PN Spring 2019 05 - Methodisthealthsystem

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Progress NotesM E T H O D I S T H E A LT H S Y S T E M M E D I C A L S TA F F N E W SVOLUME 8 IHIGHLIGHTS2Progress Notes isswitching to adigital publication4Methodist Richardsonstreams TAVR procedureon FacebookMETHODIST MANSFIELDNew president takes helmat Methodist MansfieldMethodist Health System has named Juan Fresquez the newpresident of Methodist Mansfield Medical Center. Fresquez is nostranger to Dallas-Fort Worth. He began his career at Parklandand has more than 28 years of acute care hospital managementexperience. He most recently served as chief operating officer ofCarondelet St. Joseph’s Hospital in Tucson, Arizona, a 486-bedacute care facility where he was instrumental in improving patientJuan Fresquezsatisfaction, quality, and financial performance. Before his threeyears at Carondelet, he served as the chief operating officer at Houston NorthwestMedical Center for four years.Fresquez earned a bachelor’s degree in nuclear medicine with specialization in physicsat the University of the Incarnate Word and an MBA from the University of Phoenix.He and his wife of 29 years, Carla, are happy to be back in Texas.“Fresquez is an outstanding leader with a proven track record in operationalexcellence,” says Pamela Stoyanoff, CPA, FACHE, president and chief operatingofficer at Methodist. “His background and experience will be a perfect complementto the Methodist Mansfield culture and our mission to improve and save lives inour communities with the highest level of quality, care, and compassion.”“I am looking forward to serving the community and working closely with thededicated staff, physicians, and volunteers at Methodist Mansfield,” Fresquez says.“It’s an honor to have been given the opportunity to lead this exceptional team,and I am committed to continuing the tradition of providing the best care possibleto people living in Mansfield and the surrounding communities.”5SPRING 2019Methodist CommunityPharmacy is openfor businessHealth informaticsworking to improveMethodist data literacyBrian Kenjarski, MD,MBA, FACEP,vice president andchief medicalinformatics officerSince Methodist’simplementation of Epic twoyears ago, health informaticshas identified the valuabletools, such as quick accessto reports that can improvepatient care and operationalefficiency, that are not beingused to their fullest potential.In Epic, the term Cogito refersto all things related to Epic dashboards andEpic day-to-day reporting. In December 2018,health informatics, through the departmentof clinical data management, recruited twobrand-new Cogito business analysts (CBAs)to improve campus-based data literacy andexpand system usage of Epic dashboardsand day-to-day reporting. Currently, CBAsare working with Methodist leaders to cleanup and validate information dashboard bydashboard — beginning with our patientsafety and quality, emergency department,and operating room dashboards.Most important, the CBAs will be workingon-site at the various campuses at least twodays a week, training clinicians how to accessself-service data and analytics offerings in Epic.The CBAs are starting up a Cogito power-userprogram in May that will involve representativesfrom each campus. This group of power userswill lead the effort to prioritize work on Epicdashboards and day-to-day reports that arecontinued on page 2

Digital distributionstarting this summerHealth informatics workingto improve Methodist dataliteracy continued from coverProgress Notes is going digital soon!The production team is transitioningthe publication from print to anonline version this summer. Therewill be a limited number of printedcopies in the hospital lounges, butwe will no longer be mailing thepublication to individual physicians.most useful to clinicians in an effortto optimize Epic data and analyticsavailability on a self-service basis.For help with Epic dashboards at MethodistDallas and Methodist RichardsonMedical Centers, contact John Kelleyat johnkelley@mhd.com. For help atMethodist Charlton and MethodistMansfield Medical Centers, contactBen Jacob at benjaminjacob@mhd.com.Your Epic dashboards also include accessto Epic Learning modules, where awealth of tips and tricks are archived tomake your experience using Epic moreuser-friendly. For questions about theEpic Learning Home Dashboard,contact the health informatics trainingteam at epictraining@mhd.com.Why are we making this change? We want to make sure we are sending out timely andrelevant content. This will allow us to work faster and get you the information you needon a more routine basis. Plus, we heard from some of our physicians that they wouldprefer to have digital communications for their health system news. Please reach outto your campus’ physician liaison to make sure your email address is up to date so youcontinue to receive Progress Notes.Email me Progress NotesMethodist Charlton billschneider@mhd.comMethodist Dallas adambrooks@mhd.comMethodist Mansfield bridgetflaherty@mhd.comMethodist Richardson emilyfletcher@mhd.comMETHODIST MANSFIELDMethodist Mansfield POB II now officially openThe new ProfessionalOffice Building II onthe Methodist Mansfieldcampus officiallyopened May 1 at anoon ceremony withthe Mansfield AreaChamber of Commerceand communitymembers in attendance.The new 82,000-square-foot, four-story building at the corner of Hospital Drive andMatlock Road has the following tenants:Suite 130 — John Willis, DO, Mike McInnis, MD, and Jaremy James, DO, internal medicine;Amber Hyde, MD, and Tzietal Davidson, PA-C, family medicine; Lindsey VanDyke, DO,endocrinology; and Darien Bradford, MD, cardiothoracic surgery.Suite 140 — Sarju Waghela, DO; Shrinivas Diggikar, MD; and Lixin Liao, MD, hematologyMedHealth/Methodist Medical Group facilities are staffed byindependently practicing physicians who are employees of MedHealth/Methodist Medical Group. The physicians and staff who provideservices at these sites are not employees or agents of Methodist HealthSystem or any of its affiliated hospitals.2SPRING 2019and oncology; Allison DiPasquale, MD, and Katrina Birdwell, MD, breast surgery.Suite 234 — Richard Meyrat, MD, and Nimesh Patel, MD, neurosurgery, and AntonioRozier, MD, physical medicine and rehabilitation, and Trevor Kraus, MD, pain management.Plans are underway for several more offices and an ambulatory surgery center. If you wouldlike leasing information, please contact Scott Sperling at 214-947-7837.

Methodist collaborates with VNA Meals onWheels to lower readmission ratesMethodist is collaborating withVNA Meals on Wheels in Dallason an innovative, nutritionbased program targeting seniorage patients at risk for hospitalreadmission. The grant-fundedprogram offers daily wellness checksand hot meals for patients followinghospital discharge protocols to helpprevent unnecessary emergencydepartment visits and readmissions.METHODIST CHARLTONNeurosurgicalservices expandedwith clinic hours,emergency consultsTo be eligible for the program, patients must meet the requirements outlined by VNA,which include: Recently discharged from any Methodist acute care hospital A resident of Dallas County Age 60 or older Monthly income is less than 2,300 Diagnosed with a chronic disease (patients receiving hemodialysis are not eligible).To refer an eligible patient, or learn more about the VNA – Methodist collaboration,contact Stacie Anderson, MPH, DSRIP project manager, at stacieanderson@mhd.com.Doctors can now ‘zoom’ in for OB-GYNgrand roundsA new learning opportunity for Methodist physicians kicked off on March 13. With Zoomvideo conferencing, OB-GYN physicians on other campuses can remotely view grandrounds discussions and presentations taking place through the Methodist Dallas Obstetricsand Gynecology Residency Program.Ashley Alvarez, program coordinator with the OB-GYN Residency Program, spearheadedthe project. She says the idea sparked from a conversation with Paul Lansdowne, MD, CPE,FACOG, medical director, physician service excellence at Methodist Mansfield.“He expressed interest in coming to the Wednesday morning grand rounds lectures hostedhere at Methodist Dallas,” Alvarez says. “But because of time and location, he was unable tocome. We talked about a tele-video conference, and it just kind of jump-started from there.”On March 1, Methodist Charlton expandedthe neurosurgical services offered at thehospital. Neurosurgeon Randall Graham,MD, and Kylie Rutherford, PA-C, withthe Methodist Brain and Spine Institute,will provide inpatient consultations andoffer expanded outpatient clinic hours onTuesdays and Fridays at Methodist Charlton.In addition, Dr. Graham will beginperforming noncomplex and minimallyinvasive spine procedures at the hospital.Dr. Graham and Rutherford will notonly support hospitalists and emergencydepartment physicians needingneurosurgical consultations, but they willalso allow our patients to receive necessarycare while at Methodist Charlton ratherthan be transferred to another facility.Please welcome them both to theMethodist Charlton community.Garrett Caudle, senior network engineer in information systems, suggested using Zoomtechnology so physicians could remotely view grand rounds from their computers orsmart devices.Alvarez says, “I told Garrett what we wanted to do, and he jumped right in and made it happen.”She says that this is a new opportunity for the medical staff to come alongside the aspiringphysicians for learning opportunities.SPRING 20193

METHODIST RICHARDSONMETHODIST DALLASHospital garnersnational attentionfor Facebook Liveheart surgeryHospital first in Dallas-Fort Worth to provideMARS therapy to adult patientsOn Jan. 18, Sonu Varghese, BS, RN, CCRN-K, and Belinda Cruz, BSN, RN, CCRN, became the first nurses inDallas-Fort Worth to care for an adult patient using MARS.Viewers tuned in from all over thecountry and beyond to watch a livetranscatheter aortic valve replacement(TAVR) on Methodist Richardson’sFacebook page. Cardiothoracic surgeonDerek Williams, MD, and interventionalcardiologist Nhan Nguyen, MD,both on the hospital medical staff,performed the successful procedure onThursday, Feb. 21. Asad Mohmand,MD, interventional cardiologist on theMethodist Richardson medical staff,narrated the surgery, and Mark Smith,MD, FACS, chief medical officer,answered viewers’ questions online.The family of the patient, 82-year-oldJim Klodnicki of Plano, watched thesurgery live. Jim left the hospital thenext day and is doing well. In fact, hewatched the video of his own TAVRand commented on Facebook, “Do youbelieve in miracles?”The surgery has been watched more than100,000 times so far and was covered morethan 75 times on TV stations across Texasand in other cities, including Chicago,Atlanta, and Philadelphia. This is thethird surgery that Methodist has featuredlive on Facebook.4SPRING 2019This past January, Methodist Dallas became the first hospital in Dallas-Fort Worth to providemolecular adsorbent recirculating system (MARS) therapy to adult patients. A rescue therapyfor patients with liver failure who are waiting for a transplant, this “liver dialysis” helps detoxifythe blood by selectively removing albumin-bound toxins the way the liver does.Soon after the ICU team completed their training on the system, a patient who could benefitfrom the procedure was transferred to the hospital. Because this was an urgent case, the team hadto come together quickly to prepare a protocol in two days so they could provide treatment.Parvez Mantry, MD, gastroenterologist and transplant hepatologist with The Liver Instituteat Methodist Dallas, says the treatment was successful. “The patient, who suffered fromacute liver failure, was able to live long enough to receive a liver transplant a week later.”Among the team members involved were Roberto Collazo-Maldonado, MD, nephrologist onthe medical staff at Methodist Dallas; Sonu Varghese, BS, RN, CCRN-K, nursing educationspecialist; and Belinda Cruz, BSN, RN, CCRN, staff nurse in the ICU.METHODIST DALLASCancer program gets three-year accreditationwith commendationMethodist Dallas’ cancerprogram underwent atriannual survey by theAmerican College ofSurgeons Commissionon Cancer (CoC) onFeb. 28 and passed withflying colors. The hospitalwas granted a threeyear accreditation withcommendation, which isonly awarded to facilities that exceed standard minimum requirements for accreditations.

New community pharmacy opensat Methodist DallasMethodist has opened a new whollyowned retail pharmacy, MethodistCommunity Pharmacy. A ribboncutting event on April 17 markedthe opening of the new pharmacy.Conveniently located in the lobbyof Methodist Dallas, the pharmacywill serve health system employees,members of the community,Fallon Nicolosi, PharmD, retail pharmacy manager, Methodistpatients, and visitors. It is currentlyCommunity Pharmacy, assists one of the first visitors insideopen from 9 a.m. to 5 p.m. Mondaythe health system’s new pharmacy.through Friday; extended andweekend hours of operation will start in mid-June. Jon T. Albrecht, MHA, RPh, BCNSP,FASHP, vice president of pharmacy services at Methodist, says a lot of people put in workto make sure the pharmacy would come to fruition. “I think everyone will be pleased with theservice and value they will receive,” he says.The pharmacy offers over-the-counter medications and has started filling prescriptions foremployees who are on the Methodist (Optum) insurance plan. By mid-June, most insuranceplans will be accepted and patient prescriptions will start being processed.Albrecht adds that a second pharmacy location at Methodist Charlton has been approved.It is currently planned for the hospital lobby in the former admitting space. The tentativeopening is set for December 2019.METHODIST DALLASNKF honors transplant patientThe National KidneyFoundation (NKF) ServingTexas honored MethodistDallas patient MaribelGutierrez this past winter.Maribel donated a kidneyto her 20-year-old daughter,Jessica, as tens of thousandswatched on our first FacebookLive event in June 2018.Maribel Gutierrez (right) and her daughter, Jessica Gutierrez (left), shownhere with her son, were honored by the National Kidney Foundation forallowing their transplant to be streamed live on the Methodist DallasFacebook page. Their transplant surgeon Richard Dickerman, MD, FACS,also shown here, spoke at the event honoring the mother and daughter.Maribel received the Gift ofLife award for raising awarenessof organ donation at aceremony at the Westin Galleria Dallas in February. “She gave her daughter life twice,” saidRichard Dickerman, MD, FACS, transplant surgeon on the medical staff at Methodist Dallas,when he paid tribute to Maribel.Dr. Dickerman, together with Alejandro Mejia, MD, FACS, also on the medical staff atMethodist Dallas, performed the transplant. More than 100,000 have watched the surgeryon Facebook for a total of more than 1,700 hours!METHODIST CHARLTONCDU relocated andIMC expanded toimprove patient careMethodist Charlton recently made changesto its clinical decision unit (CDU) andintermediate care unit (IMC) to enhancethe patient experience and care delivery.Methodist Charlton relocated its CDUto a newly renovated space on F4. Theserenovations have helped create a morecomfortable space for patients awaitingtransitions to a higher level of care.David Molengraaf, BSN, RN, directorof emergency services, applauded all theteams who played a role in helping makethis move happen. “A huge thank youto the CDU team and many others whomade this a smooth relocation for ourpatients,” he says.The hospital also recently expanded theIMC by adding 12 beds. During highcensus times, which Methodist Charltonregularly experiences due to the highvolume of traffic in the emergencydepartment (ED), the greatest need forbeds has usually been in the IMC. Having12 additional beds for intermediate carewill help reduce the number of patientsholding in the ED and will open up morecritical care beds for patients who areready to move out of the ICU.Methodist Charlton President FranLaukaitis, MHA, BSN, RN, FACHE,says creating more space will improvehow patients perceive the hospital.“We believe having these 12 additionalintermediate care beds will help improvepatient flow, patient care, and the overallpatient experience,” she says.MedHealth/Methodist Medical Group facilities are staffed byindependently practicing physicians who are employees of MedHealth/Methodist Medical Group. The physicians and staff who provideservices at these sites are not employees or agents of Methodist HealthSystem or any of its affiliated hospitals.SPRING 20195

METHODIST DALLASVITAS hospice unitbrings expert endof-life careEncouraging minority students to considercareers in healthcareLeaders of VITAS and Methodist Dallas gatherfor a photo during the VITAS grand opening.From left, James Wright, VITAS regional medicaldirector; Ralph Cox, VITAS associate medicaldirector; Leslie Cler, MD, Methodist Dallas chiefmedical officer; Marilyn Conley, VITAS generalmanager; Nick Westfall, VITAS CEO; JohnPhillips, Methodist Dallas president; and RaymondMunoz, MD; Methodist Dallas hospitalist.J. Darryl Amos, MD, FACS, CPE, spoke about the challengesand successes he has encountered throughout his almost30-year career during the Black Men in White Coats event.Methodist Health System recentlytook part in Black Men in White Coats,an initiative of DiverseMedicine Inc.,which aims to improve diversity withinthe medical profession. The event wasorganized in response to a report fromthe Association of American MedicalColleges revealing that more AfricanAmerican males applied to medicalschool in 1978 than in 2014 —a dramatic decline in enrollment.The full-day event at UT Southwestern welcomed nearly 1,500 students, parents, andeducators. Methodist Charlton and Methodist Dallas each sponsored the event.Physicians on the Methodist Dallasmedical staff now have an on-siteoption for terminally ill patients whosesymptoms require a higher level of care:a 16-bed hospice inpatient unit (IPU)managed by VITAS Healthcare.“We are proud to have this level ofcare available to patients and familiesacross the DFW area,” says MethodistDallas President John Phillips, FACHE.“We are equally proud that VITAS haschosen Methodist Dallas to host thisvital service.”Cynthia Mickens Ross, director of community relations and external affairs at MethodistCharlton, engaged the Best Southwest school districts, which sent two busloads of studentsfrom Duncanville and Lancaster ISDs. Laura Motta Mena, PhD, director of community andpublic relations at Methodist Dallas, recruited J. Darryl Amos, MD, FACS, CPE, executivemedical director of trauma centers at the Charlton, Dallas, and Mansfield campuses, andemergency medicine physician on the Methodist Dallas medical staff, to serve on aphysician panel. Merridth Simpson, SHRM-CP, CDP, director of human resources atMethodist Charlton, served as master of ceremonies.METHODIST MANSFIELDCelebrating National Doctors’ DayLocated on the fifth floor of SchenkelTower, the new 13,000-square-footVITAS IPU opened Feb. 6. The unitfeatures private rooms, two family areas,a kitchen, children’s area, overnightfamily accommodations, and supportspace for team meetings and familyconsultations. For more information,call 800-938-4827.Methodist Mansfield honored more than 100 physicians in March during a special NationalDoctors’ Day breakfast and lunch, followed by a physician appreciation event.Physicians were recognized for giving tirelessly of themselves each and every day. We aregrateful for their dedication, commitment to quality, and continual service to Methodist andthe community.6SPRING 2019

METHODIST CHARLTONMETHODIST RICHARDSONMammogram Poster Girls raise 50,000for breast cancer screeningSurgeon namedchair of surgery atthe TCU and UNTHSCSchool of MedicineSheri Mathis, founder of Mammogram Poster Girls (left), presents a check for 50,000 to Methodist Charltonteam members (from left) Linda McKoy, RT(R)(M), mammography manager; Sandy Sharp, community outreachcoordinator; and Amber Long, MBA, BSN, RN, OCN, CPHQ, director of cancer program administration.Methodist Charlton Women’s Imaging Center received a 50,000 donation on Jan. 16 to helpfund mammograms for women and men who would otherwise be unable to afford them.The donation will enable Methodist Charlton to provide more than 300 free mammograms.Studies show that those who take part in a breast cancer screening program have a 60 percentlower risk of dying from the disease in the 10 years after diagnosis and a 47 percent lowerrisk 20 years after diagnosis. In short, getting tested saves lives.Funds were raised during the Mammogram Poster Girls’ 2018 Shop Eat Drink PINK! VIP event.Share your medical mission or servicetrip story with us!The TCU andUNTHSC Schoolof Medicine hasappointed RohanJeyarajah, MD,FACS, as its firstacademic chair ofRohan Jeyarajah,MD, FACSsurgery. He willlead the planning, operations, andoversight within the school’s surgerydepartment. Dr. Jeyarajah is the directorof gastrointestinal surgical services anddirector of Hepato-Pancreatico-BiliarySurgery Fellowship and AdvancedGastrointestinal Surgery Fellowshipprograms at Methodist Richardson.“Dr. Jeyarajah is an ideal addition in thecritical department of surgery for ourmedical school,” says Stuart Flynn, MD,dean of the TCU and UNTHSC Schoolof Medicine. “His surgical talents andknowledge about the complexities ofsurgery are a valuable asset to our facultyand students.”We’re still looking for moresubmissions for our recentlyrelaunched Mission toMedicine series on our ShineOnline blog.The stories we feature in theseries focus on Methodistemployees and physicianson our medical staff whohave participated in medicalservice outside the hospital.Our goal is to highlightScott Layman, Hoyt Slade, and Amber Smith visit with patients in linepeople who are living outto get their recetas médicas, or prescriptions, filled during a missionclinic in February. The trio, who work on the Methodist MansfieldMethodist’s mission tocampus, volunteered with a medical mission called Heart for Honduras.improve and save livesthrough compassionate, quality healthcare outside the health system. Email Sarah Cohen(sarahcohen@mhd.com) with details about your recent medical service, including the dateand destination, and we’ll consider it for future blog articles.MedHealth/Methodist Medical Group facilities are staffed byindependently practicing physicians who are employees of MedHealth/Methodist Medical Group. The physicians and staff who provideservices at these sites are not employees or agents of Methodist HealthSystem or any of its affiliated hospitals.SPRING 20197

P.O. BOX 655999DALLAS, TX 75265-5999METHODIST RICHARDSONCampus earns strokerecertification fromThe Joint CommissionMethodist Richardson is proud toannounce The Joint Commission hasrecertified the hospital as an AdvancedPrimary Stroke Center. The surveyorhad minimal findings and renewed thecertification. Congratulations to strokecoordinators Beena Mathai, MSN, RN,CCRN, and Danielle Cooper, RN, as wellas all of the team members who playeda role in this achievement.New physicians on the Methodist medical staffThe board of directors approved the following providers as members of the MethodistHealth System medical staff between December 2018 through March 2019.METHODIST CHARLTONOB-GYNBasiouni M. Basiouni Jr., DOLuann K. Hassan, MDOPHTHALMOLOGYSteven M. Reinecke, MDSLEEP MEDICINETerry S. Peery, DOMETHODIST DALLASCRITICAL CARE MEDICINEDhruvangkumar A. Modi, MDHOSPITALISTElwaleed Elnagar, MDSalman A. Raheem, DOFAMILY MEDICINEErica L. Sails, MDMuhammad T. Siddique, MDMedHealth/Methodist Medical Group facilities are staffed byindependently practicing physicians who are employees of MedHealth/Methodist Medical Group. The physicians and staff who provideservices at these sites are not employees or agents of Methodist HealthSystem or any of its affiliated hospitals.HEMATOLOGY/ONCOLOGYTobenna I. Nwizu, MDNEPHROLOGYFahad Alobaidi, MDHuda Arif, MDBradley T. Long, MDINTERNAL MEDICINEHashim A. Majeed, MDNEUROSURGERYWilliam McCullough, MDPAIN MANAGEMENTAlan M. Sheydwasser, MDRADIOLOGY,TELERADIOLOGYJason W. Wachsmann, MDMETHODIST MANSFIELDProgress Notes Production TeamINTERNAL MEDICINEDenise K. Bruckerhoff, DONEONATOLOGYJennifer L. Boswell, MDPULMONOLOGYHarsh N. Patel, MDGERIATRIC MEDICINENeeta G. Nayak, MDAnthony K. Nguyen, DOMarina T. Vengalil, MDHOSPITALISTBrian K. Nelson, MDRADIOLOGY, DIAGNOSTICLulu L. Tenorio, MDPAIN MANAGEMENTEric R. Jenkins, MDFAMILY MEDICINEPalaniappanArumugham, MDHassan Imam, MDGENERAL SURGERYAndre Graham, MDINTERNAL MEDICINEDavid R. Ruiz-Bello, MDOB-GYNSadia A. Khandaker, MDLoan N. Nguyen, MDP.O. BOX 655999, DALLAS, TX 75265-5999GASTROENTEROLOGYSuwebatu T. OdunsiShiyanbade, MDOB-GYNCharmaine Sesay, MDMini Sreedevi, MDPEDIATRICSTina M. Isaac, DOPODIATRYJaytinder S. Sandhu, DPMRADIOLOGY, WOMEN’SIMAGINGMagda Rizer, DOPSYCHIATRYBagyalakshmiArumugham, MDUROLOGYDominic H. Tang, MDMETHODIST RICHARDSONANESTHESIOLOGYFrederick H. Browder, MDZachary S. Jones, MDShoyab A. Panchbhaya, MDSigurdur S. Sigurdsson, MDTimothy P. Sims, MDKeshava G. Suresh, MDAshley D. Wood, DOBrian Kenjarski, MDChief Medical Informatics OfficerMethodist Health SystemRosie RamirezMedical Staff ServicesMethodist Health SystemMia SimonPublic Relations CoordinatorMethodist Health SystemBill SchneiderMethodist Charlton Medical CenterLaura Motta MenaMethodist Dallas Medical CenterRADIOLOGY, DIAGNOSTICMichael D. Gouvion, MDFeng Jiang, MDFah S. Leong, MDVASCULAR SURGERYShonda L. Banegas, DOTodd A. Spencer, MDEmily FletcherMethodist Richardson Medical CenterBridget Flaherty and Angel BiasattiMethodist Mansfield Medical Center360399304

Neurosurgical services expanded with clinic hours, emergency consults On March 1, Methodist Charlton expanded the neurosurgical services offered at the hospital. Neurosurgeon Randall Graham, MD, and Kylie Rutherford, PA-C, with the Methodist Brain and Spine Institute, will provide inpatient consultations and offer expanded outpatient clinic .