East TN Medical News February 2014

FOCUS ON CARDIOLOGYSPONSORED BY WELLMONT

HEALTH SYSTEM

John C. Hoskins, MD

PAGE 3

PHYSICIAN SPOTLIGHT

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Enjoying East TennesseeSki Beech - Totally 80s Retro Ski Weekend It’s funny how a song or pieces of clothing can immediately catapult you back to the era when the song was heard or when the clothing was worn ... 7

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Patient Centered Practices ... 17

By CINDy SANDERS

As the clock ran down on 2013, a number of deductions healthcare providers have come to depended upon to lessen their tax burden expired. Last year also saw an increase

in federal tax rates, including higher taxes on investment income and capital gains. This com-bination has accountants nationwide bracing for a widespread outbreak of severe sticker shock come

April 15.Tom McGuinness, CPA, CVA, of Reimer, McGuinness & Associates, PC in Houston said his fi rm

has run tax scenarios for high net worth individuals for more than a year. “We’re doing this as a service to prepare you for the blow … but the blow is coming,” he stated. For one client whose income hit the $2 million mark, there was a six-fi gure difference in taxes owed. “Looking at 2012 actual income data,

the tax differential was 22 percent,” McGuinness said of the $860,000 that would be owed for 2013 as compared to $706,000 for 2012. “It is real money.”

He added that many of the changes in 2013 and 2014 will hit healthcare professionals and providers both as businesses and as individuals. McGuinness said at the beginning of 2013, Congress was upset about

M&A Trends in the Reform EraA look back at 2013 … Look ahead in the new year

(CONTINUED ON PAGE 8)

By STACy FENTRESS

People who live in East Ten-nessee and Southwest Virginia know the region is rich in many things – natural beauty, friendly people, and dedicated and talented healthcare providers. What they may not realize is that their region is also rich in something else – cut-ting edge medical research.

When it comes to enrolling patients in cardiovascular research studies, there’s a group in East Tennessee that competes favorably – and often surpasses – large, well-known university research centers. That group is the Wellmont CVA Heart Institute.

“The Wellmont CVA Heart Institute has been the fi rst or sec-ond top research enroller, nationally and internationally, in 20 of the top research trials,” said Chris Metzer, MD, interventional car-diologist and Medical Director of Clinical Research at the Well-

mont CVA Heart Institute. “One benefi t of being a top enroller is that we have the fi rst chance to partici-pate in important studies.”

According to Terrie Walker, Director of Clinical Research with the Wellmont CVA Heart Insti-tute, the quality of the work they do, their dependable results, and the skills and reputation of the staff work together to make the Wellmont CVA Heart Institute a sought-after study site. “I am proud

to say we were recently chosen as one of the few worldwide sites selected to bring advanced treatment to our patients with resistant hypertension,” she said.

The Wellmont CVA Heart Institute has participated in re-search for a variety of cardiovascular devices and drugs, including trials for drug-coated balloons for use in peripheral interventions

FOCUS TOPICS CARDIOLOGY MERGERS & ACQUISITIONS

To promote your business or practice in this high profi le spot, contact Sharon Dobbins at East TN Medical News.

[email protected] • 865.599.0510

Tri Cities Home to Leading Cardiovascular Research FacilityWellmont CVA Heart Institute a top enroller in the U.S


THIS MONTH’S FOCUS ON CARDIOLOGY IS

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

State of Tennessee

Thank you to our Sponsors for their support of Project Access

WASHINGTON CO. PROVIDERSAllergy Associates, P.A.Anesthesia & Pain Consultants, PCAppalachian Orthopaedic AssociatesAppalachian Radiation Oncology AssociatesBlue Ridge Family Medicine, SoFHACardiology Consultants of Johnson City, P.C.Ear, Nose and Throat AssociatesEast Tennessee Medical Associates, PCEast TN Brain & Spine CenterETSU Behavioral Health & Wellness CenterETSU Family Medicine AssociatesFirst Choice Family Practice-SoFHAGastrointestional Associates of Northeast TennesseeGray Family Clinic, PLCGray Family Health Care, PCJohn Lawson Surgical GroupJohnson City Eye ClinicJohnson City Internal Medicine, SoFHAJohnson City OB/GYN AssociatesKaring Hearts Cardiology, PLLCMedical Specialists of Johnson CityMolecular Imaging Alliance - Lifescan TennesseeMountain Empire Radiology, PCMountain Empire Surgery CenterMSMG - Family Practice Johnson CityMSMG - HIMA @JCMCMSMG-CardiologyMSMG-CVT Surgical GroupMSMG-NeurosurgeryMSMG-OrthopedicsMSMG-Trauma Services @JCMCOutpatient Cytopathology CenterPain Medicine Associates, PCPhysical Therapy Services, PAPinnacle Family Medicine, SoFHAPulmonary Associates of East TNQuality of Life - OncologyQuillen ETSU Osteoporosis CenterQuillen ETSU Phys. & Assoc. - AllergyQuillen ETSU Phys. & Assoc. - Center for Pelvic Surgery and UrogynecologyQuillen ETSU Phys. & Assoc. - Dermatology

Quillen ETSU Phys. & Assoc. - EndocrinologyQuillen ETSU Phys. & Assoc. - Gastroenterology Quillen ETSU Phys. & Assoc. - HeartQuillen ETSU Phys. & Assoc. - Infectious DiseaseQuillen ETSU Phys. & Assoc. - Internal MedicineQuillen ETSU Phys. & Assoc. - PCPQuillen ETSU Phys. & Assoc. - PodiatryQuillen ETSU Phys. & Assoc. -OB/GYNQuillen ETSU Phys. & Assoc. -SurgeryReeves Eye InstituteRegional Cancer Center - Johnson CityResolutions, PLLCState of Franklin Healthcare Associates (SoFHA)Surgical Group of Johnson CityThe Urology Clinic at Johnson CityTotal Health Family MedicineTri-Cities Pediatric CardiologyVascular Surgical Associates, PCWilson Pharmacy

SULLIVAN CO. PROVIDERSArthritis Associates, KingsportAssociated Oral Maxillofacial SurgeonsBristol Surgical AssociatesBristol Urological AssociatesCallaDerm Center for Medical & Surgical DermatologyDermatology Associates of KingsportETSU Family Physicians of BristolETSU Family Physicians of KingsportFamily FootcareGastroenterology Associates - BristolHMG - Pediatrics & Internal Med at Sapling GroveHMG Church Hill Primary CareHMG Dermatology KingsportHMG Gastroenterology BristolHMG Gastroenterology KinsportHMG General SurgeryHMG Hospitalist TeamHMG Meadowview Lane Family PracticeHMG Medical Plaza Family Practice & Internal MedicineHMG Medical Plaza Urgent CareHMG Orthopaedic Ctr of the SoutheastHMG Otolaryngology Bristol

HMG Otolaryngology KingsportHMG Rehabilitation ServicesHMG Sapling Grove Family PhysiciansHMG Sapling Grove Urgent CareHMG Seasons-Bristol OB/GynHMG Seasons-Kingsport OB/GynMeadowview Ear, Nose & ThroatPain Medicine Associates-BristolPain Medicine Associates-KingsportPulmonary Associates of KingsportRegional Kidney Care, PCRegional Orthopaedic TraumatologySoutheastern Retina Associates, PATri-City Oncology Cancer CenterWellmont CVA Heart Institute-BristolWellmont CVA Heart Institute-KingsportWellmont Health SystemsWellmont Hematology/Oncology - KingsportWellmont Surgical SpecialistsWellmont Trauma Surgeons

ANCILLARY PROVIDERSBlue Ridge Radiology, P.C.Highlands Pathology Consultants, PCHolston Valley Imaging Center, LLCMountain Empire Radiology, P.C.Mountain States Imaging@Med Tech ParkMountain States Women’s Health & Imaging CtrMountain States Wound CareSolstas Lab PartnersSynergy LabsWatauga PathologyWellmont Wound Care

HOSPITALS & MAJOR SUPPORTERSBristol Regional Medical CenterCity of Johnson CityFranklin Woods Community HospitalHolston Valley Medical CenterJohnson City Medical Center

OTHER CONTRIBUTORSArrington, Schelin & Herrell, PCBob Everhart & CrewCapteevations

Chick-Fil A, Johnson CityDispensary of HopeElixir Media GroupFamily Promise of JCHands-On MuseumHealth & Home Care of ErwinHome Depot Store #4658Medical News Inc.Modular DesignsMountain States Home HealthMr. & Mrs. Wilkes, Jr.Stephen GuinnSummit Leadership FoundationThe Penland FamilyVictory Orthotics & Prosthetics

CLINICSBluff City Medical Center/RHCCarter County Health Dept./RHCChurch Hill Free Medical ClinicCrossroads Medical MissionDry Creek Medical/RHCFriends in Need Health CenterHawkins County Health Dept./RHCHealing Hands Health CenterJCHA-Partners for HealthJohnson City Community Health CenterKingsport Medical Center/RHCLimestone Medical Center/RHCProvidence Medical Clinic of KingsportSullivan County Health Dept.Twin City Medical CenterWashington County Health Dept.

INDIVIDUAL SUPPORTERS, VOLUNTEERS & INTERPRETERSChristian Magallanes, InterpreterDaniel Gouger, InterpreterETSU Internship StudentsGinny Russell, VolunteerLili Martinez, InterpreterMaritza Wilson, InterpreterMichael Bradfi eld, InterpreterSarah Bradfi eld, Interpreter

To join our esteemed Network of Volunteer Providers, call 423-232-6700 or visit www.ProjectAccessEastTN.org

Physicians & Medical Providers in Northeast Tennessee are Making a Difference in our Communities

Thank you to the following area medical providers for their spirit, service, dedication

& compassion & for creating a better system of care for the medically uninsured

individuals in our communities. From 2008 through 2013 they have collectively donated:

The cumulative value of care thru 12/31/2013 is $30,554,389Together, Building a Healthy Community

e a s t t n m e d i c a l n e w s . c o m FEBRUARY 2014 > 3

PhysicianSpotlight

By BRIDGET GARLAND

After a conversation with retina surgeon John C. Hoskins, MD, “com-munity-centered” might top the list of his many attributes. Hoskins, who founded Southeastern Ret-ina Associates (SERA) in 1980, grew up in Knoxville and returned home after finishing his education so that he could give back to the patients of East Tennessee.

“I really want to emphasize how great it is to practice medicine here in East Ten-nessee,” Hoskins shared. “I watched my dad practice here in Knoxville and East Tennessee. I could see how gratifying it was for him, so it was easy for me to see myself doing that.”

Hoskins, who received an under-graduate degree in English from Vander-bilt University in 1966, went on to receive his medical degree from the University of Tennessee, Memphis, and completed his ophthalmology residency at Brooke Army Medical Center in San Antonio, Texas. Hoskins’ father, an ophthalmologist, was a role model for Hoskins’ career path. “Oph-thalmology was a big part of my back-ground. I really liked ophthalmology like my father did, so it just came naturally after

that,” he said. However, Hoskins

saw that, at the time, oph-thalmic subspecialties were growing and tremendously needed, so he decided to pursue a retina fellowship at the Massachusetts Eye and Ear Infirmary, Har-vard University, in Boston.

“There were not a lot of programs at the time, so I was fortunate to get

to do that,” he said. “I could see that the retina was going to be an important field of study, as age-related macular degeneration in older people was more common place, as well as the growth of diabetic problems. No one in Knoxville was doing it, so I was very fortunate to bring my training back to East Tennessee.”

As the first retina surgeon in East Ten-nessee, Hoskins has helped grow SERA into what it is today. Currently, thirteen provid-ers see patients in Knoxville, Chattanooga, and the Tri Cities, and as Hoskins pointed out, all of them are as grateful as he is to be practicing in East Tennessee.

“East Tennessee is a great place to practice, and we are able to do something here that the people would really benefit from, and they are really grateful for what we do,” he said. “Five of our physicians grew up in Knoxville and all of them came

back here because it’s a great place to live. We are a pretty unique practice in that re-gard. Four of them even attended Bearden High School, imagine that.”

“We really have been fortunate all the way down the line. We have great partners and great patients who appreciate what we do,” he continued.

An important part of his practice, Hoskins shared, is the group’s involvement in clinical trials, including historically signif-icant subretinal surgery trials (e.g. CATT, AREDS, DRCR).

“Our practice as a whole has been in-volved in a number of trials sponsored by the National Eye Institute, such as for dia-betic retinopathy and macular degenera-tion. Trials have always been a significant focal point of our practice,” he said. “We like to be tied into academic centers and re-main at the forefront of things, and that is certainly one way of doing that.

“Participation is very beneficial to our patients, as well. They can receive cutting edge therapies through trials that may not be available for a few years,” he pointed out.

Many of these trials have led to great advances in the specialty, some of the most significant advancements in pharmacologic treatments.

“For patients with what we call ‘wet’ age-related macular degeneration [AMD], the only treatment in years past was to

seal off the bleeding with a laser, and we didn’t have very good outcomes with these patients. They would often get to where they couldn’t read or drive, and AMD can significantly change their lifestyle,” he ex-plained. “Now we have anti-VEGF drugs, such as Lucentis and Avastin that we use a lot. When patients come in with bleeding in the back of the eye, we can treat them with intra-vitriol injections. They receive the in-jections every month for varied periods of time depending on the eye’s response, but so many people can keep reading and driv-ing, but in the early part of my career, we couldn’t do that. It’s pretty standard treat-ment we do in the office, and it’s a hugely significant advancement.”

For Hoskins, community is more than the patient population; it includes his healthcare colleagues as well. Hoskins has been influential in bringing ophthalmolo-gists and optometrists together in the com-munity to provide top-quality eye care to East Tennesseans.

“SERA has tried to play a part in bringing the community of ophthalmologist and optometrist together to better serve our region,” he said. “With the new healthcare laws, we feel it is even more important to work together.”

At home, Hoskins, who is married and has three grown children, is an avid golfer and University of Tennessee football fan.

John C. Hoskins, MD

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Providing comprehensive Retina Care in East Tennessee for over 30 YearsNationally recognized as the Most Experienced Retina Team in East Tennessee. Specializing in:

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Our retina specialists utilize the most advanced therapies and surgical approaches to provide the best treatment available. Southeastern Retina Associates also maintains active clinical trial and research programs to provide cutting-edge treatments to East Tennessee.

Richard I. Breazeale, M.D.

Stephen L. Perkins, M.D.

R. Keith Shuler, Jr., M.D.

Howard L. Cummings, M.D.

Joseph M.Googe, Jr., M.D.

Joseph M. Gunn, M.D.

Tod A. McMillan, M.D.

D. Allan Couch, M.D.

James H. Miller, Jr., M.D.

Francis Char DeCroos, M.D.

John C. Hoskins, M.D.

Cris Larzo, M.D.

Nicholas G. Anderson, M.D.


ClinicallySpeakingBY RICHARD M. YOUNG, MD, FACS

Close Cousins: Screenings Encouraged for both Peripheral Arterial and Coronary Artery Disease

As a vascular surgeon in East Ten-nessee where there is a high preva-lence of obesity, diabetes, and coro-nary artery disease in the population, my cardiologist colleagues and I rou-tinely share many of the same patients.

Peripheral arterial disease (PAD), the progressive buildup of plaque in the arteries outside the heart (usually in the legs), is usually caused by ath-erosclerosis, the same disease process that causes heart attack and stroke. High cholesterol, high blood pres-sure, obesity, smoking, diabetes, and a sedentary lifestyle all contribute to atherosclerosis. These cardiovascular risk factors are nearly always present in my PAD patients. Not surprisingly, PAD patients have a 1 in 3 chance of having coronary artery disease.

The most common PAD symptom/complaint is claudication, which is often described as a tired ache-like cramp in the legs when walking that is relieved when activity stops. People often dis-miss leg cramps as a natural part of

aging or arthritis, and may never men-tion it to their physician. An estimated, one in 20 Americans over age 50 has PAD, but are unaware of the condition. If PAD risk factors are not controlled, this atherosclerosis of the arteries can progress and lead to limb threat and possible amputation.

As PAD progresses, so does the inability to walk even short distances without having to stop frequently. The arteries can eventually become clogged with plaque and the blood flow so restricted, that the foot doesn’t get enough oxygen to meet its basic needs to remain viable. When we see patients in this advanced state of limb threat, there’s a high risk of limb am-putation if steps aren’t quickly taken to intervene.

Patients who present with PAD symptoms, especially those with heart disease and other high risk factors, should be encouraged to be screened for peripheral arterial disease. The simple ankle-brachial index (ABI) test,

which compares the blood pressure in the ankles to the arms, can show how well blood is flowing to the legs. A Doppler ultrasound test may be used to determine where a specific artery is blocked.

Fortunately, like heart disease, the progression of PAD can be slowed or stopped with lifestyle changes, medi-cation, or a combination of both. Being physically active, especially with a walk-ing program, can increase blood flow to the affected leg. For smokers, the most important intervention is to stop smoking immediately. Strict glucose control in diabetics and eating a low-cholesterol, low-fat diet, can also help reduce the buildup of plaque in the arteries. Medications to lower choles-terol, blood pressure, and diabetes are also a part of PAD treatment.

For patients whose PAD has ad-vanced to the stage that it is disrupt-ing their ability to work, enjoy favorite activities, or threatening a limb, circula-tion may be restored by opening the

blockage with a minimally invasive pro-cedure. This outpatient endovascu-lar procedure is performed through a catheter that opens the blocked artery and restores circulation to the leg and foot. If a long section of an artery is blocked, bypass surgery may be need-ed.

PAD treatments are not “cures,” but can provide a very durable result, especially in patients who have mini-mized the risk factors listed above and embraced a more active lifestyle and healthier diet. PAD is often a gateway indicator to one’s overall cardiovascu-lar health. Early detection and treat-ment of peripheral arterial disease can help improve patients’ quality of life and reduce the risk of amputation.

Richard M. Young, MD, FACS, is a vascular surgeon with Premier Surgical Associates in Knoxville, Tennessee. He is board certified in vascular surgery by the American Board of Surgery and a Fellow of the American College of Surgeons.

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This concert is funded under an agreement with the Tennessee Arts Commission and the National Endowment for the Arts.

Free bus service: 6:15 (Colonial Hill); 6:30 (Maplecrest & Appalachian Christian Village); 6:45 (City Hall)

Tickets: $35; Seniors (65+) $30; Students $10For more information: 92-MUSIC (926-8742) or

visit www.jcsymphony.com

Dances and Daydreamsfeaturing Chu-Fang Huang, Piano

Saturday, March 8, 7:30 p.m.sponsored by Jim and Sandy Powell

Mary B. Martin Auditorium at Seeger Chapel, Milligan College

Chinese pianist Chu-Fang Huang began studying the piano at age 7 and received a full scholarship to the Shenyang Music Conservatory’s pre-college division at age 12. She made her U.S. recital debut at 15 in the La Jolla Music Society’s Prodigy Series. Huang took first prize in 2005 in the Cleveland International Piano Com-petition and one year later she won first prize in the 2006 Young Concert Artists International Auditions. Her worldwide

appearances have included recitals in New York, Istanbul, and the Louvre Museum in Paris, and concerto performances in Canada, Australia, and China, at Lincoln Center, and in Missouri, South Carolina, Texas, Colorado, and California. A graduate of the Curtis Institute of Music under Claude Frank, she received her master of music degree and artist diploma from the Juilliard School under Robert McDonald.

Evening ProgramJohann Strauss, Jr.: To the Hunt, Op.373

Richard Strauss: Burleske in D minor for Piano and OrchestraHector Berlioz: Symphonie Fantastique, Op. 14


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HealthcareLeader

Vyvyan Derouen By BRIDGET GARLAND

Originally from Lake Charles, Louisi-ana, Vyvyan Derouen, Executive Director of Wellmont CVA Heart Institute, moved to the Tri Cities about 18 years ago, eager to start working as a new nursing gradu-ate.

“We actually moved here about two weeks after graduation,” recalled Der-ouen. “We were looking for a good medi-cal community and a good place to raise a family. I did have a family member al-ready here, so that helped influence our decision.”

Starting out in cardiac nursing, Der-ouen has remained in the cardiac field throughout her career. She worked her way up from floor nurse to charge nurse, then on to assisting cardiac surgeons, from which she slowly evolved into administra-tion, becoming an office practice nurse and then on to assuming a director posi-tion.

For Derouen, her decision to become a nurse came during her experience work-ing in a veterinarian’s office, where she as-sisted in surgery.

“I was young, 18 or 19, but after doing that, I decided I liked the medical field and wanted to go into nursing. It was my first taste of medical procedures and

the science of medicine,” she said. “I also believed nursing had the most opportu-nity for growth because of the many dif-ferent directions you can go into, whether administrative management or any of the specialized areas. Nursing also gave me the flexibility to live in different parts of the country, which was also a goal.”

Four years ago, Derouen joined Tri-State Cardiology out of Johnson City, a group of physicians who decided to merge with Wellmont CVA Heart Institute, so in October 2011, Derouen merged with them, becoming regional director of op-erations for the Johnson City, Greeneville, Elizabethton, and Erwin office locations. Soon after, she was asked to move to Holston Valley Medical Center, where she became the director of invasive car-diovascular services, which oversees the cath lab, the cardiovascular OR, and the

cardiac rehab programs. Her most recent promotion an-

nounced in December 2013 was to the executive director position of Wellmont CVA Heart Institute, which entails over-sight of all 15 office locations and the cardiovascular services at Holston Val-ley Medical Center and Bristol Regional Medical Center.

“I have a great team of managers/leaders that work with me to oversee the day-to-day operations and staff. That makes a huge difference—having a good support team,” she said.

Only a few months into the position, Derouen said her initial leadership direc-tion will be toward fine-tuning operations.

“My predecessor, Tim Attebery, who has moved on to become the president of Holston Valley Medical Center, was hugely successful in the area of growth opportunities and expansion. My goal is to continue growth in some aspects, but to use my nursing background and clini-cal background to look deeper at opera-tions on a day-to-day level. I would like for us to fine tune and improve any ser-vices, quality, that type of thing,” she ex-plained. “In other words, my direction initially is fine tuning what he has grown successfully and developing what we have further. With Wellmont CVA Heart Insti-tute being comprised of 49 physicians and over 200 staff members, Derouen’s goal is no easy undertaking, but she seems up for the challenge.

“I’m new in this particular role, but it’s an expansion so to speak of what I had been doing. I like that every day is differ-ent. You know directionally where you are going, but no two days are the same,” she said. “And the opportunities that come up

every day, working with the staff on fine tuning things, new ideas, I really enjoy the operational piece of that.”

Additionally, Derouen pointed out that she is exceptionally proud of the qual-ity of care the Institute provides to the re-gion.

“I always want to work for someone who I would want my family to see and utilize their serves, and they do,” she said. “These are all highly-educated, board-cer-tified physicians that work well together. Their focus, which is very nice to see, is on the patient and quality of care first. That’s truly why they are in this field—for the right reasons. So when you get that many people that all have the same ultimate goal working together, and you see the quality outcomes they provide and the care they are able to give to their patients, I think they are truly unique in this area.”

Always looking to offer cutting edge technologies and treatments, Derouen added, “We are continually looking to grow and expand our services to the community with the latest technological advances and will soon be offering renal denervation for treating certain types of hypertension and Topera technology for atrial fibrillation in 2014.”

Derouen also explained that Well-mont CVA Heart Institute is able to offer comprehensive services—non-interven-tional, interventional, electrophysiology, peripheral vascular, and surgery—be-cause the Institute brings together so many different skill sets that work together as a team.

“They have spent a number of years working together to build the best possible system, and it shows.”

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HEALTH SYSTEM


Giving Diarrhea the Attention it Deserves

M. SaMer aMMar, MD, FaaP, FaGa

Diarrheal disease is so common and so often short-lived, and apparently benign, that neither physicians nor parents give it the attention it deserves. Unfortunately, this lack of concern plays an important role in the high mortality rate from diarrhea among children in developing countries. It also contributes to the high numbers and costs of hospitalizations for diarrhea in the United States. An estimated 16.5 million children less than 5 years of age have between 21 and 37 million episodes of diarrhea annually. Of these, 2.1 to 3.7 million episodes lead to a physician visit, a total of 220,000 patients are hospitalized, and 325 to 425 children die.

Diarrhea is defined as an increase in frequency and water content of bowel movements. In reference to stool volume, more than 10 ml/kg/day for infants and toddlers or more than 200 ml/day for older children is an acceptable measurement index for diarrhea. The basic science terminology of diarrhea is the disturbance of water and electrolytes handling across apical and basolateral membranes of small and/or large intestine. On the intracellular level, diarrhea may be classified as osmotic or secretory. Although theoretically that distinction is possible, practical, and often the case, in any given patient, diarrhea is caused by combined osmotic and secretory mechanisms. Diarrhea is a symptom rather than a diagnosis. Based on duration of symptoms, diarrhea can be either acute, that is, less than 2 weeks, or chronic, when the patient is symptomatic for longer than 2 weeks.

As for etiology, diarrhea can be infectious versus noninfectious. Infectious etiology is when we suspect the presence of a microbial agent, whether we are able to isolate such agent or not. Usually, in nonimmunocompromised patients, infectious diarrhea is acute. There are too many causes of noninfectious diarrheal bowel movements. Although diarrhea is almost always chronic in noninfectious causes, acute intermittent presentation may be the only early red flag in a subgroup of patients. Noninfectious causes of diarrhea are congenital (e.g., congenital chloride diarrhea, congenital sodium diarrhea, microvillus inclusion disease,

tufting enteropathy, congenital disaccharidase deficiency), malabsorptive (e.g., cystic fibrosis, gluten enteropathy), inflammatory (e.g., regional ileitis, noninfectious colitis, whether ulcerative or not), or diet induced.

Effective evaluation starts with obtaining a detailed history and conducting a full physical examination. How much further the case is investigated should be based on clinical suspicions. Symptoms persisting beyond two weeks require investigation. Irritable bowel syndrome is a common cause; however, organic disease should be suspected if there is weight loss, a recent onset of diarrhea (less than three months), or nocturnal or continuous symptoms. Pale and offensive stools may suggest malabsorption. The presence of blood or mucus in stools or a family history may indicate inflammatory bowel disease. Recent hospital admission or antibiotic treatment may indicate Clostridium difficile infection. Signs of malnutrition or failure to thrive may indicate cystic fibrosis, celiac disease, or a chronic infection, such as a UTI. These are some of the red flags that may require a specialist referral.

Whenever possible, management should be directed to target and correct the underlying cause. General principles of management may include: 1) eliminate juices and high fructose corn syrup whether diet induced diarrhea is suspected or not; 2) maintain hydration; 3) almost all infants with acute diarrhea can tolerate breastfeeding; and 4) the use of antibiotics, probiotics and zinc supplementation should be individualized. Regardless of the cause of recurrent acute or chronic diarrhea, an early referral may correlate with better outcome.

GI for Kids, PLLC is a pediatric gastroenterology specialty clinic located at East Tennessee Children’s Hospital and staffed with an expert team readily available to assist in caring for such patient by providing the next step in evaluation and management. We serve all of the East Tennessee and the surrounding areas. Dr. M. Samer Ammar is a board-certified pediatric gastroenterologist with GI for Kids, PLLC.

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of the leg arteries, renal denervation treat-ment for refractory intervention, endarter-ectomy for treatment of coronary artery disease, bioabsorbable drug-eluting stents, and the list goes on. They participate in inpatient and outpatient studies.

“Through our studies, we are able to treat conditions such as carotid artery stenosis; iliac, femoral, and renal artery stenosis; as well as coronary artery steno-sis,” Walker said. “We treat electrophysi-ology disorders such as heart failure and arrhythmias and also focus on new indi-cations for approved devices currently in use.”

According to Metzger and Walker, participation in these studies helps move medical science – and the treatment of cardiovascular disease – forward. Over the years, the Wellmont CVA Heart Insti-tute has grown tremendously. “We aver-age 450 patients per year,” Walker said. “We have a very good reputation in the research community. We are good en-rollers and we produce high-quality, veri-fiable data. We have passed three FDA audits with no writable mistakes.”

“Not only do we enroll well, but our follow-up rates are outstanding,” Metzger said. “That is how we’ve been able to de-velop a good reputation in the research community. We are recognized as one of the leading research facilities for cardio-vascular research in the country.”

Metzger and Walker agree that the people involved – patients and staff at the Wellmont CVA Heart Institute – are responsible for the high enrollment and follow-up numbers. “We have an enthu-siastic research staff. They are really nice people,” Metzger said. “The staff keeps people wanting to come back, and the patients here are different than patients at other facilities. We have good patients, and there is mutual trust.”

Part of the reason for that trust is that research staff members take their time to really go through options and information with patient participants and their fami-lies.

“We make sure all consent forms are written in lay-language, and we fully ex-plain all studies to patients before they sign up,” Walker said. “We also keep in mind that these are discussions for the entire family. We are treating the entire family together. Not only do we want to get the patient into a study, but we also want to be sure we can get the patient to come back – especially in the longer three-to five-year studies.”

While study sponsors and medical science as a whole benefit from studies, so too do patients. “Through these trials, we offer patients access to new treatment technologies they wouldn’t be able to get otherwise,” Metzger said.

“We have had devices we’ve stud-ied that are now used as the standard of care for patients across the country,” Walker said. “It feels good to know we have treated patients with devices that are now known to be superior sooner than we could have treated them with those de-vices otherwise.”

Some patients also get the benefit of

additional testing because they are part of a study. “Often these patients get addi-tional or closer follow-up and more testing than they generally would if they weren’t part of a research study,” Walker said. “They have phone numbers for research nurses and are encouraged to call to dis-cuss any issues or concerns.”

For Metzger, being able to give pa-tients an opportunity to participate in world-class research studies is a good feel-ing. “Through a collaborative effort, we have evolved to a well-respected, consis-tently performing research department that offers patients access to technology they wouldn’t have access to otherwise,” he said.

Walker agrees. “It is exciting to be able to bring this kind of research to this area, where people may not be able to travel to large university hospitals,” she said. “Our patients can participate in the same studies here in our area. By partici-pating in this research here, we can keep our older, sicker patients from having to make long drives to a university medical center for treatment.”

The Wellmont CVA Heart Institute conducts studies throughout the region in their offices in Kingsport, Johnson City, and Greeneville, as well as at Bristol Re-gional Medical Center and Holston Valley Medical Center.

“We accept referrals for patients who would fit into research protocols,” Metzger said. “We generally work with patients who come through our offices or patients we come into contact with at the hospital, but we have a simple referral process as well.”

In Walker’s mind, the patients who elect to participate in studies are heroes. “We have patients who are selfless, who participate in research because they want to help others, to find answers, and to ad-vance medicine,” Walker said. “We get to know patients and their families. We see their spouses and their children. We really get to know them and want to see them do well.”

Tri Cities Home, continued from page 1

Dr. Chris Metzger working on a case in the cardiac catheterization lab at Holston Valley Medical Center.


By LEIGH ANNE W. HOOVER

It’s funny how a song or pieces of clothing can immediately catapult you back to the era when the song was heard or when the clothing was worn. That’s immediately what happens to me each time I hear Steve Miller Band’s classic “Fly Like An Eagle.” In-stantly, I’m on a church bus in jeans, bundled up and filled with anticipation heading from South Carolina to the snowy mountains of North Carolina for my very first ski trip.

In 1980, when I began dating my Tennessee native husband, Brad, he also took me to North Carolina to ski. In fact, one of my first Christmas gifts from Brad was a brand-new, teal ski suit, and I was so proud. I even had the matching hat and gloves. Even though I didn’t ski very well, I would look good… right? There was only one problem: when I was down from one of several novice falls, even the riders on the lift could spot me in my bright, new clothes!

Years later, I would go on to experience the freedom of skiing the vastness of seem-ingly endless runs out West and enjoy a little more anonymity. However, the clothes had definitely changed, and my ski wardrobe needed an update. Fitted items became the

rage, and the puffy suits were totally out of style on the slopes.

However, if you just happen to have any of the colorful 80s throwback skiwear still in a closet, during February, you will have the opportunity to reprise the fad and don the colorful duds in what’s known as “Eastern America’s Highest Town.” On February 21 – 23, 2014, the third annual

“Totally 80s Retro Ski Weekend” is happening just a short drive over the state line in North Carolina at Beech Mountain.

“The idea came from the movie ‘Hot Tub Time Machine’,” explained Public Relations Representative for Beech Mountain Tourism, Craig Distl. “It was a movie that came out in 2008 or 2009, and it was about a group of middle-aged guys who went back to a ski resort where they used to have fun. After a night in the hot tub, they wake up the next morning, and it is 1986.”

For Distl, the movie triggered an idea and a theme the whole town of Beech Mountain has embraced.

“We just ran with the idea, and it has grown every year,” said Distl. “It’s a good lighthearted weekend…, and everyone just sort of gets in the spirit and channels their inner 80s.”

Even if you’re not a skier, you can have fun with the themed weekend and go back in time.

According to Distl, participants have arrived each February on the mountain in everything from acid washed jeans and Members Only jackets to headbands and crimped hair.

‘There was a woman last year who

had the one-piece [ski suit] with the shoul-der pads,” explained Distl. “That’s the nice thing about ski clothes. You only wear them maybe once or twice a year, and maybe not even that much, so they last forever. A lot of people still have them in their closets because they don’t wear out, and you don’t want to throw them away.”

If you don’t have any pieces from the 80s left in your closet, Distl suggests locating weekend attire through friends, family mem-bers, or online at sites such as Amazon or Ebay. The retro-themed weekend seems to appeal to participants of all ages throughout the Southeast.

If you love the 80s, but you’re not a skier, the weekend also hosts 1980s themed bands as entertainment. This year’s event features Buick MacKane on Friday night at the Mile High Tavern. There will also be a “mile high moon walking” contest, which will showcase a performance by Malcolm Cox, an amateur Michael Jackson imper-sonator and winner of amateur night at the Apollo Theater in New York.

The Breakfast Club, which is consid-ered “America’s favorite 80s tribute band,” will perform on Saturday night at Beech Tree Lodge, and the Carolina Ghostbusters will make appearances in town and in the ski village with their Ecto-mobile.

Enjoying East TennesseeSki Beech - Totally 80s Retro Ski Weekend

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the fiscal cliff and proud of themselves for ‘fixing’ it. However, he continued, as 2013 tax bills come due, “It’s going to be the taxpayers turn to be mad because they are going to see how the fiscal cliff was avoided.”

Key Business ChangesBeneficial depreciation options take a

big hit in 2014. Changes to expensing quali-fied purchases, bonus depreciation, quali-fied leasehold improvements and a new IRS capitalization policy are all anticipated to impact many in the healthcare space.

“Congress did not extend the favor-able 179 deduction, which allows a tax-payer to expense immediately the cost of an otherwise capitalizable asset,” said Scott Tomichek, JD, CPA, senior tax manager for Carter Lankford CPAs PC, located in Tennessee. “The 2013 Section 179 deduc-tion was $500,000 for purchases up to $2 million and is set to be reduced to $25,000 for purchases up to $200,000 in 2014.”

Accelerated depreciation, which has been heavily used by healthcare providers and facilities to make equipment purchases more affordable on the front end was an-other incentive that expired at the end of 2013. Tomichek noted that on the purchase of capitalizable assets in 2013, a taxpayer was allowed to deduct 50 percent of that asset in the year of purchase and then depreciate the remainder. The accelerated 50 percent goes away in 2014 and reverts to the regular rules of a more even-based depreciation schedule without Congressional intervention.

Another change is in the life of quali-fied leasehold improvements, which are defined as any improvement to an interior part of a building that is nonresidential property. “Qualified leasehold improve-ments were able to be depreciated using a 15-year life and included in the previous Section 179 and bonus depreciation cal-culation in 2013,” Tomichek explained. In 2014, those improvements return to a 39-year depreciable life, which means the expenditures are depreciated at a much smaller annual amount over nearly four

decades and no longer qualify for the other depreciation benefits.

Tomichek said the new IRS capital-ization policy that went into effect on Jan. 1 is a bit of ying to the yang of losing the other deductions. “The most important part of the rule is the de minimis safe harbors that apply to not only improvements but to certain tangible property purchased,” he said. “The de minimis safe harbor allows a taxpayer to deduct purchases under a cer-tain threshold. For taxpayers with audited financial statements, the threshold is $5,000 per invoice or per item as substantiated by invoice. For those without audited finan-cial statements, the threshold is $500.” He noted that previously, these qualified items had to be depreciated but now can be ex-pensed, which is a tax benefit. However, he added, “To qualify, the taxpayer must have a written accounting policy in place at the beginning of the tax year.”

Doug Funke, CPA, a partner with Honkamp Kroeger & Co. PC, a Midwest regional CPA firm headquartered in Iowa, noted a number of other general 2014 tax changes could impact medical practices and hospitals. One example is the transit benefit allowance. “The amount of transit fringe benefits that employers can provide to em-ployees on a pre-tax basis for using public transportation and van pooling will drop from $245 per month in 2013 to $130 per month for 2014.”

He said dozens of other extenders, or tax incentives, including the work opportu-nity tax credit for hiring targeted individu-als and the research tax credit, as well as various energy credits, expired at the end of 2013. A list of expired provisions is available through the Joint Commission on Taxation at www.jct.gov.

For exempt organizations, which in-cludes many hospitals, Funke said the IRS is focusing on compliance, using information reported on Form 990. “Indicators of po-tential noncompliance that they have iden-tified include the following relationships:

• Large fundraising revenues and small

fundraising expenses,• Large fundraising revenues and small

charitable program services expense,• Large unrelated business income

but no income taxes due on the unrelated business income,

• Large total compensation to officers, directors, trustees and key employees and small annual gross receipts.”

Funke added, “An accurate Form 990 generally decreases the likelihood of being selected for examination.”

Also pertaining to some employers, Funke said, “The June 2013 U.S. Supreme Court decision related to the Defense of Marriage Act recognizing same-sex mar-riages affects employers in states where same sex marriage is recognized. Employer-provided healthcare coverage for same-sex spouses get the same tax-favored treatment.” He added the IRS announced two special administrative procedures for employers to make claims of refunds or adjustments to employment taxes for certain benefits paid to same-sex spouses during 2013.

This Time It’s PersonalMuch has been written about the

higher tax brackets and rates, but McGuin-ness said a lot of people will still be surprised at the cumulative effect.

“The top tax rate went from 35 to 39.6 percent and that happens starting at $450,000 married filing jointly or $400,000 for single filers,” he explained.

However, McGuinness continued, that’s just one of six tax changes that will impact high income taxpayers. A 5 percent increase (from 15 percent to 20 percent) in capital gains and dividends tax has also been instituted for those at the same income levels as the highest tax bracket. For individ-uals starting at $200,000 and married filing jointly at $250,000, the Affordable Care Act added a 0.9 percent additional FICA tax on wages and a 3.8 percent Medicare tax on investment income.

“The rules regarding the 3.8 percent investment income are more complicated

than you might think,” he explained in a recent blog for physicians. “You do not include income from S Corporations or a trade or business in which you are ac-tively involved … but do include interest, dividends, annuities, royalties, rents and net gain from the disposition of non-business property.”

When looking at the combination of the increased investment income and capi-tal gains taxes, McGuinness said, “What was being taxed at 15 percent is very pos-sibly going to be taxed at 23.8 percent.”

Additionally in 2014, the sales tax de-duction goes away … and for single wage earners beginning at $250,000 and married filing jointly at $300,000, itemized deduc-tions and personal exemptions are being phased out.

“If you’re taking a deduction away from me, that’s a tax increase,” McGuin-ness said of the bottom line for taxpayers. He added the itemized deduction phase-out could be quite costly, particularly to those who give large amounts to charity and have significant home mortgage interest they were used to deducting. “The personal exemption is equal to $3,900 (in 2013) per exemption you claim, and all exemptions are lowered by 2 percent for each $2,500 of income above the numbers ($250,000 single, $300,000 married filing jointly),” he explained. “The larger your family, the larger the tax increase.”

McGuinness noted there is a grow-ing feeling of frustration. At the same time many of his physician clients are paying significantly more in taxes, reimbursements are shrinking. The net result is people are having to work much harder simply to make the same money.

McGuinness said individuals should have already asked their tax advisors to pro-vide estimates of what their 2013 tax bur-den will look like. If that hasn’t happened, he suggests doing it now to prepare for April 15, 2014. Quoting one of his colleagues, he said, “It’s not going to be pretty in a lot of cases … but better than finding out on April 10 that you need to either drain your sav-ings or take out a loan to pay your tax bill.”

End Notes & DisclaimerThe experts who contributed infor-

mation to this article are members of the National CPA Health Care Advisors As-sociation. Headquartered in Nashville, HCAA is a nationwide network of CPA firms devoted to serving the healthcare industry and educating its members about the ever-changing financial and regulatory landscape impacting the industry. The fi-nancial professionals stressed the impor-tance of consulting a tax specialist to ensure advice is specifically tailored to your unique business or personal situation to minimize the tax burden while fully complying with state and federal mandates.

Additionally, the information in this ar-ticle was provided prior to the end of 2013. It is possible that some of the expiring tax incentives could be extended through legis-lative action. However, the consensus opin-ion was that Congress is unlikely to reinstate all … or even very many … of the sunset-ting extenders.

M&A Trends in the Reform Era, continued from page 1

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When it opened in 2010, Franklin Woods Community Hospital was the fi rst “green” hospital in Tennessee. The 240,000-square-foot facility is adjacent to The Wellness Center, offers 80 beds and a variety of specialty surgical services.

Heading up operations is Tony Benton, CEO, who joined Mountain States Health Alliance in 2002. As Vice President of Strategic Planning for MSHA, Benton oversaw growth from 8 to 13 hospitals, and provided oversight for additional growth within the MSHA system.

Benton is well positioned to look at not only growth and change in today’s healthcare environment, but also the unique challenges posed by the Affordable Care Act, reimbursement reductions, and other issues. To overcome obstacles, he says, healthcare operations must be effi cient and also provide top-quality patient care — achievable goals, he adds, with the right strategies in place.

East Tennessee Medical News: In today’s healthcare climate, what does innovation look like? Are new ideas taking root?

Tony Benton: We worked a lot of innovation into the design aspects of Franklin Woods itself, both from the green aspect and also by creating a patient-centered care approach. The building incorporates better use of natural light, sidewalks and many other design elements, and those tied into specifi c patient needs. A lot of thought went into who would be using this facility, both now and in the future.

Now, more than three years into operations, we’ve found a good niche in the market. We obviously work with Johnson City Medical Center because it has a Tier 1 trauma center and many other services that we do not. We are a very good secondary, community hospital, with a very strong focus on surgical services. From urology to gynecology, we have worked very hard to build our expertise in very advanced, minimally-invasive surgery, and to do what we do very well. We also have really developed our women’s services, including an in-vitro fertilization program that has a high success rate. We have about 1,200 deliveries a year. Our patient satisfaction is high, our turnaround times are very good, and we have a strong focus on our processes.

ETMN: What are some initiatives that you are looking to roll out at Franklin Woods, and how do those tie into what’s happening in healthcare throughout the region, and nation?

TB: Hospitals, health systems, and pretty much anybody in healthcare these days are working to weather all the challenges that have been implemented through things we thought we were ready for, but that changed. Hospitals and providers made a number of

Hospital Leadership 2014

Maximum impactFranklin Woods CEO touts patient focus, enhanced service line offerings

concessions with regard to the Affordable Care Act in exchange for promises that were embedded in it. Those were things like Medicare expansion and coverage of lower-income populations, as well as for people who were underserved or not served at all in the insurance market. Those things are not coming to fruition, which is extremely disappointing.

That has made it hard for us to invest, and reinvest in, things like advanced technology. At Franklin Woods, however, we are doing so in order to support our service lines as well as our surgeons who are working to advance their practices. From an innovation standpoint, we are working to standardize care, to leverage electronic medical records so we can do more in a data-rich information environment, and provide more value to the patient. EMRs are making things safer, and more effi cient, but not fast enough. We really want to focus more on managing our patients’ population health better in that regard.

At the system level, our big engine for innovation is Integrated Solutions Health Network, or ISHN. Again, we are looking at strategies to manage our population’s health better. We’ve done that with CrestPoint Health, our insurance carrier, by developing a strong Medicare advantage product for the community. We want to embed more care management in what we do, and take a proactive focus on managing health before there are needs for higher cost and higher levels of care.

ETMN: Looking ahead, what are some strategies that you at Franklin Woods, and perhaps MSHA in general, are looking to adopt in order to grow market share and maximize effi ciencies?

TB: It’s hard right now to think about strategy in the traditional sense, but it’s more crucial than ever when you have the amount of chaos and change that we are seeing. We’re addressing what’s happening by focusing very sharply on our operational excellence model. We are making sure that if our clinical outcomes are good, then they become great. If they are great, we want to continue to raise the bar.

Franklin Woods is a leader in patient satisfaction in our community, and we want that to continue alongside those positive clinical outcomes. As we strive toward perfect care, we want to make sure out team members focus on what provides the best patient experience. We also know that all this must be done as effi ciently as possible, which further refi nes that focus.

To make all this happen, we invest heavily in our team members, and nurture an organizational culture that supports those goals. That investment, and that focus, is what will get us through the storms are out there, and the challenges that continue to come. If you focus on the patient, provide the best product and value, and do it effi ciently, you’ll come out stronger and leaner — and be all the better for it.

BY JOE MORRIS

Tony Benton

PAID ADVERTISEMENT


What makes the Wellmont CVA Heart Institute the best choice for heart care?When it comes to quality care, the Well-mont CVA Heart Institute earns some of the nation’s highest praise for patient outcomes, rapid and effective heart attack treatment and patient safety. And our heart services have been recognized more than any other provider in our region. So you can rest assured you’re receiving the best heart care in the region.Our dedicated heart institute brings the strength of 49 specially trained and highly skilled cardiologists and cardiovascular surgeons and 200 non-physician practitioners to seven Wellmont Health System hospitals, Laughlin Memorial Hospital, Clinch Valley Medical Center and 15 community cardiac offices.

Experience the difference at our Centers of Excellence

Structural heart diseaseOur team offers advanced care for adult con-genital and structural heart disease. And we are the first in the region to perform transcatheter aortic valve replacement–or tavr. To date, we’ve

performed 44 tavr procedures on patients with tavr procedures on patients with tavrsevere aortic stenosis who are not candidates for open heart surgery.

Vascular diseaseBecause hypertension is becoming more prevalent, especially in our region, our providers wanted to do something about it. The heart institute will be the only site in the area ap-proved for renal denervation to treat patients with drug-resistant hypertension. And Joseph Foley, md, has joined the team to expand the vascular services offered at Bristol Regional Medical Center. And Bristol Regional will also add a third cath lab in June 2014, allowing for more vascular and electrophysiolo-gy procedures to be performed.

HeartSUCCESS®

HeartSUCCESS® focuses on improving heart failure patients’ quality of life, while minimizing overall cost and coordinating post-discharge care to keep them from needing additional hospital readmissions. Our 30-day readmission rates are less than 10 percent of the patients seen in the HeartSUCCESS® clinics. This is lower than the national readmission rates which are 23 percent.

The Arrhythmia CenterThe heart institute will be the first program in the region to utilize the new Topera electrophys-iological 3d mapping system for atrial fibrillation patients. This new system helps identify the elec-trical source of cardiac arrhythmias and improves long-term outcomes.

Advanced cardiac imagingThe Heart Center in Kingsport will soon offer pet scanning, an accurate method to diagnose coronary artery disease and detect areas of low blood flow in the heart. pet can also identify dead tissue, as well as injured tissue that is still functioning. If the tissue is viable, patients may benefit from a percutaneous coronary intervention – pci – or coronary artery bypass surgery.

HeartSHAPE® coronary calcium scoringThis early detection screening is a painless five-minute test to assess a patient’s risk of having a heart attack. Physicians can tailor treatment approaches to effectively slow or stop progression of heart disease. Heart-SHAPE® is now offered throughout our region at seven locations.

Choose the Wellmont CVA Heart Institute for the best results.

When it comes to your patients’ hearts, results matter.

Wellmont Physician Connection

Level One Heart Attack NetworkThe Wellmont CVA Heart Institute operates the region’s first Level One Heart Attack Network, allowing patients to receive quality heart care be-fore they even arrive at the hospital. This dramat-ically reduces door-to-balloon time and increases the likelihood for full recovery.Bristol Regional was the only hospital in Tennessee or Virginia to receive the American Heart Association Gold Achievement Award for 2013. This is the highest level of recognition for rapid and effective heart attack treatment.

Advanced percutaneous coronary interventionsThe heart institute is one of 200 sites selected to participate in the absorb trial conducted by Abbott. This trial uses a bioresorbable stent that is absorbed naturally into the body and is designed to restore the vessel to a more natural state. It is the only study of its kind, and we are currently the top enroller in the country. And robotic pci and bifurcation stents are also avail-able through active research studies.

Women’s heart healthHeart disease is the No. 1 killer of women in the United States. The Live Red for Women program empowers local women to take control of their heart health with screenings while mak-ing a difference in the lives of others through education. Live Red for your Heart segments featured on wcyb-tv every month continue to raise wcyb-tv every month continue to raise wcyb-tvawareness of women’s heart health issues. To date, we have shared the survival stories of 50 different female patients.

Advanced cardiac surgeryOur cardiovascular surgeons provide many state-of-the-art cardiac surgery procedures unmatched in the region, including:

• Off-pump bypass• Robotic cardiac surgery using the

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• Valvular surgery• Frequent use of arterial conduits and en-

doscopic vein harvesting for healing more quickly

With a level of sophistication, superior quality and scope of cardiovascular services that are unique in our region, the Wellmont CVA Heart Institute is where your patients’ hearts belong.

Have a patient to refer?Call 1-888-yes-wchi (1-888-937-9244).

wellmont.org/myHeart /wellmont @wellmontHealth

Quality care for your patients’ hearts• Bristol Regional and Holston Valley received

platinum performance achievement award

• Wellmont CVA Heart Institute recognized by American College of Cardiology

• Holston Valley and Bristol Regional honored by Society of Thoracic Surgeons

• Bristol Regional honored with Gold Award from Mission: Lifeline

• Holston Valley received Silver Award from Mission: Lifeline

• Holston Valley and Bristol Regional named Blue-Cross BlueShield Centers+ for Cardiac Care

• Holston Valley and Bristol Regional received Gold Award for Heart Failure Care

• Holston Valley named top ten percent in nation in five categories for medical excellence

Just a few of the 49 specially trained and highly skilled Just a few of the 49 specially trained and highly skilled Just a few of the 49 specially trained and highly skilled physicians of the Wellmont CVA Heart Institue. Pictured physicians of the Wellmont CVA Heart Institue. Pictured physicians of the Wellmont CVA Heart Institue. Pictured left to right: Pierre Istfan, left to right: Pierre Istfan, md, Rahul Sakhuja, mdmd, William Messerschmidt, md, Gregory Jones, , Gregory Jones, md.

Ready to learn more? Our doctors want to talk to you.Our physicians will review our outcomes data and value proposition with you and your staff. To schedule a presentation with one of our expert physicians at your practice, please call 423-230-5614. Or visit wellmont.org/myHeart to see our cardiac quality measures.


What makes the Wellmont CVA Heart Institute the best choice for heart care?When it comes to quality care, the Well-mont CVA Heart Institute earns some of the nation’s highest praise for patient outcomes, rapid and effective heart attack treatment and patient safety. And our heart services have been recognized more than any other provider in our region. So you can rest assured you’re receiving the best heart care in the region.Our dedicated heart institute brings the strength of 49 specially trained and highly skilled cardiologists and cardiovascular surgeons and 200 non-physician practitioners to seven Wellmont Health System hospitals, Laughlin Memorial Hospital, Clinch Valley Medical Center and 15 community cardiac offices.

Experience the difference at our Centers of Excellence

Structural heart diseaseOur team offers advanced care for adult con-genital and structural heart disease. And we are the first in the region to perform transcatheter aortic valve replacement–or tavr. To date, we’ve

performed 44 tavr procedures on patients with tavr procedures on patients with tavrsevere aortic stenosis who are not candidates for open heart surgery.

Vascular diseaseBecause hypertension is becoming more prevalent, especially in our region, our providers wanted to do something about it. The heart institute will be the only site in the area ap-proved for renal denervation to treat patients with drug-resistant hypertension. And Joseph Foley, md, has joined the team to expand the vascular services offered at Bristol Regional Medical Center. And Bristol Regional will also add a third cath lab in June 2014, allowing for more vascular and electrophysiolo-gy procedures to be performed.

HeartSUCCESS®

HeartSUCCESS® focuses on improving heart failure patients’ quality of life, while minimizing overall cost and coordinating post-discharge care to keep them from needing additional hospital readmissions. Our 30-day readmission rates are less than 10 percent of the patients seen in the HeartSUCCESS® clinics. This is lower than the national readmission rates which are 23 percent.

The Arrhythmia CenterThe heart institute will be the first program in the region to utilize the new Topera electrophys-iological 3d mapping system for atrial fibrillation patients. This new system helps identify the elec-trical source of cardiac arrhythmias and improves long-term outcomes.

Advanced cardiac imagingThe Heart Center in Kingsport will soon offer pet scanning, an accurate method to diagnose coronary artery disease and detect areas of low blood flow in the heart. pet can also identify dead tissue, as well as injured tissue that is still functioning. If the tissue is viable, patients may benefit from a percutaneous coronary intervention – pci – or coronary artery bypass surgery.

HeartSHAPE® coronary calcium scoringThis early detection screening is a painless five-minute test to assess a patient’s risk of having a heart attack. Physicians can tailor treatment approaches to effectively slow or stop progression of heart disease. Heart-SHAPE® is now offered throughout our region at seven locations.

Choose the Wellmont CVA Heart Institute for the best results.

When it comes to your patients’ hearts, results matter.

Wellmont Physician Connection

Level One Heart Attack NetworkThe Wellmont CVA Heart Institute operates the region’s first Level One Heart Attack Network, allowing patients to receive quality heart care be-fore they even arrive at the hospital. This dramat-ically reduces door-to-balloon time and increases the likelihood for full recovery.Bristol Regional was the only hospital in Tennessee or Virginia to receive the American Heart Association Gold Achievement Award for 2013. This is the highest level of recognition for rapid and effective heart attack treatment.

Advanced percutaneous coronary interventionsThe heart institute is one of 200 sites selected to participate in the absorb trial conducted by Abbott. This trial uses a bioresorbable stent that is absorbed naturally into the body and is designed to restore the vessel to a more natural state. It is the only study of its kind, and we are currently the top enroller in the country. And robotic pci and bifurcation stents are also avail-able through active research studies.

Women’s heart healthHeart disease is the No. 1 killer of women in the United States. The Live Red for Women program empowers local women to take control of their heart health with screenings while mak-ing a difference in the lives of others through education. Live Red for your Heart segments featured on wcyb-tv every month continue to raise wcyb-tv every month continue to raise wcyb-tvawareness of women’s heart health issues. To date, we have shared the survival stories of 50 different female patients.

Advanced cardiac surgeryOur cardiovascular surgeons provide many state-of-the-art cardiac surgery procedures unmatched in the region, including:

• Off-pump bypass• Robotic cardiac surgery using the

da Vinci Surgical System• Minimally invasive procedures• Aortic root replacement surgery• Surgical maze procedure for treatment

of atrial fibrillation

• Valvular surgery• Frequent use of arterial conduits and en-

doscopic vein harvesting for healing more quickly

With a level of sophistication, superior quality and scope of cardiovascular services that are unique in our region, the Wellmont CVA Heart Institute is where your patients’ hearts belong.

Have a patient to refer?Call 1-888-yes-wchi (1-888-937-9244).

wellmont.org/myHeart /wellmont @wellmontHealth

Quality care for your patients’ hearts• Bristol Regional and Holston Valley received

platinum performance achievement award

• Wellmont CVA Heart Institute recognized by American College of Cardiology

• Holston Valley and Bristol Regional honored by Society of Thoracic Surgeons

• Bristol Regional honored with Gold Award from Mission: Lifeline

• Holston Valley received Silver Award from Mission: Lifeline

• Holston Valley and Bristol Regional named Blue-Cross BlueShield Centers+ for Cardiac Care

• Holston Valley and Bristol Regional received Gold Award for Heart Failure Care

• Holston Valley named top ten percent in nation in five categories for medical excellence

Just a few of the 49 specially trained and highly skilled Just a few of the 49 specially trained and highly skilled Just a few of the 49 specially trained and highly skilled physicians of the Wellmont CVA Heart Institue. Pictured physicians of the Wellmont CVA Heart Institue. Pictured physicians of the Wellmont CVA Heart Institue. Pictured left to right: Pierre Istfan, left to right: Pierre Istfan, md, Rahul Sakhuja, mdmd, William Messerschmidt, md, Gregory Jones, , Gregory Jones, md.

Ready to learn more? Our doctors want to talk to you.Our physicians will review our outcomes data and value proposition with you and your staff. To schedule a presentation with one of our expert physicians at your practice, please call 423-230-5614. Or visit wellmont.org/myHeart to see our cardiac quality measures.


LegalMatters

Medical Practice Mergers and Acquisitions – Are You Prepared?

BY IAN P. HENNESSEY

The past few years have seen increased activity in mergers and acquisitions involving medical practices. This trend is expected to continue over the next few years as the landscape of the healthcare sector continues to encounter significant changes. While every deal is unique, there are a number of common elements that are important to understand and consider as part of any transaction involving the sale or merger of your medical practice.

Merger or Purchase AgreementThe main deal document is

the merger agreement or purchase agreement, as the case may be. In either case, the agreement will include all of the major terms of the deal, including the purchase price (and any conditions placed on payment of the purchase price), representations, and warranties as to certain aspects of the medical practice, and the conditions that need to be met before the transaction can close. In many cases, the parties will agree to indemnify one another if certain representations and warranties are breached. Please note that if no merger or purchase agreement is forthcoming, the prospective arrangement may not be

an actual merger or acquisition.

Employment AgreementsIn most cases, a provider who

plans to continue working for the medical practice (or its successor) after the closing date will require some form of written agreement either extending the existing relationship or establishing a new one. In many cases, a new agreement will be executed between the parties. Sometimes an existing agreement will be assigned or otherwise carried over post-closing, often with some amendments. Although the merger or purchase agreement is the main transaction document, equal attention should be paid to the employment or independent contractor agreement, as it will guide the individual relationship with the provider going forward. Key provisions include compensation and benefits, term and termination, and restrictive covenants. If a provider’s existing employment agreement is terminated at closing, the parties may consider having the provider execute a release agreement extinguishing any claims by the provider against the medical practice as of the closing date.

Non-Compete RestrictionsMany physicians are familiar

with the requirements for non-compete provisions in physician employment agreements. Generally, under Tennessee law, non-compete provisions in physician employment agreements are enforceable if the restriction is for two years or less and the geographical area of the restriction is the greater of either a ten-mile radius from the physician’s primary practice site or the county in which the primary practice is located. Depending on the circumstances, a physician may be restricted from practicing at any facility at which the physician provided services during the term of the employment agreement.

Tennessee also permits physician non-compete agreements in conjunction with the sale of a medical practice, which are merely required to be “reasonable under the circumstances.” Moreover, there is a rebuttable presumption that such “deal non-compete” provisions are enforceable. If a buyer is a hospital, the non-compete provision must also include a clause permitting the physician to buy back his or her medical practice. If the medical practice is repurchased from the

hospital, the non-compete provision is void. Therefore, it is important to consider any proposed restrictive covenants in light of existing relationships as of the closing date as well as with future plans in mind.

Tail Coverage and Outstanding Debt

Although the medical practice to be merged or acquired is likely to live on in some form after the closing, the parties often find it advisable to utilize a malpractice tail policy to handle any pre-closing malpractice claims. In many cases, the cost of a medical practice’s tail policy and any outstanding debt held by the medical practice is paid at closing using proceeds from the purchase price.

ConsentsPrior to closing, the parties may

be required to obtain consent to assignment (or, in some cases, change of control) with respect to certain contracts held by the medical practice. This situation often arises in the case of professional services agreements with hospitals, leases, and managed care contracts. It is important to be aware that, depending on the circumstances, the process of obtaining required consents may open up existing contracts to renegotiation.

Legal RepresentationThis article is not an

advertisement. However, any attempt to create a checklist for medical practices considering a merger or acquisition would be incomplete if there was no mention of obtaining legal representation. While business considerations are at the heart of any potential deal leading to the merger or acquisition of a medical practice, there are also serious legal implications and ramifications that require careful review and analysis to achieve a deal with which all parties can be satisfied. Please consult with an attorney familiar with issues involved in a merger or acquisition, ideally at the beginning of the process, but in any event prior to closing the deal.

Disclaimer: The information contained herein is strictly informational; it is not to be construed as legal advice.

Ian P. Hennessey is with London & Amburn, P.C. His practice focuses primarily on health law. He may be contacted at [email protected]. Disclaimer: The information contained herein is strictly informational;it is not to be construed as legal advice.

MAN OF LA MANCHA

The thrilling musical that willinspire you to dream the

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By JOE MORRIS

Cataract surgery is now the most com-mon operation in the United States, with millions of people having the procedure done every year. And while 4 million of those indi-viduals are over 65 and on Medicare, a grow-ing number of younger men and women are finding the procedure necessary as well.

What are cataracts? They are a clouding of the eye’s lens, and create blurry, dull or brownish vision. Cataracts in one or both eyes make it hard to drive, especially at night, or even read and watch television.

Many people in the Tri Cities have found relief from cataracts at the Johnson City Eye Clinic and Surgery Center, which has been helping the community see better for more than 70 years. As a comprehensive eye care and surgery center, the Johnson City Eye Clinic is completely devoted to eye care, has locations in Johnson City and Bristol and has been accredited by the Accredita-tion Association for Ambulatory Health Care, Inc.

There are several procedures for cataract surgery, and each has come a long way from the past, when a patient would be incapacitated for days, even weeks, following the procedure. Now, recovery takes place in hours, and the Johnson City Eye Clinic continues to pioneer new approaches to cataract diag-nosis, treatment, and removal. One of the most exciting advances in cataract surgery is the use of laser equipment and techniques to perform portions of the procedure. And while the laser technology is still in its infancy for cataract treatment, its effectiveness in treating other vision issues predicts a very excit-ing future, said Randal J. Rabon, MD, FACS.

“I am proud of our specialty’s advances because now people can be treated close to home, without having to travel,” Rabon said. “That’s true now of cataract surgery, but with lasers, it is becoming even better for the patient.”

There are several kinds of lasers used in eye surgery today. They include the YAG laser, which can be used to make adjustments after cataract surgery, and the Argon laser, which is used to treat detached retinas and other retinal issues.

The average cataract surgery can be done in about 10 minutes now, Ra-bon said, with much of the work being done using ultrasound. A blade is used for the initial incision, but a laser is able to perform some of the work.

“It’s becoming kind of a marriage, where the cool laser, which is also used for LASIK, can perform incisions for cataract surgery,” he says. “The laser can create a number of shapes for you, as well as make side incisions for someone with cataracts who also has astigmatism. We also used to have to manually cut a hole in the lens, and the laser can do that.”

The benefit there, Rabon says, is that the laser can draw a perfect circle every time, which even the best ophthalmologist can’t guarantee.

Advances in laser technology soon will let these devices do even more in cataract treatment. Rabon compares a cataract to a cherry, saying there are three elements that must be dealt with: skin, pulp, and pit. The laser now can

create a perfect, circular hole in the skin, and soon will be able to take over ultrasound’s role in breaking up the pulp, and the pit, into pieces for removal.

“The laser will shine into that nucleus, and let us cut it into small pieces that we can remove quickly,” he says. “And because the lasers are so fast, and precise, we can do several things simultaneously.”

That will have two benefits, he explains: one, the surgery will be more rapid, and two, the laser’s impact on the patient and his or her eye will be less damaging than the use of ultrasound.

“When you can move that quickly, you can use the ultrasound just to remove the pieces,” he says. “Ultrasonic energy may be damaging to the eye structure over time, so anything you can do to minimize that is good. These new techniques are going to make corneas look clearer and better, and do it very quickly. And

the more precise cuts you have, the better, and being able to do some of that before even getting to the operating room is another bonus.”

Currently, Johnson City Eye Clinic cataract patients recover within hours from the procedure, and usually have their need for corrective eyewear, includ-ing reading glasses, greatly reduced or even eliminated. Those with astigma-tism may also pursue intraocular lens (IOL) options, which also correct vision issues.

With current laser procedures, along with those in development and avail-able soon, these surgeries will be even more commonplace, as well as faster and more effective. And Johnson City Eye Clinic is determined to bring these new developments to the communities it serves as soon as they are available.

“Our center is known for keeping up, and we know that cataract surgery is evolving,” Rabon said. “I am very proud that you can get quality cataract surgery here. Cataract surgery is going to continue to grow because cataracts are very common, so we will continue to provide all the options available. And while our current technology is good, we are eager to bring in new equipment so we can continue to provide the very best care for our patients.”

InSights

Johnson City Eye Clinic & Johnson City Eye Surgery Center110 Med Tech Park • Johnson City, TN 37604

225 Medical Park Drive, BristolPhone: (423) 929-2111 • Fax: (423) 929-0497

Email: [email protected]

Clearing cataractsJohnson City Eye Clinic stays at forefront of laser technology

PAID ADVERTORIAL


Name of activity: Increasing Patient Safety: An Online CME Activity for Osteopathic Physicians

Name of CME provider/sponsor: Lincoln Memorial University-DeBusk College of Osteopathic Medicine (LMU-DCOM) in partnership with Oak Ridge Associated Universities (ORAU)

Date: Ongoing

Place: Online program accessible at www.docmeonline.com

Credits available: Two hours of Category 1-A AOA credit will be available to current AOA members.

Details: The two-hour online program will address acute local radiation injuries, providing a deeper understanding of the subject matter through the study of current publications, addressing related case study issues and with a panel discussion highlighting subjects of concern for osteopathic physicians. This online CME will deliver education and training curricula to address the time and resource constraints of the busy practitioner who traditionally does not have the time or resources to engage in disaster medicine CME offerings. Registration cost is $40. The program is made possible by a grant from the American Osteopathic Association.

Name of Activity: Second Annual Medicine Conference - Today’s Technology and Treatment Trends

Dates: February 28 - March 1, 2014

Place: University of Tennessee Conference Center, Knoxville, TN Credits available: Approved for 11 AMA, AAPA, AAFP, ACPE credits and 1.1 CEUs.

Information: www.tennessee.edu/cme/Medicine2014

Details: Faced with an aging population, new developments in technology and treatment options, it will be increasingly important for the health care provider to stay up-to-date on the newest developments and trends in the medical community. The Second Annual Medicine Conference will address new developments and trends in relevant areas such as osteoporosis, celiac disease, hypertension and lung cancer among others. This course is designed for primary care physicians. Physician assistants, nurse practitioners, nurses and pharmacists are also welcome to participate.

Name of activity: Trauma and Critical Care Conference

Name of CME provider/sponsor: Wellmont Health System

Date: March 28, 2014

Place: Monarch Auditorium, Bristol Regional Medical Center

Credits available: CME credits through AMA and Tennessee Office of Emergency Medical Services

Information: www.wellmont.org

Contact: Crystal Wampler, [email protected], 423-230-8103

Details: The Trauma and Critical Care Conference is sponsored by the Level I trauma center at Holston Valley Medical Center and the Level II trauma center at Bristol Regional Medical Center. The CME-certified event will be held from 7:45 a.m.-5 p.m. at Bristol Regional Medical Center, 1 Medical Park Blvd., Bristol, Tenn. The conference will cover new and innovative techniques for patients with multiple traumas, burns and other injuries in pre-patient, acute care and disaster settings.

East Tennessee CME Calendar

“Every year, we have a band on Friday night that plays somewhere in town at one of our night spots,” said Distl. “On Saturday night, we have the headliner at the ski lodge. Also, on Saturday night, we have the retro 80s apparel contest.”

As mentioned, the entire town partici-pates with the popular theme, and room rates for the weekend start at $80.80 per night. There are also three course dinner specials for $19.80 each and ski rentals for $19.80.

“Beech Mountain Ski Resort is the highest ski resort east of the Rockies,” ex-plained Distl.

If you have not been over to Beech Mountain in a while, you may be surprised by many of the improvements. For exam-ple, this marks the grand opening season of the highest ski bar in the East. Built by Um-brella Bars USA of Vermont, the attraction is unique for this part of the country.

“We have a really neat facility at the top of the mountain slopes called 5506 ski bar,” explained Distl. “That’s the elevation of the mountain, and it’s a glass roundhouse ski bar that’s built at the very top with a very large deck. So, when people get off the lift, they can hangout on the deck with their friends, take pictures, and relax and go in

the ski bar and have a drink or snack re-freshment.”

For ski enthusiasts, Distl also notes that during the past few years, many upgrades have also been added on the mountain to the snowmaking system.

“Bright … day glow colors are kind of coming back in, and Michael Jackson is as popular as ever,” said Distl. “The 80s ski clothes still do well. They’re a little puffier, but it’s late February, and it’s not usually super cold. We encourage people in any-thing they can do apparel wise. It’s like a ski slope time machine weekend!”

Now, where’s that infamous, teal ski suit?

For additional information about Beech Mountain Ski Resort or the “Totally 80s Retro Ski Weekend, visit www.beech-mountain.com or call 800-468-5506.

Enjoying East Tennessee, continued from page 7

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

Caylor Schoo l o f Nurs ing

1-800-325-0900 ext. 6324 for more information

www.LMUnet.edu

LMU-Cedar Blu� February 20 & April 1, 2014

3 p.m. to 7 p.m.

LMU-Kingsport Center for Higher EducationMarch 3, April 10 & June 3

3 p.m. to 6 p.m.

Information Sessions

Want to advance your nursing career?


By Tariq Haddadin, MD, FACC, FSCAI

Peripheral artery disease (PAD), which causes blockages in the arteries supplying extremities with nutritious blood flow (i.e. blood carrying oxygen and nutrients to the feet), is a strong predictor of adverse cardiovascular outcomes. Unfortunately, most patients are unaware of their disease.

Risk factors include age (patients of advanced age are particularly susceptible), diabetes (especially if not well-controlled), smoking or history of smoking, hypertension, hyperlipidemia (i.e. high cholesterol), and history of heart disease.

Greater awareness and earlier diagnosis of PAD could help improve adverse cardiovascular outcomes. A large percentage of PAD patients are either asymptomatic or have very minimal symptoms of pain or feet numbness. However, the following are some of the symptoms and signs of PAD that may be recognizable:

• foot, calf, thigh and hip pain, especially when walking (claudication);

• resting pain in the lower extremities (feet);

• numbness or tingling of the feet,• pale, bluish discolored feet,• slow healing foot ulcers or wounds.Once pain in the feet is persistent,

with or without tissue loss, it’s at a stage of critical limb ischemia, where intervention is a must before amputation. On exam, patients may present with weak or absent pulses, discolored feet, and

possible gangrene. DiagnosisDiagnostics which can be ordered

to support PAD diagnosis include both noninvasive and invasive testing. ABI (Ankle-brachial index) is the first noninvasive test to do after a thorough history and physical exam. ABI <0.90 is indicative of PAD. The lower the number, the worse the disease. Other noninvasive tests include arterial segmental pressure and pulse volume recordings, CT angiography, and magnetic resonance angiography (MRA). Arteriography, although invasive, can also be

used to diagnosis PAD. TreatmentSmoking cessation is the first

and most important step to be taken by a patient. An aggressive control of diabetes, hypertension and high cholesterol is also essential. Surgery involving bypass graft, which is a very high risk surgery on PAD patients, may be necessary for patients who, most of the time, have comorbidities, including heart disease.

Another treatment option is catheter-based endovascular therapy while the patient is mildly sedated. Endovascular therapy includes multiple modalities to improve blood flow to the feet. We use angioplasty, stenting, chronic total occlusion devices and atherectomy devices in the Johnson City Medical Center Cardiac catheterization laboratory. Compared to open bypass surgery, endovascular

catheter-based therapy has many advantages, including minimal recovery time, same day treatment, lower risk of infection, has up to 90% success rates, and up to 90% 2-5 year limb salvage rates.

Dr. Tariq Haddadin is a fellow of the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions. He serves as medical director of the Cardiac Catheterization Laboratory at Johnson City Medical Center and as chief of Interventional Cardiology at the Veterans Affairs Medical Center, Mountain Home.

3 Professional Park Drive, Suite 31 • Johnson City, TN 37604 • Phone: (423) 979-6000 • Fax: (423) 979-6011 • www.mymsmg.net

Physician to Physician

Diagnosis and Treatment of Peripheral Artery Disease

Blood flow, pre-intervention Blood flow, post-intervention

Pre procedure: cold foot with heel ulcer for the past 6 months. Post procedure: Two weeks later, endovascular intervention, warm foot with healed ulcer.


Knoxville MGMA Monthly MeetingDate: 3rd Thursday of each month

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

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

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

Registration is required. Visit www.kamgma.com.

Chattanooga MGMA Monthly MeetingDate: 2nd Wednesday of each month

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

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

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

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

3RD THURSDAY 2ND WEDNESDAY

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

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

Nurse Celebrates 50-Years of Caring for Patients

KNOXVILLE—The elegant silver haired grandmother of four, Mary Alice Bozeman, led the group of women, with a couple husbands in tow, past the old dormitory that now serves as admin-istrative building on the campus of The University of Tennessee Medical Center. Bozeman and her former classmates shared memo-ries, hugs and laughter as they recalled their time together as members of the class of 1963 at the University of Tennessee Memo-rial Research Center and Hospital School of Nursing.

When all the other ladies said their goodbyes and left, however, Bozeman sim-ply turned around and walked back into the hospital. She wanted to finish her workday as Nursing Director at the medical center.

Bozeman’s professional journey from that old nursing school dorm only took Bozeman about 100 feet, to what is now an entrance to UT Medical Center. Bozeman would argue, however, that the short trip to her first and only workplace resulted in gi-gantic rewards, in a career that just passed the 50-year mark.

“I never intended to be here this long,” Bozeman said. “However, the people I work with and the patients I care for just keep drawing me back in. It always seems like there’s one more thing I want to do before I retire. And to be able to provide comfort and guidance to our patients and their families through some of their most difficult times is so important.”

Bozeman graduated from nursing school as the bright eyed Mary Alice Hall. She said her nursing education, which cost a total of $410, including room and board, prepared her well to begin her career in nursing.

Bozeman currently leads an initiative at the hospital that focuses on continued im-provements in customer service for patients. She also recently took on a new project at the hospital to create of an office to assist families with bereavement during time of

loss. While Bozeman said she’s excited to see further developments at her hospital and in medicine in the coming years, she acknowledged that at age 70, she’ll need to begin thinking about retirement at some point.

While plans to end her professional career aren’t even close to being finalized, Bozeman, who received numerous pro-motions throughout her career and even served as Chief Nursing Officer for several years, admitted that her newest grandchild, born in September, seems to be calling her to think about retirement. She had a beam-ing smile as she talked about spending time with her grandchildren. Bozeman’s smile remained in place as she reflected on her career.

“It has been such an honor and privi-lege to be a part of the nursing profession and watch the medical center grow to be the fine institution it is today,” Bozeman said. “Through all the advancements, what hasn’t changed is the heart of nursing, the compassion for patients and the quest for quality care. Through these years God has blessed me with a wonderful supportive family both at home and at the medical cen-ter.”

Conley Receives MDT Certification from The McKenzie Institute®

KNOXVILLE – Parkwest Medical Center announces that Mark Conley, MSPT, OCS, CSCS, Cert. MDT and Man-ager of Parkwest Therapy Center, has recently earned his certification in Mechani-cal Diagnosis and Ther-apy®, or MDT, from The McKenzie Institute®.

Within the field of physical therapy, MDT is the most researched and one of the most sought after forms of treatment for back and neck pain. This specialized education focuses primarily on evaluation and treat-ment of mechanical spinal disorders, but also includes the extremities.

Conley holds a Master’s degree in Physical Therapy from North Georgia Uni-

versity and has practiced physical therapy at Parkwest Therapy Center for 15 years, serv-ing as the manager for nearly two years.

Severance named to Duke University Cooperative Cardiovascular Society Board of Directors

CHATTANOOGA — Harry W. Sever-ance, MD, FACEP, Medical Director for the Erlanger Institute for Clinical Research, Erlanger emer-gency medicine physician, and Director of Clinical Re-search Trials at the Univer-sity of Tennessee College of Medicine Chattanooga, has been selected to serve on the board of directors for the Duke University Cooperative Cardiovas-cular Society (DUCCS).

Severance will serve a three-year term on the DUCCS board of directors. The DUCCS is a society of current and past Duke faculty members and fellows of Duke’s cardiovascular diseases training program, along with clinical educators and investiga-tors. The purpose of the DUCCS is to en-hance collaborative efforts of its members in cardiovascular research and continuing education. DUCCS supports the scholarly interests of its members by providing re-search and educational programs.

Through his affiliation with Erlanger and the UT College of Medicine, Severance is responsible for conducting clinical re-search trials in all areas of Erlanger, ranging from intensive care to cardiovascular medi-cine. He has authored dozens of papers that have been published in national medical journals.

After receiving an undergraduate de-gree from Duke University, Severance re-ceived his medical degree from Duke Uni-versity School of Medicine. He completed his residency training at East Carolina Uni-versity.

Memorial Announces Rees Skillern Cancer Institute

CHATTANOOGA – Memorial Health Care System Foundation has announced

plans for the Rees Skillern Cancer Institute. Fred and Bettye Skillern lost their only

son to cancer two years ago at the age of 49. Rees, a business leader and investor, battled cancer for many years and received much of his treatment at Memorial, includ-ing a lengthy stay in the oncology inpatient unit surrounded by his loving family and friends. Rees expressed his wish that his es-tate be used to benefit others, and Mr. and Mrs. Skillern are honoring his wishes with a $3 million gift to the Memorial Foundation for the advancement of cancer care in our community.

In honor of Rees, Memorial’s total can-cer program will now be called the Rees Skillern Cancer Institute. This will be the umbrella name over programs, including the MaryEllen Locher Breast Center, the H. Clay Evans Johnson Radiation Center, the Schmissrauter Center for Cancer Support, and all other special programs. In addition to exterior and interior renovations of the Institute, the generous gift will fund the new Memorial Cancer Risk and Survivor Center which will offer three highly specialized ser-vices that will make a tremendous difference in the early detection and treatment of can-cer and offer services that are currently not available in the Chattanooga region.

The center will be the first dedicated, high risk genetic counseling clinic in the area. Though Memorial has been providing cancer risk counseling for 15 years, this will provide the opportunity to make genetic testing part of the total picture for early de-tection and more accurate diagnosis and treatment of cancer.

Memorial will develop the first dedicat-ed, multidisciplinary resource for adult can-cer survivors, empowering survivors to maxi-mize their health, quality of life and longev-ity. The center will also provide information on the prevention, detection and treatment complications that can result from cancer treatment.

Memorial plans to give cancer pa-tients in the area greater access to the latest treatments for cancer. While Memorial will not be performing laboratory research, it will increase the emphasis on research. The number of clinical trials and the amount of research available is expected to increase at an accelerated rate.

Memorial Welcomes New Chief Medical Officer

CHATTANOOGA – Kevin L. Lewis, M.D. recently joined Memorial Health Care System as chief medical of-ficer. Previously, Dr. Lewis was chief medical officer and chief quality officer for Hillcrest Healthcare System, Tulsa, Oklahoma, a 691-bed health system with more than 5,000 employees and 180 employed physicians.

Lewis has more than ten years of ex-perience in private practice pulmonary, critical care, and sleep medicine. Dr. Lewis earned his medical degree at the University of Texas Health Sciences Center, San Anto-nio; served an internship at the University of Nebraska Medical Center, Omaha; was a resident at the Oklahoma University Col-lege of Medicine, Tulsa; and was a fellow in pulmonary, critical care and sleep at the Uni-versity of Missouri, Columbia, and University of Kentucky, Lexington.

GrandRounds

Mary Alice Bozeman

Mark Conley

Dr. Harry W. Severance

Dr. Kevin L. Lewis


All too often, children diagnosed

with pediatric malignancies or

hematological disorders are referred

for care miles away from home. As if the

burden of the disease weren’t stressful

enough, having to travel for treatment

makes the diagnosis even more demanding.

Fortunately for children living in the

Tri Cities and surrounding regions, the

St. Jude Tri-Cities Affiliate Clinic, located

inside Niswonger Children’s Hospital, was

established in 1999 as an affiliation among

St. Jude Children’s Research Hospital®, East

Tennessee State University’s Quillen College

of Medicine, and The Children’s Hospital

at Johnson City Medical Center (now

Niswonger Children’s Hospital).

St. Jude Children’s Research Hospital,

located in Memphis, Tennessee, has helped

push overall survival rates for childhood

cancer from less than 20 percent when the

institution opened to almost 80 percent

today. It is the first and only National Cancer

Institute-designated Comprehensive Cancer

Center devoted solely to children, and no

family ever pays St. Jude for anything.

The Tri-Cities Affiliate

Clinic is one of only six

St. Jude affiliate clinics

in the country. “We

allow patients to get

the most up-to-date

therapy available without

them having to travel

far distances,” said

Katherine Klopfenstein,

MD, one of three full-time physicians

who provide care at the Tri-Cities Affiliate

Clinic. “Our arrangement provides that

when we diagnose patients with pediatric

malignancies, if needed, we send them to

Memphis so that they can be enrolled in a

clinical trial, and after they are enrolled in

the study and start treatment there, they

come back here for most of their therapy.”

Recognized as a crucial aspect of

maintaining normal child development, this

arrangement allows the patient and family

members to receive hometown support and

to continue with their usual activities as

much as possible.

The Tri-Cities Affiliate Clinic participates

in nationally sponsored pediatric clinical

trials in the treatment of childhood cancers,

including both St. Jude sponsored clinical

trials and clinical trials sponsored by the

Children’s Oncology Group (COG), funded

by the National Cancer Institute.

“Our affiliation also gives them access

to specialists who we may not have in the

community to provide for some of these rare

diseases,” she explained. “For example, if

we don’t have someone here in Johnson City

who can take out a bone tumor, we are able

to send them to Memphis to have it done,

with really no cost to the patient.”

Added Klopfenstein, “We will treat

anyone who has a pediatric malignancy

in our region, which includes Northeast

Tennessee, Southwest Virginia, and portions

of Kentucky and West Virginia.”

Referring physicians can call the clinic

at 431-3950 to recommend a patient be

seen at the Tri-Cities Affiliate Clinic, which,

in addition to the three board-certified/

board- eligible physicians who treat patients,

is also staffed by five experienced nurses

and a nurse practitioner. The staff also helps

patients who can’t afford care get enrolled

in a state Medicaid program, providing them

with whatever assistance they need for that.

With over 20 years experience working

in pediatric hematology and oncology,

Klopfenstein emphasized that patients seen

at the clinic are receiving the best, patient-

centered care for their disease or malignancy.

“It’s really a disadvantage to the family to

send them elsewhere when they can get

good care close to home,” she emphasized.

The Tri Cities Affiliate Clinic currently

sees about 30 new oncology patients a

year and follows more than 300 children

with cancer and blood disorders. Last year,

they scheduled over 3,000 clinic visits. The

clinic has eight pediatric exam rooms, and

a waiting room designated for Pediatric

Hematology/Oncology is stocked with toys

and learning materials.

For more information, visit www.msha.

com/children.

Presented in Partnership by East Tennessee Medical News and Mountain States Health Alliance

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Will Diaz Joins Parkridge Medical Group as Area Practice Manager

CHATTANOOGA – Will Diaz has joined the staff of Parkridge Medical Group as Area Practice Manager for the six Parkridge Medical Group practices in Chatta-nooga and North Georgia.

Before coming to Chat-tanooga, Diaz served as Area Practice Manager for 12 TriStar Medical Group practices in Nashville. Diaz holds a bachelor’s degree in English and Fine Arts from Virginia Military Institute and a master’s degree in Accounting from the University of Phoenix.

Court Confirms Rural/Metro Plan of Reorganization

KNOXVILLE — Rural/Metro Corpora-tion, a national provider of private ambu-lance and fire protection services based in Scottsdale, Ariz. has announced that the U.S. Bankruptcy Court for the District of Del-aware (“the Court”) has confirmed the com-pany’s Plan of Reorganization. Rural/Metro expects to formally emerge from Chapter 11 in the next few weeks.

“The Court’s confirmation of our plan is a major milestone for Rural/Metro, and we look forward to completing our financial restructuring and emerging as a stronger and more competitive company,” said Scott A. Bartos, president and chief executive of-ficer of Rural/Metro. “We will emerge with 50 percent less debt, greater capital flexibil-ity and the resources to continue investing in patient care. I want to express my grati-tude to our business partners and valued employees for their patience and support throughout this process, and I look forward to an exciting and prosperous future.”

Throughout the process, local opera-tions in 21 states and nearly 700 communi-ties have been unaffected by the corporate restructuring. Rural/Metro of East Tennes-see Regional Director Jerry Harnish reports that Knox County ambulances have been experiencing some of the highest county contract compliance rates, and it has been business as usual across its service areas in Knox, Blount, Loudon, Polk and Franklin counties.

Over a 12-month period, Rural/Metro will invest $40 million in capital enhance-ments to add more than 70 new ambulanc-es, six fire trucks and equipment, including cardiac monitors and stretchers, to opera-tions across the country, as well as develop new billing and accounting systems.

Under the terms of the plan, Rural/Metro’s bondholders will provide the com-pany with a new equity capital infusion of $135 million to help position the company for renewed growth.

Court filings and other documents con-cerning the restructuring process are avail-able at www.donlinrecano.com/rmc. Inter-ested parties can also contact Rural/Metro’s claims agent, Donlin, Recano & Company, Inc. directly by calling Rural/Metro’s restruc-turing hotline at 212-771-1128. Willkie Farr & Gallagher LLP and Young Conaway Star-gatt & Taylor, LLP are serving as legal coun-sel, Lazard Frères & Co. L.L.C. is serving as investment banker, and Alvarez & Marsal and FTI Consulting, Inc. are serving as finan-cial advisors to Rural/Metro.


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GrandRounds

Will Diaz

Name: Leslie Bishop, RT(R), RCIS

Position: Coordinator, STEMI Network, Wellmont CVA Heart Institute

At a Glance: Since 2010, Leslie Bishop has served as the STEMI coordinator with the Wellmont CVA Heart Institute, a position to which she brought years of experience working in the cardiac cath lab. The years she spent in cardiac medicine is what she says has furthered her enthusiasm for it.

“I believe in it. I have seen the change in healthcare, as long as I have been in it, and I see that the patients are getting quicker treatment and are having less damage from a heart attack,” she said. “In the past, it could take up to two hours [to get treatment], and now we can do it all in 90 minutes. If a patient has an echo six months down the road, you can’t even tell that he or she has had an event.”

Continued Bishop, “When I see all the data put together, and I show people that this is what we are doing, it excites me because it works. Patients are benefitting from this, and it is really encouraging to see how excited people are about it.”

As the STEMI coordinator, Bishop coordinates heart attack patient care from the field, and works closely with EMS agencies in Virginia and East Tennessee to coordinate the care of the patient to get them quickly to a facility that can do an angioplasty. “We work through protocols, so if EMS doesn’t have the equipment that can transmit or do a 12-lead EKG in the field, I assist them with getting that so they can do an early recognition of a heart attack patient in the field,” she explained. “We also streamline the process so that there’s no delay in getting to the cath lab at Holston Valley or Bristol, or any of the Wellmont facilities”

Bishop also works closely with some of the other, smaller facilities in East Tennessee to ensure that if the facility doesn’t have a cath lab, that they can get patients appropriate care and to a facility that can do an angioplasty on heart attack patients. Currently, protocols are streamlined so that once a patient hits the doors of the cath lab, a heart attack can be stopped in as soon as 12 minutes.

Bishop says the streamlined process really makes her job seem worthwhile. “To see the final result, to see that process work, starting at, say, the front porch of Cracker Barrel, or from the patients living room, is gratifying. We can activate a STEMI code, and the cardiologist is aware and sees the EKG within two minutes on his iPad because the EMS has the equipment to do a 12-lead,” she enthused.

Also evidence of her dedication, Bishop serves as STEMI coordinator for the American Heart Association, a volunteer position for which she coordinates meetings with other STEMI coordinators throughout the region. “From Chattanooga on up, we meet quarterly. We sit down and discuss protocols and try to get everyone on the same page and get everyone talking. We throw out politics, and we try to do what’s best for the patient.”


HEALTH SYSTEM

Parkridge Health System Appoints Karen Beam as Vice President of Quality

CHATTANOOGA - Parkridge Health System has appointed Karen Beam as Vice President of Quality.

Beam returns to the Parkridge Health System from a position as Division Vice Pres-ident of Clinical Performance with HCA’s Tri-Star Division in Nashville. A Chattanooga native, she served as the Parkridge system’s Market Director of Quality from 2006 to 2012.

In her role at Parkridge Health System, Beam will lead Clinical Education, Quality Management, and Clinical Performance for

the four Parkridge hospital campuses. Her primary responsibilities will include regula-tory compliance, management of infection control practices, leadership of patient safe-ty and Environment of Care initiatives, and management of professional education.

Beam has over 30 years of nursing ex-perience. Beam holds a Bachelor of Science degree from the University of St. Francis and a Bachelor of Science degree in Nurs-ing from Middle Tennessee Administration from the University of Tennessee at Chat-tanooga. She is currently pursuing a Master of Science in Nursing Administration from Middle Tennessee State University.


A common ophthalmic condition affecting people age 50 years and older is age-relat-ed macular degeneration (AMD). AMD may be associated with central vision loss, a devastating condition affecting an individ-ual’s ability to read, to drive a car, or even to see someone’s face if in its advanced stages. AMD can develop so slowly that it’s not until the vision is getting severely bad that the patient will notice.

The two major types of AMD are “dry” (non-neovascular) and a “wet” (neovascular). The dry form—the most common—is the early stage of the condition. Typically, there is little or no vision loss during this stage, although there are a few exceptions of a more advanced “dry” degen-eration. Wet AMD is the late stage of the con-dition, affecting about 10 percent of all people with AMD. The majority of central vision loss stems from Wet AMD, which implies leakage and bleeding in the macula due to abnormal blood vessels known as choroidal neovascular-ization. As the vessels start to grow beneath the center of the macula, they leak fl uid or blood, causing central vision loss with blurring and distortion of vision. Untreated, these abnormal blood vessels typically will grow relatively large and eventually cause scarring with permanent, often severe, central vision loss.

DIAGNOSIS

Because of the lack of visual symptoms, diagnosing the disease can be diffi cult to diagnosis in the primary care setting. Nick Anderson, MD, a retina surgeon with Southeast Retina Associates recommends that patients over the age of 65 should have an annual eye exam with their eye care provider to detect AMD and other condi-tions such as glaucoma and cataracts.

“Primary care providers should follow the guidelines set forth by the American Academy of Ophthalmology regarding the frequency of eye exams and referrals to eye care providers for patients of various ages and risk factors,” Anderson said. “In short, most patients over the age of 65 should have a dilated eye exam every year.”

When the pupils are dilated, a complete exami-nation of the front and back of the eye is con-

ducted, and if diagnosed, individuals with AMD may have several types of tests to assess the condition, including color photography of the macula to document drusen, pigment changes, and other characteristics of AMD.

Fluorescein angiography is another common diagnostic test that can aid in determining the extent of macular degeneration and helps dis-tinguish between the dry and wet forms of the condition. By injecting sodium fl uorescein dye into a peripheral vein, choroidal neovasculation in the macula can be visualized as a leaking blood vessel complex under the retina.

Optical Coherence Tomography (OCT) a non-invasive, imaging technique that uses low en-ergy laser to scan the macula and determine whether there is fl uid in the macula, potentially signifying Wet AMD. Commonly used as an ad-junct to fl uorescein angiography to help diag-nose Wet AMD, it can also be used to assess the response to treatment for Wet AMD.

TREATMENT

Treatment for AMD varies according to type. Currently, there are no FDA-approved treatments for Dry AMD, but as Anderson pointed out, many patients with Dry AMD should take a vitamin supplement consis-tent with the fi ndings of the Age-Related Eye Disease Study (AREDS), a study man-aged by the National Eye Institute, a divi-sion of the National Institutes of Health. Southeastern Retina Associates was one of the major centers that participated in the study.

“AREDS demonstrated that many patients with Dry AMD can reduce their risk of developing

Advanced AMD by about 25%,” Anderson said. “Patients cannot achieve the recommended level of vitamins through diet alone or by taking a multivitamin.”

Patient with Wet AMD should be under the care of a retina surgeon, and current treatment op-tions include medications such as Eylea, Lu-centis, or Avastin, as well as laser.

“These new medications have revolutionized the care of patients with Wet AMD,” said Ander-son. “In the past, patients with Wet AMD would almost inevitably go blind. Now, most patients with Wet AMD retain highly functional vision.”

As one of the largest retina practices in the country, Southeastern Retina Associates is very active in clinical trials programs. “Our patients have access to cutting-edge treatments that aren’t available anywhere else in the country,” Anderson enthused. “We historically haven’t had any treatment options for Dry AMD, but Southeastern Retina has almost completed re-cruiting for one clinical trial for patients with Dry AMD and will be starting another clinical trial for Dry AMD in the near future.”

Another exciting opportunity for Southeastern Retina patients with Dry AMD is the ForeSee-Home monitoring device, on which The National Eye Institute recently completed a study. “This study was actually stopped early because pa-tients using the ForeSeeHome device showed signifi cantly better results than those patients not using the device,” said Anderson. “I have only seen the NEI halt a study early a handful of times in my career due to positive results.”

Several trials for patients with Wet AMD are on the horizon, with hopes that these new treat-ments will improve the care of patients with Wet AMD.

www.southeasternretina.com

Improving Patient Outcomes for Age-related Macular Degeneration

KNOXVILLE: 888-566-9738 CHATTANOOGA: 800-365-0105 TRI-CITIES: 888-773-7287

“In the past, patients with Wet AMD would almost inevitably go blind. Now, most patients with Wet AMD retain functional vision.”

Nicholas G. Anderson, M.D. is on staff at the Univer-sity of Tennessee Medical Center and East Tennessee Children’s Hospital. His clinical interests include macular degeneration, diabetic retinopathy, retinal detachment, macular hole, and epiretinal membrane.

… one of the many highly trained surgeons and specialists available to you in our heart care family.

Dr. Steven Hopkins, Vascular SurgeonJohnson City Medical Center

1-855-655-5111For more information about Mountain States Heart Care, call toll-free

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East TN Medical News February 2014