Page 1

Contents Midwest Medical Edition

June 2011

Regular Features 2 |

From Us to You

17 |

Then and Now Examining Malpractice

25 |

Grape Expectations

Rosés Bloom in Summer By Heather Taylor Boysen

31 |

33 |

Cover Feature

News & Notes News from around the region

Learning Opportunities Upcoming Symposiums, Conferences and CME Courses

Staying for Awhile

By Alex Strauss

In This Issue 4 |

AMA’s First Physician App

6 |

New Robots Offer Surgical Options

18 |

The Case for Customer Service

19 |

Special Section Medicine in the Digital Age – Making Peace with EHR

28 |

Estate Planning with Asset Protection Trusts

In Review Acute Stroke Care, A local doctor’s guide for Primary Care Physicians



The Castle Turns Two After two years, Sanford’s free-standing acute care specialty hospital for children is still growing strong. New pediatric specialties, nine additional specialists (and more on the way), the state’s first pediatric residency program, and new satellite clinics around the world are keeping Sanford Children’s on the cutting edge of pediatric care.



From Us to You

Staying in Touch with MED


A letter from the VP and Editor

Steffanie Liston-Holtrop

Alex Strauss


ow that the harsh winter and spring thaw are finally behind us, it is time to celebrate. Here at MED, we love a celebration – especially when it means an increased level of medical care in the South Dakota region. The Sanford Children’s Hospital, dubbed the ‘Castle of Care’, has been open for just two years, but with even more pediatric specialists, exclusive specialties, and the state’s first pediatric residency program, a lot has already changed. We’re celebrating with them with an update in this month’s Cover Feature. New technology is a major theme for MED this month. A number of area hospitals have enhanced their robotic surgery options and added other advanced and noteworthy equipment for improved patient outcomes. Even if your office isn’t adding medical equipment, there is a good chance that technology is playing an increasing role in your day-to-day operation. We take a deeper look into Electronic Health Records and what they mean for South Dakota medical practices and offer some help for tackling the transition in your office in our special section, “Medicine in the Digital Age”. Our thanks to regional experts who bring us practical advice this month on keeping your workers healthy and on the job (pages 9, 14), managing your financial assets (page 28), and even choosing a perfect summer wine for your barbeque (page 25). Dr. Brad Randall speaks his mind on the always-inflammatory issue of malpractice (page 17) and Dave Hewett of SDAHO makes the case for customer service (page 18). As always, we welcome your contributions, particularly for our ongoing columns including Then & Now, Medicine & the Arts, In Review and News & Notes. You don’t have to be a writer to be a part of MED. Contact us via phone or email and share your thoughts and ideas – we can help you communicate them to your medical colleagues across the region. As the area’s only business publication for physicians and healthcare professionals in the tri-state region, MED is brought to you free with the support of advertisers who value your business. We encourage you to mention their MED presence when you have occasion to patronize these advertisers. As always, we welcome your feedback and appreciate your readership as well as the contributions you are making every day to improved healthcare in our region. In good health, —Alex & Steff

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Don’t forget we want to hear from you.


MED Magazine, LLC Sioux Falls, South Dakota

VP Sales & Marketing Steffanie Liston-Holtrop Editor in Chief Alex Strauss

Cover Design/Photo Darrel Fickbohm Design/Art Direction Corbo Design Web Design 5j Design

Contributing Editor Darrel Fickbohm

Contributing Writers Heather Boysen Dave Hewett Lori Berdahl Lindsay Cosimano Jessica Beavers Contact Information Steffanie Liston-Holtrop, VP Sales & Marketing 605-366-1479 Alex Strauss, Editor in Chief 605-759-3295 Fax 605-271-5486 Mailing Address PO Box 90646 Sioux Falls, SD 57109 Website

2011/12 Advertising / Editorial Deadlines July August Issue June 5

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Sept/Oct Issue August 5th

2012 Jan/Feb Issue December 5

April/May Issue March 5

November Issue October 5th

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Reproduction or use of the contents of this magazine is prohibited.

©2011 Midwest Medical Edition, LLC Midwest Medical Edition (MED Magazine) is committed to bringing our readership of 3500 South Dakota area physicians and healthcare professionals the very latest in regional medical news and information to enhance their lives and practices. MED is published 8 times a year by MED Magazine, LLC and strives to publish only accurate information, however Midwest Medical Edition, LLC cannot be held responsible for consequences resulting from errors or omissions. All material in this magazine is the property of MED Magazine, LLC and cannot be reproduced without permission of the publisher. We welcome article proposals, story suggestions and unsolicited articles and will consider all submissions for publication. Please send your thoughts, ideas and submissions to Magazine feedback and advertising and marketing inquiries, subscription requests and address changes can be sent to MED is produced eight times a year by MED Magazine, LLC which owns the rights to all content.

Midwest Medical Edition

Intensive Care for Newborns

In whose hands will you place her?

Physicians’ Priority Line


When a newborn is critically ill, a single call gives you instant access to our neonatal intensive care specialists and a full range of pediatric and surgical subspecialists, all supported by state-of-the-art technology and equipment. It can also link you to our neonatal transport service team, who will arrange for transport to Children’s Hospital & Medical Center based on the child’s needs. Twenty-four hours a day, seven days a week, one call links you to physician-to-physician consults, referrals and admissions. There’s no problem too large, no child too small.

AMA Unveils First-Ever Physician App

Yuri Arcurs/

Now, they’re inviting physicians to submit their ideas for the next one

The American Medical Association (AMA) has introduced its firstever app for mobile devices designed specifically to allow physicians to

quickly find CPT (Current Procedural Terminology) billing codes. The app is now available for free through the iTunes store. Developed by the AMA for physicians, the CPT evaluation and management quick reference app is an on-the-go reference guide that helps physicians determine the appropriate CPT code to use for billing. Compatible with Apple iPhone, iPod Touch and the iPad, the app features both decision-free logic and quick search options, allowing physicians to digitally track CPT codes and email them anywhere. Physicians can also save their most frequently used codes by location or type of service to allow for even more ease of use. AMA has also launched the 2011 AMA App Challenge to find the next great medical app idea. Open to all U.S. physicians, residents and medical students, the 2011 AMA App Challenge

calls on those on the front lines of medicine to submit their unique app idea for a chance to have the AMA bring it to life. Participants can submit their app ideas easily through an online form through June 30th. Two winners will be selected, one from the resident/fellow or medical student category and one from the physician category. The winners will each receive $2,500 in cash and prizes, plus a trip for two to New Orleans for the grand unveiling of their winning idea at the AMA’s meeting in November. “Quick access to accurate information physicians use daily was the goal behind creating the CPT app,” said Dr. Stack. “We are eager to discover which other medical apps physicians, residents and medical students would find useful through their App Challenge idea submissions, and we are thrilled to be able to bring two of the best ideas to the physician community.” ■

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Midwest Medical Edition


Join Forces

New Online Directory Designed to Help Physicians Choose Practice

Locally owned and operated since 2003

Management System Software Selecting the right software to use in a medical practice is critical for physicians, particularly now that all technology-based practices must be compliant with the government’s updated standard for electronic  claims transactions. The new standard, known as HIPAA Version 5010, will be required by January 1, 2012. The American Medical Association (AMA) and the Medical Group Management Association (MGMA) have made the software selection process easier by developing an online directory of software vendors designed to help physicians determine whether the vendors’ practice management systems are compliant with the 5010 standard. A companion piece to the recently released Selecting a Practice Management System toolkit, the Practice Management System Software Directory provides detailed vendor profiles, enabling physicians to easily choose the software that best fits their needs. The Practice Management System Software Directory identifies the features most important to physician practices, including: Price range for the product (excluding implementation costs), Current installed customer base for the product, t Target market for the product, t Number of years the practice management software has been offered t Affiliated electronic health record (EHR) products. t t

“In order to avoid cash flow disruption associated with the transition to the 5010 standard, it is critical for physician practices to convert their administrative systems and test their readiness well in advance of the compliance date,” said MGMA President and CEO William F. Jessee, M.D., FACMPE. “Accessing the Practice Management System Software Directory will be an important step for practices looking to implement new software that not only complies with complex federal mandates, but also takes advantage of the many administrative simplification opportunities under development in the public and private sectors.” The directory and toolkit are available on the AMA and MGMA Web sites. ■ June 2011

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Avera McKennan Adds a Second Robotic Surgical Si takes System currentdaVinci technology a step further.


Avera McKennan Hospital & University Health Center has added a second daVinci Surgical System – the daVinci Si. It is the first and only hospital in South Dakota to offer daVinci’s newest system. The hospital has also added the daVinci Skills Simulator, a new virtualreality training simulator for robotic surgery, which just became available in January. Avera McKennan purchased its first daVinci system in 2007. The daVinci Si is the next generation. “The advancements of the daVinci Si provide surgeons with unparalleled precision, dexterity and control in performing a whole host of minimally

Midwest Medical Edition

The advancements of the daVinci Si provide . . . unparalleled precision, dexterity and control. invasive procedures,” says Dr. David Kapaska, regional president and CEO of Avera McKennan. The daVinci systems integrate threedimensional, high-definition video and robotic technology to virtually extend the surgeon’s eyes and hands. The precision of robotic procedures delivers less surgical trauma to patients than open procedures or laparoscopy, allowing patients to have shorter hospital stays, lose less blood, experience less pain and get back to work sooner. Hysterectomy and prostatectomy are among the most common robotic procedures. Robotics are also used for pyeloplasty, adrenalectomy, sacral colpopexy, and other gynecologic procedures. The daVinci Si Surgical System has updated features, including: s Enhanced 3D, high-definition vision of operative field with up to 10 times magnification s New optional dual console which allows a second surgeon to provide assistance s Superior visual clarity of tissue and anatomy s Surgical dexterity and precision far greater than the human hand s Updated and simplified user interface to enhance efficiency s New ergonomic settings for greater surgeon comfort The daVinci Si will accommodate new technology as it becomes available, including blood vessel mapping, tumor mapping, and single port incision surgery. In the past three years, 18 specially-trained surgeons have performed more than 530 robotic procedures at Avera McKennan. ■

June 2011

Dr. Lee and Dr. Spanos

Sanford Offers New Procedure for Tonsil and Tongue Cancer Two surgeons are the first in the region to use new technology Sanford Health patients with tumors of the tonsil and base of tongue are now being treated with a groundbreaking new robotic surgical procedure. Surgeons John Lee, MD and W. Chad Spanos, MD, who specialize in head and neck cancer, are the first in the region to offer an innovative new technology approved within the last year by the Food and Drug Administration. The procedure, called transoral robotic surgery (TORS), allows surgeons to operate on tumors in the tonsil or base of tongue without having to make incisions in the neck. Doctors Lee and Spanos are able to remove tumors using a less intrusive approach, entering though the mouth with avoidance of potentially disfiguring neck surgery altogether. “Sanford cancer patients are already benefiting from this new surgical method, which can be carried out with significantly less blood loss than traditional oral surgery and far fewer effects on speech and swallowing,” says Dr. Lee. TORS uses the daVinci surgical robotic system to allow direct access through the patient’s mouth. According to Dr. Spanos, the technology holds the promise of fewer side effects from cancer treatment. “Patients treated with TORS may require lower radiation doses and possibly avoid the need for chemotherapy if the tumor can be completely removed accurately using this technology,” he says. ■




Midwest Medical Edition

Work as



By Lori Berdahl, OTR/L, CESS

hanks to countless research studies on the subject of work disability prevention, the trend of requiring injured employees to “be at 100%” before returning to work is becoming a thing of the past. Employees participating in early return to work can protect their jobs, income and benefits, avoid long-term disability and/or unemployment, stay physically conditioned and mentally active, and maintain the daily structure and social connections provided by work.

Benefits of Early Return to Work Studies have repeatedly shown that staying involved in some amount of work activity during recovery actually shortens injury recovery time and results in better medical outcomes. People who never lose time from work consistently have better medical outcomes than people who lose some time from work. This research base has led many medical groups such as the American Academy of Orthopedic Surgeons, the American Occupational Medical Association’s Committee of Practice, the American Medical Association and The Medical Disability Advisor to issue statements in support of early return to work after injury. Work activity can be used as part of the rehabilitation process, with functional activities gradually increased as recovery continues. Rehabilitative work activity decreases risks of deconditioning, and avoids the creation of financial agendas which may interfere with recovery motivation.

Work Disability Prevention The American College of Occupational and Environmental Medicine (ACOEM) recommends that medical providers adopt a “disability prevention” model which includes setting clear expectations of recovery with the patient, reducing fears by explaining that some discomfort is normal when resuming activities after an injury, and emphasizing the importance of staying active in safe/ conservative ways. ■

Berdahl is an Ergonomic and Loss Control Specialist with RAS, a provider of Workers’ Compensation Insurance,headquartered in Sioux Falls, SD.


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Negative Impact of Time Away From Work Research has also identified reasons why prolonged time away from work is actually harmful. The odds of a worker ever returning to work drop below 50% by just the 12th week of off-work status. Time away from work has been found to result in physical de-conditioning, co-worker resentment, loss of social interaction, loss of self-respect from earning a living, loss of the major selfidentity component, disruption of predictable daily life, loss of control over daily decisions, interruption in income, and an increased focus on justifying reasons for time away from work.

June 2011

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Turning Two By Alex Strauss

Castle of Care

For sick children and their families, staying for awhile in Sanford’s ‘Castle of Care’ means access to leading technology, highly trained specialists, and breakthrough research delivered in a bright, child-friendly atmosphere. For the region’s medical community, Sanford’s own ‘staying power’ has raised the bar for pediatric care for this region and beyond. “In the last two years, Sanford Children’s Hospital has matured into a regional center for tertiary care, not only in South Dakota but in Western Minnesota and the adjoining states,” says Sanford’s Chief Pediatric Medical Officer, Dr. Gene Hoyme, Chair of the Department of Pediatrics at the Sanford School of Medicine. Dr. Hoyme joined Sanford in 2007 and took an active role in the planning of the hospital. Sanford Children’s Hospital provides a total of 146 beds, 66 of which are general pediatric, 58 NICU, 12 PICU and 10 designated for outpatient procedures. The basement level of the ‘The Castle’ houses a dedicated pediatric imaging center and the ground floor houses the offices of Sanford Children’s Specialty Clinic, which Hoyme now describes as ‘bursting at the seams’. Sanford Children’s Sioux Falls-based pediatric subspecialty team now includes more than 60 physicians. “One of the most important things that having the hospital has allowed us to do is recruit a significant number of high quality pediatric specialists,” says Dr. Hoyme. “This gives patients little reason to go outside the area, even for highly specialized care.” As Chief Medical Officer, Dr. Hoyme has helped recruit 30 to 40 new researchers and clinicians during his four-year tenure. Although it is not located within the hospital, the cutting edge research being conducted in the Sanford Children’s Health Research Center supports the work of the hospital by advancing knowledge on subjects ranging from stem cells to brain tumors, lung disease and childhood diabetes. Much of the research is directed by the mandate of the Sanford Project, a research initiative with the goal of curing Type I diabetes. On the clinical side, Sanford Children’s now boasts pediatric medical and surgical specialties – among them, pediatric urology, nephrology, infectious disease, hospitalists, and soon, pediatric


Midwest Medical Edition

It has been two years since the region’s first free-standing acutecare children’s specialty hospital opened its doors in Sioux Falls. Behind the imaginative exterior Sanford Children’s Hospital has continued to evolve, growing a reputation for excellence, and ensuring that a higher level of pediatric care is here to stay.

. . . Here to Stay

June 2011

ENT – that are available nowhere else in the region. In the past two years, Sanford has added 9 specialists including a gastroenterologist, nephrologist, ophthalmologist, urologist, hematologist/ oncologist, optometrist, infectious disease specialist, and three additional hospitalists. The pediatric hospitalist program is one of the fastest growing subspecialty areas for the hospital. “There are many types of physicians who rarely admit children to the hospital,” says Dr. Hoyme. “They appreciate having a pediatrician in the hospital who is solely dedicated to overseeing the care of their young patients. This program has grown by leaps and bounds and we will be adding a fifth physician soon.”

A Recruit’s Perspective One of Sanford Children’s new recruits is pediatric nephrologist John Sanders, MD, who joined last summer. Dr. Sanders received his MD from East Carolina University in North Carolina and spent four years at Tripler Army Medical Center in Hawaii. The South

M. Akram. Khan, MD, Neonatologist

KayeLyn Wagner, MD, Hematologist/Oncologist

Carolina native completed a pediatric nephrology fellowship at the University of Tennessee Health Science Center. “The Army opens your eyes to the fact that there are a lot of places that are as good or better than where you grew up,” says Dr. Sanders, who was attracted to South Dakota by the opportunity to establish the area’s first pediatric nephrology program. “Many positions in my field are academic, but here at Sanford there

was the potential for teaching as well as clinical practice, and a commitment to the highest quality care.” Dr. Sanders’ treats young patients with conditions such as chronic kidney disease, proteinuria, hematuria, endocrine issues and pediatric hypertension, which can be related to kidney disease. About half of the kidney disease cases are congenital. Although adult nephrologists may concentrate much of their practice in one area, such as dialysis or

William Waltz, MD, PhD Pediatric Cardiologist


Midwest Medical Edition

New Residency Program One big change at Sanford Children’s since the hospital opened is the addition of the region’s first pediatric residency program. Accredited last May by the Accreditation Council for Graduate Medical Education and led by pediatrician and Program Director Dr. Joseph Zenel, the new 3-year program will accept its first class of six residents this summer. They are an elite six, chosen from a huge pool of applicants. “We had more than 150 applicants and ended up interviewing roughly 60 candidates for our six slots,” says Dr. Zenel. “When we did our match, we did not have to scramble at all. We easily filled our program.” Residents applied to the Sanford’s program from around the U.S. and the world. The final six, all of whom are women, hail from Missouri, Michigan, South Dakota and Minnesota. They represent both allopathic and osteopathic backgrounds. Most residents who applied to the new program ranked Sanford Children’s as their first choice, citing the newness of the program, the location, and the eye-catching building. June 2011

The floor of the Sanford Children’s atrium reflects the organization’s goal of establishing a far-reaching presence through strategic placement of its Sanford World Clinics. “It is harder to recruit new physicians today if you do not have a global focus,” says Dr. Hoyme.

“Although I stressed to them that it is NOT about the building,” says Dr. Zenel, who attracted many of those applicants with strategic use of Facebook. With South Dakota ranked among the lowest states in the nation in pediatricians per capita, Sanford is hopeful that the new residency program will not only help to turn those numbers around in the region (since doctors are more likely to stay and work where they trained), but will further establish their own reputation and quality as a premier provider of children’s specialty care. “There is no question that having a pediatric residency program will raise the academic standing of Sanford Children’s Hospital as well as the system as a whole, “says Dr. Zenel. “But, just as importantly, it supports the Institute of Medicine’s goal that physicians be lifelong learners. When you are responsible for training residents, you are forced to keep your skills sharp. It leads to inquiry and

improvement.” Zenel says the tech savvy young doctors may even lead to greater acceptance of Sanford’s increasingly electronic medical environment. A successful first residency program also makes it more likely that Sanford will be able to start other types of residency programs in the future. It may even pave the way for a fellowship program at a time when the number of pediatric subspecialists, and the programs to train them, is inadequate to meet the demand. “This is no longer just a local or even domestic issue,” says Hoyme, who cites Sanford Children’s World Clinics, established to provide care in underserved area of the world, as evidence of the organization’s outward focus. “In some ways, this has begun to drive the direction of our recruitment and residency program. We want to provide not only today’s top pediatric specialists, but also to train tomorrow’s pediatric leaders.” ■ 13

Photos by Josh LeClair, Sanford

transplantation, Dr. Sanders says pediatric nephrologists, who see much smaller numbers of patients, are more likely to be ‘Jacks of all trades’, providing the full gamut of nephrology care. “You are in the outpatient world as well as in the NICU,” he says. “You are in the general pediatric world and you’re in the pediatric critical care world. So you get to have a broad exposure but still stay specific in your focus.” Sanders, whose residency at Tripler included just five other residents, says he was looking for the same kind of collegial environment in which to practice. “I enjoyed the way physicians put their heads together, because it means you are taking care of patients in the best way possible. I found that same kind of collaborative atmosphere at Sanford Children’s Specialty Clinic.”

Building a Successful

Worksite Wellness Program


By Lindsay Cosimano, APR, PCM

he Centers for Disease Control and Prevention defines obesity as an individual with a Body Mass Index of 30 or higher and reports that healthcare claims for obese individuals are $1,429 higher than those of people of normal weight. In South Dakota, nearly 30 percent of residents are considered obese. So it stands to reason that this increased cost of care places a huge financial burden on our medical system and employers. By focusing on preventive health and wellness coaching, wellness programs are gaining national attention as a means to address rising health-care costs as well as our nation’s declining health. The Wellness Council of America recommends seven benchmarks for operating a successful program, which are outlined at Once you have a plan in place, creating a unique brand for your wellness program will help differentiate wellness from other benefit offerings and raise awareness for the cause.

Branding a Wellness Program A common misconception is that building a strong brand requires a big budget. Regardless of funding, a strong brand is possible by focusing on clarity, consistency and creativity. It is important to be clear about what your program wants to accomplish to prevent a shotgun approach where you attempt to be all things to all people. By identifying two or three specific risk areas and writing clear objectives stating


how you will impact them, you will ensure your programming stays on task. Consistency is key to any brand. For messaging to be heard, you must consistently deliver it multiple times. Whether you are inviting employees to a ‘lunch and learn’, organizing a team for a local walk, or encouraging employees to eat healthy, consistently reinforce your wellness mission and restate your operational objectives. Finally, creativity gives you the greatest opportunity to develop your wellness brand. The center of Cassling’s Platinum Well Workplace program is a fictional character named Captain Cassling. The Captain helps employees and families navigate their journey to wellness through online education, incentive programs and wellness screens and coaching. By branding every aspect of our program to the Captain and the nautical theme, the wellness program is integrated into our culture and is widely recognized within Cassling and in the community. Regardless of whether you are in

the first stages of developing a wellness program or already seeing a return on your wellness investment, a clear branding strategy to integrate wellness education and preventive health measures into your workplace can help decrease healthcare costs and improve the well being of employees and their families. ■ Lindsay Cosimano is Vice President of Marketing at Cassling.

Midwest Medical Edition

Avera McKennan Hosts

Juried Art Exhibit The Prairie Center on the campus of Avera McKennan Hospital & University Health Center is hosting a juried art exhibition, “The Art of Healing,” from June 1 to July 31. The art is displayed on the Prairie Center’s unique Community Digital Media Art Gallery. The Community Digital Media Art Gallery, the first of its kind in the region, is a digital display measuring over 15 feet long and 7 feet high. Fifteen monitors utilize cutting edge technology to provide crisp and sharp imagery of the submitted work. The digital art gallery displays ever-changing exhibits. “The digital art gallery was designed so that any kind of art could be displayed and shared with our community. Since virtually all art mediums can be photographed and displayed, we felt this offered great flexibility for so many artists,” said Michelle Lavallee, senior vice president of Strategic Marketing and Communication at Avera McKennan. The digital art gallery will host four shows per year. Artists can sign up to receive e-mails about upcoming themes at The digital media art gallery also offers the flexibility to

June 2011

share other images such as survivor stories, staff profiles or other topics of interest. The Prairie Center is also home to an

extensive original art collection, with 60 commissioned works by 15 artists, as well as numerous donated and purchased works. Artworks include a variety of watercolor and oil paintings, blown glass, photography, needlepoint tapestry, pastel and colored pencil drawings and bronze sculptures. “Avera has long believed that the arts play a critical role in the health and lives of our patients, staff and community,” Lavallee said. “That’s why we remain so committed to including an expression of the arts as part of the health care environment in our various facilities.” ■

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Sanford plans to include up to three hybrid operating suites when it opens its Heart Hospital in 2012.

Leading Edge Vascular Capabilities Now Available in Sioux Falls New hybrid operating room system imProves imaging for faster diagnosis and treatment. The Avera Heart Hospital has opened a new state-of-the-art hybrid robotic vascular lab, equipped with the new Artis Zeego robotic technology system from Siemens Healthcare. It is the same technology that will also be in place in Sanford USD Medical Center’s upgraded hybrid operating room. The technology provides unmatched positioning flexibility to enable the most advanced images and techniques. “This is a large step forward in vascular medicine,” said Dr. Mike Bacharach, vascular specialist, with North Central Heart Institute. “In the past it was sometimes difficult to obtain the visuals we needed, especially with complex cases. This new robotic lab will help us to be more precise so that patients can experience the best outcomes and the latest treatment options,” Artis Zeego’s flexibility allows for virtually unprecedented 16

Vascular Robot: The Avera Heart Hospitals new Artis Zeego allows for unprecedented freedom of movement during imaging.

freedom of movement and the ability to image 360 degrees of a patient’s anatomy in the catheterization lab. The system conforms to both the clinical needs of the patient and the ergonomic needs of the physician. Artis zeego’s roboticassisted positioning enables the 3D-visualization of larger sections of anatomy, improving diagnostic capabilities and reducing procedural radiation dose. “Complex cases can be more easily treated because the suite is designed to handle both less invasive and open procedures,” says Charles P. O’Brien, MD, president, Sanford USD Medical Center. “In the future, these advancements will allow us to replace heart valves with smaller incisions and without opening up the chest.” The new hybrid operating room equipment in the Sanford Surgical Tower will allow surgeons to move equipment to any area around the patient because of its multi-axis system. The new Sanford Heart Hospital will include up to three hybrid operating rooms when it opens in 2012. ■ Midwest Medical Edition

Then & Now Our Changing Medical Landscape

Examining Malpractice By Darrel Fickbohm


r. Brad Randall and I were having lunch the other day, looking out over the 18th street view. I asked him about changes in the healthcare profession and eventually we got to his wish list of some things that he thought should be different: Some of the consultation work I do is on malpractice, on both sides. The doctors dropped the ball on malpractice a long time ago. The profession should have set up some way of adjudicating bad results. There should have been an internal system that said, “Oh, gee Mrs. Smith, we see that you’ve had a bad result.” It should never have gotten to a legal system. We didn’t police ourselves so the courts ended up having to do it for us. For a successful lawsuit, an attorney has to prove negligence, but the definition of negligence has gotten too broad. Take pathology practice:

June 2011

there’s absolutely no doubt that of the thousands of pap smears that I’ve examined that I’ve missed something. I just didn’t see or somehow misinterpreted that one important cell out of the thousands on a pap smear. That unavoidable human error would have to be called, in this legalistic system, “negligent.” So the term has gotten so stretched out of proportion that some poor doc who’s made a human error is labeled this way. They’re labeled because it has become the patient’s only redress. What should have happened is we should have said, “Yes, Mrs. Smith, something went wrong. It’s a rare but unavoidable part of the process sometimes. We will compensate you something—it doesn’t mean someone did something wrong—it just happens.” There have been talks of emulating the Federal Aviation Administration’s manner of filing reports. If you screw

up, you file a report, which prevents you from being fined, and they use that information to find out how to improve the system—everyone benefits. Of course the malpractice apparatus— those who profit from the process—are completely against this, and a structure for compensation would have to be established, and people would have to admit their mistakes; so it’s a tough sell. But it would generate a lot of information of what’s wrong with the system. In this environment, if you lose a malpractice case, the message is, “Don’t get caught next time.” The hospitals are trying to monitor these things and do a better job than they used to. They have staff that looks at errors and mistakes, but most of this information is internal and not available to people outside the hospital. We come back around to the fact that hospitals should have the freedom to right these problems internally while assuring that the patients are properly compensated. ■

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Do you have a media review? A book, film, or article? How about an opinion on a current event? Write to us at:


The percentage of patients answering “always” to these questions is reported for each hospital in the country. For South Dakota hospitals, results can be accessed through the SDAHO web site at: http:// For the record, the range of responses for that first question relating to physician communication is significant in South Dakota with a high of 92% in three facilities to a low of 57% in one.

How we treat people matters –clinically and personally


Why Customer Service Counts


By Dave Hewett, President/CEO, SDAHO

t stands for the Hospital Consumer Assessment of Healthcare Providers and Systems, and it is CMS’s way of measuring how Medicare patients feel about the care they receive in hospitals. Pronounced “H-Caps”, these publicly reported care indicators will also affect payment levels to hospitals by 2013. They may already be affecting some patients’ decisions about where to obtain their health care services. Some are critical of HCAHPS’ measures as reflecting “just” the opinion of the patient and not the actual care the patient is receiving. I confess to having those same thoughts. I’ve had a change of heart because … Customer Service Counts. Whether someone is purchasing something from an airline, grocery superstore, hardware store, hair salon, physician’s office, or hospital, customer service counts. When making a decision to obtain services, we know that more new customers (patients) are using the 18

Internet to at least weed out those potential choices that appear not to meet their expectations or service needs. Here are the questions HCAHPS asks Medicare patients discharged from hospitals: ✦ How often did the physicians communicate well with the patient? ✦ How often did the nurses communicate well with the patient? ✦ How often did staff explain about medications before giving them to the patient? ✦ Was the patient given information about what to do during their recovery at home? ✦ Would the patient recommend this hospital to friends and family? ✦ How often did the patient receive timely help from hospital staff? ✦ How often was the patient’s pain well controlled? ✦ How often was the area around the patient’s room kept quiet at night? ✦ How often was the patient’s room and bathroom kept clean?

As for Medicare reimbursement, the Centers for Medicare and Medicaid Services (CMS) will be distributing “value based purchasing” monetary awards to those hospitals that achieve exceptional scores in patient safety and satisfaction. Patient satisfaction as measured by HCAHPS counts for 30% of that score. But besides the reimbursement aspect, the important point for physicians to remember is that you are the provider that patients are coming to see. And how patients see their care being delivered has consequences in how they fill out this patient satisfaction survey or how they talk to their friends and neighbors about their treatment experience. In an era in which “covered lives” will increasingly be the moniker by which provider success is measured, a patient’s opinion of how he or she was treated will be all the more important. I mentioned airlines above. Twenty five years ago a small regional airline adopted a new philosophy of customer service dedicated to employing “people who can do things well with laughter and grace.” Since that time, Southwest Airlines has become the world’s safest and most on-time airline and has enjoyed 24 years of profitability and massive stock growth – this all despite the general economy and the special challenges faced by the airline industry. How we treat people matters – clinically and personally. ■ Midwest Medical Edition

MED special Section

Medicine in the Digital Age

Making Peace with Electronic Health Records

By Alex Strauss

Like many rural physicians, Noreen O’Shea, DO, wears a lot of hats. As the single full-time physician and Medical Director of the Union County Health Foundation (UCHF), a long standing community health center in Alcester, she is the primary care provider for an estimated 1000 patients in the Alcester area and another 3000 or so around Elk Point. She Is the medical leader for three Physician Assistants and staff, dividing her time between the two clinics. She is also UCHF’s number one

June 2011

champion on the path toward the digital age. “We know that Electronic Medical Records are an important part of the future of medicine, but it is up to me to help make sure that, while we are transitioning to more electronic processes, we never lose sight of our ultimate goal: patient safety and good patient care,” says Dr. O’Shea. “Ultimately, the patient is the primary thing. I want to make sure we have everything in place for patient-centered care and I believe that meaningful use will follow.”


Medicine in the Noreen O’Shea, DO

Although the goal of the HITECH act (see “EHR and the HITECH Act: A Physician Primer”), is to ensure that all clinics are meeting the goal of ‘meaningful use’ of EHR systems by 2015, a recent national MGMA survey indicates that only a small percentage of EHR users are taking full advantage of their systems. Of the 62.9 percent of respondents who said they did plan to take advantage of HITECH incentives, only 26.8 percent said they were in the implementation process. The rest had either found a system and not yet started using it, or were still searching. By those standards, UCHF is ahead of the curve. In 2005, the clinic joined with other regional community health centers to research and choose an appropriate Electronic Health Records system. The group put out bids, listened to presentations, and evaluated software in their search for a vendor who could simplify their government reporting requirements, allow them to track important demographic data, and streamline patient care.


They narrowed down an initial list of eleven potential vendors to one that seemed to meet their needs. The process was running smoothly until… “Our funding ran out,” says Dr. O’Shea. “We had a system chosen but we did not have the money to purchase the hardware and software. So we just had to wait.” It wasn’t until the clinic received a Capital Improvement Project (CIP) Grant in 2009 that the necessary purchase could be made and the EHR implementation process continued. The cost of such systems is a major hurdle for many independent clinics, most of whom do not have the benefit of grant money. Choosing a system can be complex, too, given the number of vendors available. But, for many, those are not the biggest barriers to successful EHR use.

Overcoming Hurdles “We find that a lot of the skepticism has to do with fear of loss,” says Dan Heinemann, MD, Chief Medical Officer and HIT champion at Sanford. It Dr. Heinemann’s is job to help bring physicians on board with the plan to fully implement EHR system-wide by 2012. “No one wants to lose anything, so they don’t want to change. So a lot of it is about change management. We encourage physicians to understand that it’s OK to feel that loss, but we also try to help them see what they are gaining.” But Dr. Heinemann concedes that the process can be a little like “trying to

build at airplane while you’re flying”. “In many cases, physicians are being asked to do things like change the way they make notes or order tests, while they’re still seeing patients. They need a great deal of support in order to continue to deliver good patient care while they’re making the transition.” At UCHF, provider ‘buy in’ was a not a problem. Dr. O’Shea and her PA colleagues recognized the need to become more electronically savvy as a clinic. But they quickly discovered that installing a system, and figuring out how to use it for optimum advantage, can be two different things. “As demoed, the EHR system we chose looked like it would support the way we deliver care here and maybe even make things a little easier,” says Dr. O’Shea. “Frankly, I’m not sure about that right now. The sales people can do a nice song and dance, but if the person who trains you on the product is not really familiar with the way you run your practice, they may not necessarily understand what is most important. They know how their system works, but they are not always able to think creatively about the best ways to use it.”

Going Live . . . Cautiously To minimize problems and maintain patient care standards, UCHF decided to implement their new practice management system in stages, beginning this past January with basic functions like scheduling. They began using the

MED special Section


Digital Age system’s phone message feature in March and will roll out e-prescribing (sending prescriptions to the pharmacy electronically) in June. “We are also starting to do early computerized physician order entry (COPE),” says Dr. O’Shea. “This means that if I order lab tests or procedures, those orders need to be put into the super bill and I need to generate my diagnosis and link that to the orders.” The clinic’s goal is ‘go live’ with the full EHR system in mid-July. To help meet that deadline, UCFH has found it helpful to lean on the HIT specialists at South Dakota’s federally-funded Regional Extension Center, HealthPOINT, for extra support. (See “HealthPOINT: Overcoming Barriers to Meaningful Use”) “The advantage is that they have the

30,000-foot view of things and we have a 30-foot view,” says Dr. O’Shea. “When we encounter problems in using the system, they can pull us back and give us some perspective. They can show us what we’re doing right and what we’re doing wrong and in some cases show us more efficient ways to do things. With their support, we found out that we are smarter than we thought we were and that has helped us gain confidence.” Despite some inefficiency in the EHR system, Dr. O’Shea concedes that it will make it easier to examine patient population trends over time and to manage that population. With patient data at her fingertips, for instance, she can quickly find all patients who are taking a certain drug and inform them of a recall or adverse reaction. Dr. O’Shea is also enthusiastically

Dan Heinemann, MD

watching for the further development of more sophisticated decision support software that will help streamline diagnosis with up-to-the-minute health information, an invaluable feature particularly for isolated rural providers. Ultimately, Dr. Heinemann agrees that empowerment of physicians and patients is one of the greatest advantages of electronic management of health information. “The amount of medical knowledge is doubling at a rate we have never seen,” says Dr. Heinemann. “Medicine used to be like golf, but these days it’s more like baseball. It is a team sport and the patient has to be a part of that team. EHR allows doctors to engage with each other and patients to engage with their doctors like never before. When they can take ownership of their healthcare and share in decision making, it leads to more effective care. The transition period to EHR may be stressful, but patients and physicians are going to look back and see that this was the right thing to do.” ■


There are few medical practitioners who are not familiar with the concept–if not yet the use–of Electronic Health Records. The idea of managing vital practice information, from appointment scheduling to billing, prescription and test ordering, and patient record-keeping is transforming the practice of medicine, whether or not doctors are ready for it to do so. A nationwide survey conducted by the Medical Group Management Association indicates that the number of medical practices and other healthcare organizations incorporating an EHR system into their practice has increased measurably in the past decade. That’s the good news. Less encouraging for the Office of the National Coordinator for Health Information

information that would eventually drive down the cost of care.” The HITECH Act provides up to $44,000 per eligible provider treating Medicare patients ($63,750 for those treating Medicaid patients) to purchase and meaningfully use EHR systems. The act appears to be having its intended impact. Despite the dizzying array of EHR systems and vendors available, the resources required to purchase and provide staff training, and the even more potentially-daunting challenge of establishing physician and staff ‘buy in’, 72 percent of the MGMA study respondents say they do plan to take advantage of the HITECH incentives. But doing so may be more complicated than it initially

A Physician Primer

Electronic Health Records and the HITECH Act

Technology, is the fact that only 16.3% of the 52.3% of respondents using EHR systems in 2010 had fully integrated their systems into all aspects of their day-to-day patient care. To help move more practices down the road to what is termed ‘meaningful use’ by 2015, the Health Information Technology and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act, introduced monetary incentives in 2009. Incentives will be available to healthcare entities that use their systems not only to do things like schedule and check in patients and generate bills, but also to order and record medications and tests, and store physician notes, imaging studies, etc. The first incentives were paid this year. “Before Healthcare reform, the HITECH Act was healthcare reform,” says Kevin Boyum, Operations Manager of HealthPOINT, South Dakota’s Regional Extension Center charged with the task of helping practices navigate the complexities of EHR selection and implementation. “HITECH was a bipartisan bill intended to accelerate the adoption of Electronic Health Records to improve efficiency of processes, improve patient care, and start the process of promoting portability of


appears. Proper system selection and implementation is critical. To take advantage of the incentives, HITECH requires that healthcare providers choose and use an EHR system that is ‘certified’ for use by the particular type of provider, i.e. an ambulatory EHR system for office-based physicians or an inpatient hospital EHR for hospitals. The system must also provide for ‘qualified’ electronic health records, meaning records of health-related information that include patient demographic and clinical health information. A ‘qualified system’ must also have the capacity to provide clinical decision support, support physician order entry, and receive and exchange health information with other sources. In addition, the act also requires that, in order to be ‘qualified’, the chosen system must meet all privacy standards for protecting sensitive patient data. “EHR implementation is a complex process and there are no easy answers,” concedes Boyum. “The bottom line is that the concept of meaningful use is tied to patient-centered measures and outcomes. It must be shown that the system is not just in place, but that it is actively being used to improve healthcare and specific patient outcomes.” ■

MED special Section


Overcoming Barriers to Meaningful Use


ew would argue that there are advantages to electronically streamlining any business, including the business of healthcare. Thanks to the HITECH Act, remaining in the digital dark ages is no longer an option. But while many types of businesses made the electronic transition in the 80’s and 90’s, the medical establishment has been slower to get on board. For many, the prospect of a sudden and dramatic change in the way they have managed information for decades, is daunting. “There are substantial barriers to implementing these changes and they are not barriers that can be broken down simply with advice,” says HealthPOINT’s Kevin Boyum, who has first-hand knowledge of those barriers. “Successful implementation of an integrated EHR system requires intervention, expertise and people.” That is where HealthPOINT can help. Based at Dakota State University’s Center for the Advancement of Health Information Technology (CAHIT), HealthPOINT was made possible by a $5.6 million dollar grant from the

Department of Health and Human Services. It is one of 62 federally-designated Health Information Technology Regional Extension Centers (REC) established to provide unbiased assistance to all healthcare providers in their journey toward meaningful use of EHR systems.

Thanks to the HITECH Act, remaining in the digital dark ages is no longer an option.

HealthPOINT HIT specialists like Manish Kharche provide hands-on support for all stages of EHR implementation.

“Our mission is to provide expertise, particularly to healthcare groups that could not normally afford it,” explains Boyum. “We provide services that are typically very expensive, if they are available at all to rural providers. Often, vendors who may sell an EHR system to a rural provider are not willing to go there to help these organizations affectively adopt and use their new system.”

For organizations that are just starting the process, HealthPOINT’s experienced HIT team specializes in helping practices analyze their readiness for EHR and identify problems that may stand in the way of effective utilization of the system they choose. For those who have a system in place and are trying to maximize its advantages, HealthPOINT can help measure their success and keep them on track.

HealthPOINT’s Team of Healthcare IT Specialists

Holly Arends, RHIT

Kevin Atkins

Kevin Boyum

Clinical Information Technology Manager

Clinical IT Specialist Lead

Operation Manager

Terry Disburg, RN Clinical IT Lead

Dan Friedrich, CISSP Director


Understanding and overcoming potential barriers to meaningful use starts with a thorough practice assessment. HealthPOINT specialists work closely with doctors, staff and clinic managers to develop a clear picture of needs and concerns – before, during and after the EHR implementation process – and offer customized, workable solutions. Often, Boyum says, the biggest barriers are not in the technology itself, but in the people who use it. “Many organizations are finding that they are successful at flipping the switch, but the challenge comes in trying to get their people to use the technology correctly,” he says. “It is vital to ask the

questions, ’Are the people engaged in the process? Is there executive buy-in? Have they had adequate training?’ Even a good system can’t transform bad processes. So we do a lot of workflow assessment and documentation.” What HealthPOINT does not do is sell or provide technical advice on any particular EHR system. Instead, the group’s non-profit, independent status gives healthcare organizations a trusted place to turn for support and education as they attempt to forge their own unique EHR path. While it is still too early to say definitively whether or not EHR can improve a practice’s bottom line, Boyum says there is no question that it does

represent the future of medicine in the digital age. “Ultimately, patients are going to make the provider choice that is best and easiest for them,” predicts Boyum. “People are going to go with the office that allows them to access their health records while they are on vacation, or lets them make appointments online. They are becoming used to these conveniences in other areas of their lives, and they are not going to tolerate healthcare as usual ten years from now.” HealthPOINT’s services are available to all South Dakota healthcare providers. More information is available on their website at ■

HealthPOINT’s Team of Healthcare IT Specialists

Tara Gill, MSAS Clinical IT Lead


Manish Kharche, MHA, MSHI - Clinical IT Specialist

Laura Moller, RHIT Clinical IT Lead

Jeff Pickett Marketing/Training Coordinator

MED special Section

Grape Expectations

Rosés Bloom in Summer By Heather Taylor Boysen


t is finally Summer and nothing speaks to me more in the summer than a crisp, dry Rosé. Before you all start groaning, please understand that this is not your parents’, or even grandparents’, Rosé. Get the thought of sweet White Zinfandels out of your head. Sweet blush wines are nothing like a beautiful, flavorful Rosé. Even though Rosé is still a hard sell, the types and styles we can get today offer the consumer a wider range of flavors and sophistication. One of my favorites is a wine from the Hendry Winery in Napa Valley. George Hendry has a total affection for his Rosé and it is evident in his description: “It is important to note that this wine, though fruity (and yes, pink) is fermented to dryness, as are all of our wines, with no residual sugar. Wellchilled, its clean, bright, citrusy fruit and palate-cleansing acidity are just right with picnic foods on a warm afternoon, or to accompany a simple barbecue-roasted chicken on a summer evening. Great with fish tacos, too! This is a ‘screen-porch’ wine, made for warmweather drinking, well-chilled, with simple foods.” This particular Rosé is the result

of a saignée of both Zinfandel and Cabernet Sauvignon, along with just a little bit of Cabernet Franc and Primitivo. Saignée is the process of “bleeding,” or allowing the sweet, free-run juice to run out of the tank and into a smaller tank for fermentation. This lowers the alcohol in the red wine, concentrates its colors, flavors and tannins, and in the process, produces a light, dry rosé that is perfect for drinking in the summertime while the reds used for the saignée barrel age. I have four friends who also share a love of good Rosé. Yes, it seems like a small number, but it’s almost like our own little club and only the serious Rosé drinkers are allowed! I do have more than four friends, but these are the people who I can count on to really get excited about these wines. When the new vintages are released each year we take pleasure in sharing our treasures which we have found either in our travels or through our winery contacts with one another. My next “treasure”, brought to me by one of the “club members” is described by the winemaker as a “wine with bright citrus aromatics, with candied peach and perfectly ripe honeydew melon. For us, it is the most delicious signal that summer isn’t so far away”. Think of biting into a succulent peach as the flavor fills your mouth with luscious sweetness, then imagine the skin of the peach lending a dry, yet not unpleasant counterbalance to the sweetness of the fruit. Then imagine this wine with a fresh summer salad of perhaps stone fruit, greens and a light vinaigrette. Perfect!

In a couple of weeks, winemaker Erik Miller from Kokomo Vineyards will be a guest presenter for a wine tasting I am hosting. As I was perusing his selection of wine on his website I was struck immediately that he had two wines of great interest for me. One was a Late Harvest Sauvignon Blanc done in a French Sauterne style (perfect for our dessert course) and the other was a Grenache Rosé. Imagine my disappointment when I read that these two wines were “winery only” and less that 200 cases were produced every year. To my extreme gratification and excitement, our newest winemaking friend is bringing both wines with him and he would be happy to share his Grenache Rosé with us. Other than a French Rhone Rosé I once had, I don’t believe I’ve ever had another Rosé made solely with Grenache. I may have found another treasure and perhaps another club member. Cheers! ■


Avera Heart Hospital Offers New Stent to Treat Coronary Artery Blockage Back row, pictured left to right: Rita Haxton, Vice President of Patient Care and awards presenter; Eric Rineard; Sara Rodolph; Mary Klueber, Chair of the Shared Governance Council and awards presenter; Brandi Tackett; and Leann Sterk. Front row: Karla Hofkamp, Kara Schumacher, Deb Kuehn, and Terri Kirkpatrick.

Exceptional Nurses & Nurse Advocate Honored at Rapid City Regional Hospital Rapid City Regional Hospital recently honored eight outstanding employees with Nursing Star Awards, recognizing excellence in nursing. The Star Awards, developed by RCRH’s Nurse Shared Governance Council, encourage employees to nominate their fellow nurses for the following awards: Guiding Star–Mentor, Gold Star–Service, Shining Star–Community, Rising Star–Novice, Super Star–Expert, Blazing Star–Advanced Practice, Supporting Star, and Luminary Star-Nurse Advocate. The Nurse Shared Governance Council is an employee-driven council at RCRH formed to create an environment where participatory decision making will occur between staff and leadership regarding nursing professional practice issues which promote clinical autonomy and responsibility, provide opportunities and encouragement for professional development, and effectively utilize staff and resources. ■


Dr. Bruce Watt, a cardiologist with North Central Heart Institute, is the first in North and South Dakota, and the fourth in the nation to use a new minimally invasive treatment for a blockage in the coronary artery. Developed by Boston Scientific, and recently approved by the FDA, the ION™ Paclitaxel-Eluting Platinum Chromium Coronary Stent System incor porates a unique platinum chromium (PtCr) alloy designed specifically for coronary stenting and intended to improve the acute performance of coronary stent implantation.

Boston Scientific Corporation Ion Stent

This is the company’s thirdgeneration drug-eluting stent technology. Avera Heart Hospital’s coronary intervention team recently conducted their first procedure using the new device. The ION Stent System offers greater strength, enhanced deliverability and exceptional visibility. The thin-strut stent is designed for improved conformability, minimal recoil, and uniform lesion coverage and drug distribution. The advanced low-profile delivery system facilitates precise delivery of the stent across challenging lesions. ■

A MORE COMFORTABLE MRI, FROM HEAD TO TOE Siemens MAGNETOM ESSENZA MRI With the powerful yet comfortable MAGNETOM ESSENZA, many exams can be performed with the patient’s head and feet outside of the system to help reduce discomfort and claustrophobia. » Advanced technology provides fast exams, leading to improved workflow. » Quality images help physicians make a more confident diagnosis. Cassling offers Siemens imaging equipment in addition to unbeatable local service and end-to-end efficiency solutions that help increase efficiency, reduce costs and improve quality.

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Midwest Medical Edition

Dr. Adam Styz

Dr. Tomasz Stys

Sanford Advances Heart Care Introducing the new


Heart Pump Device Sanford USD Medical Center is now utilizing the world’s smallest heart pump. Sanford cardiologists Adam Stys, MD and Tomasz Stys, MD recently placed Abiomed’s Impella 2.5 heart pump in the first patient in South Dakota. The device has been used to treat conditions such as acute myocardial infarction, cardiogenic shock and low output syndrome. Impella 2.5 is a breakthrough technology that offers physicians at Sanford a minimally invasive approach in cardiac treatment. “The minimally invasive world of interventional cardiology is ever changing. We would be able to save more lives in the catheterization lab that would not have been saved before with this new technology,” says Dr. Adam Stys.  The Impella 2.5 is a cardiac assist device which is inserted using a catheter placed into a blood vessel in the cardiac catheterization lab, providing patients with up to 2.5 liters of blood flow per minute. It is seamless and immediate support for critical patients who need increased blood flow immediately.  “Adding this technology will mean more opportunities for our patients to receive less invasive procedures, especially for our heart patients. Less invasive treatments mean smaller incisions, and they continue to replace many major operations. Minimally invasive procedures allow for a much quicker recovery,” added Dr. Stys. ■ June 2011


Estate Planning with Asset Protection Trusts in South Dakota

By Jessica Beavers, CTFA, CISP


outh Dakota is one of few states in the nation that allow you to protect assets against future claims. With proper advance planning, a trust formed under South Dakota law will provide an excellent level of asset protection. Asset protection planning is the use of advanced planning techniques to place assets beyond the reach of future potential creditors. In today’s increasingly litigious environment, asset protection planning has become a significant focus within the field of estate planning. Asset protection in some respects has been a part of estate planning for as long as there has been an estate planning discipline. After all, trusts for family members are created in most instances to preserve and protect property for the future use and benefit of the trust beneficiaries. From this perspective, asset protection is really an integral part of the primary goal of the estate planning: to provide a structure to pass property, either during life or at death, to a client’s designated beneficiaries, while reducing transfer taxes and avoiding other costs and delays. One of the more popular types of domestic asset protection 28

trusts is “self-settled”. A self-settled trust in South Dakota generally has the following characteristics: ♦ The trust is irrevocable and utilizes South Dakota law; ♦ The settlor, creator of the trust, can be a discretionary beneficiary; ♦ At least part of the trust property is located in South Dakota; ♦ All or some of the trust administration is performed in South Dakota; ♦ At least one trustee must be a resident or institution in South Dakota; ♦ The transfer may not be a fraudulent conveyance (South Dakota has a 3-year statute of limitations); ♦ If properly structured, most creditors cannot reach the trust assets to satisfy legal obligations of the grantor; ♦ Self-settled asset protection trusts can generally be established even if a grantor’s gift tax exemption has been fully utilized. As long as the transfer of assets into the trust did not constitute a fraudulent conveyance, a properly drafted South

Midwest Medical Edition

Dakota Asset Protection Trust will protect the trust’s assets against all future creditors except: ♦ Domestic relations creditors ♦ Personal injury and property damage creditors that existed before the trust was created. These creditors are permitted to bring claims against the trust assets. ♦ Alimony or property settlement claims against settlors who were married when the trust was established

EXAMPLE Dr. A creates a Domestic Asset Protection Trust in 2011 and funds it with $5 million. This gift escapes gift tax because it is sheltered from gift tax by a lifetime $5 million exclusion from gift tax. Dr. A and his children are discretionary beneficiaries of the trust. Because creditors cannot reach the assets in the trust, the gift is complete. Dr. A dies in 2020 when the assets in the trust are worth $10 million. Up until the time of his death, Dr. A has been a discretionary beneficiary and received distributions from the trust. By using a Domestic Asset Protection Trust the $5 million of appreciation after funding of the trust will escape estate taxation. Many individuals use a revocable living trust to create a variety of estate planning advantages such as probate avoidance and estate tax minimization. However, these trusts provide no protection of assets from claims by potential creditors. In the event of a lawsuit, assets in these trusts can be seized by a successful claimant. The South Dakota Domestic Asset Protection Trust can be an effective tool to mitigate this risk. You have access to the South Dakota Advantage! Use it! ■ Jessica Beavers is President of Bankers Trust Company of South Dakota.

June 2011

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In Review What You’re Reading, Watching, Hearing

Acute Stroke Care

Second Edition

Authored by Ken Uchino, Cerebrovascular Center, Cleveland Clinic Jennifer Pary, CNOS, Dakota Dunes, SD, James C. Grotta, Department of Neurology, University of Texas Medical School, Houston


ou have just encountered a possible stroke patient. You ask yourself: what should I do first? How do I know it is a stroke? Is it too late to reverse the damage? How do I do the right things in the right order? This book, authored by three experts in the field of stroke care, including Neurologist Jennifer Pary of CNOS Clinic in Dakota Dunes, SD, will help you answer these critical questions. “This book is really to designed to help take the mystery out of stroke care,” says Dr. Pary. “It is essentially a pocket guide for ER personnel, medical students, primary care physicians, etc. It takes them step-by-step through the basics of stroke care.” The book provides practical advice on the care of stroke patients in a range of acute settings. The content is arranged in chronological order, covering the things to consider in assessing and treating the patient in the emergency department, the stroke unit and then on transfer to a rehabilitation facility. All types of stroke are covered. “Delivering good stroke care can be a real challenge,” says Dr. Pary. “In many medical schools, you do not even have to do a neurology rotation in order to graduate. So it is possible to graduate without this knowledge, despite the fact that stroke is the leading cause of disability in the U.S. and the third leading cause of death, according to the American Heart Association.” This new edition provides updated

information from recently completed clinical trials and added information on endovascular therapy, hemicraniectomy for severe stroke, DVT prophylaxis and stroke prevention. A comprehensive set of appendices contain useful reference information including dosing algorithms, conversion factors and stroke scales. “The first edition did not have an index, which is very helpful for finding information quickly,” says Dr. Pary. “There is also a lot of new information

in here about stroke prevention and stroke care as well as information from clinical trials completed since the first edition was published. The new edition has all of the most up-to-date information.” “Our hope is that the book helps people to see that this is not as hard as it seems. Whether you are a big hospital, or a small one, when you have the right protocols in place and the right information at your fingertips, you can deliver good stroke care.” ■

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Midwest Medical Edition

News & Notes Happenings around the region


Avera McKennan Hospital & University Health Center was honored for excellence in advertising in the 2011 Aster Awards. Avera McKennan won five awards, including one Judge’s Choice, two gold and two silver awards. Sponsored by Creative Images, Inc., the Aster Awards recognizes health care professionals for excellence in their advertising and marketing efforts. The 2011 Aster Awards received approximately 3,000 entries from across the U.S., Canada, and South America. Of those, only eight were selected for Judge’s Choice Awards. Avera McKennan won for its Building Hope Gala event materials, celebrating the opening of the Avera Cancer Institute.

This year’s annual Avera Race Against Breast Cancer on May 7 attracted 6200 participants and raised more than $360,000 to fight breast cancer locally. The event offered a new option for donation this year called “Text-to-Give”. People could make a $10 donation from anywhere using their cell phones. On-site digital mammography equipment is now in use at Avera Dells Area Hospital in Dell Rapids, thanks to a grant from the Leona M. and Harry B. Helmsley Charitable Trust. Not does the digital technology cut exam time June 2011

in half, but images can now be sent electronically immediately to radiologists in Sioux Falls. Previously, films were picked up twice weekly by courier and driven to Sioux Falls. Rural Medical Clinics located in Freeman, Menno, Marion and Bridgewater are now part of Freeman Regional Health Services in a joint operating agreement with Avera Medical Group. While Freeman Regional Health Services has owned the clinic buildings in recent years, the Rural Medical Clinics practice has operated independently. Freeman Regional Health Services includes the local hospital, Freeman Medical Center, as well as a long-term care facility, senior housing, and now the network of four clinics.


Megan Maddox, PharmD, Sanford USD Medical Center’s Medication Safety Officer and Pharmacy Supervisor, was selected as the South Dakota Pharmacist of the Year. Megan received this honor at the South Dakota Society of Health-System Pharmacists Convention, held in Sioux Falls on April 1 and 2. Megan received her Doctor of Pharmacy at South Dakota State University and completed her residency in Family Medicine at St. John’s Mercy Family Medicine in St Louis, Missouri. She has been part of Sanford Health since 2006. Kittson Memorial Health Center, a 15-bed critical access hospital, clinic, home health service and nursing home in the northwestern Minnesota town of Hallock has entered into an

associate agreement with Sanford Health. Among other things, the new affiliation will allow KMHC to access Sanford’s EMR system, allowing them to collect, store and access patient medical information in a fast, safer way.

Sanford Children’s Hospital’s chief pediatric medical officer has been presented with a national award by the Western Society for Pediatric Research. H. Eugene Hoyme, MD was recently honored with the Joseph W. St. Geme, Jr., Education Award at the society’s annual meeting. Dr. Hoyme, who has served as chair of the Department of Pediatrics at Sanford School of Medicine of the University of South Dakota since 2007, was nominated for the award by his previous trainees at Stanford and the University of Arizona. In his work at Sanford, Hoyme has served as an educator and mentor and has overseen the establishment of a new accredited pediatric residency program and the opening of the Children’s Hospital in Sioux Falls. The Sanford Diabetes Center Fargo has been certified as the second trial site for the Sioux Falls-based Sanford Project aimed at finding a cure for type 1 diabetes. The objective of the study is to determine whether a combination of two medicines can preserve the few remaining beta cells present shortly after diagnosis and whether beta cells can be regenerated. Patients between 11 and 45 who have been diagnosed within the last 6 months are eligible to participate in the trial.

Children’s Miracle Network Hospitals announced its 2010 fundraising totals and Sanford Children’s in Sioux Falls topped fundraising for small markets with populations of less than 1,000,000. Through year-round fundraising efforts, more than $1.4 million was raised in 2010 by Sanford Children’s.

Clayton Van Balen, MD with Sanford Occupational Medicine has been recognized nationally for his expertise in occupational medicine. Dr. Van Balen was recently elevated to Fellowship in the American College of Occupational and Environmental Medicine (ACOEM) at the College’s annual membership meeting in Washington, DC. Fellow is the highest class of membership within ACOEM. Lake Region Bone and Joint (LRBJ) Surgeons, P.A. based in Bemidji, MN merged with Sanford Health in April. LRBJ has been providing orthopedic services to the Bemidji region since 1988 and staff nine employees and three orthopedic surgeons including Thomas Miller, MD, Terrance Johnson, MD and Jason Caron, MD. As LRBJ joins Sanford Bemidji’s Orthopedics and Sports Medicine team, they will operate under the legal name of Sanford Bemidji Orthopedics Clinic.

Regional Custer Community Health Services (CCHS) CEO/ Administrator Jason Petik has left CCHS to take the position of CEO for Memorial Health Center in Sidney, Nebraska. Petik had been at CCHS since March 1997.


News & Notes

Happenings around the region

Shannon Takara, M.D., General Surgeon, has joined Regional Medical Clinic. Board certified in General Surgery, Dr. Takara earned her medical degree from the University of Tennessee School of Medicine in Memphis, Tenn. She completed her General Surgery residency at the University in 2005.

Black Hills Cardiovascular Research (BHCR) recently participated in a study to look at recovery of platelet function following discontinuation of antiplatelet medications. BHCR was one of four research sites that took part in the study, known as the RECOVERY trial, the results of which were announced at the 2011 American Cardiology Conference. The study was conducted over a three-month period and 13 local patients took part. Study results determined the anti-platelet effects of Effient were significantly greater and less variable than those taking Plavix.

Hospice of the Hills has become a national partner of We Honor Veterans, a pioneering campaign developed by National Hospice and Palliative Care Organization in collaboration with the Department of Veterans Affairs. As a We Honor Veterans partner, Hospice of the Hills will implement veterancentered education for staff and volunteers to help improve the care they provide to veterans. The We Honor Veterans campaign provides tiered recognition to organizations demonstrating a systematic commitment to improving care for veterans. Partners can use resources provided as part of the campaign and integrate best practices for providing end-of-life care to veterans.


Regional Medical Clinic-Aspen Centre welcomes family medicine physician Kathryn Barrett, M.D., to the clinic staff. Board certified by the American Board of Family Practice, Dr. Barrett received her MD from the USD School of Medicine and completed her residency at Iowa Lutheran Hospital in Des Moines.

Rylan Johnson, DPM, a boardcertified Podiatrist with Regional Medical Clinic, has relocated his practice to the Western Hills Professional Building directly west of Rapid City Regional Hospital. He will maintain a weekly outreach clinic at Massa Berry Regional Medical Clinic in Sturgis. Dr. Johnson specializes in the conservative and surgical management of the foot and related structures.


James D. Bowman, M.D., an internist at Regional Medical Clinic, was inducted into the South Dakota Chapter of the Alpha Omega Alpha (AOA) national honor society in May. A graduate of the USD School of Medicine, Dr. Bowman was the only alumnus selected for this year’s induction class. Board certified in Internal Medicine, Dr. Bowman earned his MD and completed his residency at USD. The South Dakota Affiliate of Susan G. Komen for the Cure has awarded a grant to the John T. Vucurevich Regional Cancer Care Institute (CCI) to assist medically underserved women in western South Dakota with challenges during breast cancer treatment. The grant will support the “Healing Pathways” program, an initiative assisting the medically underserved breast cancer patients of western South Dakota. This program will help remove the barriers of isolation by providing travel assistance while patients are receiving treatment for breast cancer.

Ryan Meis, MD, Fellowship Trained Orthopaedic Surgeon at CNOS, has passed the Subspecialty Certificate in Orthopaedic Sports Medicine examination. Certification means that an orthopaedist has achieved a level of proficiency in each of the areas comprising orthopaedic sports medicine as prescribed by the American Board of Orthopaedic Surgery. Dr. Meis received his MD from Creighton University and completed a fellowship in sports medicine and knee and should surgery at the American Sports Medicine Institute in Birmingham, AL. The South Dakota Chapter of the Crohn’s & Colitis Foundation of America will sponsor its annual “Take Steps” walkathon on Saturday, June 4, in Sioux Falls. The walk begins at 4 pm at Falls Park. Registration begins at 3:30. The event is free and open to the public. Participants are asked to raise a minimum of $25.

The Mayor of Arlington, Amiel Redfish, was awarded the Distinguished Physician Assistant award by the South Dakota Academy of Physician Assistants in March. A PA for 35 years, Redfish spent 12 years in Rosebud before beginning work in Arlington 21 years ago. He was instrumental in helping the state legislature adopt rules and regulations for physician assistants and is an Assistant Professor with the University of South Dakota. Redfish’s previous honors include the SDAPA Physician Assistant of the Year in 1997, the Doc Hayes Award for Medical Practitioner of the Year in 1998, and national Rural Physician Assistant of the Year in 1999.

Cheri Kraemer, owner of Parker Pharmacy, Clinic Pharmacy and Pharmacy Specialties in Sioux Falls has received the Women Breaking Barriers award from Women in Business. In an era where many small town pharmacies have sold out to larger chains, Kraemer has continues to successfully manage 3 independent pharmacies in different locations. She has also been honored with the SDSU Distinguished Alumni award for community service in Parker, where she lives. A compounding pharmacist since 2001, Kraemer has been recognized by the South Dakota Pharmacists Association as Innovative Pharmacist of the Year in 2002 and Pharmacist of the Year in 2006. Kraemer received the Women Breaking Barriers award at the Women in Business conference in April.

Midwest Medical Edition

Learning Opportunities Happenings around the region

June / July 2011 June 9 – 10

June 9 – 10

June 13 – 14

June 14 3:00 – 5:15 pm

June 16 8:30-am – 4:15 pm

June 27 8:00 am – 4:00 pm

June 29 – 30

July 1 8:00 – 11:00 am

July 11 7:45 am – 3:00 pm

July 15 - 16

5th Annual Thoracic Oncology Nursing Conference Location: Sanford USD Medical Center, Schroeder Auditorium CNE – 5.5 contact hours Information: Advanced Cardiac Life Support Provider Location: Avera Education Center Classroom 2 Information:322-8950,, Events Calendar Oncology Nursing Certification Review Course Location: Sanford Center for Learning, Fargo Videoconference: Sanford USD Medical Center, Schroeder Auditorium CNE – 14.1 contact hours Information: Pam Friedrich, Center for Learning, 800-437-4010 Acute Spine Injury – One Stop Care Location: Avera Education Center Classroom 2 Information: 322-8950,, Events Calendar Avera Gerontological Care Conference Location: Avera Education Center Auditorium Information: 605-322-4645 Advanced Cardiac Life Support Renewal Location: Avera Education Center Classroom 2 Information: 322-8950,, Events Calendar Certified Neuroscience Registered Nurse (CNRN) Review Course Location: Sanford USD Medical Center, Schroeder Auditorium CNE – 12.9 contact hours Information: Pam Friedrich, Center for Learning, 800-437-4010 Men and Depression: Behavioral Health Services Update Location: Avera Education Center Auditorium Information: 322-8950,, Events Calendar Pediatric Advanced Life Support Renewal Location: Avera Education Center Classroom 2 Information: 322-8950,, Events Calendar 33rd Annual Sanford Black Hills Pediatric Symposium Location: The Lodge at Deadwood CME/CNE - Maximum 11.5 AMA PRA Category 1 Credits Information:

MED reaches more than 3500 doctors and other healthcare professionals across our region 8 times a year. If you know of an upcoming class, seminar, webinar, or other educational event in the region in which these clinicians may want to participate, help us share it in MED. Send your submissions for the Learning Opportunities calendar Midwest Medical Edition to the editor at

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MED-Midwest Medical Edition-June 2011  
MED-Midwest Medical Edition-June 2011  

MED-Midwest Medical Edition June 2011 Issue