on the project for ESa, noted the radial lounge takes an innovative ap-proach to make patients more comfortable during cath lab re-covery. To reduce anxiety and en-courage immediate ambulation, a recliner in a spa-like environment replaces the typical bed.

The post-anesthesia care unit (PACU) was designed to facilitate close observation by clinicians while still allowing privacy. Miller pointed out the PACU has separate rooms for individual patients rather than curtained-off spaces. Decentralized nurse work areas allow for better patient observation.

The hybrid operating rooms, Miller continued, were designed with the latest recommended square footage to accom-modate the most advanced technology of today. Yet, fl exibility was key to being able to meet the needs of tomorrow.

“We feel that the success of the space is that the physician fl ow is fl uid in the cardiac procedure area,” said Miller. “In creating an environment to deliver the lat-est procedures and technologies, we have to also be responsive for advancements that will come in the next few years … and we designed this fi fth fl oor unit to be prepared for the future.”

Volunteer State Health Sciences Complex

Last month, Volunteer State Com-munity College in Gallatin offi cially cut the ribbon on the brand new Wallace Health Sciences Complex South. The $10 million, state-of-the-art educational facil-ity features more than 28,000 square feet

of space over two stories.Connected to Wallace Health Sci-

ences Complex North, the new building allows programming to be spread out between the two sides of the complex to allow for more instructional space overall. Programs now located in Wallace South include ophthalmic technology, sleep di-agnostics technology, emergency medical technician, diagnostic medical sonogra-phy and medical laboratory technology. The new facility marks the fi rst time the sleep diagnostic and medical laboratory programming and labs have been fully housed on campus.

The EMT labs have two rooms for use with SimMan patient simulators and a control room for faculty members to change simulations as students practice. The sonography lab houses six beds with high defi nition monitors and top-of-the-line GE ultrasound equipment. A Biolyte electrolyte analyzer and Genesys UV/VIS spectrophotometers are among the new equipment in the medical lab.

“Students majoring in health science careers will encounter cutting-edge tech-nology in their workplaces. They need to be profi cient in the use of this technology, and the only way they can gain those skills

is by hands-on experience,” noted Jerry Faulkner, PhD, president of Vol State, during the ribbon-cutting ceremony.

Moody-Nolan and Street Dixon Rick, both of Nashville, served as architects on the project with Hardaway Con-struction, also of Nashville, overseeing the build. Ground-breaking was held in 2012 and completed in time for the start of 2014 classes.

Recent Debuts, continued from page 7

Vanderbilt Heart & Vascular Institute Radial Lounge

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The Big PictureAlthough various groups have looked

to limit or abolish the CON process, particularly during years when HSDA is under sunset review, there are many staunch supporters of the system. The Tennessee Hospital Association listed keeping the CON program running in its current format among its top legislative priorities last year.

“In Tennessee, we’ve had a CON program for 40 years. It’s a very stable process, and it’s one the healthcare indus-try understands,” Hill said. “I think it’s a growth management tool, and also it’s a cost savings tool.”

Hill said perhaps one of the most im-portant functions of her agency is to help ensure quality programming is available in Tennessee. The impact of the CON

process on cardiovascular surgery out-comes has been the focus of a number of studies. Hill said, “A 2002 report from the University of Iowa College of Medicine showed states without CON programs for open heart surgery had a 21 percent higher mortality rate.”

Similarly, she continued, when the Pennsylvania CON law expired, the state saw an infl ux of open heart surgery pro-grams … quickly growing from 35 to 62. “They saw morbidity and mortality increase,” Hill said. “Any time you see that dramatic growth, you are decreasing volume for surgeons.” Less volume … less experience, she pointed out.

Hill concluded, “You still have peo-ple who say the CON process is anti-com-petitive, but it’s really not … it provides a level playing fi eld.”

Building or Expanding, continued from page 8

Coming Soon

A number of other Middle Tennessee projects are in various stages of planning, development and execution. The Lentz Public Health Center on Charlotte Pike is scheduled to open this summer.

Saint Thomas West broke ground last spring on a $110 million, four-year expansion and mod-ernization project. The centerpiece is an inpatient tower featuring 155,000 square feet of space. Additionally, renova-tions are expanding the square footage of critical care rooms and more than a dozen operating rooms. Architect for the multi-phase project is Freeman White, and Turner Construction has been named con-struction manager. The renovations and new construction are expected to be complete in 2017.

ESa is designing the new Monroe Carell Jr. Children’s Hospital Vander-bilt at Williamson Medical Center, which broke ground at the end of 2013. The $65 million expansion project is expected to open in early 2015.

On the main campus, the Monroe Carell Jr. Children’s Hospital at Vanderbilt is moving forward with expansion plans to boost the pediatric facility to nearly a million square feet of inpatient space. A four-fl oor tower is being built on top of the hospital’s southeast façade at the corner of Chil-dren’s Way and Medical Center Drive. At approximately 40,000 square feet of patient care space per fl oor, the new project should add more than 150,000 square feet of space. Construction is anticipated to begin next year.

Lentz Public Health Center

Saint Thomas expansion rendering

The new Wallace Health Sciences Complex South at Vol State greatly expands instructional space and adds state-of-the-art labs.


By CINDy SANDERS

As the leading builder of healthcare and medical research facilities in the nation, chances are you are familiar with a Turner Construction Company project.

From the Ronald Reagan UCLA Medical Center in Los Angeles to the Yale University Health Services Center in Con-necticut, Turner projects literally crisscross the country. Closer to home, Turner was the builder in charge of the Middle Ten-nessee Medical Center replacement facility (now Saint Thomas Rutherford Hospital) and is working on HCA’s new downtown building project. After building the original hospital back in the 1970s, Turner has been named construction manager of the $110 million Saint Thomas West expansion and modernization plan, and the company also has worked on various building projects at Vanderbilt University Medical Center for more than three decades.

Founded in New York in 1902, Turner has a number of international offices, as well as more than 40 North American of-fices across 24 states and two Canadian provinces. The company, which has a global staff of 5,200 employees, has an an-nual construction volume of $9 billion. Of that total, a little more than 20 percent … close to $2.1 billion last year … is in health-care construction. The company’s Nashville office oversees much of the builder’s medi-cal construction work nationwide.

The Trends“Over the last 10 years, certainly I

would say technology is the driving trend-changer in healthcare,” said Howard Allums, a vice president in the healthcare practice who is based out of Nashville. The demand for elec-tronic health records and hybrid ORs, plus a focus on specialty procedures, has helped fuel the need for increasingly complex building and en-gineering configurations.

Flexibility is another request by many clients. “A lot of people say, ‘I want a 50-year building,’” Allums noted. Of course, he continued, it’s hard to predict exactly what will happen over the next five de-cades, but universal rooms that can be re-configured to meet multiple needs are one solution. “They can spend more money on the up front side but save money in the long run,” he added of clients who invest in flex-ible spaces.

Chip Cogswell, vice president and national healthcare director who is based in Atlanta, con-curred, noting another phrase being used is ‘acuity adaptable rooms.’ Traditionally, an ICU

and standard inpatient room would be built differently to meet very specific equipment needs. “Now, hospitals aren’t sure what the census will look like so they want rooms that will do both,” Cogswell said.

“There’s no question with healthcare reform and other activities, we are seeing a lot more outpatient facilities,” he continued of the incentive to keep people out of the hospital.

The various building trends noted by Turner’s healthcare team dovetail neatly. As more care is delivered in the outpatient setting, the acuity level of patients in hos-pitals is rising thus fueling the demand for increased technology capabilities and more flexibility of inpatient spaces.

The ProcessTiming is everything … particularly in

a healthcare world focused on cost and ef-ficiency. When it comes to bringing in the construction team, Cogswell said sooner is much better than later.

“In a perfect world, we would tell a cli-ent we’d like to be at the table the day after they pick an architect,” Cogswell said.

Allums added the benefit often shows up in the form of significant cost savings. The T-Cost Modeling System, which Turner has developed over the last decade, allows clients to immediately see the impact of materials and design decisions before de-signs are finalized.

“It allows us at a very, very early stage to help a client understand the impact of their decisions,” Allums said. “We can con-struct a model of that hospital from a bud-get standpoint.”

The analytical system shows not only the cost of materials – for example an ex-terior finish of brick, concrete panels, stone or glass tiles – but also how that decision impacts energy costs and long-term opera-tions and maintenance.

Something as simple as a flooring de-cision can have a major impact. Cogswell pointed out choosing between PVC or ter-razzo tiles might seem like an easy choice from an immediate perspective, but that view could alter when considering costs over time. The inclination, he noted, is to say, “‘Let’s go with the cheapest one from a first cost standpoint,’ but then they have to wax it every week.” When a client realizes

a different material might offer a three-year payback, the decision could change … par-ticularly considering the lifespan of many healthcare facilities.

A little later in the process … but typi-cally still before the first brick is laid … ar-chitects provide a model of the building design so that Turner’s experts can add in materials and mechanical and electrical specifications to create a three-dimensional model of the project. Building Information Modeling (BIM) means building twice, once on the computer and then in the field, but like the T-Cost Modeling System, it can save clients money in the long run.

Allums said equipment costs and com-munications systems are areas that are often under-budgeted and too often cause sticker shock well into the building process. “If cli-ents miss those costs, the only place they have to make up those numbers is out of the construction budget.”

It’s a key reason why Turner’s Medi-cal Equipment Planning and Management service, also headquartered out of Nash-ville, is a win/win for the builder and client. “There are not very many companies that I know of in the construction business that offer this kind of service,” Cogswell said.

Having spent more than two decades in healthcare program management before joining Turner two years ago, Cogswell added he is all too familiar with the problems caused by having to go back to a board and ask for more money to offset cost overruns.

“Our real value proposition,” he said of Turner’s breadth of experience, “is we offer predictability of outcome. The owner can march forward with confidence.”

While the majority of the healthcare group is located in Nashville, Allums and Cogswell said most every office has a local healthcare champion to help oversee this important sector of Turner’s work.

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Chip Cogswell

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By CINDY SANDERS

The recession took a heavy toll on healthcare construction projects across the nation. However, as the economy has begun to improve, projects are beginning to move forward again.

Experts in healthcare real estate de-velopment and evidence-based design recently shared their insights with Medi-cal News regarding the current state of healthcare construction projects in the ambulatory setting.

Real Estate DevelopmentAfter seeing a number of plans put on

hold over the last few years, Bond Oman, chief executive offi cer of OGA, a na-tional full-service real estate development and project management fi rm based in Nashville, said there has been an increase in activity lately. While dialysis projects have remained fairly steady throughout, he said, the improved fi nancial environ-ment has resulted in an uptick in ambulatory surgery centers, urgent care centers and behav-ioral health facilities, among other sectors.

Oman said OGA presently has 21 projects in various stages of pro-duction. That is about a 30 percent increase over what the com-pany was doing during the recession and quickly approaching pre-recession num-bers, according to Oman. The company’s current portfolio includes work crossing the United States from California to Texas, Ohio to Florida.

One trend Oman said he is seeing nationwide is an emphasis on building smarter. He noted clients are trying to be more effi cient by using basic green design to lower ongoing costs and keeping the building footprint as tight as possible.

“With the health systems we are working with, we haven’t done a total gold or silver building,” he said, referring to Leadership in Energy and Environ-mental Design (LEED) status. However, Oman added, many employ green design when it comes to choosing lighting, in-sulation, windows, paint, and other ele-ments that increase energy effi ciency. In most cases, developers are still trying to strike a balance between the cost of add-ing green elements and the payoff in re-duced monthly costs.

As a whole, Oman said he thinks fa-cilities are being built a little smaller on the front end but with room for growth. “We are designing a large number of our buildings for expansion,” he noted. Rather than creating facilities with shell space to be fi nished off later, Oman said he is really seeing more facilities com-pletely fi nished but designed from the outset with the ability to blow out a wall for future outward expansion.

What might be surprising to some is how quickly pricing has rebounded. Oman noted those considering develop-ing healthcare properties aren’t going to fi nd any real deals. “The cost of doing business is getting back to where it was pre-recession,” he noted. “I’d say we’re defi nitely going to see an increase in cost because the economy is doing better … not doing great but defi nitely doing a little better each year.”

Oman noted landowners who sur-vived the recession are holding fi rm on real estate prices. Many municipalities that dialed back or waived impact fees to try to entice developers a few years ago have reinstated, and in many cases increased, those fees. He said prices are also inching up for mechanical, electrical and plumbing.

In general, Oman said healthcare de-velopment doesn’t tend to be speculative in nature. “It’s a different animal than a lot of the other real estate sectors,” he said, noting a demonstrated patient base and service need must be present before most in the medical industry will consider building. He added that while some mar-kets — including Dallas, Denver, Hous-ton and Nashville — are “on fi re” right now, there is still a feeling of cautiousness across most of the nation. Still, projects that were halted a few years ago are be-ginning to get the green light again.

An Evidence-Based Design Aesthetic

Where facilities are sprouting up, more and more of them are relying on research to inform design decisions.

Ellen Taylor, AIA, MBA, EDAC, an architect for more than 25 years, began volunteering with the Center for Health Design (CHD) before she began work-ing with the organiza-tion in 2008. As director of research, the New York-based Taylor helps spread the word about the best available infor-mation and latest credi-ble research to help those creating healing spaces.

“The Center for Health Design is a nonprofi t based in California that looks at how the built environment can affect health outcomes … whether for the patient or staff,” she noted, adding CHD accomplishes this goal through research, education and ad-vocacy.

While elements of evidence-based design (EBD) have intuitively been in-corporated in healing spaces for centu-ries, the formalized concept is relatively new. Taylor said a landmark 1984 study by Roger Ulrich, PhD — which found surgical patients with a view of nature had a reduced length of stay, required reduced levels of narcotics and had fewer complications — really captured people’s

attention and launched the EBD move-ment. Since 2009, CHD has offered the Evidence-Based Design Accreditation (EDAC) to those who have proven their expertise in the fi eld.

Although launched in the acute set-ting, Taylor said an increased awareness of how design impacts outcomes and a focus in the Affordable Care Act on en-gaging patients and keeping them out of the hospital have combined to create a recognition that EDB has an important role in outpatient settings, as well.

Another major trend for ambulatory spaces, she said, is the notion of fl exibility and adaptability. It isn’t uncommon for one specialty to utilize a space two days a week with another specialty using it the rest of the time. “There’s this real need to be nimble,” Taylor said. “You can’t have a room that’s just designed for one purpose.”

Taylor added the concept of the patient-centered medical home has re-ally had an impact on facility design, as well. It is increasingly common to see out-patient clinics and facilities, particularly community health centers, include larger multipurpose rooms that could be used for a support group, to teach a health class or to hold neighborhood meetings.

When working on safety net facil-ity design in California, Taylor noted a center added a walking trail behind the facility so that a physician could prescribe ‘four loops’ to a patient in need of physical activity. To make it truly useful, a play-ground was installed in the center of the trail so parents could easily keep an eye on children, who coincidentally were also engaging in fun, physical activity playing outside. Similarly, some facilities have begun hosting a farmer’s market or have created a community garden and offer cooking classes to demonstrate the ben-efi ts of making simple, nutritious meals.

Along the same vein, Taylor said it is becoming increasingly common for outpatient settings to be embedded in re-tail locations. Vanderbilt One Hundred Oaks in Nashville is an example of hav-ing mixed health and retail venues under one roof. Storefronts featuring supplies a patient needs to support a prescribed treatment sit next to national retailers featuring clothing or home goods. “It’s that concept of the one-stop-shop … if you can make it easier, you’ll have better compliance,” Taylor said.

The Mayo Clinic, she continued, of-fers another example of innovative, fl ex-ible design. “They started realizing not everyone needed to disrobe for every ap-pointment with physicians,” Taylor said. To address this, ‘Jack and Jill’ rooms were created — two offi ces with an exam room in between them. One patient could meet with his physician in the of-fi ce, while another patient was using the exam room … or a patient might begin in the physician’s offi ce and then move to

the exam room to complete the appoint-ment. “You have a more effi cient fl ow,” Taylor pointed out. “You are freeing up that valuable exam space.”

In addition to effi ciency, however, Adelante Healthcare in Arizona is also studying whether or not the setup might also reduce stress levels and lead to in-creased patient satisfaction. Is it easier to pay attention and be more engaged in a conversation with a physician when fully clothed in an offi ce compared to sitting on an exam table in a cold room while wearing a thin gown? Does the setting change patient behavior? Does the setup change outcomes? Finding quantifi able answers to those types of questions is key to EBD.

Adelante is also studying other de-sign tweaks that might shift the traditional power concept between physician and patient. Something as simple as having patients and physicians sit side-by-side and share a computer screen while dis-cussing treatment options or giving a pa-tient the ability to choose what they wish to view on a video monitor while waiting to see a provider can shift the perception of power. “That’s creating much more equality in care,” Taylor said. “There is a cultural awareness that needs to happen from a physician side, but then the design needs to accommodate that, as well.”

Taylor concluded, “Ultimately what we hope is that the design of the built environment is one tool in the toolkit to improve outcomes and improve health overall.”

Developing & Designing Effective Ambulatory Facilities

Bond Oman

Ellen Taylor

2014 Healthcare Design Conference

With a theme of “better care through better design,” the annual Healthcare Design (HCD) Conference is scheduled for Nov. 15-18, 2014 at the San Diego Convention Center in San Diego, Calif.

The premier event devoted to how the design of responsibly built environments directly impacts the safety, operation, clinical outcomes, and fi nancial success of healthcare facilities, the conference attracts architects, interior designers, top hospital and practice administrators, facility managers, healthcare construction professionals and researchers.

For more information on the 2014 agenda or to register, go online to healthcaredesignmagazine.com/conference.


GrandRounds

Let’s Give Them Something to Talk About!Awards, Honors, Recognitions

Sumner Regional Medical Center Chief Nursing Officer Anne Melton was honored by her colleagues from across the state during the annual Tennessee Organization of Nurse Executives (TONE) meeting where she was awarded the annual Excellence in Nursing Leadership Award. Melton came to SRMC in 2006 as nursing director, was named vice president of Clinical Services in 2008 and named CNO the following year.

ReviveHealth has won The Holmes Report 2014 In2 SABRE Award for “Most In-novative – Content Creation/Syndication” for its LinkedIn native ad campaign to drive brand awareness.

The inaugural In2 SABRE Awards were created to recognize and showcase innova-tive work in the emerging areas of social and digital media.

Alzheimer’s Foundation of America has named Nancy Pertl of Mental Health America of Middle Tennessee as the national Alzheimer’s Dementia Care Professional of the Year. Pertl has been the coordinator of Alzheimer’s and Aging programs for 12 years. Throughout her tenure, she has taught emergency department personnel to distinguish between dementia and delirium, created and copyrighted a 4-series training for family caregivers, made weekly in-home visits to train caregivers one-on-one, and led numerous support groups.

Michael L. Kirshner, LPC/MHSP, director of Business Development for the Mental Health Cooperative (MHC) was awarded the 2014 President’s Leadership Scholarship spon-sored by Argosy University in partnership with the Center for Nonprofit Management in Nashville. The full tuition scholarship is only awarded once per year to a candidate with a high degree of leadership potential. Kirshner will be pursuing his MBA.

Wishes GrantedPatrick Grohar, MD, PhD, assistant professor of Pediatric Hematology at Monroe

Carell Jr. Children’s Hospital at Vanderbilt, has been awarded a $250,000 Reach Award from Alex’s Lemonade Stand Foundation to support Ewing sarcoma research. Grohar’s work aims to develop new approaches to target the gene, EWS-FLI1, which causes Ewing sarcoma tumors to grow and spread throughout the body.

The BlueCross BlueShield of Tennessee Health Foundation is providing $3 million in support of the Governor’s Foundation for Health and Wellness and its Healthier Tennessee initiative. The grant will provide $1 million per year in funding for three years. The Healthier Tennessee initiative strives to increase the number of Tennesseans who are physically ac-tive for at least 30 minutes five times a week, promote a healthy diet, and reduce the number of people who use tobacco.

Vanderbilt University’s AIDS Clinical Trials Unit (ACTU) has received a seven-year grant renewal from the National Institutes of Health (NIH). The ACTU will receive approximately $1.4 million this year to continue studies aimed at improving treat-ment and ultimately devel-oping a vaccine to prevent HIV infection.

Recent Certifications, Accreditations & Commendations

Three directors at TriStar StoneCrest Medical Center earned a Certificate in Health-care Leadership from Union University - Center for Excellence in Health Care Practice. Amy Higgins, director of medical-surgical services; Jeff Johnson, director of physical medicine; and Dawn Warren, director of imaging and Sarah Cannon services, recently completed the 2013 TriStar Health Leadership Academy, a 12-month program offered through the TriStar Healthcare Educational Institute at Union University, Hendersonville.

The American Society of Hypertension (ASH) has recognized the Vanderbilt Hyperten-sion Clinic as an ASH Designated Comprehensive Hypertension Center. Cheryl Laffer, MD, PhD, professor of Medicine, directs the Hypertension Service within the Division of Clinical Pharmacology. The clinic is now one of eight ASH Comprehensive Hypertension Centers in the United States.

Giselle Krieger, RN, BSN, MS, CPHRM, vice president of Risk Management at Capella Healthcare, has earned the designation of Certified Professional in Healthcare Risk Manage-ment (CPHRM). Administered through the American Hospital Association, a professional is required to have at least 3,000 hours of risk management experience to even qualify to sit for the exam.

TriStar Summit Medical Center’s Breast Center has been granted a three-year, full ac-creditation designation by the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons. TriStar Summit is the latest facility in Middle Tennessee to earn this elite designation.

Anne Melton (center), pictured with leaders of TONE.

BlueCross officials present a check to Gov. Bill Haslam. Pictured (L-R) Scott Pierce, Chelsea Johnson, Bill Gracey, Gov. Haslam, Calvin Anderson and Dawn Weber.

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GrandRoundsCigarran Resigns from Healthways Board

Last month, Healthways, Inc. an-nounced Thomas G. Cigarran had re-signed from the board of directors of the company he co-founded, effective Feb. 14, 2014.

Cigarran, 72, helped launch the company in 1981 and served as its CEO from 1989 to 2003 before retiring to serve as chair-man until 2010, when he became chair-man emeritus. In a letter to John Ballan-tine, current board chair, Cigarran said he was “no longer willing to continue as a director and watch this company fail to meet its potential and the reasonable ex-pectations of its shareholders.” He added Healthways is well positioned to become a great company, but Cigarran said he did not think this could be accomplished “without changes in company focus and direction.”

Ballantine released a statement thanking Cigarran for his years of service and expressing surprise at the decision. The statement continued, “Our gover-nance guidelines require directors to tender their resignation upon age 72, but given his extensive history with the com-pany, the board had asked Tom to stand for election again this year. The board is surprised that he has chosen not to con-tinue to work with his fellow directors to enhance shareholder value in the rapidly evolving healthcare industry, especially given the market adoption of the compa-ny’s well-being improvement solutions.”

Ballantine added Healthways has just executed a very successful year of cus-tomer retention and new sales and reit-erated the board’s support of embattled CEO Ben Leedle and the Healthways management team. North Tide Capital, which owns 11 percent of the Franklin-based company, has objected to Leedle’s leadership and strategic direction for the company and vowed to present its own slate of directors this spring.

Vanderbilt Scientists Contribute to Finding that Could Lead to RSV Vaccine

Vanderbilt University scientists have contributed to a major finding, reported last month in the journal Nature, which could lead to the first effective vaccine against respiratory syncytial virus (RSV), a significant cause of infant mortality. The virus, which worldwide causes nearly 7 percent of all deaths among children ages one month to one year and is the leading cause of hospitalizations among children under two, has been notoriously resistant to vaccine-design strategies.

The Vanderbilt scientists and other researchers analyzed in an animal model a new method developed at The Scripps Re-search Institute (TSRI) in La Jolla, Calif., for

designing artificial proteins capable of stim-ulating an immune response against RSV.

“This project is the first work in which a protein that was designed on a com-puter has been shown to work as a vac-cine candidate for a human pathogen,” said Vanderbilt’s James Crowe, MD, Ann Scott Carell Professor and a leading RSV researcher.

The TSRI scientists developed a new software app, “Fold from Loops,” to de-sign proteins that folded around their functional fragments more naturally in a way that mimicked the viral epitope and which could serve as a key component of an effective vaccine. In rhesus macaque monkeys, whose immune systems are quite similar to humans,’ the designer “immunogen” proteins showed great promise. After five immunizations, 12 of 16 monkeys were producing robust amounts of antibodies that could neutralize RSV in the lab dish.

Collaboration Improves Efficiency in Pharmacogenetic Testing

Nashville-based Common Cents Sys-tems, Inc. (ApolloLIMS) and Translational Software have successfully collaborated to improve Pharmacogenetic (PGx) testing and reporting processes. This strategic col-laboration combines Apollo’s platform for operational excellence with Translational Software’s PGx decision support system to enable customers to improve turnaround time, decrease errors, and make test results more relevant for clinicians.

The ApolloLIMS Lab Automation component gives the lab automated pro-grammatic processes that intelligently send and receive data directly with the laboratory testing equipment without requiring data entry by the operator. By combining that with the Apollo eXchange HL7 Interface engine, the companies have been successful in creating a bi-direction-al seamless integration from the pre-ana-lytic, analytic, and post-analytic phases.

LBMC Launches Tennessee Health Reform Online Resource

While some questions have been answered, many more remain when it comes to healthcare reform. Lattimore Black Morgan & Cain, PC and the LBMC Family of Companies, one of the South-east’s largest accounting and business consulting firms, recently developed and launched a Tennessee Healthcare Reform website to provide the latest healthcare reform information in a consolidated site at TNHealthcareReform.com.

Centerre Names Maxhimer COO

Nashville-based, Centerre Healthcare Corporation has announced the appoint-ment of Terry Maxhimer as chief operating officer.

Maxhimer brings more than two decades of inpa-tient rehabilitation hospital experience, which has fo-cused on leading clinical and organizational excel-lence. His background includes an empha-

sis on positive partner relationships through healthcare joint venture partnerships.

In the COO role, Maxhimer will lead the operations of the company’s free-standing inpatient rehabilitation hospitals.

PhyMed Promotes TwoPhyMed Healthcare Group, an an-

esthesia practice management company based in Nashville, recently announced two key appointments at Anesthesia Medical Group (AMG), which serves Saint Thomas and Centennial Medical Centers and is the flagship operation of PhyMed.

Michael Morgan has been named COO of AMG. He was formerly PhyMed’s chief business development officer and will continue to serve in that capacity. Be-fore joining PhyMed, Morgan was CFO and COO of FOAA Anesthesia Services in Washington, DC.

Tammy Myers has been named di-rector of operations. Most recently she served as PhyMed’s director of integration and has served as AMG’s CFO. Myers has more than 20 years experience working at AMG.

Cogent Names Halasyamani CMO

Brentwood-based Cogent Health-care recently named Lakshmi Halasya-mani, MD, chief medical officer. The hos-pitalist fills the executive role left open when company founder and former CMO Ron Greeno, MD, moved to a new posi-tion overseeing strategy and innovation.

Halasyamani received her undergrad-uate degree from Saint Louis University and her medical degree from Harvard. She had been an attending physician at St. Jo-seph Mercy in Ann Arbor, Mich. Since 2000 and was named CMO in 2011. .

LifePoint Adds Two VPsBrentwood-based LifePoint Hospi-

tals® recently announced the addition of two new vice presidents.

Chip Staton has joined the company as vice president of the company’s newly established Enterprise Program Management Of-fice. He comes to LifePoint from Deloitte, where he led the project manage-ment office responsible for ensuring the firm’s com-pliance with the federal government’s contractor regulations. A certified public accountant in Texas, Staton received his bachelor’s degree in Accounting in from Texas A&M University.

Jennifer C. Peters has joined the com-pany as vice president and chief operations counsel. Most recently, she served as general counsel, secretary and chief com-pliance officer for Simplex Healthcare. Peters received her undergraduate degree from Buffalo State Univer-sity, her master’s in Health-care and Finance Manage-ment from the Johns Hopkins School of Hygiene and Public Health, and her law de-gree with a concentration in health law from the University of Maryland.

Terry Maxhimer

More Grand Rounds Online

nashvillemedicalnews.com

Chip Staton

Jennifer C. Peters

Thomas G. Cigarran


GrandRounds

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Van Donkelaar Takes on Financial Role for Two Capella-Saint Thomas Partner Hospitals

Rodney A. Van Donkelaar has been named senior chief financial officer for River Park Hospital in Mc-Minnville, Tenn. and High-lands Medical Center in Sparta, Tenn. The two hospitals are both part of the Capella-Saint Thomas Upper Cumberland health system, which also includes DeKalb Community Hospi-tal in Smithville, and Stones River Hospital in Woodbury.

Most recently, Van Donkelaar served as CFO for Grandview Medical Center in Jasper, Tenn. Originally from Michi-gan, Van Donkelaar earned his degree in Business Administration Accounting from Davenport University in Grand Rapids.

Cumberland Adds Two Partners

Two principals at Cumberland Con-sulting Group have been promoted to partners.

Mike Penich joined Cumberland in 2004, shortly after the company’s inception, and specializes in project management, systems analy-sis and design. He received his bachelor’s degree in Op-erations Management & Information Systems from Northern Illinois University and is a certified Project Man-agement Professional (PMP).

Greg Varner, a registered nurse with more than 22 years of experience in clini-cal healthcare delivery, has a successful track record as a consulting executive in healthcare IT. He earned his bachelor’s degree from the University of Tennes-see at Chattanooga.

Both are members of the Project Management Institute and the Healthcare Information & Management Systems Society.

Capella Announces PromotionsCapella Healthcare recently an-

nounced the promotions of three senior leaders to executive management positions and four others to its senior management team.

Promoted to executive vice president are:

Neil Kunkel, EVP, chief legal and ad-ministrative officer,

Andy Slusser, EVP, chief development officer, and

Denise Warren, EVP, chief financial of-ficer.

Promoted to senior vice president po-sitions are:

Mark Medley, SVP, president – Hospi-tal Operations,

Carolyn Schneider, SVP – Human Re-sources,

Alan Smith, SVP, chief information of-ficer, and

Lori Wooten, SVP, chief financial offi-cer – Hospital Operations.

Ardent Appoints Adams VP of Reimbursement

Ardent Health Services recently an-nounced the appointment of Jim Adams as vice president of reim-bursement. With nearly 20 years of experience, Adams brings a broad background in healthcare reimbursement with expe-rience in both health sys-tems and national business consultancies.

Most recently, he served as direc-

tor of strategic reimbursement for the healthcare practice of Wipfli, LLP, a top 25 accounting and business consulting firm. Previously, he was a senior consul-tant with Ernst & Young where he spe-cialized in Medicare and Medicaid reim-bursement. A certified public accountant, Adams is a graduate of the University of South Alabama.

White Joins Clearwater Compliance as VP

Communications veteran Andrea White has joined Nashville-based Clearwa-

ter Compliance as vice presi-dent of marketing. .

Most recently, White worked with Walgreens, leading innovations project management initiatives for the Take Care Health Em-ployer Solutions Group.

The Nashville native, received her undergraduate degree from Georgetown University and earned her MBA at the Uni-versity of Virginia Darden School of Busi-ness.

Rodney A. Van Donkelaar

Mike Penich

Greg Varner

Jim Adams

Andrea White

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