                                                                                                           ACCEPTED
                                                                                                     03-14-00765-CV
                                                                                                             4402607
                                                                                            THIRD COURT OF APPEALS
                                                                                                      AUSTIN, TEXAS
                                                                                                  3/6/2015 2:11:03 PM
                                                                                                    JEFFREY D. KYLE
                                                                                                               CLERK
                                           NO. 03–14–00765–CV
                                       IN THE COURT OF APPEALS
                                                                         FILED IN
                                   FOR THE THIRD DISTRICT OF TEXAS 3rd COURT OF APPEALS
                                               AT AUSTIN               AUSTIN, TEXAS
                                                                             3/6/2015 2:11:03 PM
                                                                               JEFFREY D. KYLE
                                         NANCY JO RODRIGUEZ,                         Clerk

                                                          APPELLANT,
                                                     V.
        THE WALGREEN COMPANY AND SARA ELIZABETH MCGUIRE,
                                                          APPELLEES.

                                   On Appeal from the 419th District Court
                                          Travis County, Texas


                                         BRIEF OF APPELLEES


                                                   JUDITH R. BLAKEWAY
                                                   State Bar No. 02434400
                                                   judith.blakeway@strasburger.com
                                                   CYNTHIA DAY GRIMES
                                                   State Bar No. 11436600
                                                   Cynthia.Grimes@strasburger.com
                                                   STRASBURGER & PRICE, LLP
                                                   2301 Broadway
                                                   San Antonio, Texas 78215
                                                   (210) 250-6003 Telephone
                                                   (210) 258-2706 Facsimile

                                                   ATTORNEYS FOR APPELLEES




1751449.6/SPSA/87282/0138/030615
                                    Identity of Parties and Counsel

          In accordance with Rule 38.1(a) of the Texas Rules of Appellate Procedure,

Appellees provide the following complete list of all parties and counsel to the trial

court’s order that forms the basis of this appeal.

                            Party                               Trial Counsel
NANCY JO RODRIGUEZ                                 Lannie Todd Kelly
          Appellant                                State Bar No. 24035049
                                                   THE CARLSON LAW FIRM, P.C.
                                                   11606 N. IH–35
                                                   Austin, TX 78753
                                                   Telephone: (512) 346–5688
                                                   Facsimile: (512) 719–4362
                                                   tkelly@carlsonattorneys.com
THE WALGREEN COMPANY, INC.                        CYNTHIA DAY GRIMES
and                                               State Bar No. 11436600
SARA ELIZABETH MCGUIRE                            Cynthia.Grimes@strasburger.com
    Appellees                                     STRASBURGER & PRICE, LLP
                                                  2301 Broadway
                                                  San Antonio, Texas 78215
                                                  (210) 250-6003 Telephone
                                                  (210) 258-2706 Facsimile
                                                        Trial Counsel
                                                  JUDITH R. BLAKEWAY
                                                  State Bar No. 02434400
                                                  judith.blakeway@strasburger.com
                                                  CYNTHIA DAY GRIMES
                                                  State Bar No. 11436600
                                                  Cynthia.Grimes@strasburger.com
                                                  STRASBURGER & PRICE, LLP
                                                  2301 Broadway
                                                  San Antonio, Texas 78215
                                                  (210) 250-6003 Telephone
                                                  (210) 258-2706 Facsimile
                                                         Appellate Counsel

                                                  ii
1751449.6/SPSA/87282/0138/030615
VIVEK GOSWAMI, M.D. and               Chris Knudsen
AUSTIN HEART, PLLC                    State Bar No. 24041268
    Defendants (not parties to this   cknudsen@serpejones.com
    appeal)                           nandrews@serpejones.com
                                      Nicole Andrews
                                      State Bar No. 00792335
                                      SERPE JONES ANDREWS
                                      CALLENDER & BELL, PLLC
                                      2929 Allen Parkway, Suite 1600
                                      Houston, Texas 77019
                                      (713) 452–4400 Telephone
                                      (713) 452–4499 Facsimile

ST. DAVID’S HEALTH CARE               Missy Atwood
PARTNERSHIP                           State Bar No. 01428020
     Defendant (not a party to this   GERMER, BEAMAN & BROWN, PLLC
     appeal)                          301 Congress Avenue, Suite 1700
                                      Austin, Texas 78701
                                      (512) 472–0288 Telephone
                                      (512) 472–0721 Facsimile
                                      matwood@germer-austin.com




                                      iii
1751449.6/SPSA/87282/0138/030615
                                                    Table of Contents

Identity of Parties and Counsel ................................................................................. ii

Table of Contents ......................................................................................................iv

Table of Authorities ..................................................................................................vi

Statement of the Case................................................................................................. 1

Issue Presented ........................................................................................................... 1
          Did the trial court abuse its discretion in dismissing Plaintiff’s claims
          against Walgreen and McGuire? ..................................................................... 1

Statement of Facts ...................................................................................................... 1
Summary of Argument .............................................................................................. 4

Standard of Review .................................................................................................... 6

Argument.................................................................................................................... 8
          I.         A Chapter 74 report must be from a qualified expert and
                     address in non–conclusory terms the standard of care, breach
                     and causation. ........................................................................................ 8
          II.        The trial court did not abuse its discretion in dismissing claims
                     against Walgreen and McGuire. ............................................................ 9

                     A.            Mr. Hardy’s report is deficient.................................................... 9
                                   1.      Mr. Hardy’s opinion is speculative and conclusory. ........ 9

                                   2.      Mr. Hardy is statutorily disqualified from
                                           addressing causation. ...................................................... 11

                                   3.      Mr. Hardy’s report fails to distinguish between
                                           multiple defendants......................................................... 13

                                   4.      Mr. Hardy is not qualified as a practicing
                                           pharmacist. ...................................................................... 14



                                                                 iv
1751449.6/SPSA/87282/0138/030615
                     B.            Dr. Breall’s expert report is deficient. ...................................... 15

                                   1.      Dr. Breall’s report does not even mention
                                           Walgreen or McGuire. .................................................... 16

                                   2.      Dr. Breall’s report is speculative and conclusory. .......... 17

                                   3.      Dr. Breall is not qualified to testify to the standard
                                           of care for a pharmacy or pharmacist. ............................ 19

Conclusion ............................................................................................................... 19
Certificate of Service ............................................................................................... 21

Certificate of Compliance ........................................................................................ 21
Appendix .................................................................................................................. 22

          1.         Order dated December 3, 2014 ........................................................... 22
          2.         Mr. Hardy’s CV and report ................................................................. 22

          3.         Dr. Breall’s CV and report .................................................................. 22
          4.         TEX. CIV. PRAC. & REM. CODE §74.351 .............................................. 22

          5.         TEX. CIV. PRAC. & REM. CODE §74.402 .............................................. 22




                                                               v
1751449.6/SPSA/87282/0138/030615
                                         Table of Authorities

                                                                                                    Page(s)
CASES
American Transitional Care Centers of Texas Inc. v. Palacios,
  46 S.W.3d 873 (Tex. 2001).......................................................................6, 7, 8, 9

Apodaca v. Russo,
  228 S.W.3d 252 (Tex. App.–Austin 2007, no pet.) ............................................ 17

Austin Heart, P.A. v. Webb,
  228 S.W.3d 276 (Tex. App.–Austin 2007, no pet.) ................................13, 14, 17
Austin Regional Clinic v. Power,
  2012 Tex. App. LEXIS 5242 (Austin 2012, no pet.).......................................... 17

Bogar v. Esparza,
  257 S.W.3d 354 (Tex. App.–Austin 2008, no pet.) ............................................ 17
Bowie Mem’l Hosp. v. Wright,
  79 S.W.3d 48 (Tex. 2002)...............................................................7, 9, 12, 13, 18
Broders v. Heise,
   924 S.W.2d 148 (Tex. 1996) .............................................................................. 15

Constancio v. Bray,
  266 S.W.3d 149 (Tex. App.–Austin 2008, no pet.) ............................................ 18
Cooper v. Arizpe,
  No. 04–07–00743, 2008 Tex. App. LEXIS 2506 (Tex. App.–San
  Antonio, April. 9, 2008, pet. denied) .................................................................. 10

Doades v. Syed,
  94 S.W.3d 664 (Tex. App.–San Antonio 2002, no pet.) .................................... 13

Estate of Allen v. Polly Ryon Hosp. Auth.,
   No. 01–04–00151–CV, 2005 Tex. App. LEXIS 1691 (Tex. App.–
   Houston [1st Dist.] Mar. 3, 2005, no pet.) (mem. op.) ....................................... 12
Fung v. Fischer,
  365 S.W.3d 507 (Tex. App.–Austin 2012), overruled in part by Certified
  EMS, Inc. v. Potts, 392 S.W.3d 625 (Tex. 2013) .........................................10, 16

                                                      vi
1751449.6/SPSA/87282/0138/030615
Jelinek v. Casas,
   328 S.W.3d 526 (Tex. 2010) ................................................................................ 7

Jernigan v. Langley,
   195 S.W.3d 91 (Tex. 2006)...........................................................................6, 7, 9

Kocerek v. Colby,
  No. 03–13–0057–CV, 2014 Tex. App. LEXIS 9336 (Tex. App.–Austin
  2014, no pet.) ...................................................................................................... 18
Lenger v. Physician’s Gen. Hosp.,
   455 S.W.2d 703 (Tex. 1970) .............................................................................. 12

McMenemy v. Holden,
  No. 14–07–00365–CV, 2007 Tex. App. LEXIS 8830 (Tex. App.–
  Houston [14th Dist.] Nov. 1, 2007, pet. denied) (mem. op.) .............................. 12

Murphy v. Mendoza,
  234 S.W.3d 23 (Tex. App.–El Paso 2007, no pet.) ............................................ 11
Perez v. Daughters of Charity Health Servs. of Austin,
   No. 03–08–00200–CV, 2008 WL 4531558 (Tex. App.–Austin, Oct. 10,
   2008, no pet.) (mem. op.).................................................................................... 18

Reddy v. Hebner,
  435 S.W.3d 323 (Tex. App.–Austin 2014, pet. filed) ........................................ 16
Rittmer v. Garza,
   65 S.W.3d 718 (Tex. App.–Houston [14th Dist.] 2001, no pet.) ....................... 13
Samlowski v. Wooten,
  332 S.W.3d 404 (Tex. 2011) ............................................................................ 7, 9

Scoresby v. Santillan,
   346 S.W.3d 546 (Tex. 2011) ................................................................................ 9

Smith v. Wilson,
  368 S.W.3d 574 (Tex. App.–Austin 2012, no pet.) ........................................ 7, 18

Taylor v. Christus Spohn Health Sys. Corp.,
   169 S.W.3d 241 (Tex. App.–Corpus Christi 2004, no pet.) ............................... 14



                                                           vii
1751449.6/SPSA/87282/0138/030615
Tenet Hospitals Ltd. v. De La Riva,
   351 S.W.3d 398 (Tex. App.–El Paso 2011, no pet.) .......................................... 14

Walgreen Co. v. Hieger,
  243 S.W.3d 183 (Tex. App.–Houston [14th Dist.] 2007, pet. denied) ............... 12

Walker v. Gutierrez,
  111 S.W.3d 56 (Tex. 2003)................................................................................... 7

STATUTES
TEX. CIV. PRAC. & REM. CODE 74.001(a)(10) .......................................................... 15

TEX. CIV. PRAC. & REM. CODE § 74.351 .................................................................... 8

TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i)..................................................... 16

TEX. CIV. PRAC. & REM. CODE § 74.351(r)(6) ...................................................13, 18
TEX. CIV. PRAC. & REM. CODE § 74.402 ..................................................................... 19

TEX. CIV. PRAC. & REM. CODE § 74.402(b)(1)–(3) .................................................. 14
TEX. CIV. PRAC. & REM. CODE § 74.402(c) ............................................................. 15

TEX. CIV. PRAC. & REM. CODE § 74.403(a).............................................................. 11




                                                      viii
1751449.6/SPSA/87282/0138/030615
                                   Statement of the Case

          This is an interlocutory appeal from an order dismissing a health care

liability claim against Walgreen and its pharmacist McGuire for failure to serve

adequate expert reports. Ms. Rodriguez claims that the district court abused its

discretion in concluding that she failed to serve expert reports that comply with

Chapter 74 of the Texas Civil Practice and Remedies Code.

                                      Issue Presented

          Did the trial court abuse its discretion in dismissing Plaintiff’s claims
          against Walgreen and McGuire?

                                    Statement of Facts

          Ms. Rodriguez sued her cardiologist, Dr. Goswami, Walgreen and its

pharmacist, McGuire, claiming that Defendants were negligent because after

Dr. Kessler (who was in the same group as Dr. Goswami) advised that Pradaxa be

discontinued, Walgreen continued to fill a prescription previously issued by

Dr. Goswami. C.R. 6. Dr. Goswami issued the prescription on February 14, 2012,

C.R. 335, with a prescription refill on March 16, 2012. C.R. 336. Ms. Rodriguez

alleged that continued use of Pradaxa caused her to be admitted to the hospital with

hypertension, acute kidney injury and gastrointestinal bleeding. C.R. 6. In support

of her claim, she served reports from Jeffrey Hardy, Pharm. D., M.S., C.R. 39–42,

and Dr. Jeffrey Breall, a professor of clinical medicine. C.R. 43–44.




1751449.6/SPSA/87282/0138/030615
          Mr. Hardy opined that Walgreen, McGuire and a pharmacist with the initials

MDD breached the applicable standard of care because (1) they failed to verify

whether the prescription previously written by Dr. Goswami for Pradaxa should be

continued and (2) dispensed a prescription for Pradaxa after Dr. Kessler indicated

that it be discontinued.

          His report stated:

                                                Standards of Care
          The standard of care required to fill Ms. Rodriguez’s dabigatran
          etexilate (PRADAXA) prescription are as follows:

                                  Pharmacists have a duty to contact the prescribing
                                   physician if patient harm is possible to validate the
                                   prescription
                                  Pharmacists are responsible for ensuring a prescription is
                                   accurately communicated and dispensed as intended by
                                   the prescriber
                                  Pharmacists are responsible for communicating with the
                                   prescribing physician to validate continuation of therapy
                                   when no refills remain on a prescription
                                        Breach of Standard of Care
          Walgreens, Sara Elizabeth McGuire (pharmacist), and pharmacist
          with initials MDD breached the applicable standards of care.
          Specifically, Walgreens, Sara Elizabeth McGuire (pharmacist), and
          pharmacist with initials MDD conduct fell below the standard of care
          by:

                                  Continuing to dispense a prescription for dabigatran
                                   etexilate (PRADAXA) after the prescribing physician
                                   indicated it should be discontinued; and




1751449.6/SPSA/87282/0138/030615                         2
                                  Failing to verify if the prescription for dabigatran
                                   etexilate (PRADAXA) should be continued with the
                                   prescribing physician

          Walgreens, Sara Elizabeth McGuire (pharmacist), and pharmacist
          with initials MDD should have provided Ms. Rodriguez with the care
          and treatment in the standard of care paragraph above. However, this
          expected care was not provided to Ms. Rodriguez as set forth in the
          preceding paragraph.

C.R. 40–41.

          Plaintiff did not offer Mr. Hardy’s opinion as to causation, but instead relied

on the report of Dr. Breall. C.R. 359; R.R. 32. Dr. Breall’s report did not mention

Walgreen or McGuire; it was instead directed solely to the conduct of Dr.

Goswami. C.R. 44. Dr. Breall stated the following about causation:

          Failure to discontinue the use of Pradaxa was a direct cause of her
          subsequent acute admission to the hospital with hypotension, acute
          kidney injury and apparent gastrointestinal bleeding – known side
          effects of the over–use of Pradaxa. Ms. Rodriguez’s entire
          hospitalization was attributable to the failure to stop Pradaxa therapy
          as ordered by Dr. Kessler. More likely than not, had the Pradaxa
          medication been discontinued as requested, Ms. Rodriguez’s
          hospitalization would never have needed to take place.

C.R. 44.

          Walgreen and McGuire objected to both reports, C.R. 64–74, and moved to

dismiss. C.R. 212–20. The trial court granted their motion. C.R. 375–76.

Ms. Rodriguez appeals. Supp. C.R. 3–4.




1751449.6/SPSA/87282/0138/030615                      3
                                   Summary of Argument

          The trial court did not abuse its discretion in dismissing Ms. Rodriguez’s

claims against Walgreen and McGuire. Her experts were not shown to be qualified

and their reports failed to implicate Walgreen or its pharmacists. Neither expert

provided a factual basis for his opinions. Both reports were based on the unstated

assumption that Walgreen and McGuire knew Dr. Kessler had instructed Ms.

Rodriguez to discontinue Pradaxa. Even when read together, there was no report

that implicated the conduct of Walgreen or its pharmacists because Mr. Hardy was

incompetent to render a report as to causation and Dr. Breall never even mentioned

Walgreen or McGuire in his report. The trial court’s dismissal should be affirmed.

          The trial court did not abuse its discretion in finding Mr. Hardy’s report

deficient. First, his report is conclusory ––he fails to provide any facts to support

his conclusion about why Walgreen and its pharmacists failed to meet the standard

of care. He does not recite any facts about the date of Dr. Kessler’s advice to stop

Pradaxa, to whom the instruction may have been communicated, whether

Walgreen or its pharmacists ever had any notice of the advice, the circumstances

under which Walgreen continued to refill her Pradaxa prescription, or any other

relevant facts. If Walgreen received the prescription written by Dr. Goswami,

C.R. 335, and the five refills of Pradaxa, C.R. 336, and was not aware of

Dr. Kessler’s subsequent indication to stop using Pradaxa, there would be no



1751449.6/SPSA/87282/0138/030615            4
reason for Walgreen to refuse to refill her prescription using the prescription it had

on file. Nevertheless, Mr. Hardy’s report does not even mention the fact that

Walgreen had a prescription refill that predated the hospital admission during

which Dr. Kessler said to stop Pradaxa. Nor does it mention whether Walgreen or

McGuire were ever informed of Dr. Kessler’s instruction.

          Second, Mr. Hardy was statutorily disqualified from testifying to causation.

Ms. Rodriguez concedes that Mr. Hardy was unqualified to render an opinion

regarding causation; only a physician may render opinions regarding causation.

Nevertheless, Ms. Rodriguez asserts that when Mr. Hardy’s report is read in

conjunction with Dr. Breall’s report, the causation requirement is satisfied. While

it is true that the expert report requirement may be satisfied by utilizing more than

one expert report, Dr. Breall’s report does not supply the missing causation.

Dr. Breall’s report does not even mention Walgreen or its pharmacists much less

identify any conduct, act or omission attributable to them.

          Third, when a plaintiff sues more than one defendant, the expert report must

set forth the standard of care applicable to each defendant and explain the causal

relationship between each defendant’s acts and the plaintiff’s injury. A claimant

must provide each defendant with an expert report that sets forth the manner in

which the care rendered by that defendant failed to meet the standard of care and




1751449.6/SPSA/87282/0138/030615            5
the causal relationship between that failure and the injuries claimed. This Mr.

Hardy and Dr. Breall failed to do.

          Fourth, Mr. Hardy was not qualified. There is nothing in the four corners of

his report to indicate that he was a practicing pharmacist filling prescriptions at the

time the claim arose or when he made his report.

          The trial court did not abuse its discretion in finding that Dr. Breall’s report

does not bridge the gaps in Mr. Hardy’s report. First, his report does not even

mention Walgreen or McGuire much less recite any facts that Walgreen’s

pharmacists were on notice of Dr. Kessler’s instruction. Second, his report is

speculative and conclusory on the issue of causation. It fails to identify the

prescription used by Ms. Rodriguez after Dr. Kessler said to stop using Pradaxa,

the circumstances under which Walgreen continued to refill the prescription, or

how doing so contributed to Ms. Rodriguez’s injury. Third, Dr. Breall is not

qualified to testify to the standard of care for a pharmacist.

          The trial court’s dismissal should be affirmed.

                                   Standard of Review

          A trial court’s rulings on motions to dismiss health care liability claims are

reviewed for an abuse of discretion. Jernigan v. Langley, 195 S.W.3d 91, 93

(Tex. 2006); American Transitional Care Centers of Texas Inc. v. Palacios,

46 S.W.3d 873, 877 (Tex. 2001). A trial court abuses its discretion by rendering an



1751449.6/SPSA/87282/0138/030615              6
arbitrary and unreasonable decision lacking support in the facts or circumstances of

the case or by acting in an arbitrary or unreasonable manner without reference to

guiding rules or principles. Samlowski v. Wooten, 332 S.W.3d 404, 410 (Tex.

2011) (plurality op.) When reviewing matters committed to the trial court’s

discretion, an appellate court may not substitute its own judgment for that of the

trial court. Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002). A trial

court does not abuse its discretion merely because it decides a discretionary matter

differently than an appellate court would in a similar circumstance. Id.; see also

Jelinek v. Casas, 328 S.W.3d 526, 542 (Tex. 2010) (Jefferson, C.J., dissenting)

(“The dividing line between a sufficient and an inadequate report is impossible to

draw precisely. We have said, therefore, that the determination must be made in

the first instance by the trial court, and review of that decision asks not how an

appellate court would have resolved that issue, but instead whether the trial court

abused its discretion.”) (citing Jernigan v. Langley, 195 S.W.3d 91, 93 (Tex.

2006); Walker v. Gutierrez, 111 S.W.3d 56, 63 (Tex. 2003)). But if an expert

report contains only conclusions about the statutory elements, a trial court has “no

discretion but to conclude . . . that the report does not represent a good–faith

effort” to satisfy the statute. Palacios, 46 S.W.3d at 877, 880; Smith v. Wilson,

368 S.W.3d 574 (Tex. App.–Austin 2012, no pet.).




1751449.6/SPSA/87282/0138/030615         7
                                        Argument

I.        A Chapter 74 report must be from a qualified expert and address in
          non–conclusory terms the standard of care, breach and causation.
          Pursuant to Section 74.351, medical–malpractice plaintiffs must provide

each defendant health care provider with an expert report or voluntarily nonsuit the

action. TEX. CIV. PRAC. & REM. CODE §74.351. If a claimant timely furnishes an

expert report, a defendant may file a motion challenging the report’s adequacy. Id.

The trial court shall grant the motion only if it appears, after hearing, that the report

does not represent a good faith effort to comply with the statutory definition of an

expert report. See id. §74.351(l). The statute defines an expert report as a written

report by an expert that provides, as to each defendant, a fair summary of the

expert’s opinions, as of the date of the report, regarding: (1) the applicable

standards of care; (2) the manner in which the care provided failed to meet the

standards; and (3) the causal relationship between that failure and the injury, harm,

or damages claimed. See id. §74.351(r)(6).

          Although the report need not marshal all the plaintiff’s proof, it must include

the expert’s opinions on the three statutory elements––standard of care, breach and

causation. See Palacios, 46 S.W.3d at 878. In detailing these elements, the report

must provide enough information to fulfill two purposes: first, it must inform the

defendant of the specific conduct the plaintiff has called into question, and, second,

it must provide a basis for the trial court to conclude that the claims have merit.


1751449.6/SPSA/87282/0138/030615             8
Scoresby v. Santillan, 346 S.W.3d 546, 556 (Tex. 2011) (citing Palacios,

46 S.W.3d at 879). A report that merely states the expert’s conclusions as to the

standard of care, breach, and causation does not fulfill these two purposes. Id. A

report that omits one or more of these required elements, or states the expert’s

opinions as merely conclusions without supporting facts, is insufficient to

constitute a “good faith effort” at compliance with Chapter 74. See Samlowski v.

Wooten, 332 S.W.3d 404, 409–10 (Tex. 2011); Jernigan v. Langley, 195 S.W.3d

91, 93–94 (Tex. 2006) (affirming trial court’s dismissal of suit because expert

reports omitted any allegation about how doctor breached standard of care and

causation); Bowie Mem’l Hosp., 79 S.W.3d at 52. (“[T]he expert must explain the

basis of his statements and link his conclusions to the facts.”) Furthermore, in

assessing a report’s sufficiency, a trial court may not draw any inferences, and

instead must rely exclusively on the information contained within the report’s four

corners. See Scoresby v. Santillan, 346 S.W.3d 546, 556 (Tex. 2011) (citing

Palacios, 46 S.W.3d at 878).

II.       The trial court did not abuse its discretion in dismissing claims against
          Walgreen and McGuire.

          A.         Mr. Hardy’s report is deficient.
                     1.            Mr. Hardy’s opinion is speculative and conclusory.
          Mr. Hardy’s report is speculative because it relies on the assumption that

Walgreen and McGuire were aware of Dr. Kessler’s advice to discontinue the use


1751449.6/SPSA/87282/0138/030615                       9
of Pradaxa. It fails to make a causal link between an allegedly breached standard of

care and injury by requiring an inference that if Walgreen and McGuire had known

of Dr. Kessler’s advice, then Ms. Rodriguez’s outcome would have been different.

His opinions all hinge on Walgreen and McGuire knowing of Dr. Kessler’s advice.

Yet there is nothing in Mr. Hardy’s report that affirmatively shows that Walgreen

and McGuire were aware of the information that is identified as key to their

liability. Any breach of the standard of care discussed in Mr. Hardy’s report is

entirely dependent on what Defendants knew and when. Yet Mr. Hardy’s report is

silent on these crucial facts. Further, Mr. Hardy’s report says Walgreen should

have contacted the prescribing physician––Dr. Goswami. But there is no indication

that at that time Dr. Goswami even knew of Dr. Kessler’s advice or would have

communicated it to Walgreen or McGuire.

          By relying on assumptions instead of facts, the report provides no basis for a

trial court to conclude that the claims against Defendants have merit. Fung v.

Fischer, 365 S.W.3d 507, 533 (Tex. App.–Austin 2012), overruled in part by

Certified EMS, Inc. v. Potts, 392 S.W.3d 625 (Tex. 2013) (finding that report that

depended on unsupported assumptions about what a defendant knew and when he

knew it was speculative); Cooper v. Arizpe, No. 04–07–00743, 2008 Tex. App.

LEXIS 2506 at *9–10 (Tex. App.–San Antonio, April. 9, 2008, pet. denied)

(holding that report that relied on assumption that notes were in chart was



1751449.6/SPSA/87282/0138/030615            10
conclusory and speculative); Murphy v. Mendoza, 234 S.W.3d 23, 28 (Tex. App.–

El Paso 2007, no pet.) (holding that expert’s opinion as to breach of the standard of

care was speculative and conclusory as it was unsupported by facts in report’s four

corners and relied on assumption).

          Mr. Hardy’s opinions regarding Walgreen’s negligence, breach of the

standard of care, and causation––which depend on unsupported assumptions as to

what Walgreen and McGuire knew and when they knew it––are conclusory and

speculative at best. They do not provide a basis for the court to conclude that

Ms. Rodriguez’s healthcare liability claim against Walgreen and McGuire has

merit.

                     2.            Mr. Hardy is statutorily disqualified from addressing
                                   causation.
          Mr. Hardy, Pharm. D., M.S., is a pharmacist and not a medical doctor. Only

a physician can render an opinion on causation. TEX. CIV. PRAC. & REM. CODE

§74.403(a). Therefore, Mr. Hardy, by statute, cannot render an opinion on

causation.

          Moreover, Mr. Hardy’s statement of causation is entirely conclusory in that

it fails to explain the relationship between the alleged injuries and the failure to act

according to the standard of care. He simply states “…It is clear that the long-term

use of dabigatran etexilate (Pradaxa) as dispensed by Walgreens and Sara

Elizabeth McGuire (pharmacist), and pharmacist with initials MDD caused


1751449.6/SPSA/87282/0138/030615                    11
Ms. Rodriguez’s acute kidney injury, anemia, and gastrointestinal bleeding (which

have led to her long-term clinical demise and medical injuries).” C.R. 42.

          The causal connection in healthcare malpractice suits must be made “beyond

the point of conjecture” and “must show more than a possibility” to warrant

submission of the issue to a jury. Lenger v. Physician’s Gen. Hosp., 455 S.W.2d

703, 706 (Tex. 1970); see Bowie Mem’l Hosp., 79 S.W.3d at 53. Reports providing

a “description of only a possibility of causation do not constitute a good–faith

effort to comply with the statute.” Walgreen Co. v. Hieger, 243 S.W.3d 183, 186–

87 (Tex. App.–Houston [14th Dist.] 2007, pet. denied) (holding that expert report

stating claimant had symptoms “consistent with” known side effects of medication

was insufficient to demonstrate causal link); see McMenemy v. Holden, No. 14–

07–00365–CV, 2007 Tex. App. LEXIS 8830, at *15–16 (Tex. App.–Houston

[14th Dist.] Nov. 1, 2007, pet. denied) (mem. op.) (concluding that expert’s report

expressing uncertainty about possibility of positive outcome for patient failed to

make causal link indicating plaintiffs’ claim had merit); Estate of Allen v. Polly

Ryon Hosp. Auth., No. 01–04–00151–CV, 2005 Tex. App. LEXIS 1691, at *16–17

(Tex. App.–Houston [1st Dist.] Mar. 3, 2005, no pet.) (mem. op.) (holding that

expert’s report failed to meet statutory causation requirement by opining merely

that breach of standard of care “could have contributed” to decline in claimant’s

condition).



1751449.6/SPSA/87282/0138/030615          12
          Further, a court may not fill in gaps in a report by drawing inferences or

guessing what the expert meant or intended. Austin Heart, P.A. v. Webb,

228 S.W.3d 276, 279 (Tex. App.–Austin 2007, no pet.). Instead, the report must

include the required information within its four corners. Bowie Mem’l Hosp.,

79 S.W.3d at 53. This Mr. Hardy’s report fails to do. The trial court thus did not

abuse its discretion in finding it inadequate.

                     3.            Mr. Hardy’s report fails to distinguish between multiple
                                   defendants.
          Also, Mr. Hardy’s report does not separately set out the alleged acts of

negligence and causal connection for each of the multiple defendants. When a

plaintiff sues more than one defendant, the expert report must set forth the standard

of care applicable to each defendant and explain the causal relationship between

each defendant’s individual acts and the injury. See TEX. CIV. PRAC. & REM. CODE

§74.351(r)(6) (a claimant must provide each defendant with an expert report that

sets forth the manner in which the care rendered failed to meet the standard of care

and the causal relationship between that failure and the injuries claimed); Doades

v. Syed, 94 S.W.3d 664, 671-72 (Tex. App.–San Antonio 2002, no pet.); Rittmer v.

Garza, 65 S.W.3d 718, 722-23 (Tex. App.–Houston [14th Dist.] 2001, no pet.).

          An expert report may not assert that multiple defendants are all negligent for

failing to meet the standard of care without providing an explanation of how each

defendant breached the standard of care and how that breach caused or contributed


1751449.6/SPSA/87282/0138/030615                     13
to cause the injury. Austin Heart, 228 S.W.3d at 282-83 (finding deficient expert

report that was “silent as to whether a single physician, multiple physicians, or all

physicians’ mentioned in the report failed to meet the standard of care and caused

injury to [the patient]”); Tenet Hospitals Ltd. v. De La Riva, 351 S.W.3d 398 (Tex.

App.–El Paso 2011, no pet.) (finding deficient expert report that failed to state who

among multiple defendants caused the injuries); Taylor v. Christus Spohn Health

Sys. Corp., 169 S.W.3d 241, 245–46 (Tex. App.–Corpus Christi 2004, no pet.)

(finding deficient expert report that failed “to state what each defendant should

have done in order to meet the standard of care, what each defendant failed to do,

and how such failure led to [the patient’s] death”).

          Because Mr. Hardy’s report does not explain what conduct, act or omissions

are attributable to which of the defendants, it is deficient, and the trial court did not

abuse its discretion in finding it did not satisfy the statutory requirements.

                     4.            Mr. Hardy is not qualified as a practicing pharmacist.
          A person may qualify as an expert witness on whether a health care provider

departed from accepted standards of care only if, at the time the claim arose or at

the time the testimony is given, he is practicing the same type of care or treatment

as the defendant, and is qualified by training or experience. TEX. CIV. PRAC. &

REM. CODE §74.402(b)(1)–(3). In determining whether a witness is qualified, a

court considers whether the witness (1) is certified by the licensing agency, and



1751449.6/SPSA/87282/0138/030615                       14
(2) is actively practicing health care in rendering health care services relevant to

the claim. TEX. CIV. PRAC. & REM. CODE §74.402(c). “Health care” is defined as

“any act or treatment performed or furnished, or that should have been performed

or furnished, by any health care provider for, to or on behalf of a patient during the

patient’s medical care, treatment, or confinement.” TEX. CIV. PRAC. & REM. CODE

74.001(a)(10). A plaintiff offering medical testimony must establish that the expert

has expertise regarding “the specific issue before the court which would qualify the

expert to give an opinion on that particular subject.” Broders v. Heise, 924 S.W.2d

148, 153 (Tex. 1996). The analysis focuses on “the very matter” on which the

expert is to give an opinion. Id.

          Here, there is no showing in the four corners of his report that Mr. Hardy is

practicing and rendering health care in “the very matter” on which he is giving an

opinion. Mr. Hardy’s CV shows only that he is involved in pharmacy “information

technology.” There is no showing that he was, at the pertinent times, filling

prescriptions for patients. Nothing in the four corners of Mr. Hardy’s report

indicates that he is qualified to opine on the standard of care, breach or causation.

          B.         Dr. Breall’s expert report is deficient.
          Conceding that Mr. Hardy is prohibited by statute from stating any opinions

on causation, Ms. Rodriguez still asserts that when Mr. Hardy’s report is read in

conjunction with the report provided by Dr. Breall, causation is found. While it is



1751449.6/SPSA/87282/0138/030615                15
true that the expert report requirement may be satisfied by utilizing more than one

expert report, and thus, a court may read those reports together to supply missing

elements, see TEX. CIV. PRAC. & REM. CODE ANN. §74.351(i), Dr. Breall’s report

does not supply the missing causation.

                     1.            Dr. Breall’s report does not even mention Walgreen or
                                   McGuire.
          Dr. Breall does not mention Walgreen or McGuire, does not discuss any

standard of care pertaining to Walgreen or McGuire, and does not discuss any

causal connection between anything done or failed to be done by Walgreen or

McGuire and the injuries sustained by Ms. Rodriguez. In fact, the report does not

mention Walgreen or McGuire at all; instead, the report discusses only

Dr. Goswami. His report thus does not constitute an expert report as required to

maintain a suit against Walgreen and McGuire. Accordingly, the trial court was

correct to grant the motion to dismiss.

          When a defendant is not identified within the four corners of a report, the

report is, for that reason alone, deficient as to that defendant because it requires the

reader to infer or make an educated guess as to whose actions caused the injuries.

See Reddy v. Hebner, 435 S.W.3d 323, 328 (Tex. App.–Austin 2014, pet. filed)

(finding report that did not mention doctor or discuss how doctor’s treatment did

not meet the standard of care, did not constitute a good-faith effort to comply with

the statutory requirements); Fung v. Fischer, 365 S.W.3d 507, 529 (Tex. App.–


1751449.6/SPSA/87282/0138/030615                    16
Austin 2012, no pet.) overruled on other grounds by Certified EMS, Inc. v. Potts,

392 S.W.3d 625 (Tex. 2013) (concluding that report did not implicate defendant

when it did not allege breach by defendant or any causal link between defendant’s

breach and injury); Austin Regional Clinic v. Power, 2012 Tex. App. LEXIS 5242

(Austin 2012, no pet.) (concluding that trial court abused its discretion by denying

motion to dismiss claims against certain defendant when the expert report did not

mention that defendant); see also Bogar v. Esparza, 257 S.W.3d 354, 363 (Tex.

App.–Austin 2008, no pet.); Austin Heart P.A. v. Webb, 228 S.W.3d 276, 281

(Tex. App.–Austin 2007, no pet.); Apodaca v. Russo, 228 S.W.3d 252, 257-58

(Tex. App.–Austin 2007, no pet.). Dr. Breall’s report falls below the minimal

standard and thus does not constitute an expert report as required to maintain a suit

against Walgreen and McGuire.

                     2.            Dr. Breall’s report is speculative and conclusory.
          Like Mr. Hardy’s, Dr. Breall’s report would have to be based on the

assumption that Walgreen and McGuire––although they are never mentioned––

knew about Dr. Kessler’s advice to stop Pradaxa. But there is nothing in his report

about to whom the advice was communicated, whether the prescription that was

used by Ms. Rodriguez predated the advice, or any other circumstances under

which Ms. Rodriguez continued to refill her prescription. Dr. Breall simply does

not provide facts to establish the causal link between Walgreen’s alleged breach



1751449.6/SPSA/87282/0138/030615                       17
and Ms. Rodriguez’s injuries, one of the required statutory elements of an expert

report. See TEX. CIV. PRAC. & REM. CODE §74.351(r)(6). “To avoid being

conclusory, an expert must explain the basis of the statements to link his

conclusions to the facts.” Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex.

2002).

          This Court has consistently required more than what Dr. Breall has provided

in terms of expert testimony on causation. See Kocerek v. Colby, No. 03–13–

0057–CV, 2014 Tex. App. LEXIS 9336 (Tex. App.–Austin 2014, no pet.)(holding

insufficient expert report that failed to show specific actions defendant did or did

not take would have prevented patient’s injuries); Smith v. Wilson, 368 S.W.3d

574, 578 (Tex. App.–Austin 2012, no pet.)(holding that expert failed to show how

doctor’s alleged breach of standard of care caused patient to commit suicide);

Constancio v. Bray, 266 S.W.3d 149, 157–58 (Tex. App.–Austin 2008, no pet.)

(holding insufficient expert report that alleged that breach of standard of care by

doctor caused patient’s death when report did not explain how increased

monitoring of patient, detection of hypoxemia, and other consequence would have

prevented patient’s death); Perez v. Daughters of Charity Health Servs. of Austin,

No. 03–08–00200–CV, 2008 WL 4531558, at *4 (Tex. App.–Austin, Oct. 10,

2008, no pet.) (mem. op.) (concluding expert report insufficient on causation

because it did not link hospital’s actions to patient’s death or any cause of death



1751449.6/SPSA/87282/0138/030615           18
and did not identify any specific injury that would have been prevented had

hospital complied with standard of care). To find Dr. Breall’s report sufficient on

causation, the trial court would have had to make inferences beyond the four

corners of his report, which it could not do. For this additional reason, the trial

court was correct to grant the motion to dismiss.

                     3.            Dr. Breall is not qualified to testify to the standard of care
                                   for a pharmacy or pharmacist.
          An expert report must demonstrate within the four corners of the report that

the purported expert is qualified to testify about the particular matters for which the

opinion is offered. TEX. CIV. PRAC. & REM. CODE §74.351, 74.402. Dr. Breall is

not a pharmacist qualified on the basis of training or experience to offer an expert

report regarding accepted standards for a pharmacy or pharmacist. Because he is

not qualified to give opinions as to the standard of care, he cannot connect any

breaches of the standard of care with the damages claimed. Therefore, the Court’s

dismissal of Ms. Rodriguez’s claims against Walgreen and McGuire was correct.

                                                CONCLUSION

          The trial court was correct in dismissing the claims against Walgreen and

McGuire. Its order should be affirmed.




1751449.6/SPSA/87282/0138/030615                       19
                                   Respectfully submitted,

                                    /s/ Judith R. Blakeway
                                   JUDITH R. BLAKEWAY
                                   State Bar No. 02434400
                                   judith.blakeway@strasburger.com
                                   CYNTHIA DAY GRIMES
                                   State Bar No. 11436600
                                   Cynthia.Grimes@strasburger.com
                                   STRASBURGER & PRICE, LLP
                                   2301 Broadway
                                   San Antonio, Texas 78215
                                   (210) 250-6003 Telephone
                                   (210) 258-2706 Facsimile

                                   ATTORNEYS FOR APPELLEES
                                   THE WALGREEN COMPANY AND
                                   SARA ELIZABETH MCGUIRE




1751449.6/SPSA/87282/0138/030615     20
                                    CERTIFICATE OF SERVICE

          Pursuant to E-Filing Standing Order, I certify that on March 6, 2015, I

electronically filed the foregoing with the Clerk of Court using the

EFile.TXCourts.gov electronic filing system which will send notification of such

filing to the following:

     Lannie Todd Kelly
     State Bar No. 24035049
     THE CARLSON LAW FIRM, P.C.
     11606 N. IH–35
     Austin, TX 78753
     Telephone: (512) 346–5688
     Facsimile: (512) 719–4362
     tkelly@carlsonattorneys.com
            Attorneys for Appellant Nancy Jo Rodriguez

                                                   /s/ Judith R. Blakeway
                                                   JUDITH R. BLAKEWAY




                                   CERTIFICATE OF COMPLIANCE

          In accordance with Tex. R. App. P. 9.4(i)(1), I hereby certify that this Brief

of Appellees contains no more than 4,460 words.


                                                   /s/ Judith R. Blakeway
                                                   JUDITH R. BLAKEWAY




1751449.6/SPSA/87282/0138/030615              21
                                           NO. 03–14–00765–CV
                                       IN THE COURT OF APPEALS
                                   FOR THE THIRD DISTRICT OF TEXAS
                                               AT AUSTIN

                                         NANCY JO RODRIGUEZ
                                                          APPELLANT,
                                                     V.
         THE WALGREEN COMPANY AND SARA ELIZABETH MCGUIRE
                                                          APPELLEES.

                                   On Appeal from the 419th District Court
                                          Travis County, Texas

                                                APPENDIX


1.        Order dated December 3, 2014

2.        Mr. Hardy’s CV and report
3.        Dr. Breall’s CV and report

4.        TEX. CIV. PRAC. & REM. CODE §74.351
5.        TEX. CIV. PRAC. & REM. CODE §74.402




1751449.6/SPSA/87282/0138/030615                     22
APPENDIX 1
DEC-03-2014     14:56                                                                                                       P.002/006
                                                                                                         FHed In The District Court
                                                                                                          of Travis County, Texas

                                                                                                                  DEC 03 2014      {If1-
                                                   CAUSE NO. D-l-GN-000903
                                                                                                         AL       ' :~l1 fa:' _M.
                                                                                                                         a; Clark
                                                                                                         Amalia RJdriguez.Mendo

       NANCY.TO          RODRIGUEZ                                     §               IN THE DISTRICT            COURT    OF
                                                                       §
                           PLAINTIFF,                                  §
                                                                       §
                vs,                                                    §
                                                                       §                      TRAVIS    COUNTY, TEXAS
       THE WALGREEN     COMPANY, SARA                                  §
       ELIZA6ETH    MCGUIRE, AUSTIN HEART                              §
       PLLC,     sr.
                 DAVID'S HEALTH CARE                                   §
       PARTNERSHIP,   DA YID 1<ESSLERt MD,                             §
       AND VIVEK GOSWAMl,     MD                                       §
                                                                       §
                           DEFENDANT.                                  §                 419TR JUDICIAL            DISTRICT
                                                                       §

                                                                   ORDER

                 On the 291h of October, 2014, the Court considered             the Chapter 74 Motion to Dismiss and for

       Attorneys'      Fees filed by Walgreen Co. and Sara Elizabeth McGuire.                 After considering    the motion.

       any responses thereto, arguments            of counsel, and all other relevant matters of record, the Court is of

       the opinion that the motion is meritorious                and Should be GRANTED          IN PART and DENlED            IN

        PART. It is therefore.

                 ORDBRED         that Walgreen Co. and Sara Elizabeth McGuire's               Chapter 74 Motion to Dismiss

        is granted.    It is therefore,

                 ORDERED          that all of Plaintiff Nancy 10 Rcdrigucz' claims and causes of action, as well as

        those that could have been asserted,               against Walgreen   Co. and Sara Elizabeth    McGuire     arc hereby

        dismissed with prejudice.         It is further,

                 ORDERED          that Walgreen      Co. and Sara. Elizabeth      McGuire's    request for attorneys'   fees is

        DENIED.

                 All other relief not granted herein with respect to the the Chapter 74 Motion to Dismiss and

        for Attorneys'     Fees filed by Walgreen Co. and Sara Elizabeth McGuire is Denied.
DEC-03-2014      14:56                                                       P.003/006




                                                 O..c" C- ~   f, l(""-   I

                  Signed this       3- ~¥-6MBER,              2014.




       APPROVED              AS TO FORM:




                IA DAVG
       State Bar No. 1143
       STRASBURCER & PRICE, LLP
       230 I Broadway
       San Antonio, Texas 78215-1157
       (210) 250-6000 - Main
       (2 ! 0) 250-6100 - Pax
       (210) 250-6003 - Direct
       CynthL:"t..ril·ilncl:l(d'Slrasbllrg~l',!t.\ll.D.
       Attorneys/or Defendants Walgreen Co. and Sara Bllzabeth McGuire



        L. TODD KELLY
        State Bar No. 24035049
        ELIZABETH A. RHODES
        State Bar No. 24083726
        THE CARLSON            LAW FIRM~ PC
        11606N.1H35
        Austin, Texas 78753
        (512) 346-5688 - Telephone
        (512) 719.4362 - Fax.
        tkell V (ci'J\:l\ rI sonattornevs.colll
        f.: rhod es(Ci'!cItrlsOnll (torn evs.com
        Attorneys for Plaintiff
DEC-03-2014         14:57                                                                                              P.004/006




                         Signed this __              NOVEMBER,2014.




                                                                                ..--'-"~---'--:-C""""""   -=-:------
                                                                       HONORABLE GUS J. STRAUSS
                                                                       PRESIDlNO JUDOE




              APPROVEll AS TO .FORM:




              CYNTHIA DAY GRlMES
              State: BarNo. 11436600
             STRASBURGER & PRJCE,I,LP
             2301 Broadway
             San Antonio, Te:t8S 7821 :;-1157
             (210) 250-6000 - Main
             (210) 250-6100 - Fax
             (210) 250~6003 - Direct
              Cynthia.Grimes@strasburger.!?olTI
             Attorneys     /01'   De/emuwts        Walgreen Co. and Sara Elizabeth   ll'fc(iuiTI!



             /~"--,=-L:W--,,gd-__
    //l.:~;;~~~YsJ49
  /...././   :ett?*B-E-Hi-*~-Rtiel'fffiS
             Sta!~~
             THE CARLSON             LAW      FIRM, PC
              1t606 N. IH 35
             Austin, Texas 78753
             (512) 346-5688 - Telephone
             (512) 719-4362 - Fax:
             tkclly(&,cnrlsonllttomeys.com
             erhodes@car)sQnattomeys.com
             Attorneys for Plaintiff




             16l26ll.~ISPSAIR'721!.2101JRIII0611
DEC-03-2014   14:57                                                       P.005/006




          !COLE G. AND EWS
        State Bar No. 00792335
        MARGARET GARIS
        State Bar No. 24072108
        SERPE JON!'': ANDREWS CALLENDER       & BELL, PLLC
        America Tower
        2929 Allen Parkway, Suite 1600
        Houston, Texas 77019
        IN;erib@serpejones.cotn
        nf\l1drcws@sel'Peione~.com
        Attorneys/or Defendants Austin Hearl, PLL(,.~ David Kessler, MD
        And Vivek Goswaml, MD




        MISSY ATWOOD
        State Bar No. 01428020
        R. CHAD GElSLER
        State Bar No. 00793793
        GERMER BEAMAN & BROWN, PLLC
        301 Congress Avenue, Suite 1700
        Austin, Texas 78701
        (5 J 2) 472-0288 ~ Main
        (512) 472-9280 - Fax
        (512) 482-5 J 71 - Direct
        1J)!~~N.t!(w~(!nner.allstin.colll
        Attorneys for Defendant Sf. David's Health Care Partnership
DEC-03-2014     14:57                                                       P.006/006




        NICOLE G. ANDREWS
        State Bar No. 00792335
        MARGARET GARIB
        State BarNo.       24072108
        SERPE JON!!; ANOREWS CALLENDER                & BELL, PLLC
        America Tower
        2929 Allen Parkway,           Suite 1600
        Houston. Texas 77019
        mgl\riQ@llerpcionc,'i.colli
        n.OJ.~@.s.r:!lt~i5In~K.c.Qm
        Attorneys for Defendant» Austin Heart, PLLC, David Kessler, MD
        And Vivek Goswami, MD




       ~~
        State Bar No. 01428020
        R. CHAO GEISLER
        State Bar No. 00793793
        GERMER BEAMAN & BROWN,                 PLLC
        301 Congress Avenue, Suite 1700
        Austin, Texas 7870]
        (512) 472-0288 - Main
        (512) 472-9280 - Fax
        (512) 482·5171 - Direct
        mat):'LQQQ@g"e);mer-(LlIslin.com
        Attorneysfor Defendant St. David's Health Cure Partnership




         1631G31.4I6PSNBm2/illlRllla~ 14




                                                                         'I'O'l'AT. P.   nos
APPENDIX 2
62 W. Tapestry Park   Cr.Th& Woodlands, TX 17381
Phone: 281.352.3038   • FaIC:281.203.0816 • E-Moll: chad@rxpolnlconsuHing.com




Summary

An experienced healthcore information solutions and pharmacy operations manager.            Experience in
Implementation and management         of heolthcore information technologies and operational practices In
military and private sectors. Demonstrated accomplishment       managing and implementing clfnlcal policies and
procedures in healthcare systems. Trained cnmctcn and heolthccre provider with experience in parenteral
nutrition. neonatal, pedlatric and general medlcine populations. Well-organized, goal oriented professional
wIth abnity to implement standards, procedures, and processes that improve heclthcore and pallent safety.
Proven management      skllls,capable of leading and rnotlvotlnq individuals to augment efficiency and
productivity In a team oriented environment. Exceptional communicator       and negotiator.


Experience

~hormClcy Consultant, Houston TX                                    July 201' - Pre$ent
operations and standards consultant to some of the leading heolthcore systems In the Uniled states. Design
and support expert on Medication Use tools In electronic neottn records. Provides experience in policy and
procedure implementation.    Works closely with pharmacy and heolthcore leaders to optimize poilent care
workflows and pharmaceutical     care delivery systems. leverages knowledge of technology and pharmacy
practice 10 solve complex clinical workllows. Expert pharmacy witness providing services to a brood range of
clients in the US.



Phcrrnccy Opercrllons Monogement,         Houston TX                Mor. 05 - Apr, 12
ResponsIble for direction and management of technology-related       pharmacy services, including practice
stondords and worknows for most areas of practice. Team oriented leader of pharmacy staff members,
providing assessment, Implementation,     support, and maintenance of healthcare systems. Operational
inforrnatlon systems clinical content manager tor both Inpatient and outpotient operations. Responsible for 3
inpatient hospitals and 16 outpatient pharmacies. Works to better the department wilh the application of
clinical knowledge to ensure proper effective and timely patient core. Involved in fiscal planning. contract
negotiation. and vendor interactions. ExperIence with clinical medIcation parameters and advanced decision
support for Epic Ambulatory. EpicRX. and Epic Inpatient. Represents Pharmacy on multidisciplinary project
teams and Inttlatives. Responsible for clinical systems and process compliance with regulatory governance and
The Joint Commission. Reports to Chief Pharmacy Officer. Currently serving In a consulting capacity.



strafegic Accounts Manager,      McKesson                          Jut 03 - Mar. 05
strategic representative for heoltncore automation cvslomers. Responsible for all account activities Including:
finance, upgrades, technical support, engineering, soles, pharmacy practice consulting, and customer
service. Regional responsibilities Include Texas. Oklahoma. New MexIco, Kansas, Nevada, Wyoming, Nebraska,
Minnesota, California, and Colorado. In addition. program Manager for Department of Defense security
inltiotives to ensure standardization and Increased security posture for all products, HIPAA Security consultant
for engineering group. Pharmacy prcctlce consultant for executive management           Responsible for managing
projects involving department or cross-functional teams focused on the denverv of HIPAA and DoD approved
products,




                                                                                              EXHIB'T

                                                                                          I       A                13
Department     Head, US Navy                                         Sep. 01 - Jut OS
Motivational and logistical leader. Responsible for clinIcal practice, formulary, supply, financial. and personnel
management.     Managed an annual operational budget of $25 million. Visionary for 3 facilities and over 40
personnel. Inpotient, outpotlent, and hospital wide multifunctional officer.    Accomplished healthcare IT
lecturer and mentor. Command technology leader and cross-tunctlonol team champion.              Recipient of Naval
Medal of Commendation,      2003,



Division Officer. US Navy                                            Jun. 00 - Sep. 01
Managed the inpatient pharmacy operation in a 350-bed state of the art focllrty, Responsible for business
planning. operational readiness, clinical coordination and sterile product compounding         for a dolly census of
over 200 patients. ResponsIble lor annual combined budget of $25 million. Manager for 38 subordinates,
Automated Medication System upgrade implementation          lead, totaling a .$2.8 million purchase, Senior
command member of JCAHO compliance team. Total Parenteral Nutrition Upgrade implementation lead.
responsible for decreasing medication errors, improving efficiency, and providIng pharmac:eutical care to
critical patients. Senior TPN Pharmacist. Credentialed in Total Porenteral Nutrition, PharmacokInetics, and
inpatient pharmacy practice, Experiential Coordinator for 6 area colleges of obormccv and 30 students
annually. Design lead for Neonatal, Chemotherapy       and Discharge pharmacy satellites,



Historical Experience
Flooler Pharmacist, Wal·Mort stores, VirgInia Beach, VA:            Aug. 00 - Sep, 03
Chief Information Officer, Prniing Technology, Dallas, TX:          Jun. 97 - May 00
Systems Analyst, Unlv, of Texas at AustIn. TX:                      Aug, 96 - Jun. 98
Certified Pllorrnocy Technician, Tom Thumb Pharmacy, TX:            Aug. 92 - Dec. 98




Education

Univ. 01 Texas (II Austin. Doctorate of Pharmacy                    2000

Capella   University, MS In Inlormatlon   Technology                2005


PresentatIons     and Publications

ClinIcal decision support for drug-drug     Interactions:    Improvement    needed,   Am ,J Health Syst Phorm May 15,
2013 70:905-909.

Computerized    Pharmacy Order Entry Guidelines ......m J heotlh-Svst Phorrn, published 2010.

Technology Enabled Practice'. A Vision Statement            by ASHPSection of Pharmacy    Informatics and Technology,
Am J heallh·Syst Phorm, 2009; 661573-1577.

Maxirnlzing 340B Savings with an Autornoted       Solution. Pharmacy       Purchasing and Products, June 2009;VoI6 No 6
pg 10-12.




                                                                                                                          14
Pharmacy Information Systems. The Pharmacy         Informatics Primer, 1st ed., Ch <1 pg, 65-76. 2008.

American Society of Health System Pharmacists IASHP) Informatics Bytes, Midyear Meeting 2007.

Texas SOCiety of Health System Pharmacists (TSHP)Technicians In Automation.         Annual Meeting 2008.

Medication   Use Technology:     PHCA 6397. Lecture.   University of Houston College of Pharmacy 2013.

What is Pharmacy Informatics. ASHP funded webinar. 8/23/10.

Pharmacy Informatics and Residency Opportunities.        Lecture. Texas Southern University and University of Houston
College of Pharmacy. 2007-2011

Nursing satisfaction with Barcoded    Medication   Adminislra1ion. poster presentation.   ASHP Summer Meeting 2009.

Moderator,   Ambulatory   Care Informatics Networking Session. ASHP Midyear Meeting 2009.

Moderator.   Provider Order Entry Networking SeSSion.ASH? Midyear Meeting 2008.

Moderator,   Provider Order Entry Networking Session. ASHP Midyear Meeting 2007.




Professionallnvolvemenf

ASHP Committee    on Nornlnotlons 20 I a-present

ASHP Executive Committee.       2008-2011.

ASH? Immediate    Past Chair. 2010-2011

ASHP Seclion of Pharmacy Informatics and Technology         Chair, 2009-2010.

ASHP Cholr Elect. 2008-2009.

ASHP Section of Pharmacy       Informatics and Technology   Advisory Group Chair. 2007-2008.

Gulf Coast Society of Health Systems Pharmacists Member at Large. 2007-2011.




                                                                                                                        15
February 21, 2014



VIA EMAIL

L. Todd Kelly
The Carlson Law Firm. P.C.
11606 North Interstate Highway 35
Austin, Texas 78753

Re: Nancy Jo Rodriguez File Number 32-4438

Mr. Kelly:

My name is Jeffrey Chad Hardy. ! am a licensed pharmacist in the State of
Texas.

I have been asked in my capacity as an expert in pharmacy operations to
evaluate the conduct and actions of Walgreens Pharmacy ("Walgreens"),
Sara Elizabeth McGuire (pharmacist) and pharmacist with initials MDO as it
relates to the dabigatran etexllate (PRADAXA) of patient Nancy Rodriguez
filled by Walgreens pharmacy on 4/26/2012 and 6/15/2012.          Based on
the information available to me at this time, the medication provided to
Ms. Rodriguez was not authorized by her physician. Ms. Rodriguez's
resulting complications and clinical demise were most likely related to the
extended. unauthorized use of dabigatran etexilate (PRAOAXA) and its
impact on her health.

I have reviewed the information provided to me regarding the potential
pharmacy malpractice case against Walgreens, Sara Elizabeth McGuire
(pharmacist), and pharmacist with initials MOD. In preparation of this
report I reviewed the following documentation:

   1. Insurance Profile of Nancy Rodriguez as printed by Walgreens
      Pharmacy for 1/1/06 to 12/11/12




                                EXHIBIT

                          I C                                                 39
   2. Images of Prescription # 2046442-06861 as filled by Walgreens
      Pharmacy on 6/15/12
   3. Cardiology Consultation Note performed by Vivek Goswami on
      patient Nancy Rodriguez on 2/10/12
   4. Visit notes from Austin Heart on 2115/12, 3/27/12, and 8/14/12.
   S. Medical Records of Nancy Rodriguez from Seton Hospital
      emergency room and Intensive Care Unit visits

 t conclude that the applicable standards of care and pharmacy practice
regarding Walgreens, Sara Efizabeth McGuire (pharmacist), and pharmacist
with initials MDD handling of Ms. Rodriguez's prescription of dabigatran
etexilate (PRADAXA) were not met, resulting in Ms. Rodriguez's injuries.

                [~!.!1!l.!iil[l1:Y yv!tb...,tJ:t~_~t~nq~rd..9f" Cru-!l

I am familiar with the standard of care for pharmacy operations, including
the handling of prescriptions in situations similar to that of Ms.
Rodriguez's prescription of dablqatran etexilate (PRADAXA), including the
refilling and processing of the prescription through my education, training,
experience, continual interdisciplinary pharmacological education and
review of specialty medical texts as well as medical articles covering
pharmacy operations. As a pharmacy operations specialist, I have
experience in multiple pharmacy settings in the US. In addition, I am
currently practicing as a Pharmacy Operations Consultant, helping
pharmacies implement regulatory compliance, procedural, and operations
standards. I am specifically familiar with the standard of care applicable
to pharmacists in situations like this for Walgreens, Sara Elizabeth McGuire
(pharmacist), and pharmacist with initials MOD based on my work in these
areas of practice. Please also see my C.V. which is attached hereto and
incorporated by reference for a full list of my education and experience.

                             St~!l~ards.9..f Car~
The standard of care required to fill Ms. Rodriguez's dabigatran etexilate
(PRADAXA) prescription are as follows:




                                                                               40
   •   Pharmacists have a duty to contact the prescribing physician if
       patient harm is possible to validate the prescription
   •   Pharmacists are responsible for ensuring a prescription is accurately
       communicated and dispensed as intended by the prescriber
   •   Pharmacists are responsible for communicating with the prescribing
       physician to validate continuation of therapy when no refills remain
       on a prescription




                      i31eJ!.I;.h   9f.S_t~.rlg!:!n;t Qf_-C\!fJil
Walgreens, Sara Elizabeth McGuire (pharmacist), and pharmacist with
initials MDD breached the applicable standards of care. Specifically,
Walgreens, Sara Elizabeth McGuire (pharmacist), and pharmacist with
initials MODconduct fell below the standard of care by:

   •   Continuing to dispense a prescription for dabigatran etexilate
       (PRADAXA) after the prescribing physician indicated it should be
       discontinued; and
   •   Failing to verify if the prescription for dabigatran etexllate
       (PRADAXA) should be continued with the prescribing physician



Walgreens, Sara Elizabeth McGuire (pharmacist), and pharmacist with
initials MDD should have provided Ms. Rodriguez with the care and
treatment In the standard of care paragraph above. However, this
expected care was not provided to Ms. Rodriguez as set forth in the
preceding paragraph.




                                                                               41
                             C~JJ.~.   ofJ-f~rm
In reasonable medical probability, the above itemized breaches in the
standard of care resulted in Ms. Rodriguez's continued long term use of
dabigatran etexllate (PRADAXA). Therefore it is clear that the long term
use of dabigatran etexllate (PRADAXA) as dispensed by Walgreens, Sara
Elizabeth McGuire (pharmacist), and pharmacist with initials MDD caused
Ms. Rodriguez's acute kidney injury, anemia, and gastrointestinal bleeding
(which have lead to her long term clinical demise and medical injuries).

I reserve the right to amend this report should further discovery be made
available.


Sincerel    •     .'/1
  d;£~'~·
/f;1 C
       7(Y
Dr.~tefffey Chad'Hardy, Pharm.D., M.S.




                                                                             42
APPENDIX 3
                                   CURRICULUM VITAE
                                                                                Prepared 01/01114
Name:                          Jeffrey Alan BreaU, M.D., Ph. D.

Address:                       Krannert Institute of Cardiology
                               Indiana University School of Medicine
                               1800 North Capitol Avenue, Room E-490
                               Indianapolis, IN 46202

Phone:                         Home: (317) 496-8680          e-mail: jbreall@iu.edu
                               Work: (317) 962-0561          FAX: (317) 962-0566

Date of Birth:                 May28,1956

Place of Birth:                San Francisco, California

Citizenship:                   United States

Education:
                  1978         B.A. in Physiology, University of California,
                               Berkeley, CA
                  1983         Ph.D. in Physiology, University of California,
                               San Francisco, CA
                  1987         M.D., Albert Einstein College of Medicine,
                               Bronx, NY

Postdoctoral Training Internship and Residencies:

                  1987-1988    Intern in Medicine, Beth Israel Hospital,
                               Boston, MA
                  1988-1989    Junior Assistant Resident, Internal Medicine,
                                       Beth Israel Hospital, Boston, MA
                  1989-1990    Senior Assistant Resident, Internal Medicine,
                               Beth Israel Hospital, Boston, MA
                  1990-1993    Research and Clinical Fellow in Cardiology,
                                       Harvard Medical School and
                               Beth Israel Hospital Boston, MA

Research Fellowships:
              1978-1979        Regent's Fellow in Physiology, University ofCaIifornia,
                               San Francisco
                  1984         Research Fellow, Coronary Research Laboratory,
                               Albert Einstein College of Medicine
                  1990, 1992   Cardiovascular Research Training Grant,
                               Harvard Medical School and Beth Israel Hospital


                                                                                                EXHIBIT

                                                                                          j         B
                                                                                                          6
                                                                          Jeffrey Alan Breall (2)

Licensure and Certification:

               1989-1994       Massachusetts License for Medicine and Surgery #7133 (inactive)
               1990-2000       Diplomate-American Board of Internal Medicine #133098
               1993-2001       D. C. License for Medicine and Surgery #20206 (inactive)
               1993-2003       Diplomate-American Board of Internal Medicine,
                 2012-2022     Subspecialty in Cardiovascular Diseases #133098
               1999-2009       Diplomate-American Board of Internal Medicine,
                 2013-2023     Subspecialty in Interventional Cardiology #133098
               2000-           Indiana License for Medicine and Surgery #01052687 A

Academic Appointments:

       July 1987-June 1992 Clinical Fellow in Medicine, Harvard Medical School,
                           Boston, MA
       July] 992-June 1993 Instructor in Medicine, Harvard Medical School,
                           Boston; MA
       July 1993-June 1998 Assistant Professor of Medicine (Cardiology)
                           Georgetown University, Washington, D.C.
       July 1998-June 2000 Associate Professor of Medicine (Cardiology)
                           Georgetown University, Washington, D.C.
       July 2000- Present  Professor of Clinical Medicine (Cardiology)
                           Indiana University School of Medicine, Indianapolis, IN

Hospital/Clinical Appointments:

       July1989-June 1990      Physician of the Day, Boston Veterans
                               Administration Hospital, Boston, MA
       JuJy1989-June 1993      Medical Officer of the Day, Brockton Veterans
                               Administration Hospital, Brockton, MA
       July1990-June 1993      Urgent Care Physician, Peabody Medical Associates,
                               Peabody,MA
       July1990-June 1993      Urgent Care Physician, Walk-In Center,
                               Beth Israel Hospital, Boston, MA
       July 1990-June 1993     Clinical Fellow, Cardiovascular Division,
                               Beth Israel Hospital, Boston, MA
       July 1992-June 1993     Attending Physician, Emergency Room,
                               Beth Israel Hospital, Boston, MA
       July 1993-June 2000     Attending Cardiologist and Associate Director,
                               Cardiac Catheterization Laboratory
                               Georgetown University Medical Center, Washington, D.C.
       July I 994-June 2000    Attending Physician (WOC), Cardiology Section
                               Washington Veterans Administration Hospital




                                                                                                    17
                                                                          Jeffrey Alan Breall (3)

Hospital/Clinical Appointments (continued):

        July2000- Present    Attending Cardiologist, Cardiac Catheterization Laboratories and
                             Interventional Cardiology, Indiana University
        July 2000-Present    Attending Cardiologist, Methodist, University, West and North
                             Hospitals (Indiana University Health), Indiana University
        July 2000-Present    Attending Cardiologist, Wishard Memorial Hospital
                             Indiana University, IUPUI
        July 2000-Present    Attending Cardiologist, Richard 1. Roudebush V. A. Hospital
                             Indiana University, IUPUI
        July 2000-2012       Director, Cardiac Catheterization Laboratories and Interventional
                             Cardiology, Indiana University
        2012- Present        Chief Information Technology and Safety Officer,
                             Cardiovascular Service Line, Indiana University Health

Awards and Honors:

                1978         Baccalaureate with Honors, University of California,
                             Berkeley, CA
                1979-1980    Teaching Assistantship, University of California,
                             San Francisco, CA
                1982-1983    Patent Fund Recipient, University of California
                             San Francisco, CA
                1987         Alpha Omega Alpha - Albert Einstein College of Medicine
                1996         Excellence in Teaching Award, Cardiology
                             Georgetown University Medical Center
                1997         Outstanding VisitlExcellence in Teaching Award
                             Georgetown University Medical Center, Dept of Medicine
                2000         Lawrence A. Kyle Award for Excellence in House Staff Education
                             Georgetown University Medical Center, Department of Medicine
                2000         Sol Katz Society Award for Consistent Teaching Excellence
                             Georgetown University Medical Center, Department of Medicine
               2009-2010     Outstanding Teacher Award
                             Indiana University School of Medicine Junior Medical Students
                2010-2011    Department of Medicine Teaching Award
                             Indiana University School of Medicine

Invited Lectures:

                1984         Perinatal Research Conference Lecturer,
                             The New York Hospital-Cornell Medical Center
                1992         Emergency Medicine Lecturer,
                             Beth Israel Hospital, Boston, MA




                                                                                                    18
                                                                           Jeffrey Alan Breall (4)


Inv:ited Lectures (continued):

                1993             Cardiovascular Grand Rounds
                                 LAC + USC Medical Center, Los Angeles, CA
                1993,1995        Department of Surgery Grand Rounds
                                 Georgetown University Medical Center
                1994-1998        Current Trends in Cardiology
                                 Sacred Heart Medical Center, Cumberland, MD
                1995             Department of Medicine Grand Rounds
                                 Georgetown University Medical Center
                1995             Rockingham Memorial Hospital Continuing Medical Education
                                 Rockingham Memorial Hospital, Harrisonburg, VA
                1996             NYLCare/Georgetown University Physician Update
                                 Cardiology in General Medicine, Rockville, MD
                1996-1999        American College of Physicians Internal Medicine Board Review
                                 Georgetown University Medical Center
                1996             Multi Disciplinary Grand Rounds
                                 Georgetown University Medical Center
                1996             Health Care Finance Administration/Peer Review Organization
                                 Forum on Quality Improvement Interventions, Boston, MA
                1996             Third Annual Mid-Atlantic Conference for Cardiovascular
                                 Fellows, Georgetown University Medical Center
                1996             MAMSIJGeorgetown University
                                 Chest Pain Update, Bethesda, MD
                1996             Vencor Hospital-Cardiology Update
                                 When to use Primary Angioplasty, Alexandria, VA
               1997              Acute Myocardial Tnfarction- The First 72 Hours
                                 ACCess AMI Teleconference, American College of Cardiology
               1997              Harvey-Hufnagel Symposium
                                 Georgetown University Medical Center
               1998              Cardiology for the General Practitioner
                                 Georgetown University Medical Center
               1998              Management of Non Q-Wave Myocardial Infarction
                                 University of Maryland Medical Center
               2000-2008         Cardiology Update for Primary Care Physicians
                                 Krannert Institute of Cardiology, Indiana University
               2001              Invited Debate: The Radial Approach to Coronary Intervention:
                                 Not Routinely in the Patient's Best Interest
                                 American College of Cardiology, Orlando, FL




                                                                                                     19
                                                                          Jeffrey Alan Breall (5)


Invited Lectures (continued):

               2001             Acute Coronary Syndromes-the      current era
                                Indiana University Internal Medicine Board Review
               2001             Current Management of Acute Coronary Syndromes
                                Cardiac Surgery Grand Rounds, Indiana University
               2002             Session Co-Chair: Optimal Stent Results
                                American College of Cardiology, Atlanta, GA
               2002             Panelist: Atherectomy-When, Where, Why and How
                                American College of Cardiology, Atlanta, GA
               2002             Session Co-Chair: Stent Selection
                                American College of Cardiology, Atlanta, GA
               2002             Division of Cardiology Grand Rounds: Peripheral Vascular
                                Disease for the Cardiologist
                                Indiana University School of Medicine
               2002             Department of Medicine Grand Rounds: Optimal Reperfusion
                                Therapy for Acute Myocardial Infarction
                                Indiana University School of Medicine
               2002             Department of Medicine Grand Rounds: Management of Acute
                                Coronary Syndromes
                                Indiana University School of Medicine
               2001-            Department of Medicine Noon Lecture Series:
                                Treatment of Acute Myocardial Infarction
                                Indiana University School of Medicine
               2003             Drug Coated Stents, Cardiovascular Nursing Update,
                                Clarian Health Partners
               2004             Update in Thrombosis Symposium, Acute Coronary Syndromes
                                The CARE Group
               2004             Division of Cardiology Grand Rounds: Treatment of Unstable
                                Angina
               2004             Applications in Diagnostic Imaging,
                                American Roentgen Ray Society, Indianapolis/Chicago


Administrative Positions and Committees:

               1978-1981        Committee on Human Research, University of California,
                                San Francisco, CA
               1980-1983        Graduate Student's Council, University of California,
                                San Francisco, CA
               1983-1987        Committee on Admissions, Albert Einstein College of Medicine,
                                Bronx,NY
               1984-1986        Faculty-Student Senate, Albert Einstein College of Medicine




                                                                                                    20
                                                                        Jeffrey Alan Breall (6)

Administrative Positions and Committees (continued):

              1993-2000      Associate Director, Cardiac Catheterization Laboratories and
                             Interventional Cardiology, Georgetown University Medical Center
              1993-2000      Residency Selection Committee, Department of Medicine
                             Georgetown University Medical Center
              1993-1997      Chair, Cardiopulmonary Resuscitation Committee
                             Georgetown University Medical Center
              1994-1997      Animal Care and Use Committee
                             Georgetown University Medical Center
              1994-1995      Research Planning and Operations Committee,
                             Dept of Medicine, Georgetown University Medical Center
              1995-1996      Chair, PTCA Clinical Process Committee,
                             Georgetown University Medical Center
              1995-2000      Cardiac Catheterization Credentials Committee,
                             Georgetown University Medical Center
              1995           Chair, Chest Pain Clinical Process Committee,
                             Georgetown University Medical Center
              1996,2002-     Ad Hoc Reviewer; National Heart, Lung, and Blood Institute,
                             Clinical Trials Review Committee
              1996-1997      Clinical Resource Steering Committee,
                             Georgetown University Medical Center
              1996-1999      Quality hnprovement Committee, Department of Medicine
                             Georgetown University Medical Center
              1996-1997      Quality bnprovement Council.
                             Georgetown University Medical Center
              1997           Chair, Task Force on Graduate Training Opportunities,
                             Department of Medicine, Georgetown University Medical Center
              1997           Co-Chair, Hospital Task Force on Case Management,
                             Georgetown University Medical Center
              1997-2000      American Heart Association-
                             Committee on Cardiac Catheterization
              1997-2000      University Faculty Senate-Georgetown University
              1997           Clinical Service Standard Subcommittee
                             Georgetown University Medical Center
              1998-2000      At-Large Member, Faculty Practice Group Board
                             Georgetown University Medical Center
              1998-2000      Vice Chair. Pharmacy and Therapeutics Committee
                             Georgetown University Medical Center
              1998-2000      Committee on Medical Education
                             Georgetown University Medical Center
              2001-          Peripheral Vascular Disease Committee
                             American College of Cardiology




                                                                                                  2]
                                                                           Jeffrey Alan Breall (7)

Administrative Positions and Committees (continued):

               2001-2008      Abstract Grader, Scientific Sessions, American Heart Association
               2000-          Director, Interventional Cardiology Section, Krannert Institute of
                              Cardiology, Indiana University
               2000-          Cardiology Fellowship Selection Committee, Krannert Institute of
                              Cardiology, Indiana University
               2000-          Director, Cardiac Catheterization Laboratories and
                              Interventional Cardiology, Methodist Hospital,
                              Indiana University Health
               2001-          Co-Chair, AMI Clinical Process Committee, Methodist Hospital,
                              Methodist Hospital, Indiana University Health
               2002-          Member, Cardiovascular Operations Committee,
                              Methodist Hospital, Indiana University Health
               2002-          Member, Cardiovascular Program Care Data Management
                              Committee, Methodist Hospital, Indiana University Health
               2003-          Member, Executive Committee, Krannert Institute of Cardiology,
                              Indiana University
               2003-          Member, Krannert Institute of Cardiology-Director-
                              Search Committee, Indiana University
               2005-          Member, Pharmacy and Therapeutics Committee, Methodist
                              Hospital, Indiana University Health
               2006-          Member, Levell Heart Attack Program Committee,
                              Methodist Hospital, Indiana University Health
               2006-          Chair, Cardiovascular PCI Process Committee,
                              Methodist Hospital, Indiana University Health
               2009-          Board of Directors, Indiana Chapter,
                              American College of Cardiology

SUMMARY OF CLINICAL ACTNITIES

During the past twelve years I have continued teaching medicine. 1 at1end2 weeks per year on
the general cardiology service at Indiana University Health Methodist Hospital. During this time
the team admits 40 new patients for initial evaluation. The team consists of a second or third
year medical resident, two first year medical resident and frequently a third and fourth year
medical student. The team may include pharmacy students, pharmacy residents, nursing
students, physician assistants and nurse practitioners. In addition, I perform diagnostic and
therapeutic cardiac catheterization procedures three days per week at the Indiana University
Health Methodist Hospital and the Richard L. Roudebush Veterans Administration Medical
Center. I specialize in teaching and performing high-risk percutaneous coronary interventions.




Teaching Assignments:




                                                                                                     22
                                                                             Jeffrey Alan Breall (8)

Ambulatory (Outpatient) Cardiology Elective:

        Serving as a preceptor for house-staff and junior medical students in outpatient cardiology
        clinic (four hour/week, Direct contact- cardiology system, history taking, bedside
        examination, and management plan formulation). 1993-present

The time spent in teaching medical students, residents and fellows on the cardiology service is a
highlight of my academic year. I have spent years developing an approach to teaching that
involves teaching the process of developing clinical judgment, disease pathogenesis, physical
examination skills and presentation skills. The experience of teaching the eager students and
residents continues to excite me as I remember my own experience on the medical service at the
Bronx Municipal Hospital as a student. I continue to teach medical students, interns and
residents, and fellows on the cardiology service at Indiana University Health Methodist Hospital
and the Richard L. Roudebush Veterans Administration Medical Center-all under the auspices
of Indiana University.

Weekly Conferences:

        Interventional Cardiology Conference (Every Tuesday),
        One hour conference dedicated to clinical case presentation, and year-long didactic
        lecture series devoted to invasive and interventional cardiology fellows.

        Clinical Decision Making Conference (Every Friday)
        One hour conference dedicated to clinical decision making and cardiac catheterization.
        Conference attended by cardiology fellows, medicine house-staff and medical students on
        cardiology rotation.

Monthly Conference:

        Co-chair: Morbidity and Mortality Conference
        One hour conference dedicated to morbidity and mortality in cardiac catheterization
        laboratories including didactic presentations.

Hands-on-training and supervision for general cardiology fellows during cardiac catheterization
rotation. Teaching basic principles of radiation safety, X-ray imaging, and all diagnostic aspects
of cardiac catheterizations (3 days/week)
Hands-an-training and supervision for interventional cardiology fellows during their one-year
interventional cardiology fellowship. Teaching principles and practice of interventional
cardiology procedures including balloon angioplasty, stent, atherectomy and valvuloplasty
procedures. Advanced invasive diagnostic procedures such as intravascular ultrasonography
(NUS), intracoronary physiologic lesion assessment (Doppler and pressure wire) (4 days/week)




                                                                                                       23
                                                                            JefIrey Alan Breall (9)

Administrative Assignments:
       Assist with advancing appropriate use criteria and quality indicators for cardiology across
       all ru Health facilities

        Assist with procurement and standardization of all interventional cardiology equipment
        across all ill Health facilities

        Assist with procurement and standardization of a cardiovascular picture and archiving
        system across all ill Health facilities

SUMMARY OF ADMINISTRATIVE               ACTIVITIES

I have continued the work that I began nearly 20 years agcr-building a superb clinical program,
For the past twelve years this was as director of the interventional cardiology program at Indiana
University Health. As such Ihelped develop protocols for best outcomes, helped establish the
use of new procedures and devices for percutaneous intervention, and administered over a busy,
high quality laboratory. Ihave now directed my efforts more recently on device standardization
and price reduction across the Indiana University Health System. I am also serving as the clinical
liaison as we implement a state-wide cardiovascular picture and report archiving system. Iam
also the clinical liaison for regulatory compliance for the cardiovascular service line, making
recommendations about rules and regulations with respect to appropriate usc, documentation and
privacy.

Multi-center Clinical Investigations:

                1991           Co- investigator, Zatebradine trial for chronic stable angina
                1992           Co-investigator, Thrombolysis in Myocardial Ischemia Study
                               (TIMI 3), Beth Israel Hospital
                1992           Associate-Director, Core Angiographic Laboratory,
                               Thrombolysis in Myocardial Infarction Study (TIMI 4),
                               Beth Israel Hospital
                1992           Co-investigator, Thrombolysis in Myocardial Ischemia
                               Study (TIMI 7), Beth Israel Hospital
                1993           Co-Principal Investigator, Biobehavioral Triggers of
                               Myocardial Ischemia Study (TOMIS),
                               Georgetown University Medical Center
                1993           Co-Principal Investigator, Coronary Regression with Estrogen
                               in Women, Study (CREW), Georgetown University
                1994           Co-investigator, Balloon versus Optimal AtherectomyTrial
                               (BOAT), Georgetown University Medical Center
                1994           Co-investigator, Thrombolysis and Thrombin Inhibition and
                               Acute Myocardial Infarction Study (TIMI 9),
                               Georgetown University Medical Center




                                                                                                      24
                                                                         Jeffrey Alan Breall (10)

Multi-center Clinical Investigations (continued):

               1995            Co-investigator, Randomized Efficacy Study of Tiro fiban
                               (MK-383) for Outcomes and Restenosis (RESTORE)
                               Georgetown University Medical Center
               1995            Co-investigator, Randomized trial of aspirin versus aspirin plus
                               heparin, versus aspirin plus hirudin in patients with acute
                               myocardial infarctions not receiving thrombolytic therapy
                               (ASIS-I), Georgetown University Medical Center
               1995            Co-investigator, Stent Anti-thrombosis Regimen Study (STARS)
                               Georgetown University Medical Center
               1996            Co-investigator, Myocardial Infarction with Novastan and t-PA
                               (MINT) Trial, Georgetown University Medical Center
               1996            Co-investigator, ACS Multi-Link Stent Clinical Equivalencein
                              De Novo Lesions Trial (ASCENT),
                              Georgetown University Medical Center
               1996           Co-investigator, Carotid Stent Supported Angioplasty (CSSA)
                               Georgetown University Medical Center
               1996           Co-investigator, Reduced Anticoagulation after Vein Graft
                              Stenting Pilot Study (RA YES Pilot),
                              Georgetown University Medical Center
               1997           Co-investigator, Palmaz-Schatz Crown Balloon Expandable
                              Stent with Power Grip Study,
                              Georgetown University Medical Center
               1997           Co-investigator, Medinol Nirvana Balloon Expandable Stent
                              Georgetown University Medical Center
               1997           Principal Investigator, EXCITE Trial (Evaluation of oral
                              Xemilofiban in Controlling Thrombotic Events in patients
                              undergoing coronary angioplasty or stent placement)
               1997           Co-investigator, Bard EXTRA Trial (Evaluation of the XT
                              stent for Restenosis in native Arteries)
               1998           Clinical Events Committee
                              Biocompatibles div Ysio Stent Randomized Control Trial
               1999           SCIMED SYMBIOT Covered Stent Feasibility Study
                              Clinical Events Committee
               1999           Co-investigator, Prevention of Rest enos is with Tranilast
                              and Its Outcomes (PRESTO)
                              Georgetown University Medical Center
               1999           Principal Investigator, Norvasc for Regression of Minimal
                              to Moderate Atherosclerotic Lesions by Intravascular Sonographic
                              Evaluation (NORMALISE)
                              Georgetown University Medical Center
               2000           Embol-X Aortic Cannula Feasibility Study
                              Clinical Events Committee




                                                                                                    25
                                                                         Jeffrey Alan Breall (11)

Multi-center Clinical Investigations (continued):

               200 1          Principal Investigator, Phannakokinetic Study of Enoxaparin in
                              Patients Undergoing Percutaneous Coronary Intervention (PEPCI)
                              Indiana University Medical Center
               2000           Principal Investigator, Coronary Revascularization.Utilizing
                              INTEGRJLIN and Single-bolus Enoxaparin (The Cruise Study)
                              Indiana University Medical Center
               2001           Principal Investigator, Sound Wave Inhibition of'Neointimal
                              Growth (The Swing Study) Indiana University Medical Center
               2001           Principal Investigator, Sonotherapy Prevention of Late Arterial
                              In-Stent Hyperplasia (The SPLASH Study) Indiana University
                              Medical Center
               2001           Co-Investigator, Evaluation of the RX ACHIEVE Drug Coated
                              Coronary Stent System in the Treatment of Patients with De Novo
                              Coronary artery Lesions (DELIVER Clinical Trial)
                              Indiana University
               2002           Study Assessing Goals in the Elderly (SAGE) Trial
                              Chairman, Cardiovascular Events Adjudication Committee
               2002           Co-investigator, A Prospective Randomized Trial Evaluating the
                              Symbiot ill Covered Stent System in Saphenous Vein Grafts
                              (SYMBIOT III) Indiana University
               2003           Principal Investigator, Investigator, Protection During Saphenous
                              Vein Graft Intervention to Prevent Distal Embolization (PRIDE
                              Study), Indiana University
                2002          Principal Investigator, Spinal Cord Stimu1ation for the Treatment
                              of Refractory Angina, Indiana University
               2002           Principal Investigator, ACT Guided Coronary Interventions
                              Registry using Dalteparin (ACT - 1), Indiana University
               2003           Steering Committee, ACT Guided Coronary Interventions Registry
                              using Dalteparin (ACT -1), Indiana University
               2004           Co-investigator, Proximal Protection during Coronary Intervention
                              using the Proxis Embolic Protection System: A Randomized
                              Multicenter Clinical Trial
               2003           Principal Investigator, A Multicenter, Randomized, Double Blind
                              Controlled Study to Evaluate the Efficacy and Safety of AdSFGF-4
                              in Patients with Stable Angina (AGb""NT-3),Indiana University
               2003           Principal Investigator, e-Cypher Registry, Indiana University
               2004           Principal Investigator, The Assessment of the Medtronic AVB
                              Interceptor Saphenous Vein Graft Filter System (AMEthyst),
                              Indiana University
               2005           Principal Investigator, Safety and Efficacy of Enoxaparin in PCI
                              patients, an international randomized Evaluation (STEEPLE),
                              Indiana University




                                                                                                    26
                                                                         Jeffrey Alan Breall (J 2)

Multi-center Clinical Investigations (continued):

               2004            Principal Investigator, A randomized comparison of Angiomax
                              versus Lovenox in patients undergoing early invasive management
                               for acute coronary syndromes without ST -segment elevation (The
                              ACUITY Trial), Indiana University
               2004           Principal Investigator, (ARRIVE 2), Multi-Center Safety
                               Surveillance Program, Taxus Express Drug Eluting Stent Platform,
                              Indiana University
               2005           Principal Investigator, A comparison ofCS-747 and clopidogrel in
                               acute coronary syndrome subjects who are to undergo percutaneous
                              coronary intervention (TIMI-38), Indiana University
               2005           Co-investigator, Multicenter trial of the Orqis Medical CRS for the
                              Enhanced Treatment of CHF Unresponsive to Medical Therapy
                              (MOMENTUM), Indiana University
               2005           Principal Investigator, FREEDOM TRIAL: Future
                              Revascularization Evaluation in Patients with Diabetes Mellitus:
                              Optimal Management of Multi vessel disease, Indiana University
               2006           Principal Investigator, ENDEAVOR IV Trial: A Randomized
                              Controlled Trial of the Medtronic Endeavor Drug (ABT -578)
                              Eluting Coronary Stent System versus the Taxus Paclitaxel-Eluting
                              Coronary Stent System in De novo Native Coronary Artery
                              Lesions, Indiana University
               2006           Co-investigator, VA Coronary Artery Revascularization in
                              Diabetes Study-VA CARDS, Roudebush VA Medical Center
               2006           Principal Investigator, ZoMaxx II Trial: A Randomized Controlled
                              Trial of the ZoMaxx Drug Eluting Coronary Stent System versus
                              the Taxus Express Paclitaxel-Eluting Stent System in do novo
                              Coronary Artery Lesions
               2007           Principal Investigator, PERSEUS Trial: A Randomized Controlled
                              Trial of the Taxus Element Drug Eluting Coronary Stent System
                              versus the Taxus Liberte' Paclitaxel-Eluting Stent System in do
                              novo Coronary Artery Lesions
               2008           Abbott Vascular SPIRIT SV and SPIRIT PRIME DES trials
                              Chairman, Data and Safety Monitoring Committee
               2009           Principal Investigator, PLATINUM Trial: A Randomized
                              Controlled Trial of the Promus Element Drug Eluting Coronary
                              Stent System versus the Promus Everolimus-Eluting Stent System
                              in do novo Coronary Artery Lesions
               2013           Chairman, Safety Oversight Committee: ABSORB Japan: A
                              Clinical Evaluation of AVJ-301 Comparing with Metallic Drug-
                              eluting Stent in the Treatment of Subjects with Ischemic Heart
                              Disease in Japan




                                                                                                     27
                                                                           Jeffrey Alan Breall (13)


Organizations and Societies:

                1983           American Medical Association
                1984           New York Academy of Sciences
                1989-1993      Massachusetts Medical Society
                1994-          Fellow, American Heart Association,
                               Council on Clinical Cardiology
                1994-1996      Affiliate, Society for Cardiac Angiography and Interventions
                1994-          Abraham M. Rudolph Developmental Cardiology Society
                1995-          Fellow, American College of Cardiology
                1995-          Fellow, American College of Chest Physicians
                1995-          Fellow, American College of Physicians

Manuscript Review:

               1.     Cardiovascular Drugs and Therapy
               2.     Catheterization and Cardiovascular Intervention
               3.     Journal of the American College of Cardiology
               4.     Journal of the American Medical Association
               5.     American Journal of Cardiology
               6.     Coronary Artery Disease
               7.     Journal of the American Society of Echocardiography

Editorial Boards:

               1.     Diagnostic and Invasive Cardiology
               2.     Cardiology Case Reports
               3.     World Journal of Clinical Case Conference

Research Interests:

               1. New devices for coronary interventionlhigh risk angioplasty
               2. Quality Assurance in the Cardiac Catheterization Laboratory
               3. Cost-effectiveness of coronary interventions
               4. Primary angioplasty in acute myocardia] infarction
               5. Peripheral Vascular Disease




                                                                                                      28
                                                                         Jeffrey Alan Breall (I4)

                                          Publications

Articles:

    1. BreaU JA, Rudolph AM, Heymann MA: Role of thyroid hormone in postnatal circulatory
        and metabolic adjustments. J Clin Invest 1984; 73:1418-1424.
    2. Khayyal MA, Eng C, Franzen D, Brean JA, Kirk ES: The effects of vasopressin
        on the coronary circulation: reserve and regulation during ischemia. Am J Physiol1985;
        248 :H516- H522.
    3. Levine MJ, Harada K, Meuse Al, Watanabe J, BrealJ l. Carrozza JP, Bentivegna L,
        Franklin A, Johnson RG, Grossman W, & Morgan JP: Excitation -contraction uncoupling
        during ischemia in the blood perfused dog heart. Biochem Biophys Res Commun 1991;
         179:502-6.
    4. Breall JA, Kim 0, Bairn DS, Skillman JJ, Grossman W: Coronary-subclavian steal; an
        unusual cause of angina pectoris after successful internal mammary coronary artery
        bypass grafting. Cathet Cardiovasc Diagn 1991; 24:274-276.
    5. BreaU JA, Goldberger AL, Warren SE, Diver OJ, Sellke FW: Posterior mediastinal
        masses: rare causes of cardiac compression. Am Heart J 1992; 124:523-526.
    6. Breall lA, Watanabe J, & Grossman W: The effect ofzatebradine on contractility,
        relaxation and coronary blood flow. JAm Coli Cardiol1993; 21:471-477.
    7. BreaU JA, Grossman W, Stil1man IE, Gianturco LE, Kim D: Atherectomy of the
        subclavian artery for patients with symptomatic coronary-subclavian steal syndrome. J
        Am Coil Cardiol1993; 21: 1564-1567.
    8. Cohen OJ, BreaU JA, Ho KKL, Weintraub RM, Kuntz RE, Weinstein MC, Baim DS: The
        economics of coronary revascularization: comparison of costs and charges for
        conventional angioplasty, directional atherectomy, stenting and bypass surgery. JAm
        Coli Cardiol1993; 22: 1052-1059.
    9. Gordon PC, Kugelmass AD, Cohen DJ, BreaU JA, Friedrich SP, Carrozza JP Jr, Diver
        DJ, Kuntz RE, Bairn DS: Use of balloon post-dilation to safely improve the results of
        successful (but SUb-optimal) directional coronary atherectomy. Am J Cardiol 1993;
        72:71E-79E.
    10. The TIMI IIIB Investigators: Effects of tissue plasminogen activator and a comparison of
        early invasive and conservative strategies in unstable angina and non-Q-wave myocardial
        infarction: Results of the TIM! IDB Trial. Ore 1994; 89; 1545-1556.
    11. Cohen DJ, BreaU JA, Ho KKL, Kuntz RE, Goldman L, Bairn DS, Weinstein MC:
        Evaluating the potential cost-effectiveness of stenting as a treatment for symptomatic
        single-vessel coronary artery disease: use of a decision-analytic model. eire 1994;
        89: 1959-] 874.
    12. Gibson eM, Cannon CP, Piana RN, BreaU JA, Sharaf B, Flatley M, Davis V, Diver DJ,
        McCabe CR, Flaker Ge, Bairn DS, Braunwald E, for the TIMI 4 Study Group:
        Angiographic predictors of'reocclusion following thrombolysis: results from the TIMI 4
        study. JAm Col! Cardiol1995; 25:582-589.




                                                                                                    29
                                                                          Jeffrey Alan Breall (IS)

Articles (continued):

    13. Colleran JA, Burke AB, Moseley AL, Green SE, BreaU JA, Vinnani R: Subvalvular left
         ven1ricular outflow tract obstruction caused by "rhino-nodular" calcification. Cardiovasc
        Patlzo11995; 4:123-126.
    14. BreaU JA., Gersh BJ: Common manifestations of valvular heart disease in the elderly.
         Cardiology in Review 1995; 3:150-157.
    15. Colleran JA, Tierney JP, Prokopchak R, Diver DJ, BreaU JA: Angiographic presence of a
         myocardial bridge after successful percutaneous transluminal coronary angioplasty. Am
        Heart J 1996; 131: 196-198.
    16. Bui MN, Sack MN, Moutsatsos G, Lu DY, Katz P, McCown R, Breall JA, Rackley CE:
        Autoantibodies titers to oxidized low-density lipoprotien in patients with coronary
         atherosclerosis. Am Heart J 1996; 131:663-667.
    17. Schultz SC, BreaU J, Hannan R: Acute cardiac tamponade secondary to congenital factor
        V deficiency. Cardiology 1997; 88:48-9.
   18. Berger AK, Breall JA, Gersh BJ: When is PTCA the treatment of choice for acute MI?
         Contemporary lntrnal Medicine 1997; 9:45-55.
   19. Tavel ME, Brean JA, Gersh BJ: Ischemic heart disease with congestive heart failure. In:
        Tavel M ed. Clinical Problems in Cardiopulmonary Disease Chest 1998; 113:1119-1122.
   20. Berger AK, Edris DW, Breall.TA, Oetgen WJ, Marciniak TA, Molinari GF: Resource
        utilization and quality of care for Medicare patients with acute myocardial infarction in
        Maryland and the District of Columbia; Analysis of data from the Cooperative
        Cardiovascular Project. Am Heart J 1998; 135:349-356.
   21. Breall JA, Solomon AJ, Gersh BJ: Non-Q wave myocardial infarction: You cannot
           judge a book by its cover. ACC Current Journal Review May/June 1998: 15-18.
   22. Solomon AJ, BreaU JA, Gersh BJ: Unstable angina: Current recommendations and new
        directions. ACC Current Journal Review May/June 1998: 18-23.
   23. Weissman NJ, Sheris SJ, Chari R, Mendelsohn FO, Anderson WD, BreaU JA, Tanguay J-
        F, Diver DJ:Intravascuiar Ultrasonic analysis of plaque characteristics associated with
        coronary artery remodeling. Am J Cardiol1999; 84:37-40.
   24. Berger AK, Schulman KA, Gersh BJ, Pirzada S, BreaU JA, Johnson AB, Every NR:
        Primary coronary angioplasty vs thrombolysis for the management of acute myocardial
        infarction in elderly patients. JAMA 1999; 282:341-348.
   25. Rashid H, Marshall R.T, Diver DI, Breall JA: Spontaneous and diffuse coronary ru1ery
        spasm unresponsive to conventional intracoronary pharmacologic therapy. A case report.
         Cathet CardiovascInterv 2000; 49:188-191.
   26. Rashid H, Marshall RJ, Diver DJ, Breall JA: Use of atropine in the treatment of
        spontaneous coronary artery. Cathet Cardiovasc Interv. 2000; 50:375B-376.
   27. Patel SR, Breall JA, Diver DJ, Gersh BJ, Levy AP: Does bradycardia promote coronary
       collateral growth in humans? Coronary Artery Disease. 2000; 11:467-472.
   28. Sheifer SE, Rathore SS, Gersh BJ, Weinfurt KP, Oetgen WJ, Breall JA, Schulman KA:
       Time to presentation with acute myocardial infarction in the elderly. Association with
       race, gender, and socioeconomic status. Circ 2000; 102: 1651-6.




                                                                                                     30
                                                                            Jeffrey Alan Breall (16)

Articles (continued):

   29. Berger AK, BreaU JA, Gersh BJ, Johnson AE, Oetgen WJ, Marciniak TA, Schulman KA
        Effect of diabetes mellitus and insulin use on survival after acute myocardial infarction in
        the elderly (The Cooperative Cardiovascular Project). Am J Cardiol2001; 87:272-277.
   30. Kalaria VO, Rouch C, Bourdillon PD, BreaU JA: Distal emboli protection in patients
       undergoing percutaneous coronary intervention after a recent myocardial infarction.
        Cathet Cardiovasc Interv. 2002; 57:54-60.
   31. Panchal VR, Kalaria V, Breall JA, March KL: Catheter-based gene therapy for
        angiogenesis. Applications in Imaging Cardiac Interventions: Oct 2002
   32. Kalaria VG, Koradia N, Breall JA: Myocardial bridge: A clinical review. Cathet
        Cardiovasc Interv 2002; 57:552-556.
   33. Bhatt DL, Lee BI, Castrella PJ, Pulsipher M, Rogers M, Cohen M, Corrigan VE, Ryan
        TJ Jr, BreaU JA, Moses JW, Eaton OM, Sklar MA, Lincoff AM: Safety of concomitant
       therapy with eptifibatide and enoxaparin in patients undergoing percutaneous coronary
       intervention-results of the CRUISE study. J Am Coli Cardiol 2003; 41 :20-25.
   34. Bhakta D, Breall JA, Kalaria VO: Complete sinus inversus and bicuspid aortic valve
       stenosis. J Invas Cardiol 2003; 15:213-215.
   35. Cline SL, Kalaria VO, von der Lohe E, Breall JA: Cerebrovascular complications of
       Cardiac Catheterization. In: Biller and O'Donnell, eds, Seminars in Cerebrovascular
       Disease and Stroke, New York, NY Elsevier, 2003, 3: 194-199.
   36. Ramanuja S, BreaU JA, Kalaria VO: The approach to "aspirin allergy" in cardiovascular
       patients. Cire. 2004; 11 0: el-e4.
   37. Carrozza JP Jr, Caussin C, Braden G, Braun P, Hansell F, Fatzinger R, Walters G,
       Kussmaul W, BreaU J; TriActiv Pilot Study Investigators. Embolic protection during
       saphenous vein graft intervention using a second-generation balloon protection device:
       results from the combined US and European pilot study of the TriActiv Balloon Protected
       Flush Extraction System. Am Heart J. 2005,149:1136.
   38. Coram R, Oeorge Z, Breall JA: Percutaneous intervention through a Cabrol composite
       graft. Cathet Cardiovasc Interv. 2005 66:356.
   39. Carrozza JP Jr, Mumma M, BreaU JA, Fernandez A, Heyman E, Metzger C and for the
       PRIDE Study Investigators; Randomized Evaluation of the TriActiv Balloon-Protection
       Flush and Extraction System for the Treatment of Saphenous Vein Graft Disease
       J Am Call Cardiol. JAm Coli Cardiol2005 46: 1677.
   40. Karlsson G, Rehman J, Meltser HM, Kalaria VO, BreaU JA: Increased Incidence of Stent
       Thrombosis in Patients with Cocaine Use. Cathet Cardiovasc Interv. 2007 69:955.
   41. Kirtane AJ, Heyman ER, Metzger C, BreaU JA, Carrozza JP Jr: Correlates of adverse
       events during saphenous vein graft intervention with distal embolic protection: A PRIDE
       Sub Study. JAm Coil CardiolIntv 2008 1: 186
   42. Kereiakes DJ, Turco MA, Breall J Farhat NZ, Feldman RL, McLaurin B, Popma JJ,
       Mauri L, Zirnetbaum P, Massaro J, Cutlip DE, on behalf of the AMEthyst Study
       Investigators. A novel filter-based Embolic protection device for percutaneous
       intervention of saphenous vein graft lesions: Results of the AMEthyst randomized
       controlled trial. JAm Coil Cardiol In tv 2008. 1: 248




                                                                                                       31
                                                                         Jeffrey Alan BreaU (17)

Articles (continued):

   43. El Masry H, BreaU JA: Alcohol septal ablation tor hypertrophic obstructive
       cardiomyopathy: A review. Curr Cardiol Rev 2008, Volume 04, No. 03.
   44. Antoun P, EI Masry H, Breall JA: Sudden cardiac death complicating alcohol septal
       ablation: a case report and review of literature. Cathet Cardiovasc Interv. 73: 9562009.
   45. Benson MD, BreaU J, Cummings OW, Liepnieks JJ: Biochemical characterization of
       amyloid by endomyocardial biosy. Amyloid. 2009. 16:9.
   46. Lasala JM, Cox DA. Morris L, BreaU JA, MahoneyPD, Horwitz PA, Shaw D, Hood KL,
       Mandinov L, Dawkins KD: Two-year results of paclitaxel-eluting stents in patients with
       medically treated diabetes mellitus from the TAXUS ARRIVE program. Am J Cardiol
       2009, 103:1663.
   47, Lasala JM, Cox DA, Dobies D, Baran K, Bachinsky WB, Rogers E, BreallJA, Lewis
       DH, Song A, Starzyk RM, Mascioli SR, Dawkins KD, Baim OS: Drug-eluting stent
       thrombosis in routine clinical practice: 2 year outcomes and predictors from the TAXUS
       ARRNE Registries. Circ Cardiovascular Interventions. 2009,2:285.
   48. Bhatt DL, Lincoff AM, Gibson CM, Stone GW, McNulty S, Montalescot G, Kleiman NS,
       Goodman SG, White HD, MahafIey KW, Pollack CV Jr, Manoukian SV, Widimsky P,
       Chew DP, Cura F, Manukov I, Tousek F, Jafar MZ, Arneja J, Skerjanec S, Harrington
       RA; CHAMPION PLATFORM Investigators. Intravenous platelet blockade with
       cangrelor during PCI. N Engl J Med. 2009 361(24):2330
   49. Kreutz RP, Stanek EJ, Aubert R, Yao J, BreaU IA, Desta Z, Skaar TC, Teagarden JR,
       Frueh FW, Epstein RS, Flockhart DA: Impact of proton pump inhibitors on the
       effectiveness of clopidogrel after stent placement: The Clopidogrel MEDeO Outcomes
       Study. Pharmacotherapy. 2010 30 (8): 787.
   50. Jaradat ZA, Sayfo SM, BreaU JA: Percutaneous alcohol septal ablation following
       surgical myectomy. J Invasive Cardiol. 201022 (8): 207.
   51. Stone GW, Teirstein PS, Meredith IT, Farah B, Dubois CL, Feldman RL Dens J,
       Hagiwara N, Allocco OJ, Dawkins KD; PLATINUM Trial Investigators: A prospective,
       randomized evaluation of a novel everolimus-eluting coronary stent: the PLAT~'UM (a
       Prospective, Randomized Multicenter Trial to Assess an Everolimus-Eluting Coronary
       Stent System [pROMUS Element] for the Treatment of Up to Two de Novo Coronary
       Artery Lesions) trial. JAm Coil Cardiol2011. 57: 1700
   52. Bolad lA, Alqaqa'a A, Khan B, Srivastav SK, von der Lohe E, Sadanadan S, BreaU JA:
       Cardiac events after non-cardiac surgery in patients with previous coronary intervention
       in the drug-eluting stent era. J Invasive Cardiol. 2011; 23 (7): 283
   53. Suradi H, BreaU JA: Successful use of the lmpella device in Giant Cell Myocarditis as a
       bridge to permanent left ventricular mechanical support. Tex Heart Inst. 2011; 38(4): 437
   54. Furlan AI, Reisman Massaro J, Mauri L, Adams H, Albers GW, Fe1berg R, Herrmann H,
       Karr S, Landzberg M, Raizner A, Wechsler L. CLOSURE I Investigators: Closure or
       medical therapy for cryptogenic stroke with patent foramen ovale. N Engl.T Med. 2012;
       366 (11): 991




                                                                                                   32
                                                                         Jeffrey Alan Breall (18)

Articles (continued):

    55. Kreutz RP, Nystrom P, Kreutz Y, Miao J, Destra Z, BreaU JA, Li L, Chiang CW, Kovacs
        R, Flockhart DA, Jin Y: Influence of'paraoxonase-I Q192R and cytochrome P450 2C19
        polymprphisms on clopidogrel response. Clin Pharm: Advances and Applications. 2012.
        4: 13.
    56. Kreutz RP, BreaU JA, Kreutz Y, Owens J, Lu D, Bolad I, von der Lohe E, Sinha A,
        Flockhart DA: Protease receptor-I (PAR-I) mediated platelet aggregation is dependent on
        clopidogrel response. Thromb Res. 2012. March 27.
    57. Roe MT, Armstrong PW, Fox KA, White RD, Prabhakaran D, Goodman SG, Cornel JH,
        Bhatt DL, Clemmensen P, Martinez F, Ardissino D, Nicolau JC, Boden WE, Gurbel PA,
        Ruzyllo W, Dalby AJ, McGuire OK, Leiva-Pons JL, Parkhomenko A, Gottlieb S,
        Topacio GO, Hamm C, Pavlides G, Goudev AR, Oto A, Tseng CD, Merkely B,
        Gasparovic V, Corbalan R, Cinteza M, McLendon RC, Winters KJ, Brown EB,
        Lokhnygina Y, Aylward PE, Huber K, Hochman JS, Ohman EM; TRILOGY ACS
        Investigators: Prasugrel versus c1opidogrel for acute coronary syndromes without
        revascularization. N Engl J Med. 2012.367:14.

   58. Farkouh MS, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, Yang M, Cohen
       OJ, Rosenberg Y, Solomon SD, Desai AS, Gersh BJ, Magnuson EA, Lansky A, Boineau
       R, Weinberger J, Ramanathan K, Sousa JE, Rankin J, Bhargava E, Buse J, Reub W,
       Smith CR, Muratov V, Bansilal S, King S 3rd,Bertrand M, Fuster V; FREEDOM Trial
       Investigators: Strategies for multivessel revascularization in patients with diabetes. N
       Engl J Med. 2012. 367:2375.
   59. Godley RW, Joshi K, BreaU JA: A comparison of hand injection versus automated
       contrast injectors during cardiac catheterization . .J Invasive Cardiol. 2012. 24:628.
   60. Kreutz RP, Owens J, Brean JA, Lu D, von der Lohe E, Bolad I, Sinha A, Flockhart DA.
       C-reactive protein and fibrin clot strength measured by thromboelastography after
       coronary stenting. Blood Coagu/ Fibrinolysis. 2013 3:321.
   61. Kreutz RP, Owens J, Jin Y, Nystrom P, Desta Z, Kreutz Y, BreaU lA, Li L, Chiang C,
       Kovacs RJ, Flockhart DA. Cytochrome P450 3A4*22, PPAR- c, and AR.'1\fT
       polymorphisms and clopidogrel response. Clin Phannacol20135: 185.

Book Chapters:

       1. BreaU JA, Gersh BJ. The Results of Transluminal Interventions in Coronary
          Artery Disease. In: Bertrand M, Serruys P, Sigwart U, eds. Handbook of Car-
          diovascular Interventions. London, UK: Churchill Livingstone, 1996,501-514.
       2. BreaU JA, Rodak DJ: Intermediate Coronary Syndrome. In: Conti CR, ed.
          Adult Clinical Cardiology Self Assessment Program (ACCSAP) on CD-ROM.
          American College of Cardiology/American Heart Association, 1997; 2000.
       3. Gersh BJ, BreaU JA, Diver D.T:The Ro]e of Primary Angioplasty in the
          Management of Acute Myocardial Infarction. In: Opie LH and Yellon DM, ed.
          Cardiology at the Limits.The Rustica Press, 1997,26-49.




                                                                                                    33
                                                                        Jeffrey Alan Breall (19)

Book Chapters: (continued):

        4. Diver DJ, BreaU JA: Balloon valvuloplasty: aortic valve. In: Yusef S, Cairns JA,
            Camm AJ, Fallen EL, Gersh BJ, ed. Evidence Based Cardiology. Tavistock
            Square, London: BMJ Books, BMA House, 2nd ed. 2003, 782-795.
        5. Meuth MJ, Green CE, BreaU JA: Interventional techniques for coronary artery
           disease. In: Taveras JM & Ferrucci JT, eds. RADIOLOGY Diagnosis*Imaging*
           Intervention. 2: 132. Philadelphia, PA: Lippincott Williams & Wilkins, 1999.
        6. Meldrum DR, Raiesdana A, BTeal! lA, Brown JW: Heart Transplantation. In: Harken
           AH & Moore EE, eds. Abernathy's Surgical Secrets, 91 :319. Philadelphia, PA: Hanley
           & Belfus, 2004
        7. Meldrum DR, RaiesdanaA, Breall JA, Brown JW: Heart Transplantation. In: Harken
           AH & Moore EE, eds. Abernathy's Surgical Secrets, 91 :323. Philadelphia, PA: Hanley
           & Belfus, 2004
        8. Breall JA, Aroesty 1M, Simons M: Overview of the management of unstable angina
           and acute non-ST elevation (non-Q wave) myocardial infarction. In: Rose BD, ed.
           UpToDate™ in Cardiovascular Medicine, Waltham, MA, 2012
        9. Brean JA, Simon M: Risk stratification after unstable angina or non-ST elevation
           (non-Qvwave) myocardial infarction. In: Rose BD, ed. UpToDate™ in Cardiovascular
           Medicine, Waltham, MA, 2012
        10. BreaU JA, Simons M: Coronary arteriography and revascularization
             following unstable angina or non ST-elevation (non-Q wave) acute myocardial
             infarction. In: Rose BD, ed. UpToDate™ in Cardiovascular Medicine, Waltham, MA,
             2012
        11. Emery M, BreaU JA: Disparities in the delivery of cardiovascular care. In: Rose BD,
            ed. UpToDate™ in Cardiovascular Medicine, Waltham, MA, 2012

Non-peer reviewed publications:

       No-Reflew Phenomenon During PCI I Diagnostic and Invasive Cardiology July] 5, 2011
       When to Consider Revascularization of Coronary Chronic Total Occlusion] Diagnostic
       and Invasive Cardiology March 19, 2012
       Understanding Contrast-Induced Nephropathy I Dr Cardiology May 15,2012
       Justifying the Use of Vascular Closure Devices rDI Cardiology September 13,2013

Abstracts

       1. Brean JA and Nicoll CS: Somatotrophic Effects of Prolactin in Neonatal Rats.
          Western Regional Conference on Endocrinology. Santa Cruz, CA 1978.
       2. Clyman RI, BreaU J, Maher P, Campbell D, Maury F: Thyroid Hormones and the
          Ductus Arteriosus. The Society for Pediatric Research. Washington, D.C. 1985.
       3. BreaU JA, Watanabe J, Grossman W: Comparative Effects ofULFS-49 and
          Verapamil on Heart Rate and Contractility in Isolated Hearts. American College of
          Cardiology. Atlanta, GA 1991.




                                                                                                   34
                                                                         Jeffrey Alan Breall (20)

Abstracts (continued):

       4. Cohen DJ, BreaU JA, Ho KKL, Bairn DS: Comparative Costs of Two New
            Technologies, Conventional Angioplasty, and Bypass Surgery for Elective Coronary
            Revascularization. American Heart Association, New Orleans, LA 1992.
       5. Cohen DJ, Kuntz R., Brean JA, Ho KKL., Goldman L, Weinstein MC, Baim DS: The
            Incremental Cost-Effectiveness of Coronary Stenting versus Conventional
          Angioplasty: A Decision-Analytic Model. American Reali Association, New
          Orleans, LA 1992.
       6. Gibson CM, Cannon CP, Piana RN, Maher KA, Davis SD, Brean JA, Davis V, Diver
            DJ: Relationship of Coronary Flow to Myocardial Infarction Size: Two Simple
            Methods to Sub-classify TIMI Flow Grades. American Heart Association, New
            Orleans, LA 1992.
       7. Gibson CM, Piana RN, Davis SF, Maher KA, BreaU JA, Davis V, Diver DJ, Bairn
           DS: hnprovement in Minimum Lumen Diameter During First Day After
           Thrombolysis. American Heart Association, New Orleans, LA 1992.
       8. Gibson CM, Cannon CP, Piana RN, Breall JA, Davis SF, Maher KA, Flatley M,
           Davis V, Diver DJ, Bairn DS for the TIMI 4 Study Group: Consequences ofTThtII
           Grade 2 vs. 3 Flow at 90 Minutes Following TIrrombolysis. American College of
           Cardiology, Anaheim, CA 1993.
       9. Cohen DJ, Kuntz RE, Friedrich SP, Gordon PC, BreaU JA, Ho KK, Weinstein MC,
           Bairn DS: Cost-Effectiveness of Directional Atherectomy, Stenting, and
           Conventional Angioplasty in Single-Vessel Disease: A Decision-Analytic Model.
           American College of Cardiology, Anaheim, CA, 1993.
       10. Gordon P, Kugelmass AD, Breall JA, Friedrich SP, Cohen DJ, Diver DJ, Bairn DS:
           Selective Use of Balloon Post-dilation Can Safely Improve the Results of Successful
           (but Sub-optimal) Directional Coronary Atherectomy. American Heart Association,
           Atlanta, GA 1993.
       11. Cohen DJ, Gordon PC, Friedrich SP, Breall JA, Diver DJ, Weinstein MC, Bairn DS:
           The Cost-Effectiveness of Selective Adjunctive Balloon Dilation after Successful (but
           Sub-optimal) Directj.onal Coronary Atherectomy: A Decision-Analytic Model.
           American Heart Association, Atlanta, GA 1993
       12. Moscucci M, Kugelmass AD, Piana RN,Gordon PC,Wood M, Friedrich SP, Breall
           JA, Kuntz RE: The Value of Using Simple Logistic Models of Target Site-Related
           Clinical Events in the Evaluation of Vein Graft Restenosis. American Heart
           Association, Atlanta, GA 1993.
       13. Diver DJ, Brown BG, Breall JA, Berger C, Dunn S, ThompsonB, McCabe CH,
           Braunwald E: Characterization of Patient Management and Outcomes in the TIMI-
           IlIA Trial. American College of Cardiology. Atlanta, GA 1993.
       14. Sack MN, Katz P, McCown R, BreaU JA, Rackley CE: An Enzyme Linked
           Immunosorbent Assay of Autoantibodies to Oxidized Low-Density Lipoproein as a
           Predictor of Coronary Artery Disease. American College of Cardiology. Atlanta, GA
           1993.




                                                                                                    35
                                                                       Jeffrey Alan Breall (21)

Abstracts (continued):

       15. Bui MN, Moutsatsos G, Sack MN, Lu D, BreaU lA, Katz P, Rackley CE:
           Autoantibody Titers to Oxidized LDL in Patients with Coronary Artery Disease and
            Stable and Unstable Angina. American Federation for Clinical Research. San Diego,
           CA 1995.
       16. Gannuscio JR, BreaU JA, Diver DJ, Lawrence W; PTCA Clinical Process Team
           Decreases Hospital Costs and Length of Stay. Transcatheter Cardiovascular
           Therapeutics. Washington, D.C. 1996.
       17. Arora UK, Chari R, BreaU JA, Diver DJ, Weissman NJ: Does Coronary
           Calcification Predict Atherosclerotic Placque Burden: A 3-Dimensional Intravascular
           Ultrasound Analysis. American Heart Association, New Orleans, LA 1996.
       18. Weissman NJ, Chari R, Mendelsohn FO, Foster GP, Anderson WD, BreaU JA,
           Tanguay J, Diver DJ, Gersh BJ: Patient and Plaque Characteristics Associated with
           Coronary Remodeling: An Intravascular Ultrasound Analysis. American College of
           Cardiology, Anaheim, CA 1997.
       19. Weissman NJ,Arora UK, BreaU JA Gannuscio JR, Diver DJ, Gersh BJ: In Vivo
           Gender Differences in Coronary Artery Plaque Morphology Assessed by Intravascular
           Ultrasound. American College of Cardiology, Anaheim, CA 1997.
       20. Arora UK, Chari R, Mendelsohn FO, Foster GP, Breall JA, DiverDJ, WeissmanNJ:
           Altered Plaque Distribution in Hypertensive Patients. American College of
           Cardiology, Anaheim, CA 1997.
       21. Arora UK, Chari R, BreaU JA, Diver OJ, Weissman NJ: Calcified Luminal Surface
           Area: An Improved Method to Quantify Coronary Calcification Using 3D NUS
           Analysis. American Society of Echo cardiography, Orlando, FL 1997.
       22. Arora UK, Chari R, Mendelsohn FO, BreaU JA, Diver DJ, Weissman NJ: Increased
           Coronary Atherosclerotic Plaque Burden and Calcification in Diabetic Patients by 3D
           Intravascular Ultrasound Analysis. American Heart Association, Orlando, FL 1997.
       23. Arora UK, Chari R, BreaU JA, Diver DJ, Weissman NJ: The Aging Atherosclerotic
           Plaque: In Vivo Morphologic Analysis and Gender Differences using Intravascular
           Ultrasound. American Heart Association, Orlando, FL 1997.
       24. Arora UK, Chari R, Breall JA, Diver OJ, Weissman NJ: Adventitial Changes with
           Atherosclerosis: In Vivo Observations and Implications for IVUS Assessment of
           Plaque Morphology. American Heart Association, Orlando, FL 1997.
       25. Arora UK, Little RW, Chari R, BreaU JA, Diver DJ, Weissman NJ: Are Plaques
           Different in African Americans? A 3D Intravascular Ultrasound Study of Coronary
           Plaque Morphology. American Heart Association, Orlando, FL 1997.
       26. Berger AK, BreaU JA, Johnson AE, Schulman KA, Gersh BJ, Oetgen WJ, Pirzada
           SR, Frederick PR, Every NR: Primary Angioplasty versus Thrombolytic Therapy in
           the Elderly: The CCP Experience. American Heart Association, Orlando, FL 1997.
       27. Berger AK, Johnson AE, Breall JA, Oetgen WJ, Marciniak TA, Gersh BJ, Schulman
           KE: The Effect of Diabetes on Mortality in Medicare Beneficiaries with Acute
           Myocardial Infarction? American Heart Association, Orlando, FL 1997.




                                                                                                  36
                                                                         Jeffrey Alan Breall (22)

Abstracts (continued):

       28. Every NR, Pirzada SR, Frederick PD, Robinson MB, BreaU JA, Schulman KA:The
            Association Between Procedure Volume and Mortality in Primary PTCA: The CCP
            Experience. American Heart Association, Orlando, FL 1997.
       29. Deutch E, Gordon PC, Diver DJ, Breall JA, fitzPatrick M, Senerchia C, Ho KKI:
            Safety and Efficacy of Coronary Stenting after Recent Myocardial Infarction: Results
            From the Stent Anticoagulation Regimen Study (STARS). American Heart
            Association, Orlando, FL 1997.
       30. Patel SR, BreaU JA, Gersh BJ, Levy: Does Bradycardia Promote Coronary Collateral
            Growth in Humans? American College of Cardiology, Atlanta, GA 1998.
       31. Berger AK, Johnson AE, BreaU JA, Schulman KA, Gersh B1: Does Diabetes Affect
           the Clinical Presentation of Elderly Patients with Acute Myocardial Infarction?
           American College of Cardiology, Atlanta, GA 1998.
       32. Oetgen WJ, Berger AK, Edris DW, Lesher ML Jones J, Sdhuster M, Karge G, BreaU
           lA, Fitzgerald M, Molinari GF: hnprovement in Treatment Quality Indicators For
           Elderly Patients with Acute Myocardial Infarction: The Cooperative Cardiovascular
           Project in Maryland and the District of Columbia. American College of Cardiology,
           New Orleans, LA 1999.
       33. Kalaria VG, Breall J, Class S, Sprague K, Bahro AG, Falcone W, Shoultz C,
           Dorogy ME: The Safety & Economic Impact of Immediate Ambulation after
           Diagnostic Catheterization Using a Suture Mediated Closure Device. Society of
           Cardiac Angiography and Intervention. Boston, MA 2003.
       34. Karlsson G, Rehman J, Meltser HM, Kalaria VG, BreaU JA: High Rate of Stent
           Thrombosis in Cocaine Users Undergoing Coronary Stent Placement. American
           College of Cardiology, New Orleans, LA 2004.
       35. Rampurwala A, BreaU J, von der Lohe E: Trend Towards Reduced Vascular
           Complications in Women Undergoing Diagnostic Heart Catheterization with 4 French
           Versus 6 French Catheters. Society for Cardiac Angiography and Interventions,
           Chicago, IL 2006.
       36. Kerieiakes D, Turco M, McLaurin B, Feldman R, Farhat N, BreaU J, Foster M: The
           AMEthyst Trial; A prospective randomized controlled study of the Medtronic
           Interceptor PLUS Coronary Filter System for PCI of Degenerative SVG. TeT
           Washington, DC 2007.
       37. Lasala JM, Cox DA, Morris DL, Breall JA, Mahoney PD, Horwitz PA, Shaw D,
            Mandinov L, Dawkins KD: TAXUS Mitigates the Effects of Diabetes on Restenosis
            Independent of Patient Risk Profile: 2-Year Results of the TAXUS ARRIVE
           Program. TCT. Washington, DC 2008.
       38.singh IM, Antoun PS, Shoemaker TJ, Terry C, Kwo PY, Tector JA, Breall JA,
           Sadanandan S: Cardiac Catheterization as a Strategy for Pre-Operative Risk
           Stratification in Patients Undergoing Liver Transplantation. SCAl Washington DC
           2008




                                                                                                    37
                                                                      Jeffrey Alan Breall (23)

Abstracts (continued):

       39. Stanek EJ, Aubert RE, Flockhart DA, Kreutz RP, Yao J, BreaU JA, Desta Z, Sklaar T,
           Freuh FW, Teagarden JR, Epstein RS: A National Study of the Individual Proton
           Pump Inhibitors on Cardiovascular Outcomes in Patients Treated with Clopidogrel
           Following Coronary Stenting: The Clopidogrel Medco Outcomes Study. SCAL Las
           Vegas, NV 2009




                                                                                                 38
jE:~ffrey .A. Brec111 M.D., Ph.C).
Jeffrey A. Breall M.D., Ph.D.   L. Todd Kelly, Esq.
 13960 Salsbury Creek Dr        The Carlson Law Firm, p,e.
Carmel, IN 46032                11606 N, IH-35
317 -496-8680                   Austin, TX 78753
jbreall@iu.edu




                                March 18,2014


                                RE: Nancy Jo Rodriguez



                                Deat Mr. Kelly:

                                Thank you very much for the opportunity to review the records in the case
                                involving the above named individual. At your request, Thad the opportunity to
                                review, in detail, all of the materials which you sent to me including Ms.
                                Rodriguez's various in-patient hospital records at Seton Northwest, outpatient
                                cardiology records from Austin Heart, extended care facility records at Ashwood
                                Assisted Living, and her outpatient counseling records.

                                I hold a medical license .in the State of Indiana. I am over eighteen, years of age,
                                and of sound mind. I earned my undergraduate degree from the University of
                                California, and my medical degree from Albert Eins tein College of Medicine. I
                                have been practicing cardiovascular medicine for 21 years. By virtue of my
                                education, training and experienced, I am qualified to render opinions regarding
                                the standard of care in treating a patient such as Nancy Jo Rodriguez, as well as
                                causation In this case. I was practicing medicine at the time of the care rendered .in
                                this matter and continue to practice medicine at the time of this report.

                                I possess the following qualifications for rendering my opinions in the above-
                                referenced matter: I am currently board certified by the American Board of
                                Internal Medicine in the fields of Cardiovascular Diseases as well as in
                                Interventional Cardiology; I have published numerous articles In these fields and I
                                teach these subjects to trainees             011   a daily basis; I hold numerous administrative
                                positions. To further delineate these qualifications, an update copy of my
                                {'YII77t'11111f11   oitae is enclosed.




                                                                               EXHIBIT

                                                                         I          o                                              43
In   my   opinion     the care and treatment       provided     to Nancy Jo Rodriguez         by Austin
Heart fell below the accepted          standards     of care in the following      particulars:
Despite     Dr. David Kessler, one of her cardiologists              from Austin Heart, requesting
tbat the Pradaxa be discontinued             (in this patient who, at best, has bipolar disorder
and at times was confused,          this was a reasonable        request),   Pradaxa    therapy
nevertheless       was continued     after bet acute hospitalization.         This request     to stop
the medication        was not appreciated      by her    primary cardiologist,     Dr, Vivek
Goswami        (who was in the same group as Dr. Kessler).               Furthermore,      Ms.
Rodriguez      appeared     to be obtaining     refills for this medication      authorized       by
nurses and staff of this same heart group who recommended                       discontinuing          this
medication      (Austin Heart).      The standard       of care would have been to follow the
orders    of Dr. Kessler to stop the administration             of Pradaxa,


FaiIme to discontinue         the Use of Pradaxa was a direct cause of her subsequent
acute admission        to the hospital with hypotension,          acute kidney injury and apparent
gastrointestinal      bleeding - known side effects of the over-usc              of Pradaxa,      Ms.
Rodriquez's        entire hospitalization    was attributable     to the failure to stop Pradaxa
therapy as ordered         by Dr. Kessler.     More likely than not, had the Pradaxa
medication      been discontinued       as requested,     Ms. Rodriguez's      hospitalization         would
never have needed to take place.


I hold these opinions to a reasonable            degree of medical certainty.          They are based
upon     my   education,    training and experience       as well as the records which I have
reviewed,


If I can answer any further questions            or he of any further service, at any time,
please do not hesitate to contact me immediately.




Professor     of Clinical Medicine




                                                                                                               ,,)
                                                                                                              <.




                                                                                                               44
APPENDIX 4
                                                             LEXSTAT

                                              LexisNexis (R) Texas Annotated Statutes
                                      Copyright © 2014 by Matthew Bender & Company,             Inc.
                                                 a member of the LexisNexis Group
                                                         All rights reserved.

                              ***   This document   is current through the 2013 3rd Called Session      ***
                                          CIVIL PRACTICE AND REMEDIES CODE
                                               TITLE 4. LIABILITY IN TORT
                                            CHAPTER 74. MEDICAL LIABILITY
                                        SUBCHAPTER H. PROCEDURAL      PROVISIONS

                                        GO TO TEXAS       CODE ARCHIVE DIRECTORY

                                           Tex. Civ. Prac. & Rem. Code § 74.351       (2014)

§ 74.351.    Expert Report

  (a) In a health care liability claim, a claimant shall, not later than the 120th day after the date each defendant's original
answer is filed, serve on that party or the party's attorney one or more expert reports, with a curriculum vitae of each
expert listed in the report for each physician or health care provider against whom a liability claim is asserted. The date
for serving the report may be extended by written agreement of the affected parties. Each defendant physician or health
care provider whose conduct is implicated in a report must file and serve any objection to the sufficiency of the report
not later than the later of the 21 st day after the date the report is served or the 21 st day after the date the defendant's
answer is filed, failing which all objections are waived.

     (b) If, as to a defendant physician or health care provider, an expert report has not been served within the period
specified by Subsection (a), the court, on the motion of the affected physician or health care provider, shall, subject to
Subsection (c), enter an order that:

       (1) awards to the affected physician or health care provider reasonable         attorney's   fees and costs of court incurred
by the physician or health care provider; and

         (2) dismisses   the claim with respect to the physician   or health care provider,    with prejudice   to the refiling of the
claim.

     (c) Ifan expert report has not been served within the period specified by Subsection (a) because elements ofthe
report are found deficient, the court may grant one 30-day extension to the claimant in order to cure the deficiency. If
the claimant does not receive notice of the court's ruling granting the extension until after the 120-day deadline has
passed, then the 30-day extension shall run from the date the plaintiff first received the notice.

     (d) to (h) [Reserved].

     (i) Notwithstanding   any other provision of this section, a claimant may satisfy any requirement of this section for
serving an expert report by serving reports of separate experts regarding different physicians or health care providers or
regarding different issues arising from the conduct of a physician or health care provider, such as issues of liability and
causation. Nothing in this section shall be construed to mean that a single expert must address all liability and causation
issues with respect to all physicians or health care providers or with respect to both liability and causation issues for a

                                                                                                                                 Page 1
                                              Tex. Civ. Prac. & Rem. Code § 74.351




physician    or health care provider.

     U) Nothing in this section shall be construed      to require the serving of an expert report regarding   any issue other
than an issue relating to liability or causation.

     (k) Subject to Subsection     (t), an expert report served under this section:

       (I) is not admissible   in evidence by any party;

       (2) shall not be used in a deposition,    trial, or other proceeding;   and

       (3) shall not be referred to by any party during the course of the action for any purpose.

     (l) A court shall grant a motion challenging the adequacy of an expert report only if it appears to the court, after
hearing, that the report does not represent an objective good faith effort to comply with the definition of an expert report
in Subsection (r)(6).

     (m) to (q) [Reserved].

     (r) In this section:

        (I) "Affected parties" means the claimant and the physician or health care provider who are directly affected by
an act or agreement required or permitted by this section and does not include other parties to an action who are not
directly affected by that particular act or agreement.

       (2) "Claim" means a health care liability claim.

       (3) [Reserved].

      (4) "Defendant" means a physician or health care provider against whom a health care liability claim is asserted.
The term includes a third-party defendant, cross-defendant, or counterdefendant.

       (5) "Expert" means:

            (A) with respect to a person giving opinion testimony regarding whether a physician departed from accepted
standards     of medical care, an expert qualified to testify under the requirements of Section 74.40 I;

            (B) with respect to a person giving opinion testimony regarding whether a health care provider departed from
accepted     standards of health care, an expert qualified to testify under the requirements of Section 74.402;

         (C) with respect to a person giving opinion testimony about the causal relationship between the injury, harm, or
damages claimed and the alleged departure from the applicable standard of care in any health care liability claim, a
physician who is otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence;

         (D) with respect to a person giving opinion testimony about the causal relationship between the injury, harm, or
damages claimed and the alleged departure from the applicable standard of care for a dentist, a dentist or physician who
is otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence; or

        (E) with respect to a person giving opinion testimony about the causal relationship between the injury, harm, or
damages claimed and the alleged departure from the applicable standard of care for a podiatrist, a podiatrist or physician
who is otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence.

       (6) "Expert report" means a written report by an expert that provides a fair summary of the expert's opinions as of
the date of the report regarding applicable standards of care, the manner in which the care rendered by the physician or
                                                                                                                            Page 2
                                         Tex. Civ. Prac. & Rem. Code § 74.351




health care provider failed to meet the standards, and the causal relationship between that failure and the injury, harm,
or damages claimed.

    (s) Until a claimant has served the expert report and curriculum vitae as required by Subsection (a), all discovery in
a health care liability claim is stayed except for the acquisition by the claimant of information, including medical or
hospital records or other documents or tangible things, related to the patient's health care through:

      (I) written discovery as defined in Rule 192.7. Texas Rules of Civil Procedure;

      (2) depositions on written questions under Rule 200. Texas Rules of Civil Procedure; and

      (3) discovery from nonparties under Rule 20S. Texas Rules of Civil Procedure.

     (t) If an expert report is used by the claimant in the course of the action for any purpose other than to meet the
service requirement of Subsection (a), the restrictions imposed by Subsection (k) on use of the expert report by any
party are waived.

    (u) Notwithstanding any other provision of this section, after a claim is filed all claimants, collectively, may take
not more than two depositions before the expert report is served as required by Subsection (a).

HISTORY: Enacted by Acts 2003, 78th Leg., ch. 204 (H.B. 4), § 10.01, effective September 1,2003; am. Acts 2005,
79th Leg., ch. 635 (H.B. 2645), § I, effective September I, 2005; am. Acts 2013, 83rd Leg., ch. 870 (H.B. 658), § 2,
effective September I, 2013.




                                                                                                                     Page 3
APPENDIX 5
                                                         LEXSTAT

                                         LexisNexis (R) Texas Annotated Statutes
                                  Copyright © 2014 by Matthew Bender & Company, Inc.
                                            a member of the LexisNexis Group
                                                   All rights reserved.

                          ***   This document is current through the 2013 3rd Called Session     ***
                                       CIVIL PRACTICE AND REMEDIES CODE
                                            TITLE 4. LIABILITY IN TORT
                                         CHAPTER 74. MEDICAL LIABILITY
                                        SUBCHAPTER I. EXPERT WITNESSES

                                    GO TO TEXAS CODE ARCHIVE DIRECTORY

                                       Tex. Civ. Prac. & Rem. Code § 74.402 (2014)

§ 74.402. Qualifications of Expert Witness in Suit Against Health Care Provider

  (a) For purposes of this section, "practicing health care" includes:

      (I) training health care providers in the same field as the defendant health care provider at an accredited
educational institution; or

      (2) serving as a consulting health care provider and being licensed, certified, or registered in the same field as the
defendant health care provider.

    (b) In a suit involving a health care liability claim against a health care provider, a person may qualify as an expert
witness on the issue of whether the health care provider departed from accepted standards of care only if the person:

       (1) is practicing health care in a field of practice that involves the same type of care or treatment as that delivered
by the defendant health care provider, if the defendant health care provider is an individual, at the time the testimony is
given or was practicing that type of health care at the time the claim arose;

        (2) has knowledge of accepted standards of care for health care providers for the diagnosis, care, or treatment of
the illness, injury, or condition involved in the claim; and

       (3) is qualified on the basis of training or experience to offer an expert opinion regarding those accepted standards
of health care.

    (c) In determining whether a witness is qualified on the basis of training or experience, the court shall consider
whether, at the time the claim arose or at the time the testimony is given, the witness:

       (I) is certified by a licensing agency of one or more states of the United States or a national professional
certifying agency, or has other substantial training or experience, in the area of health care relevant to the claim; and

      (2) is actively practicing health care in rendering health care services relevant to the claim.

     (d) The court shall apply the criteria specified in Subsections (a), (b), and (c) in determining whether an expert is
qualified to offer expert testimony on the issue of whether the defendant health care provider departed from accepted

                                                                                                                        Page 1
                                          Tex. Civ. Prac. & Rem. Code § 74.402




standards of health care but may depart from those criteria if, under the circumstances, the court determines that there is
good reason to admit the expert's testimony. The court shall state on the record the reason for admitting the testimony if
the court departs from the criteria.

     (e) This section does not prevent a health care provider who is a defendant, or an employee of the defendant health
care provider, from qualifying as an expert.

      (f) A pretrial objection to the qualifications of a witness under this section must be made not later than the later of
the 21st day after the date the objecting party receives a copy of the witness's curriculum vitae or the 21st day after the
date of the witness's deposition. If circumstances arise after the date on which the objection must be made that could not
have been reasonably anticipated by a party before that date and that the party believes in good faith provide a basis for
an objection to a witness's qualifications, and if an objection was not made previously, this subsection does not prevent
the party from making an objection as soon as practicable under the circumstances. The court shall conduct a hearing to
determine whether the witness is qualified as soon as practicable after the filing of an objection and, if possible, before
trial. If the objecting party is unable to object in time for the hearing to be conducted before the trial, the hearing shall
be conducted outside the presence of the jury. This subsection does not prevent a party from examining or
cross-examining a witness at trial about the witness's qualifications.

HISTORY: Enacted by Acts 2003, 78th Leg., ch. 204 (H.B. 4), § 10.01, effective September 1,2003.




                                                                                                                      Page 2
