Can I Have it Both Ways?

CONTENTS VOLUME 14, NO. 2

2

Index to Advertisers

3

IN THIS ISSUE

MARCH/APRIL 2012

It was the Best of Times; It was the Worst of Times

By Richard R. Sturgeon, M.D.

4

PRESIDENT’S MESSAGE

To Interoperability and Beyond...

By Peter J. Dehnel, M.D. Page 26

5

TCMS IN ACTION

By Sue Schettle, CEO

6

LETTERS

Transfusion Practices ELECTRONIC HEALTH RECORD

7

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Colleague Interview: A Panel Discussion with Area Chief Medical Information Officers

13

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My Experience with an EMR in the Primary Care Setting

By Ellen DeVries, M.D.

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The EMR in the Tertiary Care Setting: What’s Good, What’s Bad?

By John F. O’Leary, M.D.

Page 7

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Electronic Health Records Current State

By Scott W. Tongen, M.D.

19

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Doctor and Patient Relationships in the Age of EMRs and PHRs

By Becky Schierman

20

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YOUR VOICE

Electronic Health Records: Hope or Hype?

By Richard J. Morris, M.D.

21

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Implementing EHR: Unintended Consequences

By Mike Flicker, MBA

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Page 28

Page 25

Coordinating Health Information Technology Through CHIC

By Cheryl M. Stephens, Ph.D.

25

Mary K. Brainerd Receives Shotwell Award

26

TCMS Celebrates 3rd Annual Board Dinner

28

First A Physician Award/National Healthcare Decisions Day

29

In Memoriam/West Metro Medical Society Alliance Archives/ Career Opportunities

30

New Members

32

LUMINARY OF TWIN CITIES MEDICINE

Glen D. Nelson, M.D. MetroDoctors

The Journal of the Twin Cities Medical Society

On the cover: In transition to the digital world, hang on to the art of medicine.

Articles begin on page 7.

March/April 2012

1

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

March/April Index to Advertisers TCMS OfďŹ cers

President: Peter J. Dehnel, M.D. President-elect: Edwin N. Bogonko, M.D.

Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Gregory A. Plotnikoff, M.D., MTS Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reect the ofďŹ cial position of TCMS.

Advanced Dermatology Care.........................19 Audiology Concepts .........................................12

Secretary: Lisa R. Mattson, M.D.

CrutchďŹ eld Dermatology.................................. 2

Treasurer: Kenneth N. Kephart, M.D.

The Davis Group .............. Inside Front Cover

Past President: Thomas D. Siefferman, M.D.

Fairview Health Services .................................31

TCMS Executive Staff

Hazelden ..............................................................29

Sue A. Schettle, Chief Executive OfďŹ cer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Executive Assistant (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Katie R. Snow, Project Coordinator (612) 362-3704 ksnow@metrodoctors.com For a complete list of TCMS Board of Directors go to www.metrodoctors.com.

Healthcare Billing Resources, Inc. ...............18 Lockridge Grindal Nauen P.L.L.P. ................. 6 Minnesota Epilepsy Group, P.A....................18 Minnesota Physician Services, Inc. ...................

Inside Back Cover The MMIC Group .............Inside Back Cover MMIC Health IT ........... Outside Back Cover Neighborhood HealthSource.........................31 Noran Clinic Sleep Center .............................16 Saint Therese.......................................................16 Stillwater Medical Group................................30 Toshiba Business Solutions.............................14 Uptown Dermatology & SkinSpa................22 Winona Health ..................................................31

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Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

Exceptional Care for All Skin Problems

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For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Katie Snow at (612) 362-3704.

2

March/April 2012

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The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

It was the Best of Times; It was the Worst of Times

W

hile not actually facing the guillotine, physicians and other clinicians face daunting disruptive changes inherent in the digital transformation of the delivery of health care. All physicians, but especially Independent Physicians, are under significant stress during this transition.

Studies have evaluated the impact of EHRs on documentation time for physicians and nurses. For physicians, an average increase of 17.5 percent in documentation time was identified. They are reluctant to embrace technology that pulls caregivers from their primary objective — patient care.

To further complicate this problem, the incentive for physicians to invest in EHR is out of alignment in the present environment. Benefits of health information technology are often noted as reductions in overall health care costs. These benefits may not be realized by providers who make the financial investment in a system, but rather are allocated to Medicare and to private payers.

On the other hand...Embracing e-healthcare and treating Information Technology as a tool to improve patient safety and the quality of care enables health care professionals to benefit from the technology formerly used for management purposes.

Continuous systems enhancements and perhaps more important, continuous user training/learning will increase efficiency of today’s health care IT. Workflow improvements will eventually require less and less keyboard time. Point of care intuitive decision support will increase effectiveness of delivered care. We have a golden opportunity to create a metro-wide system.

Several large systems already share basic EPIC software. They have already invested significant capital in this common system. Proprietary business information can be sequestered while effectively making clinical information instantaneously available.

A whole new world is expected with the next generation of information technology at the point of care. Data becomes immediately available as information. New efficient workflows will be cost effective and free up the physician to reclaim the interpersonal patient-doctor space.

In this issue of MetroDoctors, guest contributors present views from the trenches using today’s technology.

The Colleague Interview has a special significance. We bring you a virtual panel discussion on the issues provided by six metro area Chief Medical Information Officers. You will find their collective response to the operational and vision questions to be informative, realistic and reassuring.

This collegial and collaborative bunch has agreed to provide us future panel discussions on more focal timely IT topics. If you have questions or issues you would like to have them discuss, send them to Nancy Bauer, editor.

By Richard R. Sturgeon, M.D. Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

Ellen DeVries M.D., pediatrician, has had a positive experience both in her pediatric clinic and hospital setting. She finds it very easy to pull up tests and images to review with the patient/ family — a more efficient and effective process. She notes value of thorough training before going live and “at the shoulder help” when first using an EMR. John O’Leary M.D., surgery specialist in a tertiary hospital, notes that his patients often involve multiple specialists. The EHR allows input and communication between and among these experts in real time, including off site. He has instant data retrieval including imaging with the additional assist of decision support and alerts.

Scott Tongen M.D., hospitalist, describes some EHR benefits to his practice: access, legibility, treatment reminders, allergies and drug interaction alerts. He feels we are in a “toddler stage” of learning to use this new tool.

Rebecca Schierman provides a patient’s perspective. She likes having control of her Personal Health Record to access information and conduct quick and convenient interactions with her clinic. She dislikes the physician focus on the EHR instead of the patient. She sees a future use of EHR to actively involve patients in managing their own health.

Richard Morris M.D., specialty clinic, says conversion to digital records is “progress” in some ways: data exchange, eRX (safer), research/report generation, decreased transcription, better charge capture and systematic peer review of “Best Practice.” Drawbacks include increased data entry burden which reduces productivity and interferes with patient contact.

Mike Flicker, MMIC Health IT Team, says the immediate availability of clinical data combined with embedded programs to alert physicians of optimal care plans has the potential to significantly reduce adverse outcomes and malpractice risks. However, the electronic health record has also shown to bring unintended consequences that could increase the frequency of events that increase practice risk.

Cheryl Stephens represents 170 diverse stakeholders in her role with Community Health Information Collaborative (CHIC). They look to identify and take advantage of opportunities to coordinate health information technology.

Progress is impossible without change. As difficult as it may be, it is in our best interest to embrace this new technology and influence the transformation.

March/April 2012

3

President’s Message

To Interoperability and Beyond...

PETER J. DEHNEL, M.D.

Medical records are, in their broadest sense, at the core of medicine and a signiďŹ cant part of the “value addedâ€? that physicians bring to the doctor-patient relationship. This edition of MetroDoctors focuses on the seismic transformation from a paper-based system to one where all data elements are digitally encoded and available for an incredible variety of manipulation, tracking, analysis and, ideally, better patient care and outcomes. This title is based on the 1995 Pixar ďŹ lm, Toy Story, which brought us, “To inďŹ nity and beyond!â€? It is the tag line of the space ranger action ďŹ gure Buzz Lightyear, who mistakenly believes the rocket pack on his back is real and that “beyond inďŹ nityâ€? is an attainable goal.

In contrast to reaching the other side of inďŹ nity, there is a much broader world beyond basic electronic health record interoperability. A few cautionary words are important before getting there, however.

I need to ďŹ rst reassure some of you that I am a ďŹ rm believer in the potential that electronic health records bring to the delivery of health care and the better practice of medicine. That said, there is a long ways to go before they fulďŹ ll the six basic requirements of the Institute of Medicine for quality health care: safe, effective, efďŹ cient, patient-centered, timely and equitable.

At the risk of oversimpliďŹ cation, but for the purposes of illustration, consider how ďŹ ve different EHR “systemsâ€? — A, B, C, D and E — handle the following description: “The rain in Spain falls mainly in the plain.â€? Systems A, B and C process and store this description in 35 separate data elements — 5 letter a’s, 2 e’s, 1 f , 2 h’s, 6 i’s, 4 l’s, 1 m, 6 n’s, 2 p’s, 1 r, 2 s’s (one of which is capitalized), 2 t’s (one of which is capitalized) and 1 y. There are, in addition, 8 spaces. System A stores them in 13 categories (each letter is a separate category) in descending order of size of the category. System B stores them as categories in alphabetical order. System C stores them in reverse alphabetical order, and needs to separate capitalized from lower case elements. These do not share information easily, because the rules for handling these data elements are unique and proprietary.

System D stores this description as individual word elements and therefore 8 categories (“in� is used twice). It appears more sophisticated than the systems that store individual letters as data elements, but it cannot “reconstruct� the words from these other systems because the software-based rules are proprietary.

System E saves this as an intact statement, but can only “share� with other systems an image of the phrase and is not readily available for manipulation or broader analysis.

Note that in this example, the systems are all using an “alphabet compliant� format — standard English system letters.

Imagine if you allow for Chinese, Japanese or Arabic “data elements.�

Broaden your view to now include real patient data instead of just letters — height and weight, BMI and/or BMI percentile, blood pressure (systolic and diastolic), immunization information (which includes variable combination vaccines, the manufacturer’s lot number, site of administration and expiration date), medication allergies, family history, physical exam and even cancer type, stage of involvement and pertinent genetic or hormonal markers. The ongoing challenge is to safely, effectively and reliably transmit this crucial data from one system to another.

So what is on the other side of basic EHR interoperability? It is designing, building and operating a “trusted health care information platform.� According to Steve Tirrell, (Information Management Team at IBM), this can be summarized as an information system (platform) that can: s !CQUIRE DATA EFFECTIVELY FROM DISPARATE SOURCES s 'OVERN UNSTRUCTURED DATA PERCENT OF CLINICAL INFORMATION IS IN AN UNSTRUCTURED FORMAT s -ANAGE hBIG DATAv ˆ STREAMING CONTENT WEB LOGS SOCIAL NETWORKING ETC s #LEANSE AND STANDARDIZE DATA AS WELL AS AUGMENT AND ANNOTATE IT s -ASTER KEY BUSINESS ENTITIES SUCH AS PATIENTS AND CLINICIANS s 0ROVIDE A GOVERNANCE AND MANAGEMENT INFRASTRUCTURE THAT ENSURES DATA ACCURACY ACCESSIBILITY SECURITY AND PRIVACY I sincerely hope that you enjoy this edition of MetroDoctors. I also hope that you will see the importance of physicians actively engaged in the development and implementation of these “information platforms� that will result in outcomes that we all hope to see — better care for our patients.

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March/April 2012

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

TCMS Annual Meeting

The Twin Cities Medical Society annual board of directors meeting was held on Tuesday, January 24, 2012 at the Town and Country Club in St. Paul. See page 26 for pictures and highlights. I provided a year in review using a TCMS Year by The Numbers document. See below. TCMS had a very busy and productive year thanks to many of you. Our work with Honoring Choices Minnesota as well as the Twin Cities Obesity Prevention Coalition has really raised the profile of TCMS as an organization that takes public and community health seriously.

basis. If you have an interest in joining the TCMS Policy Committee please let us know.

We have two openings. To learn more about the Policy Committee visit our website at www.metrodoctors.com.

East Metro Medical Society Foundation

The East Metro Medical Society Foundation has a new member joining the Board of Directors. Ken Britton, M.D. is a family physician/physical medicine and rehab specialist practicing in St. Paul. Dr. Britton joins his colleagues on the EMMS Foundation Board of Directors serving his first term from 2011-2013.

2011 By the Numbers The East Metro Medical Society Foundation is also embark9Healthcare systems participating in Honoring Choices ing on an endeavor to increase its profile in the East Metro.

Minnesota. LARGESTorganized advance care planning program Frank Indihar, M.D. has been in the COUNTRY (and World?). 900 people trained to have chairing the EMMS Foundation end-of-life discussions. 23 physicians involved in TCMS obesity Development Committee and is helping to spearhead the effort. prevention efforts. 12 cities approached for the Healthy Eating Look for more information about Active Living Obesity Prevention Resolution. 2 Lunch n’ Learns the EMMS Foundation in future with medical students. 2 awards received for MetroDoctors. issues of MetroDoctors including information about an award that Over $1 million grant dollars raised to support operations. will be given out to recognize 15 meetings with HOHFWHG RIÀcials. 116 New members East Metro physicians. involved.

3,466 members subscribed to TCMS E-Newsletter.

377 members involved with the Senior Physicians Association.

33 Facebook followers. 28 Twitter followers. 7,748 unique

West Metro Medical Foundation

The West Metro Medical Founvisitors to the TCMS website from 65 different countries. dation welcomes Lisa Bishop, MB, ChB., a pediatrician with 1 Very Productive Year!

Allina Medical Group (Maple Grove), Joseph Bocklage, M.D., a retired orthopedic surTCMS Policy Committee geon, and James Struve, M.D., family I’d like to say thanks to Ann Wendling, medicine, practicing at Fairview BloomingM.D. and Lynne Steiner, M.D. for their ton Lake Clinic. time and commitment as members of the The WMMF Board is continuing its TCMS Policy Committee since 2010. Both strategic planning discussions with a goal to Lynne and Ann spent countless hours serving establish a new mission statement and direcon the committee which meets on a monthly tion for the Foundation.

MetroDoctors

The Journal of the Twin Cities Medical Society

Twin Cities Obesity Prevention Coalition

The TCOPC continues to make progress in raising the awareness of the obesity epidemic in Minnesota (and the country) by working with local elected officials to introduce resolutions supporting obesity prevention efforts.

Over 20 physicians are directly involved in this initiative. To learn more and get directly involved, visit our website at www.metrodoctors.com.

Honoring Choices Now in Wisconsin!

The Wisconsin Medical Society is leading an effort in Wisconsin to standardize Advance Care Planning across the state. They are basing their model on Honoring Choices Minnesota and have even licensed our name.

We have also discussed the opportunity for licensing some of the content that we have developed as part of our relationship with Twin Cities Public Television.

Book to be Released

The Honoring Choices Minnesota model has been getting some national attention lately. In fact, Kent Wilson, M.D. and I were asked to contribute a chapter in a book, called Having Your Own Say that is being pulled together by the Centers for Health Care Transformation out of Washington, DC. The book is scheduled to be published at the end of February 2012. We hope to elevate the profile of our project through this book.

March/April 2012

5

Become Involved! Write a resolution, serve as a delegate, attend the MMA Annual Meeting

LETTERS

Medicine is rapidly changing. Many powerful inuences are impacting our practices. Change will come. It is vital for you to have a say in the future direction and shape of our health care system and our practices. Our patients depend on us to protect them from the worst of these changes and to assure that they have ready access to the best that medicine can offer. If we say nothing, others will decide.

This is your opportunity to have your say!

All members of the Twin Cities Medical Society are invited and encouraged to become engaged in setting the priorities and next year’s agenda for organized medicine.

This is the time to indicate your interest to serve as a Delegate. Being a Delegate keeps you informed and it assures that your voice is heard. The process works like this: s

#ALL FOR 2ESOLUTIONS $UE BY -ONDAY -AY E MAIL TO NBAUER METRODOCTORS COM Start thinking about issues that you would like to address through the MMA. What issues are important to you, your practice and your patients? Sample resolutions on TCMS website: www.metrodoctors.com. Click on In Action tab, then Caucus.

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!TTEND --! !NNUAL -EETING -INNEAPOLIS -ARRIOTT #ITY #ENTER Friday, September 14 and Saturday, September 15, 2012

For more information, contact Nancy Bauer at nbauer@metrodoctors.com or (612) 623-2893.

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March/April 2012

Transfusion Practices The thorough and informative series of articles on transfusion practices in the January/ February issue was an important contribution to medical practice. My interest in transfusion medicine dates back 35-45 years of pathology practice at North Memorial, where I had CME and blood bank responsibilities. In fact, by combining the two, I became involved in what my colleagues described as a “crusade.â€? These efforts culminated in an article in Minnesota Medicine (March 1983), describing dramatic improvement in transfusion practices. Herb Polesky, formerly medical director of the Memorial Blood Center, unofďŹ cially conďŹ rmed to me that North administered one-fourth to one-third as many blood transfusions for a comparable mix of surgical cases as any other Twin City hospital.

The current literature (NEJM December 29, 2011) on transfusion practices suggests that we may be “reinventing the wheel.�

What we accomplished at North decades ago is now presented as a new idea; namely that “less� is “better� practice, both economically and professionally. By transfusing less, in an era when hepatitis C was not known, we prevented hundreds of cases of serious liver disease.

A peripheral yield to our efforts was demonstrating that CME could modify physician behavior in a positive direction.

This question had been raised repeatedly in CME groups nationally, often without solid evidence. Although long retired, my “crusade� is history, even though we may be “reinventing the wheel.�

Thank you for coordinating the transfusion series. It is worthy of wider dissemination.

Seymour Handler, M.D.

MetroDoctors

The Journal of the Twin Cities Medical Society

Electronic Health Record

Colleague Interview: A Panel Discussion with Area Chief Medical Information Officers

S

ix hospital and health system CMIOs participated in a group dialogue focused on the topic of Electronic Health Records.

Standing from left: Brian Patty, M.D., HealthEast Care System; Michael Shrift, M.D., Allina Health; Rod Tarrago, M.D., Children’s Hospitals and Clinics of Minnesota; Ray Gensinger, M.D., Fairview Health Systems. Seated from left: Kevin Larsen, M.D., Hennepin County Medical Center; Irfan Altaffula, M.D., North Memorial Medical Center.

Where do you see the EHR “going” as the product gets better and the users more adept?

I see more advanced Clinical Decision Support (CDS) tools allowing the EHR to warn clinicians if patients begin showing signs of sepsis, vital sign instability and other conditions that often go undiagnosed or unnoticed until they are in more advanced stages or the patient “codes.”

This would allow for earlier intervention and decreased morbidity and mortality. – Brian Patty, M.D., HealthEast There are two areas that I see evolving in the next several years. As Brian mentioned, CDS is still in its infancy and is relatively unsophisticated.

There is tremendous duplication of work in customizing alerts across institutions. We need to come to some relative agreement on standard CDS that needs to be part of every EHR in areas such as drug toxicities and interactions, specific disease or condition alerts, and methods to encourage following of standard clinical guidelines. The other key area is usability. We’ve seen the great strides taken in usability in other consumer electronics, yet the EHR continues to be complex and not intuitive. – Rod Tarrago, M.D., Children’s As Brian and Rod mention, optimization of the EHR is a big part of the road map for the next 10 years. The Twin Cities are blessed to have such a strong EHR base. Leveraging this base for better care means fewer MetroDoctors

The Journal of the Twin Cities Medical Society

clicks, better workflow, continuous training and especially, excellent clinical decision support. Optimization means the time spent in the EHR is the best it can be, and that there is more and better time to spend with patients and their families, with our colleagues and clinical staff, and with our own families. – Michael Shrift, M.D., Allina I’ll take a bit of a different tack on what I think needs to evolve. First, I think that the vendors need to back off from their proprietary nature and embrace their tool more as a platform that encourages other vendors to plug in or to offer additional apps that can plug in. The EHR space is going to consolidate as there just aren’t enough opportunities for large players. Creating an effective Software Development Kit (SDK) that other vendors can leverage will allow a product to mature faster than under the direct control of the principal vendor. This can enable the suggestions made above. Additionally, I believe that we need to leverage the capabilities of our EHRs to rethink documentation and workflows. There is still WAY TOO MUCH duplication that makes us all inefficient. – Ray Gensinger, M.D., Fairview I certainly agree with the others, but in my opinion the key change will be that the EHR will shift its focus from the doctor and the hospital

(Continued on page 8)

March/April 2012

7

Electronic Health Record Colleague Interview (Continued from page 7)

to the patient and the home. We are in the business of keeping people healthy, monitoring their illness and providing patients with information.

With the explosion of technology, we can now do much more over the web-home monitoring, e-visits, condition specific patient social media site and giving people access to rich information. This will not only save patients money, it will save the system money and decrease the burden of health care that people have in their lives. – Kevin Larsen, M.D., HCMC The EHR of today is essentially a first generation tool. There are tremendous possibilities for making the systems more “intelligent.” This would include innovative ways of data entry with sophisticated speech recognition, touch screens, etc. that would make it easier and more efficient for users. I can see future EHRs “learning” through use, analyzing data in real time and presenting options to users at point-of-care. The current system of alerts is crude and not very effective and will have to improve. I also agree with Kevin that EHRs will become the portal for fusing data from home monitoring, smart sensors, etc. and will also serve as a vehicle for telemedicine. – Irfan Altafullah, M.D., North Memorial

Will Independent Practices be able to financially keep up with the technology and training requirements?

I fear the expense associated with the purchase and maintenance of EHRs will force small groups to either merge with larger groups or health care systems or, at the very least, be “tethered” to these larger systems as a result of “outsourcing” their EHR management and maintenance to these systems. – Brian Patty, M.D., HealthEast We’re currently seeing many practices in the Twin Cities and across the country align themselves to various degrees with larger groups and hospital systems in order to obtain state of the art EHR software systems. As we see increased federal regulations, fewer smaller software vendors will be able to meet these guidelines, thus limiting the number of available choices to smaller practices. – Rod Tarrago, M.D., Children’s I suspect that they will if they have a dependable vendor that will stay in business. A very difficult future to predict. If the national CONNECT standards continue to evolve effectively then I don’t think this will be as big of an issue as others might think. The expectation by federal agencies to have this be their method of communication will help those vendors that hit the mark earliest. My preference would be to have standards that allow sites to pick their own vendors and easily connect with me. I offer my EHR out to others only as a convenience for them in the short term. It is tough being a vendor and a provider both. – Ray Gensinger, M.D., Fairview

are being replaced by Google documents and customer management systems by salesforce.com. Under our current model of EHRs, there is considerable technical skill required to maintain them — servers, upgrades, networks, etc. Currently large hospital and health systems are essentially selling software as a service to many of these independent providers. Someone is going to figure out this market and a software vendor will supply a fully functional web-based EHR for a subscription fee. – Kevin Larsen, M.D., HCMC This has been a challenge for independent practices — not just the initial investment, but ongoing training and optimizations. Thankfully, the free market has responded and there are a host of companies offering web-based “software as a service” and some of the products are quite sophisticated and user friendly. I see a shake-up of the industry and consolidation in a few years, once the ongoing frenzy of new installations dies down. – Irfan Altafullah, M.D., North Memorial

How should we abet universal access to patient information at point of care? Would we allow the patient to control and “carry” his EHR (e.g. using Microsoft vault or hard copies)?

Yes, although I see “version control” becoming an issue. If we do not allow for a central “source of truth” there is the potential for multiple “versions” of any given patient’s EHR with the critical version at their primary care physician’s office becoming “out-of-date.” – Brian Patty, M.D., HealthEast This is an area where medicine as a whole is still evolving. As more systems implement patient portals, issues of confidentiality and privacy will come to the forefront. We have been working with our families in this area at Children’s since we have many patients who are not legally able to have their own personal records, but at the same time may have issues that are discussed with their provider in privacy. We also are seeing many discussions about a patient’s ability to interpret results that may not have yet been verified by the provider. – Rod Tarrago, M.D., Children’s If done well, universal access to information improves the conversation among the patient, the family and the care-giving team. There are more and more good practices about how to do this to reduce any risks and concerns and maximize the benefit. – Michael Shrift, M.D., Allina I fully support the concept of the patient owning and retaining their record. At Fairview we say that the record does in fact belong to the patient and that we are only the caretakers of that record for them. I don’t know that the record will ever be physically portable. We seem to add data to it faster than manufacturers can create a portable device to hold it all. As the CONNECT standards and cloud-based services mature then I think the HealthVault model may have some legs. – Ray Gensinger, M.D., Fairview

The market is primed for a robust software as a service model. Look at what is happening in the business world, individual software applications 8

March/April 2012

MetroDoctors

The Journal of the Twin Cities Medical Society

Patients want to own their information, but currently the tools to do that are clumsy. More importantly, the health care systems have not built our EHRs to have interoperable data. We first need to have full transparency for patients — let them see everything in our EHRs. Then we need to have a system based on interoperable data. When this is achieved there will be many ways to aggregate a patient’s information. Maybe it is in the cloud; maybe on a USB; maybe it is federated and compiled at each visit. Most likely, all of these will happen. For a chronically ill person a USB may be the ideal solution; however, for a healthy person with few encounters in health care, a record compiled at each visit may be the right solution. – Kevin Larsen, M.D., HCMC This issue is complicated by privacy and data safety as well as a lack of universal standards for EHRs. Further, society might not be ready to accept a massive centralized database of sensitive medical information.

This is an area where societal norms will have to lead technological innovation. – Irfan Altafullah, M.D., North Memorial

Comment on the current status of clinical decision support tools in eliminating variation and increasing the value of the care delivered. Have genuine savings been realized? Who benefits?

Great examples are showing up of “sepsis alerts” and the like being developed and drastically reducing mortality from sepsis at the hospitals that have deployed them. At HealthEast we co-developed with our EHR vendor a Ventilator Associated Pneumonia (VAP) monitor that displayed in real-time all of the IHI VAP bundle elements on all ventilated patients and we were able to markedly reduce the incidence of VAP in all of our ICUs. These types of CDS-related morbidity and mortality reductions are showing real savings in health care costs — not to mention the lives saved. – Brian Patty, M.D., HealthEast We are in the process of implementing various CDS tools to improve safety, quality and efficiency. We’ve used a daily online safety checklist in our pediatric ICU to help intensivists address specific issues each day.

We’ve seen significant improvements in the rate of utilization of enteral medications instead of IV formulations, thus reducing the likelihood of line infections. We are also beginning to look at tools to improve our utilization of blood products as well as certain medications and IV nutrition. Evidence-based electronic order sets have also improved the standardized use of data driven therapies. – Rod Tarrago, M.D., Children’s Allina is blessed to have such a wonderful, dedicated and clinically-focused CDS team and Excellian (Epic) support team. The key is to listen to the clinical expert groups and translate their best practice, evidence-based care into hardwired workflows. The results, such as our heart failure, MI and diabetes care excellence, are a testament to this teamwork and collaboration. – Michael Shrift, M.D., Allina CDS offers great promise for us all. And I have no better examples than those already listed. We have some that have in fact saved hundreds of

MetroDoctors

The Journal of the Twin Cities Medical Society

thousands of dollars as well. Sadly, at this year’s American Medical Informatics Association meeting there was a presentation that suggests that CDS is a double-edged sword ready to create a legal feeding frenzy. On one hand, if providers expect CDS there is the risk that their independent critical thinking abilities may be blunted and actions are taken perhaps where not most prudent. Conversely, if a clinician chooses to ignore a CDS recommendation does it create medical legal conflict between the provider and organization? I suspect that while this is where the greatest opportunity lies, we will have to be very deliberate on how we advance in this space. – Ray Gensinger, M.D., Fairview An ideal CDS intervention automates the parts of medicine for which there is universal agreement, allowing the providers to focus more of their time on complex problem solving with patients and less time in remembering and doing routine tasks. For example flu shots. This is not a sexy CDS topic; however, if we could get flu shots to all patients it would have a great impact on overall health and medical care. In organizations that have done this effectively, like Virginia Mason, it has also given the provider and patients some time back to discuss other issues during a medical visit. CDS also holds tremendous potential for giving visibility to complex information and interconnections. For example, doctors are trained to risk stratify patients, but the human mind can only calculate with a small number of variables at once — maybe 4-5. With a sophisticated CDS algorithm, many more variables can be part of a risk stratification decision. This will help us make better, more sophisticated decisions, not take away our decision making autonomy. – Kevin Larsen, M.D., HCMC We have implemented a two-pronged approach. Within the EHR, we are using the available CDS tools to improve the quality of care with sepsis and VAP bundles. Off-line we have implemented a third party data warehouse and are using analytic tools to improve care in some areas where we see variability, for example elective induction of labor, diabetes care. The greater challenge is to change workflows and behavior patterns of users and we have established Guidance Teams for each initiative.

We see great potential in this area, going forward. It is challenging to quantify gains, though anecdotal data are promising. – Irfan Altafullah, M.D., North Memorial

How do you capture patient data from providers who are not on a health care systems’ platform, yet part of a network and part of the total cost of care performance? Do tools exist or is there a common attribution model?

We are in the early stages of blending clinic data with our inpatient data in our data warehouse using Enterprise Master Patient Index (EMPI) technology that uses federated matching techniques to match patient ABC in system Y with the same patient ABC in system Z. – Brian Patty, M.D., HealthEast (Continued on page 10)

March/April 2012

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Electronic Health Record Colleague Interview (Continued from page 9)

This is a challenge for all systems, especially when dealing with groups who are still on paper. The first step will be creation of health information exchanges (HIE) between EHRs. We are also starting to look at email, web, and text-based portal strategies that allow us to push and pull data to and from providers who have yet to move to electronic records. – Rod Tarrago, M.D., Children’s Much opportunity in this space. MN HIE failed in the cities as there wasn’t enough willingness to help grow the model. It is very expensive for automated data exchange, especially when there are few partners and high startup costs. Many are failing across the country. A couple are doing well but those have considerable grant funding or capital endowments to sustain them. Connecting to those on paper has much to be desired. We are looking at portal-like methods of gathering the key elements needed as well as working with payers to extract those elements that they have access to and we do not. – Ray Gensinger, M.D., Fairview We have identified several “strategic partner” practices and are building interfaces with their systems and the enterprise EHR. There are numerous challenges in this area including legal, technical and financial. In my opinion, this is one of the big challenges we face in the short term — how to make the EHR truly patient-centric so that information can follow the patient across the health care continuum. The Care Everywhere model is a great example. – Irfan Altafullah, M.D., North Memorial

Please describe how you assess and get feedback on the impact of your EHR on the daily work of clinicians.

A number of practicing physicians believe that their keyboard input is inefficient and interferes with direct doctor-patient communication and we hear complaints from patients regarding lack of interpersonal contact inherent to the EHR. We survey our providers routinely in order to identify their pain points with our EHR. We also have support staff routinely rounding on providers as they work to assess work-flow issues and other sources of frustration with the EHR. In addition we provide resources to our providers on our intranet and via our Physician Portal that help them better interact with patients and work the EHR and computers into their workflow. – Brian Patty, M.D., HealthEast We have performed EHR satisfaction surveys to get key information on usability. We also routinely round with users to see first hand the challenges they face. As CMIO at Children’s, I have also made it a point to continue to practice at least half time in order to use the system first hand. Finally, we’re about to begin leveraging vendor usability tools that give us objective data regarding user efficiency. We are able to determine which users have taken direct routes in their tasks, and which users have used workarounds and more clicks to accomplish the same tasks. This will

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allow us to more efficiently target users in most need of education. – Rod Tarrago, M.D., Children’s This is a very important issue and a large challenge for an 11 hospital 100 clinic health system. We are constantly trying to improve the usability of our clinical technologies. A few examples of the way we listen to end users include: hospital EHR committees, Excellian site support, Excellian medical directors, Excellian user groups, Excellian super users and more. The Allina Excellian Physician Users’ Group has proved a very successful and high functioning forum for understanding end user needs and improving the system. – Michael Shrift, M.D., Allina I had to chuckle as I read the question as my chief assessment tool often is how often the message waiting light is blinking on my telephone. I typically provide my cell phone number as a way of reaching me if things are really problematic. Not too many calls end up there and those that do typically warrant my immediate attention. We can always do better at getting feedback. We also try and mature a concept of super users.

Those are real users practicing real medicine on our EHR. They have extra training as well as direct lines of communication back to the development teams to facilitate communication. Our staff has thousands of awesome ideas. The hard part is sifting through them and getting those done that will add the most value overall. – Ray Gensinger, M.D., Fairview Like the others, we have a series of feedback loops. We survey providers, have practicing clinicians who work with our EHR teams, we watch our users and have user groups. We are working to figure out how we can give more ownership of the system and system decision directly to the users. – Kevin Larsen, M.D., HCMC Our model is similar. We have many practicing physicians who actively participate in EHR maintenance and optimization. There are several physician champions who are lightning rods for feedback — both good and bad! — who are valuable conduits of information. In addition, our organizational size enables us to have a lot of one-on-one contact with users, in person and through email. – Irfan Altafullah, M.D., North Memorial

Do you favor segregating personal or sensitive personal information in psychiatric cases? If so, please describe how? What role does the patient or patient’s family have in developing and reviewing the information contained in a patient’s EHR? This argument has two sides. We have segregated some types of sensitive results and allowed only certain providers to see them in order to maintain privacy. It is always a difficult decision though as many of these segregated conditions could be important knowledge to others providing care for the patient, and absence of the information could theoretically compromise care in certain situations. – Rod Tarrago, M.D., Children’s

MetroDoctors

The Journal of the Twin Cities Medical Society

I often argue that segregated chart segments create a false sense of security for everyone in that elements like medication lists, problem lists, and medical history items live at the level of the patient and are not controlled in the same way as say a clinic visit to the ED for symptoms of an STD. While I could “hide” the ED encounter and maybe even the problem or diagnosis, all those with chart access would still be able to see that I administered intramuscular ceftriaxone as well as prescriptions for a single dose of 1gm azithromycin. Every physician and nurse knows what those mean.... Our job is to manage a record that ensures the very best and complete care for the patient. Anything we do to restrict data access then limits that expected result. We favor a heavy auditing procedure and accountability for behaviors. – Ray Gensinger, M.D., Fairview Patients need to control the flow of their own information. In order for them to continue to trust us as an organization, me as a doctor and our EHR, a patient must trust that their information is protected in the ways they value. This is possible even for “sensitive” information. We find that the vast majority of patients want this sensitive information to move easily between providers. Therefore, we have not put many technical segregation points in the system, but more alerts like “do you really need to look at this information?” – Kevin Larsen, M.D., HCMC I don’t necessarily favor segregating information, especially since some of that information might be very relevant to patient care. We must constantly strive to treat all aspects of the medical record as “sensitive” and develop our culture accordingly. One of the big advantages of an EHR over the traditional paper record is that now it is much easier to keep an audit trail, implement “break the glass” alerts, etc. Once again, the major issue here is institutional culture and behavior rather than anything to do with the EHR necessarily. – Irfan Altafullah, M.D., North Memorial

As CMIO of a health care system, how do you encourage local engagement and innovation while simultaneously standardizing and disseminating best practices across the broad integrated family of organizations?

We hold firm on standardizing where there is clear evidence of best practice in the literature and allow for monitored variation (in an effort to establish localized best practices) where there is no clear evidence of a best practice. – Brian Patty, M.D., HealthEast This is a growing area of interest in medicine. The days of “I do it this way because that’s the way I was taught” are becoming less common as we see more and more evidence-based care. In areas where there is no evidence, we encourage some degree of standardization in order to determine best practices. Some centers have now begun to leverage the EHR to actually create evidence where it may not exist. In areas where the literature is lacking, the EHR can actually be used to extract case series data to drive therapy decisions. – Rod Tarrago, M.D., Children’s Managing this tension is the work of great health care. Our Clinical Service Lines increasingly and continuously improve evidence-based,

MetroDoctors

The Journal of the Twin Cities Medical Society

best practice care. Through conversation among these clinicians and our CDS and Excellian Support teams, these practices are standardized.

The number of our Allina order sets has decreased as a result. – Michael Shrift, M.D., Allina My colleagues have nailed the issues. The only addition that we have is by virtue of our affiliation with the University of Minnesota. We want to create care pathways that can be analyzed by our scientists and then fed back into clinical practice much more rapidly than the historic cycle has demonstrated. We all have a role and responsibility to define the new standards of care. – Ray Gensinger, M.D., Fairview I aim to standardize and automate where there is good medical evidence and agreement. This frees up time for providers to talk with patients more and to focus more energy on difficult decisions where their isn’t good evidence. – Kevin Larsen, M.D., HCMC This is one of the more challenging aspects of my job. I agree with my colleagues that where there is good evidence for best practices, there is little push back from users. However, so much of our day-to-day medical practice is still influenced by past experience and community standards of care which, while effective, might not be “evidence-based.” Here, one has to balance the physician’s autonomy with standardization of care, and I find it most effective to focus the discussion on what’s best for the patient, which is really everyone’s goal. – Irfan Altafullah, M.D., North Memorial

Given the diverse array of vendors already in independent practices, please give an overview on metro-wide connectivity, compatibility and confidentiality.

We really don’t have good cross-vendor/cross-health care system connectivity in our area to any extent to date. – Brian Patty, M.D., HealthEast At Children’s we are working on improving the interface between Cerner and eClinical Works in associated practices. However, until we have true interoperability, we will not be able to truly leverage the power of the EHR across the community. – Rod Tarrago, M.D., Children’s We continue to support the concepts of health information exchanges and work closely with our vendor to demand interoperability and then work with our local practices to create the same level of urgency among their vendors as well. Like Rod mentions, we are starting with our core vendor and those with the largest market presence and working our way back to the rare vendors. – Ray Gensinger, M.D., Fairview We are a very interconnected market, largely because many of us use an application from the same vendor that is interconnected. I agree with Ray that we need further interconnectivity, not just to other hospitals and health systems, but also to nursing homes, pharmacies, home health and others that provide medical care. – Kevin Larsen, M.D., HCMC (Continued on page 12)

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Electronic Health Record Colleague Interview (Continued from page 11)

I agree that we have a good start, especially in the Twin Cities, but still have a long way to go. I am confident we will get there in a few years because the marketplace will demand it — patients, payers and regulators. – Irfan Altafullah, M.D., North Memorial

Lastly: What should we be celebrating?

1) All of the hospitals in the greater Twin Cities metro area are up on EHRs and CPOE! I am not aware of any other large metro area that can make that claim. 2) Three of the Top 25 Clinical Infomaticists in the Nov. 11, 2011 issue of Modern HealthCare came from the Twin Cities, tied with California for the highest number from any one state. Both of these point to the high level of engagement and success in our region with EHRs. – Brian Patty, M.D., HealthEast Despite the use of several different vendors, there is increasing collaboration between institutions with the goal of improving patient outcomes.

We are also starting to look at areas in which we can improve the user experience across the Twin Cities and truly make it a connected health care system. – Rod Tarrago, M.D., Children’s

Collaboration. We regularly get together. More so those of us with the same EHR systems, but as CMIOs we have always shared thoughts and ideas. We give freely to each other as the work we accomplish benefits patients and those that serve them. – Ray Gensinger, M.D., Fairview

And what must yet be accomplished?

Regional patient data connectivity. – Brian Patty, M.D., HealthEast We still need to further leverage the EHR to truly improve patient safety, quality and efficiency. Errors in medicine are still too common, and there are many areas where technology could help as long as it is accompanied by significant culture changes. – Rod Tarrago, M.D., Children’s As discussed above, once the EHR is implemented, it must be optimized.

An optimized EHR translates ultimately into the triple aim of high quality, affordable care that improves the health of our communities. – Michael Shrift, M.D., Allina I agree with Michael. We refer to it as transformation in that we want to leverage our skill (clinical providers) and our tools (technologies that include the EHR) to demonstrate magnification of the value of the care that we provide. – Ray Gensinger, M.D., Fairview

The quality and safety of health care in Minnesota is among the best in the nation. This is due in no small part to the diligent efforts of the EHR teams here. Very well done! – Michael Shrift, M.D., Allina

Jason Leyendecker, Au.D., Doctor of Audiology

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MetroDoctors

The Journal of the Twin Cities Medical Society

My Experience with an EMR in the Primary Care Setting

T

he implementation of electronic medical records (EMR) has been an opportunity for initiating changes in practice, enhanced communication, increased effectiveness of organization of patient data, and increased efficiency. As with anything that dramatically changes the way we work, there are also obstacles and difficulties present with the current use of EMRs. This article is meant to be an objective view of both the pros and cons of my experience as a pediatrician both at Park Nicollet in the clinic and at Fairview Ridges Hospital as both organizations implemented EPIC within the past six months.

Park Nicollet was one of the first clinics to implement EMR with Lastword several years ago. Lastword had multiple short comings because of its age, so I will admit I was looking forward to using EPIC. In EPIC it is extremely easy to pull up tests and review with patients, go over radiology studies in the room, and review records with the patient. Plotting growth curves, plotting trends and presenting data in a variety of formats for not only my review but also to present to the patient has been dramatically improved. It is easy to see that greater understanding by the patient will hopefully lead to increased compliance with treatment and overall satisfaction. What I have been surprised at is that currently it seems to be limited to data review. There is no current presentation of cost-effective drug options, treatment options or differential diagnosis based on combinations of signs, symptoms and test results or analysis of results. While it is very easy to see that these improvements are on the horizon, I am surprised given our technological advancement that these benefits are not already available in EPIC.

By Ellen Devries, M.D.

MetroDoctors

I was also surprised at the tremendous time input required outside of the clinic to make the transition. This involved going to class, reviewing and practicing online, developing smart notes (templates for the variety of encounters), and then once implemented reviewing patient data, updating problem lists and family histories. This led, in the interim, to decreased productivity until I became more proficient at the slow and tedious data entry.

The time was also necessary and directly dependent on the training level of the ancillary staff. In those situations where the staff was well trained and had a “super user” accessible in the department at all times that they could access, there was little tension and things flowed well. Those departments that did not invest the upfront time to have someone highly trained suffered terribly with frustration, tension, and poor efficiency. As a result, more time was spent redoing information they entered, clarifying, etc. Training is critical, not just for physicians, but probably even more important for staff.

What has been extremely useful has been the sharing of templates, experiences between physicians, and the opportunity to train again.

At Park Nicollet we have had IT people skilled

The Journal of the Twin Cities Medical Society

in EPIC who come back multiple times to answer questions, share tips, shortcuts, and serve as an effective means of communication with errors or problems we have encountered.

They have also been helpful in sharing potential sources of errors, and increased tremendously my skill in using EPIC. While we have tried to be hyper vigilant to avoid errors, there are sources of error inherently built in the program which needed to be changed. An example was rounding off dosages of prescriptions calculated by weight. While rounding “up” on an 8-year-old to the nearest ml would seem logical, rounding on a neonate with a 10 or 20 percent increase in the dose is not acceptable. There also has been a failure to have a maximum dose for suspension in pediatric patients. Those changes were made quickly when the communication was facilitated by the appropriate people. Other specialties have discovered other potential errors in the program.

In summary, the benefits of EMR are well known and praised by the public, with ease of access, increased communication and better data organization. While the benefits of prevented errors are well publicized, it is my experience that there still exists the potential for wrong entries, orders and dosage errors. I would highly encourage anyone contemplating the implementation of EPIC to do sufficient training, especially of ancillary staff, have templates designed and in place before implementation and invest in retraining. Only with extensive training before and after implementation will the true benefits of the system become evident.

Hopefully the next step of analysis of data will develop the current unutilized potential for enhanced tools for diagnosis, treatment, and quality measures.

Ellen DeVries, M.D., pediatrics, Park Nicollet.

March/April 2012

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The EMR in the Tertiary Care Setting: What’s Good, What’s Bad? “Nowadays, the clinical history often weighs more than the patient.” Martin H. Fischer

I

n the old world of paper records, this was occasionally literally true in a tertiary care center. The challenging patient with multi-organ disease and multiple recurrent admissions, often back-to-back, always had an enormous multi-volume chart. Inevitably, the last and most important volume was inaccessible, usually on a shelf in the medical records department awaiting signatures, when a complicated, acutely ill patient arrived in the ER at midnight. Now, I pop open the EMR and all is revealed instantly! Or is it? As in the old world of scratched handwritten notes, the usefulness of the record still depends on the quality of the input and output. (Remember GIGO, i.e., garbage in garbage out?) In this article, I’d like to review my experiences with the good, the bad and the ugly aspects of the electronic medical record in a large tertiary care center.

The value of an EMR system in a tertiary care setting is manifest. None of us can imagine how we practiced without it just five or six years ago. Essentially every patient at our institution requires multi-specialty input, and communication between these experts is essential. Prior to the EMR revolution this involved a great deal of phone calls and face-to-face interactions, which was great for staff camaraderie, but inefficient.

Now the thoughts of everyone are easily available in real time, even at off-site locations.

As we continually expand our patient care procedural and testing armamentarium, the rate of data generation seems to grow exponentially. The EMR offers instant data retrieval and graphic/tabular summarization. Remote imaging viewing lets practitioners review X-ray,

By John F. O’Leary, M.D.

MetroDoctors

CT, US and MRI images from anywhere, often while discussing them via telephone with the radiologist. This can save time and lives especially when rapid on-site decision-making is required about an unstable patient.

Complex patients require complex drug treatment regimens. The concomitant risk of improper ordering, administration error and drug-drug interaction is inevitably magnified.

Built-in EMR prompts and decision support systems aim to prevent such errors. This seems like an obvious advantage over paper systems, however, published data have shown variable results in terms of actual error rate reduction.

So what’s bad and even ugly? Documentation is obviously an essential function but the most difficult and dangerous job the EMR must perform relates to computerized physician order entry (CPOE). There are major unsolved problems in both areas. I will deal with documentation issues first.

Misuse of the “copy-and-paste” is especially tempting in our complex patient/multi-specialty environment. Progress notes proliferate forward and grow like fungus, becoming obfuscatingly long and filled with self-contradictory statements, e.g., stating that a “patient needs cholecystectomy,” while noting further on in the same note that a “cholecystectomy has been performed.” Coding demands often drive this process, but the implications for patient care and legal liability are significant.

Tertiary care centers usually are teaching institutions as well. If residents and students rely on templates, will they still internalize the structure of a history and physical and all that it represents as a basis for sound patient evaluation? Will they let “smart” computer prompts replace critical thinking? These issues are already subject to study by the academic community.

The Journal of the Twin Cities Medical Society

The final concern I have about documentation concerns the “Tower of Babel” resulting from the lack of system-to-system compatibility standards. In a referral hospital setting, this is especially troubling since many of our patients come from “out-of-system” facilities. Often their records are electronically inaccessible to us and ours to them, creating communication problems both at admission and discharge.

Hopefully, a cottage industry will develop that will build information bridges between disparate EMRs. The ordering of actual tests, drugs and procedures is obviously a key determinant of patient outcomes. This is also a daunting task for EMR designers. How do we take the vast and endlessly intricate universe of possible medical interventions and create a set of discrete parameters compatible with information system technology? Can medical decision-making be “cook-booked?” Much time is lost at our hospital in the frustrating search for just the right (Continued on page 16)

March/April 2012

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Electronic Health Record EMR in the Tertiary Care Setting (Continued from page 15)

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order for a test or procedure, often named in non-conventional language. It’s a huge learning process, which probably explains the contradictory results, mentioned above, found in studies comparing medication-related error rates before and after EMR implementation. Hopefully, as systems evolve and experience grows, the EMR effect will be positive.

Finally, there’s the social cost. Video studies have shown that EMR users spend 25 to 40 percent less time looking at their patients when a computer is in the exam room. So far, it’s also apparent that for many providers, time spent on documentation has gone up with EMR introduction, taking time away from direct patient contact as well as their home life. Collegial relations also suffer when all one sees in the doctors’ lounge are the backs of troglodytes hunched over computer screens. Ah’ well, ’tis a brave new world!

John F. O’Leary, M.D. is a general surgeon at Abbott Northwestern Hospital in Minneapolis, who struggles with weighty issues as chair of the hospital’s EMR Committee.

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The Journal of the Twin Cities Medical Society

Electronic Health Records

Current State How Did We Get Here?

Over the last several years more and more hospitals, clinics, and health systems have been installing some form of electronic health record system. Until recently, these efforts were seen as voluntary, innovative strategies to provide what was believed to be “better care.”

Some in the physician community have questioned the wisdom of implementing these costly systems and profoundly changing the practice of medicine at a very personal level.

The Electronic Health Record

Before we look at the issue of quality improvement we should ask what, exactly, do EHR systems offer over traditional paper charts?

1. Viewing — The ability to review patient information on previous encounters at other facilities.

2. Documentation and Care Management — All documentation is legible and independent of handwriting, common problem-lists, medication lists, and allergy lists across encounters.

3. Ordering — Allows for the system to alert the user to allergies and drug interactions, while eliminating transcription errors.

4. Messaging — Allows for reminders, care hand-offs, and improved care coordination.

5. Analysis and Reporting — Allows for measurement at all levels. Previous abilities were primarily financial in nature, now systems can produce a bounty of reports and measures without expensive, time-consuming manual chart extraction.

6. Patient-Directed Functionality — Allows for patients to become more involved in their health care with access to their

By Scott W. Tongen, M.D.

MetroDoctors

medical information online. Enhances patient education possibilities.

7. Billing — Allows for more comprehensive integration between billing and the documentation required for optimal reimbursement.

8. Access — Allows more than one individual to work in the chart at the same time, while not restricting the user to be at the bedside.

We should also look at what EHRs are not.

They don’t think. They can be programmed with a variety of best practice advisories and all manner of clinical decision support, but are still prone to garbage-in-garbage-out issues. Electronic health record systems offer an abundance of documentation tools, but it is up to the user to use them correctly and conscientiously. It is not the fault of the software when a physician copies and pastes a prior day’s note to today but neglected to edit the text to reflect that the well-described diabetic foot ulcer is no longer present because of an interval amputation. Order sets can be written to help a clinician order the appropriate antibiotics for a community-acquired pneumonia, but they can’t force the physician to use them.

They don’t interfere with the doctor-patient relationship any more than cell phones cause

The Journal of the Twin Cities Medical Society

accidents. Drivers who use cell phones cause accidents, not cell phones. And physicians who focus more on the computer than on the patient need to learn a better approach. They were likely the same ones who rudely focused on the paper chart instead of listening to their patient.

One of the greatest difficulties in understanding the benefits of EHRs lies in the expertise of the user. For example, the insurance industry charges much higher premiums for drivers with a recent history of accidents or traffic violations. They also charge higher rates for new drivers in spite of their pristine clean records because the actuaries know that they are much more likely to have an accident than an experienced driver. It is easy to see how this relates to the learning curve for users of a new EHR. Indeed, those with the most training and hands-on experience cannot only demonstrate improved quality, but they also can deliver that quality with greater efficiency and with measurable outcomes; but that is only my observation.

Why some physicians may be so vehemently opposed to EHRs: 1. Change — The implementation of an EHR is the most profound change to a physician’s practice and workflow that they will likely experience.

2. Typing — Those without, at least modest, skills will have the greatest challenge. Even though a small investment into improving computer and keyboard skills would result in an enormous return on investment, many physicians won’t even consider this an option and continue to struggle.

3. Exposure — There are some physicians who may be concerned that their practices may come under increased scrutiny.

(Continued on page 18)

March/April 2012

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EHR Current State (Continued from page 17)

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March/April 2012

EHRs may reveal issues that have otherwise gone undetected. (e.g. Inappropriate use of non-licensed individuals to “expedite� work that must be done only by the physician.)

4. Distrust of Data — EHRs allow measurement of an incredible array of variables and physicians may fear that this data will show they are not “as good� as others or that the data may be misused or misinterpreted.

The EHR is long overdue, and the real truth is that it is here to stay. As the Borg told Captain Piquard, “Resistance is futile.� New physicians coming out of training expect to use these tools, and many intentionally avoid joining hospitals or practices where an EHR has not been implemented. Some day we will look back and ask in bewilderment, “how did we ever do it without an EHR?�

While electronic health record systems are still in their toddler years in terms of development maturity, they are our only hope in managing the volume and complexity that health care has become. No longer do we have to reorder studies because results from another facility are not available. No longer do we have to wait for a patient to return from radiology to review what a consultant wrote in the chart. No longer do we have to trek down to Medical Records in the bowels of the hospital to sign charts.

The real value will be when EHRs can truly use the data they store to tell us more about the population of patients we serve so we can serve them better. They will make an even larger improvement in care when they are programmed to provide diagnostic assistance and alert us to long-term trends that we would otherwise miss. These systems will continue to make a profound impact on health care.

As scientists at heart we should embrace the beneďŹ ts they offer and learn new ways to do our work with these tools.

Scott Tongen, M.D has worked as a hospitalist since 1991. He currently is a medical director at United Hospital and “physician championâ€? for the Epic electronic health record and works for Vitalize, a consulting ďŹ rm that assists hospital systems with EHR installations of many vendors.

MetroDoctors

The Journal of the Twin Cities Medical Society

Doctor and Patient Relationships in the Age of EMRs and PHRs

D

o you remember the 1996 movie Jerry McGuire? The one with the unforgettable one-liners like “show me the money,” or “you had me at hello.” You may be wondering what Tom Cruise has to do with electronic medical records, but stick with me.

One of the themes in Jerry McGuire is the importance of personal relationships in business.

Jerry craves real relationships with his sports star clients. He passionately calls on his fellow sports agents to remember that at the core of their profession is the relationship between the athlete and the agent and he urges them to put the relationship and the well-being of the athlete at the center. Sound familiar? For several years the health care community has issued a similar call: focus on patient-centered care and build meaningful physician and patient relationships.

The HITECH Act, Meaningful Use, and incentives programs encourage the adoption of health information technologies and may be the show-me-the-money-moment for physicians. But, at its core, health care is still about the relationship between health care providers and patients. In my experience, health information technologies have changed the dynamics of these relationships for the better — and in some cases, for the worse.

My clinic aggressively promoted and encouraged use of their personal health record — or PHR — at every opportunity. I am glad they did. The PHR had me at hello. I like being able to access my test results, track data trends, and I appreciate the convenience and efficiency of scheduling appointments online.

As a patient I can take a more active role in my health care. But, what is missing for me in

By Becky Schierman

MetroDoctors

this relationship is what happens in-between my annual — or in a bad flu year, twice-yearly — clinic visits. Couldn’t PHRs provide an opportunity for an ongoing connection between patients and health care providers? Couldn’t my clinic use the PHR to regularly promote adopting better health goals? Remind me to exercise, make suggestions for healthy foods to eat, or encourage other positive, tailored health behaviors. If I knew my physician was keeping an eye on me I would feel more supported and empowered. Doctors, this is your “help me, help you” moment. Take advantage of it.

Ironically, the same technology that helps me be a better patient has left me feeling a little disappointed in personal interactions. We all know the importance of communication to foster relationships — with spouses, friends, and with patients. With the EMR in the room it now seems that my physician disengages with me and engages with the EMR. I have also found that meaningful conversation about me and my health — has all but disappeared.

For the record, these are not exactly “you complete me” moments in my relationship with my physician. As efforts to measure patient experience get underway it will be important for clinics to ensure effective and meaningful communication are a part of each patient’s experience. Rather than focus only on filling out checkboxes that are embedded in the EMR, providers can still ask open-ended questions that get at the patient’s health agenda, assess emotional concerns, and explore how health problems are affecting a patient’s life. As a patient, this is what makes our relationship unique and trusting.

Like in Jerry McGuire, I believe that no matter how health care transforms and technology advances — the key will always be the

The Journal of the Twin Cities Medical Society

relationships physicians have with their patients. But, relationships are created and cultivated. So, how do you have a meaningful relationship with someone you interact with only a few times per year, for about 15 to 20 minutes at a time? Use the new sources of information, technology, and tools from your EMR to educate and engage your patients, connect with patients on a continual basis, promote ongoing health, and engage people in their health care.

Becky Schierman, MPH, Minnesota Medical Association Manager, Quality Improvement.

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19

Electronic Health Record YOUR VOICE

Electronic Health Records: Hope or Hype?

TECHNOLOGY IS BOTH A BLESSING AND A CURSE. A mere hundred years ago, automobiles replaced horses as our preferred mode of transportation. Few would argue the benefits in comfort, speed, load capacity, and commercial profit, but they came at enormous costs for infrastructure, depletion of fossil fuels, regulation, pollution, and lives lost in accidents.

Electronic health records are like that. Digital records are “progress,” in some but not all ways, and at great costs.

About 30 percent of clinics nationwide have an EHR; in Minnesota it’s about 60 percent. (In 2010, there were 46 different vendors’ products in use in Minnesota.) EHR advantages are uneven for different users. The VA system probably couldn’t function today without an electronic record. Small clinics won’t gain as much.

Putting our faith in an EHR requires considerably more fundamental analysis than just price. Consider the benefits. Data can easily be moved among clinicians and offices. There is better report generation, better opportunity for clinical research. Charge capture may improve. Costs can be saved in transcription. (One administrator I interviewed reduced her transcriptionists from 20 to 2.) Chronic disease management might be facilitated. Prescribing is safer. Best practices will be easier to achieve and peer review will be systematic.

What challenges offset the gains? There are daunting costs in time, capital, and never-ending maintenance and upgrades; administrative distraction; temporarily reduced clinical productivity and revenue; difficulty interfacing with systems on different platforms; predictable rapid obsolescence; an increased burden on clinicians for data entry; and security (Mayo Clinic has over 30,000 terminals to secure). Independent subspecialists consulting for multiple primary clinics which use different EHRs have a serious quandary.

Some experts opine that current EHR technology focuses on “…data dumps…that merely result in electronic versions of clinically cumbersome, uninformative patient records.” And, we lack national standards for EHRs. Interoperability is still a distant dream. What if your EHR isn’t compliant when national standards do arrive? Oops.

Will patients reap benefits from EHRs? They’ll be annoyed by their doctor’s distraction by the computer. As one of our own, Dr. Morrie Davidman, noted after a recent hospitalization: “The new bond sometimes is with the keyboard as opposed to the person sitting in the office.” If the doctor opts for more eye contact, s/he will be

entering data for hours after clinic. (Dinner with the kids? Not tonight dear.) Notes may not be as rich and informative for colleagues.

In a major two-part review of EHRs in December 2011, Harvard’s Dr. David Blumenthal, former national coordinator for health information technology, said: “The difficulty of using current EHRs constitutes a major potential barrier to their adoption and meaningful use. Clinicians frequently comment that ‘I work for my EHR instead of my EHR working for me.’” He has also said “Actual evidence of the efficacy and cost-saving potential of HIT is scarce.”

Dr. Matthew Weinger of Vanderbilt University School of Medicine wrote: “Until there is a better understanding of the safety and usability of EHRs, their widespread promulgation is premature.

The adverse consequences of the rush to EHR adoption — spurred by incentives — are many.”

All things considered, will patients get better quality of care?

Who’s to say? Personally, I have little faith in Minnesota Community Measurement to tell us. The National Ambulatory Medical Care Survey found no improvement with the change to an EHR in 15 of 17 quality measures. Another threat to quality is using paraprofessionals with EHR decision support to “replace” many physicians. A 2011 review summarizes that “commercial EHR products have not had a measurable effect on the very goals to which meaningful use aspires…the challenge of ensuring that meaningful use actually leads to meaningful benefits, such as improvements in safety and quality of care, remains a serious concern.” Simply stated, EHRs will not ipso facto improve health care.

Why did the federal government budget $19,000,000,000 to rush the conversion? Some suspect an ulterior motive to prepare the American health care system for eventual federal control. Interoperable EHRs will force consolidation of our profession and enable manipulation of clinical decisions (“rationing”) by an outside payer, either private or governmental. Only the naïve would think otherwise.

Progress is inexorable. Technological change is good as long as it’s intelligently planned and for the right reasons. Like the transition to automobiles, converting to EHRs comes with tremendous benefits and risks, both financial and professional. There’s a need for sober realism amidst all the testimonials and marketing hype. It’s incumbent upon physicians and medical societies to lead the effort with eyes wide open.

By Richard J. Morris, M.D.

ED: References withheld due to space requirements; they are available upon request.

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March/April 2012

MetroDoctors

The Journal of the Twin Cities Medical Society

Implementing EHR: Unintended Consequences

T

he electronic health record brings new technology, new workflow, and a new structure to document clinical patient care. The immediate availability of clinical data combined with embedded programs to alert physicians of optimal care plans has the potential to significantly reduce adverse outcomes and malpractice risks. However, a poorly implemented electronic health record has also shown to bring unintended consequences that could increase the frequency of events that increase practice risk.

This article will cover six specific unintended consequences of the EHR: 1) Data Overload; 2) Erratic Documentation; 3) Poor Workflow Design; 4) Alarm and Alert Mismanagement; 5) Omissions on Medication and Problem Lists; and 6) Emotional Disengagement.

Data Overload

Data Overload refers to the sheer volume of items that require a clinician’s attention during the course of providing patient care. Data overload originates from insufficient time for clinicians to process the list of EHR tasks that require an approval or response.

The overload effect increases when each request requires multiple “clicks” to sort through and process screens of data to find the one piece of information critical to complete the EHR task. All of this activity contributes to the physician complaint, “I am less efficient with the EHR than I was with paper.”

Data organization of user screens can minimize user overload. EHR systems that add irrational complexity to finding the right

By Mike Flicker, MBA

MetroDoctors

clinical information prior to making a decision increases the odds that clinicians do not find critical information within the EHR. Erratic Documentation

Tools to document patient care typically include options of voice recognition, free text entry, and predefined templates. Erratic Documentation becomes an unintended consequence of an EHR when the documentation in the system does not reflect what the clinician intends to have documented in the system.

One example of erratic documentation is created by systems that utilize automatic defaults in portions of specific templates.

Automatic defaults have the potential to have a “negative” finding in the permanent record that was not consciously selected by the clinician.

Hybrid templates that incorporate free text along with checking boxes on a template have a documentation advantage by allowing the clinician to document unique aspects of the encounter. However, hybrid templates do have a downside. If clinicians are not uniform when documenting issues as “free text,” then the ability to query specific patients for follow-up may be limited. Further, clinicians may miss key information if clinical data is in the body of a template for one patient, and other times in the miscellaneous “free text” addendum of another patient.

Poor Workflow Design

EHR systems change workflow in a health care organization. Mapping the transition

The Journal of the Twin Cities Medical Society

of workflow in the paper world to the digital world is a critical piece of the installation process.

Risks increase when proper time is not allocated for planning workflow changes. One common symptom of poor workflow design is the presence of user “work around” paper systems rather than utilization of the electronic tool to complete tasks. Examples of a “work around” include the use of paper sticky notes to convey information on a patient phone call, or to order a test, or to inform a clinician of a requested prescription refill. The cause of the paper sticky note is usually a “disconnect” (Continued on page 22)

March/April 2012

21

Electronic Health Record Implementing EHR (Continued from page 21)

between the electronic tools available for the task, and a well designed workow for users to utilize that tool. Documentation concerns arise when the sticky note becomes a document that has patient information on it or reects a clinical decision that is not documented in the electronic record.

Inaccurate Medication and Problem Lists

Recently published studies suggest that medication and problem lists are incomplete more often than clinicians anticipated. Efforts to maintain an accurate medication list can be difďŹ cult. For example, different organizations may have different policies that deďŹ ne what constitutes a “medicationâ€? within the record.

Therefore, the same patient may have an extensive over-the-counter listing in one setting, and lack those entries in another setting. Further, the clinician is usually dependent on support staff’s ability to accurately update medication

lists. The “problem listâ€? has similar pitfalls of accuracy around data entry by staff, and by internal deďŹ nitions of what constitutes a “problem.â€?

Clinicians who access different EHR systems in multiple locations are also asked to be proďŹ cient in Medication and Problem List utilization under differing organizational deďŹ nitions.

Alarm and Alert Mismanagement

Alarm and Alert Mismanagement may be the most frequently experienced unintended consequence of electronic health records. Alert Fatigue is a well-known term, and reaching epidemic proportions in the departments of some facilities.

Teams charged with creating electronic alerts have a difďŹ cult task. The beneďŹ ts of welldesigned alerts are clear. For example, systems can prompt clinicians to avoid speciďŹ c medications or to consider suggested care pathways.

However, concerns originate when alerts are closed without documentation around the

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reasons for ignoring the alert suggestion. In many locations, entire categories of alerts are disabled at the system level because the volume of false alerts overwhelms the available time of the user being asked to respond. Deactivating alerts eliminates the potential of a system to utilize many decision support tools.

Emotional Disengagement

Emotional Disengagement of system users is an unintended consequence of EHR implementation. Developing and implementing standardized documentation policies are a required component of an EHR. Inevitably, standardization causes users to lose a certain degree of freedom to “individualize� how clinical activities are ordered, documented and accessed.

The process used by the organization to prepare for that loss of “individualism� directly affects the level of user disengagement. Disengaged individuals may increase the frequency of incomplete or inaccurate entries in the EHR that other clinicians rely on in providing patient care.

Anticipating unintended consequences of electronic health records enables organizations to avoid potential pitfalls of the EHR. With careful planning and auditing of system utilization, clinicians and patients will experience the full beneďŹ t of the electronic health record in delivering patient care.

Mike Flicker is a member of the MMIC Health IT team. He has over 25 years of experience in the health care ďŹ eld as administrator of rural multispecialty clinics. Mike has presented at regional and national conferences on topics ranging from EHR implementation to creating rural hospital/ physician partnerships. He has an MBA in Health Care from St. Thomas University.

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March/April 2012

MetroDoctors

The Journal of the Twin Cities Medical Society

Coordinating Health Information Technology Through CHIC

T

he Community Health Information Collaborative (CHIC) is a unique partnership among hospitals, clinics, long-term care facilities, tribal health facilities, higher education institutions and public health departments in Minnesota that maximizes the health care services members are able to provide through innovative use of technology.

By identifying and taking advantage of opportunities to coordinate health information technology, CHIC provides strictly controlled access to patient health care records among care facilities; sends Medicare claims efficiently and quickly; recruits and trains users for MIIC, the state’s immunization registry; administers USAC applications for members, and coordinates emergency preparedness for health care partners under a contract with MDH Office of Emergency Preparedness.

CHIC was developed under a Federal Office of Rural Health Policy — Network Development grant in 1997. Taking advantage of the opportunity the grant provided, CHIC invested significant time and resources to develop trust and productive working relationships among providers that led to the creation of a self-sustaining organization financed by dues from its more than 170 members who represent the entire health spectrum.

The Federal Office of the National Coordinator and the state of Minnesota’s Office of Health Information Technology have mandated that electronic health records (EHR) systems be installed in a variety of health care provider organizations. You folks know who you are; this is not going to be a discussion of Meaningful Use or the process of implementing an

By Cheryl M. Stephens, Ph.D.

MetroDoctors

EHR. We are going to take a look at the other less famous part of these requirements — the need for interoperability and the exchange of a standard format called the Continuity of Care Document (CCD). This means that, no matter what type of EHR system you may install, it must be able to exchange information with everyone else’s EHR. Not such an easy task as some may tell you. In fact, a new industry has evolved to provide just this service.

Parts of this industry are very technical — for instance, the data we exchange 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, any person that may request information must adhere to a Military Level 3 Authorization/Authentication process each and every time they enter into the HIE-Bridge™ system.

Final note, no information is ever released from HIE-Bridge unless a signed patient release is attested to or it is an emergency.

CHIC and its subcontractor, ApeniMED, worked under a federal cooperative agreement

The Journal of the Twin Cities Medical Society

to assist in the specifications and technical architectural design of the Nationwide Health Information Network (NwHIN). We were also closely involved in developing policies and procedures for joining the NwHIN and, in the finalization of the trust agreement, the Data Use and Reciprocal Support Agreement (DURSA). Through this work, we have contracted with the Social Security Administration to exchange Disability Determination patient records electronically. This new workflow of 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 we have “gone live” with a Veteran’s Administration program called the Virtual Lifetime Electronic Record (VLER) designed to build a record for all service persons, both active and retired, containing information from the private provider’s records as well as the VA’s VISTA system. Thus, no matter where a service person is stationed or where an elderly veteran may receive care, all of their patient information will be available for their treatment.

We are currently working on creating an exchange that provides a greater breadth of services. To that end, we have joined forces with ABILITY Network and Emdeon who have also been certified as Health Data Intermediaries through the state’s Health Information Exchange Service Provider certification process.

The HIE-Bridge service has been certified by this same process as a Health Information Organization — the only one in the state to date.

CHIC’s existing HIE-Bridge network is

(Continued on page 24)

March/April 2012

23

Electronic Health Record CHIC (Continued from page 23)

currently implemented with a provider directory, a federated record locator service, and a consent management system that meets the requirements of Minnesota’s current RLS legislation. Expanding this platform with laboratory directories and record locator information from Emdeon, along with interim directories developed by ABILITY Network for the interim solution, offers an existing solution poised to meet the long-term requirements for Minnesota and its health care providers.

The details of the updated offerings, architectures, and strategies each partner brings to the total solution, what is to be developed and implemented under the new direction of statewide shared HIE services and core HIE services will continue to align with CHIC’s core principles. These include: s #ONTINUED INVOLVEMENT WITH PARTICIPATING members for requirements, prioritization of projects, and governance. s #OMMITMENT TO -INNESOTA S STRICT PATIENT privacy and security laws including patient authorized access to their information. s 4RUSTED AND COLLABORATIVE STEWARDSHIP OF services and patient information. s $ISTRIBUTED FEDERATED NETWORK ALLOWING control of patient information to stay with the covered entities.

To best address the near- and long-term health information exchange needs of Minnesota, Community Health Information Collaborative (CHIC), ApeniMED, ABILITY Network, and Emdeon have agreed to collaborate to deliver best-in-class services for statewide shared services including both shortand long-term technical infrastructures and Core HIE Services. This will begin with parallel

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March/April 2012

Direct and Connect strategies, recognizing the efforts of all three existing technical infrastructures. The short-term statewide shared HIE services will use technologies based on (1) the Federal Direct Project specifications and (2) the Federal NwHIN Connect specifications already implemented in certain health care provider organizations and being further implemented under the 2011 eHealth Connectivity Grant.

In addition, we will augment these services with Core HIE services to address obvious, immediate needs around both push and pull message exchanges, as well as for 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 NwHIN Direct-based message “pushes” to NwHIN Exchange-based messages, queries, and “pulls.” Likewise, we anticipate that for other use cases (such as primary to specialist care referrals), evolution may not involve so much a change of transport mechanism (e.g., NwHIN Direct-based exchange) but rather better integration with existing workflows (e.g., native EMR/HIS integration) or adoption of higher-level standards (such as those underway as part of the Federal Standards and Interoperability Framework initiative). Thus, our intent is to provide an evolving and “right-sized” technology platform at the times and places, as well as in the manners, needed to ensure effective and sustainable health information exchange in Minnesota and with surrounding states.

Much has been done to help hospitals and clinics move to the electronic age with health information technologies. Incentive programs such as REACH, Meaningful Use dollars, and eHealth Connectivity grants have all focused on these specific health care providers. These have been important and meaningful initiatives and have helped advance the use of electronic health records and health information exchange in Minnesota.

CHIC is hoping to target another important segment of the continuum of care for patients, particularly the elderly and invalid population residing in long-term care facilities throughout Minnesota. CHIC has a goal to integrate them into a health information

exchange to improve patient care with more timely and complete information. We also anticipate improvement in information flow during transitions of care between these facilities and hospitals.

We have commitments from Aging Services of Minnesota and Care Providers of Minnesota to work together on outreach and implementation efforts with the plethora of facilities around the state — virtually all of whom are members of one of these two agencies.

An interesting dimension to our strategy is that both agencies supporting long-term care align with respective EHR vendors (Point-Click and MDI Achieve). Both vendors offer cloud solutions for their customers, thereby offering remote services. Both vendors have agreed to work with us and our developers to integrate HIE-Bridge services into their systems, thereby allowing their customers to use the HIE-Bridge health information exchange as a feature of their offerings.

Leadership at Aging Services and Care Providers are excited to be able to offer this service to their members. We will work with these agencies to promote this service, its benefits, and ease of implementation. We also will identify the hospital and clinics that refer patients to and receive patients from these long-term care facilities and encourage them to participate in HIE-Bridge as well. By so doing, the value of the exchange is enhanced, for both the long-term care facilities and the hospitals and clinics, since there is a greater degree of confidence that a query for information will be successful in bringing patient data to the requesting provider.

CHIC’s history of providing relevant services to its members, through close collaboration with members in a trust-based environment, provides the basis from which our vision for health information exchange is founded. All of the participating developers, ApeniMED, ABILITY Networks, and Emdeon work with CHIC in either existing or required relationships due to the HIESP Certification program in Minnesota which provides oversight of this new and complex industry.

Cheryl M. Stephens, Ph.D., president and CEO, Community Health Information Collaborative.

MetroDoctors

The Journal of the Twin Cities Medical Society

Mary K. Brainerd Receives Shotwell Award

T

he 2011 Shotwell Award was presented to Mary K. Brainerd at the January 10, 2012 meeting of the Abbott Northwestern Medical Staff. Richard D. Schmidt, M.D., chair of the West Metro Medical Foundation of the Twin Cities Medical Society and Kent Wilson, M.D., Shotwell Award Selection Committee member, copresented the award.

The Shotwell Award is bestowed annually to a person within the state of Minnesota who has made significant innovations and/ or improvements in health care delivery.

Mary Brainerd has been an innovative leader in health care since 1984. She currently is president and chief executive officer for HealthPartners, a position she has held since 2002, and served as executive vice president and chief operating officer prior to this appointment. Before joining HealthPartners in 1992, Mary held senior level positions with Blue Cross and Blue Shield of Minnesota, including senior vice president and chief marketing officer. She was also senior vice president and chief executive officer of Blue Plus.

Dedicated to serving the community in multiple facets, Mary is recognized as one of the founding CEOs of the Itasca Project, a group of 40 government, civic and business leaders addressing the issues that impact long-term economic growth, including jobs, education, transportation and economic disparities. She also serves on the boards of Minnesota Life/Securian, Minnesota Council of Health Plans, The St. Paul Foundation, Minneapolis Federal Reserve and SurModics.

In 2010 Mary accepted a leadership role as corporate champion for Honoring

MetroDoctors

Mary Brainerd receives the 2011 Shotwell Award, presented by Drs. Lee Aristogui (L), Kent Wilson and Richard Schmidt (R).

Choices Minnesota, an advance care planning initiative of the Twin Cities Medical Society (TCMS) and its foundation. She successfully challenged the broader community, including all hospitals, health plans and insurers, to embrace and implement a community-wide end of life care planning initiative. Sue Schettle, TCMS chief executive officer, said “Mary is an incredibly passionate advocate for issues that make communities strong and vibrant.

The Journal of the Twin Cities Medical Society

She’s a terrific communicator and leader.”

A St. Paul native, Mary received her master’s degree in business administration from the University of St. Thomas and a bachelor of arts degree from the University of Minnesota. She has received numerous awards for her accomplishments as a health care executive, a community leader and a role model.

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March/April 2012

25

TCMS Celebrates 3rd Annual Board Dinner PETER DEHNEL, M.D. was installed as the 3rd president of the Twin

Cities Medical Society at the annual meeting of the Board of Directors on Tuesday, January 24, 2012. His term succeeds Thomas Siefferman, M.D., 2011 president, who was acknowledged with the outgoing President’s Award. This sculpture, 98.6°, crafted by Jeff Barber, was commissioned in recognition of the dedicated service of the outgoing President of the Board.

98.6° stands as the norm for health. This sculpture symbolically interprets the degrees for temperature as degrees in angles. Variations in dimension further the notion that people are not exactly 98.6° at all times.

The adult figures balance with the angles — and are directly symbolic of those who intercede to maintain the critical balance of 98.6°; those who have chosen medicine as their life’s interest.

Edward P. Ehlinger, M.D., commissioner, Minnesota Department of Health, and the first president of TCMS, was the featured speaker, emphasizing the “health of the state of Minnesota.” He noted our successes as we are #1 for lowest rates in the country for cardiovascular disease, occupational hazards and physical health rates. However, as we have dropped from the first or second healthiest state in the nation to number six, there is work to be done. Adult binge drinking has become a huge public health issue. Minnesota has the 46th highest rate in the state, with the majority of binge drinkers over the age of 25. Lack of public health interventions which can be addressed with individual responsibility in the context of community responsibility and ethnic health disparities round out the top three health issues facing our state.

He concluded by stating that there is great opportunity for public health and medicine to work together to return our state to the healthiest in the nation.

Lyle Swenson, M.D., MMA president, offered greetings from the MMA. Dr. Swenson gave a brief update on MMA Strategic Planning activities and highlighted the four strategic goals — to make Minnesotans the healthiest in the nation, to make Minnesota the best place to practice medicine, to position MMA as the source for advancing professionalism in Minnesota, and ensuring that MMA membership is an indispensable benefit for all Minnesota physicians.

Dr. Swenson also noted the current MMA effort aimed at better understanding the issues facing physicians in independent practice. He welcomes any and all questions or comments and looks forward to being of assistance to Minnesota physicians.

Peter Dehnel, M.D., president, highlighted several of the accomplishments of TCMS throughout the past year, calling special attention 26

March/April 2012

Thomas Siefferman, M.D. receives the outgoing President’s Award from Peter Dehnel, M.D.

to Honoring Choices Minnesota and the Twin Cities Obesity Prevention Coalition.

He also noted another major project that was undertaken by the TCMS Policy Committee — the compilation of a physician developed model for value-added health care delivery, called the TC Network, currently in its final review. Making light of the challenging work of this committee, Dr. Dehnel offered: TOP TEN SIGNS THAT YOU MAY HAVE SIGNED UP FOR THE WRONG ACO 10. You are required to carefully read all 696 pages of the final rule of Medicare’s Accountable Care Organization description.

9.

In a previous job, your CFO won the Tom Petter’s Award for Creative Accounting.

8.

Your sole hospital partner just announced an agreement with CMS to pay back $350 million in Medicare over-charges.

7.

Your largest group of specialty physicians just announced they were all moving to Texas and selling their practice to a group of recent graduates from the American University of the Caribbean.

6.

Your designated EHR station looks strangely like an early 1990s Atari game console.

MetroDoctors

The Journal of the Twin Cities Medical Society

5.

You read in the paper this morning that your chief legal consultant is under investigation by the Office of the Inspector General.

4.

Your Chief Safety Officer was recently featured on the Discovery Channel’s “Deadliest Catch” program.

3.

Your CEO’s previous job was overseeing administrative improvements within the Postal Service.

2.

The primary reference sources for your clinical algorithms turn out to be Google and Wikipedia; and

1.

You need to disclose your bank information and other financial holdings on the very unlikely chance that your ACO will underperform financially.

Dr. Matt and Heather Hunt.

The work of the Board of Directors can only be as successful as its members. On behalf of the board, Dr. Dehnel extended gratitude to the members completing their terms: Ronnell Hansen, M.D. (also served on the executive committee); Tony Orrechia, M.D. (also served as TCMS Secretary); Shari Ohland, MMGMA Representative; Charles Terzian, M.D. (MMA Trustee); and Peter Wilton, M.D. And, the following new members were announced: Steven Darrow, M.D., AMA Alternate Delegate; Courtney Jordan-Baechler, M.D.; Sandra Kamin, President Elect MMGMA; William Nicholson, M.D., AMA Alternate Delegate; and Stefan Pomrenke, M.D.

Eric Crockett, president, MMGMA and Janet Silversmith, director of health policy, MMA

Medical student Jessica van Lengerich and Ben Whitten, M.D.

TCMS staff from L: Barbara Greene, Nancy Bauer, Andrea Farina, Katie Snow, Sue Schettle, and Jennifer Anderson.

Sanjiv Kumra, M.D.

Dr. Will and Leah Nicholson, Ken Crabb, M.D., Roxanne Rosell and Robert Moravec, M.D.

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The Journal of the Twin Cities Medical Society

Lyle Swenson, M.D., MMA president.

Sue Schettle, TCMS CEO, and Commissioner Ed Ehlinger, M.D.

March/April 2012

27

First a Physician Award Robert W. Geist, M.D. 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 lives of others in our community.

The Award is given at the annual meeting of the TCMS board of directors.

Ronnell Hansen, M.D. presents Robert W. Geist, M.D., the First a Physician Award to 2011 First a Physician Award reRobert W. Geist, M.D. (left). cipient is perhaps best known to the community of volunteer physician and legislative public policy activists. He has expended truly incalculable personal time and resources over more than 40 years as an advocate of the highest integrity on behalf of the profession of physicians, and for the protection of

patients. Engaging in often complex analysis of legislative proposals, health law, and medical economics is both challenging and demanding, even for the seasoned policy expert, requiring long hours of study, rational scrutiny, and referencing of the literature. Dr. Geist continues to provide this service on behalf of his colleagues and our patients daily, with energy and purpose year after year, often for colleagues with an under appreciation of just how difficult this can be. It is often true that it is easier to be critical of educational efforts than for an audience to fully expend the energy to understand the depth of the issue. With remarkable tenacity, this physician continues to remain lighthearted and positive when in the crucible of critics, faithfully returning again and again to present his analysis. He has also founded and organized committees which have served as open forums to encourage direct dialogue of physicians with diverse policy experts to examine and critically dissect public policy direction and affect the creation of legislation as it affects physicians and patients within Minnesota and nationally. He is truly the thinking person’s physician and patient advocate. In grateful recognition of his work to enhance the medical community’s ability to practice quality medicine, the First a Physician Award was presented to Dr. Geist.

Get Involved in National Healthcare Decisions Day on April 16 Honoring Choices Minnesota, along with other organizations across the country, is endorsing an effort which highlights the importance of advance care planning — National Healthcare Decisions Day (NHDD) on April 16. NHDD provides an opportunity to raise awareness about the value of future health care decisionmaking and completing health care directives.

In 2011, with only 25 percent of participating organizations reporting, 2.2 million facility staff members received NHDD information or training and more than one million members of the general public participated in NHDD events or received information on health care directives. We hope to add to these numbers significantly in 2012.

In addition to signing up your organization to participate, here are some of the ways 28

March/April 2012

s

Twin Cities Medical Society members can help this important cause: s &IRST AND FOREMOST, lead by example…be sure you have thoughtfully considered and made your own health care decisions known. s .EXT MAKE SURE EVERYONE IN YOUR ORGANIzation is informed about NHDD (including all staff, board of directors, volunteers and others) and ask for their involvement to promote NHDD to your patients. s 0ROVIDE A LINK ON YOUR WEBSITE TO nationalhealthcaredecisionsday.org or the Minnesota site, mnhealthcaredecisions.info

3ET UP AN EXHIBIT ABOUT .($$ AT YOUR main entrance and offer information about advance care planning as people come by. s $ISTRIBUTE .($$ PROMOTIONAL MATERIALS and advance care planning educational brochures in patient rooms or at upcoming community events or health fairs.

For details and tools available for download, including a well-done promotional video, visit the national website at www.nationalhealthcaredecisionsday.org. If you plan to hold an event or display in honor of NHDD, contact Katie Snow at Twin Cities Medical Society (KSnow@metrodoctors.com, (612) 362-3704).

Please join us on April 16!

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The Journal of the Twin Cities Medical Society

In Memoriam THOMAS W. O’KANE, M.D., passed away on December 17, 2011 at the age of 97. Dr. Kane graduated from the University of Illinois Medical School. He became the chief of staff at St. Joseph’s Hospital in 1964. Dr. Kane saw over 40,000 patients, performing surgeries and general eye care from the 1930s until the mid-1980s. Dr. Kane has been a member since 1946.

EUGENE C. OTT, M.D., passed away on January 12, 2012 at the age of 82. He graduated from the University of Minnesota Medical School in 1954. Dr. Ott was a family physician in Edina and assistant professor in the Department of Family Medicine for Hennepin County Medical Center. Dr. Ott was president of the Hennepin County Medical Society in 1994, in addition to serving on several other professional boards throughout his career. His time spent volunteering locally and abroad will be remembered, including serving as medical director of St. Mary’s Health Clinics. Dr. Ott has been a member since 1956.

Minnesota History Center Houses WMMS Alliance’s 100 Year History On a cloudy, rainy and blustery day in October of 2011, my husband Jim and I visited the Minnesota History Center to view the recently completed archival of the West Metro Medical Society Alliance (WMMSA) Hennepin Medical Society Alliance/Auxillary (HMSA) 100 year history.

The history of the WMMS Alliance is well organized and filed in the archive section of the Minnesota History Center. The archive includes original hand written minutes, pictures, newsletters, newspaper articles and other materials that span from 1910 – 2010. It was reassuring to know that such a rich history of 100 years of volunteerism by West Metro (Hennepin County) physician spouses is so meticulously preserved.

CAREER OPPORTUNITIES

If you have WMMSA (HMSA) materials/records such as minutes, financial records, pictures, articles, etc. that you would like to add to the collection or you would like to visit the archives, please contact: Duane P. Swanson, Curator of Manuscripts Division of Library, Publications and Collections Minnesota Historical Society 345 Kellogg Boulevard West St. Paul, MN 55102-1906 (651) 259-3318 duane.swanson@mnhs.org Diane Gayes, past president, West Metro Medical Society Alliance (HMSA).

See Additional Career Opportunities on page 30.

STACY ROBACK, M.D., age 70, passed away on January 20, 2012. Dr. Roback graduated from the Tulane University School of Medicine. He completed internships and residencies in pediatrics, general surgery, pediatric surgery, and thoracic/cardiovascular surgery at the University of Minnesota, becoming board certified in all specialties. Dr. Roback was a senior partner at Pediatric Surgical Associates and the former chief of staff at Children’s Medical Center. Throughout his 45 year career Dr. Roback shared his knowledge and experience by mentoring and teaching students entering the field of medicine. Dr. Roback received the 2011 Charles Bolles Bolles-Rogers award from the Twin Cities Medical Society recognizing his contribution and leadership in the medical profession. Dr. Roback has been a member since 1977.

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The Journal of the Twin Cities Medical Society

March/April 2012

29

New Members

-ARK 2 -OUNT - $ Allina Medical Clinic – Coon Rapids Otolaryngology

-OHIBA + 4AREEN - $ Dermatology Consultants, P.A. Dermatology

"EN 2 "ACHE 7IIG - $ Abbott Northwestern Hospital Internal Medicine

#HRISTOFER ! 3MITH - $ Fairview Oxboro Clinic Internal Medicine

*EANETTE - 4HOMAS - $ Park Nicollet C linic – Chanhassen Obstetrics and Gynecology

!BDHISH 2 "HAVSAR - $ Retina Center, P.A. Ophthalmology 'REGORY ! "ROWN - $ -0( Park Nicollet C linic – Meadowbrook Orthopedic Surgery/Sports Medicine *OHN # &OLEY - $ Progressive Eye-Care Associates, P.A. Ophthalmology %RINE / &ONG - $ Emergency Physicians and Consultants, P.A. Emergency Medicine +ATHRYN ! 'EHRIG - $ Skin Care Doctors, P.A. Dermatology

CAREER OPPORTUNITIES

See Additional Career Opportunities on page 31.

Internal Medicine?

Family Medicine?

Yup.

NEW clinic in Mahtomedi, MN?

!NDREA - (OOGERLAND - $ Children’s Respiratory & Critical Care Specialists, P.A. Pediatric Critical Care Medicine

Internal and Family Medicine Opportunities

"RADFORD 6 *OHNSON - $ Fairview Crosstown Clinic Internal Medicine

Stillwater Medical Group is an 90+ provider multi-specialty group practice afďŹ liated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services with locations in the St. Croix Valley, just east of the Twin Cities metro area.

$EEPAK +ADEMANI - $ Maxillofacial & Oral Surgery, P.A. Oral and Maxillofacial Surgery

Internal and Family Medicine Physician Opportunities:

3TEPHANIE # +IM - $ North Memorial Medical Center Internal Medicine 6ANESSA , +NOEDLER - $ Metropolitan Obstetrics and Gynecology, P.A. Obstetrics and Gynecology !NITA 3 -AC$ONALD - $ HealthPartners Health Center for Women Family Medicine 2OBERT 0 -C#ABE 3R - $ Minnesota Gastroenterology, P.A. Internal Medicine, Gastroenterology

Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN. Mahtomedi, MN? (Ma-toe-me-dye) So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside avor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education.

For further information please contact: Patti Lewis, Director Human Resources 1500 Curve Crest Blvd, Stillwater MN (651) 275-3304, plewis@lakeview.org stillwatermedicalgroup.com

We’ll make it all better.

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March/April 2012

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The Journal of the Twin Cities Medical Society

CAREER OPPORTUNITIES

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Contact Cathy Fangman t cfangman@winonahealth.org .BOLBUP "WF t Winona, MN 55987 t 800.944.3960, ext. 4301 t winonahealth.org March/April 2012

31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, M.D.

GLEN D. NELSON, M.D.

T

here are many more ways to “practice medicine” beyond those of directly ministering to patient needs in a clinic/office or hospital setting. Our current Luminary, who has an impressive background in direct patient care, has made remarkable contributions to his chosen profession and his community in a variety of other fashions.

Glen Nelson, M.D. was locally born and bred. He did his undergraduate work at Harvard University and graduated from our U of M Medical School in the early ’60s. His General Surgery Residency at Hennepin County Medical Center led to certification by the American Board of Surgery in 1970 and nearly 20 years of surgical practice at Park Nicollet Medical Center (PNMC).

The expansion of his medically related interests began to blossom during his time at PNMC. In the midst of a significant growth period there, Dr. Nelson served as chairman, president and chief executive officer. There followed a long association with Medtronic where he first functioned as a director and thereafter was employed as an executive vice president and a vice chairman. While at Medtronic, he was involved in a variety of cardiac device projects and a deep brain stimulation procedure for Parkinsonism. Paralleling those profound care advancements was a marked organizational and revenue evolution in that highly successful corporation. A pattern of organizational growth emerged in those early portions of his career. Dr. Nelson states, “I just love to play a role in the growth of an idea or a company.”

For the last 10 years, Dr. Nelson has engaged in supporting a wide range of medically related activities. Elements of that support have included electronic medical records and technological initiatives as validated by clinical research and the standardization and measurement of care delivery interventions. He currently is involved in assisting health care startup ventures with an emphasis on Minnesota-based companies. He presently holds a variety of Board positions and in the recent past was the chairman of MinuteClinic during its inception period. His remarkable record of success in the growing of ideas and organizations speaks for itself.

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March/April 2012

Through the years, Glen has contributed to an engaging variety of medical, educational and community bodies and activities, including: Minnesota Public Radio (Trustee), The United Way (Division Chairman), St. John’s University (Regent), Blake Schools (Trustee), Minneapolis Chamber of Commerce (Director and Chairman), The Jackson Hole Group (Member), Hennepin Avenue Methodist Church (Board Member), Harvard University (numerous Committee and Board appointments), Walker Art Center (Director), the Johns Hopkins Board of Advisors…and he’s been a member of our medical society for over 40 years.

Dr. Nelson was elected to the Bakken Society for outstanding technical and scientific contributions, received an Outstanding Achievement Award from the U of M, holds a Lifetime Achievement Award by proclamation of the Governor of Minnesota and is an Emeritus Clinical Professor of Surgery at the U of M. In a recent conversation, Dr. Nelson stated, “I’ve been lucky; most people have only had one career and I am thankful for the balanced understanding I’ve gained and the rewards I’ve received. The rewards in surgery are more immediate, and though those in the commercial world are slower, they are no less gratifying.”

Dr. Glen Nelson — a visionary with an entrepreneurial spirit whose career has been defined by an innovative and energetic work ethic — is a welcomed addition to our gallery of Luminaries…a medical renaissance man.

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.

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The Journal of the Twin Cities Medical Society

Proceeds from MPS help to support the operations of TCMS. Please consider our business partners listed below as you look to reduce your operational costs.

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To Learn More, Call (612) 362-3704

see what MMIC can do for you.