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Pima County Medical Society

Home Medical Society of the 17th United States Surgeon-General


How to discourage a physician

SOMBRERO August/September 2016

Pima County Medical
Society Officers

Official Publication of the Pima County Medical Society

Jerry Hutchinson, DO
Roy Loewenstein, MD
Kevin Moynahan, MD
Snehal Patel, DO
Wayne Peate, MD
Kenneth Sandock, MD
Sarah Sullivan, DO
Salvatore Tirrito, MD
Debra Townsend, MD
Fred Van Hook, MD
Scott Weiss, MD
Leslie Willingham, MD
Jaren Trost, MD (Resident)
Aditya Paliwal, MD (alt. resident)
Jared Brock (student)

Timothy C. Fagan, MD
Michael A. Dean, MD
Susan J. Kalota, MD
Unfilled / Appointment
Melissa D. Levine, MD

PCMS Board of Directors

David Burgess, MD
Howard Eisenberg, MD
Kelly Ann Favre, MD

Members at Large

Vol. 49 No. 7

At Large ArMA Board

Charles Krone, MD
Clifford Martin, MD

Robert M. Aaronson, MD
R. Screven Farmer, MD

Board of Mediation

Pima Directors to ArMA

Timothy C. Fagan, MD

Thomas Griffin, MD
Evan Kligman, MD
George Makol, MD
Sheldon Marks, MD
Mark Mecikalski, MD

Delegates to AMA
Timothy C. Fagan, MD (alternate)
Gary R. Figge, MD
Michael F. Hamant, MD (alternate)
Thomas H. Hicks, MD

Arizona Medical
Association Officers
Michael F. Hamant, MD
Vice President
Thomas C. Rothe, MD
Outgoing Past President

Executive Director
Bill Fearneyhough
Phone: (520) 795-7985
(520) 323-9559
E-mail: billf

Bill Fearneyhough
I welcome your feedback and story ideas.
E-mail: billf

West Press
Phone: (520) 624-4939

Dennis Carey
Phone: (520) 795-7985
(520) 323-9559

Art Director
Alene Randklev
Phone: (520) 624-4939
(520) 624-2715

Pima County Medical Society
5199 E. Farness Dr., Suite 151
Tucson, AZ 85712
Phone: (520) 795-7985
Fax: (520) 323-9559


SOMBRERO (ISSN 0279-909X) is published monthly

except bimonthly June/July and August/September by the
Pima County Medical Society, 5199 E. Farness, Tucson,
Ariz. 85712. Annual subscription price is $30. Periodicals
paid at Tucson, AZ. POSTMASTER: Send address changes
to Pima County Medical Society, 5199 E. Farness Drive,
Ste. 151, Tucson, Arizona 85712-2134. Opinions expressed
are those of the individuals and do not necessarily represent
the opinions or policies of the publisher or the PCMS Board
of Directors, Executive Officers or the members at large,
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advertising submitted. Copyright 2016, Pima County
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SOMBRERO August/September 2016

5 How to Discourage a Physician: A sneak peak into the
mind of one health care consultant.
7 Letter to the Editor: Not everyone agrees with PSRs
8 ArMA News: President Gretchen Alexander, MD,
addresses the issues of health care in the 21st
11 Road Trip: Eastern Arizona provides an opportunity
to cool off and explore pioneer history.
14 In Memoriam: Remembering Dr. David Hardy and
Dr. Alma Hansen.
15 End of Life Care: EOLCC reaches out to Pima County
through workshops and presentations.
18 UA College of Pharmacy: Students launch new search
tool to help patients and physicians find prescriptions.
20 New Technology: Neurosurgeon Joseph Christiano
pioneers procedure to insert new MRI-compatible
spinal cord stimulator.
21 HIPAA: Attorney Bryan Bailey discusses the trend of
texting and staying compliant with HIPAA.
24 News Briefs: TMC Mega Raffle results, UA Fills
leadership positions, Rural Health and diabetes
programs receive funding.

On the Cover
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SOMBRERO August/September 2016

How to discourage a doctor

By Richard Gunderman, MD

ot accustomed to visiting
hospital executive suites, I
took my seat in the waiting
room somewhat warily. Seated
across from me was a
handsome man in a welltailored three-piece suit, whose
thoroughly professional
appearance made me in my
rumpled white coat, sheaves of
dog-eared paper bulging from
both pockets feel out of place.
Within a minute, an
administrative secretary came
out and escorted him into one
of the offices. Shortly thereafter, I noticed that he had left a
document on an adjacent chair. Its title immediately caught my
eye: How to Discourage a Doctor.
No one else was about, so I reached over, picked it up, and began
to leaf through its pages. It became immediately apparent that it
was one of the most remarkable documents I had ever read,
clearly not meant for my eyes. It seemed to be the product of a
healthcare consulting company, presumably the well-dressed
mans employer. Fearing that he would return any moment to
retrieve it, I perused it as quickly as possible. My recollection of
its contents is of course somewhat imperfect, but I can reproduce
the gist of what it said.
The stresses on todays hospital executive are enormous. They
include a rapidly shifting regulatory environment, downward
pressures on reimbursement rates, and seismic shifts in payment
mechanisms. Many leaders naturally feel as though they are
building a hospital in the midst of an earthquake. With prospects
for revenue enhancement highly uncertain, the best strategy for
ensuring a favorable bottom line is to reduce costs. And for the
foreseeable future, the most important driver of costs in virtually
every hospital will be its medical staff.
Though physician compensation accounts for only about 8% of
healthcare spending, decisions that physicians strongly influence
or make directly such as what medication to prescribe, whether
to perform surgery, and when to admit and discharge a patient
from the hospital have been estimated to account for as much
as 80% of the nations healthcare budget. To maintain a favorable
balance sheet, hospital executives need to gain control of their
physicians. Most hospitals have already taken an important step
in this direction by employing a growing proportion of their
medical staff.
Transforming previously independent physicians into employees
has increased hospital influence over their decision making, an
effect that has been successfully augmented in many centers by
tying physician compensation directly to the execution of hospital
strategic initiatives. But physicians have invested many years in
learning their craft, they hold their professional autonomy in high
esteem, and they take seriously the considerable respect and
SOMBRERO August/September 2016

trust with which many patients still regard them. As a result, the
challenge of managing a hospital medical staff continues to
resemble herding cats.
Merely controlling the purse strings is not enough. To truly seize
the reins of medicine, it is necessary to do more, to get into the
heads and hearts of physicians. And the way to do this is to show
physicians that they are not nearly so important as they think they
are. Physicians have long seen the patient-physician relationship
as the very center of the healthcare solar system. As we go
forward, they must be made to feel that this relationship is not the
brilliant sun around which everything else orbits, but rather one of
the dimmer peripheral planets, a Neptune or perhaps Uranus.
How can this goal be achieved? A complete list of proven tactics
and strategies is available to our clients, but some of the more
notable include the following:
Make healthcare incomprehensible to physicians. It is no easy
task to baffle the smartest people in the organization, but it can
be done. For example, make physicians increasingly dependent
on complex systems outside their domain of expertise, such as
information technology and coding and billing software. Ensure
that such systems are very costly, so that solo practitioners and
small groups, who naturally cannot afford them, must turn to the
hospital. And augment their sense of incompetence by making
such systems userunfriendly and
unreliable. Where
possible, change
vendors frequently.
Promote a sense of
insecurity among
the medical staff.
A comfortable
physician is a
confident physician,
and a confident
physician usually
proves difficult to
control. To
confidence, let it be
known that
physicians jobs are
in jeopardy and their
compensation is
likely to decline. Fire
one or more
physicians, ensuring
that the entire
medical staff knows
about it. Hire
replacements with a
minimum of fanfare.
Place a significant

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percentage of compensation at risk, so that physicians begin to

feel beholden to hospital administration for what they do get.
Transform physicians from decision makers to decision
implementers. Convince physicians that their professional
judgment regarding particular patients no longer constitutes a
reliable compass. Refer to such decisions as anecdotal,
idiosyncratic, or simply not evidence based. Make them feel that
their mission is not to balance benefits and risks against their
knowledge of particular patients, but instead to apply broad
practice guidelines to the care of all patients. Hiring, firing,
promotion, and all rewards should be based on conformity to
hospital-mandated policies and procedures.
Subject physicians to escalating productivity expectations.
Borrow terminology and methods from the manufacturing
industry to make them think of themselves as production-line
workers, then convince them that they are not working sufficiently
hard and fast. Show them industry standards and benchmarks in
comparison to which their output is subpar. On the off chance that
their productivity compares favorably, cite numerous reasons that
such benchmarks are biased and move the bar progressively
higher, from the 50th to the 75th to the 90th percentile.
Increase physicians responsibility while decreasing their
authority. For example, hold physicians responsible for patient
satisfaction scores, but ensure that such scores are influenced by
a variety of factors over which physicians have little or no control,
such as information technology, hospitality of staff members, and
parking. The goal of such measures is to induce a state that
psychologists refer to as learned helplessness, a growing sense
among physicians that whatever they do, they cannot
meaningfully influence healthcare, which is to say the operations
of the hospital.
Above all, introduce barriers between physicians and their
patients. The more directly physicians and patients feel
connected to one another, the greater the threat to the hospitals
control. When physicians think about the work they do, the first
image that comes to mind should be the hospital, and when
patients realize they need care, they should turn first to the
hospital, not a particular physician. One effective technique is to
ensure that patient-physician relationships are frequently
disrupted, so that the hospital remains the one constant.
Another is. . . .
Just as I started to read this last sentence, the office door opened
and the man in the three-piece suit emerged. Both he and the
hospital executive to whom he had been speaking were shaking
hands, smiling. As he turned, I hurriedly tossed the document
back onto the chair, but he caught a glimpse out of the corner of
his eye. He approached me, his face assuming a cross expression.
What have you been doing? he asked. Have you been reading
that? That is proprietary material, you know. You are not
supposed to have access to that information. Suddenly, I didnt
feel so discouraged anymore.
Dr. Gunderman is chancelors professor of radiology, pediatrics,
medical education, philosophy, liberal arts, philanthropy, and
medical humanities at Indiana University. He is also president of the
Indiana Radiological Society and elected member of the Council
steering Committee of the American College of Radiology.
SOMBRERO August/September 2016

Leer to Editor

Not everyone agrees with PSRs agenda

see from the letter by Dr. Graap and Dr. Hilts that Physicians for
Social Responsibility (PSR) is still out there calling for zero
nuclear weapons, along with its current main anti-affordable
electricity agenda. As always, the focus is primarily on U.S.
weapons, which are greatly diminished since PSRs efforts began.
Proliferation continues, however, and Russia and China are
upgrading and expanding their arsenals.
Not everybody agrees with PSRs assertion
that nuclear weapons are not usable under
any circumstances. The risk of war is
extremely high. What will happen if a
suitcase bomb is detonated by a suicide
bomber, or nuclear-armed missiles are
launched, deliberately or by mistake?
PSR seems to agree with U.S. policy that
assures the maximal number of U.S.
casualties. Millions of preventable deaths
could occur or lack of information. Most
importantly: if you see a bright flash, drop
and cover, and breathe through your mouth.
(If you see a flash, you are not in the fireball
but are about to get hit with a blast wave.)
And what about fallout? The EPAs RadNet
and FEMAs Rad Responder network are
sparsely distributed and wholly inadequate.
Most government instruments are for
interdiction, not response. They max out at
low levels and would be worse than useless
in the presence of dangerous levels of
radiation. Hospitals and government
buildings could have an Automated Radiation
Monitoring Station on their roof for less than
$10,000, which would shut down the HVAC
system and protect the interior from
contamination, but people are in deep denial
about the need. One of these stations is on
the roof of the office of the Medical Reserve
Corps of Southern Arizona, constantly
transmitting readings by internet.


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SOMBRERO August/September 2016

ArMA News

Physician engagement for the 21st century:

How your medical association can help you
Editors note: This speech was
presented during the June 4-5
Annual ArMA meeting and was
published in the summer issue
of the ArMA magazine AZ
As a fourth generation
physician, I grew up in the
1960s part of an extended
family in which public service
and self-sacrifice were core
values. At the dinner table, I
heard tales of my greatgrandfathers adventures as a
medical missionary in China,
and how, while working in
Gretchen Alexander, MD
Egypt in the 1 930s, he
ArMA President
deliberately infected himself
with schistosoma haematobium in order to bring schistosomiasis
into the U.S. to be studied in vivo at New York University. Good
doctors dont worry about how much money they make I was
told. Family conversations revolved around medical missions to
Africa, editing journals and medical school administration.
Implicit in my medical socialization was the understanding that a
social contract exists between doctors and society: we are
expected to altruistically, competently, and in a moral and ethical
fashion work not only to heal our patients, but for the public
good. In return, we expect professional autonomy and the
privilege of self-regulation, reasonable financial rewards, and a
functioning healthcare system. (1)
And yet, over the course of the last two or three decades, we
have seen that social contract be used to hold us accountable not
to our patients but increasingly to corporate entities whose aims
relate more to income, profits and shareholder value than to
patient care. The reasons for this change, and some of the
consequences to our profession and patients are as follows:
Healthcare in the U.S. today is big business, with total
expenditures in 2014 reaching $3 trillion (2). Of this figure, it is
interesting to note that physician compensation accounts for only
10% (3), while administrative costs have been estimated at 30%,
with one out of every four healthcare workers being engaged in
administrative work as opposed to direct patient care (4). Our
healthcare system is increasingly complex, fragmented and, at
times, ineffective. The direct costs of administrative complexity
and failure of care coordination were estimated to be between
$132 and $434 billion in 2011 (5). This inefficiency is occurring in
spite of unprecedented levels of consolidation among insurers,

hospital systems and large group practices in recent years (6).

Over these same years the largest healthcare insurers and
hospital groups saw record profits and stock prices (7). Possibly
not coincidentally, those years also saw record amounts spent on
legislative representation of corporate interests in healthcare (8).
Who is not doing so well in the new world of Big Healthcare?
Our patients, for one. At least twenty-seven percent of personal
bankruptcy cases in the U.S. are related to medical bills (9).
Health outcomes in the U.S. notoriously lag those of our peers in
the developed world in benchmarks such as life expectancy and
infant mortality rates. And recent work suggests that medical
error may be the third most common cause of death in the
United States with an estimated 250,000 deaths per year (10).
Physicians are also suffering in this system. As we become
subject to a corporate construct where our work is seen as a
product intended to drive a revenue stream, rather than a calling,
we find ourselves conflicted between a corporate culture that
tends to value affability, efficiency and expediency and our own
medical culture in which thoughtful diligence in the service of our
patient is the highest value. Regulatory requirements for quality
metrics and preventive health add additional tasks to the
physicians already full plate. A recent study estimated that a
primary care physician would spend 21.7 hours per day to
provide all recommended acute, chronic, and preventive care for
a panel of 2,500 patients (11). The typical medical practice
spends $83,000 per physician per year on administrative costs
(12) and the typical physician spends about 16% of his or her
workweek engaged in non patient care-related paperwork, with
more time spent on paperwork by physicians using entirely
electronic health records (13).
These working conditions are unsustainable, and they are
significantly impacting physician engagement and wellness.
Burnout rates for our profession range from 30%-65% with higher
rates for emergency medicine, general internal medicine, and
female physicians (14). 58% of physicians would not recommend
medicine as a career for their children (15) and 15-30% of medical
students and residents are found on screening to have symptoms
of depression (16).
As our professional engagement falters, access to medical care is
being affected. Physicians are working fewer hours, seeing
fewer patients and limiting access to their practices...The
research estimates that if these patterns continue, 44,250 fulltime-equivalent physicians will be lost from the work force in the
next four years (17).
In spite of all, we should maintain hope. It is my opinion that we
have a great deal to be thankful for. Physicians still, by and large,

SOMBRERO August/September 2016

enjoy a level of financial security that many U.S. workers do not.

Our work is intellectually stimulating, and when we are given
time to do it well, there is no better reward than the
appreciation of our patients and their families. We must work
hard to preserve those positive features.
Our profession involves unique stressors in the forms of delayed
gratification, chronic sleep deprivation, limited control over our
daily workflow, and ever-increasing cognitive workloads. There
must be some degree of balance so that our profession can
continue to attract qualified young people who want to be engaged
in full-time patient care, as opposed to administrative work.
We must become more comfortable about working within
organized medicine to ensure that our professional organizations
work effectively to set limits and advocate for our profession, for
in doing so, we are ultimately advocating for our patients and
the quality of the medical care that they receive.
In order to accomplish this successfully, we must work to
improve physician engagement not only in our profession but
with each other, and with the efforts of organized medicine.
With this overarching goal in mind I propose objectives for ArMA
in the following areas:
Legislative representation: Our overseers are writing healthcare
policy which advantages them in the business arena, to the
detriment of both patients and physicians. In order to respond
effectively, organized medicine must move from a defensive to a
proactive legislative stance. We must be participating in writing
healthcare policy, not just reacting to legislation we dont like. An
opportunity in this area has arisen from ArMAs work over the
last year to create a liaison with the state department of
insurance which could advocate for physicians attempting to
deal with health plan violations. It has become apparent from
those efforts that a statutory approach would be most effective.
I have asked that for 2016-2017, a goal of our legislative
department be to seek introduction of a bill in the next session
which would create an office within the insurance department
dedicated to addressing physician complaints and concerns.
Currently, and perhaps surprisingly, no such function exists. This
needs to be rectified.
An additional area of potential opportunity for proactive
legislation would be in the area of Maintenance of Certification.
No one can deny that lifelong learning is a critical aspect of
responsible medical practice. However, the current iteration of
the MOC system is deeply compromised by concerns about lack
of evidence of efficacy, financial impropriety and the
administrative burdens of required data collection and QI
activities. Several states have recently passed legislation
preventing MOC status to be required for licensure or medical
credentialing. In my opinion, consideration should be given to
ArMA supporting such legislation in Arizona.
A secondary objective for the year would be enhanced physician
engagement in ArMAs legislative work. I have begun talks with
Chic and with Pele Fisher, our VP of Policy and Political Affairs
about strategies that ArMA could use to facilitate member
communication with legislators and participation in advocacy
efforts. In the coming year we hope to achieve some small but
useful changes that will facilitate such engagement.
SOMBRERO August/September 2016

Finances: In order for an organization to be effective, it must be

financially sound. ArMA must continue to work toward
establishing an operating reserve comparable to the reserves
that other state medical societies maintain. Such reserves allow
organizations to respond effectively to unanticipated losses in
revenue or significant advocacy challenges. In support of this
goal, I have requested that the 2016-2017 budget reflect an
increased net margin over that which has been previously
instituted and observed.
An additional goal in this area is the long-discussed sale of the
ArMA building. Our building was designed for us in 1969 by
Bennie Gonzales, a distinguished architect who was a native
Phoenician and was responsible for the design of many delightful
structures across Arizona including the Heard Museum, the
Gloria Dei Lutheran Church in Paradise Valley and most of the City
of Scottsdales civic buildings. Our building is a wonderful
example of Gonazales unique contemporary Southwest style and
it has served us well; however, as it ages, its maintenance costs
significantly impact our bottom line. A financial analysis carried
out last year shows that it would be more fiscally prudent for
ArMA to rent comparable space and put the proceeds from the
sale of the building into operating reserves. Therefore, the
Executive Committee has requested that ArMA make a firm
commitment to accomplishing the listing of the building for sale,
this year. Once the building is sold, proceeds from the sale will be
used to create a separate operating reserve fund.
Consolidation and coordination of efforts within the house of
medicine: In order to effectively advocate for our profession, we
must learn to speak as one voice. We are, at times, working to
oppose forces which have effectively used consolidation to
acquire increasing degrees of power over the future of
healthcare. We must look to consolidate ArMAs efforts with
those of other organizations in the medical community. In
support of this goal, I intend to continue the highly successful
expansion of quarterly meetings with our states medical
specialty societies which Dr. Laufer initiated last year.
Additionally, continued exploration of partnership opportunities
with other medical societies will be actively pursued.
Membership: Enhanced engagement of our membership is critical.
The continued fiscal health of ArMA depends on sufficient revenue
from membership dues to support our mission; opportunities for
membership growth exist among female physicians and primary
care physicians. Also importantly, through effective engagement of
our members, we can address burnout by helping to support
improved professional self-efficacy. Opportunities for social and
educational programs that support mastery of our increasingly
difficult practice environment are key in providing that support.
With this in mind, I am focused on member programming for the
coming year to include the following:
Continued expansion of the successful physician leadership
conference introduced by Dr. Mueller in 2014. This program has
been a popular forum for our members to meet with one another
and with leaders in the healthcare industry to freely exchange
thoughts and ideas about the future of healthcare. I pledge to do
whatever is necessary to ensure its continued success.
Accomplishment of a membership needs assessment, in order to
gain actionable insight into the concerns of practicing physicians

in Arizona. By knowing what concerns our members and

potential members the most, ArMA will create targeted
programming in order to stay responsive to member needs.

Last, but not least, thanks to all of you for the opportunity to
serve you in the coming year. Please feel free to contact me at with comments, questions or suggestions.

Institution of a more effective means by which House of

Delegates resolutions are considered by the Board for active
implementation. Each year, great suggestions are made by our
membership through the resolution process for advocacy work
by ArMA. Seeing these resolutions through wherever possible, to
meaningful action on the part of ArMA, will enhance member
engagement and organizational efficacy.

1. Cruess SR, Cruess RL. Professionalism and Medicines Social Contract
with Society. AMA Journal of Ethics, April 2004, Vol 6, No 4.
2. National Health Expenditures 2014 Highlights. https://www.cms.
3. Rampell, C. Doctors Salaries and the Cost of Health Care. The New
York Times. November 14, 2008. http://economix.blogs.nytimes.

Smaller and more informal meetings to provide socialization and

practical guidance to our members on matters of interest to
practicing physicians such as contract negotiation and effective
practice management in the face of MACRA. Only through talking
to each other can we unite and become effective. ArMA must
continue to look for ways to provide Arizona physicians with
those opportunities.

4. Pfeffer, Jeffery. The Reason Health Care Is So Expensive: Insurance

Companies. April 2016.
5. Berwick, Hackbarth. Eliminating Waste in U.S. Health Care. JAMA
6. Top ten health industry issues of 2016: Consolidation. PwC Health
Research Institute.

None of this can occur without significant effort on the part of all
involved. I would like to thank my supportive husband and our
wonderful children George, Anna and John who have tolerated
many late nights, mediocre dinners and opportunities to babysit
each other as I engaged in ArMA work over the last several years.

7. La Monica, P. Thanks, Obamacare! Health insurer stocks soar. CNN

Money. January 21, 2015.
8. Lobbying/Industry: Pharmaceuticals/Health Products, 2015. Center

I would also like thank our hardworking ArMA staff, the Board of
for Responsive Politics.
Directors and the House of Delegates for their active participation
and guidance. Thanks are also due to past presidents Orford,
9. Mathur, Aparna. Medical Bills and Bankruptcy Filings. American
Thrift, Rothe, Mueller and Laufer and also my department chair
Enterprise Institute. July 2006.
at MIHS, Dr. Carol Olson, for their invaluable mentorship over the
last several years.








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Janis Gasch, Au.D.
Doctor of Audiology, Founding Director


11. Altschuler,Margolius,Bodenheimer,
Grumbach. Estimating a Reasonable Patient
Panel Size for Primary Care Physicians With TeamBased Task Delegation. Ann Fam Med:
September/October 2012vol. 10no. 5396-400.

RINGING 12. D. Morra, S. Nicholson, W. Levinson et al., U.S.

Learn more about why we are a
preferred audiologistplease visit our website:
We are preferred providers
on most insurance plans.

10. Makary MA. Medical errorthe third leading

cause of death in the US. BMJ2016;353:i2139.

Physician Practices Spend Nearly Four Times as

Much Money Interacting with Health Plans and
Payers Than Do Their Canadian Counterparts,
Health Affairs Web First, Aug. 3, 2011.

13. Administrative work consumes one-sixth of

U.S. physicians time and erodes their morale,
researchers say. Physicians for a National Health
Program. October 23, 2014. http://www.pnhp.
14. Linzer M1,Levine R,Meltzer D,Poplau
S,Warde C,West CP. 10 bold steps to prevent
burnout in general internal medicine. J Gen Intern
Med.2014 Jan;29(1):18-20. doi: 10.1007/s11606013-2597-8.
15, 17. A Survey of Americas Physicians: Practice
Patterns and Perspectives. The Physicians
Foundation. September 2012.
16. Andrew, L. Physician Suicide. Medscape.
June 1, 2016.

SOMBRERO August/September 2016

Road Trip

Mountaintop Meander
What to do in the summer heat? Feast your eyes on big sky
panoramas, explore pioneer history, and take it from there.
By Monica Surfaro Spigelman / Photos by Leigh Spigelman

ts here: Our desert-frying, wilting summer. If visions of shaded

porch swings are stirring, theres a high mountain adventure in
the eastern corner of Arizona to cool this summers meltdown.
Its a place where a forest canopy crowns an astounding view and
allows you to walk in the footsteps of pioneers.
From either Tucson or Phoenix, the drive is less than two hours to
start this absorbing and refreshing trip through Graham and
Greenlee counties. Here, you will meander through small towns
while enjoying a sprinkling of astronomy, small museums, local eats
and mountaintop recreation.
Discovery Park (west off US 191 onto Discovery Park Blvd.) in
Safford is a starting point of interest: Its a multi-purpose
educational complex where you may explore a natural habitat
while enjoying extensive vistas of towering Mt. Graham.
Discovery Park also is where to make reservations for a shuttle
ride up to Mt. Graham International Observatory. There are
interpretative tours of the Observatorys three huge, unusual
telescopes (the Vatican Advanced Technology Telescope, the
Submillimeter Telescope and the Large Binocular Telescope), and
tours are offered weekends, now through October. Tours feature
the scenic trip up to Mount Graham, a lunch near the mountain
summit and a guided visit of the Observatory.
Riding The Old West Highway

Outstanding vistas and fragrant mountain air, as well as hiking

trails, camping and hunting, all are part of the experience when
driving the Coronado Scenic Byway.

Society showcases its collections of Mormon family exhibits, area

mining histories, Native American artifacts and pioneer-related
This area also is home to the Salsa Trail so visitors can expect a
sampler of Mexican restaurants, a chili farm and a tortilla factory,
with authentic Mexican cooking and home-style treats.

An old highway route along the fertile Gila Valley offers another
After browsing the Old West Highway towns and Saffords
interesting detour, just outside of Safford. US 70 West passes
Discovery Park, its time to
through cotton and
head north onto US 191,
rancher towns settled by
toward the Apache
Mormons in the 1870s: In
Sitgreaves National Forest.
Thatcher, Eastern Arizona
This is where youll find the
College houses a
Coronado Trail Scenic
significant collection of
Byway, which follows a
ancient cultural artifacts,
portion of the path made
including hundreds of
by Spanish conquistador
restored pottery
Francisco Vzquez de
excavated from
Coronado, who led an
archaeological sites in
expedition from Mexico in
New Mexico and Arizona.
1540, in search of the
In Pima, you can refresh at
Seven Cities of Gold. Its a
Taylor Freeze, an oldstunning, winding road
fashioned drive-in with
passing through over 400
tasty soft-serves, burgers
switchbacks that traverse
and shakes. You also can
high desert, national
browse through the three
forest, and panoramas full
historic buildings in town,
The climb up along the Coronado Trail Scenic Byway, through the Apacheof scenic land and Western
where the Eastern Arizona
Sitgreaves National Forest, takes drivers through multiple topographic
Museum and Historical
zones, include vast grasslands.
SOMBRERO August/September 2016


The remote Hannagan Meadow Lodge has been operational

since 1926 Visitors find rustic solitude, perched in a grassy
meadow in at 9100+ feet.

To tour Mount Graham International Observatory, visit Eastern

Arizona Colleges Discovery Park Campus, weekends now through
October. Reservations to tour the Observatory are required.

Pioneer Escapades
A stop along US 191 about 12 miles north of Safford is Clifton, the
Greenlee County seat that also is known as Geronimos
birthplace. In the mid 1800s, copper ore brought a boom of
claims and the railroad to Clifton, which is a rough and tumble
small town set in a rocky San Francisco River canyon. Historic
Chase Creek houses Cliftons main street a row of mining-era
territorial architecture that now accommodates several local
shops. To get the full picture on local history, the Greenlee County
museum and historical society building has exhibits documenting
Coronado, Apache, miner and rancher history, and is open on
weekends or by appointment. Other Clifton landmark marvels
include a restored early 1900s railway station and a stone,
Bastille-like jailhouse built in the 1800s. There are many stories
of Wild West bandits incarcerated in this famous old stone jail.

abundant wildlife, including wild turkey, elk and bighorn sheep.

Making Tracks with Coronado

Remember to bring your responsible driving skills along during

this exhilarating ride. Drive slowly, savoring the sights and
stopping at pullouts for your photography.
After about 60 miles along this untamed scenic road, your
dramatic climb levels off into a notch of mountain grassland
called Hannagan Meadow. In this land of lumberjacks and
conquistadors, you can spend a couple of nights in restful,
inspiring solitude. Hannagan Meadow Lodge has operated in
some form since the highways dedication in 1926. The Lodge is a
beacon of hospitality, where you can browse Lodge scrapbooks or
play horseshoes. You can dally through your cowboy-styled
breakfast, lunch and dinner, served in a rustic dining room with
meadow views that often include passing wildlife. There are
cowboy cook-outs during summertime Saturday evenings.

Please be aware that there is no cell service at Hannagan

Hopping back on US 191 North, the drive passes a tiny hillside
Meadow the highest-altitude weather reporting station in
cemetery and then a pull out at Morenci, where as far as the eye
Arizona. However, there is a Lodge landline phone as well as
can see are multi-colored terraces from one of the Western
limited Wi-Fi in the Lodge lobby. If you plan to stay the weekend,
Hemispheres largest open pit mines. Although Morenci stirs
youll have your choice of four-season recreation, including
mixed feelings among environmentalists, theres no doubt that
photography, off-trail hunting and hiking. There is excellent
the mining behind the spectacle helped shape Arizonas history
camping and fishing (trout and catfish) in the Apache Sitgreaves
and economy. Continuing just
National Forest. Drives from
past the mine, youll enter the
your Hannagan Meadow
Apache-Sitgreaves National Forest
hideaway lead you to various
and begin your climb upward
panoramic turnouts, or to rides
along the Coronado Trail Scenic
along forest roads that offer
Byway. This segment of U.S. 191
glimpses of bighorns and turkey
that approximates Coronados
as well as scenery.
path is a motor enthusiasts
Best in Class Detours
dream. The hundreds of curves
After visiting the Hannagan
ascend about 5,000 feet, and take
Meadow Lodge, you may
drivers through multiple
continue travels north, to the
topographic zones. There is still
next mountain town of Alpine
damage to be noted from the
(excellent eats at Bear Wallow
2011 Wallow fire, but the vast
Caf), or 45 miles further north
vistas are stunning, and the road
to Springerville, where the
wiggling is rewarded. If youre
National Historic Landmark and
lucky youll catch glimpses of
The Bastille-like 1800s jail in the historic mining town of Clifton
is one of the most famous in Arizona.

SOMBRERO August/September 2016

Old-fashioned Americana eats, including shakes and burgers,

are found at family-run Taylor Freeze.

The Eastern Arizona Museum is housed in three historic Pima

buildings (circa 1800s).

archaeological site called Casa Malpais awaits, with its Great Kiva
and rock art sites.

Extremely high altitude (10,400 feet); check website for health


For additional options, head back south on US 191, to US 70, this

time heading east through Duncan, where theres more Greenlee
County remote goodness in local birding and history. Theres also
rock hounding for fire agates nearby the Lazy B ranch, the
childhood home of Supreme Court Justice Sandra Day OConnor
(high clearance vehicles suggested).


Sometimes we want to soak up surprises, poking through
territorial towns or motoring along historic roads with extra
pizzazz. Theres no doubt that this memorable trip through
Graham and Greenlee counties conjures up a wild and
picturesque southwest pallet and its mountaintop diversion is
perfect for a summer outing that offers much to love and explore.
Mt. Graham International Observatory Tour
Eastern Arizona Colleges Discovery Park Campus
1651 W. Discovery Park Blvd., Safford
There are exhibits and a simulator at the Discovery Park center.
For reservations up to the Observatory: $40 ticket includes
transportation, lunch & full day tour

SOMBRERO August/September 2016

Greenlee County Chamber of Commerce

100 N. Coronado, Clifton
Save the Dates:
Colors of Copper Art Fair in Clifton (November 2016)
Greenlee County Fair, Rodeo and Mud Drag finals (September
Graham County Chamber of Commerce
1111 Thatcher Blvd., Safford
(Salsa Fest: September 2016)
(Pima Chili Cook-off and Desert Auction, Fall 2016)
Hannagan Meadow Lodge
23150 U.S. 191
(Saturday Cowboy Cook-Outs, Summer 2016)


In Memoriam

Dr. Alma Kelsch Kelly

Hansen 1922-2016

Dr. David L. Hardy


lma Kelsch Kelly

Hansen MD, ophthalmologist and 50-Year
Member of the Pima County
Medical Society, passed away
June 25, 2016. He was 94.
Hansen was born January
16, 1922 in Richfield, Utah.
After graduating from
Richfield High School in
1940, he served in the Air
Force during World War II.
He completed his medical
studies in 1946 at the
University of Utah Medical
School. He finished his
internship at Wesley Memorial Hospital in Chicago in 1947 and
went into general practice in the Air Force for two years and then
in Lewiston, Utah until 1953. He completed his ophthalmology
residency at the University of Iowa Hospital in 1956 and moved to
Tucson to begin his private practice.
After joining PCMS in March of 1956, Hansen was an alternate
delegate from 1965-1968 and named parliamentarian in 196768. He served on the Public Health and School Medicine and
Member Program Committees. Hansen was selected as a
delegate to the Arizona Medical Association from 1967-1970. He
remained active in the Society until his retirement in 1981.
Hansens interests other than medicine included golf, dancing,
spending time with his family on their boat at Lake Powell or at
their cabin at Hawley Lake. He was a member of the Mormon
Church and elected president of the Tucson Rotary Club in 1978.
He was preceded in death by his wife Polly. His children indicated
there was no service according to his wishes.

nesthesiologist and
long-time Tucson
resident David L. Hardy, MD,
passed away June 23, 2016.
He was 83.
Hardy was born in Ancon in
the Panama Canal Zone on
June 16, 1933. He studied at
the University of Kansas
where he received his BA and
graduated from medical
school in 1959. Hardy finished
his internship at William
Beaumont General Hospital in
El Paso in 1960 and completed
his residency in
anesthesiology in 1963 at Brooke General Hospital, Fort Sam
Houston, Texas. He practiced and taught anesthesiology residents
and nurse anesthetists at Tripler General Hospital in Hawaii for four
years before coming to Tucson.
He started his practice and joined the Pima County Medical
Society in October 1967. He was a member of PCMS until 1998.
He was also a member of the American Society of
Outside his practice, Hardy was interested in herpetology and
snakes. He did extensive research into the behavior and venom of
rattlesnakes in southern Arizona in partnership with
herpetologists at the University of California.
He was preceded in death by his wife of 58 years, Billie Frances
(Bergen) Hardy. He is survived by his brother Perium Hardy and
sister-in-law Diane Hardy; his daughter Margaret C. Hardy and
son-in-law Danny L. Rowland; his son David L. Hardy and four
grandchildren William, Anna, Katarina and Annika. Donations in
his memory can be made to the Tucson Herpetological Society or
the Arizona Sonoran Desert Museum.

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520.624.4939 | 888.637.0337
SOMBRERO August/September 2016

End of Life Care

Coalition advocate for end-of-life planning

By Rachel Peterson, MA, MPH

his summer, the Banner University Medical Center General

Internal Medicine primary care clinics started a new
initiative: every patient who walks through the door will be asked
to consider completing a durable medical power of attorney or a
living will.
These documents should be part of our health care
maintenance the same as colonoscopy or mammography,
explained Dr. Mindy Fain, Anne & Alden Hart Professor of
Medicine and Chief of the Division of Geriatrics, General Internal
Medicine and Palliative Medicine at the University of Arizona.
This is part of routine care.
The goal of this initiative is to normalize the conversation for both
patients and providers including internal medicine residents,
whom Fain says she hopes will continue the practice throughout
their careers.
The End of Life Care Coalition similarly is working to normalize
end of life care planning in Pima County. During the past few
years, the coalition has educated seniors and caregivers about
the importance of completing written documentation to reflect
ones medical, spiritual and personal care preferences in the
event they are unable to advocate for themselves. The group has
reached more than 1,600 community members through inperson workshops and outreach, and tens of thousands more
through media.
Both of these initiatives are part of a growing movement toward
better planning and communication for end of life care. This issue
will continue to gain importance as more people live into
advanced age with chronic illness alongside advances in lifeprolonging medical technology.
Frank Williams, co-chair of the End of Life Care Coalition and
Director of Social Services for Casa de la Luz Hospice, agrees that
these conversations need to occur earlier.
Its not just about advanced directives or the last six months of
life, he said. The more important issue is having a conversation in
a family about how we want to live, and how we want our families
to be a part of the process when we move into our elder years.
Rev. Karen MacDonald, co-chair of the End of Life Care Coalition
and Health Education Manager for Interfaith Community Services
added that while some people dont want to talk about death,
end of life care planning can bring comfort to older adults and
their families.
Completing an advance directive helps ensure that ones values
and wishes for how to live through the end of life are honored, she
said. It also helps loved ones navigate the fraught time of dying by
providing guidelines for health care decisions, reducing the guilt
loved ones may feel in having to make such difficult decisions.
Currently it is estimated that only a third of the population has
SOMBRERO August/September 2016

completed any form of advance directive. According to Fain, these

low numbers reflect general misperceptions and discomfort
among healthcare providers about their role in and the timing of
advance care planning discussions and end of life care.
Not every patient with hypertension needs a cardiologist, and
not every patient with serious or life limiting illness needs a
palliative care specialist, she said. Palliative care is a skill set for
improving the quality of life for patients and families with serious
illness, which should be practiced by all providers.
Practicing palliative care skills and having these critical
conversations is one of Fains training goals for UMC residents.
For the majority of patients age 18 and older, priority is placed on
completing the durable health care power of attorney, and
encouraging the conversation about their care preferences with
their designated person. However, living wills also are important,
as most include organ donation preferences, Fain noted.
These conversations are a comfortable way to engage people in
thinking about their life, their goals and values, their death, and
who they trust to make decisions, Fain said. Bad things happen
unexpectedly to all of us. Thats when challenges arise.
Introducing advance care planning among younger and healthier
patients can establish norms about these discussions, and
generate conversations within the larger family that can influence
parents and grandparents, Fain added. Preferences evolve over
time, so it is good practice to reconfirm the durable power of
attorney with younger patients periodically.
For patients in their last 5 to 10 years of life, greater emphasis is
placed on completing a living will. According to Fain, this is easiest to
do with new patients because it provides an opportunity to
establish goals of care at the beginning of the relationship. The
initial visit is the best time to ask the patient about their
understanding of their medical problems, and to learn what their
last provider told them to expect regarding their medical conditions.
For continuing patients, providers need to create an opportunity
to have these conversations on a routine basis, rather than to
always couple it with bad news, Fain noted.
Establishing the patients understanding of their condition is
essential before anything else happens, she said. Despite how
great of communicator you are and how long youve had a
relationship with the patient, there is always a gap with the
patients understanding. Always ask for their understanding of
their condition right now. Step back and get a sense of whether
everyone is on the same page, but be careful not to ask it in a way
that it seems like a test. Then ask if they have questions, framing
it in a way that makes it easy for them to ask.
One barrier that has prevented these conversations, according to
Fain, is that providers struggle to identify when a patient is in
their end of life.

Healthcare providers are bad at recognizing when patients are

seriously ill. We dont like to prognosticate, and we treat death as
the enemy, Fain observed. We hope to teach our residents to
step back and ask, Would I be surprised if this patient died in the
next six months? This helps to filter those patients who have
more serious illness and are possibly at the end of their life.
Integrating the conversation into routine visits helps to address
this issue. Fain trains her residents on a six-step process to guide
when and how to have the conversation:
1. Start soon after the diagnosis of a life-limiting condition.
2. Be prepared with the facts of the case.
3. Listen and respond to the patients feelings, and ask openended questions (not yes or no) about the patients
wishes and worries.
4. Restate your understanding of the persons priorities.
5. Recommend a care plan based on the patients goals,
including treatments, monitoring, tests and medications.
6. Restate the goals and next steps. Debrief. Discuss with key
staff. Document.
This approach, done in a primary care setting, overcomes many
of the concerns and bad outcomes that are often associated with
end of life care conversations, including those reported in a study
published in JAMA on July 5. Entitled Effect of Palliative Care
Led Meetings for Families of Patients with Chronic Critical Illness,
the trial found that palliative-care conversations did not reduce
anxiety or depression among families of patients with critical
illness, and in some cases caused post-traumatic stress.
These were not really acute care-palliative care consults, which
typically take three visits or more, Fain said of the study. These
were actually prognostication consults done in one or two visits,
on average.
These findings provide justification for the ongoing conversation
she is training residents to have early and often in her clinics, Fain
Given the lack of staffing and pressures for productivity in current
hospital and clinical settings another barrier to the completion
of living wills Fain is not surprised by the studys results, she
The trick, according to Fain, is to integrate end of life care
planning into the work flow. Information on the durable medical
power of attorney and living will forms can be given at the front
desk upon check in, and community resources, such as
educational workshops provided by the End of Life Care Coalition,
can be made available. All staff should be able to answer basic
questions about the documents, Fain said, which will also help to
prime the conversation for the healthcare provider.
Integrating these documents into clinic flow further helps to
normalize the process and overcome an additional barrier that
Fain has identified: the misperception that patients dont want to
have these conversations. While this may be true for some, it has
not been the experience of the End of Life Care Coalition
members. In the past year alone, the group has facilitated the
completion of about 800 advance directives.
While MacDonald acknowledges that younger and healthier
people tend not to want to think about issues of death and dying,

What is the End of Life Care Coalition?

The End of Life Care Coalition, an Action Team of the ELDER
Alliance, is dedicated to community outreach and
education to support adults of all ages in the conversation,
planning and documentation of advance directives. The
vision is for every individual in Pima County to engage in
end of life care planning.
The End of Life Care Coalition (EOLCC) promotes education
on end of life care issues by offering workshops,
presentations and resources. The EOLCC has reached more
than 1,600 individuals through its strategic community
outreach. From July 1, 2015 to June 30, 2016, nearly 800
adults in Pima County documented and reported the
completion of advance directives through the EOLCCs
Count Me In online and paper-based tracking process.
The EOLCC members represent the diverse sectors in which
end of life care planning occurs, and include communitybased organizations, healthcare, hospices, academic
institutions, and businesses whose mission is to promote
education and resources to prepare for end of life care.
The End of Life Coalition is supported by the Sharon Kent
Foundation at the Community Foundation for Southern
Arizona, Pima Council on Aging and United Way of Tucson
and Southern Arizona.
Upcoming End of Life Care Events:
September 9, 1-3 p.m., at the JCC: Your Life, Your Choices:
Straight Talk about Tough Issues, presented by JFCS of
Southern Arizona, The Mel Sherman Institute on Mental
Health Series, with Paige Hector, LMSW. Attendance is free.
RSVP online at or call 520-795-0300
ext. 2238
November 11, 8:30 a.m. to 4 p.m., at The Westin La Paloma:
Casa de la Luz Foundation presents 2016 End-of-Life
Community Conference, The Skills and Art of
Compassion, featuring Frank Ostaseski. Attendance is $65.
For more information, visit

a larger obstacle for completing an advance directive is

understanding the complexity of possible health care treatments
that are available, and weighing their costs and benefits. This is
where healthcare providers have a critical role. We aim to
expand our work by connecting with healthcare providers and
other partners to promote end-of-life care planning throughout
the community, MacDonald said.
According to Fain, healthcare providers should take the lead in
these conversations. At some point the patient is going to want
to talk to you and you want to hear from them what their goals of
care are because they drive the care plan. It doesnt have to be a
tough conversation. It is different depending on the persons
clinical circumstances. The focus is on that persons values.
Rachel Peterson is a Health Educator, Senior, University of Arizona
Center on Aging and End of Life Care Coalition Member
SOMBRERO August/September 2016

Dr. Chandler joins Personalized

HealthCare of Tucson

ucson native and UA

Medical School honors
graduate Aldine S. Chandler,
MD has joined Personalized
HealthCare of Tucson. She
will practice alongside
founding practice physician
Dr. Steve Wool.
She completed her internal
medicine residency training
at the University of
Washington in Seattle,
which was ranked first
nationally for primary care
training by US News &
World Report 2016 and has
distinguished herself in multiple areas during her educational and

professional development. She earned honors in the majority

of her clerkships including, Intensive Care Medicine, Internal
Medicine, Surgery, Hematology-Oncology, OB/GYN and
Pediatrics. She has demonstrated her commitment to
underserved populations through her work with Seattles
Homeless Health programs, Teenage Mentor Program, and has
served to advance her profession through mentoring and
She is Board Certified in Internal Medicine by the American Board
of Internal Medicine and received additional training as a
hospitalist to enhance her primary care experience.
Chandler is accepting new patients and will cover call for the
practice and help with same-day and urgent patient
appointments. To make a referral please call Personalized
HealthCare of Tucson, 547-1661.


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SOMBRERO August/September 2016


UA College of Pharmacy

Students launch medication search tool

UA Health Sciences Office of Public Affairs

ow often has this happened to one of your patients?

You call or fax a prescription order to the patients pharmacy, only

to get a call from the patient the next day saying she was unable
to pick up the prescription, for one of these reasons:

She got to the pharmacy only to learn they were out of that

medication. The pharmacist tried but failed to find another

store that had the medication in stock.

Her pharmacy has the medication on its shelves, but the

patients insurance does not cover the prescription, and she
could not afford it on her own.

Her pharmacy has the medication and her insurance covers it,
but the prescription still costs more than the patient can afford
to pay.
Three entrepreneurial UA College of Pharmacy students are
creating a transparent network that they hope will put an end to
these frustrating situations. Jason Kwan, Jingxin Yang and
Osamah Eljerdi, students of the PharmD Class of 2017, spent
several months developing this resource, which they named
LinkX at It is available on your phone or desktop by
going to the URL in the search bar. Its a website consisting of a
medication database that reports drug availability and cash prices
from local pharmacies. The websites pithy slogan is Search
Smarter. Choose Better.
Using LinkX, patients whose insurance doesnt cover their
prescription or coverage is not sufficient enough can find a local
pharmacy that has the drug they need in stock at a reasonable
price. A user simply:

searches for his or her prescription

reviews the resulting list of pharmacies

reserves the drug at one of the pharmacies for 24 hours

picks up the drug from the pharmacy with a hard copy of the


The founders of LinkX were well prepared to start their company.

Kwan completed the McGuire entrepreneurship program through
the UA Eller College of Management during pharmacy school,
and before that, as an undergraduate at Arizona State University,
he took a class called Lean Launch, which teaches students how
to start a business. Yang earned her undergraduate degree in
marketing; and Eljerdi brings clinical knowledge to the team.
The idea for LinkX emerged when Kwan and Yang took the health
care entrepreneurship course at the College of Pharmacy, in
which students were required to brainstorm a business idea or a
new type of pharmacy. Kwan drew on his experience working at a
local pharmacy, where he received a lot of phone calls about
medication stock and pricing.
I remember one patient who needed eye drops for surgery, and
he came the day before his surgery and we couldnt just order it
that same day, Kwan recalled.

It took several months to develop the innovative search tool for

pharmaceuticals. The new website slogan: Search Smarter.
Choose Better. L-R: Osamah Eljerdi, Jingxin Yang and
Jason Kwan.

So basically, he was forced to leave our pharmacy and go to other

pharmacies until he found one that carried the eye drops. And I
thought then that information should be easily available online.
Theres no reason a patient should have to call around town or
drive all over to find out if a medication is available, and what the
price is. I noticed a lot of these questions could easily be automated
and just save the time of the pharmacist and the patient.
The trio was awarded about $1,000 in funding from the Perkins
Coie Innovative Minds Challenge in the spring of 2015. They hired
an independent contractor to create the website, found a Tucson
pharmacy willing to be their first partner, and launched LinkX.
There is no charge to doctors or patients for using the search tool.
The site is primarily aimed at people who are looking for
medications not covered by insurance, such as hormones,
dermatology creams, and pet prescriptions.
As of mid-June, two Tucson pharmacies had signed up with LinkX:
Acacia Apothecary and Wellness Compounding Pharmacy, 1845
W. Orange Grove Road, near Northwest Medical Center; and
Green HealthMart Pharmacy, 5523 E. Grant Road, east of Tucson
Medical Center.
For now, we are kind of going with the old-fashioned approach,
using a small amount of money to get the best results right now,
Kwan said. Were talking to doctors and talking to pharmacies to try
to get them in our network. Our goal is to have as many independent
pharmacies and providers as possible supporting us in Arizona.
SOMBRERO August/September 2016

The students hope to eventually expand LinkX beyond Arizona.

With LinkX, Kwan says, We can remove the sticker shock. The
patient can know before he or she comes into the pharmacy how
much it will cost and whether its going to be there for them.
The students discussed the highs and lows of developing LinkX.
It was a challenge, and it was also something that we learned in
developing, starting from the ground up, said Yang. We filed for
LLC, we had to go to a lawyer there are a lot of aspects of it that
I never really got exposure to in business school, so this was
Kwan added, Trying to find someone to code the website was
really difficult, finding the right fit. And when you have the

Your partner

person, you have to communicate very clearly what you want, so

that was a challenge.
All three talked about the challenge of pitching their product time
after time. The three also talked about the rewarding opportunities
theyve been exposed to as a result of developing LinkX.
For me, the best part of developing this tool was developing
relationships with some of these professionals in the field,
Eljerdi said. Its just good insight into how things work in the
independent pharmacy business.
If you have any further questions about LinkX or its pharmacy
partners, you may contact Jason at
or at 623-282-2105.

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Coordination of care with other
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Scheduling an assessment is fast and easy.
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SOMBRERO August/September 2016


New Technology

Christiano pioneers new implant device

By Dennis Carey
Neurosurgeon Joseph
Christiano, MD, loves new
technology. He is not raving
about the latest I-phone or
Android. On March 23, he
became the third surgeon in
the United States to implant a
new type of spinal cord
stimulator to treat chronic

Dr. Joseph Christiano

While spinal cord stimulators

have been around for years,
the new Medtronic SureScan
Spinal cord stim paddle lead is
the first to be MRI compatible.
Only 15 surgeons nation-wide
participated in the first round
of procedures to implant the
This is huge because a large
majority of patients who use

spinal cord stimulators will eventually find themselves in a

situation where they need an MRI. Christiano said. This
provides a lot of diagnostic freedom for these patients. The
system comes with a lot of bells and whistles, but the major
break-through is the MRI compatibility
Spinal cord stimulators send electrical impulses to the nerves to
interfere with the nerve impulses that cause pain. Until now, a
patient using one was unable to get an MRI or would have to
have it removed before getting scanned. An MRI could cause the
stimulator to overheat and cause permanent nerve damage.
Christianos first surgery using the new-generation stimulator was
done in Tucson on Special Forces veteran Robert Valdez. The
procedure is usually done in an outpatient setting and takes
under two hours.
If a patient does not have any underlying health issues that
could complicate the surgery, it can be done without an overnight
stay, Christiano said. Ive done several since that first one. The
results have been very promising.
Christiano is a surgeon with Western Neurosurgery Ltd. in Tucson.
He has been a member of the Pima County Medical Society since
2003. He has worked extensively with
patients with chronic pain and movement
disorders. His national reputation in this
specialty was a major reason he was
selected to be among the first to implant
the new stimulators.
Technology is changing rapidly in medicine
and that is probably especially true in
neurosurgery. It is important to keep up
with any new techniques and procedures
that are coming along, Christiano said. I
was fortunate to have some connections
that placed me in the program. I am excited
to be bringing this advancement to the
Tucson area.
Tucson provides a lot of leadership in
medical advancements. The UA does a lot
of great work and that might be expected
in an academic environment, but other
Tucson hospitals and practices have been
aggressive in testing new procedures and
technology. This is just one example.


SOMBRERO August/September 2016


Violating HIPAA in 140 characters or less

By Bryan Bailey, Esq.

hysicians were one of the early adopters of text messaging

for business purposes. For example, in 2011, the College of
Healthcare Information Management Executives conducted a
survey and found that 96.7% of their members allowed
physicians to text orders to nurses and each other as part of their
bring your own device policies.1 Text messaging can expedite
physicians communications, possibly resulting in improved
patient care. Ninety-eight percent of texts are opened within 15
minutes of receipt and the average person takes 90 seconds to
respond to a text.2 Surgeons and other hospital-based physicians
also can receive texts in places within a hospital where they cant
receive phone calls or emails.
However, have you ever wondered whether texting patient
information complies with HIPAA? In 2013, the Department of
Health and Human Services (DHHS) posted its answer to the
following frequently asked question: Can you use texting to
communicate health information, even if it is to another provider
or professional?3 Like most things in healthcare, DHHSs answer
was: It depends.
Sending a text message to the wrong number can be
embarrassing, but texting patient information to the wrong
person can violate the Privacy Rule4 and require notification
under the Breach Notification Rule.5 If the text wasnt encrypted,
it also would violate the Security Rule.6
With penalties of up to $50,000 per violation and the
government continuously punishing healthcare providers for
breaches involving mobile devices,7 physicians would be well
advised to ensure their text messages comply with HIPAA. This
article discusses the risks associated with texting patient
information and identifies steps physicians can take to ensure
Whats Wrong with Texting Patient Information?
Of the 1.92 trillion text messages sent in the United States during
2014,8 most of them were via short message service or SMS.
Text messages sent via your cellular carrier are SMS texts. SMS
texts are inherently problematic under HIPAA because they arent
encrypted; you cant confirm whether the text was received by
the intended recipient; and the texts remain on the cellular
carriers server, perhaps indefinitely.
For example, if Dr. A uses his wireless plan to send a text message
containing patient information to Dr. Z and Dr. A is with Verizon
and Dr. Z is with T-Mobile, at a minimum, the text will be on both
doctors mobile phones, both wireless carriers servers, and it
may have been routed over the internet. Im not tech-savvy
enough to know how to intercept (hack) a text message from any
of these sources (but either doctors kids may read the text while
borrowing the phone which, incidentally, would violate both
the Privacy and Security Rules), but apparently it isnt difficult for
certain individuals.9
SOMBRERO August/September 2016

Bryan has a broad-based

practice in health care law
and business transactions. He
represents individuals and
companies in the health care
and life sciences industries
regarding transactional,
regulatory and operational
issues. He has extensive
experience helping clients
structure, negotiate and
implement effective and
compliant relationships with
their business partners,
including hospital/physician
joint ventures, management
and administrative service
arrangements, professional
service agreements and other business relationships. He
regularly advises clients regarding federal and state health care
laws and regulations, including the Anti-Kickback laws, the
Stark Law, HIPAA, Federal and State licensing and certification
requirements and a myriad of other health care laws. Bryan is
one of a handful of attorneys in Arizona with substantial
experience advising health care providers regarding Medicare
and Medicaid (AHCCCS) reimbursement laws, including
representing providers involved in governmental and
commercial payor audits, investigations and appeals. He also
represents providers in government investigations and
enforcement actions related to licensing and health care claims.

Recognizing these problems, third-party developers have

developed and implemented stand-alone secure (i.e., encrypted)
texting applications. TigerText is an example of a secure texting
application. These applications can help physicians comply with
HIPAA, but just because they say they are HIPAA-compliant
doesnt mean they are. No matter what anyone tells you, there is
no such thing as a HIPAA-compliant application or device. The
HIPAA Security Rule is technology neutral. Complying with it
means youve implemented various physical, administrative and
technical safeguards.
In addition, a lot of these applications do not integrate with
electronic medical records. Under Arizona law, a text message
that relates to a patients physical or mental health or condition
and that was sent or received for purposes of patient diagnosis
or treatment constitutes a medical record.10 Medical records
must be retained for at least six years from the last date of
service.11 A physician who fails to maintain a medical record or
the confidentiality of a medical record may be disciplined by his
or her licensing board for unprofessional conduct.12
Moreover, the Privacy Rule provides individuals with the right to
access and amend their information that is maintained in a

designated record set.13 A designated record set includes

patient information (i.e., protected health information) which is
used, in whole or in part, by or for a covered entity to make
decisions about individuals.14 Thus, a physician who fails to
provide an individual with access to or the right to amend the
individuals information in the physicians text message could
violate the individuals rights under the Privacy Rule.15
Lastly, not all of these secure text application developers will sign
a Business Associate Agreement. A Business Associate Agreement
is required with any vendor who will receive, maintain or transmit
text messages containing patient information.16
How Can I Text Patient Information and Comply with HIPAA?
If youve already decided that it isnt feasible to prohibit texting
patient information, the first step in determining how you can
text patient information is to perform a risk analysis. The Security
Rule requires a risk analysis to determine potential threats to a
covered entitys electronic protected health information (ePHI).
Among other things, a risk analysis should identify potential
threats to ePHI; analyze the sufficiency of current security
measures; determine the likelihood and potential impact of a
threat occurring; assign risk levels to the different threats; and
identify and implement measures to address the threats. Failing
to perform a risk analysis often is cited as a basis for HIPAA
violations in settlement agreements with OCR.
Some of the more common threats involved with texting patient
information are the risk of loss, theft or improper disposal of a
mobile device containing patient information; an unintended
recipient gaining access to a text; and a third-party storing a text

without a Business Associate Agreement. The next step is

developing a risk management plan.
In 2012, recognizing the threats posed by mobile devices, DHHS
published online guidance regarding securing mobile devices.17
DHHS recommends the following steps to protect and secure
patient information when using mobile devices:

Install and enable encryption to protect health information

stored or sent by mobile devices;18

Use a password or other user authentication;

Install and activate wiping and/or remote disabling to erase the

data if the mobile device is lost or stolen;

Disable and do not install or use file-sharing applications;

Install and enable a firewall to block unauthorized access;19

Install and enable security software to protect against

malicious applications, viruses, spyware and malware-based


Keep your security software up to date;

Research mobile applications before downloading;

Maintain physical control of your mobile device. Know where

it is at all times to limit the risk of unauthorized use;

Use adequate security to send or receive patient information

over public Wi-Fi networks; and

Delete all stored patient information on your mobile device

before discarding it.20
I recommend utilizing a third-party application to send and receive
encrypted texts. However, for the reasons previously stated, I
would only use an application if I have a Business Associate
Agreement with the applications developer and only if the
application integrates with my electronic health record.

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SOMBRERO August/September 2016

Lastly, no risk management plan can be effective unless it is

reduced to writing and training is provided. Regular training is vital
to minimizing the risk of a HIPAA violation and reportable breaches.
All forms of communication present some form of risk and text
messaging is no different. Remember there is no HIPAA
compliant device or application that will ensure your compliance
with HIPAA. Compliance is a never-ending process, requiring
ongoing analysis, planning, implementation, auditing and review.
What works for one group may not work for another. If you or
your group must text patient information, follow the steps
outlined above to minimize your risk of non-compliance.
1. Diagnotes. Behind the Product Design: Redesigning Secure Texting
for Healthcare. Available at:
Accessed March 23, 2016.
2. TextMarks. 6 Benefits of Text Messaging: Why Your Organization
Should Use SMS. Available at: Accessed March 23, 2016.
3. Department of Health and Human Services. Office of the National
Coordinator for Health Information Technology. Frequently Asked
Questions. Available at: Accessed March 23, 2016.
4. The HIPAA Privacy Rule is at 45 C.F.R. Parts 160 and 164, Subparts
A and E.

violating a privileged communication), (21) (failing or refusing to

establish and maintain adequate records on a patient), and (35)
(violating a federal law, a state law or a rule applicable to the
practice of medicine.).
13. See 45 C.F.R. 164.524, 164.526.
14. 45 C.F.R. 164.501.
15. Of course I am assuming the physician is a covered entity subject
to the Privacy Rule.
16. See 45 C.F.R. 160.103 and 45 C.F.R. 164.504(e).
17. Department of Health and Human Services. Office of the National
Coordinator for Health Information Technology. Guide to Privacy
and Security of Health Information. Your Mobile Device and Health
Information Privacy and Security. Available at: https://www. Accessed March 23, 2016.
18. Encrypted patient information likely does not constitute
unsecured protected health information, when mean no
notification is required under the Breach Notification Rule if the
information is lost or compromised.
19. I dont know if it is possible to install a firewall on your smart phone;
check with you IT professional.
20. Department of Health and Human Services. Office of the National
Coordinator for Health Information Technology. How Can You
Protect and Secure Health Information When Using a Mobile
how-can-you-protect-and-secure-health-information-when-usingmobile-device. Accessed March 23, 2016.


5. The Breach Notification Rule is at 45 C.F.R. Part 164, Subpart D.

6. The HIPAA Security Rule is at 45 C.F.R. Parts 160 and 164, Subparts
A and C.
7. See March 17, 2016 Department of Health and Human Services
Office for Civil Rights (OCR) press release regarding $3.9 million
settlement of HIPAA violations arising from stolen laptop containing
patient information. Available at:
See also September 2, 2015 OCR press release regarding $750,000
settlement of HIPAA violations with radiation oncology group
arising from stolen laptop containing patient information. Available
at: Accessed
March 23, 2016.

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8. 2014 CTIA Annual Wireless Industry Survey. Available at: http:// Accessed March 23, 2016.
9. iSpyoo. How to Hack Text Messages on Mobile Phone? Available
at Accessed March 23, 2016.
10. A.R.S. 12-2291(6).
11. A.R.S. 12-2297(A).
12. See A.R.S. 32-1401(27)(a) (violating any federal or state laws,
rules or regulations applicable to the practice of medicine), (b)
(intentionally disclosing a professional secret or intentionally
disclosing a privileged communication), and (e) (failing or refusing
to maintain adequate records on a patient); see also A.R.S. 321854(1) (knowingly betraying a professional secret or willfully
SOMBRERO August/September 2016

ROC #278632


News Briefs

Dr. Benjamin Lee

new chief of urology
Dr. Benjamin Lee, a national
leader in kidney and prostate
cancer surgery and research,
has joined the UA Medical
Center and the UA Department
of Surgery as professor and
chief of the Division of Urology.
He is one of about 20 new
faculty physicians joining the
hospital and UA college of
Medicine-Tucson this summer.
Lee comes to Tucson from the
Tulane University School of
Medicine in New Orleans,
where he was a professor of
medicine and urology and
director of the schools fellowship program in robotics,
laparoscopy and endourology.
He has extensive experience with minimally invasive approaches
to treat renal cell carcinoma, prostate cancer, transitional cell
carcinoma and kidney disease, pioneering several innovative
surgical techniques and principles.
In addition to his role as urology division chief, he will serve as
director of the Gastroenterology/Urology Cancer and Disease
Strategic Planning Team at the UA Cancer Center and as team lead
of urologic imaging with the UA Department of Medical Imaging.

Telephone CPR improves

cardiac arrest outcomes
The implementation of a
Telephone Cardiopulmonary
Resuscitation (TCPR)
program increases survival
rates and favorable
outcomes for patients who
experienced an out-ofhospital cardiac arrest,
according to a UA
Department of Emergency
Medicine study published
online in JAMA Cardiology.
Although out-of-hospital
cardiac arrest (OHCA) is a
major public health problem
in the U.S., we have a lifesaving treatment CPR.
Most cardiac arrest victims,

however, dont get that treatment before trained rescuers arrive,

said Bentley J. Bobrow, MD, professor at the UA College of
Medicine in Tucson and Phoenix and co-director of the Arizona
Emergency Medicine Research Center-Phoenix, part of the UA
Department of Emergency Medicine.
Bystander CPR (BCPR)has been shown to double or even triple
survival from OHCA. Despite decades of public CPR training, in
most communities fewer than half of all individuals with cardiac
arrest receive any BCPR, and bleak survival rates persist.
Both the American Heart Assoc. and the Institute of Medicine
have emphasized the importance of telecommunicators (9-1-1
call takers and dispatchers) identifying cardiac arrest and assisting
lay rescuers (people without medical training) in providing BCPR
to improve survival.

Dr. Hutchinson named

director of cardiac program
Mathew D. Hutchinson, MD is
the new director of the Cardiac
Electrophysiology Program in
the Division of Cardiology at
the UA College of MedicineTucson.
He is board certified in
cardiovascular disease and
clinical cardiac
electrophysiology and
specializes in treating complex
heart rhythm disorders, such
as atrial fibrillation and
ventricular tachycardia.
Hutchinson comes from the
University of Pennsylvania
where he was an associate professor of medicine at the Perelman
school of Medicine. He completed his medical degree at St. Louis
University school of Medicine and his medical residency at Beth
Israel Deaconess Medical Center and Harvard Medical School in
Boston. His cardiology and electrophysiology fellowships were
completed at the Hospital of the University of Pennsylvania.

Rural health grant supports

small hospital improvement
Since 2010, 76 rural hospitals have closed and another 673 are
vulnerable to closure in the U.S. Last year, a rural hospital in
Douglas, AZ closed, forcing individuals to travel long distances to
access care and 60 people lost their jobs.
Bentley J. Bobrow, MD

In response, the UA Center for Rural Health was awarded a threeyear $348,000 grant by the Health Resources and Services
Administration to support the Arizona Small Rural Hospital
Improvement Grant Program.
SOMBRERO August/September 2016

The grant supports 13 small rural hospitals with fewer than 50

beds for health system reforms such as value-based purchasing
programs, accountable care organization and payment bundling.
All but two of the hospitals are federally designated critical access
hospitals with fewer than 25 beds and located more than 35
miles from another hospital.

UA Cancer Center receives

NCI grant
The UA Cancer Center has been recognized for its multidisciplinary
cancer research and research-driven clinical care through a highly
competitive grant award from the National Cancer Institute. The
NCI renewed the Centers status as a comprehensive cancer center
and awarded a five-year, $17.6 million Cancer Center Support Grant,
based on the strength, depth and breadth of basic Laboratory,
clinical, prevention, control and population-based research.
The UA Cancer Center is one of only 45 NCI-designated
comprehensive cancer centers in the nation and is the only one
headquartered in Arizona. The renewed designation as a
Comprehensive Cancer Center gives patients throughout Arizona
and the greater Southwest access to the most comprehensive,
research-driven cancer care and treatments.
The Center received its initial NCI designation in 1978 and was
elevated to Comprehensive Cancer Center status in 1990.

Dr. Steven Wang named

interim chair of OTO,
Head and Neck Surgery
Steven J. Wang, MD, has been
named interim chair of the
Department of Otolaryngology
Head and Neck Surgery at
the UA College of Medicine
Tucson, effective June 1.
Dr. Wang brings considerable
clinical experience in head and
neck cancer treatment as well
as a strong research portfolio
to the College of Medicine,
said Joe G.N. Skip Garcia,
MD, UA senior vice president
for health sciences and the Dr.
Merlin K. DuVal, professor of
Were excited to welcome him to lead our team of
otolaryngologists who provide comprehensive care to patients in
Arizona and throughout the Southwest, said Charles B. Cairns,
MD, FACEP, FAHA, interim dean of the College.
Wang currently is professor-in-residence, and head and neck
oncologic surgeon, in the Department of Otolaryngology Head
and Neck Surgery at the University of California, San Francisco.
SOMBRERO August/September 2016

His clinical focus is on treating disorders of the head and neck,

including tumors of the oral cavity, larynx, thyroid and salivary
glands as well as melanoma and advanced skin cancers of the
head and neck. He also has expertise in transoral robotic surgery
and head and neck microvascular reconstructive surgery.
He has a research interest in head and neck cancer and conducts
laboratory-based translational research investigations of oral
cavity and oropharynx carcinoma. At UCSF, Dr. Wang is principal
investigator of an NIH-funded prospective study of the role of
HPV in head and neck cancer and co-PI of an ECOG-sponsored
clinical trial of transoral robotic surgery for oropharynx tumors.
He has co-authored 60 peer-reviewed articles and nine book
chapters. A frequently invited speaker, Dr. Wang has given more
than 90 presentations at medical conferences and academic
institutions throughout the United States, Asia and Europe.
Wang is a fellow of the American Academy of Otolaryngology Head and Neck Surgery, the American Head and Neck Society, the
Triological Society, the American College of Surgeons and a
member of the Society of University Otolaryngologists. He
graduated summa cum laude from Harvard University and
received his medical degree from Harvard Medical School. Wang
completed his OHNS residency at UCLA, followed by a Head and
Neck Oncologic and Microvascular Reconstructive Surgery
fellowship at the University of Michigan.
He will replace Alex Chiu, MD, who will leave the UA effective
June 6, to serve as chair of the Department of Otolaryngology at
the University of Kansas, where he also will hold the Russell E.
Bridwell, MD, Endowed Chair in Otolaryngology.

Mega Raffle Sets

Fundraising Record
A record-setting $1.2 million was raised from this years Tucson
Medical Centers Mega Raffle. Proceeds are used to support
hospital patient care programs and services.
Last year, more than $1 million was raised to help a variety of
services including continued education programs for nurses
caring for stroke patients, lactation support programs for new
mothers, occupational therapy for pediatric patients, and adult
rehabilitation and occupational therapies.
We are extremely grateful for the tremendous support and
participation, stated Michael Duran, vice president of TMC
Foundation. As the only non-profit community hospital in
Tucson, the TMC Mega Raffle helps us raise funds and awareness
for the many patient care programs and services we provide and
continue to push forward in order to meet their needs.
The raffles final drawing, held on April 11, brought the number of
winners to almost 10,000 during the past four years. In addition
to supporting TMC, the raffle is known for its incredible prize
packages and one and 20 odds of winning. Prizes included cars,
luxury vacations, and high-end consumer goods.
The Mega Raffle is scheduled to launch again in early 2017, when
it celebrates its 5th year.


Members Classifieds
Immunology practice seeking an experienced nurse
practitioner to add to our group. Allergy background
preferable, but not necessary. We are looking for a fulltime or nearly full-time practitioner. Competitive salary
and benefits, profit sharing and 401K with match. Contact
Dr. George Makol at Alvernon Allergy, phone number 3229426, ext 115. May submit resume by fax to 520-322-8462.
One NovaSure Endometrial Ablation RF Controller with
cavity assessment Model 09;
One NovaSure Endometrial Ablation Footswitch;
One NovaSure Endometrial Ablation AC Power Cord.
(Please note that the NovaSure CO2 canisters used in
conjunction with the operation of this machine are not
available for sale. The sterile single-patient use NovaSure
Disposable Device is not for sale either. These must be
purchased from the manufacturer).
One ACMI Micro digital IP4.2 Single-Chip Image
Processing Video Endoscopy Camera System. Includes
camera and adaptor.

One ACMI ALU-2B 150 watt halogen light source w/

detachable light cord
Sony Color Video Printer UP-21MD
Magnavox 15 Color Monitor
Contact Catherine Westerband, MD at 520-498-5000 or
MEDICAL OFFICE FOR LEASE - Well situated on Northwest
Medical Center campus with great visibility on Orange
Grove. Well designed, 4,300 square feet, aestheticallypleasing with high efficiency, suited for 4-6 providers, built
in 2006. Features 12 exams rooms, including 1 procedure
room; 4 offices; and 1 large reception area; spacious
storage area for supplies; at door parking. Available April
2016 (Current leaser is merging with another practice)
Competitive rates. Contact Catherine Westerband, MD,
520-488-7515 or
FULL-TIME PEDIATRICIAN Great family and golf
community. Full-time Pediatrician BC/BE to join well
established Pediatric practice in Tucson, AZ. Competitive
salary with excellent benefit package, including bonus
compensation. Send CV to

Being Mortal

Free Film Screening & Discussion

Hope is not a plan.

Dr. Atul Gawande

Join us for a for a free screening and discussion of

the PBS FRONTLINE documentary Being Mortal. Based
on the bestselling book by Dr. Atul Gawande, this film
explores the hopes of patients and families facing
terminal illness and their relationships with the doctors,
nurses and family members who care for them.

September 13, 2016

7:30 p.m.
The Loft Cinema
3233 E. Speedway Blvd

See the film and be part of a national conversation

taking place in our community that asks: Have you
and your family had these important conversations
and planned ahead?



SOMBRERO August/September 2016

The RadVision Mobile App has arrived!

Introducing our new
iOS Mobile App!
Mobile App allows you to access patient reports
quickly and easily from your hand-held device. This app is also
HIPAA-compliant, which ensures safety for you and your patients
personal health information.
Go to the iOS App Store.
Search for our mobile app partner Royal Solutions Group.
Download Royal Solutions Group app.
Enter access code Tucson.
Enter username and password to begin reviewing reports.
If you do not have a username and password, please call
the RadVision Hotline at (520) 901-6747.

Benefits Include
Alerts for finalized
patient reports
Customizable notifications
Alert preferences
User friendly interface
Compatible with
iPhone and iPads
(Android app coming soon)
Free download from
the iOS App Store

For more information, contact RadVision Technology Services at (520) 901-6747 or

SOMBRERO August/September 2016



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For 40 years MICA has provided our members with answers.
Contact us today for a quote and to discuss how we can help
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SOMBRERO August/September 2016