Minnesota Physician April 2012 by Minnesota Physician Publishing

Volume XXVl, No. 1

April 2012

The Independent Medical Business Newspaper

Transformations in care

System-wide innovation addresses challenges By Paul Johnson, MD; Pamela Clifford, RN, MPH; Jennifer DeCubellis, LPC; Sheila Moroney; and Mark Linzer, MD

Preventing youth violence

material.htm. Counseling schedhile homicide rates Evidence-based ules list violence prevention topand other indicators ics to introduce and topics to approaches of violence fluctuate reinforce at each visit, including from year to year, youth vioBy Iris Wagman firearms, bullying, lence remains a leading public Borowsky, MD, PhD and conflict resohealth problem in Minnesota lution skills. The and across the nation. guide is well organized, For physicians heeding the call to strength-based, and thorough address this preventable cause of morbidity in providing resources that and mortality among young people, there are cover many important areas. numerous policy statements and counseling Certainly, child and adolesrecommendations. For example, in 2006 cent health professionals are the American Academy of Pediatrics (AAP) uniquely positioned to interdeveloped a violence prevention guide called before violent behaviors vene â&#x20AC;&#x153;Connected Kids,â&#x20AC;? accessible on the AAP website at www2.aap.org/connectedkids/ VIOLENCE to page 10

ublic hospitals are facing many challenges, including revenue issues, complex patient populations, and operational changes due to health care reform. To address these challenges and innovate in the face of shrinking resources, Hennepin County Medical Center (HCMC) launched the Center for Healthcare Innovation (CHI) in 2011. CHI encourages and oversees new, unique, and state-of-the-art programs that will transform care at HCMC. We have several transformations to report. Last year HCMC launched a coordinated care delivery system (CCDS) to care for 10,000 patients who had lost state-supported insurance. This year, we have partnered with Hennepin County and TRANSFORMATIONS to page 12

IN THIS ISSUE:

New Generation Technology Page 20

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CONTENTS

APRIL 2012 Volume XXVI, No. 1

FEATURES Preventing youth violence Evidence-based approaches

By Iris Wagman Borowsky, MD, PhD

Transformations in care System-wide innovation addresses challenges

By Paul Johnson, MD; Pamela Clifford, RN, MPH; Jennifer DeCubellis, LPC; Sheila Moroney; and Mark Linzer, MD

View your home in a new way.

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

8 Lucinda Jesson

POLICY The heartbeat of health reform

By Sanne Magnan, MD, PhD

PHYSICAL THERAPY Physical therapy for Parkinsonâ&#x20AC;&#x2122;s disease

By Rose Wichmann, PT

Department of Human Services

SPECIAL FOCUS: NEW-GENERATION TECHNOLOGY New horizons for telehealth

Bridge-building 20

By Cheryl Stephens, PhD

By David Hemler

Re-igniting the spark Pediatric medical devices 26

By Dale Wahlstrom

By Bradley F. Slaker, BSME, MBA

Getting connected

By McLain Causey

The Independent Medical Business Newspaper

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE John Berg jberg@mppub.com ACCOUNT EXECUTIVE Sharon Brauer sbrauer@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace legal, tax, business or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

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CAPSULES

Mayo Finances Are Strong, Annual Report Finds Mayo Clinic has nearly doubled its income since 2009, and its healthy financial results will lead to major capital projects in coming years, officials with the Rochester-based system say. Mayo Clinic is seeing total annual revenues of $8.5 billion, according to financial figures recently released. After expenses, the system had $610 million in income in 2011, compared with $515 million in 2010 and $333 million in 2009. The annual report listed several areas of booming operations for Mayo Clinic, including more than 1 million patients cared for at facilities in Arizona, Florida, Iowa, Minnesota, and Wisconsin. Mayo research programs brought in nearly $367 million in funding from outside sources such as government grants. Researchers were involved in close to 8,000 study projects in 2011. Mayo’s College of Medicine educated 2,446 medical students, with 1,491 residents and

fellows also receiving training. Officials say Mayo Clinic’s operating margin of just over 7 percent will allow it to pursue its long-term objectives, including upgrading and expanding capital assets. “In 2012, Mayo Clinic will launch $600 million in capital projects. We estimate spending $700 million per year in capital projects for the next five years,” says Shirley Weis, the clinic’s vice president and chief administrative officer. “We anticipate that the next three to five years will be marked by higher-than-average job growth and continued capital spending as we execute a set of strategic initiatives designed to meet patients’ evolving needs.”

MDH Reports Uninsured Rates Remain High in State Despite better economic times, uninsured rates in Minnesota remain high, officials with Minnesota Department of Health (MDH) say. A biannual report from

MDH has found that the uninsured rate for Minnesotans remained at 9.1 percent in 2011, un-changed since 2009. In the 2009 report, data showed the rate of uninsured people in Minnesota increased, from 7.2 percent in 2007. That followed an upward trend since 2001, when the uninsured rate was 6.1 for state residents. Officials say an estimated 490,000 Minnesotans were uninsured in 2011, compared to 480,000 Minnesotans in 2009 and 374,000 in 2007. MDH says approximately 70,000 children were without health coverage in 2011. “This report indicates that we have not recovered from the losses in health insurance coverage that we sustained subsequent to the Great Recession,” says Commissioner of Health Ed Ehlinger, MD. “It is also clear that the cost of insurance is a barrier to coverage. We absolutely must redouble our efforts focused on disease prevention, public health, and payment reform so that health coverage becomes more affordable for

Minnesotans.” The report notes several areas of concern. For one, the fact that the economy has improved would normally lead to more people having insurance through employer-sponsored programs. The fact that uninsured rates have stayed the same suggests that jobs being created do not offer insurance, or that some employers are dropping coverage for existing workers. In addition, the report finds a decline in the number of people who choose to enroll in employer-sponsored health plans—perhaps an indication that health insurance is becoming too expensive for some Minnesotans. Another concern is the number of people uninsured for an entire year, a group that is sometimes called “long-term uninsured.” Officials say those numbers are increasing. “For the first time in 2011, the all-year uninsured accounted for more than half—51.1 percent—of [the uninsured], up from 44.3 percent in 2009, potentially representing a trend toward more long-term uninsurance that

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deserves to be monitored closely,” the report says.

EMRs Still A Challenge, Optum Study Says A study on how hospitals are adopting health information technology (HIT) finds that although 87 percent of hospitals now have electronic medical records (EMRs), significant challenges remain with the technology. The study was released by Eden Prairie-based Optum, a division of UnitedHealth Group. Optum commissioned a survey of 301 hospital executives on the overall progress of adapting new HIT systems in their facilities. According to the survey, 87 percent of hospitals now have EMR systems in place, which is an increase over an earlier survey that found slightly more than 50 percent of hospital systems had EMRs in place. “Hospitals are making substantial gains in adopting electronic medical records, participating in health information exchanges, and achieving ‘meaningful use,’” said Simon Stevens, chairman of the Optum Institute. “But hospital chief information officers are clearly signaling that technology gaps remain, genuine interoperability remains elusive, and—as a result—most U.S. hospitals are still some way off from being fully ready to play their part in managing population health and its related financial risk.” Among the challenges identified in the survey, the report finds that many EMR systems have required serious upgrades or changes. Nearly 80 percent of respondents said they had to modify their EMR systems significantly or purchase another system entirely. This has led to increased spending; hospital CIOs say that so far, EMRs have raised hospital operating costs rather than reduced them. Other problems identified include gaps in care information, interoperability issues among components of health organizations, and compliance issues.

Dueling Exchange Bills Signal Impasse At Capitol Republican and DFL lawmakers offered competing health care bills in recent weeks, with the DFL side embracing the insurance exchange concept required by the federal Affordable Care Act (ACA) and the Republican lawmakers rejecting insurance exchanges and instead calling for freemarket solutions to the state’s high rate of uninsured citizens. The two sides introduced bills addressing the health exchange issue on March 5 in St. Paul. The DFL bill was sponsored by Rep. Erin Murphy (DFL–St. Paul) and Sen. Jeff Hayden (DFL–Minneapolis). This legislation would create a marketplace for consumers and provide resources for purchasing health insurance based on the exchange model. It is similar to a bipartisan insurance exchange bill introduce by Rep. Joe Atkins (DFL–St. Paul) in February, with supporters of the new bill saying it better addresses conflict of interest concerns regarding governance of the exchange. The Republican bill is essentially a rejection of the health insurance exchange concept, not a surprising development given Senate GOP leaders’ insistence that the ACA is an unconstitutional, big-government solution forced on states. At a March 5 press conference, the bill’s authors were highly critical of the state’s ongoing efforts to plan for the exchange. “We have a governor … who is in lockstep with the federal government in creating a federal program to take away people’s choice on insurance in Minnesota. We don’t believe that’s right,” said Sen. David Hann (R–Eden Prairie), one of the co-authors of the bill. The developments cast doubts on the prospects for compromise during this session, as the Republican bill seems far removed from the framework envisioned by the ACA. The GOP approach would allow individuals to pool money from sources such as families, partCAPSULES to page 6 APRIL 2012

MINNESOTA PHYSICIAN

CAPSULES

Capsules from page 5 time employers, and charitable organizations in a kind of health savings account. Supporters of the bill say an insurance exchange is not necessary, since there already are online tools to compare insurance plans. Rep. Steve Gottwalt (R–St. Cloud) said Minnesota previously has put in place many of the ideas promoted by the ACA, such as high-risk pools and accountable care organizations. In a testy exchange with reporters, the GOP leaders rejected the idea of leaving their current taxpayer-supported health insurance plans for the kind of system they envision with their bill. “The state of Minnesota is our employer, they offer health care coverage to their employees,” Gottwalt said.

Medica, Fairview Roll Out Accountable Care Organization Medica and Fairview Health Services have begun rolling out their accountable care organiza-

tion (ACO) for Medica members in the Twin Cities area. For employer-based health plans, the ACO will be available through Medica’s My Plan insurance product, under the name Fairview Health Advantage with Medica. The My Plan product is also available with the Medica Choice Passport network, but officials say the ACO option could lower payroll deductions by as much as 50 percent for enrollees. For individuals, a product called Harmony with Medica and Fairview will be offered. Officials note that the individual market is more expensive in general, so savings are somewhat more modest—approximately 10 percent less than products with traditional provider networks. Medica officials say the new ACO model will provide several new innovations to members, including care teams to manage health, online health assessments, and virtual appointments.

MDH Says SHIP Needs More Time to Improve Outcomes The Minnesota Department of Health (MDH) has given the Minnesota Legislature a report on the Statewide Health Improvement Program (SHIP), saying the program has pro moted wellness, good nutrition, and healthy lifestyles in communities throughout the state. The report comes at a time when the GOP-controlled legislature has questioned whether the program is worth the state’s investment in a time of tight budgets. SHIP was passed in 2008 as part of bipartisan health-care reform legislation, and legislators saw it as a strategy for curbing rising health care costs through prevention efforts. Officials say SHIP's goal is to improve health and reduce health care costs by reducing the number of Minnesotans exposed to tobacco and the percentage of Minnesotans who are obese or overweight.

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The new report finds that in its first two years, the program has promoted good health in a variety of settings. In the workplace, SHIP has helped more than 870 employers sponsor worksite wellness initiatives. It has increased access to local produce for more than 200,000 Minnesotan students. It also has promoted exercise and tobacco cessation programs. Despite the report of progress towards its goals, SHIP is likely to receive greater scrutiny from lawmakers. With last year’s deficits, many health programs saw cuts and SHIP programs were cut by 70 percent, which the report says had a negative impact on the program’s results. The report adds that improving health outcomes takes time. “In order for health care savings to be realized, progress may be more likely when measuring it from the beginning of SHIP in 2010 and viewed as a long-term investment,” the report says.

MEDICUS

Howard Epstein, MD, has joined the Institute for Clinical Systems Improvement (ICSI) as chief health systems officer. He had been the medical director for quality and health management at Blue Cross and Blue Shield of Minnesota. Epstein has long been involved in ICSI activities, having chaired the Committee on Evidence-Based Practice and served on committees for several ICSI health-care redesign initiatives. Howard Epstein, MD In addition to his new position with ICSI, Epstein is a general internist and hospitalist on staff at Regions Hospital, and is past president of the board of directors for the Minnesota Network of Hospice and Palliative Care. Nancy Raymond, MD, has been named associate dean for faculty affairs for the University of Minnesota Medical School. A professor in the Department of Psychiatry, Raymond also provides psychiatric consultation to the Department of Family Medicine & Community Health’s Program in Human Sexuality. In her new role, Raymond will be responsible for overseeing and directing the Medical School Office of Faculty Affairs. Raymond will continue serving as director of the Deborah E. Powell Center for Women’s Health and continue her efforts with the Building Interdisciplinary Research Careers in Women’s Health grant from the National Institutes of Health. The Twin Cities Medical Society has presented Robert Geist, MD, with the First a Physician Award. The First a Physician Award, established in 2007, recognizes a member of the medical society who has made a positive impact on organized medicine by selflessly giving of his/her time and energy to improve the public health, enhance the medical community’s ability to practice quality medicine, and/or improve the Robert Geist, MD lives of others in our community. Geist practiced at Metropolitan Urologic Specialists, PA in St. Paul for 30 years prior to his retirement in 1997. He also founded and organized committees, which have served as open forums to encourage direct dialogue between physicians and diverse policy experts, to examine and critically dissect public policy direction on health care as it affects physicians and patients within Minnesota and nationally. The award called Geist an “advocate of the highest integrity on behalf of the profession of physicians, and for the protection of patients. He is truly the thinking person’s physician and patient advocate.“ Laurie Drill-Mellum, MD, MPH, has been named chief medical officer of MMIC, a Minneapolis-based company that provides professional liability insurance, risk and claims management, and health information technology Laurie Drill-Mellum, services to health care providers. In this newly MD, MPH created role, Drill-Mellum will work to develop integrated risk reduction and risk mitigation strategies, and will build a network of physician consultants that will work closely with physicians and hospitals throughout MMIC’s eight-state region. DrillMellum has practiced emergency medicine since 1991 at Ridgeview Medical Center in Waconia, where she held roles as chief of the medical staff and medical director of the emergency department. The American Academy of Family Practice (AAFP) has announced that two members of the Minnesota Academy of Family Practice (MAFP) have been appointed to serve on national commissions. David Hutchinson, MD, Duluth, has been appointed to the AAFP Commission on Education. Hutchinson, a former MAFP president, is an assistant professor in Family Medicine and Community Health in the University of Minnesota–Duluth Medical School, and is assistant director of the Duluth Family Medicine Residency. Lynne Lillie, MD, Woodbury, has been appointed to the AAFP Commission on Quality and Practice. She is medical director at Healtheast’s Woodwinds Campus in Woodbury, and is also a former MAFP president.

MINNESOTA HEALTH CARE ROUNDTABLE

T H I R T Y- S E V E N T H

SESSION

Specialty pharmacy Controlling the cost of care Thursday, June 7, 2012 1:00 – 4:00 PM • Symphony Ball Room Downtown Mpls. Hilton and Towers

Background and focus: Medications treating chronic and/or life-threatening diseases are frequently new products, which are often more expensive than generic or older, branded products that treat similar conditions. The term specialty pharmacy has come to be associated with these medications. Exponents claim the new technology improves quality of life and lowers the cost of care by reducing hospitalizations. Opponents claim the higher per-dose cost spread over larger populations does not justify the expense.

The cost of research, both failed and successful, is reflected in product pricing. Current federal guidelines allow generic equivalents marketplace access based on the patent date, not the release date, of a product. This considerably narrows the window in which costs of advances may be recovered. A further complicating dynamic involves the payers. Physician reimbursement policies sometimes reward utilizing lower-cost “proven” products and cast those prescribing higher-cost products as “over-utilizers,” placing them in lowertiered categories of reimbursement and patient access.

Objectives: We will discuss the issues that guide the early adoption of new pharmaceutical therapies and how they relate to medical devices. We will examine the role of pharmacy benefit management in dealing with the costs of specialty pharmacy. We will explore whether it is penny-wise but pound-foolish to restrict access to new therapies and what level of communication within the industry is necessary to address these problems. With the baby boomers reaching retirement age, more people than ever will be taking prescription medications. As new products come down the development pipeline, costs and benefits will continue to escalate. We will provide specific examples of how specialty pharmacy is at the forefront of the battle to control the cost of care. Panelists include: N Sara Drake RPh, MPH, MBA, Pharmacy Program Manager, Minnesota Department of Human Services N Alan H. Heaton, PharmD, RPh, Director, Pharmacy Management, UCare N Daniel Johnson, MEd, Vice President of Public Policy, National Multiple Sclerosis Society N Timothy Stratton, PhD, BCPS, FAPhA, Professor, College of Pharmacy, UMD N Gene Stringer MD, Stillwater Medical Group

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APRIL 2012

MINNESOTA PHYSICIAN

INTERVIEW

Overseeing a time of change at DHS ■ Tell us about how you see your role as commis-

sioner of DHS.

Lucinda Jesson Department of Human Services Lucinda Jesson is the Minnesota Commissioner of the Department of Human Services (DHS). Jesson has formerly served as the founding director of the Health Law Institute at Hamline University, attorney general for health and licensing in the Minnesota Attorney General’s Office, and chief deputy Hennepin County attorney. Jesson is in charge of an agency that provides a range of health care services, with a mix of state and federal funding. Minnesota spent $4.7 billion on health care programs in the most recent fiscal year. DHS provides health insurance coverage for more than 700,000 Minnesotans and works with approximately 118,000 providers.

An important part is really running a very large, very complex agency that does very important work. As you think about it, we touch the lives of over a million Minnesotans every year, many of the most vulnerable of our citizens. We have over 6000 employees and a budget of, just in state dollars, almost $11 billion—twice that if you include the federal funds. A large part of the job is really just running a complex agency. I also have a role as a policymaker, advising the governor on how we should be doing our work. Because 80 percent of our dollars are spent on health care, I spend a lot of my time trying to think about how we can further the triple aim—better patient experiences, lower cost, and higher quality. ■ What is the role of DHS in health care reform?

A large part of the way we contribute at DHS to health reform is through using our power as a payer. It’s not just about saving money. We’re going to be developing gainsharing models and driving towards better outcomes so we’re not just paying on a fee-for-service basis. That’s an example of where we’re using our power as a big purchaser to try to get better outcomes. For example, take our role as the state authority for mental health and substance abuse. That system, the way we do mental health, has the potential to dramatically change under health reform. If you think about it, most people in their insurance policy now, don’t have real chemical dependency coverage. It’s going to be an essential health benefit under the Affordable Care Act (ACA). We need to redesign our system for a system where people have that coverage. Obviously, the health insurance exchange is very important to us because the ACA says that people on public programs enter through the exchange. We have a great interest in making sure that exchange is up and running, and that it’s going to work well for public program enrollees. People think about it in the individual and small group markets, which are important, but our public enrollees may have different needs for an exchange, so we want to be very involved in that.

■ What will health exchanges mean for patients

and providers in the state? A great thing for consumers is you should be able to make apples to apples choices amongst health plans. You are able to put in what’s important to you, whether it’s important for you to have a low deductible or a high deductible. You can make choices between plans and look at their quality ratings, because that’s going to be built in, to dive deeper and say, who are the providers for this plan? As an individual, I can go to the exchange, and then it tells me whether or not I qualify for a public program subsidy, and then knowing what that subsidy is, I go shopping. It will provide consumers a lot more information and get them more involved in their health care choices. If we don’t get consumers more involved in their health care and how much they’re paying for it and see the incentives to take charge of their health care, we’re never going to get our arms around the challenges we have. For providers, there’s an opportunity—if we do it right—for provider networks to be a part of this so that there are organizations for providers who want to contract with Medicaid. While I think there’s a real role for health plans, and some provider organizations absolutely want to be working through health plans, some don’t. This gives them some more options. Obviously, if there’s more transparency about provider choice, that’s a good thing for providers. The other thing about the health exchange with the mandate, more people are going to have insurance, just with the Medicaid expansion, even before you think about people following the mandate. More people having insurance means less uncompensated care.

We are moving toward a better system.

■ What are some of the challenges and achieve-

ments you’re seeing in implementing state and federal health reforms? One of the obvious challenges is the political divide over the ACA. It is unfortunate; so many things in the ACA are things that we were doing here in Minnesota years before the federal government started to do them. If you think about health care homes, for an example, that’s something that

Minnesota started long before. Some of the payment reforms that are important, the ideas behind the ACOs, we started that long before the federal reform. I’m glad the Supreme Court took the case [challenging the ACA]. I want to have some decisions. I believe that most of us in Minnesota are preparing for implementation. In some places you see holding patterns, and that’s not helpful. I think there’s a real excitement, and we are moving towards a better system. Not just because it will save us money, but it will [also] be paying for better outcomes.

MINNESOTA PHYSICIAN APRIL 2012

■ Lawmakers have been calling for more trans-

parency for Medicaid programs. Talk a little about what DHS has done in this area. One of the big changes we made coming in was to put our largest contracts out for bid. There have been questions about what the state was spending

all of these billions of dollars on? Are we getting our money’s worth? In the past, what we have done is look at what we paid the health plans over the past three years and then add a medical trend, and then that’s what we paid them the next year. There wasn’t a lot of incentive for efficiency. That’s why I think the competitive bidding process really just kind of pushed a reset button. It was competition; there were winners and losers. It was a hard thing for the marketplace, but I believe it answered some questions. And it told us, I think, that we were paying too much. That’s how we captured the savings. That’s one piece of transparency. The governor, in his executive order last March, also made it clear that he wanted audits of the health plans to be conducted. The Department of Commerce is going to contract with an outside auditor on a rotating basis to audit the health plans, which will be another piece of transparency. The proposals in the Legislature are for additional outside audits; I’m supportive of that. I think there really is a question on the part of the public, are we getting our money’s worth? There’s a gap in public trust. The outside audits, just like competitive bidding, are a way to address that.

Congratulations!

■ Sometimes we hear that providers ques-

population health. I think a lot about the social determinants of health and how we all need to do a better job at keeping people fed and eating healthy food and getting exercise and living in places where they have access to all those things. That’s not something you can delegate to government. That’s something we all have to do as a society. And that’s something I feel that physicians as a group probably understand better than most other groups. And finally, tell me what we can do better!

tion why their reimbursements from the state are being frozen or cut back, and then they see an increase going to the plans for Medicaid programs. I can only talk about what’s happened since I’ve been commissioner. Let me tell you, last year the plans did not get an increase. That’s what we learned through competitive bidding, and overall, they took a significant hit. The other thing I would say on provider reimbursement rates, that’s why we’ve got to get a different, better way of paying providers. That’s what we’re trying to do with these demonstration projects and embedding that in all the contracting that we do, whether it’s through the plans or directly with providers, to make sure that any incentives are pushed down to the provider level. It’s not just risk sharing with the plans, because then they can just keep the money, right? We’re insisting in our contracts with them that it be pushed down to the provider level.

■ You mentioned embracing change. That’s

not always easy. Not everyone in the provider community is resistant, but I’m sure you get some foot-dragging. Well it’s not just physicians, I’m a lawyer, and nobody drags their feet more than lawyers do! I think physicians, the ones I work with, are usually very focused on their patients. When you think about what’s best for the patient, they will see the way the incentives in our current fee-for-service system do not benefit patients, for the most part. So when people focus on that, then we’re willing to look at options. I think most of us would say the status quo isn’t sustainable. Once you understand that, there’s a willingness to look at other options.

■ What message do you have for physicians

of the state? I feel lucky to be commissioner of human services in this state with so many outstanding providers, especially physicians. I would encourage them to join us in embracing change. Change in the way we pay for health care, but also in the way we think about

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MINNESOTA PHYSICIAN

it. Research shows that children’s exposure to background TV is high and may be just as strongly associated with conduct problems as the amount of TV watched.

Violence from cover occur. The question is, which of these counseling recommendations are backed up by evidence showing that they are effective in the clinical practice setting? While a counseling recommendation may sound like a good idea and certainly not harmful, time spent on screening or counseling that is not evidence-based can take away from other physician tasks of proven benefit. Randomized controlled evaluation studies in clinical settings are greatly needed to guide practice. However, decades of research have revealed much about what works and what doesn’t work in preventing youth violence. Effective interventions include strategies at the individual level, such as training for elementary school students to increase their social problemsolving skills; at the family level, such as parent training programs; and at the extrafamilial environmental level, such as mentoring programs. The following discussion highlights “Minnesota Best

Address behavior and mood

“Minnesota Best Bets” practices are both feasible in the clinical setting and worth clinicians’ time. Bets,” a set of recommendations with a locally inspired mnemonic (LAKES) and some local resources to draw upon. These practices are both feasible in the clinical setting and worth clinicians’ time because there is at least some good evidence that each reduces violence among children and adolescents. • Lower media exposure • Address behavior and mood • Key adults: mentoring programs • Education and support for parenting: parent training and

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home visitation programs • Safe firearm storage Lower media exposure

Hundreds of studies demonstrate the link between exposure to media violence and real-life violence. As reported in Archives of Pediatrics and Adolescent Medicine in 2001, Robinson and colleagues conducted a randomized controlled study of a classroom curriculum to reduce media use among third- and fourth- grade students. They found that the curriculum successfully reduced media use and aggressive behavior among students in the intervention group. Regarding office-based counseling about media exposure, a study by Barkin and colleagues, published in Pediatrics in 2008, found that brief motivational interviewing by pediatricians and offering minute timers for limiting media use were significantly associated with media use reduction among children ages 2 to 11. Motivational interviewing generates patient-centered solutions through assessment of 1) family interest in changing behaviors, e.g., How important is it to reduce your [the patient’s] media use? and 2) confidence in changing behaviors, e.g., How confident are you that you [the patient] can cut back on media use? Following AAP guidelines, recommend no more than one or two hours a day total screen time, including watching TV and movies, playing video games, and using the computer (unrelated to homework). Also ask how many hours the TV is on in the home even when the child is not watching

In 1975, R.J. Haggerty described psychosocial problems as the “new morbidity”; now they are the most common chronic condition for pediatric visits. Several studies have found that roughly one in five children attending pediatric practices have significant mental health problems. The new morbidities are “hidden” because many studies have shown that most child mental health problems are not detected in pediatric practice. They are “unheeded” because there is evidence that once the problems are identified, only a fraction of children with emotional and behavioral disorders receive appropriate mental health treatment. In addition to occurring frequently, untreated emotional and behavioral disorders contribute to severe health consequences, including violence. There are effective or promising treatments for many childhood mental disorders. One approach to facilitating recognition of psychosocial problems is to use a screening questionnaire. The Pediatric Symptom Checklist (PSC) was developed specifically to facilitate recognition of psychosocial problems as part of routine primary care visits. The 35-item tool is short, well-validated in diverse populations of children and adolescents, feasible to administer in primary care practices, and has a cut-off point for easy scoring. A newer version of the screen, the 17item PSC, is not only shorter but also incorporates three subscales, allowing providers to quickly see where their patient is having problems. The three subscales—internalizing problems, attention problems, and externalizing problems—address important risk factors for violence involvement among youth, The PSC is available for public use and versions are available in multiple languages (including Spanish, Hmong, and

Somali), at www2.massgeneral. org/allpsych/psc/psc_home.htm. Developed as a parent-completed screening questionnaire by Jellinek and colleagues, the PSC has also been validated for completion by youth. It is important to remember that the PSC is a screening, rather than a diagnostic, tool. A positive test should prompt a discussion with the family to assess the child’s functioning and the seriousness of any problems. This brief interview adds some time to the visit, but it is time recovered by not pursuing further questioning of children who score negative on the screen. Studies have shown that 20 to 25 percent of youth presenting to pediatric practices score positive on the PSC. Psychosocial screening may help identify youth who would benefit the most from violence prevention interventions.

important referral resource for physicians. These programs recruit an adult to meet with a young person on a regular basis, in an effort to duplicate the kind of relationship with a caring adult that is so protective for youth against an array of healthrisk behaviors. Most mentoring programs have not been evaluated as anti-violence interventions. A large-scale evaluation of the Big Brothers Big Sisters (BBBS) program in 1992 and 1993 in eight U.S. cities found that mentored youth were less likely than wait-listed controls to skip school, initiate alcohol and drug use, or hit someone over an 18-month period. Providers can find a local BBBS agency at www.bbbs.org. Parents can call directly or providers/office staff can make the initial call, and the program will contact the family to start the intake process. Education and support for parenting

Mentoring programs have shown promise in preventing youth violence and thus, for appropriate patients, are an

Parent training and education. Family-level interventions are among the most promising youth violence prevention

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Key adults: mentoring

approaches known to date. Many randomized controlled studies have demonstrated the effectiveness of parent training programs in improving parenting skills and family cohesion, and in reducing behavioral problems, violent and delinquent behavior, and substance use among children and adolescents. Yet, despite their effectiveness in families from diverse economic backgrounds and among children and adolescents with serious as well as milder behavioral problems, parent-training programs have not been widely disseminated. In a 2004 study in Pediatrics, Borowsky et al. combined two strategies that we thought were both feasible in the primary care setting and might really make a difference in reducing violence involvement among youth: • Identify, prevent, and treat mental health problems among youth through psychosocial screening using the PSC-17 and appropriate mental health referral and follow-up. • Promote healthy child-parent

relationships through psychosocial screening and appropriate referral to a telephonebased positive parenting program. In a randomized controlled trial, we found that the intervention significantly decreased aggressive and delinquent behavior, attention problems, bullying, physical fighting, and fightrelated injury for which medical care was sought among the youth at nine-month follow-up. In Minnesota, our legislature supports parenting education for parents of infants and young children ages birth to five years through Early Childhood and Family Education (ECFE). A resource to help direct parents to ECFE programs is the Minnesota Parents Know website at http://parentsknow.state.mn.us/ parentsknow/index.html. The website has links to contact numbers for ECFE programs in every school district, as well as parenting education on a variety of topics for parents of infants, children, and adolescents. Additional resources include the VIOLENCE to page 38

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APRIL 2012

MINNESOTA PHYSICIAN

Transformations from cover Metropolitan Health Plan (MHP) to produce a novel care model for 10,000 vulnerable patients through an accountable care-like organization demonstration project, Hennepin Health. We have also initiated a Medicine Psychiatry Program for integrated care of medical psychiatric patients, and convened a Vibrant Clinic Design Group to redesign our medicine clinics. Finally, HCMC continues to drive improvement of the patient experience. Using patient- and family-centered care as our platform for engagement, HCMC is undergoing a cultural revolution that puts the patient and family at the center of everything we do. Coordinated care delivery system

Hennepin County Medical Center is a 477-bed public teaching hospital in downtown Minneapolis. The hospital serves diverse populations with complex social determinants of health. Sixty-five percent of our

patients are people of color, and 20 percent are immigrants or refugees. The state provided health insurance for poor, nondisabled, single adults (General Assistance Medical Care, or GAMC) until June 2010, when this arrangement was dissolved due to a budget crisis. In place of GAMC, the state provided four hospitals (HCMC, North Memorial, Fairview, and Regions) with minimal funding to cover essential health services. HCMC suddenly was faced with responsibility for 10,000 indigent adults. Given the modest funding, there was a strong incentive to avoid unnecessary expense and eliminate wasteful services. The GAMC population was a high-cost group. Health issues typically were complicated by homelessness, mental health problems, chronic pain, and chemical dependency. HCMC targeted care management resources to the highest-cost segment: the 250 intensive users of inpatient services. The Coordinated Care Clinic (or CCC, described in “Hot spot-

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MINNESOTA PHYSICIAN APRIL 2012

ters,” Minnesota Physician, September 2011) was established to provide enhanced, intensive outpatient care to this population. Meanwhile, the other 9,750 patients were seen in HCMC’s medicine and community clinics, at Northpoint Health and Wellness Center, and in other affiliated sites. Advanced access clinics (three to four sessions per week) were staffed by HCMC general internists and advanced practice providers. New programs and linkages were developed for mental health care, pain management, and chemical dependency. Most of this occurred at lightning speed: Quite simply, all four CCDS hospitals had to respond, and we did. The CCC Care Model

The CCC was developed for the highest-utilizing patients (>2 hospitalizations per year). Current CCC staff, managing 150 patients, includes a 0.5 FTE physician, 1.0 FTE nurse practitioner, 1.0 FTE RN care coordinator, 1.0 FTE licensed social worker, 0.5 FTE chemical dependency counselor, 0.5 FTE pharmacist, 0.1 FTE clinical psychologist, and other clinic operations staff. We have identified eight factors underlying the need for complex care coordination: 1) chronic pain, 2) impaired cognition, 3) chemical dependency, 4) medical nonadherence, 5) mental health problems, 6) unstable housing, 7) medical complexity, and 8) lack of community or family support. These challenges are addressed in daily staff “huddles” and twiceweekly team meetings. A clinic patient registry is regularly reviewed. Clinic visits involve meetings with two to four team members (MD/NP, SW, CD counselor, PharmD), and provider schedules are intentionally light (approximately six visits per session). The CCC model has resulted in dramatic improvements in utilization. Recent analyses show hospitalizations reduced by 54 percent and emergency department visits reduced by 41 percent, with an

attendant increase in outpatient CCC visits. Keys to success include patient engagement, care coordination, multidisciplinary teamwork, walk-in availability, and high-intensity care. Lessons from CCDS. CCDS ended in the spring of 2011, when Gov. Mark Dayton endorsed Medicaid expansion. But CCDS’ nine months in operation left an indelible impression. We learned that we could rally around our mission of caring for those in need to provide a comprehensive, patientfocused model of care for a large number of patients in a short period of time. Although the resource constraints were extraordinary—and, in that sense, unsustainable—we learned how to maximize what could be done for patients with a minimal amount of support, and which programs were worth carrying forward into the future. Developing Hennepin Health

Shortly after CCDS ended, Hennepin County Human Services and Public Health Department (HSPHD), and the Hennepin County Board convened a workgroup to create a model of care for a demonstration project to expand upon the best practices of CCDS. The Hennepin Health project uses the concepts of an accountable care organization: improving quality, improving the patient experience, and driving down costs. A new care model (see Fig. 1) based on the patient-centered medical home was developed to address medical, social, and behavioral determinants of health. Partners for this program are HSPHD, HCMC, NorthPoint Health and Wellness Center, and Metropolitan Health Plan. The 10,000 Hennepin County patients who will participate are similar to those cared for under CCDS: ages 21 to 64, nondisabled, without dependent children, and at or below the federal poverty level of 75 percent. The care model is patient-centered, focusing on care coordination within health care homes. Once enrolled, patients will undergo assess-

ment in medical, behavioral, and social domains. Patients and their care teams will collaboratively develop care plans. Utilization data and disease complexity will be used to “tier” patients, and the CCC will care for the high-utilizing tier. These patients will have prioritized access to housing services, chemical dependency counseling, mental health care, financial assistance and vocational counseling, and will have ready access to primary care clinics with expanded hours. Community health workers, care coordinators, social workers, chemical dependency counselors, and mental health professionals will collaborate in caring for patients. A patient registry will help in managing patient panels. Pharmacists will perform medication reconciliation and support medication home delivery. Providers will order what is necessary to ensure quality outcomes while avoiding duplicate testing or tests of questionable value. A total-cost-of-care funding arrangement has been negotiated, with financial risk for all partners. There are numerous administrative hurdles to overcome. Organizations that are not used to working together must create seamless interfaces and ready access to services. Dozens of new health care workers will need an efficient structure that connects them and allows them to function and communicate well with clinicians and patients. And patients will see new efforts to enroll them in shared medical decisions and to address life issues outside the traditional medical model. If Hennepin Health is effective with its first 10,000 vulnerable patients, there are plans to roll this out to as many as 140,000 patients cared for annually at HCMC. Integrated medicinepsychiatry program

The CCDS experience made us aware of our patients’ tremendous needs for integrated care for mental and physical health: thus was born HCMC’s Integrated Medicine Psychiatry

FIGURE 1. Hennepin Health care model Program. First, we built a group of mental health clinicians (three PhDs, a psychiatrist, and an advanced nurse specialist) to work in the medicine clinic. This decentralized approach to mental health care will bring a substantial proportion of the mental health care for medicine clinic patients onsite where general medical care is provided. We also moved an internist one half-day per week to the day treatment program where psychiatric outpatients are seen on a daily basis. This program manages acute and chronic medical issues for the psychiatric outpatients and will soon perform structured risk assessment for cardiac and diabetes risk. We have a highly regarded psychiatric consultation liaison service on the medical inpatient wards, and we have instituted strong support for medical care on the 102-bed psychiatric inpatient service. Weekly rounds with medicine and psychiatry chiefs of service, attending physicians, advanced practice providers (PAs and NPs), residents, nurses, pharmacists, and students address challenging cases, as well as symptoms, laboratory values, or signs that triggered a medical consultation. Integrated medicine-psychiatry units are also being devel-

oped for the inpatient medicine and psychiatry services. The overarching theme is that a unified approach to mental and physical health can improve patient satisfaction, the patient experience, and care outcomes.

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MINNESOTA PHYSICIAN

POLICY

The heartbeat of health reform

he beat of health reform is everywhere—and it is quite loud. Some think it will soon fade away; others hope the beat stops altogether; and still others are invigorated by the increasing steady rhythm. I would argue that just as physicians are constantly monitoring the heartbeat of their patients, we must attend to and be motivated to action by the heartbeat of health reform. Why? Because our society demands it. We spend more money on health care than any nation in the world, yet we do not have commensurate quality outcomes. Many people have no health care at all. Rising health care costs are limiting investments in other sectors of our society, such as healthy communities, education, affordable housing, and job development, that arguably are stronger factors for population health than is access to health care. Locally and nationally, many health reform efforts are in alignment with the concept of the Triple Aim introduced by Don Berwick, MD, while he was

Co-creating the future of health By Sanne Magnan, MD, PhD

at the Institute for Healthcare Improvement (Health Affairs, 27, 759–769, 2008). In Minnesota, we often talk of the Triple Aim as improving the health of the population; the experience of care, including quality; and affordability by reducing per capita costs of care. These aims are designed to help us transform a fragmented, fee-for-service, volume-driven, providerfocused system that is very expensive and unsustainable into a coordinated, outcomebased, value (quality/costs) -driven, patient-centered system that is affordable and sustainable. When I was Minnesota commissioner of health (2007–2010), Minnesota State Economist Tom Stinson, PhD, and Minnesota

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MINNESOTA PHYSICIAN APRIL 2012

State Demographer Tom Gillaspy, PhD, created a presentation called “Minnesota and the New Normal” (www.amsd.org/ docs/2011%20winter%20conference/Gillaspy%20Stinson%20ppt .pdf) that forecast some significant changes in our state. For example, there will be more people over age 65 than school-age children by 2020, with increasing diversity among those children. While they predict increased state revenue over the next 25 years, rising health care costs mean the state cannot increase spending on other services such as education, housing, community and job development, transportation, and parks. Referencing Minnesota health reform initiatives to address costs, I asked Gillaspy and Stinson what else we should do to address the new normal. Gillaspy said, “Invest in our children.” Much is going to be demanded of a smaller and smaller group, so they must be the brightest, most productive, healthiest children our state can have. Stinson said, “Change the social compact,” meaning we must re-evaluate what we “give and get” in our society—from our governments and from each other—and what roles we play in our communities. Certainly, their words reinforced the need for health reform and tackling rising health care costs. However, thriving in the new normal and changing the social compact present tremendous challenges. Following is what I see as the right chemistry, the right signals, and medical alerts of which to be mindful, so the heartbeat of health reform remains strong. The right chemistry

First, leaders in Minnesota’s health community are increasingly understanding the new normal with its imperative to

address health care costs. A physician on the board of the Institute for Clinical Systems Improvement (ICSI) has called rising health care costs “the national issue of the day.” Another physician recently remarked that “with rising health care costs, we are creating unsustainable communities.” Second, the payment system is changing from a fee-for-service model to varying forms of “total cost of care” models, providing a needed technical and philosophical alignment with the Triple Aim. Many nonprofit local health plans are entering into provider contracts with accountability and incentives for improving total costs along with improved health outcomes and experience. In 2010, the Minnesota Legislature mandated that the Department of Human Services develop a “… demonstration project to test alternative and innovative health care delivery systems, including accountable care organizations that provide services to a specified patient population for an agreed-upon total cost of care or risk/gainsharing payment arrangement” (Minn. Statute § 256B.0755). And in 2011, the Centers for Medicare & Medicaid Services (CMS) Innovation Center launched its Pioneer Accountable Care Organization (ACO) model, which also moves payment away from fee-for-service to a shared savings model based on total costs. Minnesota medical groups are early adopters of these initiatives. Nine proposals have been submitted for the state’s Health Care Delivery System Demonstration Project, and three Minnesota provider groups have been selected for participation for the CMS Pioneer ACO model. An aligned payment system heading toward the Triple Aim is an important element of health reform. Although a different payment system is a needed technical change, it must be accompanied by adaptive changes in the culture. Stakeholders must talk about different roles, identities, corresponding losses and changes in power and control. Articulating our fears and uncer-

tainties openly and honestly is a huge step toward true health reform. Subsequently, we must develop plans to address needed transitions, lest our losses and fears become insurmountable hurdles. The chemistry created by leadership in the health care community, payment reform initiatives, and needed adaptive changes within our health systems and communities support a strong heartbeat for health reform. Encouraging signals

Promising signals and signs also abound. We are seeing increasing transparency of quality measures and anticipated transparency in total cost of care measures, through the state’s Provider Peer Grouping and/or national/local measures such as the Total Cost of Care measure recently approved by the National Quality Forum. While some may hope measures on total cost of care will go away, we should find ways to make them better. An example is the local improved quality measure-

Leaders in Minnesota’s health community are increasingly understanding the “new normal” with its imperative to address health care costs. ment through MN Community Measurement (MNCM) over the past eight years, and alignment of measurement with state efforts. Let’s do the same for measuring total cost of care. We are solidifying the importance of primary care for this health reform effort. Clinics continue to be certified as health care homes in Minnesota. Medical groups are building teambased care that embraces innovation and patient-centeredness. There is increasing focus on outcomes, not just on activities. We must show that different payment models such as coordinated care payments produce better patient results and save money. The new normal requires us to form new and broader collaborative alliances that help us accelerate change across the state. RARE (Reducing Avoid-

able Readmissions Effectively) is an example of using our hospitals more effectively (www .rarereadmissions.org). The campaign has brought together ICSI, Minnesota Hospital Association, and Stratis Health as operating partners; MNCM and Minnesota Medical Association as supporting partners; and more than 60 community partners to set an aggressive goal: Decrease avoidable hospital readmissions by 20 percent by Dec. 31, 2012. This translates into 16,000 more nights of sleep in their own beds for patients and families. We are creating pathways that go upstream, to focus on the social determinants of health or factors that make us healthy. The Statewide Health Improvement Program (SHIP), part of Minnesota’s 2008 health care

legislation, seeks to reduce chronic diseases by addressing the two leading causes of illness and death—tobacco use and obesity—through policy, systems, and environmental changes. I am very encouraged that the state has continued to fund this program in 2012. Campaigns such as Honoring Choices, from the Twin Cities Medical Society and its Foundation with support from Twin Cities Public Television, are engaging citizens in crucial conversations around end-of-life care planning (www.honoring choices.org). “Medical alerts”

Despite the improving chemistry and promising signals for the heartbeat of health reform, current efforts face several major hurdles. First, the problems we are trying to solve are the same ones that “managed care” tried to address in the 1970s through mid 1990s—rising costs without corresponding improvements in quality and productivity. We have many more tools available REFORM to page 19

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PHYSICAL

tatistics indicate that one in 100 people over the age of 60 will be diagnosed with Parkinsonâ&#x20AC;&#x2122;s disease (PD). This chronic progressive illness results in dopamine depletion in the basal ganglia, causing bradykinesia, resting tremor, muscle rigidity, and postural instability. An interdisciplinary team model of care is recommended to best achieve comprehensive management of complex PD symptoms. Physical therapists are trained, licensed professionals who are experts in restoring and improving motion to achieve greater physical function. As integral members of an interdisciplinary team approach to management of PD, physical therapists play an important role throughout the continuum of care, from time of diagnosis to advanced stages of the disease. Referrals to physical therapy are beneficial to address functional deficits in mobility, develop an individualized exercise program, improve postural awareness/alignment, and reduce/eliminate pain. Patient

Physical therapy for Parkinsonâ&#x20AC;&#x2122;s disease An important role in the continuum of care By Rose Wichmann, PT and family education provided by physical therapists offers greater understanding of PDâ&#x20AC;&#x2122;s impact on mobility as well as instruction in movement enhancement strategies, compensation techniques, safety, and stress reduction. Just as physicians refer their

ment disorders. Skilled observations during a physical therapy session can be extremely helpful to physicians in regard to optimizing patient medications or managing secondary symptoms. Familiarity with and use of elements from widely accepted PD scales provide a common lan-

As Parkinsonâ&#x20AC;&#x2122;s disease progresses, gait pattern changes become more pronounced. patients to colleagues in appropriate specialties, it is important to refer PD patients to physical therapists with the appropriate interest, training, and experience in treating patients with move-

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THERAPY

MINNESOTA PHYSICIAN APRIL 2012

guage for rating Parkinsonâ&#x20AC;&#x2122;s primary and secondary symptoms. (Visit www.toolkit.parkinson.org, designed by National Parkinson Foundation, for a comprehensive overview of recommended evaluation, tests, and treatment.) The physical therapist should be familiar with current, evidencebased, validated test measures for examination of individuals with PD. Interventions are based on the impact of PD symptoms on patient function, and treatment goals should be written to accurately measure improvement of these daily functional tasks. Physical therapy in early-stage Parkinsonâ&#x20AC;&#x2122;s disease

The widely accepted Parkinsonâ&#x20AC;&#x2122;s treatment algorithm notes the importance of exercise in early stages of Parkinsonâ&#x20AC;&#x2122;s, and current research demonstrates neuroplasticity (exercise-induced brain repair) in animal models of early stage PD. Unfortunately, many PD patients do not receive a referral to physical therapy at early stages of the disease, leaving them unaware of the importance of exercise, or unsure of what exercises would be most beneficial. Exercises should include a foundation of stretching activities due to muscle rigidity and its accompanying potential for

loss of flexibility. Inclusion of exercises promoting spinal flexibility appears to be particularly needed in early stages of Parkinsonâ&#x20AC;&#x2122;s. Movement enhancement strategies with attention to making motions more mindful and complete further enhance exercise performance. Amplitudebased therapies emphasize theories of neuroplasticity, including retraining of normal use, intensive practice, repetition, increasing complexity, and regular feedback. Regular conditioning exercises are incorporated to maintain activity tolerance and cardiovascular fitness. Recent studies have demonstrated benefits using treadmill training, tandem biking, and dance. Physical therapists also address concerns regarding posture and gait changes, stress reduction/relaxation, workplace issues, leisure interests, or pain at this stage of Parkinsonâ&#x20AC;&#x2122;s. Physical therapy in moderatestage Parkinsonâ&#x20AC;&#x2122;s disease

As Parkinsonâ&#x20AC;&#x2122;s disease progresses, patients begin to experience greater difficulties with physical mobility skills such as getting out of bed, rising from a chair, or getting out of the car. Gait pattern changes become more pronounced, with increased shuffling, difficulty turning, and occurrence of festination and/or freezing of gait. Many patients experience significant balance problems and report episodes of falling. Motor fluctuations often develop, further complicating mobility skills as patients experience variations in function throughout the day. Physical therapy is helpful with all these mobility challenges, offering interventions and instruction in compensatory strategies, adaptive equipment, and appropriate exercise to effectively cope with changes in these daily tasks. Gait changes in Parkinsonâ&#x20AC;&#x2122;s include narrowed base of support; decreases in step size, heel strike, and arm swing; en bloc turns; and reduced gait velocity. Excessive dyskinesia or dystonic posturing also negatively affects the gait pattern. Motor fluctuations, often seen as Parkinsonâ&#x20AC;&#x2122;s disease progresses, cause some individuals with Parkinsonâ&#x20AC;&#x2122;s to

Resources experience only periodic deficits, or to exhibit significant changes in function between “on” and “off” periods throughout the day. Retropulsion, festination, and freezing of gait are frequently seen at this stage of Parkinson’s, requiring gait training in physical therapy to most effectively cope with these deficits. Instruction in attentional, visual, auditory, and/or kinesthetic cueing is often helpful to reduce freezing episodes (inability to move). Taped lines in a doorway threshold, use of metronomes, and/or focused attention on weight shift prior to initiating gait allow PD patients to bypass the depleted basal ganglia and use intact frontocortical pathways to “break” the freeze and initiate movement. A referral to physical therapy is essential to receive recommendations regarding appropriate gait-assistive devices and ensure proper sizing. Physical therapists are also a resource for information about locations for equipment purchase and medical reimbursement. Postural instability is the primary symptom of Parkinson’s that is least responsive to available medications. A 2005 Struthers Parkinson’s Center survey of 1,061 patients with Parkinson’s disease showed 55.4 percent reporting at least one fall within the past year, with 65.3 percent of fallers reporting injury, and 32.9 percent of fallers reporting a fracture. If a patient is falling, instruction in safe techniques to get up from the ground is essential to minimize injury risk. In the event of a fracture, illness, or other injury, a physical therapy referral should be initiated as soon as the patient is medically stable, as prolonged bedrest or inactivity significantly impairs mobility and complicates the rehabilitation process. Physical therapy referral for care partner instruction should not be overlooked in this stage of Parkinson’s disease. Many family care partners begin to offer assistance with transfers, exercises, or other daily cares without instruction in proper technique or body mechanics. The likelihood of care partner injury can be significant without

To find physical therapists in your area, visit www.parkinson.org (National Parkinson Foundation), www.lsvtglobal.com (lists therapists certified in the LSVT BIG exercise program for Parkinson’s patients, or www.nfnw.org (lists therapists who have attended a Parkinson’s Wellness Recovery exercise and treatment course), or contact Struthers Parkinson’s Center at 888-993-5495 (www.parknicollet.com). proper instruction. Instruction in providing clear, concise cues with reduction of excessive verbal stimuli is particularly helpful and reduces frustration for both patient and care partner. Physical therapy in advancedstage Parkinson’s disease

Although some physicians or other members of the health care team may feel that an individual lacks “rehab potential,” there is still a role for physical therapy in comprehensive management of individuals with advanced-stage Parkinson’s disease. In advanced PD, medications may become less effective for symptom control, and medication side effects may become more prominent. Immobility coupled with advancing cognitive changes cause patients to require assistance with almost all activities of daily living, and with performance of a daily exercise program. At this stage, care partners play a larger role in care of the patient and frequently need instruction, support, and respite care to cope with these complicated problems. Physical therapy referrals are beneficial in areas of posture, positioning, pain control, transfers, and care partner-assisted exercise. As PD advances, this treatment often transitions to a homebased setting where these needs can be assessed and treated. As care needs increase, many patients are faced with the transition to a new living environment. A move to assisted living, a skilled nursing facility, or other new environment can be extremely stressful for both patients and their care partners. Unfortunately, not all health care providers within these facilities are familiar with the symptoms or challenges of living with Parkinson’s. Physical therapy evaluation of the new living environment is helpful to maximize patient safety and comfort. A physical therapist can help provide staff education for

assisting patients experiencing fluctuating mobility, freezing, or other mobility challenges related to Parkinson’s disease. Instruction in Parkinson’s symptoms, as well as specific transfers and movement enhancement strategies, aids staff understanding and improves patient care. Evidence-based practice: research and physical therapy

An increasing amount of research has been published that demonstrates the effectiveness of physical therapy for patients with Parkinson’s disease. A continued focus on evidence-based practice is needed to establish benefits of treatment and best practice patterns for all physical therapy professionals. Comprehensive explanation of current physical therapy practice is available in the “Guide to Physical Therapist Practice,” a collaborative work published by

the American Physical Therapy Association. Physical therapists use the information developed for the guide within their clinical practice, as well as for professional education purposes. The guide defines physical therapy’s scope of practice, and provides preferred practice patterns grouped into several major categories. Throughout the continuum of care, physical therapists play an important role in comprehensive PD management. Referrals to PT professionals with interest and expertise in treatment of movement disorders provide patients with opportunities for maximized function and quality of life. Rose Wichmann, PT, is the manager of Struthers Parkinson’s Center in Minneapolis. She has co-authored several publications for National Parkinson Foundation, including “Advanced Stage Parkinson’s” and “Practical Pointers for People with Parkinson’s.” To download these and other patient resources free of charge, visit the National Parkinson Foundation website at www.parkinson.org.

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MINNESOTA PHYSICIAN

The Hennepin Health project uses the concepts of an accountable care organization.

Transformations from page 13 electronic medical record (EMR), and relatively low reimbursement compared with subspecialists. HCMC has begun a redesign process to change the structure and culture of the medicine clinics to be more welcoming to both patients and providers. The Center for Patient and Provider Experience at HCMC performs research to align patient and provider goals for care. Martin Stillman, MD, senior medical director for the medical specialties at HCMC, has convened the Vibrant Clinic Design Group to develop, from the ground up, clinics that will embody what is desired and needed for both patients and health care workers. Stillman says, “Better functioning teams will improve patient care and provider satisfaction. We want patients to see a new system of care, and make health care a more personal experience.” Patient experience initiative

Over the past several years, a cultural revolution has taken hold at HCMC and in organized

medicine throughout the country. Care systems and behaviors are becoming more patient- and family-centered, with patient involvement driving care reorganization. More than 550 doctors, nurses, advanced practice providers, and hospital leaders have participated in four patient experience rallies. More than 60 patients and families have shared their stories and offered feedback at these fullday events. Interactive sessions lead attendees through principles of patient-centered care and offer simple steps for how care team members can work with our patients, rather than doing things to them. In this era of electronic communication, human contact and interaction remain the bedrock of health care delivery. The rallies, and HCMC’s “Centered Around You” campaign, highlight what mat-

MINNESOTA PHYSICIAN APRIL 2012

ters to patients beyond their physicians’ clinical expertise. They help us recognize that patients notice the nuances of what we say and do—even something as simple as walking a patient to the door or inviting a family member into a bedside discussion. Patients are now attending hospital meetings, and more than 40 patients are actively involved as advisers or focus group members. When a new project is considered, patient and family feedback is part of the planning process. A patient story starts many leadership meetings, and patients’ comments about their care are shared with the medical staff. When we can tell our patients that we are truly “centered around you” at HCMC, it grounds us in the real reasons we come to work every day.

Medical homes for new “family members”

HCMC is well known as a levelone trauma center providing exceptional care for those in urgent need. Now we are implementing system-wide programs to provide exceptional, patientcentered primary and subspecialty care for all patients, including those with few resources who need our support the most. We are enthusiastic about our future plans and look forward to implementing them for our patients, our providers, and Hennepin County residents, who will all be family members in our new “medical homes.” Paul Johnson, MD is clinic lead for the Coordinated Care Clinic; Pamela Clifford, RN, MPH, is director of the Center of Health Care Innovation; Sheila Moroney is director of patient experience services; and Mark Linzer, MD, is director of the division of general internal medicine, all at Hennepin County Medical Center. Jennifer DeCubellis, LPC, is area director for the Hennepin County Human Services Public Health Department and director of the Hennepin Health project.

Reform from page 15 today, but a key to health reform working this time is to co-create our future by engaging our patients, families, and community stakeholders. Ideally, citizens should be helping us interpret and translate the Triple Aim into action. Both the private and public sectors in Minnesota are exploring how we include patients’ perspectives even more, and how we engage communities in improving health as well as addressing costs. This would be a step toward “changing the social compact.” How do we help stakeholders see their different roles in health and health care at a local level that creates different “gives and gets”? Without their involvement, we run the risk of missing the mark again— only instead of “managed care backlash,” we will have “accountable care backlash.” Clearly, there is a great deal to learn from one another about how to enter this new territory together. We must measure and manage going forward with an environment for continuous

A real danger is that we risk a great deal if we fail this time, as the window is narrowing to turn the trajectory on rising health care costs. learning. But we must not let the “organization” part of ACOs take the front seat; the focus must be on accountable, responsible care for those we serve. And we must engage patients and citizens in our communities in new ways— ways that change the power structure and really make them the center of our concerns. To do it well, we will have to listen deeply—and hear hard things that we need to change. A real danger is that we risk a great deal if we fail this time, as the window is narrowing to turn the trajectory on rising health care costs. Although many activities are moving us from a fragmented system to a coordinated system, we have been unclear about the outcomes needed for our patients and communities. Clear goals are critical. Don Berwick

once said, “Some is not a number and soon is not a time.” A local health care leader recently said, “When we set a goal of decreasing our total cost of care over the next three years by 20 percent, it galvanized our thinking and creativity.“ Just as the RARE goal has centered our thinking on how to tackle avoidable readmissions, so can other community-wide goals. To achieve the Triple Aim, we need to co-create some SMART (specific, measurable, actionable, realistic, and timebound) goals along with our patients and community stakeholders. A strong heartbeat

I am optimistic that with the right chemistry, the right signals, and attention to our medical alerts, physicians and other

health leaders will step up to the challenges ahead with a collective wisdom and a building of trust with communities to tackle problems, seize opportunities, and co-create solutions. There has never been a greater time for collaboration and for learning from one another. No one organization can figure this out. Changing the health system is like turning the mother ship, and we need all hands on deck. The health reform heartbeat in Minnesota is as strong as ever. Part of our job will be to find the right pace and rhythm for the days, months, and years ahead. There are certainly forces that would speed up or slow down that heartbeat. But there is no doubt that the leaders in our state plan to keep the heartbeat of health reform alive and well. Sanne Magnan, MD, PhD, is the president and CEO of the Institute for Clinical Systems Improvement (ICSI) and former Minnesota commissioner of health. She is also a practicing physician at the Tuberculosis Clinic at St. Paul–Ramsey County Public Health.

In person

Inbox

When changes in the local health care landscape promised a major influx of new UCare members coming through metro-area clinics and hospitals, we made sure those providers were prepared. In a span of just two weeks, May Ly was among the UCare staff that personally visited 449 unique health care locations to offer a heads-up and explain the impacts. Because being responsive to our partners’ needs isn’t just talk—it’s what we mean by health care that starts with you.

| provider assistance: 1-888-531-1493 | ucare.org/providers |

APRIL 2012

MINNESOTA PHYSICIAN

SPECIAL

FOCUS:

technology comes in myriad forms. This month’s

describe improvements in communications technol-

TECHNOLOGY

New horizons for telehealth

Innovation in health care

special focus articles

N E W - G E N E R AT I O N

Enhanced communications = enhanced health care and efficiencies By David Hemler

ogy—whether through interoperable electronic health records, as a means of delivery care, or to enhance security and information protocols; a unique organization aimed at improving pediatric care products; and trends in the medical device industry and how to support physicianindustry collaboration in creating, testing, and marketing new devices.

he intersection of technology and health care is nothing new. We’ve witnessed an unprecedented advance in public health over the last 70 years, thanks to the availability of disease-fighting vaccines and antibiotics and innovations such as robots and lasers that improve surgical precision and recovery time. Yet, with all the lives saved and benefits delivered by these technologies, none have materially improved what is arguably the most critical and fundamental asset in the delivery of health care: communication. Enter telehealth. Telehealth is an expansion of telemedicine, encompassing the delivery of

both clinical and nonclinical health-related services and information via telecommunications technologies. It’s a relatively broad practice aimed at bridging communication gaps in the care delivery process, ranging from basic utilizations —for example, allowing multiple health professionals to discuss a case over the telephone or enabling physicians to communicate with patients and order drugs by email—to highly sophisticated applications such as facilitating consultation, during robotic surgery, among members of a medical team in facilities at opposite ends of the globe.

Telehealth as a concept emerged decades ago, but it is now on the verge of becoming ubiquitous and routine as a result of factors, including a looming physician deficit, a growing elderly population, and more connected and demanding health care consumers. However, because telehealth comprises such a wide range of applications and technologies, physicians are faced with complex decisions about which telehealth solution, if any, is a wise investment of time, money, and resources, given their care delivery needs and objectives. The case for connecting

When considering whether to embrace telehealth, physicians must ultimately place a value on the role effective communication plays in fulfilling their duties to patients, in terms of both quality of care and efficiencies in delivering it. Physicians can look to the following key benefits of telehealth technologies as criteria to help them TELEHEALTH to page 24

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APRIL 2012

MINNESOTA PHYSICIAN

Victoza® (liraglutide [rDNA origin] injection) Rx Only BRIEF SUMMARY. Please consult package insert for full prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions]. INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied. CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dosedependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiving liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a comparator-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have subsequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most frequently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with ontreatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consistent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calcitonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebotreated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evaluation. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

MINNESOTA PHYSICIAN

APRIL 2012

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other potentially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medications known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug. ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparatortreated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer. Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial All Victoza® N = 497 Glimepiride N = 248 (%) (%) Adverse Event Term Nausea 28.4 8.5 Diarrhea 17.1 8.9 Vomiting 10.9 3.6 Constipation 9.9 4.8 Upper Respiratory Tract Infection 9.5 5.6 Headache 9.1 9.3 Influenza 7.4 3.6 Urinary Tract Infection 6.0 4.0 Dizziness 5.8 5.2 Sinusitis 5.6 6.0 Nasopharyngitis 5.2 5.2 Back Pain 5.0 4.4 Hypertension 3.0 6.0 Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials Add-on to Metformin Trial All Victoza® + Placebo + Glimepiride + Metformin N = 724 Metformin N = 121 Metformin N = 242 (%) (%) (%) Adverse Event Term Nausea 15.2 4.1 3.3 Diarrhea 10.9 4.1 3.7 Headache 9.0 6.6 9.5 Vomiting 6.5 0.8 0.4 Add-on to Glimepiride Trial All Victoza® + Placebo + Glimepiride Rosiglitazone + Glimepiride N = 695 N = 114 Glimepiride N = 231 (%) (%) (%) Adverse Event Term Nausea 7.5 1.8 2.6 Diarrhea 7.2 1.8 2.2

APRIL 2012

MINNESOTA PHYSICIAN

Telehealth from page 20 evaluate how these technologies affect their work: • If you are committed to delivering the highest quality care without sacrificing profitability, cost efficiencies are a priority. Telehealth has been shown to reduce the cost of health care and increase efficiency through better management of chronic diseases, shared health professional staffing, reduced travel times, and fewer or shorter hospital stays. • If you want to coordinate care plans with other providers and caregivers more efficiently, a unified communications platform can offer the ability to streamline communications. This telehealth technology allows physicians to engage, and add mid-meeting, multiple complementary providers in discussions about care plans; “right-size” communications by using the most efficient mode of communication for any given interaction; reserve

Physicians must ultimately place a value on the role effective communication plays in fulfilling their duties to patients. in-person office visits for only those matters requiring physical examination or in-depth discussion; and document or even record conversations for future recall. • If you want to increase your accessibility and availability, improved access is important to your practice and to your patients’ well-being. Telehealth improves access to patients in distant locations or who are too ill or financially stressed to travel, while enabling physicians and other health care professionals to expand their reach, beyond their own facilities. • If you believe that consumerdriven health care is not a “movement” but a new industry status quo, you’ll be interested in how great patient demand is for telehealth. Patients’ expectations are ris-

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ing, due to their desire to connect with health care providers whenever and however it’s convenient for them. This trend of accessibility stems from other activities such as online banking, online shopping, and online meetings, making health care the latest frontier to address true “accessibility” as other industries have. Additionally, a growing body of data indicates that telehealth may be a solution to several distressing medical trends. The American Medical Association has reported that up to 70 percent of doctor office visits and 40 percent of emergency room visits are unnecessary, and the American Academy of Family Physicians has predicted the shortage of family doctors will reach 40,000 in the next 10 years, as medical schools send about half the needed number of graduates into primary care medicine. Both of these challenges—and hundreds more— can be effectively met with telehealth collaboration and communication tools that enable right-place, right-time providerpatient interactions. A past with challenges; a future with great promise

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Despite its potential as a care delivery model, telehealth has historically failed to reach broad adoption for two primary reasons—the challenge of reimbursement and the cost of implementation. Most health insurers, including the federal government through Medicare, do not cover the cost of a virtual visit via telehealth. There are some exceptions, but in general reimbursement models have made it difficult to deliver telehealth under a traditional fee-for-service approach. Newer delivery models such as accountable care organizations encourage the use of telehealth to better manage overall cost and out-

comes, even if an individual doctor-patient interaction is not directly reimbursed. We are already starting to see shifts by the largest health insurers; WellPoint, UnitedHealth, and Aetna have all announced changes to providers’ reward and compensation models to more strongly incentivize quality and efficient primary care. Also, the implementation cost of traditional telehealth solutions has been prohibitive— dedicated networks were needed, with expensive and specialized equipment that connected a single location to another single location in a point-to-point fashion. As an example, a dedicated, physical connection between a clinic and a hospital required significant capital expenditures on the part of health care systems, and could be implemented in just a few locations. Despite these obstacles, adoption of telehealth is experiencing something of a boom in the state. MN Community Measurement, a Minneapolisbased health care-quality group, says that approximately 13 percent of medical clinics surveyed in the state—152 out of 1,198— reported offering electronic visits in 2010. That number nearly doubled in 2011 as 334 clinics of 1,313 surveyed—25 percent of the total—said their clinic or organization offered e-visits. We anticipate that in years to come, these numbers will continue to climb as more versatile, dynamic, and cost-effective telehealth solutions penetrate the marketplace. Physicians and patients, unified

A unified communications system can overcome some of the greatest challenges facing telehealth and the medical profession. As a set of real-time and non-real-time services and products, unified communications provides a consistent user interface and user experience across multiple devices and media types—for both providers and patients. Over the past few years, the advent of cloud computing—the use of remote servers hosted on

the Internet to store and manage data, rather than a local server or PC—has had a revolutionary effect on the affordability and functionality of telehealth. Cloud-based unified communications can be economically accessible to growing health care organizations, allowing easier start-up and implementation, as well as continuing to drive cost efficiencies once implemented. A comprehensive and compliant unified communications system can improve communications through its various capabilities: webcam videoconferencing; secure file transfers such as a pdf of a patient record or treatment protocol; VoIP telephony (communications services transported over the Internet); secure email that is HIPAA compliant; secure screen sharing; and text messaging. Because all of these communication interfaces are facilitated securely via the cloud, a unified communications suite doesn’t require the expensive, dedicated infrastructure typically associated with telehealth or telemed-

A growing body of data indicates that telehealth may be a solution to several distressing medical trends. icine solutions. Both providers and patients save time and money when they have flexibility to connect outside of an office visit, which is possible with a comprehensive unified communications suite’s wide range of remote applications. Interactions between provider and patient ultimately are more efficient when the right tool is used to relay information—for example, using email to communicate drug indications—and both parties are saved a resource-intensive office visit. Certain unified communications platforms quickly authenticate and automatically validate patients’ identification, greatly shortening session times. Further efficiencies are made possible being able to switch communication modes mid-interaction, enabling parties to escalate from an online chat to a phone

conversation or video session without interruption. Time and cost efficiencies are real objectives on the operational side of medicine, but it’s important to understand that reputable telehealth services are designed with patient care at the forefront. Shortened wait times, more streamlined consultations and a low barrier to entry are worth nothing if patients don’t receive quality care. Quality is in the eye of the beholder (in this case, the patient), and quality improvement may take many forms— faster and easier access to care; clarification of a lab result delivered from the provider’s portal without the need for a follow-on appointment; or the ability to include a loved one or outside caregiver in a virtual doctor visit to help coordinate care, communications, and follow-up. Unified communica-

tions is a telehealth win–win that marries high-quality care to efficiency and effectiveness in care delivery. The future is connected health care

Just as the smartphone has emerged as a multipurpose solution to consumers’ demand for integrated media, productivity, and communications tools, unified communications answers the health care industry’s need for integrated care delivery tools that deliver health care at the right time, in the right way, and at lower cost. For physicians for whom telehealth has seemed too costly or complicated to integrate into their practices, unified communications is within reach … and with it, so are their patients. David Hemler is CEO of Bloomingtonbased Revation Systems, Inc.

Delivering care that makes patients feel known and understood At Essentia Health, we have a supportive group of 750 physicians across 55 medical specialties. Located in large and small communities across Minnesota, Wisconsin, North Dakota and Idaho, Essentia Health is emerging as a leader in high-quality, cost-effective, patient-centered care. EOE/AA

LEARN MORE

EssentiaHealth.org/Careers 800.342.1388 ext 63165

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FOCUS:

Local company aims to close a product gap By Bradley F. Slaker, BSME, MBA

10 constitute less than 13 percent of the U.S. population, so the pediatric medical device market is a very small fraction of the size of the adult medical device market. As neonatologist Andrea Lampland, MD, of Associates in Newborn Medicine, St. Paul, has said, “Little people equals little funds.” This leads to large gaps in the availability of appropriately designed pediatric medical devices, leaving many children’s clinical needs either unmet or underserved. A few years ago, I concluded that attacking the gaps in the pediatric device products portfolio required an entirely new business approach. DesignWise Medical was founded to do just that.

“As physicians, we have so many unknowns coming our way... One thing I am certain about is my malpractice protection.” Medicine is feeling the eﬀects of regulatory and legislative changes, increasing risk, and profitability demands—all contributing to uncertainty and lack of control. What we do control as physicians: our choice of a liability partner. I selected ProAssurance because they stand behind my good medicine. In spite of the maelstrom, I am protected, respected, and heard. I believe in fair treatment—and I get it.

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Pediatric medical devices

hildren are not small adults—one of the main points of pediatric orthopedic surgeon Robert Campbell’s testimony to the U.S. Senate in 2007 when he stated, “Children deserve access to devices that are safe, effective, and made just for them. Yet today many devices are not made with these considerations in mind, and some necessary devices are not made at all.” Children not only are much smaller in size; they are continually growing, are more active, have a wide range of cognitive and maturity levels, and have different body structures and functions than adults. As a result, pediatric medical devices—used to diagnose and treat diseases and medical conditions of children—are often borrowed from adult applications and jury-rigged to fit children and function properly—if they exist at all. The main reason the market lacks pediatric devices is that the financial return on investment is often minimal or nonexistent. Children under the age of

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Filling gaps in the pediatric products portfolio

After working for more than 20 years developing medical devices in small start-ups and larger medical device companies, I wanted to refocus my background and experience on clinical needs that were either unmet or unaddressed by the for-profit medical device industry. Recognizing and experiencing the gap in the resources committed to developing adult medical devices versus children’s devices, I founded DesignWise Medical with the philosophy that children’s medical needs should receive the same level of attention and applicable technology as adult medical needs. In its first three and a half years of operation, DesignWise Medical has initiated development programs for nine new pediatric medical products and devices based on clinical needs identified by clinicians as well as parents. The solutions developed will have a positive impact on children’s health care outcomes and quality of life; specific projects are targeting children with rare lung diseases that require supplemental oxygen therapy; those with type 1 diabetes; and those who require intravenous access. These projects have resulted from the efforts of more than 240 volunteers (including about 160 higher education students) who are passionate about children. They have collectively donated more than 25,000 hours of their time in the last three and a half years. By founding DesignWise Medical as a 501(c)(3) nonprofit corporation, we have avoided becoming just another entry in the large field of medical device startup companies looking for venture capital and promising quick profits. Instead, we aim to capitalize on the broad appeal of

our mission and purpose and will seek initial funding in the form of charitable contributions from individuals, grants from foundations, and sponsorships from like-minded companies. As DesignWise commercializes and introduces products into the medical device marketplace, we will develop sources of earned income through technology licensing or other revenuesharing agreements with forprofit partners in the medical device industry. A volunteer-driven development process

Only by changing the dynamics of the pediatric medical device development process can DesignWise Medical be effective. The overarching philosophy driving our mission is that by facilitating the collaboration of volunteer and philanthropic resources, we can develop pediatric medical devices at a fraction of the cost of the traditional approach employed by the forprofit industry, thereby removing the main barrier keeping appropriate medical devices from the children that need them. DesignWise Medical uses a three-step process in fulfilling its mission: 1) Identify unmet and underserved pediatric medical device needs 2) Develop solutions to those needs 3) Deliver the solutions to the marketplace and to children in need Identifying medical needs requires engaging clinicians, children’s hospitals, parent groups, and disease foundations. Developing solutions is achieved by employing an unpaid volunteer network of active and retired professionals from a variety of disciplines, as well as students and university partners. Additionally, by sponsoring student projects in a variety of areas (e.g., marketing, business, engineering, biomedical, design, regulatory affairs, clinical), DesignWise Medical is able to help provide realworld, project-based learning opportunities to colleges and universities.

For example, in early 2011 we took 18 senior industrial design students from the University of Wisconsinâ&#x20AC;&#x201C;Stout, in teams of three, to Gillette Childrenâ&#x20AC;&#x2122;s Hospital in St. Paul for an entire shift of shadowing, observing, and interviewing the clinicians, nurses, and parents within the Pediatric Intensive Care Unit and other areas of the hospital. Our purpose was to uncover and document unmet and underserved needs for childrenâ&#x20AC;&#x2122;s medical devices and products. From this master list of identified pediatric needs, each student initially developed 50 design concepts addressing some of those needs. The students then consolidated their effort down to three needs and design concepts for those three needs. Following a mid-semester critique from industry professionals, each student focused the final six weeks of the semester on developing one main concept addressing one main identified need. In mid-May, the semester ended with each student conducting a design review on their final product and a senior show that showcased the work they did during the project. The final deliverables were a fully functional or scale-model prototype of their design, along with product packaging and marketing materials. We are currently evaluating the output of the studentsâ&#x20AC;&#x2122; work for possible continuation as product development projects within DesignWise. Gillette Childrenâ&#x20AC;&#x2122;s was a fantastic partner on this project and was extremely accommodating to our company and the students from UWâ&#x20AC;&#x201C;Stout. We are refining the needs-discovery process based on what we learned from this pilot project and are planning to conduct further semester-long projects like this on an annual basis. Delivery of these solutions will likely involve strategic partnerships with established medical device companies. Taking charge of a product that DesignWise Medical has developed and which has already received FDA marketing clearance, the strategic partner can deliver the product to the mar-

ketplace and into the hands of the caregivers and children that need them. These partnerships eventually will provide DesignWise Medical with sustainable earned income and revenue sources. First device in prototype stage

The Overnight Pediatric Oxygen Delivery (OPOD) system is the first product developed by DesignWise Medical. The OPOD provides a noncontact method of delivering supplemental overnight oxygen to infants and young children who have chronic lung conditions. These children do not need supplemental oxygen for life support, but without it they may not develop normally and may develop pulmonary hypertension. The OPOD, a hemispherical hood placed over the childâ&#x20AC;&#x2122;s head, provides an alternative to cannula and facemasks, which are not well tolerated by young children. The OPOD was inspired by a parent I met at a National Institutes of Health conference. The parent described the difficulty of delivering overnight oxygen to her son, who has a rare lung disease called NEHI (neuroendocrine cell hyperplasia of infancy). Her son pulled the taped nasal cannula off his face so frequently that his parents had to fasten the oxygen tubing to a teddy bear that he would hold closely, and then had to take turns watching over him all night. We will be targeting respiratory and/or sleep products companies as potential distribution partners for the OPOD by either selling or licensing the rights to the product. The earned income from this product will be used to fund our next round of projects.

various opportunities are available for student group projects, internships, and volunteering. Sponsorship opportunities are available for individuals, organizations, and educational institutions that want to specifically support the development of future professionals through project-based learning opportunities. Sponsorship opportunities include sponsoring a student project or supporting a student internship. Benefits to stakeholders

DesignWise Medical also offers benefits to our many stakeholders. First and foremost are the children, parents, and families that will benefit from the products we develop. Children will receive products developed specifically for their unique needs while pediatric clinicians will have the appropriate tools to help them deliver the care needed. Childrenâ&#x20AC;&#x2122;s hospitals and health-care clinic partners will benefit by having a very visible, tangible way of showing their commitment to continuous improvement and innovation in

childrenâ&#x20AC;&#x2122;s health care. Students and volunteers gain valuable experience and mentorship opportunities that help prepare future professionals with real-world, projectbased learning opportunities. Medical-device industry sponsors and partners will be able to demonstrate to stakeholders their commitment to childrenâ&#x20AC;&#x2122;s medical devices in a way that doesnâ&#x20AC;&#x2122;t detract from their strategic plans. It is our hope that the presence of this unique company will help in a small way to diversify and strengthen our regionâ&#x20AC;&#x2122;s leadership in the medical device and health care industries. Bradley F. Slaker, BSME, MBA, has more than 20 yearsâ&#x20AC;&#x2122; experience in the for-profit medical device industry and is founder and CEO of DesignWise Medical, a nonprofit pediatric medical device company based in Minneapolis. For more information, visit www.designwisemedical.org.

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Collaboration and sponsorships

DesignWise Medical has sponsored 30 student projects to date that have spanned various disciplines, including engineering, regulatory affairs, intellectual property, marketing, and business. We have developed partnerships with eight local colleges and universities and will be expanding to other regional institutions as needed. In addition to formal student projects,

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or years the complexity and cost of health care exchange have forced providers to stick to obsolete, insecure, expensive, error-prone, and time-consuming, paper-driven workflows involving printers, couriers, and fax machines. Today with the Direct Project, we finally have the secure health Internet our patients and providers deserve, and secure health communications are available to providers of all shapes and sizes and their patients. Years ago, the Office of the National Coordinator for Health Care IT (ONC) of the U.S. Department of Health and Human Services had a vision that medical records could be shared across disparate providers electronically. As a means to reach that goal, the ONC, through its Nationwide Health Information Network (NwHIN, formerly NHIN), created NwHIN Connect open-source software to support secure electronic health information exchange. NwHIN Connect was built on Web services and designed to meet use cases such as querying a health

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Getting connected Direct offers a simple, secure, and open communication protocol for all By McLain Causey

network for the records of an unconscious patient presenting in an ER. But adoption of Connect has been hampered by technical and legal complexities; providers often cannot afford the products and maintenance associated with the technical intricacies of these workflows, and the legal framework is expensive and risky. The HITECH stimulus act, part of the 2009 economic stimulus bill, also aimed to enhance electronic communication among providers by offering incentives and introducing a framework for “meaningful use” of electronic health records (EHR) systems. However, it soon became apparent that smaller providers—the ones with the greatest need for stimulus and

Internal Medicine Physician Ridgeview Medical Center and Clinics have a well-earned reputation for clinical excellence and compassionate care. Patients say the Ridgeview experience is remarkably different from what they have encountered elsewhere. One of the few remaining independent health care systems in Minnesota, Ridgeview responds to local and community needs through innovative care, cutting-edge service and partnerships with the best specialists. Ridgeview is recruiting a full-time Internal Medicine Physician to join its Outpatient Clinic and Hospitalist practices. Seeking a candidate that is board certified or board eligible in Internal Medicine for a practice model that is approximately 80-90 percent outpatient-based medicine at Ridgeview Chaska Clinic at Two Twelve Medical Center, with scheduled shift work as a Hospitalist at Ridgeview Medical Center. Forward curriculum vitae and letter of interest to: Human Resources, Ridgeview Medical Center, 500 South Maple St., Waconia, MN 55387, or email: physician.recruitment@ridgeviewmedical.org.

www.ridgeviewmedical.org EOE/AA

TECHNOLOGY

MINNESOTA PHYSICIAN APRIL 2012

for modernization—would be the least able to participate in these transactions, due to financial and operational constraints. At the same time, White House chief technology officer Aneesh Chopra was listening to a primary care doctor’s frustrations with not being able to securely send patient data to a referring physician. Dan Blumenthal, then national coordinator for the ONC’s Health Information Technology, wanted physicians to be able to communicate protected health information (PHI) easily and electronically, instead of continuing the widespread use of paper-driven workflows (e.g., those involving printers, copiers, couriers, and fax machines). In response to the issues raised by Chopra and Blumenthal, as well as the ONC and providers, Ability Network (then VisionShare, Inc.) proposed a protocol to facilitate simple transactions available to providers. The Minneapolisbased communications company is the largest secure health information network in the nation, NwHIN Direct, an extension of the NwHIN, was announced at the 2010 HIMSS (Health Information and Management Systems Society) conference by the director of the Office of Standards and Interoperability. Below is a brief look at how Direct has evolved since then and what the advances in its development mean for health care providers. Developing a federal standard

The Direct standard was developed using the concept of open governance, adopted from the world of open source software. This model involves the open collaboration of groups of stakeholders. The process of defining the requirements, as well as the development of reference implementations, is collaborative and

open to interested parties that want to contribute or simply to monitor the process. Open governance as a means of developing federal standards was a rousing success. Industry partners teamed up with health care colleagues and organizations to form committees, and a federal standard went from inception to reality within a year. The first transaction on the network, in early 2011, was an immunization message sent from Hennepin County Medical Center to the Minnesota Department of Health’s immunization registry. Since that historic milestone, Ability has been named as the first health data intermediary in Minnesota, was certified as a health information service provider (HISP, a term for a provider of Direct services) in Rhode Island, and became the HISP for the Wisconsin Health Information Network and for the Delaware Health Information Network. The company also helped providers take advantage of the Minnesota e-Health grant initiative. One of the reasons for the success of the federal standard was the charter given to the industry participants and government interests in developing it. They adhered to tenets like “Keep it simple; think big, but start small” and “Design for the little guy so that all participants can adopt the standard and not just the best resourced.” Their approach resulted in a standard that reused proven, understood technologies where possible in order to reduce complexity— and, thus, cost. Performance, scalability, and ease of adoption are all wellknown quantities with Direct. Direct is literally “secure email”; it is based on email’s proven, 30-year-old transport technology (Simple Mail Transport Protocol, or SMTP), underlying a proven, 25-year-old security framework (x.509 Public Key Infrastructure, or PKI) with another proven, 30-year-old directory service (Domain Name System, or DNS) for certificate discovery. Uses of Direct include transactions such as: • Physician-to-specialist (in which a primary care physi-

cian sends clinical data to referring physicians). • Provider-to-provider (in which a hospital sends a discharge summary to a patient’s home health agency). • Clinic-to lab-to clinic (in which a clinic sends an order to a lab, which returns a lab report to the clinic). Direct and meaningful use

Direct messaging can also satisfy the federal government’s EHR meaningful use objectives such as these, for stage 1 (which sets the baseline for electronic data capture and information sharing): • Exchange clinical information: Capability to exchange key clinical information (such as problem list, medication list, medication allergies, diagnostic test results, etc.) among providers of care and patient-authorized entities electronically. • Structured lab data into electronic health record (EHR): Incorporate clinical lab-test results into certified EHR technology as structured data. • Electronic copy to patients: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, discharge summary, procedures) upon request (see Direct and Patient Engagement, below). • Discharge instructions: Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request. • Clinical summaries to patient: Provide clinical summaries for each office visit. • Send patient reminders: Send reminders to patients per patient preference for preventive/follow-up care. • Provide patient access: Provide patients with timely electronic access to their health information (including lab results, problem lists, medication lists, medication allergies) within four business days of the information being available to the eligible professional. • Provide patient education:

Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient, if appropriate. • Summary of care: Providers receiving a patient from one setting of care and referring to another setting of care should provide a summary of care record for each transition of care or referral. • Immunization registry: Capability to submit electronic data to immunization registries and actual submission in accordance with applicable law and practice. • Report to public health: Capability to submit electronic data on reportable (as required by state or local law) lab results to public health agencies and actual submission in accordance with applicable law and practice. • Syndromic surveillance: Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice. • Report clinical quality measures to CMS: Provide aggregate numerator, denominator, and exclusions through attestation electronically (pending CMS readiness).

1) Ask the patient if he or she would like to receive his or her medical records electronically using a free PHR product and a secure messaging standard. 2) If the patient consents, ask for his or her email address. 3) Send a Direct message to newuser@direct.healthvault .com with the patient’s email address in the subject field. 4) HealthVault will create a Direct address for the patient and send him or her a link to a Web page to activate the address and a HealthVault PHR account for free. 5) The provider sends a Continuity of Care Document—a standard electronic, structured medical record—to the patient’s HealthVault account. The records are imported into the appropriate sections of the PHR, and the patient can respond to the message with questions. Using a PHR with patients establishes a bidirectional communication channel between patient and provider that is as

Expanding health care communication

By creating a federal standard for electronic exchanges through open-source collaboration, the Direct messaging system has expanded the conversation in health care in several ways: • It provides a simplified (and thus cost-effective) means of extending secure digital communications to previously disenfranchised entities such as patients and smaller providers. • It replaces costly and inefficient paper-driven workflows. • It simplifies connectivity among disparate health information systems. Direct can truly be the future of health care communication. McLain Causey, a product manager at Ability Network in Minneapolis, has a background in computer science and industry experience in cybersecurity and health care technologies.

Family Medicine St. Cloud/Sartell, MN We are actively recruiting exceptional part-time or full-time BC/BE family medicine physicians to join our primary care team in Sartell, MN. This is an out-patient only opportunity and does not include labor and delivery or hospital call and rounding. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Previous electronic medical record experience is preferred but not required. We use the Epic electronic medical record system at all of our clinics and admitting hospitals.

Direct and patient engagement

A number of the stage 1, Directcompliant meaningful-use measures listed above involve engaging with patients via electronic technology. One way to do so is through a personal health record (PHR). The PHR is the patientfacing version of an EHR: an electronic repository of clinical information for patient use. Many health system EHRs offer PHRs to patients. If a practice or hospital does not have a PHR of its own, there are other options, such as Microsoft HealthVault, a PHR that is free for patient use and costs providers nothing. Microsoft is an Ability partner that has been engaged in Direct projects. As an example, using the HealthVault PHR to satisfy a patient-engagement meaningfuluse measure through Direct, a provider could do the following:

easy to use as email, but secure enough to transmit PHI legally.

Our HealthPartners Central Minnesota Clinics – Sartell moved into a new primary care clinic in the summer 2010. We offer a competitive salary, an excellent benefit package, a rewarding practice and a commitment to providing exceptional patient-centered care. St Cloud/Sartell, MN is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with a traditional appeal. For more information, please contact diane.m.collins@ healthpartners.com or call Diane at 800-472-4695 x3. EOE

healthpartners.com ©

APRIL 2012

MINNESOTA PHYSICIAN

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f you’re a physician in Minnesota, you know that the U.S. Office of the National Coordinator and the Minnesota Office of Health Information Technology have mandated that electronic health records (EHR) systems be installed in a variety of healthcare provider organizations. Minnesota’s state implementation plans call for all health care providers and hospitals to have an interoperable EHR system by 2015. Essentially, this means that no matter what type of EHR system your facility in-stalls, it must be able to ex-change information with everyone else’s EHR. This is not an easy task, and a new technology industry has evolved to provide the services needed to make it happen. In Minnesota, the nonprofit Community Health Information Collaborative (CHIC) is leading the way toward EHR interoperability through its state-certified health information exchange called HIE-Bridge. HIE-Bridge gives health providers access to authorized patient information

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Bridge-building Advancing health information exchange in Minnesota By Cheryl Stephens, PhD through a secure Web-based information exchange platform. Providers from different health care systems can exchange clinical documents electronically, using a Continuity of Care Document—a snapshot patient summary containing the pertinent clinical, demographic, and administrative data for a specific patient. Nearly 200 health organizations in Minnesota and Wisconsin now use the HIEBridge system, and CHIC and its technology partners are bolstering the infrastructure required to expand its health information exchange services Evolution of a health information exchange

Duluth-based CHIC was developed under a federal Office of Rural Health Policy–Network

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www.siouxfalls.va.gov 30

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MINNESOTA PHYSICIAN APRIL 2012

Development grant in 1997. It is now a self-sustaining organization financed by dues from its more than 170 members, which represent the entire health spectrum—hospitals, clinics, longterm care facilities, tribal health facilities, higher education institutions, and public health departments in Minnesota. This unique partnership allows CHIC members to maximize the health care services they can provide. By coordinating health information technology, CHIC provides its members strictly controlled access to patient health care records among care facilities; sends Medicare claims efficiently and quickly; recruits and trains users for the state’s immunization registry; administers telecommunications services applications for members; and coordinates emergency preparedness for health care partners under a contract with the Minnesota Department of Health Office of Emergency Preparedness. Beginning in 2004, CHIC assisted in developing the specifications and technical architectural design of the Nationwide Health Information Network Exchange (NwHIN), a set of standards, services, and policies that enable secure health information exchange over the Internet. We were also closely involved in developing policies and procedures for joining the exchange. As an outgrowth of this work, in 2010 CHIC contracted with the Social Security Administration to exchange Disability Determination patient records electronically. CHIC developed an extensive Continuity of Care Document that met Social Security’s requirements, and the project went live in September 2011. The streamlined electronic work flow for an old process has improved the turnaround time for decisions

regarding disability insurance and decreased the time it takes for providers to receive payments under this same program. Additionally, in the Duluth area CHIC has implemented a Veterans Administration program called the Virtual Lifetime Electronic Record (VLER). The program is designed to build a complete electronic health record for all service persons, both active and retired, that will contain information from the private provider’s records as well as the Veterans Health Information Systems and Technology Architecture (VistA) system. Thus, no matter where service people are stationed or where veterans receive their care, all of their patient information will be available for their treatment. HIE operations

CHIC is currently working on expanding its electronic information exchange system to provide a greater breadth of services. To that end, we have joined forces with Emdeon, a technology company that is also certified as a health data intermediary through the state’s Health Information Exchange Service Provider certification process. The HIE-Bridge service has been certified through this same process as a health information organization—the only one in the state to date. [More on the state’s certification process for health information exchange is available at www.health.state.mn.us /e-health/hie.html.] Data that is exchanged through the HIE-Bridge is encrypted before it is moved across the Internet and decrypted just after it is dropped off at the other end. At no time is any information available for reading while traversing the Internet. Also, all users requesting information must adhere to a Military Level 3 Authorization/ Authentication process every time they enter into the HIEBridge system. No information is ever released from HIE-Bridge unless a signed patient release is attested to or it is an emergency. CHIC’s existing HIE-Bridge network is currently implemenBRIDGE to page 32

Practice Well. Live Well.

Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner.

Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life.

The perfect match of career and lifestyle.

Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Dermatologist • Family Medicine • Emergency Medicine

Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties:

• Hospitalist • Internal Medicine • Pediatrics

For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227

• ENT • Family Medicine • General Surgery • Geriatrician/ • Outpatient Internal Medicine

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APRIL 2012 MINNESOTA PHYSICIAN

Bridge from page 30 ted with a provider directory; a federated record locator service (RLS) that serves as an electronic â&#x20AC;&#x153;card catalogueâ&#x20AC;? for patient records; and a consent management system that meets the requirements of Minnesotaâ&#x20AC;&#x2122;s current RLS legislation. To meet the long-term requirements for Minnesota and its health care providers, this platform will be expanded with laboratory directories and record locator information from Emdeon, along with directories for the Direct messaging program, which facilitates sending secure, encrypted messages over the Internet. CHIC and Emdeon have agreed to collaborate to deliver best-in-class services for statewide shared services, including both short- and longterm technical infrastructures and core HIE services, so that exchange members can exchange health information across their organizational boundaries. The short-term statewide shared HIE services will use technologies based on federal specifications already

implemented in certain health care provider organizations. We will augment these services with core HIE services to address obvious, immediate needs around message exchanges, as well as laboratory services. We anticipate that the need for more robust and query-based forms of health information exchange will result in a natural progression of certain initial use cases from a reliance on Directbased message â&#x20AC;&#x153;pushesâ&#x20AC;? (e.g., sending clinical information between two known entities, e.g., from a specialist to a primary care provider) to exchange-based messages, queries, and â&#x20AC;&#x153;pullsâ&#x20AC;? (e.g., querying for information about a patient, and responding with information on the location and/or the content of a patientâ&#x20AC;&#x2122;s records). For other use cases (such as primary-to-specialist care referrals), evolution may involve not so much a change in the electronic transport mechanism but, rather, better integration with existing workflows or adoption of higher-level standards of interoperability.

The intention is for HIEBridge to provide an evolving and â&#x20AC;&#x153;right-sizedâ&#x20AC;? technology platform at the times and places, and in the most appropriate manner, needed to ensure effective and sustainable health information exchange in Minnesota and with surrounding states. Future directions

Much has been done to help hospitals and clinics move to the electronic age with health information technologies. Incentive programs such as REACH (Regional Extension Assistance Center for Health Information Technology), Meaningful Use dollars, and eHealth Connectivity grants have all focused on these specific health care providers. These initiatives have helped advance the use of electronic health records and health information exchange in Minnesota. In the coming year, we hope to target another important segment of the continuum of care for patients, particularly the vulnerable population residing in long-term care facilities

throughout Minnesota. We have commitments from Aging Services of Minnesota and Care Providers of Minnesota to work together on outreach and implementation efforts with the numerous facilities around the stateâ&#x20AC;&#x201D;virtually all of whom are members of one of these two agencies. We anticipate that integrating long-term care facilities into HIE-Bridge will improve patient care, with more timely and complete information. We also anticipate improved information flow during transitions of care between these facilities and hospitals. CHICâ&#x20AC;&#x2122;s history of providing relevant technology services to its members, through close collaboration in a trust-based environment, provides the basis for our vision for health information exchange. Along with our participating developers ApeniMED and Emdeon, we will continue working toward achieving that vision. Cheryl Stephens, PhD, is president and CEO of the Community Health Information Collaborative.

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MINNESOTA PHYSICIAN APRIL 2012

Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/ BE full-range family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice.

Chief Medical Officer Rice Memorial Hospital has an outCandidates submit a cover standing opportunity for the right letter and resume to: person to serve as its Chief Medical Michael Schramm, CEO Officer (CMO). Rice Memorial Hospital Reporting directly to the CEO, this 301 SW Becker Avenue Willmar, MN 56201 senior executive will be responsible for leading the medical staff in the planRice provides a competining, facilitating and implementing of tive salary and generous programs to enhance physician effecbenefit package. To learn tiveness, quality of practice, clinical more see our website at integration and patient satisfaction. www.ricehospital.com The CMO will be line administrator for physician services within the Emergency Department and is expected to provide direct patient care at least four shifts per month in the Emergency Room. The position requires an MD or DO with a license to practice medicine in the State of Minnesota; as well as a minimum of seven years of clinical experience and at least two years of physician leadership experience. An MBA or Masters degree in public health is desirable. Located in the lakes region two hours west of the Twin Cities, Rice Memorial Hospital is the state’s largest municipal hospital, providing a vast array of services to the residents of west central Minnesota, including high-tech diagnostics, rehabilitation, long-term care, DME, mental health, dialysis, radiation oncology and hospice. Rice recently completed a $52 million building and renovation project.

For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@ healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community

Two BC/BE Orthopaedic Surgeons wanted to join four orthopaedic surgeons at Sanford Bemidji Orthopaedics Clinic in Bemidji, Minnesota. Part of an 85-physician, multi-specialty group practice and 118 bed acute care hospital. 1:6 call anticipated. Competitive compensation/benefits package, paid malpractice, relocation assistance and more. Sanford Health of Northern Minnesota has 1,450+employees and is part of Sanford Health system based in Fargo, ND and Sioux Falls, SD. Bemidji, Minnesota, located in northwestern Minnesota, is a beautiful resort community offering exceptional schools, a state university, and yearround cultural activity as well as great access to the outdoors for year-round recreation activity. To learn more about this excellent practice opportunity contact: Kathie Lee, Director Physician Placement Phone: 701-280-4887 Fax: 701-280-4136 Email: Kathie.Lee@sanfordhealth.org AA/EOE

The Northwest Wisconsin Region of Mayo Clinic Health System has more than 300 physicians representing a wide range of medical specialties in a community healthcare setting. We are a respected and financially secure organization with strong emphasis on high quality care and patient satisfaction. A Mayo One emergency medical helicopter is based in Eau Claire, offering surrounding communities access to the area’s only verified Level II trauma center. Our current opportunities include: Dermatology Oncology Emergency Medicine Orthopedic Surgery – General, Sports, & Trauma Endocrinology Palliative Care Family Medicine Pathology General Surgery PM & R Hospitalist Psychiatry – Adult Internal Medicine Rheumatology Neurology Urology If you wish to learn more or to express interest in this position, please contact: Cyndi Edwards/Christie Blink by phone (800-573-2580); email edwards.cyndi@mayo.edu or blink.christie@mayo.edu

APRIL 2012 MINNESOTA PHYSICIAN

SPECIAL

innesota is a great place to live and work, especially for members of the health care industry. Health care professionals and medical industry employees alike can take enormous pride in our state’s history of contributions to medical science. The environment that exists in Minnesota has supported the development of high-knowledge content and life-supporting medical technology in collaboration with world-class health care delivery and reimbursement systems, leading to many medical “firsts” in our state. The uniqueness of our Minnesota environment has created an “economic ecosystem” that has become the envy of much of the world. The state's medical device industry has benefited from and contributed to advancing this collaborative and highly entrepreneurial environment. Minnesota is home to over 400 medical technology companies that produce final products and 600 supporting companies that provide everything from legal services to high-technology

FOCUS:

N E W - G E N E R AT I O N

TECHNOLOGY

Re-igniting the spark Taking stock of the medical device industry By Dale Wahlstrom components and special testing capabilities. More than 250,000 people in Minnesota are either directly or indirectly employed by the medical technology industry, making our state home to the most densely concentrated medical technology cluster per capita in the United States. According to research published by management and technology consultant Kelvin Willoughby, PhD, in January 2009, Minnesota is 3.35 times more concentrated in medical technology than the country as a whole. This highly concentrated industry has helped to improve and save patients’ lives worldwide, created thousands of highpaying jobs, and supported our vibrant social community through charitable giving and other community involvement.

It is an integral part of our economic health and local culture. Unfortunately, today the national and local medical device industries are being pressured by a variety of factors. For example, last year the U.S. Department of Trade reported that in 2008 the U.S. imported more medical devices than we exported. Medical devices have been a dominant industry for our country, a source of wealth, and an offset to our burdensome trade deficit. We have yet to see whether this trend of increased imports will continue or not. The forces hampering the level of growth in the medical device industry are both internal and external. This situation is a cause for concern but also provides a challenge for our community to overcome. Five issues are key to understanding the medical device industry today and determining how to retain our state’s leadership position within it: collaboration, regulation, investment, technology commercialization, and global pressures. Collaboration

We invite you to explore our opportunities in: In the heart of the Cuyuna Lakes region of Minnesota, the medical campus in Crosby includes Central Lakes Medical Clinic, a 30-physician multispecialty group, and Cuyuna Regional Medical Center, a critical access hospital offering superb new facilities with the latest medical technologies. Outdoor activities abound, and with the Twin Cities metropolitan area just a short drive away, you can experience the perfect balance of recreational and cultural activities. Enhance your professional life in an environment that provides exciting practice opportunities in a beautiful Northwoods setting. The Cuyuna Lakes region welcomes you.

• Family Medicine • Internal Medicine

CENTRAL LAKES MEDICAL CLINIC P.A.

Contact: Todd Bymark, tbymark@cuyunamed.org (866) 270-0043 / (218) 546-4322 | www.cuyunamed.org

MINNESOTA PHYSICIAN APRIL 2012

As an engineer and senior manager at a large medical device company in a prior life, and now as the president and CEO of LifeScience Alley, I’m most concerned about the breakdown in the culture of collaboration among different segments in the health care environment. When I started my career, more than 30 years ago, the day-to-day interaction among health care delivery, reimbursement, and medical device industry professionals was the key to success in identifying and implementing system solutions. One need only recall the story of physician Walt Lillehei and electrical engineer Earl Bakken inventing the pacemaker, which ignited the creation of the medical device industry in Minnesota, to understand the need for and benefits of this type of collaboration.

In my opinion, collaboration among stakeholders is the reason that Minnesota is the most densely concentrated medical products industry community in the U.S. When the different members of the health care ecosystem work together, clinical need is internalized and invention occurs. As a result, all members of the ecosystem benefit—especially the patients. However, in this era of health care reform and mounting cost pressures in the health care system, many constituents have taken to blaming other sectors for the issues the industry faces. There are reimbursement people who feel that all medical device products add to healthcare system costs, and device people who feel that the only true cost-reduction possibilities are device-driven. The reality likely lies somewhere in the middle, but these concerns cannot be addressed successfully without collaboration in good faith among all parties. In addition, productive collaboration in the U.S. is increasingly complicated by a pervasive fear of conflict of interest. In an effort to avoid the appearance of inappropriate relationships between clinicians and device makers, companies functioning as a “middleman” are meeting with doctors and health care professionals, interpreting their needs, and then communicating those needs to medical device manufacturers. Unfortunately, increasing the distance between clinicians at the point-of-care and technology/therapy producers only hampers the ability to bring about novel, and much needed, solutions to patients. Regulation

One of the most publicized issues facing the medical products industry today is the unpredictable nature of the regulatory approval cycle. No one is advocating for a lack of oversight and regulation of the industry, as we all value the safety of the patients whose lives we endeavor to improve and save. The concern within industry is the unpredictable nature of requirements and uncertain timelines for approval or disapproval. SPARK to page 36

Practice Well. Live Well.

Lake Region Medical Group is seeking a full-time Certified Physician Assistant to join our Lake Region Healthcare team of 3 orthopedic surgeons; providing care in a multi-specialty clinic with 50+ providers.We are looking for a hardworking, conscientious individual committed to providing quality care to our patients as we develop our Orthopedic Center of Excellence.

Duties will include new and follow-up patient visits, assisting with surgery, post-op visits and hospital rounds in our 108 –bed community based hospital.The ideal candidate will have 2-5 years experience in orthopedics. We offer a competitive salary with a healthy benefit package. For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227

712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424

Lake Region Healthcare is an Equal Opportunity Employer. EOE

www.lrhc.org

St. Cloud VA Health Care System is accepting applications for the following full or part-time positions: • Associate Chief, Primary and Specialty Medicine (Internist-St. Cloud) • Dermatology (St. Cloud)

• Internal Medicine/ Family Practice (Alexandria, Brainerd, St. Cloud, Montevideo) • Medical DirectorExtended Care & Rehab (IM or Geriatrics) (St. Cloud)

• Director, Primary & Specialty Medicine (Internal Medicine) (St. Cloud)

• NP/PA (Montevideo)

• Disability Examiner (IM or FP) (St. Cloud)

• Psychiatrist (Brainerd, St. Cloud)

• ENT (St. Cloud)

• Radiologist (St. Cloud)

• General Surgeon (St. Cloud)

• Urgent Care Provider (MD, PA or NP)

• Geriatrician (Nursing Home-St. Cloud)

• Weekend Medical Officer of the Day (IM or FP) (fee for service appointment, St. Cloud)

• Hematology/Oncology (St. Cloud)

US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Hematology/Oncology positions. Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible relocation bonus. EEO Employer.

Excellent benefit package including: Favorable lifestyle

Competitive salary

26 days vacation

13 days sick leave

CME days

Liability insurance

Interested applicants can mail or email your CV to VAHCS

St.Health Cloud VA Care System Brainerd | Montevideo | Alexandria

Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-654-7650 or Telephone: 320-252-1670, extension 6618

APRIL 2012 MINNESOTA PHYSICIAN

Spark from page 34

Investment

The Food and Drug Administration (FDA) has taken note of the situation and is making efforts to improve the process. One of its initiatives, launched in August 2011, is called the Strategic Plan for Regulatory Science. The agency recognizes the limitations of clinical studies and traditional bench-testing to identify product performance concerns. The regulatory science strategic plan seeks to apply advanced predictive modeling and testing as a tool to help the FDA assess new products, with goals of better predicting chronic product performance and providing faster approval cycles. We recognize that industry and academia can play a role in this process, which is why LifeScience Alley has signed a memorandum of understanding to work with the FDA on improving regulatory science. Through this project, industry and academic stakeholders will work to form a center of excellence in Minnesota focused on regulatory science as applied to medical devices.

The uncertainty in achieving a regulatory decision is causing entrepreneurs to hold back on starting new companies; large companies to reduce their research and development investments; and the venture capital community to reduce or stop investing in medical technology. The BioBusiness Alliance of Minnesota, a strategic affiliate of LifeScience Alley, provides support to start-up companies. We have supported 272 companies in the start-up stage over the past three years. This year, for the first time, we have seen three company business plans with no intention to release their products in the U.S. We have also received anecdotal input from some members that they are moving their design, clinical testing, and product approval efforts offshore to avoid some of the uncertainties of the commercialization process. The good news is that the community shares our concern over the dearth of funding available to promising start-up companies. In 2011, the BioBusiness Alliance of Minnesota created

NEW POSITIONS:

Family Practice Urgent Care Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •

Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned

Please contact or fax CV to: Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429 763-504-6600 • Fax 763-504-6622

Visit our website at www.NWFPC.com

MINNESOTA PHYSICIAN APRIL 2012

the Minnesota Angel Network (MNAN) to accelerate the growth of early-stage companies through multidisciplinary education and connections to investors, strategic alliances, and business resources. In the fourth quarter of 2011 alone, MNAN attracted 50 individual accredited angel investors and 20 self-identified accredited angel funds/angel networks as direct members. MNAN invited 24 companies to participate in the process, certifying six of them by year’s end. Technology commercialization

While Minnesota still has a thriving entrepreneurial community, our academic and business communities have struggled to transfer world-leading research seamlessly into the private sector for commercialization. Leaders from business and from the University of Minnesota have been working on this issue. In a very promising breakthrough, the university recently announced a philosophical and practical change in how it handles the transfer of intellectual property from industry-funded research. The new system, dubbed MN-IP, provides a simpler and more business-friendly framework for transferring research into the private sector. There is still work to be done, but the necessary parties are having the right conversation for sustained improvement. Global pressures

Many countries have begun to appreciate the value of the medical device industry and are making large investments in developing their own industries. Medical technology has attractive attributes: It is clean, average wages are significantly higher than for other industries, and it adds value to people’s lives and to society. As a knowledgebased economic sector, it is not dependent on local, natural resources and therefore is “portable.” While other industrialized nations are doing their best to entice U.S. companies to establish operations overseas, many of those countries are not able to provide the one resource without which Minnesota’s

device industry would perish: our interconnected industry ecosystem. Beginning with the transition of highly skilled mainframe computing engineers and scientists into medical technology disciplines, we have built a full-spectrum ecosystem with all of the service providers necessary to support our medical product manufacturers right here in Minnesota. It is possible to find entrepreneurial physicians, IP attorneys, regulatory and reimbursement specialists, contract manufacturers, product marketing firms, clinical study locations, and world-class health care facilities all within the Twin Cities alone. Despite the strength of our supporting community, establishing operations in countries like Japan and China is still an attractive option for many of our companies. However, we have an opportunity to engage with these countries in a way that can be mutually beneficial. Our local medical device community can open up business opportunities in other countries while retaining operations at home. Continuing innovation

As a state, we have the ecosystem, the talent, the knowledge, and the resources to continue leading the world in medical device and health care delivery innovation. However, it will require us to work together for the benefit of all stakeholders and, most importantly, for the patients. The good news is that these discussions are already taking place and are beginning to occur more frequently. Medical officers of device companies are meeting with medical officers of reimbursement companies and health care institutions. Given our history of innovation and our community’s deep understanding of the interaction between health care delivery and medical products, Minnesota is uniquely positioned to help guide and set the course to keep the device industry centered in the United States. Dale Wahlstrom is president and CEO for LifeScience Alley and the BioBusiness Alliance of Minnesota. In 2006 he retired from Medtronic, after 24 years.

FAMILY PRACTICE w/OB Live in the relaxed lake country of Mille Lacs and practice medicine where you will make a difference. We’re looking for a Family Physician to join us at Mille Lacs Health System in Onamia, Minnesota. Loan forgiveness options may be available. Contact: Fern Gershone: fgershone@mlhealth.org or Dr. Tom Bracken: tbracken@mlhealth.org

Caring for body, mind and spirit. Onamia, MN • mlhealth.org • 877 - 535-3154

Crookston, MN and Roseau, MN • Country Lifestyle.... Urban Technology • Dedicated Team Approach • Competitive Salary & Benefits Idylic Practice Opportunities located in family friendly communities. Leave the hassle and bustle of the city behind. Contact: Kerri Hjelmstad, Physician Recruiter Altru Health System PO Box 6003 Grand Forks, ND 58201-6003 1-800-437-5373 Fax: 701-780-6641 khjelmstad@altru.org

7 FAMILY PHYSICIANS • 8 PAs • 1 GENERAL SURGEON • CRITICAL ACCESS HOSPITAL ER STAFFED 24/7 • ATTACHED GERIATRIC UNIT & LTC FACILITY • 4 CLINICS

www.altru.org

When Surgery is Necessary Medical management is key to the care of patients with Crohn's disease, but surgery is needed at times. When surgery is necessary, it is important to have a surgeon with experience and interest in surgical care of patients with inflammatory bowel disease, particularly Crohn's disease. Colon and Rectal Surgery Associates has specially trained surgeons with that expertise and experience. We provide comprehensive care you can trust! www.crsal.org

Coon Rapids/Plymouth 651-312-1717 • Edina/Burnsville 651-312-1700 • MInneapolis 651-225-7855 • St. Paul 651-312-1620 Pelvic Floor Center 651-225-7800 • Riverside Endoscopy Center 651-225-7999

APRIL 2012 MINNESOTA PHYSICIAN

Violence from page 11 University of Minnesota Extension: Parenting Education Resources at www.parenting .umn.edu, and Shoulder to Shoulder: Raising Teens Together at www.shoulderto shoulderminnesota.org. Home visitation programs. Another effective family-level youth violence intervention is home visitation programs. These programs involve weekly to monthly visits by nurses during pregnancy, continuing for the first two years of a child’s life. The nurses provide parenting information, emotional support, counseling, and linkage to social services. Long-term follow-up in randomized controlled studies conducted by Olds and colleagues indicates that children who are visited have lower rates of offending as teenagers, less antisocial behavior, and less substance use than those not receiving home visitation. The success of this model is a powerful illustration that an intervention during the first two years of a child’s life can have an enduring

Family-level interventions are among the most promising youth violence prevention approaches known to date. effect on development. Physicians should refer high-risk families for home visitation. Programs in Minnesota are funded through the Minnesota Department of Health, with local public health departments choosing how to implement their programs (see www.health .state.mn.us/divs/fh/mch/fhv). Safe firearm storage

A case-control study of firearms conducted by Grossman and colleagues, published in the Journal of the American Medical Association in 2005, found that safe storage practices—specifically, keeping firearms stored

unloaded, in a locked place; and storing ammunition locked and in a separate location—each had a protective effect against unintentional firearm shootings and suicide attempts among children and adolescents. Thus, these are the evidence-based storage practices to convey to gun-owning families. In a study reported in Pediatrics in 2000, Grossman et al. found that brief counseling and providing written information on household firearm risks or firearm removal, safe storage, and storage device coupons in the office setting did not lead to statistically significant changes

A Diverse and Vital Health Service

in gun ownership or storage at three-month follow-up. In a subsequent primary care-based study in Pediatrics in 2009, Barkin and colleagues found that brief motivational interviewing and offering cable locks were significantly associated with using cable locks for safer firearm storage at six month follow-up. In both studies, 24 percent of families were gun owners. Project ChildSafe (www .projectchildsafe.org) is an organization that works with law enforcement to distribute cable gunlocks. Medical practices may be able to obtain gunlocks by working with their local law enforcement offices. As child and adolescent health care providers incorporate youth violence prevention counseling into their clinical encounters with youth and families, think LAKES—a handful of evidence-based youth violence prevention recommendations. Iris Wagman Borowsky, MD, PhD, is an associate professor in the Department of Pediatrics at the University of Minnesota Medical School, Minneapolis.

Boynton Health Service

Welcome to Boynton Health Service >ŽĐĂƚĞĚ ŝŶ ƚŚĞ ŚĞĂƌƚ ŽĨ ƚŚĞ dǁŝŶ ŝƟĞƐ ĂƐƚ ĂŶŬ ĐĂŵƉƵƐ͕ ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŝƐ Ă ǀŝƚĂů ƉĂƌƚ ŽĨ ƚŚĞ hŶŝǀĞƌƐŝƚǇ ŽĨ DŝŶŶĞƐŽƚĂ ĐŽŵŵƵŶŝƚǇ͕ ƉƌŽǀŝĚŝŶŐ ĂŵďƵůĂƚŽƌǇ ĐĂƌĞ͕ ŚĞĂůƚŚ ĞĚƵĐĂƟŽŶ͕ ĂŶĚ ƉƵďůŝĐ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŽ ƚŚĞ hŶŝǀĞƌƐŝƚǇ ĨŽƌ ŶĞĂƌůǇ ϵϬ ǇĞĂƌƐ͘ /ƚ͛Ɛ ŽƵƌ ŵŝƐƐŝŽŶ ƚŽ ĐƌĞĂƚĞ Ă ŚĞĂůƚŚǇ ĐŽŵŵƵŶŝƚǇ ďǇ ǁŽƌŬŝŶŐ ǁŝƚŚ ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚǇ ƚŽ ĂĐŚŝĞǀĞ ƉŚǇƐŝĐĂů͕ ĞŵŽƟŽŶĂů͕ ĂŶĚ ƐŽĐŝĂů ǁĞůůͲďĞŝŶŐ͘ ŽǇŶƚŽŶ͛Ɛ ŽƵƚƐƚĂŶĚŝŶŐ ƐƚĂī ŽĨ ϮϱϬ ŝŶĐůƵĚĞƐ ďŽĂƌĚ ĐĞƌƟĮĞĚ ƉŚǇƐŝĐŝĂŶƐ͕ ŶƵƌƐĞ ƉƌĂĐƟƟŽŶĞƌƐ͕ ƌĞŐŝƐƚĞƌĞĚ ŶƵƌƐĞƐ͕ D Ɛͬ>WEƐ͕ ƉŚǇƐŝĐŝĂŶ ĂƐƐŝƐƚĂŶƚƐ͕ ĚĞŶƟƐƚƐ͕ ĚĞŶƚĂů ŚǇŐŝĞŶŝƐƚƐ͕ ŽƉƚŽŵĞƚƌŝƐƚƐ͕ ƉŚǇƐŝĐĂů ĂŶĚ ŵĂƐƐĂŐĞ ƚŚĞƌĂƉŝƐƚƐ͕ ƌĞŐŝƐƚĞƌĞĚ ĚŝĞƟƟĂŶƐ͕ ƉŚĂƌŵĂĐŝƐƚƐ͕ ƉƐǇĐŚŝĂƚƌŝƐƚƐ͕ ƉƐǇĐŚŽůŽŐŝƐƚƐ͕ ĂŶĚ ƐŽĐŝĂů ǁŽƌŬĞƌƐ͘ KƵƌ ŵƵůƟĚŝƐĐŝƉůŝŶĂƌǇ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ŚĂƐ ďĞĞŶ ĐŽŶƟŶƵŽƵƐůǇ ĂĐĐƌĞĚŝƚĞĚ ďǇ , ƐŝŶĐĞ ϭϵϳϵ͕ ĂŶĚ ǁĂƐ ƚŚĞ ĮƌƐƚ ĐŽůůĞŐĞ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ƚŽ ŚĂǀĞ ĞĂƌŶĞĚ ƚŚŝƐ ĚŝƐƟŶĐƟŽŶ͘ ƩĞŶĚŝŶŐ ƚŽ ŽǀĞƌ ϭϬϬ͕ϬϬϬ ƉĂƟĞŶƚ ǀŝƐŝƚƐ ĞĂĐŚ ǇĞĂƌ͕ ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ƚĂŬĞƐ ƉƌŝĚĞ ŝŶ ŵĞĞƟŶŐ ƚŚĞ ŚĞĂůƚŚ ĐĂƌĞ ŶĞĞĚƐ ŽĨ h ŽĨ D ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚǇ ǁŝƚŚ ĐŽŵƉĂƐƐŝŽŶ ĂŶĚ ƉƌŽĨĞƐƐŝŽŶĂůŝƐŵ͘

Gynecologist/Clinical Supervisor ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŝƐ ƐĞĞŬŝŶŐ Ă 'ǇŶĞĐŽůŽŐŝƐƚ ƚŽ ƐĞƌǀĞ ĂƐ ůŝŶŝĐĂů ^ƵƉĞƌǀŝƐŽƌ ĨŽƌ ƚŚĞ tŽŵĞŶ͛Ɛ ůŝŶŝĐ͘ dŚĞ ůŝŶŝĐĂů ^ƵƉĞƌǀŝƐŽƌ ǁŝůů ĞŶƐƵƌĞ ƐƚĂī ĂĚŚĞƌĞŶĐĞ ƚŽ ƌĞůĞǀĂŶƚ ƌĞŐƵůĂƟŽŶƐ͕ ĂƐƐƵƌĞ ŚŝŐŚĞƐƚ ƉƌŽĨĞƐƐŝŽŶĂů ĂŶĚ ĞƚŚŝĐĂů ƐƚĂŶĚĂƌĚƐ͕ ĂŶĚ ǁŽƌŬ ǁŝƚŚ ƚŚĞ ŝƌĞĐƚŽƌ ĂŶĚ ŚŝĞĨ DĞĚŝĐĂů KĸĐĞƌ ŝŶ ĨŽƌŵƵůĂƟŶŐ ůŽŶŐ ƌĂŶŐĞ ƉůĂŶŶŝŶŐ ĂŶĚ ƉŽůŝĐŝĞƐ͘ ƐŵĂůů ƉĞƌĐĞŶƚĂŐĞ ŽĨ ƟŵĞ ǁŝůů ďĞ ƐƉĞŶƚ ƉƌŽǀŝĚŝŶŐ ĐůŝŶŝĐĂů ĂŶĚ ƚĞĂĐŚŝŶŐ ƐĞƌǀŝĐĞƐ ĨŽƌ ƚŚĞ ĐĂĚĞŵŝĐ ,ĞĂůƚŚ ĞŶƚĞƌ KďͲ'ǇŶ ĞƉĂƌƚŵĞŶƚ ĂŶĚ hŶŝǀĞƌƐŝƚǇ ŽĨ DŝŶŶĞƐŽƚĂ WŚǇƐŝĐŝĂŶƐ͘ dŚŝƐ ƉŽƐŝƟŽŶ ŽīĞƌƐ Ă ĐŽŵƉĞƟƟǀĞ ƐĂůĂƌǇ ĂŶĚ Ă ŐĞŶĞƌŽƵƐ ĂĐĂĚĞŵŝĐ ƐƚĂƚƵƐ ƌĞƟƌĞŵĞŶƚ ƉůĂŶ͘ WƌŽĨĞƐƐŝŽŶĂů ůŝĂďŝůŝƚǇ ĐŽǀĞƌĂŐĞ ŝƐ ƉƌŽǀŝĚĞĚ͘ ƉƉůǇ ŽŶͲůŝŶĞ Ăƚ ŚƩƉƐ͗ͬͬĞŵƉůŽǇŵĞŶƚ͘ ƵŵŶ͘ĞĚƵ ĂŶĚ ƌĞĨĞƌĞŶĐĞ ƌĞƋƵŝƐŝƟŽŶ ŶƵŵďĞƌ 176093͘ dŽ ůĞĂƌŶ ŵŽƌĞ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ,ŽƐĞĂ KũǁĂŶŐ͕ ,ƵŵĂŶ ZĞƐŽƵƌĐĞƐ ŝƌĞĐƚŽƌ ;ϲϭϮͿ ϲϮϲͲϭϭϴϰ͕ ŚŽũǁĂŶŐΛďŚƐ͘ƵŵŶ͘ĞĚƵ͘ dŚĞ hŶŝǀĞƌƐŝƚǇ ŽĨ DŝŶŶĞƐŽƚĂ ŝƐ ĂŶ ƋƵĂů KƉƉŽƌƚƵŶŝƚǇ͕ ĸƌŵĂƟǀĞ ĐƟŽŶ ĚƵĐĂƚŽƌ ĂŶĚ ŵƉůŽǇĞƌ

ϰϭϬ ŚƵƌĐŚ ^ƚƌĞĞƚ ^ ͻ DŝŶŶĞĂƉŽůŝƐ͕ DE ϱϱϰϱϱ ͻ ;ϲϭϮͿ ϲϮϱͲϴϰϬϬ ͻ ǁǁǁ͘ďŚƐ͘ƵŵŶ͘ĞĚƵ

MINNESOTA PHYSICIAN APRIL 2012

You wouldnâ&#x20AC;&#x2122;t give a 4-year-old a drink, so why would you give one to an unborn child? As a physician, itâ&#x20AC;&#x2122;s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy. Share 049: Zero Alcohol For Nine Months.