pain Changing the conversation about INSIDE: 4 Telemedicine overview 5 Lung nodule clinic 6 MRI-fusion biopsy

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1 PROVIDENCE Clinical insights from Providence Health & Services march 2018 Vol. 6, Issue 1 Changing the conversation about pain INSIDE: 4 Telemedicine overview 5 Lung nodule clinic 6 MRI-fusion biopsy

2 Tools you can use to help your patients manage their Ruben Halperin, M.D. Vice-chair, Oregon Pain Management Commission Internal medicine Providence Medical Group-Northeast 5050 NE Hoyt St., Suite 540 Portland, OR Brinton Clark, M.D. Internal medicine Providence Medical Group-Northeast 5050 NE Hoyt St., Suite 540 Portland, OR With more than 260,000 Oregonians reported as having persistent pain, providers are working diligently to meet their patients needs while also finding effective alternatives to prescribing narcotics. Overuse of opiates has become a significant public health problem, both in Oregon and around the United States. Providence Health & Services, Oregon has developed some key tools to help community providers and their patients begin important conversations about persistent pain, talk about effective treatment strategies, and work together to develop personalized treatment plans. Culturally, there s been a big shift when it comes to prescribing opiates for chronic pain. There s much more hesitation to start patients on chronic opiates now, and when opiates are prescribed they are at the lowest possible dose. Exceptions are patients at the end of life and patients with cancer. Patients sometimes ask for increasingly strong doses of narcotics to combat their pain leading to overusage, misuse, addiction and sometimes overdoses. So what can providers do to care for these patients effectively while also being attentive to the dangers of overprescribing opioids? We believe it boils down to changing the conversation about pain. This means giving providers the right tools to help patients better understand and manage their persistent pain. Toolkits at your fingertips Providence created a toolkit specifically for providers, along with a parallel toolkit targeted toward patients. Both toolkits include plenty of resource handouts, classes to help educate patients about pain, and information about non-pharmacologic methods for managing pain. Resources for providers also include education, clinical decision-making tools, sample phrasing when talking with patients, PowerPoints of recent lectures and more. In addition, Providence Medical Group and other Providence-employed providers have access to a Treatment of Opioid Use Disorders online resource: SitePages/OpioidUseDisordersTreatment.aspx Examples of how to talk with your patients about their pain One of the most challenging aspects of caring for patients with persistent pain is how to support them by opening up meaningful, productive conversations. This can be especially true when patients have been prescribed narcotics in the past and may feel frustrated that the treatment plan has changed. Persistent pain program Providence s Persistent Pain Program has a number of services and tools for patients and providers, including: Toolkits (different versions for providers and patients): Persistent pain program information and classes (many are low- or no-cost): 2 Providence inscope

3 The provider toolkit provides some great examples of how to start these important conversations: Patient: People keep telling me my pain is all in my head that it s not real. Provider: What people may mean is that we now understand that the brain controls our pain. Your pain is very real, but here s the good news: There s a lot that you, your brain and your nervous system can do to reduce that pain. There s a great class I d like you to attend (or watch online) that explains this more. Patient: How long until I feel better? Provider: Let s target some key goals, including getting back into daily activities. You probably will still have pain during this time, but you ll find that gradually you ll be able to tolerate more activity and get back to your life. As a provider, you then can continue the conversation and begin to develop a plan with your patient. You might say to your patient: Let s take a moment to think about a main goal you have in your life right now, something you would like to get back to doing. We can work on a plan together to help you return to the things you want to do. Making important inroads Oregon health care leaders, as well as the U.S. Centers for Disease Control and Prevention, have adopted stricter guidelines about prescribing narcotics. One potential result has been a decline in opioid-related overdose deaths in Oregon declining to 245 in 2016 after peaking at 332 in One complex issue about opioids is that they can actually amplify pain, especially if they re used long term. It s our duty as providers to help our patients understand this even if they re initially resistant to the idea and to work as their partner to develop alternative treatment plans. Only then will we be able to continue to reduce the public health crisis associated with excessive opiate use. n Using virtual reality goggles to reduce pain A cartoon bear that giggles when you chase it. A dolphin that swims in a beautiful ocean. Warm, flickering firelight accompanied by guided meditation. How can these be used to relieve pain effectively? Christina Becerra, a child life specialist at Providence St. Vincent Medical Center in Portland, has seen firsthand how virtual reality goggles help her young patients. About six months ago thanks to a generous donor, Kathy Salquist the hospital began using virtual reality goggles to help pediatric patients who are in pain, are nervous about undergoing a procedure, or are tired of being in the hospital. We ask kids before we start what their pain level is (1-10), we do a 30-minute goggle experience, and then ask them to rate their pain afterward. Patients have reported significant reductions in pain when using the goggles, says Becerra. Becerra uses the goggles on young patients 7 and older in Providence St. Vincent Children's ER, in the outpatient surgery center, in inpatient units, and in the PICU. The goggles, made by Applied VR, provide games and activities specifically designed for a medical setting. Each session can last from three to 30 minutes and includes activities such as guided meditation and games such as Bear Blaster, in which a ball shoots out and hits a bear which then begins giggling. Bear Blaster is just one of about 20 experiences available so far on the goggles. The kids are very excited when they get to use the goggles, and there are lots of fun options for them, says Becerra. They become completely immersed in this experience. Distraction is a very effective pain management technique. Virtual reality goggles aren t just for kids. A Cedars-Sinai study in 2017 examined 100 adult inpatients who experienced pain. Fifty patients received virtual reality therapy using goggles, and they reported a 24 percent drop in pain scores. In comparison, the other 50 patients viewed a standard, two-dimensional nature video with relaxing sights and sounds. They reported a 13 percent drop in pain scores. Becerra isn t surprised. I see this potentially being a very effective tool for patients of all ages who are in the hospital, she says. For physician referrals, see page 7. Providence inscope 3

4 Telehealth services: The future of health care Jim Tuchschmidt, M.D. Chief executive Clinical programs and physician strategy Providence Health & Services, Oregon Amy Winkelman Director of product development and telehealth Providence Health & Services, Oregon Every Monday, Nicholas Barber, M.D., a Providence Cancer Institute physician in Portland, sees patients in Seaside for follow-up medical oncology visits. That s not unusual, except that Dr. Barber s office is in Portland and the visits are conducted virtually over the internet. This means Dr. Barber can care for patients on the coast without ill patients and their families having to travel the 85 miles to Portland. This is just one example of telehealth s potential to transform how we deliver care, especially for patients in underserved or rural communities. A recent study indicates more than 70 percent of consumers would consider a virtual health care service 1, while another suggests that percent of health care visits could be eligible for a virtual encounter. 2 Many types of telehealth There are growing types and uses of telemedicine, including: Provider to provider: virtual consults Typically conducted in the emergency department or inpatient unit, provider-to-provider telehealth enables a remote specialist to virtually consult with a local clinician. Telestroke is the most well-known of these services, and other services now include psychiatry, neonatal and pediatric intensive care, critical care/eicu and hospitalist care. Provider to patient: virtual visits in the clinic Specialists also are working with outpatient clinics to see patients, most often in rural critical access areas. Outpatient telehealth services range from behavioral health visits for primary care patients, to more specialized services such as endocrinology, oncology, pulmonology and sleep medicine. Provider to consumer/patient: virtual visits anywhere Telehealth s most significant growth comes from providers conducting virtual visits with patients wherever they are in their own home, at work or anywhere they have privacy and an internet-connected device. Visits also can occur for minor ailments and are targeted to consumers who may or may not have a previous relationship with a provider or health system. Offered at a low price, these on-demand telehealth services (such as Providence Express Care Virtual) are increasingly covered by commercial and Medicaid insurers. Remote patient monitoring Another area of telehealth growth is remote patient monitoring, which allows patients to use equipment at home to automatically transmit clinical readings back to their provider. Telehealth is here to stay The growth of telehealth will continue to follow the rise of mobile technology, expansion of web-based services, and use of video in everyday communications. While they won t replace bricks-and-mortar clinics, we believe more and more clinicians and patients will use virtual care in the future. n For more information about Providence Oregon TeleHealth Telehealth: Express Care Virtual: Telestroke: Telehospitalist: 1. Frances Dare, Voting for Virtual Health, Accenture report, JT Ripton & Stefan Winkler, How Telemedicine is Transforming Treatment in Rural Communities, Becker s Hospital Review. April 8, Providence inscope

5 Taking the fear out of lung nodule detection Heather Merry, M.D. Thoracic surgeon Providence Lung Nodule Clinic Providence St. Vincent Medical Center 9135 SW Barnes Road, Suite 261 Portland, OR At Providence Cancer Institute's Lung Nodule Clinic, patients understandably often come in with a heightened sense of alarm after discovery of a lung nodule. We try to reduce their distress by immediately addressing their chief concern: Is my lung nodule cancerous or not? Based on feedback from patients and providers, Providence Cancer Institute's Thoracic Oncology Program saw a need for immediate, customized care for patients who are diagnosed with a lung nodule. Our goal was to create a clinic where patients can be seen quickly to help address their concerns, ease their minds and lessen their anxiety around lung nodules. Providence Lung Nodule Clinic was created in July 2017 and is located on the Providence St. Vincent Medical Center campus. We have daily appointments available for people who have been told they have a lung nodule and aren t sure what to do. We review their images and come up with a tailored personal plan for next steps. The clinic is part of the Providence Thoracic Oncology Program, which provides a team of lung cancer experts including medical oncologists, radiation oncologists, thoracic surgeons and pulmonologists. Weekly conferences allow the team to be collaborative in treatment planning, from cutting-edge diagnostic procedures to the latest surgical options and treatment. In addition to lung nodules, the lung nodule clinic helps patients dealing with various types of lung- and chest-related ailments, including infections and breathing problems. And while not all lung nodules are cancerous, every patient case is always followed up to ensure that a nodule that wasn t previously cancerous doesn t change over time. The most common risk factor for lung nodules is a history of smoking. This applies primarily to those who have smoked a pack a day for 30 or more years, are currently smoking, or have quit smoking within the last 15 years. One great thing Medicare has begun recently is paying for lung cancer screenings. If patients are notified they have a lung nodule, it s highly recommended that they take the opportunity to get screened for lung cancer. If the nodule is not cancerous, the lung nodule clinic team will continue to track and monitor it both shortand long-term, while also keeping the patient s primary care provider apprised. If it is cancerous, we connect patients with oncology experts. n For more information: Providence Lung Nodule Clinic Providence Thoracic Oncology Program Providence Lung Nodule Clinic provides a team of experts to help determine the best diagnostic procedures and treatments for patients with a lung nodule. For physician referrals, see page 7. Providence inscope 5

6 MRI-fusion biopsies to detect prostate cancer now available in southern Oregon Bruce Barrows, M.D. Urologist Providence Medford Medical Center Rogue Valley Urology Chad Ringger, M.D. Radiologist Providence Medford Medical Center Medford Radiology Group Thanks to the latest technology and protocols, specially trained radiologists and urologists now can team up to provide MRI-fusion biopsies that precisely pinpoint areas of potential prostate cancer leading to more accurate biopsies and better outcomes. Providence Medford Medical Center is the only health system in southern Oregon that provides this technology and level of care. Special software is used with 3-D MRI imaging of the prostate to identify suspicious areas. Later the MRI images are fused with ultrasound imaging in real time during biopsies. As a result, experts now can get much clearer visualization of suspicious lesions and can conduct more accurate biopsies. The technology: How it works The UroNav Fusion Biopsy System has been in place at Providence Medford since early fall The technology and the team trained to use it helps to eliminate the previous educated guesswork that occurred due to poor visualization of potential lesions. This can reduce the number of biopsy specimens taken, rather than relying on random samples that may or may not have included the most suspicious areas of the prostate. Now we can be more confident that we ve made a correct diagnosis and that we ve sampled the most worrisome areas. After a multiparametric MRI is conducted on the patient, the specially trained radiologist creates a 3-D model of the prostate gland and marks any suspicious abnormalities. Those images are then overlaid, or fused, to the ultrasound images that are used during biopsy. This essentially provides a roadmap and target for the urologist conducting a biopsy. During the biopsy, the fusion software shifts the overlaid MRI image as needed to provide a 3-D ultrasound view. The urologist uses the fused image to guide the biopsy needles precisely to the lesion to be sampled, rather than inserting the needles using only ultrasound guidance. This ensures he can collect accurate samples with a higher degree of confidence than before this technology was available. Easing the way for care team and patients The imaging part of the protocol typically is performed weeks before the biopsy occurs. The 3-D images are created on an auxiliary computer in the reading room at the same time the MRI is read. This process adds only a few extra minutes for a trained radiologist to interpret the images, compared to traditional prostate MRIs. The system also can be used for watchful waiting or surveillance. A negative prostate MRI has a very high negative predictive value for clinically significant prostate cancer. This means that a patient with negative MRI, in some cases, may not need a biopsy at all. In addition, a patient with a low-risk prostate cancer diagnosis may not need treatment right away but instead can undergo an MRI for active surveillance to help monitor the disease. If a change occurs later in the MRI s appearance, the images can be used for a highly targeted, effective biopsy. Overall, this system can reduce wait time for patients who want to get their procedures done quickly and who want to alleviate prolonged anxiety about a diagnosis. Looking to the future Prostate imaging and protocols continue to advance and improve significantly. Providence Medford is committed to bringing the latest advances in prostate cancer diagnoses and treatment. We re now able to provide these cutting-edge treatments that previously were available only in large university-based health systems or in large cities. Prostate cancer continues to be highly treatable, and with this and other future technologies, we will continue to be at the forefront of early detection and effective treatments. n 6 Providence inscope

7 noteworthy Providence to add outpatient surgery center Providence begins construction on a new outpatient surgery center at its Providence St. Vincent Medical Center campus in April, allowing for more procedures in a lower-cost setting. The center is a partnership among 18 local doctor-investors, Providence in Oregon and Surgical Care Affiliates (a management company). Providence owns 41 percent, the doctors 49 percent and Surgical Care 10 percent. The center will be connected to the hospital and expects to treat more than 4,000 patients a year. Neurology expands to south Clackamas, Marion counties Providence Brain and Spine Institute is opening two new clinic locations and adding three new neurologists to the team: Kevin Jamison, M.D., Heidi Loganbill, M.D., and Thomas Phipps, M.D. Providence Neurological Specialties will open two new neurology clinics: Providence Neurological Specialties-Willamette Falls 1510 Division St., Suite 180, Oregon City, Providence Neurological Specialties-Keizer 175 Shore Point Place N., Suite 202, Keizer, Patients also can be seen at clinic locations at Bridgeport in Tigard, Providence Newberg Medical Center, Providence St. Vincent Medical Center or Providence Portland Medical Center. New specialists join Providence Kristen Massimino, M.D., joins Providence Cancer Institute as medical director of the Providence Breast Cancer Program. A board-certified surgical oncologist, Dr. Massimino specializes in breast cancer surgery and also has expertise in treating melanoma. She is a clinical researcher and completed a fellowship in complex general surgical oncology at Memorial Sloan Kettering Cancer Center in New York City. Ricky Chen, M.D., joins Providence Brain and Spine Institute and Providence Cancer Institute as director of the Providence Neuro-Oncology Program. Dr. Chen works with a multidisciplinary team to care for adult patients with primary brain tumors, cancers metastatic to the brain, and neurological complications of cancer. Dr. Chen comes to Providence after extensive training at Oregon Health & Science University, University of Utah Health, and the University of California, San Francisco. Providence Medicare Advantage Plans one of 16 in nation to receive highest rating Providence Medicare Advantage Plans recently earned Medicare s highest rating for health care quality and service. The health plan was ranked among the best in the nation, performing in the top 4 percent and receiving an overall rating of 5 stars by the Centers for Medicare and Medicaid Services (CMS). A health plan s star rating is designed to help Medicare members choose high-quality plans, determine payment for quality and expand enrollment opportunities for the MA plan. Only 16 health plans, out of nearly 400 total MA plans in the country, received a 5-star rating. Referral resources When your patients need advanced care, our specialists are right at your fingertips. Call toll-free 844-ASK-PROV ( ) for: Nonurgent consults and referrals, 8 a.m. to 4:30 p.m., Monday-Friday More resources General information Integrative medicine East Portland: West Portland: Home medical equipment Home services Hospice Neurodiagnostic services Regional lab services Rehabilitation services Providence inscope is a bi-monthly publication for providers in Oregon and southwest Washington. Providence executive advisory board Doug Koekkoek, M.D., chief executive, Providence Clinical Services, Providence Medical Group Tom Lorish, M.D., chief executive, Providence Outreach James Tuchschmidt, M.D., chief executive, Providence Clinical Programs and Physician Strategy Contact Providence InScope Holly Young, editorial director, Subscribe to our CLINICAL newsletters Providence inscope 7

8 4805 NE Glisan St. Portland, OR NONPROFIT US postage PAID PORTLAND or PERMIT no 5510 Even experts need advice That s why we created ASK PROV. When your patients need advanced care, our specialists are at your fingertips. Call toll-free 844-ASK-PROV ( ) to connect with a Providence-employed or affiliated specialist for nonurgent consults and referrals. Available 8 a.m. to 4:30 p.m., Monday-Friday.