SOMBRERO

Pima County Medical Society

Home Medical Society of the 17th United States Surgeon General

J U N E / J U LY 2 0 1 3

SPECIAL TUCSON MEDICAL CENTER ISSUE TMCs new look, top-notch technology, same compassion

D DIIS SA AB BIIL LIIT TY YL LIIM MIIT TS SO ON NT TH HE ER RIIS SE E

YOU YOUEXAMINE EXAMINEYOUR YOURPATIENTS PATIENTSEVERY EVERYDAY, DAY,OFTEN OFTENDISCOVERING DISCOVERINGRISKS RISKSNOT NOTOUTWARDLY OUTWARDLYAPPARENT. APPARENT. BUT BUT HOW HOWOFTEN OFTENDO DOYOU YOUEXAMINE EXAMINEYOUR YOUROWN OWNRISKS? RISKS? IT ITMIGHT MIGHTBE BETIME TIMETO TOTAKE TAKEA ACLOSER CLOSERLOOK. LOOK.
PP im im aa CC oo uu nn tt yy M M ee dd ii cc aa l l SS oo cc ie ie tt yy aa nn dd W W ee aa lt lt hh M M aa nn aa gg ee m m ee nn t t SS tt rr aa tt ee gg ie ie s s aa rr ee pp rr oo uu dd t t oo oo ee rr m m ee m m bb ee rr s s aa nn ee w w dd is is aa bb ii li li tt yy i n in cc oo m m ee i n in ss uu rr aa nn cc ee pp la la nn . . TT hh is i s ee xx cc i ti i ti nn gg pp ll aa nn oo ee rr s s dd ee ee pp ly l y dd is is cc oo uu nn tt ee dd i i nn dd iv iv id id uu aa l l aa nn dd bb uu ss in in ee ss s s dd is is aa bb ii li lt it yy pp ll aa nn ss , , aa nn dd uu nn ll ik ik ee m m aa nn yy pp la la nn ss , , tt hh ee s s aa m m ee l l oo w w pp rr ic ic in in gg aa pp pp ll ie ie ss t t oo bb oo tt hh m m ee nn aa nn dd w w oo m m ee nn . . DD ee pp ee nn dd in in gg oo nn yy oo uu r r nn ee ee dd ss , , yy oo uu cc aa nn cc hh oo oo ss ee aa pp la la nn oo r r cc oo m m bb ii nn aa titi oo nn oo f f pp la la nn ss t t hh aa t t cc aa nn hh ee lp l p yy oo uu :: PP rr oo tt ee cc t t yy oo uu rr i i nn cc oo m m ee i f i f yy oo uu aa rr ee uu nn aa bb le l e tt oo w w oo rr kk , , oo r r uu nn aa bb le l e tt oo r r ee tt uu rr nn t t oo yy oo uu rr f f uu l l l dd uu t ti e ie ss ee r r ee titi rr ee m m ee nn t t cc oo nn tt rr ii bb uu titi oo nn s s oo nn yy oo uu r r bb ee hh aa lf lf CC oo nn titi nn uu CC oo vv ee r r bb uu ss ii nn ee ss s s ee xx pp ee nn ss ee ss PP rr oo tt ee cc t t aa nn yy bb uu ss ii nn ee ss s s pp aa rr tt nn ee rr ss PP rr oo tt ee cc t t yy oo uu rr rr ee vv ee nn uu ee i i f f aa kk ee yy ee m m pp ll oo yy ee ee i s i s dd ii ss aa bb le le dd

J JO OHHN N DD. . LLEEVVI IN N, , CCLLU U 66001111 EE. . G GRRAAN NTT RRDD. . TTU UCCSSO ON N, , AAZZ 8855771122 552200. .775511. .22000000 J JO OHHN N@ @W WM MSSAASSSSO OCCI IAATTEESS. .CCO OM M W WW WW W. .W WM MSSTTRRAATT. .CCO OM M
Associates Associatesof ofWealth WealthManagement ManagementStrategies Strategieso o er ersecuri securi titi es esthrough throughAXA AXAAdvisors, Advisors,LLC LLC(NY, (NY,NY NY212-314-4600), 212-314-4600),member memberFINRA, FINRA,SIPC. SIPC. Investment Investmentadvisory advisoryproducts productsand and services serviceso o ered eredthrough throughAXA AXAAdvisors, Advisors,LLC, LLC,an aninvestment investmentadvisor advisorregistered registeredwith withthe theSEC. SEC. Annuity Annuityand andinsurance insuranceproducts productso o ered eredthough thoughAXA AXANetwork, Network,LLC. LLC. Wealth Wealth Management ManagementStrategies Strategiesisisnot notaaregistered registeredinvestment investmentadvisor advisorand andisisnot notowned ownedor oroperated operatedby byAXA AXAAdvisors Advisorsor orAXA AXANetwork. Network. AXA andAXA AXANetwork Networkare arenot not AXAAdvisors Advisorsand a a liated liated with with Pima Pima County County Medical Medical Society. Society. PPG PPG 69384 69384 (07/12) (07/12)

SOMBRERO June/July 2013

SOMBRERO
Pima County Medical Society Ofcers
President Charles Katzenberg, MD President-Elect Timothy Marshall, MD Vice President Melissa Levine, MD Secretary-Treasurer Steve Cohen, MD Past-President Alan K. Rogers, MD

Official Publication of the Pima County Medical Society Members at Large

Richard Dale, MD Anant Pathak, MD

Vol. 46 No. 6

PCMS Board of Directors

Diana V. Benenati, MD R. Mark Blew, MD Neil Clements, MD Executive Director Bill Fearneyhough Phone: 795-7985 Fax: 323-9559 E-mail: billf 5199@gmail.com Advertising Phone: 795-7985 Fax: 323-9559 E-mail: billf 5199@gmail.com

Michael Connolly, DO Bruce Coull, MD (UA College of Medicine) Stewart Dandorf, MS, MPH (student) Howard Eisenberg, MD Afshin Emami, MD Randall Fehr, MD Jamie M. Fleming (student) Alton Hank Hallum, MD Evan Kligman, MD Melissa D. Levine, MD Clifford Martin, MD Kevin Moynahan, MD Soheila Nouri, MD Jane M. Orient, MD Guruprasad Raju, MD Scott Weiss, MD Victor Sanders, MD (resident) Editor Stuart Faxon Phone: 883-0408 E-mail: tjjackal@comcast.net Please do not submit PDFs as editorial copy. Art Director Alene Randklev, Commercial Printers, Inc. Phone: 623-4775 Fax: 622-8321 E-mail: alene@cptucson.com

Thomas Rothe, MD, president-elect Michael F. Hamant, MD, secretary

Board of Mediation
Bennet E. Davis, MD Thomas F. Griffin, MD Charles L. Krone, MD Edward J. Schwager, MD Eric B. Whitacre, MD

At Large ArMA Board

Ana Maria Lopez, MD,

Pima Directors to ArMA Timothy C. Fagan, MD R. Screven Farmer, MD Delegates to AMA

William J. Mangold, MD Thomas H. Hicks, MD Gary Figge, MD (alternate)

Arizona Medical Association Ofcers

Gary Figge, MD, immediate past-president

Printing Commercial Printers, Inc. Phone: 623-4775 E-mail: andy@cptucson.com Publisher Pima County Medical Society 5199 E. Farness Dr., Tucson, AZ 85712 Phone: (520) 795-7985 Fax: (520) 323-9559 Website: pimamedicalsociety.org

SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson, AZ. POSTMASTER: Send address changes to Pima County Medical Society, 5199 E. Farness Drive, Tucson, Arizona 85712-2134. Opinions expressed are those of the individuals and do not necessarily represent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Ofcers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright 2013, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

GORGEOUS MASONRY HOME

In popular Sabino Vista Hills. Timeless architecture and ne craftsmanship, 2,500 sq. ft., 5 bedroom, 3 bath, including separate guest quarters. On a spacious lot with pool, sports court and mountain views.

$429,000

3.3 acres in gated Estates and Starr Pass. Sited to take advantage of sweeping city and mountain views. No expense spared, dream kitchen, retracting wall of windows, energy efcient construction. 4,000 sq. ft., 3 bedroom, 3 bath. Negative edge pool.

CITY & MOUNTAIN VIEWS

Madeline Friedman
ABR, CRS, GRI

$990,000

Madeline is Your Connection to Tucsons Favorite Neighborhoods! www.tucsonazhomes.com TucsonHomeFinder@aol.com

296-1956 888-296-1956

Vice President

EQUAL HOUSING OPPORTUNITY

SOMBRERO June/July 2013

Inside
5 About this issue. 6 Orthopaedic and Surgical Tower: New facility opened May 6. 8 Perioperative Governance Council: Physicians given stronger role in policy.

27 Canyon Ranch Institute: TMC partners with

Tucsons famous spa in a 12-week program for wellness. details how our organization is key to physicians being heard.

29 Dr. Charles Katzenberg: The PCMS president

10 TMCs certifications and accreditations. 13 Arizona Coordinated Care: What it is, and is not. 19 Lean streamlines TMCs procedures. 21 Chief Medical Information Officer: What
Dr. Brian Cammarata does.

22 THMEP: Many area physicians have come from 24 TAVR: An alternative to open-chest surgery.

the Tucson Hospitals Medical Education Program.

25 Ventana Medical Systems: TMC collaborates to

strengthen diagnostics.

26 Healthy Living Connections: In this TMC program

for seniors, peers support each other in making positive life changes.

On the Cover
The Tucson Medical Center Orthopaedic and Surgical Tower is a state-of-the-art orthopaedic center and surgical facility.

WE ANSWER FOR YOU!

Live Answering Remote Receptionist Appointment Scheduling Order Taking Message Delivery via Pagers Live Operator, Email, Voice Mail Text Messaging, I.V.R. (InterActive Voice Mail or Fax Voice Response)
Medical Society Exchange

24 Hours 7 Days A Week

PIMA COUNTY MEDICAL SOCIETY SINCE 1981
Authorized Answering Service for

2434 N. Pantano

Se Habla Espaol

www.RinconCommunications.com
4 SOMBRERO June/July 2013

790-2121

Established 1971

About this issue...

By Bill Fearneyhough PCMS Executive Director
ast year PCMS officers began meeting with CEOs of local health organizations with the goals of learning which strategies they are using to cope with change, and learning how PCMS can help the organizations succeed because we want all our hospital systems to thrive. We found that no two organizations are using the same tactics, and that each had valid data and ideas for innovation. In our February issue we re-introduced the remodeled Carondelet St. Marys Hospital and introduced the new Carondelet Heart & Vascular Institute to the medical community, working with Carondelet Health Network External Communications to portray some of the dedication, innovation, commitment and investment at the facility. In this issue TMC Communications profiles Tucson Medical Centers recent changes including its efforts as an Accountable Care Organization. This Sombrero will have a wider circulation than a regular monthly issue. If you are an M.D. or D.O. who is not a PCMS member, you can download a membership application at pimemedicalsociety.org, or call 795.7985 for an application. First-year dues are only $100. As a 108-year-old organization, we continually strive to increase our influence and outreach. We believe that today more than ever, physicians need to unite and speak up for their profession. Today is good day to commit and become part of our family of physicians. n

Why choose Desert Mountain Insurance?

see why our customers did...
Our physicians were so impressed with how multitalented your team was and that we were able to get our malpractice, office, workers comp, health and disability policies in what seemed like an instant. I would not hesitate to say Desert Mountain Insurance is the best insurance source in the Southwest! Eric, Administrator
Read more testimonials at desertmountaininsurance.com

VALUED VENDOR FOR THE PIMA COUNTY MEDICAL SOCIETY AZ MGMA MEMBER

ONE STOP INSURANCE FOR

I Physicians & Surgeons I Other Medical Professionals I Healthcare Facilities & Services

COVERAGE INCLUDES
I Professional Liability I General Liability & Property I Employee Benefits

866.467.3627
866.467.3611 fax info@desertmountaininsurance.com

www.desertmountaininsurance.com
SOMBRERO June/July 2013 5

Its open!
A
massive project costing more than $100 million with wide economic impact on the surrounding community, the TMC Orthopaedic and Surgical Tower officially opened on May 6. As a community hospital it was important to us to use as many Arizona contractors and local workers as possible, said Richard Prevallet, TMC vice-president of facilities. To that end, more than 78 percent of the project was awarded to Tucson companies, with the rest being awarded to Arizona companies. At any one time, there have been anywhere from 100 to 375 workers on site. The first floor includes a general lobby, support services, and the medical offices and clinics of Tucson Orthopaedic Institute, an independent physician group that leases the space. The second floor houses TMCs Surgical Service, with 14 state-of-the-art ORs that provide integrated technology for all specialties, plus interventional suites, cystoscopy, and dedicated pediatric surgery waiting, pre-op, and recovery areas. Two of the surgical suites on this floor are hybrid rooms that will be used in both cardiac and vascular surgeries. The two rooms include the most innovative equipment on the market. Such top-ofthe-line equipment will enable surgeons to treat a wider range of people, including the sickest of patients. As PCMS member, Dr. Matthew Namanny of Saguaro Surgical explains, I can operate on people who are in their 80s or 90s, whereas before, these people were not candidates for the surgery because the mortality risk was too high. With this new system, the sky is the limit, said Dr. Luis Leon, vascular surgeon with Agave Surgical Associates. He explained Playing with children in the pediatric waiting area in the tower helps parents entertain that the extraordinary imaging the new and distract children while waiting to be brought to surgery. equipment offers allows surgeons to be incredibly precise.In a minimally invasive procedure, everything is done through a needle stick which gives In addition to vascular surgery, a hybrid OR makes it possible to us access to put in catheters.Most of the time, surgeons are interweave specialties, giving a patient the most comprehensive operating while looking at a screen.You absolutely need good care and best outcome in one setting. imaging in order to do this.
6 SOMBRERO June/July 2013 A nurse helps a patient in one of 40 private procedure recovery rooms in the new TMC Orthopaedic and Surgical Tower overlooking the Santa Catalina Mountains.

The new surgical suites are nearly double the size of previous OR space. High-tech surgical equipment is attached to ceiling booms, eliminating cords on the floor, providing for safer movement of surgeons and assistants.

New hybrid operating rooms on the towers second floor allow for both non-invasive and more complex surgical procedures in the same OR, eliminating need to move patients, or in most cases equipment, in order to operate.

The third floor is devoted to orthopedic surgery, with 10 operating rooms and a new education conference center. The buildings top floor features 40 all-private patient rooms designed for orthopaedic post-surgical care and acute therapies. Two of those rooms are designed for bariatric surgery patients. The flow of the design focuses on how patients arrive, how they are received, how they go to pre-op, surgery and post-op, and how they leave the area. Patient rooms have received comparable collaborative attention. Similar to TMCs new pediatric rooms, the orthopedic patient rooms are broken into three distinct zones (serving the patient, the family, and the caregivers) to ensure quality of care and a positive patient experience. While the construction project was daunting, work done behind

the scenes in preparation for the move and operation of the tower have perhaps been even greater accomplishments. TMC leadership understood early on that this project represented a unique opportunity to examine existing processes and find ways to be more effective and more efficient. Work groups encompassing staff in areas throughout the hospital were formed to address these challenges and come up with working solutions. Everything from OR supplies to surgery scheduling to elevator etiquette was diagrammed, dissected, and worked through. Staff in key areas around the hospital have worked hard to question how we could do things better operationally, said Linda Wojtowicz, TMC senior VP and chief operations officer. We were able to zero in on our processes to assess what was not working, what could work better, and how best to fix it. n

SOMBRERO June/July 2013

Physicians given stronger role in improvement, policy determination

The TMC Perioperative Services team consists of experts in a range of pre-op and surgical procedures, from routine to complex.

he new TMC surgical tower is poised to offer 24 state-ofthe-art operating rooms and new opportunities for extraordinary patient care. In addition, it is propelling a fundamental shift toward a shared governance model, empowering physicians as they partner with hospital administration in a new way to achieve superior patient outcomes. The move to the new building provided a strong incentive to take a critical look at day-to-day processes. Any practices that werent working efficiently would need to be adjusted to make sure they were as up to date as the new tower. Top-driven directives have not always proven to be the best way to generate buy-in from the folks who are directly involved with

patient care, TMC President and CEO Judy Rich said, so it became increasingly clear to us that physicians were going to have to have a stronger voice in crafting rules and policies to meet the changing demands of healthcare. Fourteen physicians and 10 hospital staff members took their seats on the new Perioperative Services Governance Council in June 2012, setting in motion a structure for professional collaboration that never existed before. With 22 years of experience at TMC, including stints as anesthesiology department chairman, surgery department medical director, and chief of staff, PCMS member Matthew Atlas, M.D. knew that there were some long-standing practices that could work better. So when he agreed to serve as a consultant in

SOMBRERO June/July 2013

creating the governance structure and the charter for the new governance council, he immediately grasped the opportunity for significant change. This is an opportunity to have all the players work together to create the rules and find the solutions, Dr. Atlas said. It works way better than anything else. Among the top orders of business: Streamlining block scheduling for elective case surgeons in the operating rooms. Its a complex puzzle. Too much blocked time means other physicians in the community cant book cases for surgery because of a shortage of open time slots. Such reduced flexibility also could mean that when emergency cases come in, or if cases run longer than expected, it could push back other cases and trigger delays, causing stress to staff and patients. With efficient block scheduling as key to full use of the new ORs, the team combed through reams of data to see whether the blocked time matched actual patterns of usage, from whether surgeons had too much time allotted to them or too little, and whether mechanisms existed to release blocks of time that werent needed. Dr. Atlas and many others met with every surgeon who had block timemore than 50to gauge their needs and share findings. Ultimately the system was recalibrated to meet the industry standard of having no more than 80 percent of the OR schedule electively blocked, providing more flexibility for scheduling as well as more open time to handle overruns and urgent surgeries. The current economic climate has left little choice but to carve out efficiencies, even when the solutions may initially be laborintensive and sensitive, Dr. Atlas said. People are often afraid of change and there can be a culture of resistance in any large system. But if any hospital wants to survive in this environment, with the economics that are going on, they have to look at fundamentally changing how they do things. In the old days when there was a lot of fluff, it was a different story. But with hospitals seeing margins of 1 to 2 percent, you need to use the resources you have more efficiently. If you sit still, youre going to get run over. Dr. Atlas has been around long enough to see initiatives come and go, but predicts that success will cement this new way of doing business.
SOMBRERO June/July 2013

If you look at where we started, and where we are today, its monumental the things we have accomplished, he said. The things we were fixing were long-standing things that had cultural components, and as weve all heard, culture eats process for lunch every day. To change minds and hearts so that people see there is a better way might be a long process, but its also an exciting one. n

We know Tucson. We are Tucson.

We are Tucsons homegrown law rm providing
legal services for Southern Arizona since 1969. We can assist with all legal needs, from Business and Real Estate, to Bankruptcy, Family Law, Estates and Trusts, and Personal Injury.

Barry Kirschner was recently selected by his

peers for inclusion in The Best Lawyers in America 2013 in the eld of Litigation ERISA*. Barry knows disability insurance law. He understands the specialty occupation and own occupation features of disability contracts sold to professionals. He has prevailed for doctors practicing subspecialties within radiology, cardiology, and nurse practitioners who are denied benets by insurance companies unwilling to stand by the commitments made in their own Policy of insurance.
* Copyright 2012 by Woodward/White, Inc., of Aiken, SC.

For more info on Barry or the rm visit

www.learnaboutwechv.com

An independent member of LAW FIRMS WORLDWIDE

Williams Centre | 8th Floor | t 520.790.5828

TMC recognized for cardiovascular excellence

ucson Medical Center is proud to be the first hospital in Arizona to be awarded Atrial Fibrillation certification, and the first hospital in Tucson to receive Congestive Heart Failure (CHF) accreditation. TMC has also been re-accredited in Chest Pain, after earning its original endorsement in 2010. The three designations come from the Society of Cardiovascular Patient Care (SCPC), an independent, nationally recognized accreditation non-profit organization focused on transforming cardiovascular care by assisting facilities in their efforts to bring together quality, cost, and patient satisfaction.

TMC earned these distinctions by meeting or exceeding a wide set of Dr. Darren Peress, electrophysiology lab director, works with one of only 175 stereotactic ablation systems worldwide, and the only one in Southern Arizona. stringent criteria, demonstrating its expertise and commitment to quality patient care. The SCPC come here, theyre going to get a full range of good care. TMC conducted extensive and objective reviews of TMCs A-Fib, CHF has processes in place to care for these patients in a very efficient and Chest Pain programs. waywere providing the right care to the right patient at the Atrial Fibrillation Certification right time. TMCs protocol-driven and systematic approach to evaluating and Congestive Heart Failure Accreditation managing A-Fib patients allows physicians to reduce time to TMCs dedication to higher standards in enhancing care quality is treatment. It also allows them to stratify patients by risk to also recognized through CHF accreditation. The hospital has decrease their length of stay in the ED and the hospital. adopted an operational model for CHF patients to organize By improving TMCs processes and outcomes for A-Fib patients, care delivery in a systematic manner using evidence-based SCPC is fulfilling its mission to reduce cardiac-related deaths. guidelines and quality initiatives. With this accreditation, TMC Patients can be confident they are receiving critically appraised has expressed a deep interest in these patients well being by evaluation, treatment, and management of A-Fib. According to not only maintaining the standard of care, but also constantly SCPC, there are currently nearly 3 million A-Fib cases in the U.S. improving it. Heart failure is a leading cause of morbidity and By 2050, it is projected that this number will jump to more than mortality in the U.S., affecting an estimated five million 7.5 million. Americans. This accreditation demonstrates TMCs ability to This certification means that TMC is providing a recognized effectively manage the increasing number of these patients. standard of care, said TMC cardiac electrophysiologist and PCMS TMC realized several years ago that a true collaborative effort member Darren Peress, M.D., of Pima Heart Associates. All of among cardiologists, cardiothoracic surgeons, and hospital the physicians here are providing the same level of care.Were all administrators was necessary to ultimately improve quality practicing in a way thats evidence-based, and thats been metrics and patient care, said TMC cardiologist and PCMS recognized as good medicine. Patients should know that if they member Gregory Pennock, M.D., of the Heart Center of Southern
10 SOMBRERO June/July 2013

Arizona. Thus, in a fairly revolutionary idea at the time, the cardiology/CT surgery SLA (service line agreement) was formeda joint management venture between hospital administrators and physicians. Results have been impressive, and the hospital accreditations reflect those efforts.Patient satisfaction and quality metrics have improved, and physician satisfaction has improved. Physicians have more ownership in the management of hospital processes and resources, and relationships between physicians and administrators have improved. Perhaps the most interesting and important aspect of the SLA is that multiple physician groups that were once fiercely competitive with each other are now much more collaborative. I would like to think that TMC has tried to figure out a model to preserve private practice in the region. This model is vastly different than an employed physician model used by other hospitals and networks. In general, I think physicians didnt go into this profession to be shift workers, dictated to by administrators, accountants or the government. Chest Pain Re-accreditation TMCs Chest Pain re-accreditation ensures that patients who come to the hospital complaining of chest pain or discomfort are given the immediate treatment necessary to avoid as much heart damage as possible.

Protocol-based procedures developed by leading experts are part of TMCs cardiac care, to reduce time to treatment in the early stages of a heart attack. With TMCs accredited status, patients can be confident that they will be treated according to bestpractice guidelines from the American College of Cardiology and the American Heart Association, and get education about treatment and prevention of heart disease. In addition, staff members receive education about signs and symptoms of heart disease, and the resources TMC has to treat chest pain patients. SCPCs goal is to use evidence-based medicine to eliminate heart disease as the No. 1 killer worldwide. Accrediting TMC as a chest pain center brought together multiple disciplines working toward the goal of rapid response to heart attack and efficient responses to less urgent presentations, said TMC cardiologist Dr. Mark Goldberg of Camp Lowell Cardiology. The re-accreditation process brought even closer scrutiny to our methods of providing care. Again, EMTs, ED nurses and physicians, cath lab personnel, and cardiologists worked together to fine-tune a system in which time is critical. We are very pleased with the quality measures that weve been able to report and the progress weve made in making the system more efficient, Dr. Goldberg said. This progress definitely translates to better patient outcomes. n

Share prime medical office space located at 6226 E Pima St. (central Tucson) with physician-owner who specializes in Medical Aesthetics and Wellness Care. Close to Tucson Medical Center and St. Josephs Hospital. We offer flexible, below-market lease rates for one or more offices/exam rooms. Ideal for physicians, psychologists, therapists, etc. who are looking for a more private and upscale professional environment. For more detailed information, including floor plan, photo gallery, etc., please visit www.TucsonPrime.com or call Steve at (520) 795-4560.
SOMBRERO June/July 2013 11

Dr. Ganns Diet Of Hope

Prevention-Disease Management-Nutrition

520-696-DIET (3438)
Dietmar Gann MD FACC Elizabeth Gann CNC

Dietofhope.org

To avoid hypoglycemic and hypotension reactions, temporary changes of medication are necessary.

Experience with 76 insulin dependent type 2 diabetics DAY ONE: We stop regular insulin We stop long acting insulin at night and gradually reduce it during the six weeks We stop all sulfonylureas We stop most diuretics* We stop fibrates**

Margaret A. Ross FNP-C

Abby Michieli FNP-C

*Eliminating refined carbohydrates produces a spontaneous diuresis **Elevated triglycerides are related to refined carbohydrate intake

SIX WEEKS

Lori Popeski PMHNP-BC

DIABETES II IS PREVENTABLE AND OFTEN REVERSIBLE

42 Patients stopped insulin 34 reduced insulin

Cheryl Parker FNP-C

Hippocrates: Let food be your medicine and medicine be your food

LOCATION 268 E. River Suite 130, Tucson Arizona 2096 N. Kolb Suite 107, Tucson Arizona Gene Power FNP-C Sierra Vista Arizona Michael Laux M.D. San Carlos Mexico
12 SOMBRERO June/July 2013

TMC proud partner in AzCC

T
ucson Medical Center announced in March that it had joined an innovative new alliance that would not only focus on keeping people healthier over the long term, but also help put healthcare on a more sustainable trajectory. With such Accountable Care Organizations promoted in the Patient Protection and Affordable Care Act of 2010, the success of Arizona Connected Care will hinge largely on making sure chronically ill patients are better equipped to manage their conditions so they can avoid repeat hospitalizations and costly interventions. We asked IM physician Jeffrey Selwyn, M.D., who took part in the planning for the new organization over the past three years, and Family Practitioner John Wadleigh, D.O., a relative newcomer to the new path, to explain what drew them to the approach and how its already helping them better serve patients. Both are PCMS members. Dr. Wadleigh, what made you consider signing on with the ACO? Were in an unusual time in medicine. In the past its always been about quality of care. Now, its about quality and cost-effective care, and that is a much bigger challenge. The original term Accountable Care Organization meant holding an organization accountable to patients and their families. I really like that concept and I like that we have control here locally. By being local, you are more accountable, because you live among your patients. Theyre your neighbors. Theyre the people you see in the store and who take care of you in restaurants, so the local management of medical dollars is very important. Dr. Selwyn, youve been engaged in the ACO now for several years, from its inception to a fully operational entity. How is your practice different? I have to say that New Pueblo Medicine has been at the forefront of really understanding and perpetuating this vision of coordinated care through improving the health of the population, engaging patients in wellness,
SOMBRERO June/July 2013

promoting health awareness, and managing chronic disease. So for me, the way of practicing hasnt changed. But Im seeing more of the things Ive desired come true: Better outcomes, better chronic disease management, more patient education, and more patient engagement. Thats been largely fulfilled because of what weve been able to do with the electronic medical record. That was a difficult transition for me as an older physician. I thought I could do charts better than anyone and I didnt see the value. Admittedly, it was a painful transition. But as I look back on that, and being on the other side of the fence right now, its night and day in terms of how you can manage your patients. Do you have an example of that? Well, as an example, very easily with the click of a button you are now able to pop up different screens and templates about what health maintenance and disease management steps each patient

YOUR PATIENTS DESERVE

the best hearing care possible

We are preferred providers on most insurance plans. Helping you hear your best
Janis Wolfe Gasch, Au.D.
7574 N La Cholla Blvd Tucson, AZ 85741

Doctor of Audiology, Founding Director

We appreciate your referrals!

512 E Whitehouse Canyon Rd, #196 Green Valley, AZ 85614

6969 E Sunrise Dr, #203 Tucson, AZ 85750

520.742.2845

520.742.2845

520.648.3277

www.arizonahearing.com

13

Dr. Wadleigh, youve come to this more recently. How do you anticipate your practice changing? Ask any office-based primary care provider and theyll tell you theyve had this exact experience. A patient will come in and theyll tell you that since you saw them six months ago, theyve had a heart attack, went to the hospital, had a bypass, spent time doing rehabilitation and then had some home healthcareand we had no idea that ever occurred. With the robust information technology systems we have in place now, well know these things so we can be better advocates for our patients.

A patient consults with Dr. Jeffrey Selwyn, medical director of Arizona Connected Care.

needs. You could do that before with a paper chart, but if you couldnt read your partners writing or if things were left out or the chart was disorganized, the ability to retrieve information from a written chart was much more difficult. The ability to keep meticulous, organized, concise records has just exploded with EMRs. That allows me, as a physician managing 1,600 patients, the ability with a click of button to make sure that my diabetic patient has received appropriate labs within a reasonable time framework, and has had an eye exam, and a foot check or anything else that might be appropriate for that patient. It has allowed me to work smarter, not harder, and has allowed things to be much more transparent.

But you also see ACOs as having the potential to fundamentally change medicine? We are getting fewer and fewer primary care providers than at any time in history, and thats because the people who make the decisions at the HMOs and Medicare have made decisions that push new students into anything else but primary care. The hassle factor is higher, between having to do primary care verifications and referrals and prior authorizations. And since payments have been cut back, doctors are trying to see more patients, since the more you see, the more your income is. But running through so many patients is really not what we want to do. Rather than seeing 30 or 40 patients a day, wed rather see half that and give the care that we really want to give. Thats going to change medicine. Now, theres an option for those young providers who really want to do the kind of primary care where you knew your patients as children and then as young adults and then you get to know their children and its a 30-year relationship. We have to have a system that promotes office-based primary care providers and the ACO is really the only thing going that may do that. Dr. Selwyn, youre about to join Dr. Richard Johnson in the shared role of medical director for Arizona Connected Care. As you continue to build the network, what are the opportunities youre seeing now for physicians in the community? The network and membership is open to any and all who are really interested in adopting a collegial mentality to promote better healthcare. We have roughly 200 primary care doctors participating now. Change for anyone, including physicians, is not easy, since wed prefer to stay in a comfort zone.
SOMBRERO June/July 2013

Plan ahead for your increased patient load and physician

shortages due to:
Retirement Recruitment Vacation Illness Sabbatical Maternity Leave CME

CMR has provided permanent and locum tenens services in Arizona since 1991. With over 300,000 active candidates in all specialties, we provide personal, professional, and proven service!

Catalina Medical Recruiters, Inc. P.O. Box 11405 Glendale, AZ 85318 phone: 602-331-1655 fax: 602-331-1933 joan@catalinarecruiters.com www.catalinarecruiters.com

14

One of the Nations Premier Retinal Subspecialty Groups

Visit Our New Green Valley Location.

Common conditions treated include: Macular degeneration Diabetic retinopathy Macular diseases, e.g., macular hole and macular pucker Flashes and oaters Retinal tears Retinal detachment Central and branch retinal vein occlusions Pediatric retinal conditions Tumors involving the retina and choroid Second opinions

You may reach all locations at (520) 886-2597 or toll free at (800) 769-5874
Cameron Javid MD, April Harris MD, Egbert Saavedra MD, Mark Walsh MD

St. Josephs Medical Plaza 6561 E. Carondelet Drive Tucson, Arizona 85710
Opened Sept. 2011

Northwest Medical Center 6130 N. La Cholla Blvd., Suite 230 Tucson, Arizona 85741
Opened Oct. 2012

New treatments available in clinical research trials for wet & dry macular degeneration and diabetic retinopathy

1055 N. La Caada Dr., Suite 103 Green Valley, Arizona 85614

New Ofce March 2013

For maps of ofce locations, visit the contact us page.

SOMBRERO June/July 2013

www.retinatucson.com

15

But by moving forward in small steps with the help of a transformation team, physicians will find its a much less painful process than if they try to do it on their own. How do you think its helping patients, Dr. Wadleigh? Theres a wonderful saying that doctors take terrific care of the diabetic patients who come to the office. Its the ones who dont come to the office who go back and forth to the hospital and the emergency room and are spending the majority of money because theyre not getting preventive care. We need the time and the personnel to do outreach to those individuals to make sure theyre taking meds and theyre doing visits and getting labs done to prevent problems. But ultimately, I think everyone wants to have a provider who they feel is their advocate, and I think weve lost that in medicine. We go to our primary care doctor if we have a cold or sore throat. We go to CVS pharmacy for an earache. We go to an urgent care for that laceration and we go to a specialist for this or that. What weve lost is someone who will pick up the phone and say, Yes, Ive known Mr. Martinez for 20 years. Whats happening? The vast majority of Americans need to have that kind of relationship with their doctors if they are to get the care they all want. Hopefully, this can help promote that. Dr. Selwyn, youve been affiliated with TMC for four decades now. How important is it that TMC is participating in this effort?

I believe in TMC. I believe in what theyre trying to do in the community. I am totally invested in their commitment to making such an organization be successful and a model for other places in the country. With clinics also part of the ACO, it means were no longer working in silos. I really like that collegiality. I like the fact were all on the same team and working together for a common goal and a common vision. Everybody wins because were doing a better job and saving money by doing the right thing.

AzCC myths vs. facts

Because many in our community are still not sure what Arizona Connected Care is and is not, here are a few myths we have heard, and facts we can report about what Tucsons first Accountable Care Organization (under PPACA) is actually doing. Myth: Arizona Connected Care (AzCC) isnt really a physiciangoverned organization. Fact: A physician chairs AzCCs board of directors, and eight of its 13 governing board members are doctors. Two other members are community representatives, and three board members hold TMC affiliations. Although TMC is a major supporter of AzCC, it holds only a minority governance position in this physician-driven organization. Myth: The goal is to generate business for participating partners. Fact: The goal is to provide quality healthcare to the patients we serve, when and where they need it. The only way participating clinicians can benefit from AzCC is by providing excellent and efficient healthcare with strong patient satisfaction results. AzCC clinicians work to keep people healthy enough so they dont need tertiary care, so the focus is on prevention and wellness. If an AzCC patient does require hospitalization, AzCC works closely with primary care physicians and hospital staff to provide appropriate transitions to make sure patients needs are met after discharge, but the goal is to minimize unnecessary admissions. Myth: AzCC thinks the quality of care provided by area physicians needs improvement. Fact: This is absolutely not true! Physicians work extraordinarily hard on behalf of their patients, including uncompensated time helping their patients stay well. AzCC believes it is the system we all work with that needs to be modified, including offering incentives for physicians for wellness checks, preventive

16

SOMBRERO June/July 2013

outreach, and many other aspects of quality care that focus on keeping people well. Myth: AzCC will limit care in order to improve the bottom line. Fact: Center for Medicare Services rules would prohibit any such effort, and such an approach is diametrically opposite AzCCs mission. Patients in Arizona Connected Care could actually receive more care. AzCC providers offer preventive care focused on keeping patients healthy as the best way to bend the cost curve. Our formula is: More consistent care = healthier patients = lowering total healthcare cost. Myth: AzCC will tell physicians how to practice medicine. Fact: Arizona Connected Care is not different from its physicians; it is its physicians. They set the policies. They define quality and best practices. They hold each other to an agreed-upon high standard. Because patients also serve on the board, they, too, have a say in establishing those standards. This collaborative approach gives clinicians the information they need to practice evidence-based medicine, and office efficiencies so they can spend more time with their patients and less time on the business of medicine. Arizona Connected Care helps physicians envision their ideal practice, and then helps them achieve it. Myth: Patients wont really see any difference. Fact: Patients of AzCC-participating clinicians enjoy clear communication with their providers and become more engaged in their own healthcare. They receive greater support where they need it, including at home. They experience smoother transitions when leaving a hospital or other care facility. AzCCs success is predicated on positive outcomes and patient satisfaction, something patients can and will notice. n

Now youre Thinkin Smart

Simplify your communications with Simply Bits state-of-the-art managed voice and data services

ROC #278632

SOMBRERO June/July 2013

17

Disabled. Insured. Getting the Runaround?

If you need help with a disability insurance claim, contact Ed Comitz for a complimentary legal consultation.
Direct: 480.219.5436 ecomitz@cobelaw.com

A T T O R N E Y S A T LA W

480.998.7800 | www.disabilitycounsel.net
18

6720 North Scottsdale Road, Suite 150, Scottsdale, Arizona 85253

SOMBRERO June/July 2013

The watchword is Lean

And for those sick enough to go to the emergency room, a long wait combined with anxiety makes for unhappy patients. To take the wait out of the waiting room, Tucson Medical Center has embraced efficiency methods developed at Toyota half a century ago. Known as the Lean management process, it has spread across many sectors around the world. TMC uses this system in order to build a culture of learning designed ultimately to increase patient satisfaction, streamline processes, and strengthen the hospitals financial position. Although the Toyota Production System was developed to eliminate waste and streamline processes in manufacturing, the principles are being used at TMC to take a hard look at productivity measurements across the hospital, from the cafeteria to the OR.

o one likes to wait.

Emergency Department nurses show Lean management changes across the organization, aiming to streamline processes by improving work flow and reducing waste.

When the new director of patient care services in the emergency services area heard about the effort, she literally begged to be the first project, even though it meant inviting significant scrutiny. I was really excited about the idea because I knew I needed help to address important areas, from retention rates to employee morale, Melissa Moreno said. Under the Lean process, teams followed patients through the length of their emergency department stay, logging how long patients waited at every step in the process to ferret out the logjams and bottlenecks. The teams drilled down deep, even looking at how rooms were situated to see if medical staff had key equipment at their fingertips or had to search for it. Every practice was weighed based on whether it added value for the patient. For Moreno, it was an intimidating process. It takes a lot of courage to sit back and let someone else tell you whats going wrong in your department, but its been worth it, she said. Even though the work only began in January, changes have already been implemented: Too many patients were sitting in the emergency department
SOMBRERO June/July 2013

waiting for discharge, so a discharge lounge was constructed where they can comfortably wait for prescriptions and other instructions to be finalized, while freeing up beds for other patients. And because it is staffed with a nurse assigned just to discharge duties, patients report theyve had more one-on-one time and better understand the steps to take when they leave the hospital. When data indicated some of the backup was attributed to patients waiting too long for diagnostic tests to come back, the staff not only shaved some time off of CT scan returns, but also placed a mid-level provider up front to see patients. That way, pain is addressed faster, and X-rays and other diagnostics can be ordered so that when the patient is seen, the information is there. Lets say a nurse had a patient with nausea and wanted to order a medication. Previously, the nurse had to leave the area to find the physician, who worked in another area. Now, the space is organized into pods, where the nurse can literally turn around in a chair to talk with the doctor. No more searchingand it provides a stronger team approach. Make no mistake. It is an investment. Key staff members have been pulled from departments throughout the hospital to work on the project full time. Teams then had extensive training, and

19

traveled to hospitals where it is working, such as Seattles Virginia Mason Medical Center. In a Lean model, process improvement is driven by frontline staffthose who are closest to the work and know best how to improve processes. It hasnt always been easy. Even Moreno, who was so welcoming initially, had to overcome a tendency to push back, particularly when she was asked to standardize a days work for her charge nurses. It seemed preposterous, in an environment as hectic as an emergency room, to dictate when lunch and rounds will take place. But after the nurses created their standards, they were proud.

At the end of the day, they have a clean slate to hand off to the next charge nurse and theyre no longer driving home thinking, Oh. Did I get that done? Now they know, because they checked it off their list, Moreno said. Dr. Richard Rosenthal, medical director of the emergency department, agreed that its been worth carving out the time for analysis and evaluation. And he hopes in the next few years to get to a place where theres very little wait at all for patients. You dont want patients to be in a waiting room. Even if someone has seen them briefly, you dont know how serious they are, so you want them back in the treatment area where you can observe them and take care of them, Dr. Rosenthal said. With Medicare reimbursement increasingly taking into account whether patient expectations were met, he predicts more hospitals will look more closely at measures of patient satisfaction. Leans goal is to root out waste, and that encompasses more than waiting. Using the acronym DOWNTIME, heres a look at the eight types of waste that staff is trained to find and address: Defects Overproduction Waiting Not being clear Transportation Inventory Motion Excess processing

CALL 520-205-7520 TO REFER YOUR PATIENT FOR EVALUATION.

Another prediction: Lean work will never be done. Not even when the Lean teams disband after combing through procurement, food services, and other areas of the hospital. Id hate to be at a point where we assume weve reached nirvana and cant do any better, Dr. Rosenthal said. I hope were always on the cutting edge of improving patient care and satisfaction. Its an exciting time for us. Its challenging, but we really enjoy this focus on making things better. n

20

SOMBRERO June/July 2013

Dr. Brian Cammarata: CMIO

I started my undergraduate career in management information systems and had intended to work with computers, Dr. Cammarata said. Through a series of events, I became interested in medicine. After I graduated from medical school, I never anticipated using my computer background. The two fields, however, are now merging in interesting ways. The evolution of healthcare informatics will provide substantive improvements to medical care delivery. We are able to improve care for both individual patients and entire populations through improved information technologies. Like technology itself, the job is evolving, Dr. Cammarata said. The job seeks to improve patient care through enhanced information access and availability. This job is new to TMC and undergoing evolution. When we first developed the position, it was difficult even to place specific objectives and criteria on paper. We continue to learn about and develop the role every day. The biggest challenge goes back to when TMC went live with its electronic medical record in 2010, Dr. Cammarata said. As an institution, we were an early adopter of the technology. At that time, a fully electronic medical record was a significant practice change for most of our medical staff. While the idea of a full implementation of EMR was somewhat new, TMC leadership believed that the concept would mature to substantively improve patient care. Our biggest challenge on the horizon is data management. We have become effective at collecting data, but we need to continually develop better methods of using this data in meaningful ways. These include evaluating outcomes, improving patient safety, and meeting the hospitals growing list of compliance measures. The ultimate goal is improving patient care.
The unique skill sets of Dr. Brian Cammarata, TMCs first chief medical information officer.

he role of chief medical information officer, dealing with healthcare information technology, is still fairly new to medicine, but is rising in significance as industry leaders nationwide realize how technology is shaping healthcares future. Brian Cammarata, M.D., took the new position in January because he found it a great match with his original interests.

We use this information in a number of ways, Dr. Cammarata said. For hospitalized patients, we are working to improve care in multiple areas, such as minimizing the number of patients who develop blood clots and improving sepsis care. Another aspect is using information to help keep patients with chronic diseases out of the hospital. For example, for a patient with diabetes, using information to improve blood sugar control, minimize complications, and keep the patient out of the hospital is a winwin for everyone. The approach improves patients lives and saves healthcare system dollars. Healthcare ITs ultimate goal, Dr. Cammarata said, is to assist our physicians and nurses in providing the safest and most effective care for every patient at Tucson Medical Center. n

SOMBRERO June/July 2013

21

THMEP: Improving with age

Medical education program still shines at TMC
Tucson Medical Center this year is celebrating half a century of helping to educate current and future physicians. The Tucson Hospitals Medical Education Program (THMEP), the education arm of TMC, was established in 1963 as the original medical education program for the community, since the University of Arizona had not yet opened its M.D.-producing college or begun its postgraduate residency training programs. Tucson Medical Center remains one of the states major teaching hospitals for both residents and medical students alike. TMC sponsors a one-year transitional Dr. Robert Aaronson works with a patient while mentoring residents and doctors in the graduate program for those individuals and continuing medical education programs at TMC. moving on to specialty residencies elsewhere. TMC Starting in July, the program will add another important also independently sponsors a pharmacy residency and is in the residency, which will be a novel concept offered in conjunction process of getting approval for a podiatry residency, which will be with A.T. Still University, El Rio Community Health Center, and the co-sponsored by Midwestern University. Wright Center in Pennsylvania. The collaboration will pilot a THMEP partners with a number of universities to meets its national family practice residency built on a model that focuses educational mission. Through THMEP, TMC is a major teaching on community health centers in order to train primary care institution for medical students and residents from several physicians to better meet the needs of medically under-served University of Arizona programs, including Internal Medicine, populations. Surgery, Pediatrics, Neurology, Emergency Medicine and others. Designed to address a troubling shortage of primary care In all, more than 200 residents a year come through TMC. physicians, funding provided through the Affordable Care Act will One thing that residents really value about coming to TMC is they encourage innovative training and will showcase a model that get a different perspective than they otherwise would in a purely could be replicated elsewhere. university-based setting, said PCMS member Robert Aaronson, We are really excited about this opportunity, Dr. Aaronson said. M.D., THMEP executive director, who is board-certified in IM, Residents accepted into this program are individuals who have pulmonary, critical care, sleep, and neuro-critical care medicine. stated a desire to deliver primary care and to focus that care on a Residents take important knowledge and lessons away from needy population. That absolutely fits with TMCs mission, which every setting in which they practice, but here at TMC people get is to provide service to those across the entire economic to see a wide variety of patients from very different cultural and spectrum. socio-economic backgrounds. They also have the opportunity to Dr. Aaronson said that the opportunity gives students and work with skilled clinicians in a medically and technically residents the chance to tap into the resources of TMC, including a sophisticated but real-world setting to learn cost-effective and strong focus on data collection, which has been driven through medically effective approaches to patient care.
22 SOMBRERO June/July 2013

establishment of the electronic medical record and, more recently, through partnership with the ACO, Arizona Connected Care. With THMEP accredited by the Arizona Medical Association to provide CME programs that will meet the needs of physicians in the community, TMC also recently made a substantial investment in providing a subscription for all physicians on staff to UpToDate, a resource that provides the latest information on new clinical developments and recommendations. One of the advantages to this resource is that physicians can earn CME credits when they research a clinical question.

Dr. Charles Daniel reviews a patient case with a resident participating in THMEP.

At THMEP our mission is to improve community health through the education of physicians at TMC and within our community, as well as at the

undergraduate and graduate levels, Dr. Aaronson said. Its been very rewarding to grow our own, with a focus on high quality, effective, and efficient care. n

SOMBRERO June/July 2013

23

Alternative to open-chest surgery gives hope to patients previously thought untreatable

Patients once deemed too high-risk for open chest surgery may soon get a new chance at a higher quality of life. Tucson Medical Center is poised to offer surgeons the ability to perform Transcatheter Aortic Valve Replacement (TAVR), which was approved for wider use by the U.S. Food and Drug Administration last fall. Candidates for the surgery suffer from a narrowing of the aortic valve, weakening the heart over time as it works harder to push blood through the tighter valve. In the new procedure, instead of opening the chest, Dr. William Thomas, structural heart medical director, sponsors TAVR. an artificial aortic valve is fed through a tube inserted through the groin and up Implementing the program is a rigorous process that demands into the heart. Its far less invasive and offers much faster extensive training, adherence to strict criteria, and specialized recovery time. equipment. The new TMC surgical tower will house two hybrid Cardiologist and PCMS member William Thomas, M.D., one of ORs large enough not only for the equipment, but for the large, the lead physicians helping to develop the program, said that collaborative surgical team, which consists of a surgeon, a without the procedure patients too sick for traditional vascular surgeon, two cardiologists, a cardiac anesthesiologist, surgery have a 50 percent chance of dying over the imaging specialists, and other clinicians. subsequent 12 months, facing limited lifestyle along with the Anita Bach, TMC director of cardiac services, said she hopes to high mortality risk. offer the procedure sometime within the next calendar year. We For doctors in the community who currently have only one have a great group of cardiologists and surgeons who work well local option for the procedure, the new capability at TMC together, and now that we have the room and the equipment provides additional flexibility, Dr. Thomas said. He added that it and the trained staff, were really in a perfect place to offer this will also provide a more open program to allow cardiologists to alternative, Bach said. Physicians are always looking to present cases and participate in a comprehensive valve clinic technology for the newest, most innovative ways to improve that will provide evaluation and treatment options for complex healthcare. This is the kind of advancement that will allow them valve disease. to give their patients a better alternative. n

24

SOMBRERO June/July 2013

Unique collaboration with Ventana strengthens diagnostics

T
ucson Medical Center now offers a fully automated laboratory that optimizes staff efficiency, improves turnaround time and reduces the potential for human error. The hospital upgraded the laboratory under an innovative collaboration with Ventana Medical Systems, a member of the Roche Group, a leader in tissue diagnostics. couldnt. Without manual dipping, every slide has a fresh stain of very high consistency that makes it easier to read, reducing the possibility of misdiagnosis. The automation also allowed for stronger management of patient identification throughout the process. The use of a barcode eliminates mislabeling. And because one pathologist works with one patient at a time through the entire process, there is greater continuity of care. The laboratory also now features two machines that use immunohistochemistry to help differentiate one tumor type from another and one tissue type from another.

Ventana, the #1 provider of anatomic pathology and histology staining equipment in the world, had been looking for an affiliation that would allow the company to showcase important n todays healthcare technological advancements while environment, its more critical strengthening the health of the community through increased than ever to provide patients educational outreach. with information about the

A BenchMark stainer with 24 special In todays healthcare environment, its value of diagnostic testing, along stains also allows laboratory staffers to process more slides and improve their more critical than ever to provide with accurate, comprehensive turnaround time compared to the older patients with information about the diagnostic results to ensure quality, manual process the lab previously value of diagnostic testing, along with featured. accurate, comprehensive diagnostic cost-effective treatment. results to ensure quality, cost-effective We are as fully automated as any treatment, said Megan Bailey, senior histology lab. We are state-of-the-art marketing manager for Ventana Medical Systems. for staining techniques and workflow management, Allen said. The discussions began in July, shortly after John Allen came on as The laboratory also added an iScan Coreo digital pathology slide the director of lab services at Tucson Medical Center. scanner, which will allow the hospital to do more analyses in house, particularly with breast cancer, instead of sending those From Ventanas perspective, the alliance furthered its mission to out to other labs. improve the lives of all patients with cancer. With TMC, this takes on special meaning, as the patients affected are members Although the laboratory was completed at the end of February, of our own community, Bailey said. In discussions with TMCs TMC and Ventana are continuing to work on building a long-term leadership, it was clear they share a similar vision and are intent relationship that will not only provide premiere cancer on delivering the best diagnostic result for every patient they diagnostics, but also a forum for educational collaboration. From serve. Were proud to provide solutions to help them achieve Ventanas perspective, it also is helpful to have local lab staff that goal. provide ongoing feedback as they refine and develop solutions for customers. Allen said the relationship came at a perfect time. It fit a vision of where I thought we could take this lab and it fits the vision for From TMCs perspective, the new equipment helps the hospital TMC to be truly a premier provider, he said. position for growth while providing exceptional quality and reliability. The new systems will allow the hospital to perform more inhouse tests, reducing the need for outside laboratories. Allen noted: Getting state-of-the-art techniques allows us to be The new automated hematoxylin and eosin-staining equipment capable of top quality, state-of-the-art results. n advances patient safety in ways the previous dip style stainer

SOMBRERO June/July 2013

25

Bridging the gap...

Peers support each other in making positive life changes

here may well be a recipe for reducing a patients risk of re-admission to the hospitaland the mix includes a phone call, a volunteer care coach, and several home visits. Tucson Medical Center launched a pilot program in March that harnesses the power of peers in helping patients with one or more ailments meet personalized health goals, whether its implementing a heart-healthy diet, increasing physical activity, losing a few pounds, or simply engaging more with life. The goal is to gauge whether lay people can make a difference in helping patients who need additional support beyond what they can get from their health professional alone. A volunteer, trained in motivational interview techniques, accompanies a nurse or social worker on a 30-minute introductory home visit. Patients who choose to proceed sign a contract agreeing to work on their health goals with their coach over a sevenweek cycle.

Administrators of Healthy Living Connections, the programming umbrella for TMC Senior Services, recorded more than 150 educational classes and community outreach events in 2012. The program continues to offer adults access to key community health and wellness resources.

The coaching is not designed to replace, but rather augment, regular physician care. Some patients may be more honest with a peer about their adherence to a treatment regimen or challenges they might experience in making behavioral changes, said LDon Sawyer, director of Senior Services at Tucson Medical Center. These discussions might be a little less threatening with a peer who is there just to support them, she said. Plus, they are not under the same kind of time constraints in the hustle and bustle of a doctors office. Since Tucson Medical Center is a founding participant in an Accountable Care Organization called Arizona Connected Care, Sawyer noted the program fits with the vision of reducing hospital readmissions and more costly health interventions through a more robust focus on managing chronic disease. The job description for the coaches doesnt include counseling or help with financial management, grocery shopping, or finance management. Rather, they serve as a motivational support system to make sure their partners take responsibility for making a positive change.
26

What we want to do is get people thinking of their strengths, Sawyer said. We will acknowledge weakness, but we dont play to it, because everyone can do something, and it is the job of our volunteers to find out what their partners can dowhat small steps they can take for successand help them build confidence and self-efficacy. That personal connection is what makes the assignment so rewarding, said Mary Ellen Beaurain, a retired social worker who said she was drawn to volunteer with the coaching program because of the one-on-one interaction. To have someone tell you that they had some scary things happen and now they want to make the changes they need to make to have a second chance, I just find it so gratifying, Beaurain said. This kind of soul-searching and this kind of change can be very hard work, and no one should have to do it alone. An added benefit: The program has prompted Beaurain to revisit her own health priorities. Sawyer said she hopes another round of volunteers can be trained by the end of the year, once care teams have a chance to analyze the effectiveness of the pilot-program. n
SOMBRERO June/July 2013

Leveling the healthcare playing eld

TMC and Canyon Ranch Institute partner to bring wellness to the community
atients in under-served communities are not likely to use certain phrases with their physicians: Would you mind repeating that diagnosis? I didnt understand. Would you review the instructions with me? Are there any lifestyle changes I should make to ease my symptoms? The physicians office can be intimidating to anyone, but for patients who lack access to care because of age, geography, or socioeconomic barriers, a doctors office can be especially difficult to navigate. Patients facing the greatest economic challenges are also most likely to have low health literacy, which is strongly linked to shorter lifespan, poorer total health, and the need for more costly interventions.

A program offered through a new partnership between Tucson Medical Center and Canyon Ranch Institute (CRI) aims to level this playing field. CRI, a non-profit charity established in 2002 by Canyon Ranchs founders to bring wellness into community settings, is teaming up with TMC to offer the 12-week CRI Life Enhancement Program designed to help participants take better control of their health.

Julie Ward, TMC chest pain coordinator, gives a presentation about the Life Enhancement Program, a new community offering that highlights an integrative approach to health and health literacy.

you should do with your diet. Now go forth and get better. Thats not working. Small things may be big barriers, she suggested. For example, many people dont know how to cook without using oil, while others are confused about how to shop healthfully at the grocery store. The program helps patients through interactive sessions, individual consultations, and hands-on activities. A presentation about portion sizes, therefore, might be followed by a cooking demonstration. A presentation about the importance of movement might be followed with a hands-on session about how to use fitness equipment. Atkinson said the CRI Life Enhancement Program dovetails with the mission of TMC and Arizona Connected Care, which aims to keep people healthy while controlling healthcare costs. Beyond that, she said, the partnership with CRI was appealing because of data showing that the CRI Life Enhancement Program works. CRI partners have been offering the program around the nation since 2007, and TMC will be Tucsons second local site. CRI started partnering with El Rio Community Health Center in 2010. The changes are statistically and clinically significant. Nationally and locally, CRI Life Enhancement Program participants have lost
27

The participants, mostly adults 50 and older in the first group that started in April, receive intensive training with an integrative team of TMC health professionals. Based on the Life Enhancement Program pioneered at Canyon Ranch, participants first have a health assessment, including blood work, a behavioral health review, and a range of tests to measure strength, flexibility, and cardio fitness. The TMC team includes nurses with a passion for prevention, physical therapists, dietitians, a pharmacist, a spirituality professional, and behavioral health specialists. The team takes an evidence-based approach to help participants form an individually effective health improvement plan. We want to empower them so they can take ownership of their health and start to reduce at least the symptoms of their chronic conditions, said TMC Director of Wellness Mary Atkinson. In healthcare, Atkinson said, a lot of times youll hear us say, Your glucose is too high. Heres your prescription. Heres what
SOMBRERO June/July 2013

weight, adopted exercise behaviors, reduced depression, lowered their blood pressure, increased their ability to manage stress, and been empowered to make healthier food choices, among other changes. Jennifer Cabe, CRI executive director and a board member, said that although CRI is approached on a daily basis by organizations seeking to partner in its successful programming, TMC met a stringent selection process for new partners. Its a natural fit, she said. TMC is really walking the talk of community benefit, Cabe said. That commitment is illustrated not only in their systemic and culturally sensitive approach to wellness, prevention, and health literacy, but through their strong desire to move to evidencebased wellness approaches. The goal is not just to help people have a greater depth of understanding, but to inspire them to move beyond understanding to action that will improve their lives for generations to come. TMC will also work with CRI to pilot a new CRI Life Enhancement Program for families, teaming at least one adult and one child from a family. If we can get to them earlier with good information that can drive good habits, Atkinson said, we may be able to prevent disease instead of just reducing the symptoms. Atkinson said she hopes physicians, by calling 324-5227, will refer patients who could benefit from improvements in nutrition, exercise, stress management, and mindfulness. Beyond that, she said she hopes physicians may have more conversations with patients about whats preventing them from following their medication regimen or maintaining an appropriate weight. If there are gaps that theyre seeing, perhaps we as a community hospital can help them fill those gaps, whether it turns out we have to give grocery store tours or host talks about exercise, she said. The bottom line is that we hope to empower people to stay well, not just to keep them out of the hospital and using services appropriately, but out of a genuine concern for making their lives the best they can be. n

Honor

In hospice, I learn to be open to the teaching of each moment and each person. These lessons are offered selflessly, and I am humbled and honored to be able to provide hospice care.
Sandy Tiano, MSW, Kanmar Place Manager

Casa de la Luz Hospice provides superior care at end of life to patients and their loved ones. Call us today for more information.

...because every day counts.

(520) 544-9890 I www.casahospice.com I Find us on Facebook and Twitter

Hospice services paid for by Medicare.

28 SOMBRERO June/July 2013

Pima County Medical Society EOB

(Explanation of Benefits)
By Charles Katzenberg, M.D. PCMS President

rganized medicine is something of an oxymoron. We physicians have abdicated many of our leadership roles in our healthcare system. Whether employed or independent, we have been, and will be assaulted with multiple challenges to our autonomy and our freedom to practice in an environment increasingly controlled by hospitals, insurance companies, administrators, lawyers, and regulators. Pima County Medical Society and the Arizona Medical Association exist to support and give voice to physicians, whether they are employees or in private practice. PCMS is your local physicians lobbyist, and functions with ArMA statewide, working for appropriate legislation. Of what benefit is this to you? Why continue to be a PCMS supporter? Why join? Some even ask, What have they done for me lately?without realizing that they are you. PCMS activities, accomplishments, and initiatives fall into several categories: Tort reform advocacy No entities have pushed harder for tort reform than PCMS and ArMA. Results include: 1.To qualify as an expert witness, the expert must have been in practice in the same field as the defendant within the past year. 2. All malpractice cases require an Affidavit of Merit from an expert with the above qualifications. 3. I am sorry. When things go south we often tell patients that we are sorry. This was previously used in court as admission of guiltbut no longer. 4. Burden of proof has been raised from preponderance of proof (50 percent) to clear and convincing (75 percent). 5. Results of the above efforts include 27 percent fewer malpractice claims during the past 10 years, an average 18 percent decrease in malpractice insurance premiums, and most of us have received premium rebates or dividends: real money in the bank.
SOMBRERO June/July 2013

Advocacy also includes supporting referenda in 1996 and 2000 to provide AHCCCS coverage up to 100 percent of the Federal Poverty Level, including childless adults. We are currently supporting Gov. Jan Brewers plan to expand AHCCCS. Advocacy means supporting efforts to get funding to support The University of Arizona Medical Centers Level 1 Trauma program, improving funding for childhood vaccinations, and increasing graduate medical education funding that helped establish the UofA medical school in Phoenix. PCMS supports local physicians 1. PCMS fields at least one call daily from a physician with a question related to his/her practice or regulatory issues. 2. PCMS handles about 2,000 requests annually from the public for physician referrals. 3. PCMS maintains a speakers bureau for community events. 4. PCMS is here to counsel physicians regarding Arizona Medical Board complaints. 5. PCMS in the coming months will launch a member physician search website available to physicians and the public. 6. Sunrise Process: PCMS and ArMA lobbied the Arizona Legislature to require submission of applications to the Joint Legislative Audit Committee for anyone who wants to expand their scope of practice. This process has resulted in denials to chiropractors who want to inject medications, and psychologists who want to prescribe medication. Politics, regulation, and policy PCMS maintains relationships with local, state, and federal legislators representing Pima County. PCMS is often a behind-the-scenes resource for the legislature and the Arizona Medical Board where new ideas and proposals are floated out for review before they are written into laws or statutes. PCMS initiatives have resulted in physician-supportive changes at AMB.
29

Community 1. PCMS, along with local hospitals and UPH, started the Pima Community Access Program (PCAP), to offer insurance to those in the notch group with incomes above the FPL, but too low to be able to afford private health insurance. 2. In 2000, PCMS worked with ArMA to pass the Managed Care Accountability Act. This comprehensive set of reforms deals with pre-authorization, denials, billing, advertising, payments, and contracting. This act made insurers more accountable and responsive to both patients and physicians. 3. PCMS recently started a Walk With a Doc/Just Walk program in which volunteer physicians lead a Saturday morning exercise walk along the Rillito with any interested and able Tucsonans. 4. PCMS has a yearly social event and fund-raiser, which in 2013 raised money for Mobile Meals. 5. PCMS monitors media and is ready to respond when needed and/or asked. 6. PCMS networks with many local groups including Pima Council on Aging, Health Information Exchange of Arizona, and the Arizona Business Coalition on Healthcare. The PCMS Board of Directors meets monthly and we have standing committees on Public Health, Bioethics, and History. PCMS formed Pima County Medical Foundation in 1990. The Foundation offers CME-related physician education programs. All physicians in Pima County should belong to PCMS. If you have read this far, you, as a member, must know several physicians who would join if asked. When you identify a potential member, please call our interim executive director, Bill Fearneyhough, at 795.7985 and give him the physicians name, cell phone number, and a time and day most convenient to talk about membership. Bill will do the rest. At the bottom line your dues are equivalent to just a couple of nights out in support of the only game in town committed to 1) supporting physicians, 2) supporting patient-focused practice of medicine, and 3) supporting the general health of the Tucson community. To learn more or to become more involved, please call or e-mail Bill or me. Bills phone is 795.7985; his e-mail is billf5199@gmail. com. You may reach me at 390.4750 or e-mail ckatzenberg123@ gmail.com. Pima County Medical Society Mission Statement The purpose of the Society shall be to secure unity and harmony in the medical profession in Pima County; to bring together in one organization all reputable, ethical and competent physicians of Pima County for the purpose of maintaining high standards in the medical profession in Pima County, and for the purpose of promoting the respected high reputation to which the medical professions history and achievement entitle it, and to promote the science and art of medicine; to develop a high type of ethical practice among its members; and to conserve and promote the public health.

Question: When was the Pima County Medical Society

founded? 1894 1904 1914 1924

Historical highlights include: 1909 - Calling for a state lab so disease outbreaks could positively identified 1919 - Working for better quarantine laws as they battled the influenza outbreak 1929 - Helping to establish the nations first city/county health department Agreeing to staff and run - at no charge - Pima County Hospital from 1939-1961 1963 - Buying vaccine and giving it to kids, making Tucson the first polio-free metro area in the United States 1975 - Creating the first HMO and attempting to end the notch group 1983 - Treating striking miners and their families for free n

30

SOMBRERO June/July 2013

Answer:

Since 1904 Pima County Medical Society has been a gathering place for physicians to address concerns.

SOMBRERO June/July 2013

Y EA R S
O F CA R E

31

MICA_Sombrero07'13ad_MICA_Sombrero05'04ad 6/7/13 4:07 PM Page 1

MICAs Board of Trustees Congratulates James F. Carland III, M.D., Recipient of the Physician Insurers Association of America 2013 Peter Sweetland Award of Excellence
At the 2013 Physician Insurers Association of America (PIAA) Annual Meeting, Dr. Carland received the Peter Sweetland Award of Excellence, recognizing his significant contributions and dedication to the medical professional liability (MPL) insurance industry and the PIAA.

Brian K. Atchinson, president and CEO of the PIAA, stated, The Peter Sweetland Award of Excellence was created to recognize an individual from our ranks who has provided great leadership and has served as an inspiration to others in the industry. Jim truly embodies the spirit of this award, and we thank him for his hard work and years of service.

(602) 956-5276 (800) 352-0402 www.mica-insurance.com

32

SOMBRERO June/July 2013