VOL. 106, NO. 5 | MAY 2013 I s o l a t H e e d a

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F + Volume 106, Number 5 May 2013 Editorials 7 Guest Editorial—Perverse Incentives—Andy Walker, MD, FAAEM CONTENTS 9 Commentary—Saving Ourselves—Steven M. Hegedus, MD, FACP Ask TMA 11 Professional Privilege Tax; HIPAA Updates Member News 13 MedTenn 2013 Wrap; HOD Vote Statement; ICD-10 Roadshow; Alert: Medical Orders; Insurance Chairman Dr. Thompson; Professional Privilege Tax; Rx Database Query; 2013 Physician Leadership College Graduates; Member Notes; IMPACT Capitol Hill Club Special Features 29 Make Corporate Compliance Your Focus in May —Angie Madden, CHC, CAPM 31 Doctors, Lawyers, and Disability Benefit Claims —Peter T. Skeie, JD, LLM 34 TPQVO: Keeping Up with Change—Eugene H. Ryan, MD The Journal 37 Original Contribution—Isolated Pyocele of Anterior Clinoid Process Presenting as a Cavernous Sinus Syndrome—Thomas J. O’Donnell, MD; L. Madison Michael, II, MD; Robert Laster, MD; 23 James C. Fleming, MD Cover Story 39 Original Contribution—Heart Failure Presenting as Myxedema Coma: Case Report and Review Article—Dhara Chaudhari, MD; “Choosing Wisely”—Medicine’s Ethical Responsibility for Venkat Gangadharan, MD; Terry Forrest, MD Healthcare Reform: The Top Five List—Stewart Edwards 41 Original Contribution—Treatment of Cerebral Malaria and Acute Dismuke, MD, MSPH, FACP, FACPM; Stephen T. Miller, MD, MACP Respiratory Distress Syndrome (ARDS) with Parenteral Arte - sunate—Harshida Chaudhari, MBBS; Jay B Mehta, MD, FCCP; Ketan Chaudhari, MD; Jeff Farrow, MD, FCCP

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The New President For the Record Dr. Chris Young—Moving the TMA Forward Through Change 44 TMA Alliance Report—Alliance Year in Review—Beth Kasper —Brenda Williams 45 New Members; In Memoriam 46 Advertisers in This Issue; Instructions for Authors; WWW.TNMED.ORG COA Instructions; Correction Tennessee Medicine communications submitted to Tennessee Medicine Copyright 2013, Tennessee Medical Association. All Journal of the Tennessee Medical Association for publication. The author or communicant shall be material subject to this copyright appearing in (ISSN 1088-6222) held entirely responsible. Advertisers must conform Tennessee Medicine may be photocopied for noncom - Published monthly under the direction of the Board of to the policies and regulations established by the mercial scientific or educational use only. Trustees for members of the Tennessee Medical Board of Trustees of the Tennessee Medical Periodicals postage paid at Nashville, TN, and at Association, a nonprofit organization with a definite Association. additional mailing offices. membership for scientific and educational purposes, Subscriptions (nonmembers) $30 per year for US, devoted to the interests of the medical profession of $36 for Canada and foreign. Single copy $2.50. POSTMASTER: Send address changes to: Tennessee. Payment of Tennessee Medical Association member - Tennesssee Medicine This Association is not responsible for the authen - ship dues includes the subscription price of PO Box 120909, Nashville, TN 37212-0909 ticity of opinion or statements made by authors or in Tennessee Medicine. In Canada: Station A, PO Box 54, Windsor, Ontario N9A 6J5

President Office of Publication Editor Editorial Board Christopher E. Young, MD 2301 21st Avenue South David G. Gerkin, MD Loren Crown, MD Bradley Smith, MD PO Box 120909 James Ferguson, MD Jonathan Sowell, MD Chief Executive Officer Nashville, TN 37212-0909 Editor Emeritus Robert D. Kirkpatrick, MD Jim Talmage, MD Russ Miller, CAE Phone: (615) 385-2100 John B. Thomison, MD Karl Misulis, MD Andy Walker, MD Fax (615) 312-1908 Managing Editor Greg Phelps, MD [email protected] Brenda Williams Advertising RepresAentative: Michael Hurst – (615) 385-2100 or michael.hurst@D tnmed.org Graphic Design: Aaron & Michelle Grayum / www.thegrayumbrella.com THE NEW PRESIDENT

Dr. Chris Young – Moving the TMA Forward Through Change

By Brenda Williams

hattanooga anesthesiologist Christopher in political activities to the extent we need to be.” C E. Young, MD, has taken the helm of the In 2006 he was elected president of the Ten- Tennessee Medical Association as its nessee Society of Anesthesiologists (TSA) and was 159th president, and says he hopes to help doc- able to help better organize and strengthen that tors navigate what he calls “the biggest change in society. It was Rae Bond, executive director of the health care since Medicare.” Chattanooga-Hamilton County Medical Society, Dr. Young said he wants physicians to realize who encouraged his involvement in the CHCMS they can still make a difference. and subsequently the TMA Board of Trustees, lead- “There’s a lot of opportunity,” he said. “Physi- ing to his run for TMA president in 2011. cians should feel empowered to make changes in As president Dr. Young will serve on the TMA health care. Focusing and working together through Board of Trustees, which is responsible for the the TMA is the best way to effect those changes.” direction and implementation of Association ac- He said the Affordable Care Act is now the law Dr. Young tivities between sessions of the House of Dele- of the land and physicians must accept it. “Doctors gates, the Association’s governing body. He will don’t have to be discouraged; we need to make the best of what we also serve as the public spokesman and official representative for have, and work to improve the law as we move forward. Our patients the TMA’s nearly 8,000 physician members. need us more than ever and our country needs leadership from Board certified in anesthesiology with specialized training in physicians to address the many healthcare challenges in front of us.” cardiovascular anesthesia and pain management, he received board Coming from a family of physicians – his father was a orthope- certification in Pain Management in 1993. Dr. Young is a former as- dic surgeon and his brother is a vascular surgeon – Dr. Young says sistant professor of anesthesiology at the SUNY Health Science Cen- he never really thought about doing anything else. He grew up in ter in Syracuse, NY where he completed his residency. He was Knoxville watching his father practice, noting he was well respected awarded the Robert D. Dripps, MD, Memorial Award for Outstand- and well liked by his patients. “I was proud to be his son.” For two ing Graduate Resident in Anesthesiology in 1989. summers he worked in the operating room after high school – Dr. Young is a founding board member of the Signal Mountain “That’s when I was exposed to the OR for the first time and really based American Haitian Foundation, and is responsible for estab- liked that environment,” he said. lishing the first solar/wind powered school in Haiti. Active in surgi- As an anesthesiologist, Dr. Young says he usually meets patients for cal mission work in Central and South America for two decades, he the first time in the pre-op setting. “They’re frightened because they’re led a surgical team to Haiti immediately following the devastating having surgery. You really only have a few minutes to talk to them but earthquake in January 2010. you need to be able to gain their confidence quickly and reassure them (Continued on page 10) they’re going to be taken care of in the operating room.” After moving to practice in Chattanooga in 1991, Dr. Young became aware of how much government impacted DR. YOUNG – AT A GLANCE the practice of medicine. “I wanted to understand how • Age: 65 • Education: BA, University of Tennessee; MD, Georgetown University regulations and laws were made and then have a part in • Family: Wife Vanessa, daughters Julia and Madeleine, son Eric trying to make it better.” He joined the American Society • Interests: Medical missions with American Haitian Foundation, golf of Anesthesiologists (ASA) and began attending its leg- • Currently reading: The Healing of America by T.R. Reid islative conference in Washington, DC, in 1999. “I came • Most important accomplishment: My family, of course to understand that as a group, physicians are not involved

Tennessee Medicine + www.tnmed.org + MAY 2013 5

GUEST EDITORIAL COMMENTARY

Perverse Incentives

By Andy Walker, MD, FAAEM

ennessee, like every other state in the nation, has a pre - T scription drug abuse problem. No one knows that better than I will follow that system of regimen which, emergency physicians. No one is in a better position to see the systemic flaws and outright failures in American healthcare than EPs. “ according to my ability and judgment, We are the tip of the spear in medicine, the canary in the coal mine, the ... well, you get the idea. I consider for the benefit of my patients, Dealing with drug abusers, and sometimes even helping them, has and abstain from whatever is always been a big part of emergency medicine. I never really minded that and looked at it as the price I paid for the chance to take care of deleterious and mischievous the critically ill and acutely injured. Over the last couple of years my — From the Oath of Hippocrates attitude has changed, however. What’s different? First, the problem seems more severe than ever before. I have worked more than one shift in recent years in which amusing example: “In Hanoi, under French colonial rule, a program every one of the first four patients I saw were, beyond any reasonable paying people a bounty for each rat tail handed in was intended to ex - ” doubt, drug abusers. I could tell easily just from reviewing their med - terminate rats. Instead, it led to the farming of rats.” ical records and ED visit histories on the computer – much less by There was a time when most of us were physicians taking care of consulting Tennessee’s Controlled Substance Monitoring Database patients, rather than businessmen catering to customers, and when (CSMD). Think what that kind of statistical sampling says about the doctors were in charge of medical care rather than being just an - ED’s patient population. Think what it means for the morale and other provider in the healthcare delivery system. Our first and most longevity of emergency physicians. It feels like 20-25 percent of my important goal was to do the right thing for our patients, not make the patients don’t have any acute medical problem at all, and are in the customers happy at all cost. Our motto was primum non nocere : ED only because they are addicted to prescription drugs – usually “First, do no harm.” opioids or benzodiazepines – and want me to give them more. Perverse incentives are eating away at that honorable tradition. I Data confirm my subjective impression. According to an analysis wonder what our motto would be if it were written now, especially by of CDC data by The Los Angeles Times (Sept. 17, 2011), drug deaths emergency physicians and the other hospital-based specialists who now outnumber traffic fatalities in the United States. Most of these are are employed at the pleasure of hospital administrators: “First, don’t from prescription drugs. How did we get to this point? The Times piss off the Joint Commission,” or “First, I must keep my number of says, “The seeds of the problem were planted more than a decade complaints in the bottom quartile”? ago by well-meaning efforts by doctors to mitigate suffering...” To put No matter how gently I explain to addicted patients that I fear it politely, that’s a big, smelly, steaming load of crap. On the contrary, they have developed a substance abuse disorder, or how sympathet - the seeds were probably planted when the Joint Commission made ically I offer referral to an appropriate treatment program, nearly all pain “the fifth vital sign” and saddled us with that ridiculous 1-10 of these patients deny being addicts and leave angry. Almost all pain scale – which brings me to the second and more important thing threaten, “I’ll have your job!” and some threaten my life. It is rare in - that has changed over the last few years: perverse incentives. deed for one to have a sudden epiphany, realize he is an addict and Wikipedia offers this definition: “A perverse incentive is an in - gratefully accept treatment for his real problem. This is a universal ex - centive that has an unintended and undesirable result which is con - perience for emergency physicians and we can shrug it off when we trary to the interests of the incentive makers. Perverse incentives are have a wise and supportive hospital administrator (God bless ‘em!). a type of unintended consequence.” It also provides this graphic and However, when we have a hospital administrator who gives complaints

Tennessee Medicine + www.tnmed.org + MAY 2013 7 GUEST EDITORIAL from drug abusers as much weight as those from the rare patient who ment bureaucrats, insurance companies, hospital administrators and caught the ED on a bad day and really should have been treated dif - maybe even tort lawyers have their place and their appropriate jobs ferently, it takes a heavy toll. Eventually we feel tremendous pressure to do. Making clinical decisions for physicians and their patients is not to make the customer happy rather than adhere to our professional one of those appropriate jobs. Neither is putting pressure on physi - ethics. I have seen colleagues, excellent physicians whom I respect, cians to harm the patient for the sake of making the customer happy. become exhausted by the constant threat of losing their jobs and give This hurts patients, damages the medical profession, and burns out in. On rare and particularly bad days when I couldn’t bear the thought physicians. of another email from my department chairman about the hospital ad - As Tennessee Medicine Editor Dr. David Gerkin said in his edi - ministrator’s “concern,” even I have thought, “I should just give him torial in the March issue, “...many doctors are retiring early or leav - a few Lortab and get him out of the ED.” And before someone casts ing the direct patient-care setting to avoid the stress of trying to the first stone, how many of you can say you never prescribe antibi - maintain quality in an environment of increasing mandates and reg - otics for colds, acute bronchitis and acute sinusitis – even though the ulations, which are creating barriers to the care they were trained to evidence is conclusive that antibiotics are all risk and no benefit for provide.” If addiction is a disease, then giving an addict more drugs these diseases, and such misuse of antibiotics has serious public prolongs the disease and actively harms the patient, in violation of health consequences? Making the customer happy, aren’t you? our oath. If the prescription drug problem is to be solved, physicians Think how much worse the pressure will be when most physi - must be free to do the right thing without penalty or outside pressure cians are employees or have been gathered up into accountable care – and often that means making the patient very, very unhappy. + organizations, and can be fired or have a performance bonus with - held by a nonphysician boss who sees patients only as customers and Dr. Walker is on the board of directors of the American Academy has none of the ethical obligations of a physician. As Lisa Rosenbaum of Emergency Medicine, is editor of the AAEM newsletter “Com - said in her recent editorial in the New England Journal of Medicine mon Sense,” and is vice-president of its Tennessee chapter. He is (“The Whole Ball Game – Overcoming the Blind Spots in Health Care also a member of the Tennessee Medicine Editorial Board. The TMA welcomes but is not responsible for opinions ex - Reform,” March 7, 2013): “We must admit that turning health care pressed in this forum. into a customer-service industry may to some extent undermine the delivery of evidence-based care.” It would have been more accurate to say quality care than evidence-based care. The medical profession does bear some responsibility for the prescription drug problem and this has been addressed in our state. Tennessee now has strict laws regulating chronic pain clinics, mak - ing it harder for that tiny fraction of physicians who are really just li - censed pushers to carry on. The CSMD makes it impossible for patients to hide their addiction to prescription drugs from us – un - less they are going to other states to fill their prescriptions. Querying the database is now required before most prescriptions for opioids or benzodiazepines. Laws against doctor-shopping have also been toughened. All these measures had TMA support. In cooperation with several state agencies, the Tennessee Pharmacy Association (TPA) and others, the TMA also created the Tennessee Prescription Safety Program. Among other activities, it identifies and re-educates those overprescribers who are being duped by their addicted patients. Also in partnership with the TPA, the TMA has applied to the Blue Cross Blue Shield of Tennessee Health Foundation for a grant to fund a pre - scription drug safety program. This will include a public awareness campaign and professional education, among other things. The measures above are important and should help over time, but the perverse incentives physicians are subjected to must be addressed. For patients to receive the best medical care possible, they must be patients first and customers second. Physicians must be in charge of medical care, free to exercise their best professional judgment on behalf of patients without being coerced by nonphysicians. Govern -

8 Tennessee Medicine + www.tnmed.org + MAY 2013 EDITORIALS COMMENTARY

Saving Ourselves

By Steven M. Hegedus, MD, FACP

ncreasingly, patients face the challenge of chronic disease which contributes to nearly seventy percent of American deaths each Ultimately, we can focus on our I 1 year. Such epidemics as obesity, diabetes and heart disease re - “ differences or hold on to our identity, sult in growing morbidity and mortality in addition to unsustainable costs worldwide. An estimated $30 trillion, roughly 48 percent of unwilling to lose ourselves. the global gross domestic product, will shift to the treatment of non- communicable diseases over the next 20 years. 2,3 Enter the evolving internist, uniquely suited to address such costly and complex med - Whether practicing in a clinic-based setting or focused in the hos - ical needs. pital, internists have always shared a common identity. As first de - 9 ” Internists see the evolution of medicine at ground level. As prac - picted by Osler’s consultant generalist and more recently defined by tice environments grow more complex, we find ourselves sometimes the American College of Physicians, 10 we focus on the prevention driving reform, sometimes along for the ride. 4 The profession of in - and treatment of all diseases which impact adults. We are equipped ternal medicine is changing, hospital rounds are diverging further to deal with any problem a patient brings and we are specially from the clinic, and our identity as internists is evolving as we ap - trained to solve complex diagnostic dilemmas. We promise to care proach a crossroads. for the whole patient throughout every stage of life, and our adher - Experts in the care of patients through their adult lives, general in - ence to this promise will define us. ternists remain in great demand. In the clinic, we nurture relation - As practice patterns diverge, consider the consequences of di - ships with our patients over a lifetime. With medical knowledge, verging identities. In the clinic, internists will focus on prevention, communication skills, patience and compassion, internists aim to alter building models of more effective primary care. Outpatient internists the devastating course of chronic disease. In the hospital, patients with will become less comfortable managing urgent situations, less fa - complex, severe acute illness crowd emergency departments 24 hours miliar with the acute sequelae of chronic disease, and more distant a day and from admission to discharge, hospitalists conduct their care. at the end of life. Likewise by surrendering chronic care to others, As outpatient physicians shift the course of chronic illness, hospitalists hospitalists will become fighters of disease rather than promotors of manage the associated acute complications. health, and we will be valued differently. Instead of expert clinicians, With growing needs in both clinic and hospital, internists are hospitalists become maximizers of efficiency, focusing on brisk pa - choosing sides. Recent graduates, in particular, are selecting hospi - tient throughput and deferring medical decisions to specialists who tal medicine, inflating the number of hospitalists from 1,000 to will follow patients over time. With the emergence of hospitalists, it 30,000 over the past 15 years. 5 Many factors have shifted internists is clear that practice environments are changing. However if we lose to hospital medicine. From classroom instruction through clinical our identity as internists and if we fail to keep our promise to our pa - training, exposure to hospital and specialty medicine has tradition - tients, then our profession will suffer immeasurably. ally overshadowed primary care. Students and residents also view After all, our breadth of experience remains one of our greatest contrasting realities as they plan their future. Outpatient physicians strengths. In the hospital, internists guide patients and families devastated must change patients’ behavior while spending less time at the bed - by illness as we also tend to the unanticipated consequences of medical side. In contrast, acute interventions of the hospitalist align more care. We observe families strengthened in times of struggle as others are easily with patients’ immediate goals. As administrative demands torn apart. We witness firsthand the value of pushing forward, and the grow, employed hospitalists yield control in exchange for simplicity. relief of letting go. In the outpatient setting, these hospital experiences Compensation is greater in the hospital and, in many systems, physi - prove essential as partner with our patients over a lifetime. Conversely, cians can spend more time at home with their families. Reform ef - in clinic we learn to communicate clearly, to accept uncertainty, and to forts such as the Patient Centered Medical Home may ultimately assume the responsibility of our patients’ care. Such vital skills, devel - strengthen the foundation of primary care but for now add to grow - oped in clinic, provide a necessary foundation for care on the wards. ing complexity and uncertainty. 6-8 Thus while internists hope to fill And so even as our practice patterns diverge, another option re - an urgent need for primary care, the body of hospitalists continues mains. We can preserve our common identity, reinforcing our ded - to grow. As internists, we will shape medicine; first we must re-ex - ication to patients through all stages of their lives. We know that to amine ourselves. keep our patients well, we must treat them at their sickest; to meet

Tennessee Medicine + www.tnmed.org + MAY 2013 9 EDITORIALS

their urgent needs, we must understand their chronic struggles; and medicine: the opportunities and challenges. Ann Intern Med 153(8):536-9, Oct 19, 2010. to help our patients live, we must sit with them as they die. As we 5. Wachter R, Goldman L: The emerging role of “hospitalists” in the American health shape curricula, legislation and self-evaluation, we can ensure that care system. N Engl J Med 335(7): 514-7, 1996. all internists remain equipped to promote health and treat illness 6. Bitton A, Martin C, Landon BE: A nationwide survey of patient centered medical home throughout our patients’ lives. For without our breadth and depth of demonstration projects. J Gen Intern Med 25(6):584-92, Jun 2010. understanding, we risk losing vital perspective. In clinic and on the 7. Alexander JA, Cohen GR, Wise CG, Green LA: The Policy Context of Patient Centered wards, our shared experience and dedication to our patients unite Medical Homes: Perspectives of Primary Care Providers. J Gen Intern Med us as internists, and we recognize that we stand stronger together 28(1):147-53, Jan 2013. DOI: 10.1007/s11606-012-2135-0; Epub Jul 13, 2012. than we can apart. Ultimately, we can focus on our differences or 8. Rittenhouse DR, Shortell SM: The Patient-Centered Medical Home - Will It Stand the hold on to our identity, unwilling to lose ourselves. + Test of Health Reform? JAMA 301(19):2038-2040, 2009. 9. Huddle TS, Centor R, Heudebert GR: American Internal Medicine in the 21st Century, References: Can an Oslerian Generalism Survive? J Gen Intern Med 18(9):764-7, Sep 2003. 1. U.S. Centers for Disease Control and Prevention: Chronic Diseases and Health Promo - 10. American College of Physicians: About Internal Medicine. Available at tion, Aug 13, 2012. Available at http://www.cdc.gov/chronicdisease/overview/ http://www.acponline.org/patients_families/about_internal_medicine/ . Ac - index.htm . Accessed Sep 2, 2012. cessed Feb 8, 2013. 2. Bloom DE, Cafiero ET, Jané-Llopis E, et al.: The Global Economic Burden of Noncom - municable Diseases. Geneva: Wrld Econ Frm 2011. Dr. Hegedus is an internist with Baptist Medical Group Hospi - 3. Gabow P, Halvorson G, Kaplan G: Marshaling leadership for high-value health care: an talists of Memphis. Contact him at [email protected]. Institute of Medicine discussion paper. JAMA 308(3):239-40, Jul 18, 2012. Tennessee Medicine welcomes but is not responsible for 4. Kocher R, Emanuel EJ, DeParle NA: The Affordable Care Act and the future of clinical views expressed in this forum.

THE NEW PRESIDENT

DR. CHRIS YOUNG — MOVING THE TMA FORWARD THROUGH CHANGE (Continued from page 5) Practicing at Erlanger Medical Center with Anesthesiology Consult - lower healthcare costs, improve quality, and increase access to qual - ants Exchange in Chattanooga, Dr. Young graduated Webb School in ity healthcare for all our citizens,” he said. “Tennessee is a great Knoxville and from the University of Tennessee-Knoxville with hon - place to practice medicine and working together, we can make it ors. He received his medical degree from Georgetown University even better.” + School of Medicine in Washington, DC. “I believe we, as physicians, have an obligation to do our part to Share your thoughts with Dr. Young at [email protected].

Flanked by his predecessors, Dr. Young gives his presidential address during inauguration ceremonies during the TMA annual meeting in April.

10 Tennessee Medicine + www.tnmed.org + MAY 2013 Ask TMA A FORUM FOR QUESTIONS, ANSWERS AND COMMENTS

PROFESSIONAL PRIVILEGE TAX; HIPAA UPDATES

Q: I found a notice for my professional privilege tax from 2012 Q: My practice administrator was telling me we have to update the other day and seem to remember there was a notice from TMA our HIPAA Notice of Privacy Practices and other HIPAA documents. about changes to the tax, but I can’t remember what it said. Are What do we need to do? Will the TMA provide any assistance? there some changes for 2013? A: Yes, the TMA Legal Department is currently working on a com - A: Yes. The Tennessee Department of Revenue will not be mailing prehensive summary of the final rule that was promulgated at the professions any notice of their $400 Professional Privilege Tax as - end of January. Legal staff has reviewed the 500-page rule and cre - sessment due on June 1, 2013. Noncompliance can result in mon - ated checklists, written articles and updated Law Guide topics to etary penalties. assist members in understanding what must be done by the com - All professional privilege tax returns filed on or after January 1, pliance date. The HIPAA updates are announced through the TMA 2013, must be filed electronically. Professional privilege tax returns Weekly and through Twitter ( @tnmed ). The Rules were effective on can be filed electronically either by individuals, or by companies March 26, 2013, and covered entities must be in compliance with who file and pay for multiple individuals. For a step-by-step guide them by September 23, 2013. to electronically file an individual professional privilege tax return, There is a grandfather-type provision for the business associate please visit https://apps.tn.gov/privtx/ . If you have a company fil - section of the rule. A Covered Entity (CE) and a Business Associate ing and paying your professional privilege tax, advise them to visit (BA) with a written BA agreement in effect prior to January 25, https://apps.tn.gov/privbatch/ . 2013, that is compliant with the old HIPAA BA requirements and is These new electronic filing requirements will permit the Tax - not renewed or modified from March 26 to September 23, 2013, payer Services Division to process your return and payment more may continue to operate under that agreement until the earlier of: timely and efficiently at a cost savings to the State. Should you have additional questions, contact the state’s Electronic Commerce Unit • The date the contract is renewed or modified after Septem - at 866-368-6374 for in-state calls or 615-253-0704 for local or ber 23, 2013; or out-of-state calls. • September 24, 2014.

TMA MEMBERS CAN “ASK TMA...” If you have any questions, please contact the TMA Legal Department at [email protected] or 800-659-1862. Law Guide topics are up - E-mail: [email protected] dated frequently and members may access the directory of topics at www.tnmed.org/lawguide (member login required). Phone: 800-659-1-TMA + Fax: 615-312-1907 + Mail: P.O. Box 120909 + Nashville, TN 37212-0909 ______Questions and comments will be answered personally and may appear in reprint for the benefit of our members.

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Expanding Access to Care, Mental Health, Rx Drugs Top Issues at MedTenn 2013 Physicians from across the trial program using Medicaid state gathered in Franklin, expansion funds to cover TN, April 5-7 and considered uninsured residents through a number of health policy po - health exchange purchased sitions for the Tennessee plans, similar to Gov. Medical Association, includ - Haslam’s proposal, or direct ing support for expanding ac - expansion. cess to healthcare coverage, “As physicians, our pa - more funding of mental tients must come first – in - health screenings and treat - creased access leads to ment, transparency of patient better health outcomes. Our charges for prescription policy is to support efforts to drugs and hospital services, make affordable healthcare maternal mortality review TMA delegates stand for a headcount vote on a resolution supporting more accessible, which is and amending restrictive expanded access to care in the Sunday session of the House of Delegates. part of the TMA’s core mis - guidelines for care provided by sion,” said Christopher physicians in training. Young, MD, of Chattanooga, who was installed as the TMA’s 159 th pres - Following passionate debate, a resolution supporting expanded ident during the meeting. access to care for all Tennesseans was approved by a majority of del - egates. The resolution supports expanded access under a three-year (Continued on page 20)

TMA Delegates Vote to Support Expanded Access to Care A statement from TMA President Dr. Chris Young

The TMA supports access to affordable, quality health care and believes We encourage the State to accept the offer from the federal gov - that our state should take advantage of funding available to expand in - ernment to pay 100 percent of the cost for increased enrollment in surance coverage for our citizens. Our House of Delegates convened TennCare as part of the Affordable Care Act for a three-year trial pe - on April 7 and after lengthy debate and passionate testimony, there riod. Whether the funding is used to subsidize the purchase of per - was a majority vote to change our position from neutral to supportive sonal policies in the commercial market or to expand the current of expanding access to care for the uninsured using federal funds. TennCare program is a choice for the Governor. There was much concern expressed about what may happen in We request that the benefits offered to patients in any expanded three years when the state has to come up with shared funds. There program be at least equal to current TennCare benefits. And we is worry that the federal government will not be able to hold up its pledge to make your Association available to the Governor and the financial promise to the state. We don’t know what will happen in General Assembly to advocate for healthcare coverage in Tennessee. three years with the program, but we do know what happens to our As physicians, our patients must come first. Our new policy sup - patients without access to care or insurance coverage: their health ports making affordable healthcare more accessible, which is part suffers and life expectancy is shorter. of the TMA’s core mission. We cannot miss this chance to shape the At the end of all the debate, the lingering fact that patients with future of health care in Tennessee. insurance have greater access to care, ultimately allowing them to Thank you for your continued support of the TMA as we repre - live longer, healthier lives, seemed to resonate with the delegates sent you in the fight for a better medicine and a better practice en - assembled. vironment. +

Tennessee Medicine + www.tnmed.org + MAY 2013 13 Member News

Catch the ICD-10 Roadshow! Member Alert: Use Caution When Signing Medical Orders Physicians who sign medical orders written by someone else could face penalties or open themselves up to possible fraud and abuse liability. That word of caution from TMA Legal officials who say one member has contacted them about a business practice by one home healthcare system in Tennessee that raises this concern. WWW.TNMED.ORG/ICD-10/ROADSHOW Physicians who sign CMS-485 Plans of Treatment for patients are responsible for Physicians and practice staff can earn up to 4 CEU credits* for attending the TMA ICD-10 those orders even if they did not write them Roadshow, appearing at locations across Tennessee throughout May. or read them. Physicians who sign an order Sponsored by BlueCross Blue Shield of Tennessee and Emdeon, the program features saying they have had face-to-face encoun - THIMA experts talking about coding and documentation compliance issues; BCBST, United ters with patients when they have not could Healthcare and Emdeon discussing testing timelines, dual processing procedures and how face penalties or false claims liability if to minimize payment delays now that they all have had time to develop their approach; and claims for unwarranted services are filed national expert, author and contributor to Talk Ten Tuesdays Denny Flint helping practices with a government payer, such as Medicare with a workable approach for implementation. or TennCare. DETAILS BACKGROUND Locations: A Tennessee primary care practice reports May 7 – Memphis, Longinotti Auditorium, Saint Francis Memphis multiple incidents of a home care entity fax - May 8 – Nashville, Owen Continuing Education Center, Baptist Hospital ing orders to the physician for his patients May 21 – Kingsport, Meadowview Marriott to receive home care upon discharge from May 22 – Knoxville, Knoxville Marriott (1st session SOLD OUT; 2nd session has been added) the hospital. In the instances reported, both May 23 – Chattanooga, BCBST Headquarters the hospital and the home healthcare busi - ness are owned by the same entity. The pri - Topics: Who should attend? mary care physician was not the physician • Roles & Responsibilities of Physicians & Staff • Physicians & Other Providers who ordered home care for the patient upon • How to Develop an Education & Transition • Practice Managers & Administrators discharge, was not aware of the patient’s Plan • Coding & Billing Specialists hospitalization, and could not make a clini - • Understanding Documentation & Compli - • IT Consultants cal judgment regarding the clinical need for ance Mandates • Clearinghouse & Revenue Cycle Managers home care because he had not seen the pa - • Choosing Implementation Tools • Hospital Ambulatory Personnel tient face-to-face recently. The physician re - • Payor Readiness fused to sign the 485 Plan, citing the fact he did not issue those orders, and then con - The half-day workshop costs $79 per person; register today at www.tnmed.org/icd- tacted the TMA. 10/roadshow . For more information, contact TMA Practice Solutions at 800-659-1862. + The TMA works to keep members ap - prised of legal and regulatory issues affecting *This program meets AAPC guidelines for 4.0 Core B continuing education credits. the practice of medicine and patient care. For legal assistance, contact the TMA Legal De - partment at 800-659-1862. +

14 Tennessee Medicine + www.tnmed.org + MAY 2013 Member News

MEET Membership Committee Chairman Dr. Jerome “Jerry” Thompson

PERSONAL COMMITTEE Official Title/Position: Chair of ENT at the University of Tennessee- Years as Chair: Three years as Insurance Committee chair, one as Memphis and chief of Surgery at Methodist Lebonheur Healthcare Membership chair Company/Years: University of Tennessee/University Methodist Why Agreed to Step into Leadership Role: (President-elect) Dr. Doug Lebonheur Pediatric Specialists, 20 years Springer asked me to be the chair of membership and I believe Practice Interests/Specialties: Pediatric airways, healthcare eco - major changes are going to happen in the structure of TMA mem - nomics bership in the coming years Most Important Accomplishment: Past associate dean of UT Mem - Goals/Philosophy as Chair: Our goal is to expand membership to phis, founding member and past president of the American Society represent more physicians in Tennessee of Pediatric Otolaryngology (ASPO) Most Important Accomplishments of Your Committee: Kept mem - Family: Married for 24 years, I have seven children, and my two mid - bership up for this year dle daughters just got into UT medical school Importance of the TMA: Fully employed physicians are going to be Something Not Widely Known About You: I love to hunt anything, a major force in future medicine in this country and I want the TMA and have a grizzly in my office that I shot to be one of the first to take advantage of this sea-change moment Currently Reading: Theodore Rex about Teddy Roosevelt +

Interested in serving on a TMA Committee? Visit http://tnmed.org/TMA_committees/ or email [email protected]. Professional Privi - Rx Database Query Only Re - lege Tax: No Notice quired on Opioids and Benzos The Board of Pharmacy/Controlled Substance Monitoring Database (CSMD) Given But Penalties has confirmed that the TMA and the Tennessee Chapter of the American Acad - emy of Pediatrics (TNAAP) are correct in our interpretations of the new state Will Be Levied prescription safety law – that only prescriptions for opioids and benzodi - The Tennessee Department of Revenue will not be mailing azepines require a query of the database. physicians any notice of their $400 Professional Privilege As part of its mission to be a physician advocate on legal and regulatory Tax due on June 1, 2013. Noncompliance can result in issues and particularly prescribing laws, the TMA continues to work behind monetary penalties. the scenes to seek adjustments and give feedback to state officials on issues All professional privilege tax returns filed on or after that arise with the CSMD. January 1, 2013, must be filed electronically. Professional privilege tax returns can be filed electronically either by LAW REQUIREMENTS individuals, or by companies who file and pay for multi - Physicians are required to begin checking the controlled substance database ef - ple individuals. Read more on those requirements and fective April 1 before prescribing opiates or benzodiazepines, with some exceptions. access a step-by-step guide to filing electronically at The law was effective April 1. At least one physician had been told that pre - www.tnmed.org/electronic-filing-pro-priv-tax. scriptions for schedules II-IV required a CSMD query. While the law language These new electronic filing requirements will permit the states, “…but are not limited to,” officials have confirmed that currently, opioids Taxpayer Services Division to process your return and pay - and benzodiazepines are the only classes of drugs that trigger a CSMD query. ment more timely and efficiently at a cost savings to the State. That will not change without further action, which could take a couple of years. Should you have additional questions, feel free to contact the To learn more about the new law, read the TMA’s online Law Guide topic state’s Electronic Commerce Unit at 866-368-6374 for in-state on the “Controlled Substance Database” at www.tnmed.org/lawguide (mem - calls or 615-253-0704 for local or out-of-state calls. See our ber login required) or call the TMA Legal Department at 800-659-1862. + related "Ask TMA" article on page 11. + Tennessee Medicine + www.tnmed.org + MAY 2013 15 Member News

TMA Congratulates Physician Leadership 2013 College

The Tennessee Medical Association is proud to annGounce the 2013r graduaates of thde TMA Phyusician Leadaership Cotllegee. The s class represents physicians from multiple specialties across the state of Tennessee. The graduates were honored during a ceremony on Saturday, April 6, at MedTenn 2013, the TMA’s 178th annual meeting in Nashville. Over the past year, these physicians have completed coursework in collaboration, decision making, advocacy, media relations and conflict resolution. In addition to learning new leadership skills, each participant has completed a leader - ship project focused on improving patient care and/or organized medicine.

We are proud of the following physicians who completed their training and are now graduates of the TMA PLC:

Ralph Atkinson, MD James Batson, MD Steve Bengelsdorf, MD, FACS Nashville Cookeville Nashville Nephrology Pediatrics General Surgery

Jennifer Dooley, MD Norma Edwards, MD Tim Gardner, MD Chattanooga Memphis Johnson City Internal Medicine General Surgery Dermatology

16 Tennessee Medicine + www.tnmed.org + MAY 2013 Member News

The TMA Physician Leadership College was created in 2007 to offer opportunities for physicians to gain invaluable experience and training in the core aptitudes to excel in leadership positions within organized medicine, medical practice and business. To date, 70 physicians have graduated from the program.

James Haynes, MD Brad Hoover, MD Clinton Musil, Jr., MD Ooltewah Hermitage Johnson City Family Medicine Emergency Medicine Child & Adolescent Psychiatry

Barbara Summers, MD Jon Ver Halen, MD Jon Ver Halen, MD Knoxville Germantown Germantown Pediatrics Plastic Surgery Plastic Surgery

Tennessee Medicine + www.tnmed.org + MAY 2013 17 Member News

MEMBER NOTES

Robert C. Lee, MD, of Kingsport, has re - Robert A. Mericle, MD, and ceived board certification in hospice Timothy P. Schoettle, MD, and palliative medicine. Currently the both of Nashville, have been medical director of Holston Medical named 2012 Compassionate Group, Dr. Lee is also certified by the Doctors, ranked among the American Board of Family Practice with top physicians in the nation special interest in geriatrics. He is a based on patient reviews by member of the Tennessee Geriatrics So - Dr. Mericle Dr. Schoettle Patients’ Choice. Of the na - ciety and the Tennessee Association of Long-Term Care Physi - tion’s 870,000 active physi - cians, as well as the Sullivan County Medical Society. cians, only three percent were accorded this honor in 2012. A former president of the Tennessee Neurological Society, Dr. Mericle practices Russell B. Leftwich, MD, of Nashville, has with HW Neurological Institute of Nashville. Dr. Schoettle has practiced been appointed to the FACA Consumer neurosurgery in Nashville since 1985, currently with Howell Allen Clinic, Technology Workgroup of the Office of the specializing in disorders of the neck and back, peripheral nerve surgery, National Coordinator for HIT Standards brain tumor treatment, brain trauma, and cerebrovascular disease of Committee. The charge of the workgroup the nervous systemBoth are members of the Nashville Academy of is to facilitate patient engagement and Medicine. data exchange between physicians and other care team members and patients William Schaffner, MD, of Nashville, has been and their family members and caregivers. He is a member of the awarded the John P. Utz Leadership Award by the National Quality Forum’s Health Information Technology Advi - National Foundation for Infectious Diseases. Dr. sory Committee and was the 2011 Physician IT Leadership Award Schaffner is chair of the Department of Preventive Recipient for the Healthcare Information and Management Sys - Medicine and a professor of Medicine and Pre - tems (HIMSS). Serving as chief medical informatics officer with ventive Medicine at Vanderbilt University School the Tennessee Office of eHealth Initiatives, Dr. Leftwich is a of Medicine. A pioneer of hospital infection con - member of the American Medical Informatics Association, trol programs, he has been a 40-year partner with HIMSS, and the Nashville Academy of Medicine. the Tennessee Department of Health investigating communicable dis - ease outbreaks and environmental hazards. Past honors include a quar - Michael C. Levin, MD, of Memphis, has terly TMA Public Health Champion award and the Walter E. Stamm been awarded a grant by the Depart - Mentor Award by the Infectious Diseases Society of America. Dr. ment of Veterans Affairs’ office of Re - Schaffner is president of the National Foundation for Infectious Dis - search and Development for a multiple eases, a member of the Executive Council of the Infectious Diseases sclerosis study. Building on his previous Society of America and has worked with the CDC’s Advisory Committee research, the study will focus on how on Immunization Practices for nearly three decades. He is a member of MS causes a patient’s own antibodies the Nashville Academy of Medicine. to attach nerve cells in the brain and spinal cord. Dr. Levin is an associate professor and director of Linda M. Smiley, MD, FACS, FACOG, of Memphis, the Multiple Sclerosis Program and Laboratory of Viral and has been appointed to the medical advisory board Demyelinating Diseases at the University of Tennessee for the Ovarian Cancer Awareness Foundation. Health Science Center and Semmes-Murphey Clinic. He has Board certified in obstetrics and gynecology and over ten years of clinical trial experience at the National In - gynecologic oncology, Dr. Smiley serves on the stitutes of Health and the university level with over 1.5 million board of directors for the Tennessee Chapter of in grants received from the NIH, Veterans Administration, and the National Ovarian Cancer Coalition. She joined the National Multiple Sclerosis Society. Dr. Levin’s articles The West Clinic in 1995, specializing in the treat - have appeared in over 50 peer-reviewed scientific presenta - ment of cervical, ovarian and uterine cancers. She received the Clinical tions and publications. Previous awards include the Alpha Oncology Fellowship Award from the American Cancer Society, 1989- Omega Alpha Student Research Fellowship Award in 1987. 1990. She is a member of a number of medical associations including He is a member of The Memphis Medical Society. The Memphis Medical Society.

18 Tennessee Medicine + www.tnmed.org + MAY 2013 Member News

MEMBER NOTES

Thomas W. “Quin” Throckmorton, MD, of Mem - nessee/Campbell Clinic, and assistant program director for the phis, has been elected to the board of trustees Campbell Clinic Sports Medicine Fellowship. An expert in elbow re - for the Campbell Foundation, established to construction, he is a member of the American Academy of Or - support the advancement of musculoskeletal thopaedic Surgeons, American Shoulder and Elbow Surgeons, research, physician education and community Association of Clinical Elbow and Shoulder Surgeons, Mid-America health. Dr. Throckmorton is a board-certified or - Orthopaedic Association, Mayo Elbow Club, Mayo Orthopaedic thopaedic surgeon with Campbell Clinic, asso - Alumni Association, Vanderbilt Orthopaedic Society, Willis C. Camp - ciate professor and associate residency bell Club, the Tennessee Orthopaedic Society and The Memphis Med - program director of orthopaedic surgery at the University of Ten - ical Society.

Are you a member of the TMA who has been recognized for an honor, award, election, appointment, or other noteworthy achievement? Send items for consideration to Member Notes, Tennessee Medicine, 2301 21st Ave. South, PO Box 120909, Nashville, TN, 37212; fax 615-312-1908; e- mail brenda.williams@ tnmed.org. High resolution (300 dpi) digital (.jpg, .tif or .eps) or hard copy photos required.

The IMPACT Board of Trustees recognizes the following IMPACT donors who have become Capi - tol Hill or Platinum Club members in the past month. We greatly appreciate all IMPACT con - tributors for their help in assuring that candidates supportive of organized medicine receive generous financial support from IMPACT. To join IMPACT or the Capitol Hill Club, please contact Capitol Hill Club Debra Maggart at 615-207-5424 or [email protected] , or log on to www.tnimpact.com.

PLATINUM LEVEL David Gerkin, MD, Knoxville Edmund Palmer, MD, Jackson Robert Herring, MD, Nashville - $10,000 Mark Green, MD, Ashland City Jeffrey Patton, MD, Nashville George Woodbury, MD, Memphis - $7,000 John Hale, MD, Union City Pete Powell, MD, Franklin William Harb, MD, Nashville John Proctor, MD, Franklin CHC Charles Hilgenhurst, MD, Brentwood Susan Raschal, DO, Chattanooga Maysoon Ali, MD, Waverly Ken Holbert, MD, Smyrna Bronn Rayne, MD, Cookeville Subhi Ali, MD, Waverly D. Marshall Jemison, MD, Chattanooga Jason Rehm, MD, Chattanooga Yasmine Ali, MD, Nashville Ben Johnson, MD, Nashville Wiley Robinson, MD, Memphis Newton Allen, MD, Nashville James Kennedy, MD, Chattanooga William Rodney, MD, Memphis Keith Anderson, MD, Memphis Robert Kerlan, MD, Germantown Perry Rothrock, MD, Cordova Samuel Bastian, MD, Franklin Gary Kimzey, MD, Germantown Larry Sargent, MD, Chattanooga James Batson, MD, Cookeville Ronald Kirkland, MD, Jackson Nicole Schlechter, MD, Nashville Steve Bengelsdorf, MD, Nashville Robert Kirkpatrick, MD, Germantown Nita Shumaker, MD, Hixson Ronald Bingham, MD, Jackson Ken Kozawa, MD, Sweetwater Jane Siegel, MD, Nashville Terry Bingham, MD, Harriman Bill Law, MD, Knoxville Thomas Smith, MD, Winchester Robert Bledsoe, MD, Athens Trey Lee, MD, Nashville Timothy Smyth, MD, Johnson City Leonard Brabson, MD, Knoxville Adele Lewis, MD, Nashville Douglas Springer, MD, Kingsport Bart Bradley, MD, Bristol Rodney Lewis, MD, Nashville Kirk Stone, MD, Union City Richard Briggs, MD, Knoxville Douglas Liening, MD, Chattanooga Tom Thomspon, MD, Morristown Mark Brzezienski, MD, Chattanooga Susan Lowry, MD, Martin Jimmy Waldrop, MD, Chattanooga Edward Capparelli, MD, Jacksboro Paul Marsidi, MD, Union City Andy Walker, MD, Hermitage Barton Chase, MD, Ramer Mickey McAdoo, MD, Milan Raymond Walker, MD, Memphis Hammond Cole, MD, Millington John McCarley, MD, Hixson Sameh Ward, MD, Blountville John Culclasure, MD, Nashville Robert McClure, MD, Columbia John J. Warner, MD, Nashville Dewayne Darby, MD, Jefferson City Michel McDonald, MD, Nashville Charles White, Jr., MD, Lexington Richard DePersio, MD, Powell Edwin McElroy, MD, Kingsport Charles White, Sr., MD, Lexington Robert Dimick, MD, Brentwood Fredric Mishkin, MD, Kingsport William Williams, MD, Jonesborough Scott Dulebohn, MD, Johnson City Lee Morisy, MD, Memphis Laura Witherspoon, MD, Chattanooga Chris Fleming, MD, Memphis William Newton, MD, Murfreesboro Mack Worthington, MD, Chattanooga Tamara Folz, MD, Germantown Patrick O'Brien, MD, Knoxville Chris Young, MD, Signal Mountain Eric Fox, MD, Cookeville Robert Osborne, MD, Johnson City Michael Zanolli, MD, Nashville Don Franklin, MD, Chattanooga Edmond Owen, MD, Memphis + Timothy Gardner, MD, Johnson City Tennessee Medicine + www.tnmed.org + MAY 2013 19 Member News

EXPANDING ACCESS TO CARE, MENTAL HEALTH, RX DRUGS TOP ISSUES AT MEDTENN 2013 (Continued from page 13)

The resolution calls for the TMA to continue to support access to af - fordable healthcare for all Tennesseans as put forth in its previous statement on health reform; to support a three-year trial to expand ac - cess to care using Medicaid expansion funds to either subsidize plans purchased by the uninsured through the federal health insurance ex - change or through direct Medicaid expansion; and to insist that the benefits purchased through the exchange remain comparable to Med - icaid/TennCare benefits. The TMA House of Delegates held its session as part of the asso - ciation’s 178 th annual meeting, MedTenn 2013. The event also offered CME and informational sessions on prescription drug abuse and neonatal abstinence syndrome, the mental health crisis in Tennessee, the state’s Controlled Substance Monitoring Database, which became mandatory for prescriber checks for certain pain medicine prescrip - Dr. Rahn Bailey, president of the TN Psychiatric Association, gives a presen - tions on April 1, health reform, electronic health information exchange tation on mental health issues in Tennessee during MedTenn CME sessions. and quality incentive programs, ICD-10 coding changes, and more. federal authorities to remove onerous language from its guidelines on RESOLUTIONS OF INTEREST care by physicians in training; and petition the AMA for requirements Increasing Access to Care – The TMA House of Delegates (HOD) voted that recognize more accurate documentation of care while allowing to support access to affordable healthcare for all Tennesseans; sup - the profession to resume educating its future colleagues in a more port a trial for three years to expand access to care by using Medicaid cost-effective and efficient manner. expansion funds either to subsidize uninsured residents to purchase health insurance through the federal insurance exchanges or through NEW OFFICERS direct Medicaid expansion; and instructed the Association to make it - In addition to Dr. Young’s inauguration as president, the following lead - self fully available to the governor and the state legislature to advocate ers were installed for 2013-2014: for healthcare coverage in Tennessee. Indigent Care – Delegates reaffirmed the importance of physicians • Dr. Douglas J. Springer, a Kingsport gastroenterologist, will serve providing free and reduced-cost care to indigent patients and directed as president-elect and on the TMA Board of Trustees. the Association to support and promote such activities. • Dr. Keith G. Anderson, a Germantown cardiologist, was reap - Mental Health Screening – Delegates voted to support efforts for pointed as chairman of the TMA Board of Trustees. more state and federal money for mental health screenings and treat - • Dr. Bob Vegors, a Jackson internal and geriatric medicine spe - ment in Tennessee. cialist, is the new vice-chairman of the TMA Board. Maternal Mortality Review – The HOD voted to support the estab - • Dr. James “Pete” Powell, internal medicine and pediatric physi - lishment of a peer review-protected and HIPAA-compliant maternal cian from Franklin, was reappointed as secretary/treasurer for mortality review process under the auspices of the Tennessee De - the TMA. partment of Health to review maternal deaths in Tennessee and make recommendations for system changes to improve healthcare services AWARDS for women in Tennessee. The TMA presented its 2013 annual awards to the following honorees: Cosmetic Surgery – Delegates passed two resolutions to pursue ex - pansion of the definition of the practice of medicine to include any sur - • Outstanding Physician: Winston P. Caine, MD, Chattanooga; gical procedure for cosmetic or aesthetic purposes; and to support Bobby Clark Higgs, MD, Jackson; John Lamb, Sr., MD, Nashville efforts to prevent unlicensed and unsupervised cosmetic surgical pro - • Distinguished Service: Marion Dugdale, MD, Memphis; B W. cedures through legislative action and enforcement by the Board of Ruffner, Jr., MD, Signal Mountain Medical Examiners. • Community Service: Greater Memphis Greenline, Inc., Mem - Health Cost Transparency – Delegates passed separate resolutions phis; Hamilton County Project Access, Chattanooga; Cathy Self, supporting the required posting of patient out-of-pocket costs for pre - PhD, Baptist Healing Trust, Nashville scription drugs and hospital charges. Medical Education & Physician Involvement – The HOD voted to pe - For a full recap of the meeting including approved policy, news re - tition the American Medical Association to work with CMS and other leases, photos and more, visit www.tnmed.org/medtenn-wrap .+

20 Tennessee Medicine + www.tnmed.org + MAY 2013 Capitol Hill Club

the IMPACT B JOIN Capitol Hill ackberry Club for $ 1,000 today for l your chance to win a two- night stay at beautiful Black - berry Farm, located in the arm heart of the Great Smoky Mountains of East Tennessee. GIVEFAWAY This resort is often described as “Easy to get to. Hard to leave.” Blackberry Farm was named the #1 Resort in North America by Travel + Leisure’s 2011 World’s Best Awards. Thank you to our friends at Blackberry Farm for donating this wonderful trip!

ENTER BY MAY 31, 2013 www.tnimpact.com

PRACTICING MEDICINE

Medicine’s Ethical Responsibility for Healthcare Reform THE TOP FIVE LIST By Stewart Edwards Dismuke, MD, MSPH, FACP, FACPM, and Stephen T. Miller, MD, MACP

Tennessee Medicine + www.tnmed.org + MAY 2013 23 PRACTICING MEDICINE DOCTORS ARE FREQUENTLY BESIEGED BY ADVICE THAT THEY SHOULD DO SOMETHING OR AVOID SOMETHING FOR THEIR PATIENTS.

Television, print media, internet searches and advertising of We now know through regional variation studies that about products all can provide unsolicited advice. We frequently ig - one third of what physicians do and where they have patient nore the chatter with good reason; now comes an admoni - care money spent does not contribute to helping our patients. tion worthy of our careful consideration. New advice is We could save one third of healthcare costs without depriving coming from our professional organizations that we can pro - any patient of beneficial care. Underlying our need to do vide better, less wasteful and less expensive services by avoid - something is our professional oath (and the American College ing some common testing or treatments that provide little of Physicians (ACP) Professional Charter) which reminds us of benefit. Inherent in this advice is the perspective that we must two things: 1) to place the interests of our patients above our do more than “test and treat.” We must provide value for our own interests—including our financial interests; and 2) that services, not only to the patient, but also to those other enti - we are committed to a just distribution of finite resources, ties than are paying most of the bills. which means we appropriately allocate resources and scrupu - lously avoid superfluous tests and procedures. TOP FIVE LISTS The National Physician Alliance conceived and piloted a proj - With leadership from ABIM Foundation (ABIMF) the national ect for physicians to practice their professional ethics and save “Choosing Wisely” Campaign has now been launched. costly dollars. They challenged physician specialties to develop Twenty-six (26) United States specialty societies representing a “Top Five” list that physicians and patients should question. 420,400 physicians developed lists of Five Things Physicians The American Board of Internal Medicine (ABIM) had stimu - and Patients Should Question in recognition of the importance lated this work through its grant program for Putting the Char - of physician and patient conversations to improve care and ter (Professionalism) into Practice. As a result physicians in eliminate unnecessary tests and procedures. Sixteen addi - internal medicine, family medicine and pediatrics each devel - tional medical specialties will release their top five lists in late oped a list of five specific steps they could take to promote 2013 (for a total of 42). Examples of recommendations from the more effective use of healthcare resources. These three the 26 active specialties include: lists were published in the Archives of Internal Medicine in 2011 in an article titled, “The ‘Top Five’ Lists in Primary Care.” 1 1) Don’t schedule elective, non-medically indicated inductions Internal medicine and family medicine independently selected of labor or Cesarean deliveries before 39 weeks 0 days three activities that were the same: gestational age. 2) Don’t diagnose or manage asthma without spirometry. 1) Don’t do imaging for low back pain within the first six weeks 3) Don’t do repeat colorectal cancer screening (by any unless red flags are present. method) for 10 years after a high-quality colonoscopy is 2) Don’t order annual ECGs or any other cardiac screening for negative in average-risk individuals. asymptomatic, low-risk patients. 4) Don’t perform PET, CT, and radionuclide bone scans in the 3) Don’t use DEXA screening for osteoporosis in women under staging of early breast cancer at low risk for metastasis. age 65 or men under 70 years with no risk factors. 5) Don’t perform cardiac imaging for patients who are at low risk.

24 Tennessee Medicine + www.tnmed.org + MAY 2013 PRACTICING MEDICINE

Of the 135 recommendations a proportionally high number are directly AMERICAN ACADEMY OF FAMILY PHYSICIANS related to diagnostic imagining. 2 Possible reasons for the inappropriate use might include worry about malpractice, generating revenue through office equipment, an over-dependence on technology, patient TEN THINGS demand, other potential conflicts of interest, etc. The article reminds us that “inappropriate imaging exposes patients to excessive radiation, in - PHYSICIANS AND convenience, and actual harms that come from the cascade of diag - nostic and therapeutic interventions that often follow identification of a lesion that proves only to be an incidentaloma.” Consumer Reports , the world’s largest independent product-testing PATIENTS organization, is working with the ABIMF to lead the effort. Several con - sumer-oriented organizations have joined Choosing Wisely to help dis - seminate information and educate patients on making wise decisions. SHOULD QUESTION On April 6, 2013, I had the pleasure of discussing the Choosing 1. Don’t do imaging for low back pain within the Wisely Campaign with about 100 Tennessee physicians who were at - first six weeks, unless red flags are present. tending the 2013 Tennessee Medical Association (TMA) meeting. The 2. Don’t routinely prescribe antibiotics for acute TMA has received a grant from ABIMF to promote the Campaign. My mild-to-moderate sinusitis unless symptoms last impression was that most of these physicians were interested and sup - for seven or more days, or symptoms worsen portive. However, our discussion focused primarily on malpractice is - after initial clinical improvement. sues and how many physicians order tests their patients may not need 3. Don’t use dual-energy x-ray absorptiometry to protect themselves from a malpractice lawsuit. They also mentioned (DEXA) screening for osteoporosis in women patients who demanded tests that were not indicated. Several of us felt younger than 65 or men younger than 70 with no that if national specialty organizations were recommending against cer - risk factors. tain tests and procedures and if we endorsed that standard locally, we 4. Don’t order annual electrocardiograms (EKGs) or would be setting our own community standard of care. Also, the su - any other cardiac screening for low-risk patients perb work of the TMA has greatly improved the malpractice climate in without symptoms. Tennessee. As the Campaign moves forward we will engage malprac - 5. Don’t perform Pap smears on women younger tice defense lawyers to give us their opinions on the strength of this than 21 or who have had a hysterectomy for non- defense. In terms of dealing with patients who demand tests and pro - cancer disease. cedures that are not indicated, we will find and provide learning tools 6. Don’t schedule elective, non-medically indicated on how to address that situation. inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age. 7. Avoid elective, non-medically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, SHARING THE 0 days unless the cervix is deemed favorable. 8. Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients. 9. Don’t screen women older than 65 years of age KNOWLEDGE for cervical cancer who have had adequate prior The Memphis Medical Society (MMS) put this grant together and will screening and are not otherwise at high risk for take a lead in its implementation. As we have successes or even fail - cervical cancer. ures in Memphis, we will pass these lessons on to our colleagues 10. Don’t screen women younger than 30 years of throughout the state. Our plan is to regularly communicate with Ten - age for cervical cancer with HPV testing, alone nessee doctors through both the TMA and MMS. We will get the rec - or in combination with cytology. ommendations out based on specialty. The hospitals and clinics for the underserved in Memphis seem interested in the Campaign so we will See the other specialty society lists of “Things Physi - partner with them. We will also work with the many medical residency cians and Patients Should Question” at www.choos - programs in Memphis and hopefully expand our efforts here across the ingwisely.org/doctor-patient-lists/. state to other programs. In Memphis we have several community-wide

Tennessee Medicine + www.tnmed.org + MAY 2013 25 PRACTICING MEDICINE

projects to improve the health of our population; Choosing we are likely to see health insurance companies, malpractice Wisely will become part of those long-term projects. The area companies, lawyers and politicians tell us how to practice the MMS is most interested in is working with physicians to re - medicine. The choice is ours. duce over-use of tests and procedures. We hope to find sev - If you have not already done so you might want to look eral areas that generate great interest. Our plan is to find at your specialty’s “Top Five” list to see if you concur. Go to funding to determine if we can systematically reduce over-use www.ChoosingWisely.org to learn more. Depending on the by convincing our colleagues to lead the charge. level of interest, the MMS and the TMA may want to do more Doctors working individually with their patients to help in this area. We hope it does, because effective stewardship of them address their health issues is the way medicine should resources and dedication to patients is the responsibility of be practiced. However, if doctors do not work individually and all physicians. + collectively to address the over-use of tests and procedures, LEARN MORE www.choosingwisely.org http://consumerhealthchoices.org/campaigns/choosing-wisely/ REFERENCES 1. Aguilar I, Berger ZD, Casher D, Choi RY, Green JB, Harding EG, et al.: The "top 5" lists in primary care: meeting the responsibility of professionalism. Arch Intern Med Dr. Dismuke Dr. Miller 171(15):1385-1390, 2011. 2. Rao VM, Levin DC: The Overuse of Diagnostic Imaging Board certified in internal medicine, general preventive medicine and the Choosing Wisely Initiative. Ann Int Med and public health and clinical lipidology, Dr. Dismuke is chair of The 157(8):574-576, Oct 16, 2012. Memphis Medical Society committee that developed the TMA Choosing Wisely grant. He is currently a professor/director in the Di - vision of Health Systems Management and Policy at the University of Memphis School of Public Health; professor emeritus and dean emeritus of the University of Kansas School of Medicine in Wichita, KS. Since his fellowship as a Robert Wood Johnson Foundation Clin - ical Scholar at the University of North Carolina, he has been inter - ested in evidence-based medicine and overuse in health care. Dr. Miller was a member of the MMS Committee that wrote the TMA Choosing Wisely Grant. A highly regarded general in - ternist in Memphis, Dr. Miller is an endowed professor and asso - ciate chair of the Department of Medicine at the University of Tennessee College of Medicine, associate chief medical officer at the UT Medical Group, and a past ACP Governor for Tennessee, currently serving as medical director, medical education and re - search with Methodist LeBonheur Healthcare. Dr. Miller hired Dr. Dismuke in 1978 to help him build a new Division of General In - ternal Medicine at the UT Memphis campus. For more information, contact Dr. Dismuke at [email protected].

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SPECIAL FEATURES UNDERSTANDING HEALTH REFORM SERIES

Make Corporate Compliance Your Focus in May

By Angie Madden, CHC, CAPM

orporate Compliance & Ethics Week • Developing open lines of communica - to enter into a resolution agreement which C is a national week-long event held tion; and included a civil money penalty over charges each year – this year it is May 5-11 – • Enforcing disciplinary standards it violated the HIPAA privacy and security highlighting the importance of ethics and through well-publicized guidelines. regulation. This shows the federal govern - compliance in the workplace. ment is getting serious about HIPAA compli - Many companies use the week as an op - VOLUNTARY VS. MANDATORY ance – and so should you. portunity to raise awareness about compli - Similar components have been contained in ance and ethics and engage employees about previous guidances issued by the OIG. How - these difficult yet vitally important topics. ever, unlike those, this guidance for physi - Other companies use the week to roll out a cians does not suggest that physician new compliance training program or hold practices implement all seven components annual compliance training activities. of a full-scale compliance program. Instead, Does your practice have a written com - this guidance emphasizes a step-by-step ap - pliance program? If so, would it be viewed proach to follow in developing and imple - as “effective” if your practice were to be au - menting a voluntary compliance program. dited? Below is an excerpt from the federal This change is in recognition of the financial register from the U.S. Health and Human and staffing resource constraints faced by Services Office of Inspector General physician practices. The guidance should (HHS/OIG) on the elements of an effective not be viewed as mandatory or as an all-in - compliance program for individual and clusive discussion of the advisable compo - small group physician practices. nents of a compliance program. Rather, the document is intended to present guidance to Components of an Effective Compli - assist physician practices that voluntarily WE CAN HELP ance Program choose to develop a compliance program. You are not alone in meeting these regula - This compliance program guidance for in - For a compliance plan to be effective, it will tions – the TMA is here to help. We can an - dividual and small group physician practices need to be tailored to fit the individual or - swer your compliance questions and have contains seven components that provide a ganization and its operation will have to be - wonderful resources from our Legal De - solid basis upon which a physician practice come an element of every step in the process partment, including a practice checklist and can create a voluntary compliance program: from initial patient encounter to the submis - summary document on the new OMNIBUS sion of a resulting claim for payment. HIPAA rules changes. Have you considered • Conducting internal monitoring and You have likely read about physician educating your office staff with our TMA’s auditing; practices receiving audits and financial set - HIPAA employee online training? What cod - • Implementing compliance and prac - tlements where in the past, small to medium ing and documentation education are you tice standards; size practices were practically exempt from performing in regard to the ICD-10 transi - • Designating a compliance officer or any real ramifications around enforcement. tion? Come grow your compliance plan with contact; You may remember this particular headline us. Host a Compliance Awareness Week • Conducting appropriate training and from April 17, 2012: $100,000 HIPAA fine event in your practice. Go over the new OM - education; designed to send message to small physi - NIBUS rules and how they apply to your • Responding appropriately to detected cian practices . The story concerned practice. Review and revise your policies to offenses and developing corrective Phoenix Cardiac Surgery, a five-physician include the changes. Update your employee action; practice that became the first small practice education. Attend our ICD-10 Roadshow to

Tennessee Medicine + www.tnmed.org + MAY 2013 29 SPECIAL FEATURES

awareness series. We issues for your practice, please contact our We will be expanding our resources to our will highlight an area Practice Solutions or Legal departments at of practice compli - 800-659-1862. + “ membership and their practices to help ance each week in May 2014 and pro - Ms. Madden is director of Practice Solu - point you in the right direction. vide resources to sup - tions for the TMA. Formerly with the state port your compliance Office of eHealth Initiatives, she has a efforts. We will be ex - background in medical practice adminis - hear from industry experts about documen - panding our resources to our membership tration, EHR consulting and implementa - tation compliance and education ap - and their pr”actices to help point you in the tion. Contact her at 800-659-1862 or proaches for the transition. right direction. [email protected]. Finally, make plans to attend next year’s For more information on compliance, TMA compliance month “Lunch and Learn” regulatory and other rubber-meets-the-road

Nominaons now being accepted for 2013/2014 The Tennessee Medical Associaon’s Physician Leadership College is an intensive leadership development program designed to train TMA members in the core aptudes to excel in leadership posions within organized medicine, medical pracce and business. For more informaon, visit www.tnmed.org/leadershipcollege

30 Tennessee Medicine + www.tnmed.org + MAY 2013 SPECIAL FEATURES UNDERSTANDING HEALTH REFORM SERIES

Doctors, Lawyers, and Disability Benefit Claims

By Peter T. Skeie, JD, LLM

octors hate disability claims, I know. LACK OF TOLERANCE CLAIMS NEED proved by objective medical evidence. If the DMany of you have told me so, and DR. SUPPORT claimant’s alleged impairments could be ob - sometimes not too politely. Never - Disability claims based on chronic pain, fa - jectively proven the claim would be approved theless, your patients need you to under - tigue, or mental problems are exceptionally due to the claimant’s lack of capacity. Conse - stand the legal issues and procedures hard to win without a treating physician’s sup - quently, when considering a lack of tolerance underlying their claims because you are vital port. There are at least four reasons why this claim adjudicators have to infer the merits of to their claims’ success. is the case: the claim from the record as a whole. In al - most all cases adjudicators will hire a med - DISABILITY IS NOT A MEDICAL 1. The merits of a lack of tolerance claim ical professional, usually a physician, to QUESTION are not immediately apparent from the assess the claimant’s residual functional ca - Doctors frequently presume that all they need medical records. Pain is entirely subjec - pacity (“RFC”) based on a review of the to do is announce that a patient is disabled to tive, chronic fatigue is exceptionally hard claimant’s medical records. In addition, ad - establish this fact. This is never the case, how - to measure, and the severity and fre - judicators will often hire a physician or phys - ever. Disability is not a medical issue. It is a quency of most mental problems are self- ical therapist to conduct a functional capacity vocational question. Whether someone is dis - reported. examination (“FCE”). abled in regard to a claim for disability ben - 2. These claims are medical outliers. They The problem with medical record re - efits depends on the source of the benefit, the concern allegations of pain, fatigue, or views and functional capacity examinations individual’s age, education, work history, mental problems that are more severe is that they are inherently biased against a salary, medical conditions, symptoms, im - than would normally be medically ex - lack of tolerance claim. Medical record re - pairments and, most importantly, the defini - pected. If the alleged symptoms and im - views can only confirm what is already tion of disability that applies to the claim. 1 pairments were medically expected the known: The claimant’s allegations are dis - claim would be approved without contest. proportionate to average medical expecta - THREE RATIONALES 3. The prospect of money for nothing invites tions. FCEs are equally problematic because 1. The claimant is disabled due to work re - malingering and even outright fraud. Un - they are presented with the façade of scien - strictions. A work restriction is some - fortunately for legitimate claimants, the tific accuracy even thought they are not vali - thing someone can do but should not do specter of illicit claims tends to predis - dated to determine an individual’s ability to because of a medical condition. The es - pose adjudicators to suspect the merits sustain the physical demands of a job. 4 De - sential question is one of public safety or of all chronic pain, fatigue and mental spite the packaging of FCEs as objective, “no risk of individual injury. health claims. 3 FCE has good predictive value when [used] 2. The claimant is disabled due to lack of ca - 4. Many doctors refuse to get involved with to predict a safe and lasting return to work.” 5 pacity. This category concerns claims based a patient’s disability benefit claim. Refus - Unfortunately, many claimants suffering on objectively measureable physical or ing to support a claim will often doom it from chronic pain, fatigue or mental prob - mental impairments. The essential question for denial. It creates the impression that lems do not realize that the medical evidence is whether the claimant has the physical or the doctor does not believe the patient collected in the course of their claim is bi - mental capacity required for a job. and it leaves the claim open to attack for ased against them. They often mistakenly 3. The claimant is disabled due to lack of being “inconsistent with objective med - think that the fact that they are disabled is tolerance. These almost always concern ical evidence.” self-apparent. This is the reason why these allegations of chronic pain, fatigue, or claimants in particular need a lawyer. A dis - mental illness. The essential question is ADJUDICATION OF LACK OF TOL - ability benefits lawyer knows that a lack of whether the claimant can sustain and ERANCE CLAIMS capacity claim is a medical outlier and that consistently meet the physical or mental Disability claims based on chronic pain, fa - the claim determination process is biased demands of a job. 2 tigue, or mental problems usually cannot be against these claims. He also knows that it is

Tennessee Medicine + www.tnmed.org + MAY 2013 31 SPECIAL FEATURES

his job to overcome this bias and to demon - distress. Although disability benefits will not CONCLUSION strate the merits of the claim. To do this well, eliminate this distress, they can make a ma - Disability claims based on medically-docu - the lawyer needs the treating physician’s terial difference to a patient’s wellbeing. 7 mented work restrictions or validated med - help. That said, the issue of money must be ical impairments are relatively addressed. After all, the patient is seeking a straightforward. The primary challenge is to THE TREATING PHYSICIAN & THE monetary benefit. Without any income, few document the validity of the claimant’s re - LAWYER claimants can afford their medical care strictions or impairments. As an advocate, the lawyer’s job is to prove much less pay for an assessment of their im - Disability claims based on chronic pain, the merits of a claim. He presumes that his pairments. Initially, the solution to this fatigue or mental problems are much more client’s allegations are true and he lacks the quandary would appear to be to charge the problematic. These claims are medical out - medical training to identify exaggerated al - patient’s lawyer. The lawyer should be able to liers. The claimant’s allegations are usually legations easily (although after a while we afford a nominal fee. The problem with this more severe than would be expected in most get a pretty good nose for this concern). Ac - solution, at least in regard to Social Security cases, and there are no validated methods to cordingly, the lawyer needs the treating doc - claims, is that these claims are adjudicated confirm the claimant’s allegations. This is the tor to signal if he thinks the claim is without in a non-adversarial administrative pro - reason these claimants need strong support merit. ceeding. This means the attorney has an eth - from a treating physician. No one is in a bet - If the claim is based on chronic pain, fa - ical duty to present any adverse evidence he ter position to explain why the claimant’s al - tigue or mental problems, the lawyer needs the obtains because no one is actively opposing leged impairments are real, valid, and treating doctor to explain why the claimant’s the claim. No attorney wants to pay for help consistent with the patient’s clinical presen - alleged impairments are real and consistent that could kill a client’s claim. tation. Accordingly, if you think your patient with the medical record — even though the is severely impaired, please help him by alleged impairments might be more severe DISABILITY & WORKERS’ COMP working with his disability lawyer. + than would be expected in most cases. CLAIMS The amount and kind of help a lawyer Some doctors refuse to get involved in disabil - References: needs varies depending on the nature of the ity claims because they perceive disability 1. The definition of disability can vary widely depend - underlying medical condition and whether claims to be akin to workers’ compensation ing upon the nature of and basis for a claim. For the claim is for Social Security or privately claims. This perception is a misperception; example, the Social Security Administration de - insured benefits. Accordingly, most disability these two are entirely different. fines disability as “the inability to do any substan - lawyers have a range of tools to minimize the The public policy behind workers’ com - tial gainful activity by reason of any medically hassle to a doctor. We have short checkbox pensation is to assure that individuals who determinable physical or mental impairment questionnaires that can be completed in sev - are injured on the job are compensated for which can be expected to result in death or which eral minutes. We draft letters for the doctor their injury while capping an employer’s fi - has lasted or can be expected to last for a continu - to edit that explain in “lay” terms the rea - nancial exposure for such injuries. In con - ous period of not less than 12 months.” (20 C.F.R. sons the claim is legitimate and that address trast, the purpose of disability benefits is to § 404.1505(a)). Many employee benefit plans de - any unfavorable evidence. When a doctor is secure a minimum income for individuals fine disability as the “inability to perform one or willing, we will even videotape and tran - who are no longer able to work or who have more of the essential functions of your own occu - scribe an interview in which the doctor lost much of their earnings capacity due to a pation.” After two years this definition frequently walks through the medical records and ex - medical condition. In addition, workers’ changes to the “inability to perform ‘any occupa - plains their significance. Regardless of the comp claims are subject to state law, tion’ for which the individual is qualified.” Individ - extent of involvement, however, whatever whereas most disability claims are subject to ually purchased insurance policies often help a doctor is willing to give always im - federal laws governing Social Security claims incorporate the policyholder’s profession into the proves the chance of a successful result. or employee benefit plans. There is even a definition of disability. Unfortunately, many doctors refuse to branch of the Tennessee Court of Appeals 2. Talmage JD, Melhorn JM, Hyman MH: Work Ability provide this support. Some doctors are con - dedicated solely to hearing workers’ com - and Return to Work, Second Edition. American cerned (ill-founded in my opinion) about li - pensation claims. Although this separate sys - Medical Association, 2011, pp. 10-14. ability. Some think that an FCE is required. tem might be the best solution to an 3. Claims adjudicators will protest this accusation. Some doctors refuse because disability impossible problem, it is nevertheless prob - Nevertheless, anyone remotely familiar with dis - claims are yet another time consuming dis - lematic. At least in my opinion, workers’ ability claims knows it to be true. traction from the practice of medicine. 6 compensation laws both encourage de min - 4. Genovese E, Galper JS: American Medical Associa - From a claimant’s perspective, however, imis claims and grossly and unjustly under- tion Guide to the Evaluation of Functional Ability. these rationales are contrary to the purpose compensate serious injuries. I suspect the American Medical Association, 2009, p. 15. of the doctor/patient relationship. Individu - doctors who refuse to get involved in work - 5. Ibid, p. 440. als seeking disability benefits are under se - ers’ compensation claims share some of vere medical, personal and financial these opinions. (Continued on page 35)

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TPQVO: Keeping Up with Change

By Eugene H. Ryan, MD

lmost 30 years ago, a group of enter - will save money over an internal process. presented documents attesting to their com - Aprising physicians took their demands The quality proof is not as difficult. Within petency and ethical conduct. Many consult - to Chattanooga area hospital admin - the first year of operation, TPQVO obtained ants suggested further tightening the noose istrators: Settle on one application for med - NCQA certification, and has undergone re - around fraudulent applicants by recom - ical staff credentialing and use a county certification every two years since that first mending criminal background checks as part medical society-sponsored credentials veri - certification in 1999. fication service to do the checking on these NCQA is all about applications. Their efforts were successful quality and our con - and soon physicians were undergoing reap - tinued designation at - Credentials verification is the process of pointment at the same time across the area, tests to our “confirming from the source an applicant’s and four or five separate processes became commitment to our one process. clients that quality is education, training, licensure and profes - Since that time, this medical society- our mission in the cre - based program expanded its client based dentialing arena. sional competence. It is part of the across the healthcare spectrum and across Achieving and main - bedrock of efforts to strengthen the qual - the country. The Chattanooga-Hamilton taining this certifica - County Medical Society’s Central Verification tion for the past 14 ity and safety of clinical care provided Service is now TPQVO, a NCQA-certified CVO years gives value and with clients from California to New York. Al - comfort to our clients within a healthcare organization. though TPQVO’s services include credentials and potential clients-- verification for IPAs, PPOs, surgery centers they know our service and hospitals and reaches nationwide, its core product meets the industry gold standard. of the credentialing process. In fact, the Ten - focus continues to be Tennessee physicians. nessee Board of Medical Examiners began ” Celebrating 15 years of service in June, RENEWED EMPHASIS ON requiring new license applicants to submit to TPQVO continues toward its motto of being CREDENTIALING a criminal background check in 2010. “your credentialing partner.” In 1999, the national media seized on the as - Some might consider the credentials ver - tonishing case of a physician serial killer who ification process “low-hanging fruit” and a THE BEGINNING – SUCCESSFUL managed to escape implication in unusual way to avoid tougher decisions concerning a PHYSICIAN ADVOCACY patient deaths at a number of training and physician’s clinical competence. Rather than Wrestling away the traditional medical staff hospital facilities. The Michael Swango case distract from the difficult task of performance office role of processing medical staff appli - highlighted the danger posed to the public by evaluation, TPQVO has always offered hospi - cations has not been easy. The “Doctor inadequate background checking, and gave tal credentialing staff a way to focus less on Power” asserted by Chattanooga and then- healthcare accreditation organizations and matching up an applicant’s self-reported ed - physician leadership in Knoxville was neces - credentialing committees renewed purpose. ucation, training and experience and more sary to get those first hospital contracts. It wasn’t just hospitals that needed to tighten on collecting internal and external quality Doctor Power is still a power we can wield up their verification processes—surgery cen - data. In this way, medical staff and creden - when working with our hospital, surgery ters were no longer allowed by accreditation tials, committees can spend more time and center, and network administrators. organizations to rely solely on hospital cre - resources scrutinizing quality of care mem - Proving to hospital administrators that dentialing as proof that physicians and other bers deliver in their facility and in the health - TPQVO is both economical and high quality healthcare providers were competent to pro - care community. has been a struggle and not always success - vide services. No longer could physicians The Joint Commission has tightened its ful. The hardest thing to prove is that TPQVO gain medical staff privileges based on self- medical staff credentialing and privileging

34 Tennessee Medicine + www.tnmed.org + MAY 2013 SPECIAL FEATURES

10 REASONS TO USE TPQVO standards with respect to a facility’s re - KEEPING UP WITH TECHNOLOGY view of whether the applicant can safely Today, TPQVO is not the same operation 1. We know what we’re doing . TPQVO is a and competently perform the requested it was in 1998 — we have embraced in - NCQA certified CVO since 1999. We are members delineated privileges. “Focused Profes - formation technology and its promise of of the National Association of Medical Staff Serv - sional Practice Evaluation” (FPPE) on cost efficient and effective data manage - ices as well as the Tennessee chapter. initial application and “Ongoing Profes - ment. In 2009, we launched client ac - sional Practice Evaluation” (OPPE) for cess to credentialing records and 2. We can perform credentials application those on staff have pushed medical staff reports and in 2011 initiated the online processing and recredentialing for less offices in new directions since 2008. application module. While credentialing than it costs for most in-house credential - TPQVO can help facility staff and com - continues to be a paper-driven, TPQVO ing operations (apples–to–apples compari - mittees spend more time on the focused has been “paperless” in its records son). review part of the credentialing and priv - management since 2006. This means we ileging process by performing these rou - serve as an archive for physician records 3. We are there to help with Joint Commis - tine background checks. for clients as well as physicians them - sion, AAAHC and NCQA reviews especially selves. during the survey process. NEW REQUIREMENTS A quarter of a century ago, physi - –PAIN MANAGEMENT CLINICS cians took up the mantle of leadership 4. We are here to help, not to replace staff. Just last year, the Tennessee Department and advocacy and created what became We free administrative staff to focus on the orga - of Health implemented rules that im - TPQVO. And TPQVO continues to look nization’s programs and activities like QI, etc. posed credentialing requirements on for ways to help physicians keep up with pain management clinics. Specifically, the ever-changing mix of credentialing 5. Clients have a built-in file backup sys - medical directors are required to estab - requirements. + tem— if you can’t find the credentialing infor - lish quality assurance policies that in - mation or file, we will have the original record or clude “documentation of the Dr. Ryan, an internist and pediatric a certified copy. Also, clients can access needed background, training, licensure, and urologist from Chattanooga, is chair - information 24/7 through our website. certifications for all . . . clinic staff pro - man of the Board of Governors of the viding patient care.” TPQVO can provide Tennessee Physicians Quality Verifica - that credentialing support and in fact, 6. We assume legal liability for the accu - tion Organization (TPQVO). Visit have pain clinic and surgery center racy and completeness of the credentials [email protected] or call 423-495- clients all over the country. Physicians information we verify. We carry $1 million/$3 1191, toll-free 888-779-0300. million errors & omissions and general liability have a place to turn to for help with insurance. these new requirements – TPQVO – the physician-owned CVO in the state. 7. TPQVO helps keep track of expiring li - censes, insurance policies, DEA registrations as well as monitors adverse licensing and Medicare and Medicaid sanction information. DOCTORS, LAWYERS, AND DISABILITY BENEFIT CLAIMS (Continued from page 32) 8. We work with physicians and their staff 6. Some doctors refuse to support a claim be - 8. The Employee Retirement Income Security directly to obtain and verify their professional cause the prospect of disability benefits can Act of 1974 (“ERISA”) governs almost all information. impede recovery, which is a rationale I can - claims related to employee benefits, includ - not protest. ing disability benefits and medical insurance 9. We are physician friendly and are owned 7. For your market intelligence, most doctors claims. by state and county medical societies. One do not charge to complete basic functional of our goals is to reduce paperwork for physi - capacity assessment forms. Some doctors Mr. Skeie is the principal of the law cians through standardized credentials applica - charge an “administrative fee” that typically firm of Peter T. Skeie & Associates, tions and recredentialing schedules. ranges from $20- $50. On rare occasions the dedicated to representing individu - demanded fee is substantially higher. The als in regard disability and employee 10. Our clients are satisfied with us! For the most I have ever paid for a treating source benefit claims. Contact him at 615- past 14 years we have measured client satisfac - functional assessment is $250, although I did 313-9111 or [email protected]. tion, our clients have rated their satisfaction with so only because I already knew what the doc - our services as “satisfied” and “highly satisfied.” tor was going to say.

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Isolated Pyocele of Anterior Clinoid Process Presenting as a Cavernous Sinus Syndrome

By Thomas J. O’Donnell, MD; L. Madison Michael, II, MD; Robert Laster, MD; and James C. Fleming, MD

SUMMARY of other sinuses. Magnetic Resonance Imag - ABBREVIATION KEY: A 37-year-old man presented with fever, de - ing (MRI) of the orbits and brain were ob - creased vision in the left eye, a partial left tained. The MRI confirmed a dehiscent floor CT = computed tomography cranial nerve III paresis, and a left cranial of the opacified anterior clinoid with a soft- MRI = magnetic resonance imaging nerve VI paresis. Neuro-imaging showed an tissue mass extending into this cavernous FOV = field of view opacification of a left pneumatised anterior sinus. Post-contrast imaging revealed signifi - T = Tesla clinoid process. After failing a course of in - cant enhancement of the left anterior clinoid TE = echo time travenous antibiotics, a craniotomy was per - and adjacent cavernous sinus (Figures 2a and TR = repetition time formed with exenteration of the cavity and b). Infectious disease and neurosurgical con - NEX = number of signals averaged resolution of symptoms. Although rare, a py - sultations were obtained, and the patient was ocele of a pneumatised anterior clinoid started on intravenous cefepime and metron - catheter for additional intravenous ceftriax - process may cause ocular morbidity and re - idazole for a presumed anterior clinoid py - one and continued metronidazole. quire surgical intervention. ocele. After about 10 days with slow Over the next few weeks, the patient’s improvement of symptoms, he was dis - pain decreased and fever subsided; he was charged home with a peripheral indwelling then switched to oral trimethoprim-sul - CASE REPORT A 37-year-old man presented to the emer - FIGURE 1. Computed tomography (CT) imaging was performed using a GE Light Speed 16 gency room with a seven-day history of left- detector scanner before and after contrast. sided eye and face pain with nausea and vomiting. Four days before admission, the patient developed diplopia, ptosis of the left 1a 1b upper lid, and periorbital pain. On oph - thalmic examination, he presented with both a left partial cranial nerve III paresis and a cranial nerve VI paresis. The re - mainder of the neurological examination was otherwise unremarkable. Computed Tomography (CT) imaging showed pneumatization of the right anterior cli - noid. There was opacification of the left an - terior clinoid with thinning of the entire circumference and deficient bone along the inferior margin with an adjacent ex - One hundred ccs of Optiray 30 were injected intravenously, and scans were obtained with transverse acquisition and pansile soft-tissue mass. There was also coronal reconstruction. Transverse parameters included a 16 FOV, thickness 2.5 mm, and pitch 1.375:1. The scan thinning of the adjacent lateral wall of the showed pneumatization of the right anterior clinoid but opacification of the left anterior clinoid. There is thinning of optic canal (Figures 1a and b). There was the anterior clinoid and an adjacent expansile soft-tissue mass. Figure 1a axial view, Figure 1b coronal view. no evidence of infection or inflammation

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mation of the orbital apex may also result in FIGURE 2. Magnetic resonance imaging (MRI) of the orbits and brain were obtained with a an optic neuropathy with vision loss. 3T GE scanner. Neuro-imaging is critical to making the diagnosis. CT is excellent for bone detail. 2a 2b MRI with and without contrast is useful to look for other lesions involving the cav - ernous sinus, such as meningiomas or nona - coustic schwannomas. Orbital views may be helpful when evaluating the optic foramen. Deshmuhk and Demonte 3 reported a case of optic neuropathy related to an anterior cli - noid mucocele that resolved with antibiotic therapy alone. Other authors who described cases with acute monocular vision loss, and diplopia stressed the need for early diagno - sis and surgery. 4-6 Our patient, who presented without vision loss, required extended an - The orbital scans showed the best delineation of the abnormal clinoid. This was performed with fat suppression tibiotic treatment to improve his symptoms; with 19 cm FOV, 3 mm thickness with spaces of 1 mm, TR 475 msec, TE 7.7 msec, matrix 320 x 224 and 2 with the recurrence of pain, he eventually re - NEX. Both transverse and coronal sequences were obtained. The MRI confirmed a dehiscent floor of the opacified clinoid with a soft-tissue mass extending into this cavernous sinus. Post-contrast imaging revealed significant en - quired neurosurgical intervention. hancement of the left anterior clinoid and adjacent cavernous sinus. Figure 2a axial view, Figure 2b coronal view. CONCLUSION Although rare, a pyocele of an anterior cli - famethoxazole with continued improvement process was removed in entirety. noid process may be considered in the dif - of his symptoms. After two months, attempts Intraoperatively, the mucosa was found to ferential diagnosis of a patient presenting with to withdraw antibiotics failed with recur - be thickened and pathology confirmed the symptoms referable to the cavernous sinus, rence of pain and persistence of sinus opaci - presence of a mucocele. Cultures taken during orbital apex, or with an atypical optic neuri - fication. The case was reviewed with the operative procedure did not grow a re - tis. Early neuro-imaging is invaluable to mak - otolaryngology and neurosurgery. It was felt sponsible pathogen. Post-operatively, the pa - ing the diagnosis. As in our patient, this may that the lesion could not be approached en - tient did well with normalization of his present as an isolated process without evi - doscopically due to its lateral position in re - neurological examination. His visual acuity dence of sinusitis elsewhere. Antibiotic ther - lation to the optic nerve. A left without correction was 20/15 bilaterally. A apy may resolve the problem in a minority of frontotemporal craniotomy was performed, paracentral depression was present on Gold - cases, but surgical intervention will likely be and extradural exposure of the anterior cli - mann visual field testing, although both required. + noid was achieved. The aerated clinoid Humphrey 24-2 and 10-2 visual field pro - grams were normal. An MRI scan performed References: five months later showed no abnormal en - 1. Miller NR: Walsh and Hoyt’s Clinical Neuro-Ophthal - FIGURE 3. An MRI scan of the brain reveals hancement; clinically, he has continued to do mology. Vol 3. 6th ed., New York City: Lippincott, no abnormal enhancement of the left anterior well without return of symptoms (Figure 3). clinoid region and adjacent cavernous sinus Williams & Wilkins; 2611, 2005. postoperatively. DISCUSSION 2. Glaser JS: Neuro-Ophthalmology. 3rd ed. New York City: Lippincott, Williams & Wilkins; 420, 1999. Mucoceles originating in the anterior clinoid 3. Deshmuhk S, Demonte F: Anterior clinoid mucocele are rare. Because of their location near the causing optic neuropathy: resolution with nonsurgical cavernous sinus and orbital apex, they may therapy. Case Report. J Neurosurg 106:1091-3, 2007. cause substantial ocular morbidity. Obstruc - 4. Thurtell MJ, Besser M, Halmagyi GM: Anterior clinoid tion of mucus drainage from a sinus may lead mucocele causing acute monocular blindness. Clin to formation of a mucocele that may slowly Exper Ophthal 35:675-6, 2007. expand and cause erosion of bone with com - 5. Chou PI, Chang YS, Feldon SE, et al.: Optic canal muco - pression of nearby structures, and a pyocele cele from anterior clinoid pneumatisation. Br J Oph - may occur with secondary infection. 1 Com - thalmol 83:1306-7, 1999. pression, inflammation, or infection of the 6. Chung DS, Park YS, Lee JH, et al.: Mucocele of the an - cavernous sinus may cause: 1) pain or sen - terior clinoid process: case report. Neurosurg 45:376- sation loss in the first trigeminal distribution; 8, 1999. 2) paresis of cranial nerves III, IV, or VI; or 3) sympathetic paresis. 2 The close approxi - (Continued on page 43)

38 Tennessee Medicine + www.tnmed.org + MAY 2013 THE JOURNAL ORIGINAL CONTRIBUTION

Heart Failure Presenting as Myxedema Coma: Case Report and Review Article

By Dhara Chaudhari, MD; Venkat Gangadharan, MD; and Terry Forrest, MD

ABSTRACT isoenzymes. For further evaluation, TSH, FIGURE 2. CXR findings of left cent prevalence Hypothyroidism is a common medical prob - ESR, blood culture, and urine culture pleural effusion, pulmonary of cases in fe - lem easily treated when diagnosed but re - were drawn. Bedside ECHO (Figure 3) edema and cardiomegaly. males, mostly in quiring regular follow-up and patient was done which showed global hypoki - winter. medication compliance. At times, this diag - nesia with Ejection fraction of 30 per - Cardiovascu - nosis can go untreated resulting in the devel - cent. Further questioning of her family lar changes as - opment of severe consequences such as members revealed the patient had been sociated with Myxedema Coma. Of all the clinical symp - previously diagnosed with hypothy - hypothyroidism toms, cardiovascular manifestations tend to roidism which had gone untreated over include de - be especially severe and often life threatening. the past two years due to financial con - crease heart straints. The patient appeared to be in rate, decreased overt heart failure likely secondary to her cardiac output, CASE untreated hypothyroidism and was sub - decreased con - A 55-year-old female presented to the ER with sequently started on aggressive treatment tractility and in - sudden onset of shortness of breath. Her past with IV diuretics and respiratory therapy. creased medical history included hypothyroidism. Vital Combining the patient's acute peripheral vas - signs showed mild hypothermia (95.2 degrees presentation of decompensated heart cular resistance F), tachycardia, respiratory rate of 10/min, failure with confusion and decreased tendon leading to diastolic hypertension. 2,3 Low T3 in reflexes, a probable hypothyroid state leads to decreased expression diagnosis of of enzymes involved in regulating calcium influx FIGURE 1. EKG with tachycardia and prolonged QT interval. Myxedema coma was in cardiac muscle, leading to a decrease in in - made. Random corti - otropic and chronotropic function of the heart sol level and free T4 and eventually impaired systolic contractions and free T3 were or - and diastolic relaxation. 2 Thyroid hormone re - dered before begin - laxes vascular smooth muscle cell by releasing ning treatment with IV thyroxine and IV hy - drocortisone; further FIGURE 3. Still ECHO image showing Global labs were ordered to hypokinesia. search for precipitat - confusion, and bilateral decreased breath ing factors. The patient recovered success - sounds, cyanotic cold clammy bilateral lower fully after a lengthy course with plans for extremity with +2 pitting edema and decreased close physician follow-up. deep tendon reflexes. Initial testing revealed sinus tachycardia with a prolonged QT interval DISCUSSION on EKG (Figure 1), CXR showed signs of pul - Myxedema coma is an endocrine emergency monary edema and cardiomegaly (Figure 2) presenting as a life-threatening form of decom - and an ABG showed respiratory acidosis. Rou - pensated hypothyroidism with underlying pre - tine labs done in the ER showed WBC 17.8, cipitating factors. 1 Scattered cases have been sodium 132, BUN 30, Creatinine 1.83, BNP of reported in medicine literature with an inci - 1534 and a negative first troponin/cardiac dence of 0.22 million per year with an 80-per -

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endothelin derived relaxation factor, which in a Although there is an increas - hypothyroid state is not enough in circulation, ing concern regarding pre - TABLE. Precipitating Factors. leading to increased contraction and peripheral cipitation of myocardial vascular resistance. 1,4 Rhythm disturbances in - infarction and arrhythmia Hypothermia cluding bradycardia, complete heart block, after the administration of in - Infection most likely pneumonia, urinary tract infection bundle branch block, prolonged QT interval travenous levothyroxine, Withdrawal of thyroid medication and QT dispersion have been reported in studies have shown improve - Drugs-amiodarone, sedatives, lithium, narcotics, barbiturates, anesthetics myxedema cases. 5 A study of heart rate vari - ment in a patient’s condition GI bleeding ability demonstrates that hypothyroid state also and a decrease in mortality Cerebro vascular accidents/trauma leads to an imbalanced sympathovagal state, by the life-saving effects of 6 leading to decreased vagal and cardiac sympa - levothyroxine. Medicine ex - CONCLUSION thetic activity and increased risk for malignant perts also demonstrate controversy regarding a Our case represents a good example of clin - arrhythmia in prolonged hypothyroidism and thyroid regimen being used, whether to use ical awareness for physicians to be mindful Myxedema coma. 6 Hypothyroid state also leads levothyroxine (T4) or liothyronine (T3), or a of Myxedema coma/severe hypothyroidism to down regulation of the LDL receptor in the combination. 1,6 Some experts advocate use of as a differential for underlying cause for liver causing hyperlipidemia (mainly LDL), as liothyronine (T3) since T3 is biologically active, heart failure, considering higher mortality well as accelerated coronary artery disease sec - and conversion of T4 to T3 is decreased in rate if left untreated, and also for patients to ondary to increased LDL, and homocysteine. Myxedema coma. Considering the unavailability understand the importance of follow-up and Precipitating factors (Table) disturb the rhythm of T3 at many places, the cost, small half-life treatment of hypothyroidism. + created by the body during hypothyroid state leading to fluctuations and adverse cardiac and push this balance toward the edge of de - events, balanced against the easy availability of References: compensated heart failure. Our patient has a T4, easy interpretation, and non detrimental ef - 1. Mathew V, Misgar RA, Ghosh S, Mukhopadhyay P, Roy - history of untreated hypothyroidism for the last fects, the majority of experts prefer the use of chowdhur P, Pandit K, Mukhopadhya S, Chowdhury S: two years, presented with signs and symptoms levothyroxine (T4). Myxedema coma: a new look into an old crisis. J Thy - of heart failure, and was in respiratory acidosis Along with thyroid hormone replacement, roid Res 2011:493462, 2011. Epub Sep 15, 2011. with lab findings suggestive of Myxedema. symptoms of heart failure can be treated with 2. Polikar R, Burger AG, Scherrer U, Nicod P: The thyroid Treatment of Myxedema requires a multi - diuretics, beta-blockers to increase myocardial and the heart. Circ 87 (5):1435–1441, 1993. dimensional approach in an intensive care unit contractility and ACE inhibitors for afterload re - 3. Tang YD, Kuzman JA, Said S, Anderson BE, Wang X, setting with emphasis on supportive care, hor - duction. 1,6 Other supportive measures in the Gerdes AM: Low thyroid function leads to cardiac atro - monal treatment and management of precipi - treatment of myxedema include endotracheal phy with chamber dilatation, impaired myocardial blood tating factors. The main backbone of intubation and mechanical ventilation for air - flow, loss of arterioles, and severe systolic dysfunction. management of heart failure associated with way protection and respiratory failure. Hypov - Circ 112 (20):3122-3130, 2005. Myxedema is medical management of heart fail - olemia and Electrolyte disturbances should be 4. Schenck JB, Rizvi AA, Lin T: Severe primary hypothy - ure and thyroid hormone replacement. Intra - corrected. Hypothermia can be managed with roidism manifesting with torsades de pointes. Am J Med venous levothyroxine is used in a loading dose external warming and treatment of underlying Sci 331(3):154-156, 2006. of 100-500 mcg followed by a maintenance precipitating factor (Table) with antibiotics for 5. Galetta F, Franzoni F, Fallahi P, et al.: Changes in heart dose of 1.6 mcg/kg. Another option of treatment infection, hemodialysis for renal failure, avoid - rate variability and QT dispersion in patients with overt is T3 which may be given at a dose of 10 to 20 ance of responsible drugs, and management of hypothyroidism. Eur J Endocrinol 158:85-90, 2008. mcg followed by 10 mcg every four hours for organ dysfunction in case of cerebro-vascular 6. Wall CR: Myxedema coma: diagnosis and treatment. Am 24 hours, then 10 mcg every six hours for one- accidents and GI bleeds if present. Fam Phys 62(11): 2485-2490, Dec 2000. to-two days until the patient can take oral meds. 1 7. Roberts CG, Ladenson PW: Hypothyroidism. Lanc Thyroid hormone replacement increases corti- PROGNOSIS 363(9411):793-803, 2004. sol clearance and it is beneficial to start the pa - Significant predictors of mortality are advanced tient on intravenous hydrocortisone while on age, bradycardia, hypotension and the need for Dr. Chaudhari is with the Department of In - intravenous levothyroxine until one can rule out mechanical ventilation. 1 Different studies are ternal Medicine and Drs. Gangadharan and adrenal insufficiency. Particular attention should reported regarding the predictors of progno - Forrest are with the Department of Cardiovas - be given to the elderly or frail and patients with sis. Sequential organ failure assessment (SOFA) cular Disease, Quillen College of Medicine, East cardiac co-morbidity while selecting a dose for is more effective. A SOFA score on the day of Tennessee State University, Johnson City, TN. thyroid hormones, usually choosing a lower ini - admission and day three of more than 6 is For reprints, contact Dr. Chaudhari at tial dose with gradual increments based on highly predictive of a poor prognosis. Our pa - 1008 Quality Circle, Apt #79, Johnson City, TN Serum TSH and thyroxine level. Follow-up tient had a SOFA score of 9 at the time of ad - 37615; phone: 423-741-9179; email: chaud - should be arranged in four-to-six weeks for mission, which signifies a less than 33-percent [email protected]. reevaluation of the patient and a repeat serum mortality, and on day three her score was 1. TSH measurement.

40 Tennessee Medicine + www.tnmed.org + MAY 2013 THE JOURNAL ORIGINAL CONTRIBUTION

Treatment of Cerebral Malaria and Acute Respiratory Distress Syndrome (ARDS) with Parenteral Artesunate

By Harshida Chaudhari, MBBS; Jay B Mehta, MD, FCCP; Ketan Chaudhari, MD; and Jeff Farrow, MD, FCCP

ABSTRACT children, pregnant women, immune-com - FIGURE 1. Peripheral blood smear shows Infection with Plasmodium Falciparum can promised individuals and international trav - ring form trophozoites of Plasmodium cause a severe form of malaria with multi- elers from non-endemic areas who are Falciparum (arrow) in the periphery of in - organ involvement. Cerebrum is one of the visiting an endemic area. Most deaths due to fected red blood cells. organs involved in the P. Falciparum malaria occur in sub-Saharan Africa. Multi- malaria, which can lead to coma, convul - organ involvement is frequent in adults with sions, and other neurological sequel. The se - malaria. 3 According to 2010 malaria sur - questration of cerebral vasculature with veillance, the majority of malaria infections parasitized red blood cells is one of the pro - in United States were imported due to trav - posed mechanisms for the development of elers visiting friends and relatives in the re - cerebral malaria. We present a case of gions with ongoing malaria transmission. malaria with multi organ involvement. Cere - There were 216 imported cases of malaria bral malaria should be suspected in any from India; out of these 14 were P. Falci - febrile patient from a malaria-endemic re - parum. 4 gion with loss of consciousness. Compared We present a case of cerebral malaria with quinine, intravenous artemisinin com - with acute respiratory distress syndrome pounds (artesunate, arteether, artemether) (ARDS) from Surat, a large city located in are well tolerated by patients and have fewer the western province of India. The patient side effects. Due to multi-organ involvement survived from this deadly disease due to and headache and was treated for viral fever. in P. Falciparum malaria, supportive ther - early diagnosis and treatment with par - After three days she developed yellowish dis - apy is crucial along with parenteral anti- enteral anti-malarial and mechanical venti - coloration in her urine and vomiting, along malarial to improve survival. lation. The Surat region is most with high-grade fever, chills, rigor, headache, industrialized and the eighth-largest metro - and body ache. On physical examination she politan area of India. People from the Surat had a temperature of 102 F, BP 110/70, pulse INTRODUCTION region comprise one of the highest immi - 100/min. and RR 22/min. She had mild Cerebral malaria is one of the major causes grant population of India located in the U.S., icterus, hepato-splenomegaly on abdominal of morbidity and mortality in people infected African countries, the United Kingdom, and examination and bilateral basal crepitations 1 with plasmodium falciparum malaria. A Canada. A majority of hotel and motel own - on chest auscultation. She was admitted to 5 high index of suspicion is required in pa - ers in the U.S. are from the Surat region. the hospital. Her blood sample was sent to a tients with impaired consciousness from Surat is one of the malaria endemic areas. laboratory for complete blood count, com - malaria-endemic areas as delayed or missed Non-resident Indians visiting this region are prehensive metabolic panel and peripheral diagnoses can be life threatening. Prompt at risk of getting malaria. smear for malarial parasites. She was started treatment of the patient with adequate anti- on IV fluids, antibiotics, antipyretics and CASE REPORT malarial in an intensive care unit is crucial antiemetic while waiting for reports. 2 for a positive outcome. Approximately half A 36-year-old female from the malaria-en - Laboratory investigation showed Hb of the world’s population is at risk for demic region of Surat, India, went to a local 12.2 gm total, WBC count 17700/mm3, and malaria. The most vulnerable groups are doctor with complaints of high-grade fever platelet count 26000. Peripheral smear was

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positive for P. Falciparum malarial parasites and renal failure. 2 According to a World (Figure 1). On blood chemistry, she had el - Health Organization (WHO) 2011 report, an FIGURE 2. Chest X-ray shows bilateral evated serum bilirubin (5.5mg/dL), mildly estimated 216 million cases and 655,000 diffuse infiltrates of lungs suggestive of elevated liver enzymes (S. SGPT 88, S. SGOT deaths were reported worldwide due to acute respiratory distress syndrome. 147), and elevated blood urea and serum malaria in 2010. Most deaths occurred creatinine (blood urea 68, S. creatinine among children living in Africa. The major - 2.2). Her chest x-ray and EKG were normal. ity of cases reported in United States were The patient was started on Inj. Artisunate imported through international travel. Nine 120 mg IV bid, Tab Mefloquine 300 mg 1 fatal cases of malaria were reported in U.S. bid, and higher antibiotics and IV fluids. malaria surveillance in 2010 due to Plas - Despite being treated with parenteral modium Falciparum malaria. All the fatal - anti-malarial, she became drowsy, and de - ities resulted either from delay in seeking veloped abnormal rapid breathing with con - treatment or delayed diagnosis. The major - fusion. On examination she had rigors with ity of these cases were imported from West drenching sweat and absence of neck stiff - Africa. Clinicians should include malaria in ness. Her blood sugar and serum elec - the differential diagnosis of any febrile pa - trolytes were normal. Urgent CT scan of the tient with a history of travel to malaria-en - brain and cerebrospinal fluid examination demic areas. 4 were normal. After exclusion of the other Two percent of patients with P. Falci - causes of encephalopathy, the clinical diag - parum infection develop cerebral malaria. nosis of cerebral malaria was made. She also Vascular sequestration of parasitized red currently the most popular in the treatment of had mild metabolic acidosis on arterial blood cells and blockage of microcirculation malaria. 9 The Artemisinin class of compounds blood gas analysis. Repeat chest x-ray affecting cerebral vasculature is the main un - has many advantages over quinine including showed diffuse infiltrates of both lung fields, derlying mechanism. Other mechanisms such activity against multidrug resistant P. Falci - suggestive of ARDS (Figure 2). as nonspecific immune inflammatory re - parum , rapid therapeutic response and re - The patient was transferred to an inten - sponse and release of cytokines are also pro - duction in gametocyte carriage. The drug is sive care unit and was kept on mechanical posed. 6 The latter is responsible for increased well tolerated by patients. However, when ventilation. After three days of aggressive man - alveolar permeability leading to ARDS. 1 Ac - given alone, recrudescence rates are high. It agement of patient with parenteral anti-malar - cording to WHO guidelines, suspect cerebral should be given in combination with other ial, antibiotics and supportive therapy, she malaria in any patient presenting with im - drugs. In the case described, we combined it regained consciousness. We gradually weaned paired level of consciousness who is from a with mefloquine. 10 her off the ventilator. After seven days of in - malaria-endemic region or has traveled to Apart from parenteral anti-malarial, sup - travenous artesunate treatment, the patient’s such region recently and who has a positive portive care of the patient is very important. clinical condition and laboratory abnormali - peripheral smear for P. Falciparum malarial Comatose patients should be treated in a crit - ties improved gradually and her parasitemia parasite, after exclusion of other causes of en - ical care unit with meticulous nursing care. cleared completely on peripheral smear. She cephalopathy. 7 Imaging modalities like CT Urethral catheter, naso-gastric tube, input- was discharged after complete recovery on scans can underestimate the extent of cere - output chart, level of coma (GC scale), an - tab clindamycin 300 mg 1 bid for seven days bral involvement as there have been many tipyretics, anticonvulsant (if the patient has to prevent recrudescence. On follow-up she cases reported with normal CT brain in pa - had seizures), manitol (for raised ICP), and had a normal peripheral smear examination tients with cerebral malaria. 8 The clinician correction of hypoglycemia are essential parts and normal blood chemistry. should be vigilant and should start prompt of supportive care. Exchange transfusion, des - treatment based on suspicion, as a major rea - ferrioxamine (an iron chelator) and pentox - DISCUSSION son for the development of severe disease is iphylline can be used in severe cases, however Malaria is a parasitic infection caused by var - delayed or missed diagnoses. not widely used. 11,12 Steroids are not recom - ious species of plasmodium ( P. Falciparum , The mainstay of treatment of cerebral mended in the treatment of ARDS or cerebral p. vivex, p. malariae, p. ovale and occasion - malaria or any form of complicated malaria is malaria. In two well-conducted studies, ally p. knowlesi). It is transmitted via bites parenteral anti-malarial treatment. Intra - steroids failed to improve morbidity and mor - of infected anopheles mosquitoes. P. vivex venous chloroquine has become outdated in tality in cerebral malaria and increased the and P. Falciparum are the most common many parts of world, including Asia, due to risk of infection and gastrointestinal bleed - 2 species found to cause human infection. 3 P. widespread resistance. Quinine, once widely ing. A malaria vaccine is still under trial. Pre - Falciparum is known for its severe compli - used, is now replaced by Artimisinins due to ventive measures (vector control, insect nets), cations such as anemia, bleeding disorders, the serious side effects such as cardio toxic - chemoprophylaxis and early treatment of in - coma, convulsions, hypoglycemia, metabolic ity, cinchonism, and hypoglycemia. Arte - fected individuals are important to prevent acidosis, fluid and electrolyte disturbances sunates, the group of Artemisinins, are morbidity and mortality from malaria.

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CONCLUSION 3. World Health Organization: Malaria. WHO Media Center 11. Sarangi G: Cerebral Malaria. The Indian Academy of Pedi - The number of cases reported in United States Factsheets 1-7, 2012. atrics–Orissa State Branch. Available at http://www.ia - in 2010 by the Malaria Surveillance team was 4. U.S. Centers for Disease Control and Prevention: Malaria porissa.org/Articles/CEREBRALMALARIA.pdf . Accessed the largest number of cases reported since Surveillance-United States, 2010. Morb Mort Wkly Rpt on Jul 6, 2012. 1980. The majority of the malaria infections 61:1-17, 2012. 12. Mohanty S, Patel DK, Pati SS, et al.: Adjuvant therapy in in the U.S. occur among people who have trav - 5. Dhingra P: Life Behind the Lobby: Indian American Motel cerebral malaria. Indian J Med Res 124:245-260, 2006. elled to malaria endemic areas. Clinicians Owners & the American Dream. Stanford University Press, should inform travelers about the risk of 2012. Drs. H. Chaudhari and Farrow are with Pul - malaria and encourage them to use chemo - 6. Barest GD, Sakai O: Diffusion-Weighted Imaging of Cere - monary Associates of East Tennessee, John - prophylaxis along with other protective meas - bral Malaria. J Neuroim 15:278-280, 2005. son City, TN. Dr. Mehta is with the ures (mosquito nets, repellents). Clinicians 7. Idro R, Jenkins NE, Newton CRJ: Pathogenesis, clinical fea - Department of Internal Medicine, James H. should include malaria in the differential di - tures, and neurological outcome of cerebral malaria. Quillen College of Medicine, East Tennessee agnosis of any febrile patient with a history of Lancet Neurol 4:827-840, 2005. State University, in Johnson City. Dr. K. travel to malaria-endemic areas. + 8. Gupta S, Patel K: Case series: MRI features in cerebral Chaudhari is with Abhay Medical Hospital, malaria. Indian J Radiol Imag 18(3):224-226, 2008. Mehsana, India. References: 9. Dondorp AM: Pathophysiology, clinical presentation and For correspondence, contact Dr. Mehta 1. Nema N, Subhyaloic JD: Hemorrhage in cerebral malaria. treatment of cerebral malaria. Neur Asia 10: 67-77, 2005. at East Tennessee State University, James H. J Vector Borne Dis 47:261-263, 2010. 10. Sun HY, Fang CT, Wang JT, et al.: Successful Treatment of Im - Quillen College of Medicine, Johnson City, 2. Pasvol G: The treatment of complicated and severe malaria. ported Cerebral Malaria with Artesunate-Mefloquine Com - TN 37614; phone: 423-439-6368; fax: 423- Brit Med Bull 75:29-47, 2005. bination Therapy. J Formos Med Assoc 105:86-89, 2006. 439-6387; email: [email protected].

ISOLATED PYOCELE OF ANTERIOR CLINOID PROCESS PRESENTING AS A CAVERNOUS SINUS SYNDROME (Continued from page 38) Drs. O’Donnell and Fleming are with the Hamil - mology from Research to Prevent Blindness, professional editing of this article. ton Eye Institute, University of Tennessee, Health Inc., New York, NY. The authors have no finan - For all correspondence, contact Dr. O’Don - Sciences Center, Memphis, TN. Drs. Michael and cial interests or conflicts of interest to disclose nell at Hamilton Eye Institute, University of Ten - Laster are with Semmes-Murphey Neurologic regarding this report. nessee, Health Sciences Center, 930 Madison and Spine Institute, Memphis, TN. No portion of this paper has been previously Avenue, Suite 470, Room 485, Memphis, TN This study is supported in part by an unre - presented or published. Medical editor Jeannie 38103; Phone: 901-448-5883; fax: 901-448- stricted grant to the Department of Ophthal - D. Haman, PhD (Houston, TX, USA), provided 1299; email: [email protected].

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Tennessee Medicine + www.tnmed.org + MAY 2013 43 FOR THE RECORD TMA ALLIANCE REPORT

Alliance Year in Review

By Beth Kasper, TMAA President

our TMA Alliance has worked dur - TMA’s Public Health Committee and made state dues. In the past, we were clear about Y ing the past year promoting the the proper use of antibiotics our goal. Vice when moneys were due but not about what good health of Tennessee and sup - President Nora Lee and Assistant Vice Presi - period they were paying for. To prepare for porting the family of medicine. Whether or dent Lorrie Villeneuve crafted a flyer for an earlier than usual convention, to make not you are a member, we are your Alliance members to distribute in their spheres of in - budgeting easier, and to go along with a because we are at the service of all Ten - fluence. Based on information found at “pay-for-it-today, get-it-tomorrow” expecta - nesseans. We want all Tennesseans to enjoy www.cdc.gov/getsmart/ , Lorrie and Nora’s tion in modern culture, we said that mem - good health and all physicians and their fam - publication helps parents and others under - bership is for a calendar year, is due on the ilies to find fulfillment in their association stand when antibiotics are useful, when they last day of the previous calendar year, and with the medical profession. Through health are not, and why it is harmful to take them has a grace period until March 1 for voting promotion projects, legislative advocacy and when not needed. rights at convention. We’ve taken this system community-building efforts, we have moved The biggest part of our legislation focus for a test drive. It sputters and coughs but the needle toward greater wellbeing for was encouraging members to attend the should be fine with a tune-up. Many thanks many in our state. TMA’s PITCH (Physicians Involved at Ten - to Vice President Emily Shore for her work, Part of my activity as president was vis - nessee’s Capitol Hill) Day at Legislative Plaza especially in mailing notices and acknowl - iting component Alliances. What struck me on March 6. Alliance members were among edgements to members-at-large. were the differences between the groups. the 132 advocates who showed up to push Finally, we have had the pleasure of Programs vary. Leadership structures vary. for medicine’s agenda. The PITCH lunch gave planning a reception for Jo Terry’s June in - Numbers vary. While most, like typical civic us a chance to do some Alliance networking stallation as AMA Alliance’s next president. groups in America, struggle to keep mem - as well as learn about legislative concerns. Congrats to Jo, a past TMAA president! I’ve bership numbers up, at least one Alliance, Vice President Gail Brabson and I thank the asked myself many times this year, “How Washington-Unicoi-Johnson, has accom - Alliance members who participated. would Jo handle that?” She is one of the plished membership increases. Attracting Our third focus area is fundraising for many good leaders and speakers from members can be done. I also learned from AMA Foundation. We do this primarily with whom I have learned during my years in the our smallest Alliance’s big accomplishments our “sharing card.” This year, Vice President Alliance. Our theme for the year, “Training that membership numbers are not the only Debbie Hilgenhurst arranged for the use of Tennessee’s Health Promotion Leaders,” factor for success. The tiny Bedford County a delightful winter scene on the cards, a highlights the Alliance as a place for us to group makes me think of the term “cell” as painting by artist Marabeth J. Quin. Most of learn skills to benefit our communities. used to describe units in underground the thousands of dollars raised with the shar - Serving the Tennessee community this past movements. Of course BCMAA members are ing card will come back to Tennessee’s med - year has been an honor and a privilege. Now not troublemakers, but the results they get ical schools’ scholarship funds. I pass the presidency into the capable hands with their little band are outsized. Our fourth focus area is membership of Heidi Dulebohn so that she may enjoy a TMAA has four focus areas. In the Health development. The big change we made this year of service to medical families and the Promotion focus, we took guidance from the year was defining our membership cycle for people of Tennessee. +

For membership information, contact Jan Headrick at 423-344-6206 or [email protected]; or TMAA Executive Assistant Judy Ginsberg at 615-460-1651, 800-659-1862 (toll free) or [email protected] .

44 Tennessee Medicine + www.tnmed.org + MAY 2013 NEW MEMBERS

BLOUNT COUNTY MEDICAL SOCIETY William M. Pugh, DO, Cookeville NORTHWEST TENNESSEE ACADEMY OF Neal W. Atchley, MD, Alcoa John D. Watson, MD, FACEP, Chattanooga MEDICINE Nancy G. Bartley, MD, Alcoa Sam W. Bradberry, MD, Union City Jennifer L. Best, MD, Alcoa CONSOLIDATED MEDICAL ASSEMBLY OF Johnny B. Joyner, MD, Dyersburg Andrew C. Dirmeyer, MD, Maryville WEST TENNESSEE Joseph W. Wolfe, MD, Dyersburg Rodney R. Ferguson, MD, Alcoa Lolly H. Eldridge, MD, Jackson Nils P. Gaddis, DO, Alcoa Spirithoula D. Vasilopoulos, MD, Jackson STONES RIVER ACADEMY OF MEDICINE Richard M. Gaddis, DO, Louisville Bhabendra N. Putatunda, MD, Lebanon Stanley S. Kelsey, MD, Maryville KNOXVILLE ACADEMY OF MEDICINE Roy E. Kuhl, Jr., MD, Alcoa Todd B. Abel, MD, Knoxville SULLIVAN COUNTY MEDICAL SOCIETY Alma K. Leaird, MD, Maryville Jason E. Cox, MD, Knoxville Marcus C. Grimes, MD, Kingsport Joe T. Mandrell, MD, Alcoa J. Caroline Haney-Weaver, MD, Knoxville William A. McCormick, MD, Bristol William R. Moore, MD, Maryville Oliver E. Hoig, MD, Knoxville Lisa A. McKinney-Smith, DO, Bristol Walter M. Novikoff, DO, Alcoa Julie W. Jeter, MD, Knoxville Kristin A. Pierce, MD, Kingsport C. Larry Rahn, MD, Walland Mariana C.M. Koonce, MD, Knoxville John R. Reisser, MD, Alcoa WASHINGTON-UNICOI-JOHNSON COUNTY Darryl L. Riegel, MD, Alcoa LAKEWAY MEDICAL SOCIETY MEDICAL SOCIETY Richard A. Savell, MD, Alcoa Conrad L. Brimhall, MD, Morristown Heather B. Breen, MD, Johnson City Jeffrey S. Scheib, MD, Alcoa Regina N. Coleman, MD, Talbott Ms. Katie Johnson, Johnson City William D. Vines, MD, Alcoa Rebecca A. Moul, DO, Morristown Hong I. Tjoa, MD, Jefferson City WILLIAMSON COUNTY MEDICAL SOCIETY BRADLEY COUNTY MEDICAL SOCIETY William D. Halford, MD, Franklin Jessica L. Clifford, MD, Apison THE MEMPHIS MEDICAL SOCIETY David J. Daniels, MD, Rochester CHATTANOOGA-HAMILTON COUNTY MEDICAL SOCIETY NASHVILLE ACADEMY OF MEDICINE Heather N. Gilliam, DO, Chattanooga Ms. Solita R. Jones, Nashville John D. Hammond, MD, Chattanooga Matthew R. McDonald, MD, Nashville Nathan E. Hartgrove, DO, Cumberland Gap William R.C. Stewart, III, MD, Brentwood Patrick B. McGinty, MD, Chattanooga Wesley P. Thayer, MD, Brentwood Jung T. Park, MD, Whitwell

IN MEMORIAM

RICHARD M. PENNY, MD, age 66. Died February 26, 2013. Graduate of WILLIAM GORDON JENNINGS, MD, age 83. Died April 3, 2013. Gradu - University of Kentucky School of Medicine. Member of Sullivan County ate of University of Tennessee Health Science Center. Direct member. Medical Society. MAURICE MASON ACREE, JR., MD, age 84. Died April 7, 2013. Gradu - WILLIAM SNODGRASS TAYLOR, MD, age 89. Died March 19, 2013. ate of University of Tennessee Health Science Center. Member of Nashville Graduate of University of Tennessee Health Science Center. Member of Put - Academy of Medicine. nam County Medical Society. WARREN BARCLAY HENRY, MD, age 89. Died April 12, 2013. Graduate MALCOLM EMORY ROGERS, MD, age 89. Died March 24, 2013. Grad - of Tulane University School of Medicine. Member of Chattanooga-Hamil - uate of University of Tennessee Health Science Center. Member of Sullivan ton County Medical Association County Medical Society.

WALTER MICHAEL BOEHM, MD, age 62. Died March 25, 2013. Gradu - ate of New York University School of Medicine. Member of Chattanooga- Hamilton County Medical Society.

Tennessee Medicine + www.tnmed.org + MAY 2013 45 CORRECTION CAREER OPPORTUNITY ADVERTISING An incorrect abstract was published as part of “Case Report and Review of the Literature: Spontaneous Aortobronchial Fistula” in the Career opportunity advertising is available for all TMA members. April issue of Tennessee Medicine (Vol. 106, No. 4, p. 39). Please return this page, with ad text typed and double-spaced, for all The correct abstract is published below: career opportunity advertising. Send to: Michael Hurst ABSTRACT Tennessee Medicine We present a fatal case of aortobronchial fistula due to ruptured ath - 2301 21st Avenue South, P.O. Box 120909 erosclerotic aneurysm of the aorta into the left lower lobe, bronchus. Nashville, Tennessee 37212-0909 Also, review of the pertinent literature is presented. Fistulas between Phone: (615) 385-2100 Fax: (615) 312-1900 the aorta and tracheobronchial tree are rare but usually lethal if not treated promptly and timely, as they can cause fatal hemoptysis. Aor - Rates are $100 for the first 50 words and then 25 cents for each additional tobronchial fistulas occur most often in patients who have a history individual word. Count as one word all single words, two initials of a name, of thoracic vascular surgery. Nevertheless, few cases without previ - single numbers, groups of numbers, hyphenated words, and abbreviations. ous thoracic surgery, trauma or infectious process of the aorta have Advertisers may utilize a box number for confidentiality, if desired, been described in the literature. in care of Tennessee Medicine, P.O. Box 120909, Nashville, TN 37212- 0909. Using this box in an ad will add eight (8) words to the total count. Tennessee Medicine regrets the error. The deadline is the 15th of the month proceeding the desired first month of publication, and will be subject to approval. Each listing will be removed after its first publication unless otherwise instructed. Please type your ad exactly as it should appear or e-mail your ad to Michael Hurst at [email protected] and send your check with a hard copy to his attention. You may call in with credit card information for payment, if needed.

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